Your Questions
Your Questions
Q: Dr. Eppley, I had a rhinoplasty done and ever since something about it has been bothering me since I have done it. I’m not sure what the doctor called it since it’s been 4 years ago. I was concerned that the side of my nose was big. It was the bone beside the bridge of the nose. I originally thought I wanted it to be smaller. I just realized after that what I was after wasn’t to get rid of that but I wanted my bridge to be smaller. I feel like now there is a hollow line of a downward from under eye to about 3-4 cm. And the width is about from the bridge to the side around 1-2 cm. I only remember him saying that he has made the bone in that area less thick. I think as a result, it leaves some kind of hollow, especially when taking picture that area seems to be looking deep and I don’t think it was like that before I did it. I think it’s not supposed to look like this. I think the doctor wasn’t skillful enough and removed too much bone and now I look kind of old. When I smile it’s the most obvious.
Is it possible at all to fill it up with something permanent fixed to my bone beside the bridge(basically to make the bone on that area thicker) that wouldn’t move when I smile? I don’t want a fat graft which doesn’t last and would move or get pushed up when I smile. Or any other material ? I’m aware that there would be a curve at the bridge down to the sides. But I’m really not sure where exactly the doctor got rid of my bones. But it wasn’t by squeezing the bone, he literally kind of use some tools to get rid of the bone.
A: I can not tell from your description whether this high paranasal deficiency is the result of nasal bone infracturing done at the time of a rhinoplasty or whether this area was directly burred from an incision inside the mouth. Regardless of its origin, the paranasal/medial maxillary process region can be built up using a variety of different material from an inside the mouth approach. (paranasal augmentation) Having built up this area before, it is a highly sensitive areas to augmentation and it only takes a few millimeters to make a very visible difference. Whatever material is used the upper edges need to have fine tapered edges ti avoid any visible external transition areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to know if a paranasal or premaxillary augmentation would help add volume to the area around my nose. Its sunken in and people always tell me I look sad when I’m not sad. Do you do this procedure using an implant? Or do you use rib cartilage?
A: The Asian midface is a common area in which I perform paranasal and premaxillary augmentation. With a genetic predisposition to a more flat facial profile (or even a concave profile), ‘pulling’ the base of the nose out by bony augmentation will certainly add volume to the base of your nose for more midface projection. The usual amount of augmentation is in the range of 6 to 8mms. I have used both implants and rib cartilage for paranasal augmentation depending on the patient’s request. The vast majority of patients opt for implants because it does not require a donor site. The few patients in which I have used rib grafts for midface augmentation is when they were also having rib taken for a rib graft rhinoplasty so they were having a donor site anyway and the paranasal augmentation was a coincidental byproduct of the other procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel like the base of my nose is sunken in and needs to be built up. I know that implants are made for the paranasal area but I just don’t want a piece of synthetic material in me. How else can this be done, injectable fillers, bone grafts etc?
A: Paranasal augmentation is the buildup of the portion of the midface around the base of the nose. It should be differentiated from submalar and premaxillary regions of the midface of which they can often be confused. When considering paranasal augmentation, the most common technique is a preformed synthetic paranasal implant. But an implant is not the only paranasal option. Other choices include injectable materials and an autogenous graft. While there are numerous off-the-shelf synthetic injectable fillers, they all have only a temporary effect. For a permanent injectable material, I would use either hydroxyapatite or HTR granules which can be ‘injected’. This is not done in the typical percutaneous approach through a fine needle. Rather it is done through a small intraoral incision and placed on top of the bone underneath the base of the nostrils. The granules or beads are packed into a syringe but are only injected through the open end of its barrel so it requires an incision and some limited subperiosteal pocket dissection to be injected. These materials are non-resorbable and gets good tissue ingrowth. From an onlay graft option, small rib grafts taken from a very small incision at the bottom of the rib cage will also work well and will not resorb unlike onlay bone grafts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Do you do premaxillary augmentation? I had a lip lift and I lost the subnasale curve so that now the subnasal is pushed in and sits a little behind the pink lip. The curve was removed from the subnasal area which I would like this procedure to put the curve there I would like to augment the area with something other than an implant. I came across this article on premaxillary augmentation and wondered if you can do it this way? Thanks.
A: Premaxillary and/or paranasal augmentation is one of the least implanted of all facial areas. Its ‘need’ is based on some degree of maxillary or low level midface deficiency. It is more common in certain ethnic groups where the maxillary profile is concave to flat rather than convex. Premaxillary augmentation specifically refers an anterior nasal base and anterior nasal spine deficiency. It is the smallest of all facial implants and is made as an off-the-shelf implant by very few manufacturers. Its implant position is unique in that it has a vertical placement at the base of the nose, which makes it more prone to shifting, and the soft tissue coverage between it and the linings of the mouth and nose is thin.
Mersilene mesh is an implant material that has been around for a long time. It is a traditional preformed implant but rather sheets of non-resorbable mesh material (intended for hernia) that it rolled and made into an implant by the surgeon. It finds its greatest use if chin augmentation. Its drawback as a facial implant is that it has no form of its own and must be rolled and cut into a crude-looking implant. However, in the small area of the paranasal/premaxillary region with no complexity to its needed shape, it will work quite well. It does have an advantage in this area as scar tissue will quickly grow into it holding it into place. Mersilene mesh is a very acceptable material for premaxillary augmentation is my experience.
Dr. Barry Eppley
Indianapolis, Indiana