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anyone know what could be done with saggy supranasolabial malar pads? They collapsed downwards post jaw surgery, surgeon says midface lifts with sutures are pure garbage, is there anything else??
 

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anyone know what could be done with saggy supranasolabial malar pads? They collapsed downwards post jaw surgery, surgeon says midface lifts with sutures are pure garbage, is there anything else??
He is correct that thread lifts are not a good option. The results dont last.

For a lsating result the soft tissue needs to be lifted off the bone and "re-heal" to the bone in a lifted way. This is why a surgical midface lift is probably the best idea.

Pics of your concern for more tailored details.
 

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He is correct that thread lifts are not a good option. The results dont last.

For a lsating result the soft tissue needs to be lifted off the bone and "re-heal" to the bone in a lifted way. This is why a surgical midface lift is probably the best idea.

Pics of your concern for more tailored details.
On a related note, I have noticed that on the right side of my face, the nasolabial fold is much more pronounced (I think you've remarked that you noticed this as well). I'm not sure if this is just coincidental, but my right eye was also measured to protrude by 3 more mm than the left eye. Do you think the right NL fold could be more pronounced because Dr. Y wasn't able to get as much lift on the right side of the face since the eyeball on that side protrudes more? If so, would it be worth it to re-do the midface lift on that side, or would orbital decompression need to be performed first?
 

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On a related note, I have noticed that on the right side of my face, the nasolabial fold is much more pronounced (I think you've remarked that you noticed this as well). I'm not sure if this is just coincidental, but my right eye was also measured to protrude by 3 more mm than the left eye. Do you think the right NL fold could be more pronounced because Dr. Y wasn't able to get as much lift on the right side of the face since the eyeball on that side protrudes more? If so, would it be worth it to re-do the midface lift on that side, or would orbital decompression need to be performed first?
First thing I would want to do is look at your 3D images and compare sides (digitally measuring them)

One eye protruding more on one side is linked to asymmetry in the entire midfacial bone structure.

But I am fairly certain your face was made symetrical with the implants?
 

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First thing I would want to do is look at your 3D images and compare sides (digitally measuring them)

One eye protruding more on one side is linked to asymmetry in the entire midfacial bone structure.

But I am fairly certain your face was made symetrical with the implants?
Here is a link to my implant design scans:


As you can see, Dr. Y only gave me 3.5 mm of augmentation on the right side as opposed to 5.5 mm on the left side. While I think both sides could've been augmented with at least ~2 more mm of projection, I think it's clear that Dr. Y went way too conservative with the amount of augmentation he gave me with the right cheek implant (not sure whether you'd agree with this statement?).

Also, I'm tentatively planning on going back at the end of next month to get the rest of the wraparound jaw implant put in. Trying to decide whether or not to revise the midface implants as well and ask for maybe 7.5 mm on the left side and 6 mm on the right side. The only reservation I have is the risk of scar tissue buildup from having the undereyes operated on a second time, since my next surgery after this will be eye area overhaul with Taban. I really wish I could quantify just how much the scar tissue-related effects of midface implant revision surgery could compromise the results of my eye area overhaul.
 

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Here is a link to my implant design scans:


1. Previous topic given the scans

As you can see, Dr. Y only gave me 3.5 mm of augmentation on the right side as opposed to 5.5 mm on the left side. While I think both sides could've been augmented with at least ~2 more mm of projection, I think it's clear that Dr. Y went way too conservative with the amount of augmentation he gave me with the right cheek implant (2. not sure whether you'd agree with this statement?).

Also, I'm tentatively planning on going back at the end of next month to get the rest of the wraparound jaw implant put in. Trying to decide whether or not to revise the midface implants as well and ask for maybe 7.5 mm on the left side and 6 mm on the right side. 3. The only reservation I have is the risk of scar tissue buildup from having the undereyes operated on a second time, since my next surgery after this will be eye area overhaul with Taban. 4. I really wish I could quantify just how much the scar tissue-related effects of midface implant revision surgery could compromise the results of my eye area overhaul.
1. We can never be sure to the exact cause and it probably not just one.
- Did you always have a more prominant NL fold on one side? It is common to have this, sometimes because of a tendancy for certain facial expressions, squinting from the sun in the car, sleeping on one side...
- If it is post surgical it could have to do how the skin redraped given the difference in globe projection which obviously displaces some soft tissue superiorly.
- Also if there was a bony asymmetry (which obviously there was because it was corrected with 2 different sized implants) than the actual area and thickness of the overlying soft tissue was likely asymetrical as well, with the corrected bone symmetry a soft tissue symmetry still remains and in some cases is made worse - this is the pitfall of facial symmetry correction with custom CAD facial implants. This is not to imply fault on the treating physician or designing engineer, it is well known that facial symmetry surgery will never be 100% perfect for the reason of unpredictable soft tissue.
- As you can see there are many reasons and maybe they all contribute to your problem some.

2. I wasn't there when you discussed your goals

3. It may be possible for the new implant to be placed intraorally which would minimize scar tissue formation in the periorbital area. This is not an option though if you need/decide to go for a revision midface lift at the time of revision midface implant which if I recall correctly you have discussed. You could probably leave that to the surgeon doing your lower lid retraction surgery but at to go into more detail isn't my place. Discuss that with your doctors.

4. Best case scenerio the original surgery was done meticulously and your body reacted well. Worst case scenerio it was opened and closed sloppily and your body healed with excessive scar formation and the revision surgeon will barely be able to tell what they are looking at in theatre and you lose the degree elasticity required to actually raise the lower lids OR certain bands and islands of scar make it such that they don't raise evenly and you look like a mild trauma reconstruction case not an elective aesthetic case.

5. Really consider Yaremchuk for both so they can be done at the same time. He has published quite extensively in the area of orbital and periorbital surgery.
 
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1. We can never be sure to the exact cause and it probably not just one.
- Did you always have a more prominant NL fold on one side? It is common to have this, sometimes because of a tendancy for certain facial expressions, squinting from the sun in the car, sleeping on one side...
- If it is post surgical it could have to do how the skin redraped given the difference in globe projection which obviously displaces some soft tissue superiorly.
- Also if there was a bony asymmetry (which obviously there was because it was corrected with 2 different sized implants) than the actual area and thickness of the overlying soft tissue was likely asymetrical as well, with the corrected bone symmetry a soft tissue symmetry still remains and in some cases is made worse - this is the pitfall of facial symmetry correction with custom CAD facial implants. This is not to imply fault on the treating physician or designing engineer, it is well known that facial symmetry surgery will never be 100% perfect for the reason of unpredictable soft tissue.
- As you can see there are many reasons and maybe they all contribute to your problem some.

2. I wasn't there when you discussed your goals

3. It may be possible for the new implant to be placed intraorally which would minimize scar tissue formation in the periorbital area. This is not an option though if you need/decide to go for a revision midface lift at the time of revision midface implant which if I recall correctly you have discussed. You could probably leave that to the surgeon doing your lower lid retraction surgery but at to go into more detail isn't my place. Discuss that with your doctors.

4. Best case scenerio the original surgery was done meticulously and your body reacted well. Worst case scenerio it was opened and closed sloppily and your body healed with excessive scar formation and the revision surgeon will barely be able to tell what they are looking at in theatre and you lose the degree elasticity required to actually raise the lower lids OR certain bands and islands of scar make it such that they don't raise evenly and you look like a mild trauma reconstruction case not an elective aesthetic case.

5. Really consider Yaremchuk for both so they can be done at the same time. He has published quite extensively in the area of orbital and periorbital surgery.
@Surgerymax thanks for the info and for breaking down each of my questions.

To respond to point 3 -- Dr. Taban actually said that he would do another midface lift during my eye area overhaul surgery (along with lower eyelid retraction correction w/spacer grafts, orbital decompression, and lateral canthoplasty). However, he said that the type of midface lift he would perform is called a SOOF lift, so I'm not sure how that differs in terms of aesthetic outcome, longevity, etc. as compared to the type of subperiosteal lift that Dr. Y performs?

To respond to point #4 -- Do you know if there is any way to tell if I still have enough elasticity in the lower eyelids in order for them to be able to be lifted (although I understand that it's impossible to predict how much elasticity will remain after revision midface implant surgery)? Would the use of spacer grafts during lower eyelid retraction surgery accommodate somewhat for any loss of elasticity that might occur from midface implant revision surgery?

To respond to point #5 -- I would be open to considering Dr. Y for the eye area surgeries, but unfortunately I just don't have the money to do all three procedures all at once right now.
 

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@Surgerymax thanks for the info and for breaking down each of my questions.

To respond to point 3 -- Dr. Taban actually said that he would do another midface lift during my eye area overhaul surgery (along with lower eyelid retraction correction w/spacer grafts, orbital decompression, and lateral canthoplasty). However, he said that the type of midface lift he would perform is called a SOOF lift, so I'm not sure how that differs in terms of aesthetic outcome, longevity, etc. as compared to the type of subperiosteal lift that Dr. Y performs?

To respond to point #4 -- Do you know if there is any way to tell if I still have enough elasticity in the lower eyelids in order for them to be able to be lifted (although I understand that it's impossible to predict how much elasticity will remain after revision midface implant surgery)? Would the use of spacer grafts during lower eyelid retraction surgery accommodate somewhat for any loss of elasticity that might occur from midface implant revision surgery?

To respond to point #5 -- I would be open to considering Dr. Y for the eye area surgeries, but unfortunately I just don't have the money to do all three procedures all at once right now.
SOOF is not subperiosteal and while it will probably improve your appearance, may not fix the nasolabial fold if it has to do with uneven re-drape. If it has to do woth uneven re-drape then actually securing the soft tissue envelope to the implant, preferably with bites in or around the zygomaticus muscle origin with sutures may help (done at the time of midfacial implant revision)

But then again SOOF lift may help a ton and has been known to improve NL folds. Nasolabial folds are multifactoral and it really depends on the "layer" that is predominantly causing it. Unfortunately I don't have a great test for you to assess that.

Spacer graft does not really make dealing with scar any easier.
 

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SOOF is not subperiosteal and while it will probably improve your appearance, may not fix the nasolabial fold if it has to do with uneven re-drape. If it has to do woth uneven re-drape then actually securing the soft tissue envelope to the implant, preferably with bites in or around the zygomaticus muscle origin with sutures may help (done at the time of midfacial implant revision)

But then again SOOF lift may help a ton and has been known to improve NL folds. Nasolabial folds are multifactoral and it really depends on the "layer" that is predominantly causing it. Unfortunately I don't have a great test for you to assess that.

Spacer graft does not really make dealing with scar any easier.
If I didn't want to risk the scar tissue consequences of revising the midface implants, do you know if Dr. Taban would be likely to actually go through the process of re-securing the soft tissue to the origin of the zygomaticus muscle? Or is this something that would probably fall under the purview of a craniofacial surgeon like Dr. Y?

Also, regarding scar tissue buildup -- is there any sort of test I can do right now to assess how much scar tissue has built up already? Or is opening up the incision site the only way to be able to know anything?
 

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If I didn't want to risk the scar tissue consequences of revising the midface implants, do you know if Dr. Taban would be likely to actually go through the process of re-securing the soft tissue to the origin of the zygomaticus muscle? Or is this something that would probably fall under the purview of a craniofacial surgeon like Dr. Y?

Also, regarding scar tissue buildup -- is there any sort of test I can do right now to assess how much scar tissue has built up already? Or is opening up the incision site the only way to be able to know anything?
I would assume Y especially since he will already be inside this pocket but different surgeons have their own rules for touching other surgeons previous work. Has nothing to do with the scope of practice of either surgeon's subspecialty. Both are overlappingly qualified.

Except for in the most severe cases of scar tissue lower eyelid retraction - opening is the only way.
 

