Should I Augment The Premaxillary Area As Well As The Paranasals?

Q: Dr. Eppley ,I suffer from a flat, even recessed, maxilla and would most likely benefit more from jaw surgery, however, my desired results could also be achieved through implants and I’d rather take the latter route as jaw surgery is way too extreme for my liking. As of now, I am definitely most interested in the paranasal implants as it is my main concern (nasolabial folds), but I am also interested in the premaxillary implant as well. I am not looking for an extreme change, but I would like an overall projection in the mid face, specifically around the base of the nose. The results I am hoping to achieve is a slightly lifted nose as well as volume in the upper cheeks right below the orbitals. Is this possible? Some concerns of mine include the upper teeth “disappearing” when smiling and talking. This is already something I have issues with because of my deep bite and would rather not emphasize it. This also includes the change of the smile. Another concern is with the implants moving, is that avoidable with screw ins? I have attached a before picture of my profile and an edited after picture of the results I am hope to achieve.

A: Thank you for your inquiry and sending your pictures. In looking at your pictures certainly jaw surgery would be too radical and based on what I believe your objectives to be would also not achieve that outcome in the way that you desire. Therefore implants are a reasonable consideration. In looking at your imaged objectives both pictures appear to be the same so it is not yet clear to me as to your exact objectives. That being said I can make the following paranasal implant comments:

1) I would be cautious about the premaxillary component as that will open up your nasolabial angle which may create an undesired effect in your case. Also when you cross the premaxillary area that increases the risk of affecting your smile and in particular having less visible to tooth show when smiling. Premaxillary augmentation should only be down when there is a clear premaxillary retrusion with a decreased nasolabial angle.

2) As you start to mention increased volume in the upper cheek area this is really beyond what a standard paranasal implant is designed to do. Such an augmentation effect requires a custom implant design to do so.

3) Implants don’t move or migrate after surgery, this is a common perceived fallacy. The surgeon and the patient may notice that the implants have a non-desired position two or three months after surgery when all the swelling goes down but this is reflective of placement not migration. The outcome of any facial implant surgery takes 2 to 3 months to fully see. Ultimately implant position is firmly established by the encapsulation scar process within six weeks after the surgery. Screws merely hold implants into the desired if the implant shape and the underlying bone onto which it is placed is not perfectly matched. Then once the scar process has occurred the screws serve no purpose. As it turns out the standard ePTFE paranasal implants have a  microporous texture which allows rapid tissue ingrowth and screws are generally not needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon