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, When placing a tear trough implant through the eyelid with internal scar and no stitches, are the tissues peeled off the bone as they are with cheek implant placement? I had cheek implants in and removed quickly which left me with mid face sagging and worse eye bags than before, minimal, but the tissues adhered a few millimetres lower than before the operation. Is this a risk with tear trough placement and or removal?, or is a mid face lift usually performed in conjunction with a tear trough implant? Which nerve functions are at risk with this implant?

A: A standard preformed tear trough implant can be placed through a transconjunctival (inside the eyelid) approach. Like all facial implants, it is necessary to make a pocket for the implant which is usually subperiosteal although is can be placed preperiosteal as well. Given the very thin nature of eyelid tissue over the orbital rim, it is best to placed it as deep under the tissues as possible. I would consider the tissue pocket locations between the orbital rim and cheek bones as different as well as the size of the implants that are placed. Cheek implants are placed from below with wide subperiosteal underming and dissection, releasing much of the midface tissues on the bone to place a moderately large implant. Thus it would not be surprising that removal of a cheek implant places one at risk for a subsequent midface sag of some degree. Conversely, the tissue pocket for a tear trough implant is much smaller and is over the medial orbital rim where the detachment of tissues will not cause a midface sag like that of the cheek area.

Tear trough implants pose no risk of nerve injury. The only close nerve is the infraorbital nerve which lies below the orbital rim and where the implant is placed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had malar and para-nasal implants, also infra-orbital porex placed in 2006, and six months ago removed because the malar increased my gaunt look, provided only lateral projection, and started to show through my thin skin. The paranasal implants didn’t really do much for me in terms of anterior volume, since they were placed so low on my long face.  Also, right infra-orbital implant became infected during removal of the malar implant and was also removed. Now I’ve got the left one still in there and, without the malars, the edges are poking through and it’s too small for my face. I trust my original surgeon and he wasn’t the one who removed the malar implants for financial and geographic reasons. Although the malars were kind of cool and from some angles gave me an “actor” look butI don’t want to replace them alone.

But, I do want to explore all options. That said, his idea is: 1) larger medpor tear trough plus midface lift. I realize the right eye is drooping. I also think there is some scar tissue where the paranasal was on right side that makes that cheek droop more and look puffy.   I know that midface lift means basically 2-month initial recovery and can leave one funky-looking, and seems to not really last that long.  I was thinking of the blepharoplasty to reposition the eye, instead??? (less invasive??) I like the idea of tear trough improvement , now that I can compare left vs. right, I see that my face needs it.

The groove and shadows beneath eyes are my biggest complaint.   Because I realistically, with my long and gaunt face because of exercise, it would take a lot to fill it out.  So I think a compromise of concentrating on eye area is the best option at this point. But I don’t want to go thru that recovery time and cost of the midface lift if it is going to fall in a year and the tear trough won’t be big enough and will start poking through….2) another surgeon I have worked with in past suggested malar-submalar combo, goretex.  But is worried that any implant will just show through. I am also open to this, to give some structure to my flatness, lower healing time, lower cost. 3) This second surgeon prefers just to use injectables.  I won’t do fat transfer because I will burn it off and it’s a waste of money and time.  It would just leave the left infraorbital implant in and try to compensate on right and in lower cheeks with filler under eye. At this point, though, I would be looking at minimum $6000 in filler.  

I had noticed the medpor porex tear trough implant and that, based on the brochure, seems to be what I’m looking for in terms of volume.  But, I don’t think my present surgeon would go for something this big,and he had mentioned the Hoenig model. Again, anything anterior he is against in order to avoid hitting the nerve.

I’m not against the midface lift, but at this point would prefer to save any lifting for a mini-lift 5 years down the road, perhaps with submalar added….  with skin excision not just suspension, when I really need it. And for the massive recovery time.  But, I have seen some awesome B & A of tear trough shadow improvement.

I don’t know…????  I started on this porex implant road and maybe just have to continue in this direction.

A: In answer to your questions:

1) Don’t do a midface lift. This is a longer recovery than most patients realize and with your facial skeletal structure you are at an increased risk of creating lower eyelid ectropion or an unusual look. With your thin facial tissues, you are always going to be at risk of tear trough implant palpability, visibility or asymmetry. But I can get more enthused about tear trough implants in you though than a midface lift.

