Q: Dr. Eppley, I am interested in paranasal implants…again. I had jaw surgery five years ago which successfully corrected my under bite, but I still have mid-face concavity. I originally sent you pictures a couple of years ago and you said I was a good candidate for this procedure. A little over year ago I had the paranasal implant surgery done locally, but there were about 3 small tears that opened opened up along the incision line, which lead to infection less than 2 weeks after the surgery. The surgeon offered to redo the procedure after 6 months of healing at a discount, but I didn’t have much faith in him after that.
For the implants, we had selected the larger 7mm porous implants, and it completely eliminated the concavity, and it looked good despite the little bit of swelling that remained.
A:Thanks for providing your paranasal implants history. You obviously had Medpor paranasal implants which I don’t like since they have a higher rate of infection due to their porosity. Paranasal implants are unique amongst facial implants because they have the thinnest soft tissue cover over them being right under the lip. Unless one gets a two layer closure over the implants, which includes a good muscle layer, wound breakdown will occur. It sounds like you probably had a combination of both that lead to an early exit of the implants. Whether the 7mm thickness of the paranasal implants is really adequate is unknown because it really takes up to 6 weeks for all the swelling to be gone. But with your history of prior surgery and now scarred tissues, I would not push it beyond that thickness anyway.
Dr. Barry Eppley
Q: Dr. Eppley, my facial problem is that I am very skinny. I have no volume in my face with flat cheekbones. The doctors say my maxilla is also very small and is retrusive by 6mms.has a reduction of 8mm. Even though my body is not skinny, I have talked with surgeons because I want more volume as my face is very flat/skinny. They placed implants in my maxilla on both side of the nose. Even tough my profile is good, my face still looks skinny and I cannot smile because the implants change my smile completely.
I want to remove these implants. I want to have my smile back and more volume in my face, but I’m afraid if I put new ones in, the result will be exactly the same. I want to talk with a new surgeon so I can get a more satisfactory facial profile result. I have attached numerous pictures of my face so you can see my deficient midface profile.
A: Thank you for sending all of your pictures. If I understand your surgical history correctly, you currently have in certain types of midface implants. (malar and paranasal implants – four total implants) You mentioned malar but I wanted to be certain that you also have in paranasal (side of the nose) implants. Paranasal implants would be the culprit of affecting your smile, not the malar implants. Overall facial volume enhancement could be improved by fat injections which would provide a more global effect. Although I would not want to see you remove your existing malar implants as they are undoubtably providing some facial volume effect. I would have to know more about your paranasal implants as the style and size in place may be the problem not just paranasal implants per se.
Dr. Barry Eppley
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
Q: Dr. Eppley, I had mid-face (mid-face rim and paranasal) implants placed last year to address my facial concavity caused by my underbite. Anyway, I’m happy with the results, but I’ve finally decided to get my bite fixed via jaw surgery.
I understand that I will require a CT scan. My question is – would it be possible to ‘erase’ the implants (and their screws) from the scan, or would I have to get these implants removed prior to getting the scan so that they don’t show up?
A: If you are having orthognathic surgery, presumably a LeFort 1 advancement, you would not necessarily need a CT scan. Traditional cephalometric x-rays can be used and the implants would not interfere with assessing the tooth relationships. If one is having their surgery planned by VSP (virtual surgery planning), then a 3D CT would be needed. But the implants can be digitally removed (although that is not really necessary) to make the virtual maxillary advancement and create the splints off of stone models.
For a LeFort 1 advancement, however, the paranasal implants will be in the way and would have to be removed to make the bone cuts. But that could be done as the same time as the LeFort surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I had cheek implants and paranasal implants placed overseas two months ago, but it appears that the ones on the left side have been infected (yellow drainage, mild swelling). My issue is that I do not have the time to get them removed right now. I’m thinking of going to a local doctor to get antibiotics to try and control the infection in the interim. If I do that and wait till year’s end to remove them, will it cause any permanent issues (excessive tissue scarring)?
As for the removal, have you ever had any cases whereby you only removed the infected implants? I understand that this will cause asymmetry, but could I use fillers for the side where the implants were removed to compensate (at least until I get the implants reinserted)?
Finally, would waiting 6 months before reinsertion be enough time for the tissues to heal and for the infection to clear? Or, would you recommend waiting even longer?
Sorry for these questions, but I can’t seem to contact my original surgeon right now, and I was hoping you could just help assuage some of my concerns.
A: This is disappointing that you trusted a doctor to do the surgery and now you can not get a hold of him to answer the most basic of questions when you have a problem that he created.
In short, antibiotics will only keep the problem at bay temporarily with infected cheek implants. Leaving them in, if infected, is just going to cause a lot of scar tissue that could make future surgery problematic. If infected it is in your best interest to have them removed, let it heal and then reinsert 3 to 6 months later. Injectable fillers or fat injections should not be placed into the cheeks after implant removal for a minimum of 6 to 8 weeks after the infection has cleared.
Dr. Barry Eppley
Q: Dr. Eppley, I am 28 year-old Asian make who is very interested in having cosmetic surgery performed for overall facial reshaping. As you offer a wide range of procedures which may be relevant to my goals, I hope to receive advice on the achievability of my goals.
First of all, I am very conscious in photos of the roundness and wideness of my face. (especially when smiling, at which point my cheeks appear very round and prominent) In addition, I would like to reduce the fullness of my lower face and make it thinner.
Secondly, I was wondering if a sliding genioplasty was advisable, as my chin appears to be relatively normal sized. I wish to make my jawline less round, and increase the vertical dimensions of my face to alleviate the aforementioned wideness.
Thirdly, I was wondering if procedures were available to create a more ‘deep-set’ look for my eyes. This, in addition to rhinoplasty to reduce the hump and raise the nose bridge, to reduce the ‘flatness’ of my face in profile.
I realize that not all of my expectations will be realistic nor all procedures advisable, so thanks for your time and expertise in advance.
A: A wide collection of procedures are available for facial reshaping as you are aware. In addressing all four areas of your facial concerns from top to bottom, I can make the following initial comments as they relate to your face.
1) I am now using performed or custom brow bone implants to build up the brow ridges. They can be placed through a limited incision endoscopic technique. That is the most effective way to create a more deep-set look to your eyes.
2) Your rhinoplasty would include a humor reduction, radix augmentation and some slight increased tip projection.
3) Cheekbone narrowing is the only way to provide some reduction in the mid-arch bizygomatic distance of probably 4 to 5mms per side.
4) I would consider paranasal augmentation, I have a new paranasal implant that I am really happy with that can not be felt and adds about 5mms projection to the nasal base.
5) I do think that a vertical lengthening genioplasty (which may have to be widened in a male) will help narrow the jawline. You do not need a horizontal advancement but when opening the vertical distance of the chin it does rotate it back a few millimeters so I would do a small advancement as well.
These are some initial thoughts. Computer imaging needs to be done to see how such facial reshaping procedures would look on you.
Dr. Barry Eppley
Q: Dr. Eppley, Just wondering what i could do about my midface deficiency. I had a cross bite and underbite correct by braces and now feel like I should have had jaw surgery …Just wondering your views on my situation.
A: I could not tell you based on your current pictures alone whether you should or should not have had maxillary advancement and whether that degree of movement forward would have made a noticeable aesthetic improvement. But after having been orthodontically corrected, that is an irrelevant issue now. The more relevant question now is whether any form of midfacial onlay augmentation will create the aesthetic improvement you seek. Paranasal implants do replicate in some ways at the nasal base level what a mild to moderate maxillary advancement would do in terms of horizontal projection. The next relevant question is whether any augmentation above that level (which is not what a maxillary advancement achieves) would also provide aesthetic improvement (malar vs malar-infraorbital augmentation) with the paranasal augmentation. I will do some computer imaging and get that back to you on both paranasal and cheek augmentation. It is a question of whether paranasal implants alone are adequate or whether a more complete mid facial augmentation is a better approach.
Dr. Barry Eppley
Q: Dr. Eppley, I had a LeFort I osteotomy some years ago to help correct my bite, my upper jaw was very recessed. My upper jaw was moved slightly forward and corrected my bite, but it is still a bit recessed gives my midface a sunken look. Also, even though my teeth and bite look really good i do not show enough upper teeth, will the paranasal augmentation alleviate that a bit?
A: While midface augmentation through a variety of bone locations (cheek, infraorbital rim and paranasal regions) can help make the part of the face at or above the LeFort 1 level match and have equal augmentation, they will not create greater upper tooth show. Even though paranasal implants are placed iclose to the upper teeth, its augmentative effect is very unlikely to raise up the upper lip for increased tooth show. If paranasal augmentation is skeletally beneficial there are other ancillary procedures that can help create upper tooth show such as a subnasal lip lift or horizontal internal mucosal upper lip resection done at the high vestibular level.