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I would assume Y especially since he will already be inside this pocket but different surgeons have their own rules for touching other surgeons previous work. Has nothing to do with the scope of practice of either surgeon's subspecialty. Both are overlappingly qualified.

Except for in the most severe cases of scar tissue lower eyelid retraction - opening is the only way.
Thanks again. If I had the money, I would absolutely consider Dr. Y for the eye area work as well. I actually got a quote from his office for what I feel like is a great price for him to put in the rest of the wraparound jaw implant, do the eye area overhaul, and revise the midface implants -- $24.5k. I just can't afford to spend that much right now, unfortunately.

So I guess this is the dilemma I'm faced with: get the midface implants revised and get the NL fold lifted at the same time but do so at the risk of possibly ruining my opportunity to ever get a decent-looking eye area with Taban, or leave the midface implants/midface lift alone for the sake of not compromising my future eye area surgery result but do so at the price of potentially condemning myself to have the NL fold forever.
 

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Paranasal-premaxillary implant prediction

Image 2-16-20 at 11.01 PM.jpg

The skeletal pyriform apeture is often erroneously imagined to be outlined by the soft tissue outline of the nose. This isn't so, it is actually smaller. The bottom of it is actually about 5mm to nearly an entire cm above the bottom of the nose so most of the bottom of the implant is completely under the nose.

What I predicted is probably really the maximum impact a premaxillary implant could ever have in the philtrum area but probably not even that much.
 

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Paranasal-premaxillary implant prediction

View attachment 8223

The skeletal pyriform apeture is often erroneously imagined to be outlined by the soft tissue outline of the nose. This isn't so, it is actually smaller. The bottom of it is actually about 5mm to nearly an entire cm above the bottom of the nose so most of the bottom of the implant is completely under the nose.

What I predicted is probably really the maximum impact a premaxillary implant could ever have in the philtrum area but probably not even that much.
Thanks for creating the morph. I definitely think it's an improvement, although I'm thinking that maybe even a bit less projection of the upper philtrum area than what is depicted in the morph might look better. I think the reason it looks a bit unnatural (sort of reminds me of one of the characters from the Grinch movie just under the nose/top of philtrum) is because of the fact that the lips weren't brought forward as well, which I understand is an unavoidable limitation of implants as compared to LF1. However, it may look more natural with lip fillers and maybe a lip lift as well. Overall, though, I like the change and think I'd be satisfied enough with a similar outcome that I wouldn't care about getting jaw surgery. It's the decision-making process over this damned midface implant revision surgery that is really tormenting me.
 

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As you can see, Dr. Y only gave me 3.5 mm of augmentation on the right side as opposed to 5.5 mm on the left side. While I think both sides could've been augmented with at least ~2 more mm of projection, I think it's clear that Dr. Y went way too conservative with the amount of augmentation he gave me with the right cheek implant (not sure whether you'd agree with this statement?).
So I wasn't able to convince you huh? Your midface projection is well above average, and much more than Cavill's, like I showed you. I would leave it alone. The max projection for my implant was ~6.5 mm, and my recession was quite severe, so I think going to 7.5 on you like you said would look uncanny. Plus as you said, revising them would complicate your other surgeries. If you are really curious about more projection, maybe try a small amount of filler on top of them.

Thanks for creating the morph. I definitely think it's an improvement, although I'm thinking that maybe even a bit less projection of the upper philtrum area than what is depicted in the morph might look better. I think the reason it looks a bit unnatural (sort of reminds me of one of the characters from the Grinch movie just under the nose/top of philtrum) is because of the fact that the lips weren't brought forward as well, which I understand is an unavoidable limitation of implants as compared to LF1. However, it may look more natural with lip fillers and maybe a lip lift as well. Overall, though, I like the change and think I'd be satisfied enough with a similar outcome that I wouldn't care about getting jaw surgery. It's the decision-making process over this damned midface implant revision surgery that is really tormenting me.
Yeah the mismatch between the lips and under nose area was sort of what I was talking about.