2)   A small thin malar shell implant for the cheeks is reasonable and far preferable to a midface lift. With your thin tissues there is not much room for error about implant size as it is easy to end up in you with a visible implant look as you have had in the past.

3) Injectable fillers or fat in your thin face will not only not work well but has a poor return on investment over time.

4) There should be no concern about ‘hitting’ the infraorbital nerve going over the edge of the infraorbital rim. The nerve is well below it. That appreciation is just a function of having placed implants there before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, why are tear trough implants such a rare procedure? Can the implants pop out of place? What are some bad things that could happen with tear through implants? I am very young with very dark eye circles and I look terrible and need to do something about it.

A: Tear trough implants are very uncommon because other simpler alternatives exist such as the use of temporary injectable fillers or fat injections. These are far more appealing to many patients, and in the appropriately selected lower eyelid defect, they can be a good and effective choice. At the least, an injection approach is a good trial to see if this more non-surgical approach can be effective. For a defnitive permanent solution to the lower eyelid tear trough/infraorbital rim deficiency, a bony-based implant can be an effective choice. Tear trough implants are placed through a lower eyelid incision. They are attached to the bone by small screws so there is no chance of them ever moving out of place. The only issues that I have ever seen with tear trough implants is that you may be able to feel them through the very thin lower eyelid skin. In addition, carving and shaping them down so they have a natural flow into the surrounding bone is important so that there are no unnatural step-offs is an important aesthetic contouring step.

Dr. Barry Eppley
Indianapolis, Indiana

Q:  I am interested in getting implants for my deep tear troughs. I have a few questions about them. What is the recovery time? Will there be any bruising or swelling? What are the aftercare instructions? ( i.e., how long are bandages worn, how long do I wear sunglasses?) Can I apply Latisse on my eyes? What kind of anesthesia is used and what are the side effects associated with this? Is there a possibility that this will affect my vision? Are there any negative outcomes or side effects of tear trough implants?

A: There will be swelling and maybe some bruising for a few weeks. Recovery is all about how you look not how you feel. There is no aftercare or anything that you need to do other than to ice the eye area for the first night after surgery. There are no bandages. You may continue to apply Latisse to your upper eyelid lashes as normal if you desire. General anesthesia is used as the lower eyelids and orbital bones are impossible for anyone to stay still except if they are asleep. This surgery will have no effect on your vision. The biggest risk of tear trough implants is getting the right size and position on the bone so you do not feel them, see them and they do not move after surgery.  Implants can be used for tear troughs but so can fat injections which is another good option. Fat injections, like tear trough implants, is an operation that is done under general anesthesia as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am asking about what to do with my under eye area.  I had a lower blepharoplasty 15 years ago. My undereye area is very sunken looking and there is a little darkness in the skin but that may be due to some shadowing as well. I am wondering if I need a redo with a canthoplasty/canthopexy and some orbital rim/tear duct/cheek implants. I have attached some photos of my eyes from different angles. I assume you can tell from photos I also had a cheek lift and other work.

A: Based on your photos, you have a significant volume loss of fat/tissue of the lower eyelids and over the lower orbital rims onto the cheeks. Whether that is due to your prior lower blepharoplasty with fat removal is speculative and irrelevant at this point. Because of the loss of lower eyelid/cheek volume and support, you also have increased scleral show. (pseudoectropion)

What you need is volume replacement of the lower eyelid and cheek. There are several different options to consider for this replacement. It fundamentally comes down to synthetic vs. autogenous graft materials. The synthetic approach is one you have already mentioned, that of an orbital rim/cheek implant either as a single piece or in two different segments. There are several different styles for this area. These have the advantage of an immediate augmentation that will be permanent. They are placed through your old blepharoplasty incision and a canthopexy would be done at the same time. The other option is that of fat injections to add volume or the placement of allogeneic dermal grafts. This approach has the advantage of not using an implant but the survival of fat is not assured and it may require more than one treatment session to get the best result.

There are advocates for either approach and it is not a proven matter than one method is better than the other. The use of implants has a more proven track history of use.

Dr. Barry Eppley

Indianapolis, Indiana