Dr. Barry Eppley
Q: Dr. Eppley, I have been diagnosed with a mild midface deficiency. I would like to have this corrected to end up with the most aesthetic appearance possible. I have been reading about facial implants and the work you have done with them. I would like to achieve a reduction of the depressions on either side of the nose, reduction of the heavy creases going down to the corners of my mouth and better projections of my face to make it look less wide and flat. In addition I am also interested in lip implants. I already have some lip implants placed. They were the type that look like spaghetti and the size was 4mm top and bottom. I would like to add to these to make my lips bigger. Specifically I would like to show more of the pink lipstick area rather than just make them stick out more. I would also like to bring the implants out to the edges of my mouth to make the lips and mouth appear wider.
A: When it comes to facial implants, there are a lot of facial changes that they can make…and there some changes that they can not. For a mild midface deficiency, consideration can be given to paranasal implants to bring out the base of the nose and anterior submalar implants to provide some upper midface projection. The lower nasolabial folds as they approach the corners of the mouth will not be affected by any bone-based implant. This area is best treated by fat injections.
In regards to the lips, you either have more recent Permalip silicone implants or older style Advanta lip implants. Either way it is not a good idea to double stack lip implants as there will be a great tendencey to have them roll or twist on one another. You may exchange them for the largest 5mm implants but, for the sake of a 1mm increase, that is not likely to make much of a difference. Furthermore, some of the lip changes you desire can not be achieved by lip implants. No implant will increase the vertical height of the vermilion (pink lipstick area) nor will they make the corners of the lip appear fuller or wider, they are too thin in this area. To make these kind of lip changes, you will need to consider a vermilion or lip advancement procedure which directly changes the location of the vermilion…which is what is needed to make the type of lip changes you desire.
Dr. Barry Eppley
Q: Dr. Eppley, I understand that malar and sub-malar facial implants can be used to add volume, 3-dimension and contour to the face. Initially the imaging you provided showed the malar implants only, I think? I am interested to know if the sub-malar implants can be added as well, and more laterally, to camoflauge the slighly hollow buccal area of my face.
Can you please also explain to me the use of paranasal implants? I understand these are largely popular in Asia.
In your opinion, would they assist in the roundening and softening of my face as a whole?
You mentioned the chin augmentation I did may have produced an extreme result, compared to what is actually achievable? Do you think I would notice a measurable reduction in both the width and length of my chin with the sliding genioplasty?
A: What I previously showed was the use of malar implants in your face. The combination of malar and submalar implants is known as malar shells. That would extend the fullness into the underlying buccal space right below the prominence of the cheek bone.
Paranasal implants are designed to add fullness to the base of the nose or push it out further. They are common in Asians because they naturally have a flatter mid face throughout. I can not tell if they would be of benefit to you without looking at picture of your face from different angles, like the side view and the three-quarter or oblique. Midface augmentation in general requires a more 3D type assessment not just a flat 2D picture from the front view.
As for our chin reduction/narrowing, what you had demonstrated was a bit too sharp and extreme which is not surgically possible. But an osseous genioplasty (not a sliding one) can reduce the height of the chin as well as make it more narrow through vertical and midline bone removal.
Dr. Barry Eppley
Q: Dr. Eppley, I just finish reading an interesting piece on your website regarding paranasal implants and premaxillary implants. I am seriously considering having this procedure done you since you seem to be the resident expert in this field. While I am aware the difference between a premaxillary implant versus a paranasal implant, I couldn’t decide which one of the two would I need, or if I need both. I personally felt that my midface is a little flat. I have had rhinoplasty done before with the hope to fix this issue and while it did improve my feature, but not to a point that I satisfied with. I’ve attached a few photo of my profile for your reference. Hopefully after looking at them, you would be able to determine which of the two I need.
A: Paranasal implants and premaxillary implants are very close cousins as they are implants that augment the pyriform aperture area. The front of the pyriform aperture is the premaxilla where the implant is placed across the anterior nasal spine. Its principal effect is to open up the nasolabial angle as it pushes out the upper lip/base of the columella. The sides of the pyriform aperture is below the sidewalls of the nostrils where it joins the cheek skin and is where a paranasal or side of the nose implant has its effect. It builds up the base of the nose by pushing out this area to reduce its concavity. These implants can be used independently or in combination.
With your natural facial profile and shape, a combined parasnasal-premaxillary implant would help complete the effect that you thought you would achieve with your initial rhinoplasty.
Dr. Barry Eppley
Q: Dr. Eppley, I have a question about paranasal implants. May I ask what do you think about fat graft to the sunken paranasal area ( and a malar implant on top)? Will fat grafts ( say inclusive of a few touch ups ) have the same effect as a paranasal implant?