My opinion, is that you go to Taban for your eye area surgery, which will improve your looks a lot and improve with your nasiolabal folds (getting more lean will improve this a lot also). Eye are should be your highest priority. You can go back to Yaremchuk a few months later if you want for your jaw implant, and, if you really want it, paranasal implants.
 

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So I wasn't able to convince you huh? Your midface projection is well above average, and much more than Cavill's, like I showed you. I would leave it alone. The max projection for my implant was ~6.5 mm, and my recession was quite severe, so I think going to 7.5 on you like you said would look uncanny. Plus as you said, revising them would complicate your other surgeries. If you are really curious about more projection, maybe try a small amount of filler on top of them.



Yeah the mismatch between the lips and under nose area was sort of what I was talking about.

My opinion, is that you go to Taban for your eye area surgery, which will improve your looks a lot and improve with your nasiolabal folds (getting more lean will improve this a lot also). Eye are should be your highest priority. You can go back to Yaremchuk a few months later if you want for your jaw implant, and, if you really want it, paranasal implants.
The thing is, even if I technically have more projection than Cavill, I still think that I objectively could benefit from more frontal projection. I can look at my face in the mirror under certain types of lighting and tell that I'm so close to having an element of sharpness and projection that would look really good... if only I had that additional projection. So in other words, even if I'm not comparing my own midface projection to Henry Cavill's, I still think I could benefit from more projection. Also, I think it's worth mentioning that @Surgerymax agrees that I'd benefit from a few more mm of anterior projection (and probably a bit more lateral projection as well). It's like, I'm just SO CLOSE to having the result I originally set out to get, if only he had listened to me when I told him I wanted another 2 mm of projection prior to the surgery after he had first emailed me photos of the implant design.

The reason I want to go ahead and do the jaw implant first before going to Taban for the eye surgeries is because Dr. Y is probably going to retire within the next couple of years, and my jaw implant has already been designed and manufactured and can be placed for $8.5k. If I wait too long and Dr. Y retires, I'll have to pay upwards of $20k to do it sometime down the road with another surgeon. It isn't feasible for me to go to Taban first and then Dr. Y a few months later because I simply can't afford to do both surgeries that close together. I don't mind waiting a bit longer on the eye surgeries since I'm pretty sure Taban isn't at risk of retiring/dying anytime soon. And even if he did take an early retirement, there are still a few other oculoplastic surgeons who could also probably do a good job with the surgeries I want.
 

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The thing is, even if I technically have more projection than Cavill, I still think that I objectively could benefit from more frontal projection. I can look at my face in the mirror under certain types of lighting and tell that I'm so close to having an element of sharpness and projection that would look really good... if only I had that additional projection. So in other words, even if I'm not comparing my own midface projection to Henry Cavill's, I still think I could benefit from more projection. Also, I think it's worth mentioning that @Surgerymax agrees that I'd benefit from a few more mm of anterior projection (and probably a bit more lateral projection as well). It's like, I'm just SO CLOSE to having the result I originally set out to get, if only he had listened to me when I told him I wanted another 2 mm of projection prior to the surgery after he had first emailed me photos of the implant design.

The reason I want to go ahead and do the jaw implant first before going to Taban for the eye surgeries is because Dr. Y is probably going to retire within the next couple of years, and my jaw implant has already been designed and manufactured and can be placed for $8.5k. If I wait too long and Dr. Y retires, I'll have to pay upwards of $20k to do it sometime down the road with another surgeon. It isn't feasible for me to go to Taban first and then Dr. Y a few months later because I simply can't afford to do both surgeries that close together. I don't mind waiting a bit longer on the eye surgeries since I'm pretty sure Taban isn't at risk of retiring/dying anytime soon. And even if he did take an early retirement, there are still a few other oculoplastic surgeons who could also probably do a good job with the surgeries I want.
I disagree that you would objectively benefit, but it's up to you.

Have you thought about getting filler to "try out" more cheekbone projection before you commit to surgery? It would also help you decide on the new shape of the implant should you go for a revision.
 

