Your Questions

Q: Dr. Eppley, I’m looking to get augmentation to the base of the nose (the area directly below the bridge/nostrils) to ‘rotate/push’ it forward as seen in the picture. (per maxillary augmentation) I’ve seen pictures of paranasal and peri-pyriform implants, but those involve augmentation of the sides of the nose, and that’s not something I do not want.

Can I check if my aesthetic goals are possible, and if so, what options are available for doing so? I understand that you do custom designed implants, but are there any off the shelf alternatives to those? 

Additionally, could fillers be used in the interim to simulate what an implant would do? This is something I would like to consider to see if I would like the augmentation before proceeding with a more permanent implant.

Thank you!

A: First, what you are trying to augment is the nasolabial angle or the nasocolumellar-upper lip junction. This is more commonly referred to as the central premaxillary region or the anterior nasal spine specifically. This has been done fro decades using a wide range of materials from autogenous materials like cartilage and bone to allogeneic materials like irradiated cartilage to a wide range of synthetic msterials. (e.g., Gore-tex, mersilene mesh, silicone implants) They all can work in such a small area. There would certainly be no reason to make a custom implant for this small areas. Whatever the implant material would be it would be ‘custom made’ or hand fashioned at the time of surgery out of any of these materials.

You can certainly test the benefits of premaxillary augmentation by using any of the injectable fillers. They may not create exactly the effects of any implant material which would have more of a push on the overlying soft tissues than softer injectable filler materials.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I understand that you are the inventor of the Brink Peri-Pyriform implant. I am writing you to inform you that this implant improved my speech and my life. I am American-born Chinese, and English is my native language. However, until I had the Peri-Pyriform implant put in, I always had a significant amount of difficulty speaking fluently and clearly.

All of my life, people have often told me that they could not hear, or make out, what I was saying, or that it seemed like I spoke with an “Asian American accent.” Several years ago, I noticed that words containing “ch”, “sh”, “j”, “zh”, “n”, and “r” sounds were especially difficult for me to articulate. I also began to notice that many other Asian people, both native and non-native English speakers, also exhibited these speech characteristics to varying degrees. Furthermore, as I am sure you already know, Asians typically have shorter head lengths than do people of other races.

This led me to a theory: In Asians whose head lengths are particularly short, separation between the upper lip and the premaxilla impairs articulation of the speech sounds “ch”, “sh”, “j”, “zh”, “n”, and “r”, and this, in turn, impairs significantly the articulation of words and sentences containing these sounds in English and French, and possibly in other phonetically similar languages.

Shortly after coming up with this theory, I had premaxillary augmentation surgery using the Peri-Pyriform implant. Immediately after the surgery, my articulation of those sounds was improved, as well as my clarity in speaking.I had always been very quiet. Now that I can speak more fluently and clearly, I am less shy about speaking, and I have a much happier disposition. Hopefully, others like me will also be able to benefit from the Peri-Pyriform implant.

A: Thank you for your relaying your experience with implant augmentation of the pyriform aperture region. I have to confess that I did not do the original design of the implant, that credit goes to Dr. Brink as indicated in the implant product’s name/description. I do have a lot of experience with this facial implant, however, and most of that is in Asian patients for the facial shape reasons you have described.

Of all the potential benefits of a Peri-Pyriform implant, speech improvement is not one I have ever heard of or could envision occurring. Your anatomic explanation/theory sounds perfectly plausible however as it can cause greater upper lip projection, particularly at the nasolabial area. That may improve upper lip contact with the lower lip which may help in articulation with certain sounds.

Regardless of how it may have helped, you are living proof that it indeed has. I could not be more happier for you that such a simple facial procedure could have been so helpful.