A: Fat grafts by themselves will not have the same effect as paranasal implants. A solid implant on the bone can very effectively push outward on the overlying mid face tissues. (it has a more rigid structure that the tissue that it is designed to displace) Conversely, a fat graft is soft and does not have the same degree of push (augmentation) as a solid implant. The overlying soft tissue has the same structural rigidity as the fat graft so there is some rebound effect and less defined augmentation than one would think. In addition, the retention of a fat graft is unpredictable.
Thus fat injections are not a comparative ‘implant’ to that to a true paranasal implant. For those opposed to the placement of an actual facial implant, fat injections are the only other option and are not unreasonable…it just does not create the same effect as a paranasal implant.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in paranasal implants. I am a young Asian male residing and am looking forward to hearing your experience and expertise in facial deficiencies. I have a slightly retrusive face with deficiency in the maxillary area and slightly in the paranasal area. I am considering doing both procedures. However, I have some questions that I hope you could assist me in answering based on your experience:
1) Can paranasal implants make the nose slightly upturn? ( I’ve seen complaints of such occurrences)
2) Will the paranasal implants cause stiffness when smiling AND change the shape of the upper lip (I’ve seen before and afters and I noticed that the upper lip tend to be thinner). Because even with my slight midface deficiency, everyone says I have a very attractive smile and I am very afraid to risk losing that. ( I would like to change the tired look when NOT smiling but maintain the current smiling face )
3) Will maxillary implant alone reduce the dent in the paranasal area ( beside the nostrils ).
4) Is at grafting and maxillary implant be possible ( and long lasting enough? )
Really hope you could help answer the questions to the best of your knowledge.
A: When it comes to midfacial implants, let me carefully define the terms, paranasal, premaxillary and maxillary implants. These three implant terms are often used almost interchangeably but they are three distinctly different regions and implants for the midface.
A paranasal implant, which wraps around the lower pyriform aperture area, augments the base of the nose under the nostrils only. (also softening some depth of the upper nasolabial fold seen externally) It does not cross under the base of the nose or under the columella or on top of the anterior nasal spine. Thus, a true paranasal implant will not may the nose upturned. Because it is placed on the bone, under the facial musculature, it does not thin out the lips and has a very low risk of any change to one’s smile. (once beyond the temporary swelling and stiffness that typically occurs in the early after surgery period)
A premaxillary implant, often confused with the paranasal implant, goes across the base of the nose under the columella. (to add to the confusion there are combined paranasal-premaxillary implants) Historically such implants have been placed from inside the nostrils, above the bone and directly into the orbicularis muscle of the lip. It is this premaxillary implant that undoubtably gives rises to upturned nose, stiff lips and altered smiles. While a premaxillary implant can be placed right down on the bone and across the anterior nasal spine from inside the mouth, caution must be given to the size of the implant to prevent these nose and lip problems.
A maxillary implant (and one can argue that the paranasal and premaxillary implants are forms of maxillary implants) is an implant that extends beyond the paranasal area across the face of the maxilla and then sits just under the cheek bone. It is a rarely used implant as it has a midfacial volumizing effect between the base of the nose and the cheek prominence.
As you can see by these proper descriptions, it is easy to confuse the effects of these midfacial implants.
Dr. Barry Eppley
Q: Dr. Eppley, I had paranasal implants placed four months ago. Is it possible you could have put one of the implants upside down.?I ask because even since the beginning of healing I can feel around the peripheral of each implant and the shapes are totally different. I have been wondering for a while. I say this because I truly wonder if its upside down. Even I can see that the fleshy higher cheek on the right was improved right next to to the lateral nostril but the fleshy cheek on the left is a lot flatter next to the nostril but then highe up the area comes forward. It is like they one is flipped upside down from the way it looks and feels.
A: I would say that the chances of a paranasal implant being upside down is very unlikely. And I say that for three specific reasons; 1) The shape of the implant has a convex and a concave side to fit into the concave shape of the paranasal region. Trying to make it fit upside down would be very obvious as it wouldn’t lay flat against the bone very well, 2) Each implant has an L (right side) or a reverse L shape (left side). Putting it in upside down would have the L facing the wrong way which would be very obvious, and 3) When placing a small screw to fix the implant to the bone, it is put into the outer flange of the implant and is only 5mms long. If the implant was flipped, its outer flange would be sticking up and the screw would not be long enough to get to the bone.
Having said that, because of the paired nature of facial implants (cheeks, paranasal, jaw angles), slight differences in their positions between the sides can be really obvious. This is particularly true the closer one gets to the facial midline. (paranasals) If the implants are even off a few millimeters up or down or side to side, such differences can be easily seen and felt. That is is the more likely scenario with your paranasal implants than that one has been placed upside down.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in getting cheek and paranasal implants. What is the best procedure to correct a deficient (flat) mid face? I’ve always hated my facial profile. I have attached some photos which I realize probably are not the quality needed for computer imaging but I was hoping you would be able to gauge if and how you might be able to correct my facial features.
