Your Questions

Q: Dr. Eppley, I am a 32 year old female with flat cheekbones that make my eyes look prominent. I have noticed that whenever I laugh the lower eyelid retraction vanishes and the eyes look quite normal. So I am thinking a fat transfer can considerably correct the problem. But I would like toknow if the maxillary hypoplasia is so severe as to make necessary the use of orbital/cheek implants. Or do you believe in using large volumes of fat transfer to treat such cases. And can fat grafts be used in the cheek eyelid junction too?

A: You have astutely discerned the two approaches to anterior midfacial/lower orbital hypoplasia. The bone can be built up with implants or fat can be added to the soft tissues that drape over the bones. Each has their own distinct advantages and disadvantages and the actual anatomy and severity of the tissue deficiency will play a major role in that treatment decision. It would be very helpful to see pictures of your face to provide a more specific answer to your exact facial concerns.

Having done a lot of both infraorbital and tear trough implants and fat grafting in this area, I am facile with both techniques and my treatment decision rests with what is best to anatomically correct the problem. Anatomic needs should dictate the treatment, not what ay surgeon is most familiar with doing. What I can tell about treating this area in general is that I often use a combination of both implants and fat grafting to get the best result. Implants can only go where the bone is, fat injection grafting can volumize soft tissues where implants can not. (e.g.,  lower eyelid above the infraorbital rim)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had  some facial feminization procedures done not too long ago. I had a sliding genioplasty as one of them. I now have the often present notch on either side of the osteotomy. I expressed concerns about minimizing this with the original doctor. The depressions are fairly evident. Also my infra orbital area is lacking. This lacking does not help with a feminine appearance. Over all I am having trouble determining what needs adjusting on my face because the face is the sum of its parts. I need an opinion so I can decide what to do over the next 12 months. I hope to improve symmetry also. I have to wait at least six months to undergo any further work since surgery was not to long ago. I have attached some pictures which hopefully are helpful although they are just one week after surgery.

A: Based on these even very early pictures, your chin is now too vertically short for your face. You have a longer thinner face and now the lower third (chin height) is too short. That is what is throwing off your facial proportions. Also as part of a longer thinner face, the cheek/infraorbital area is flatter. Thus I would recommend a chin bone lengthening (opening back up the osteotomy), infraorbital rim implants, and a subnasal lip lift. This will bring your face into better proportion and balance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a midface deficiency which is causing the skin of my midface to sag alot causing it to look pigmented, I have been told I am more suitable for orbital rim implants (after many consultations for standard cheekbone implants) but it seem a subtle implant is all that can be used due to my skin not being very hefty. What I want to know is how far around from the nasion area around to the malar lateral area does the implant reach? Will it fill out the area on outer corner of eyes where a normal persons cheekbones would normally be located? I generally have good projection on the sides of my head, but I have developed a fat face appearance and I’m only 24, this is giving a pigmented look to the unsupported skin. It’s like I’ve lost a lot of weight which I haven’t as I’m only 150lbs.I have been told I could go with fat transfer after implants if I wanted a more drastic change later on down the road. Will subtle rim implants be enough to lift the sagging skin as it feels like there is a lot? My face has no angles like it used to and has become very doughy. I’m depressed over this as I simply don’t know what to do.

A: While I will have to see pictures of you, I can make some general comments in regards to infraorbital-malar implants. There are numerous styles and designs of orbital rim, malar and combined infraorbital-malar implants. Some do reach the whole way from the medial orbital rim around and onto the malar region and up on the lateral orbital rim. How much midfacial tissue lifting these implant styles do is limited. Some malar tissue elevation is obtained but more significant amounts will likely need some form of a midface lift done concurrently with implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I have a question about cheek and orbital rim implants. I have fairly wide cheek bones that I am considering reducing via osteotomy, but the frontal cheek area directly beneath my eyes seems deficient. Are there cheek implants (or fillers) that can push out this area under the eye (a slightly near the transition of the nose)? Can the results of such cheekbone implants make a wide/flat face look less wide and more defined? Also, does cheekbone reduction cause sagging skin/prejowl?

I have fairly large eyebrow ridges, which I am generally happy about, but the ridge area close to my radix is deficient compared to the prominent ridge area near my temples (I think it pushes my eyebrows up vertically near the side of the temples). Is there a way to augment the area near the radix so that it more smoothly matches the rest of my eyebrow ridge? Would the only way to do this be to have an open-scalp incision? What would be the complications of such a procedure?

A: It is common in wide cheek or zygomatic widths to have anterior infraorbital rim deficiency. This is part of the wide midface look. There are specific infraorbital-malar implants that augment this area exclusively. They come in a variety of styles and sizes although my preference is to custom carve implants out of a Gore-tex block at the time of surgery, particularly when the amount of rim/tear trough augmentation is small.

I don’t know if you would call a combined cheekbone reduction with infraorbital rim implants making the face more defined. But it will change its shape and proportions acroos the midface area to look less wide. Calling it increased facial definition is a stretch.

Building up the radic of the nose can be done with either injectable fillers or fat for a minimal or non-invasive approach or can it be bult up with either a very small implant or cartilage from an intranasal approach. A scalp incision would never be needed.

Dr. Barry Eppley

Indianapolis, Indiana