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I disagree that you would objectively benefit, but it's up to you.

Have you thought about getting filler to "try out" more cheekbone projection before you commit to surgery? It would also help you decide on the new shape of the implant should you go for a revision.
I would really rather avoid paying for fillers since they're such a waste of money. Also, regarding the shape of the implant, I actually think the shape of the implants themselves is good, they just need more projection. I was thinking that it would be a good idea to keep the shape the same but just add more frontal and lateral projection (probably 3 mm frontal projection and 2 mm lateral projection). I know you probably don't think I'd benefit from implants that project more, but I could seriously post a collage comprised of a random mix of pre- and post-surgery photos and you wouldn't be able to tell which ones which were taken pre-surgery and which ones were taken post-surgery.
 

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Dr Y’s Asian predecessor (that I’m sure took pics of u in his office before even meeting Dr Y lol) will do a little spacer graft, the same EXACT way that Dr Y would..So there’s really no rush to get the surgery with him..

If you’re fearing that he’s going to “Retire”

I am much more familiar with Eppley as I actually got surgery with him...So idk how Dr Y does things, but you can rest assure there will be no quality drop off once he retires

I will be in Spain in the next coming months to meet with a surgeon who I’m VERY surprised hasn’t been mentioned in PSL yet, with some amazing results..he trained in the US doing custom implants, and was also a dentist when he started like Eppley..

But he DOES do cosmetic doublejaw, as I’m sure it was influenced from him growing up in South Korea and it being the norm there

I’ll let you know how it goes, and if you should potentially look into him.
 

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Dr Y’s Asian predecessor (that I’m sure took pics of u in his office before even meeting Dr Y lol) will do a little spacer graft, the same EXACT way that Dr Y would..So there’s really no rush to get the surgery with him..

If you’re fearing that he’s going to “Retire”

I am much more familiar with Eppley as I actually got surgery with him...So idk how Dr Y does things, but you can rest assure there will be no quality drop off once he retires

I will be in Spain in the next coming months to meet with a surgeon who I’m VERY surprised hasn’t been mentioned in PSL yet, with some amazing results..he trained in the US doing custom implants, and was also a dentist when he started like Eppley..

But he DOES do cosmetic doublejaw, as I’m sure it was influenced from him growing up in South Korea and it being the norm there

I’ll let you know how it goes, and if you should potentially look into him.
Yes, definitely post back and let us know how the appointment goes. So are you going to the surgeon in Spain to get a consultation on double jaw surgery? Or are you looking to revise your custom implant work?

Also, I was actually seen just prior to surgery by the doctor who was being trained by Dr. Y prior to him taking on the Asian guy you mentioned (the guy who examined me was Middle Eastern).

When you said that there shouldn't be a quality drop-off once Dr. Y retires, were you primarily referring to eye area surgeries? Or to implant-based procedures as well?

If you were referring to eye area surgeries, I agree with you completely since there's Taban and a handful of other oculoplastic surgeons who can do a good job on my eye area surgeries. But if you're referring to custom implant procedures, I kind of have to disagree, because I honestly think that Dr. Y still has one of the best aesthetic sensibilities when it comes to designing implants (seems to have fewer freaky/unnatural-looking results than most other surgeons). That's why if I do get my midface implants revised, I would prefer for it to be done by him.

Another thing to consider (as I mentioned above in another post) is that I have already paid the design and manufacturing fee to have my jaw implant created, so it will only cost $8500 to have the rest of it put in, as compared to $17k-$20k or more with any other surgeon. So if I wait too long and he retires, I'll be looking at spending at least double to get wraparound jaw implant surgery with another surgeon.
 

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@Surgerymax Quick question for you. In one of your recent posts, you suggested to me that I should ask Dr. Y about the possibility of revising my midface implants through an intraoral incision so as to not create more scar tissue in the lower eyelids. Would an intraoral incision still be feasible if the revised implants will include (as my current implants do) a zygomatic arch extension?