A: The photos you have sent show you smiling in both of them so they not only are not useful for computer imaging but have distorted the midface due to the soft tissues changes. Unfortunately if I can’t image them to see the visual change then it is difficult to say such procedures are aesthetically productive…because what ultimately counts is what you think not what I think about the potential facial look change.
Having said that, cheek and paranasal implants are useful for improving the facial profile that has some midface deficiency…which may apply to you but smiling photos pull the soft tissue up (at least on the cheeks) and make them look fuller than they really might be. I can see the paranasal deficiency which smiling actually accentuates rather than improves.
So my incomplete assessment at this point suggests that you may be correct that your midface profile could be improved by these types of implant augmentations.
Dr. Barry Eppley
Q: Dr. Eppley, I am very sorry to disturb you, I live in a remote area of Russia, and my grandson was born with craniofacial distortions of his face and skull. My friend found your contact details in the Internet. I have a few questions to you:
1) Is it possible to enhance at the same time (by one surgery) my grandson’s forehead and back of his head? They are both too flat and the maximum distance between his eyebrow line and the back of the head is 14.7 cm only. By how much is it possible to make this length longer?
2) What should it be done with his medium face? Will it be the treatment by implants, or it is possible to put there human grease/fat?
3) What else could you recommend on him ? We know that he also needs the surgeries on his jaws.
4) How much will it cost us to get the above mentioned treatments ( 1) and 2) points) at your clinic in the USA?
Thank you so much for your reply.
A: Thank you for your inquiry. In looking at your grandson’s pictures, it is clear that he was born with some form of craniofacial deformity, most likely one of the craniosynostoses. (Crouzon’s etc) It also appears based on the scars on his forehead that he may have had some initial efforts at craniofacial surgery when he was younger.
While you did not state his age, he appears to be a mid-teenager at least. I will separate his craniofacial concerns for this discussion into cranial (skull/forehead) and face.
From a skull standpoint he has a short front to back distance typical of many congenital craniosynostoses. He is shorter in the back than in the front in my assessment. The back (occiput) can be augmented significantly (up to 2 cms.) and the forehead smoothed out for a better contour. The most relevant issue here is where is his previous coronal (scalp) incision as that will determine how to approach is skull augmentation reshaping.
From a face standpoint there are two directions to go. Ideally he needs pre- and postsurgical orthodontics and a LeFort I midface advancement with a sliding chin genioplasty. The key there is orthodontic preparation. If this is not possible, the second approach is to camouflage the bony deformities by a combination of orbital, cheek and paranasal implants combined with a sliding genioplasty. (see attached imaging) That could be done at the same time as skull augmentation.
The key in any complex craniofacial problem in a mid- to late adolescent is to identify those craniofacial surgery procedures that are most practical to do that provide the greatest physical and psychological change for the patient.
Dr. Barry Eppley
Q: Dr. Eppley, I had Medpor chin and paranasal implants placed close to 3 weeks ago. The implants were both placed intraorally.However, I still have issues with stiffness and a little difficulty with lip closure. Can I just check whether these issues are normal at this stage of recovery, or is it something I should be worried about? The stiffness in movement is one that concerns me the most, as it does affect my speech a little. Lastly, if this isn’t typical, would removal of these implants be possible?
A: What you are experiencing for these types of facial implants is extremely typical. My experience and what I counsel my patients on before surgery is that to expect the following recovery as it relates to swelling, function and aesthetics…50% by three weeks, 75% by 6 weeks and 100% by three months. Thus you are being way premature to even consider implant removal as you have not gotten yet to see what the final result will be. Your perception of what you thought your recovery would be is undoubtably much less than that and this accounts for your concern at this early recovery point. Patients understandably do not appreciate that this is, in essence, very similar to bone surgery even though it is done for aesthetic purposes.
Dr. Barry Eppley
Q: Dr. Eppley, I’m considering cheek implants to address the following problem. I have a wide round face with a flat midface and I want to avoid implants that make my face look wider or rounder. Should I go for malars without edges (so ones that only address the cheekbone) what part of the cheek contributes the most at creating forward projection? My main goal is to achieve a less wide face with more projection. Thank you so much!
A: When it comes to increasing midface projection without making the face wider, all implants have to remain inside of a vertical line drawn down from outside of the lateral orbital rim. This means the options of using orbital rim implants with small malar extensions relegated to the anterior cheekbone surface, paranasal, and premaxillary implants. These are the implants that can increase midfacial projection without creating width.