Thanks again for taking the time to share your most fascinating facial implant experience,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, over a decade ago I approached a surgeon as my upper lip did not raise well when smiling and my appearance was edentulous and a little tight when I smiled. Rather than the more typical bull horn type sub nasal lip lift procedure, the surgeon performed an operation that he designed to raise the complete base of my nose and debulk the premaxillary area. He did this by taking a full thickness crescent of skin from the floor inside the nasal vestibule of each nostril as well as segment of the nasal spine lifting the nasal base and sill into the deficit on closure which also closed the naso labial angle. By lifting the nasal base the columella was slightly rotated  inward. This left me with a flatter lip which gives the impression of being overly long rather than shortened. I understand that the current wisdom is that this is not surprising. For some reason it also left me with difficulties in balancing the facial expressions involving the central elevator muscles which seem unrestrained or supported seemingly due to the missing bulk of the premaxillary soft tissue. The result has been a hyperactivity of the depressor alae or alae nasalis pulling my nasal base and lip downwards (see attached pic) and my impression is that this is in compensatory opposing the levator labii muscle or alaequa nasi. I had Restylane injected into the premaxillary area some time ago which very temporarily helped moved the central lip forward rather than downwards looking noticeably odd. I believe that the original incision needs releasing to allow the nasal labial angle to fall back into place for the best function and cosmetically (ie a de-rotation). I am unsure how to proceed or better describe the subjective problems I have and any advice or help would be welcome. If I were to describe this in more approachable terms I am trying to lower the base of my nose to its previous position by nasal spine augmentation and soft tissue repositioning / release.
I have attached some pictures pre- and post- op which demonstrate the difficulty I have in expression and smiling. I am hoping that you might be able to offer operative help or advice.

A: Certainly the operation you had done was unusual and predictably problematic. The question now, however, is how to reverse its effects. The fundamental problem appears to be a scar contracture/tissue loss at the nasal base/spine area. I would agree that the original incision and underneath it need releasing but that alone would not be adequate as it would just scar back done. It would need to be filled/augmented (premaxillary augmentation) and that is probably best done by a dermal-fat graft not an implant. You need biologic tissue that can fill the released space and not just turn into hard scar. You could do the same thing with injectable fat grafting but it would take several injection sessions to achieve a good release and tissue fill. This is better done by an open approach and en bloc tissue grafting

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, This is for the nasal sill area and I am specifically interested in the cartilage injections to augment the sills which were removed in a bullhorn liplift. Will the injectable cartilage work for this indication? I would like to take care of that first since it can be done under local. What would be the price for cartilage injection in the sill area?

 The other procedure for premax augmentation don’t you also use mersilene mesh to augment that area or do you just use rib? I think rib might be better anyway except I would be afraid of warping.

A: If your goal is to try and stretch out skin in the nostril sill area, I don’t think this will work with any form of subcutaneous augmentation. It may provide a push but I can’t see how that will make up for lost skin along the nostril sill. In addition, placing injectable cartilage can not be done under local anesthesia. While the injections could be done under local, the cartilage must be harvested usually from the nasal septum which is not a local procedure. One simple way to easily prove whether an injectable approach will worko is to first have a temporary filler like Juevderm or Radiesse injected and see if that works. If it is successful then you can move forward with injecting cartilage.

Mersilene mesh can certainly be used for premaxillary augmentation just as rib can. I would have no concerns about rib warping as that is a function of how it is harvested so it is easy problem to avoid in an enbloc augmentation application.

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

Q:  I am an Asian male and I have a retracted columella and a slightly acute nasolabial angle (I’d estimate it to be roughly 85 degrees).  I have read that it is possible to use cartilage (either from the septum or the ear) and fill in the area of the columella to increase the nasolabial angle.  I have also done research and found that a subnasal lip lift can correct the nasolabial angle as well.  I don’t want anything else done but to have the base of the columella fixed. How do you recommend it to be done?

A: Correction of the too acute nasolabial angle can be done by directly addressing the source of the problem. The nasolabial angle is effected by numerous anatomic factors but the angulation of the causal end of the septum and the anterior nasal spine most directly influence it. I am not aware that a subnasal lip lift can change the nasolabial angle to any great degree and that would not be an option unless one had a long upper lip concern also. Correction should be directed towards modifying the underlying osteocartilaginous foundation. Cartilage grafts can be used to buildup the base of the caudal septum. But attaching grafts in an end-to-end manner to the end of the septum has them being unstable and to wiggle back and forth. To be stable they have to be placed as a bilayer with the septum in the middle of the ‘sandwich’. A  more stable method is to  augment the anterior nasal spine, also known as premaxillary augmentation. Cartilage grafts and synthetic implants can be used but I find that a dermal graft is the best graft in the long-term for this area. That can be placed through an intraoral incision under the upper lip above the frenum.

Dr. Barry Eppley

Indianapolis, Indiana