Camouflage by augmentation

Malar augmentation with implants is an option to correct posttraumatic deformities as an alternative to orbitozygomatic osteotomies in selected cases where orbital wall reconstruction is not indicated.

Fat injections are useful as an adjunctive procedure or for the correction of mild deformities.

Centrifuged fat is radially injected from various sites.

The most common puncture sites are:

• Preauricular area
• Nasolabial fold
• Lower eyelid

The procedure may be repeated as needed if the desired result is not achieved initially.

Careful physical examination with special attention on existing eyelid and cheek asymmetry must be performed. Cheek ptosis, scleral show, and malposition of the external canthal ligament will demand additional corrective procedures.

Axial and coronal CT-scans with soft tissue windows are useful in assessing the three dimensional deficiency and to predict the augmentation volume.

There are a wide range of implants available and the selection of implant size and design will depend on the existing deformity and patient anatomy.

Patient specific implants are also an alternative.

The most common approach for this procedure is through a maxillary vestibular approach. Subciliary approaches may prove useful when eyelid correction or soft tissue resuspension is required.

The following pages provide general information regarding orbital anatomy and dissection

• Preoperative considerations
• Anatomy of the bony orbit
• Correlation of surface and cross sectional anatomy
• Introduction to periorbital dissection
• Orbital floor dissection
• Medial orbital wall dissection
• Lateral orbital wall dissection
• Orbital roof dissection
• Adjunctive access procedures (orbitotomies)
• Retrobulbar hemmorage

Limited subperiosteal dissection is performed to accommodate the implant.

The implant is placed as planned and fixed with screws.

Additional soft tissue suspension is performed.

Head of bed elevation may significantly reduce edema and pain.
A cooling mask may be used to further reduce edema.
A compressive head dressing is left in place until suction drains are removed (24-48 hours postoperatively). Thereafter routine wound care should be instituted.

• Analgesia as indicated
• The use of antibiotics in the perioperative period is recommended
• Regular patient follow-up after discharge including periodic imaging is recommended.