Dr. Barry Eppley
Q: Dr. Eppley, I had my upper and lower jaw advancement done 7 months ago and was not too happy with the results. I recently had chin and jaw implants together with a rhinoplasty done. I have also had some facial fillers placed under the lower eyelids and on the upper cheeks. Regardless, I still feel like my mid-face is flat and would like to know what can be done (if any) to make it more convex.
A: While I do not have the advantage of seeing any pictures of your face, I will assume by your description that you have either a malar or a combined orbito-malar skeletal deficiency from an aesthetic standpoint. This may or may not include a maxillary-paranasal deficiency as well although your recent maxillary advancement surgery may have improved that concern. Knowing which of these areas needs augmented is obviously important. But for the sake of completeness let me review all three areas.
Cheek implants are probably very familiar to you but there are four basic styles to consider that augment different areas of the cheek. To improve facial convexity, the cheek implant must provide anterolateral projection, with more anterior than lateral. This can be placed through the mouth like most traditional cheek implants. If a concomitant infraorbital deficiency exists, an orbito-malar implant can be used which is placed through a lower eyelid (blepharoplasty) incision. When a deficiency around the nasal base exists, paranasal or a premaxillary implant can be used. The difference is that one pushes out the base of the nose on the sides (paranasal) while the other pushes on the base of the columella (premaxillary) to open up the nasolabial angle.
Without seeing pictures, I could not tell you which type of midfacial implant(s) would be appropriate for you.
Dr. Barry Eppley
Q: Dr. Eppley, I feel my cheeks are a bit large so want to reduce their appearance as well as my upper outer brow bone. From the side my eyes look sunken, not for the front though. I feel that maybe reducing the brow and cheek bone would make eyes stand out and not seem so deep set from side view. However, I also have hollowness on direct sides of nose by nostril and have tried filler but it didn’t help. I also like my nose profile but from front, it looks wide around the tip so also looking into narrowing it from front view. Thank you for your help!
A: In looking at your pictures. I would not disagree with your contention about altering the bone to try and open up the eye area. There are two fundamental approaches to doing it. One option is a tail of the brow reduction through an upper eyelid incision combined with intraoral cheek reduction either done by burring or an anterior body zygomatic osteotomy. The second approach is a coronal incisional approach for lateral brow, lateral orbital and zygomatic reduction. (I think this approach is more than you need) From a nose standpoint you are describing two nasal issue, a paranasal deficiency and a broad nasal tip. Your nose concerns could be addressed by paranasal implants (placed through the same incision as for the cheek reduction) and a closed rhinoplasty for tip (dome) narrowing.
Dr. Barry Eppley
Q: Dr. Eppley, I have a question related to my paranasal implants. from Korea. Five months ago I had this augmentation but now I am disappointed with the result. I start to have awkward smile and a much longer upper lip. But because I have a sunken nose base, I do need the augmentation. In short, I am planning to remove the paranasal implant and change to a new one. I am wondering if I want to have an improved result whether I need to do these procedures separately (6months or so after removing current implant then add a new one) or can I do these two procedures together in one single surgery. It would be much easier for me to have only one surgery. But I am really worried that if I do so (removing and changing the implants at one time), that the swelling during the surgery might affect the doctor’s aesthetic decision for the new implant. Besides I am also worried that if I have only one surgery, whether it is possible the new implant would be much more likely to change its position on my face in future. Do you have any suggestion for my problem?
A: To provide a very specific answer, it would be helpful to know what type of paranasal implants these were, what was their shape and how were they placed. (through the mouth and and on the bone around the pyriform apertures or placed through the nose in the soft tissue of the nasal base) One of the advantages of having existing implants in place is now you know the result they create. That provides valuable information as to how to change them for an improved result. The existing problems with your current paranasal implants could be their size, shape, and/or anatomic location. The change should be predictable before surgery, not during the procedure. Therefore, there should be no problem removing and replacing them during the same procedure. I see no advantage to a staged procedure. In fact, I would find that actually counterproductive. Knowing what didn’t work well is a good guide to improving it.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in getting paranasal/premaxillary implant to build out my nose area. I have a few questions/concerns with these implants.
1. Will the implants cause my nostrils to show more, less or the same from front and side views? I don’t want a pig snout. I think my nostrils show too much already since my rhinoplasty so I don’t want it to get worse.
2. Will the implants cause my upper teeth to show less?
3. Approximately how long will my face be swollen and bruised?
4. Will the implant show bulky or any bulges under my skin?
5. Can you fix the area under my lower lip between the chin and lower lip to not look like it is pushed in? It’s hard to tell on the pictures, but having some teeth removed prior to orthodontics has made my lower lip look pushed in and my chin come down with smiling which you said you could fix. Is there a filler or implant I can use to get that projection instead of the dent/depression I have under my lower lip?
A: In answer to your questions about parasnasal or premaxillary implants,
1) I don’t believe it will change your nostrils to any significant degree. I am assuming when you mean nostril show that you mean the tip of the nose would move upward thus exposing more nostril show. This will not happen.
2) There should be no impact on your upper tooth show. In other words, it doesn’t lift or shorten the upper lip.
3) There will be some swelling that show largely be gone by three weeks after surgery. I have never seen any bruising with paranasal or premaxillary implants.
4) The implant will not have any visible edges. The nasal base/midfacial tissues are too think to ever show an implant edge.
5) I believe you are referring to the depth of what is known as the labiomental sulcus or crease, which is the groove between the lower lip and chin. This is best softened in depth by the placement of a subcutaneous implant (Permalip) made just for that type of augmentation.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in paranasal implants. I am not sure whether I’d be better served by a permanent filler or an implant. I had my nose done along with a lip lift about 3 years ago. I’m very happy with the positive change it affected, but the base of my nose is retruded, and so my mouth protrudes. I also think it would look a bit nicer if my nasal tip had more projection. Would I achieve the same volume increase and tip projection with a permanent filler as I would with an implant? Also- if I had paranasal implants how long would it take for the swelling to subside and would this affect my smile?
A: The simple answer based on not seeing you is that implants would be far superior. Besides the fact that there are no permanent fillers, they can not create the same degree of nasal base/columellar base push that paranasal or a premaxillary implant can. There really is no comparison when judged by long-term result and cost efficiency.
Significant swelling would be about three weeks. Your smile will feel a little stiff but should return to normal by 6 weeks after surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I am 49 years old and am interested in the LeFort 1 procedure. Please see attached photos and give me your advise, I had brace work done twenty years ago because my top teeth were behind my lower front teeth. I think a LeFort 1 procedure would have been more appropriate. Can it be done now? Please advise me as to what surgery would give me a more attractive face.
A: Thank you for sending your photos. What they demonstrate is that you have a midfacial hypoplasia and you are correct in that a LeFort I advancement done years ago would have been better for facial balance and midfacial fullness. But doing it now is not possible because it will change the way your teeth meet. This is why LeFort surgery and orthognathic surgery in general is done in conjunction with orthodontics. I have done them in patients your age and older but only if they were edentulous and wore dentures as new dentures are relatively easy to make.
What you can do now is camouflage your midfacial hypoplasia with paranasal/premaxillary facial implants to bring the base of the nose and the central maxilla more forward. This can be demonstrated with computer imaging.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in creating a more symmetrical look to my face via fillers and eventually implants. As a result of my jaw being asymmetrical, the right side of my lower face appears fuller and more defined than the left. Additionally, my upper jaw is recessed. I have consulted with oral surgeons but none believe my problems are severe enough to warrant jaw surgery as my jaw is fully functional. What do you recommend?
A: The use of injectable fillers does have a role in facial reshaping/contouring but it is more limited than most patients appreciate. Because of the volumes of fillers needed to create visible facial contour changes and their temporary effects, the use of fillers must be done judiciously. For lower jaw asymmetry, and particularly for midfacial flattening, injectable fillers have very little role to play in a long term improvement strategy. Lower jaw asymmetry is often the result of a smaller jawline or mandible on one side. That is best addressed with the consideration of a jaw angle implant. Midfacial flattening, particularly done at the upper jaw level (maxilla, LeFort 1 region), needs horizontal volume augmentation. This is best done with either paranasal, premaxillary or both types of lower level midfacial implants. These would be far more effective than any type of synthetic filler injections.
Dr. Barry Eppley
Q: I have read that paranasal implants can be done in local anesthesia. Is this right? Is local anesthesia possible also with malar implants which are placed right next to paranasal implants? Does not the lifting of the periosteum from the bone hurt in spite of the local anesthesia? Thank you very much for your information.
A: Cheek and paranasal implants are placed from an incision inside the upper lip. Besides the mucosal incision, muscles and the periosteum covering the maxillary and zygomatic bone must be lifted up and a pocket made to place the implants. Given the proximity of the paranasal area to the upper lip compared to the cheek area, it would be ‘easier’ to position paranasal implants under local anesthesia as opposed to cheek implants where greater dissection is needed and the feeling in this area has more contributing nerve endings. You are correct in that it is the periosteum that is the most sensitive part of the surgical dissection. I also prefer to us screw fixation for the implants that I place in the midface which can cause more discomfort from the bone drilling.
While just about any surgery can be done under local anesthesia, I am not sure if I was a patient that I would ever do it that way. (particularly cheek implants) Unless there is some compelling medical reason why IV or general anesthesia could not be used, it would be more comfortable and slightly less costly to use some form of anesthesia for this type of facial implant surgery.
Dr. Barry Eppley
Q: I had Medpor implants placed in the paranasal area several years ago in 2007. It appears that I will be undergoing a LeFort I osteotomy in future. I was wondering whether these implants need to be removed for this procedure and how difficult is it to do so?
A: Paranasal implants are placed around the curve of the pyriform aperture to add fullness under the nostril base of the nose. They help push out the base of the nostrils and are most commonly used to augment a midface deficiency. They are made out of different materials of which Medpor is one of them. This porous material does allow for tissue ingrowth which makes it more difficult to remove than that of silicone, for example. But they can still be removed without a lot of tissue destruction to do so.
A LeFort I osteotomy makes a bone cut directly across the pyriform aperture area. Advancing the upper jaw at this level creates midface fullness, particularly in the paranasal and anterior nasal spine area. (base of the nose) It would be absolutely necessary to remove paranasal implants when performing this procedure. The fullness created by moving the upper jaw at this level makes the need for paranasal implants after bone repositioning as irrelevant.
Dr. Barry Eppley
Q: Do paranasal implants any effect on the length of the upper lip? Do they lengthen the upper lip, what is common with premaxillary implants, or do the paranasal implants rather lift the upper lip a little bit? In one of your You Tube videos about Advanta PTFE facial implants you soaked these implants in an antibiotic solution before they are implanted. Would you similarly dip the Medpor implants in a antibiotic solution also? I noticed that you use both implant materials – silicone and Medpor – and you obviously know the advantages and disadvantages of both very well. I personally would prefer the Medpor implants because they permit tissue ingrowth. But I often hear that Medpor implants are virtually unremovable once they are incorporated. Have you ever removed an incorporated Medpor implant? Is it true that it is extremely difficult to separate the periosteum from the surface of an incorporated Medpor implant?
A: Paranasal implants will not lengthen or push the lip down like a premaxillary implant. Neither will they lift the upper lip either. They merely provide fullness to the nasal base.
I soak all implanted materials in an antibiotic solution. This is particularly valuable in porous implants where bacteria can become trapped into the pores of the implant and not easily washed or rubbed off. The porous nature of the Medpor material also allows an antibiotic solution to be impregnated into the implant with vacuum infiltration or prolonged soaking.
Tissue incorporation into a facial implant is a two-edged sword. It has a benefit of providing anchoring of the implant to the bone site through tissue fixationalthough that advantage can be gained by screw fixation at the time of placement. Removal is definitely more difficult but by no means impossible, particularly for a small anteriorly located implant under the nose. It is more tedious and more tissue disruption must be done to get them out but it is not that difficult.
Dr. Barry Eppley
Q : I’m interested in having paranasal implants and I noticed that you have experience in using these implants. Could you please tell me how exactly these implants effect the nose and the upper lip? Does this implant usually widen the alar base of the nose? Does it lift the tip of the nose, which is common in LeFort I osteotomies? Is the upper lip lifted by these implants or is the upper lip seemingly becoming smaller, because of the new relation between the new volume around the nose and the volume of the upper lip? How does it usually effect the nasolabial angle and how does the upper lip change in the profile view? Are there slightly different ways to place the paranasal implants, for example to place the implants closer together towards the spina nasalis anterior or a little bit more apart from each other? I talked to another plastic surgeon and he said they had the same effects on the nose as the LeFort 1 advancement, but I´m not sure if this is correct, because the position of the spina nasalis anterior is usually changed by performing a LeFort I osteotomy. However, by placing the paranasal implants the position of the spina nasalis anterior stays the same. Also the upper teeth stay in the same position and I wonder what effect this might have on the upper lip.
A: Paranasal implants are placed at the base of the ala along the perimeter of the pyriform aperture. They help fill out the paranasal area but will not create the same effect as LeFort I osteotomy. To do so they have to be combined with a premaxillary implant which sits in front of the anterior nasal spine. They have no significant effect on the size, shape, or position of the upper lip or the nasolabial angle.
For central midface deficiency they can help ‘pull the face forward’ when used in conjunction with cheek implants. They add fullness to the nasal base but will not change nasal tip projection. Over the years, the greatest use of them in my Indianapolis plastic surgery practice is in unilateral cleft lip and palate to help build out the upper alveolar and nasal base deficiency.
Dr. Barry Eppley