Q: Dr. Eppley, I have a recessed premaxilla even after jaw surgery, and I’m looking to ‘rotate” the base of my nose forward as per the image without increasing the volume at the side of my nose. Just wondering, does such an implant exist, and if not, how much will it cost to have it custom made?
A: What you are looking to do is increase the projection of the anterior-inferior portion of the pyriform aperture area, known as the premaxilla. There is, as you may know, a facial implant known as a peri-pyriform implant. This is really a combined premaxillary-paranasal implant. One could either remove the paranasal portion of the existing off-the shelf implant, hand carve the exact design from a carving block or have a custom premaxillary implant made. It is really all about how much projection (thickness) that the implant needs to have.
The premaxillary implant is placed through an intraoral incision across the lower edge of the pyriform aperture and across the anterior nasal spine of the maxilla in the midline. I would place two micros crews on each small wing of the premaxillary implant to ensure its positional stabilization after surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a combination of procedures including:
1. Brow bone implant augmentation using a custom made brow bone implant and possibly forehead augmentation as well. As you can see from the attached pictures this area of my face lacks definition. i would like a more masculine look. I had upper eyelid surgery done some six years ago. Unfortunately that was a botched operation, the surgeon operating on me sliced off too much of my left eyelid which has left the eye about half way to a third open when I close my eyes. The left eye is wider than the right when open. I was wondering, since the brow augmentation is performed around this area, would this type of surgery cause my eyes,particularly the left one to open further, thereby leaving the eye completely open when shut or when i am asleep? I guess implanting around this area is bound to pull the upper eyelid area upwards and pressure on the tissue surrounding that area.. I would not consider going ahead with brow bone implant augmentation if this is the case. Your opinion on this is greatly appreciated
2. Lip reduction to lower and upper lips. Just minor reduction to counter drooping which I notice and is probably due to me getting on in age. When at rest I can see the pink of my inner lips showing.
3. Alar base reduction in combination with Weir incisions to reduce nasal side walls and inner nostrils as well. When I smile my nostril flare excessively which bothers me, so I refrain from smiling as much as I can.
4. Finally I would like to raise/heighten my dorsal bridge as well as trim the bony area along the bridge to give definition. In addition I would like the bulbous nasal tip defatted if this is something you can do. Again, I just a subtle change as I do not want it looking to pointy.
5. I have had previous rhinoplasty with a premaxillary implant inserted below nasal base and I want to remove this.
Are these procedures you can do? Can you perform these procedures at the same time? Have you any experience performing all the procedures i have mentioned above on ethnic people like me?
A: Thank you for your inquiry and sending all of your pictures. In answer to your procedural questions:
- When it comes to a brow bone implant it is critically important that the decision for total forehead augmentation be considered using computer imaging. That has to be factored into the implant design. With the slope of your forehead I suspect brow bone augmentation only may only make the forehead look more inclined backward. As for the effect on the eyes, I have not really seen much effect on the eyelid position. If anyway I would think it would push the eyelids down lower and not pulled upward.
- Lip reduction almost produces less of a lip reduction effect than most patients want. So a more subtle lip reduction effect is the more likely one to be achieved as opposed to too much of a reduction.
- Reduction of nostril width changes the outer location of the nostril but has no effect on the inner nostril along the midline columella.
- The height of the nasal bridge can be raised and this can be done by either an implant or a rib graft. Since you may already being having a brow bone-forehead implant, I suspect the implant option would be more appealing. Reducing a bulbous tip in thick-skinned men always produces more of a subtle change and never a dramatic or a pointy one.
- The premaxillary implant can be easily removed.
All of these procedures can be done at the same time (custom forehead implant, rhinoplasty, lip reduction and premaxillary implant removal) The only thing ‘ethnic’ about your procedures is that of the nose and I have done many such ethnic rhinoplasties.
Dr. Barry Eppley
Q: Dr. Eppley, I saw a topic on premaxillary implants on your website and I am really interested in it. I am wondering whether this can be done separately with & before my revision rhinoplasty? In fact, the result I’m trying to achieve as a before-after is in the first attachment (not the second one, that is just an over exaggerated example). I have consulted one plastic surgeron but he seems to be working primarily on the “nose” itself instead of the surrounding area(s). I am trying to get a bigger nose, and more precisely speaking, I think the reason my last rhinoplasty was failed was because the doctor doesn’t know this internal area; he was trying to achieve the result just by pulling the nose itself outward which is laborious to the skin itself.
A: Premaxillary implants have been around for years and were initially developed to open up an obtuse or recessed nasolabial angle. (as your first illustration image demonstrates albeit extremely so…this must be a photoshopped image not an actual surgical result) There were developed to be used in conjunction with rhinoplasty surgery and were inserted into the subcutaneous space through an intranasal incision.
As the technique of premaxillary augmentation has evolved, it is clear it needs to be placed on the bone in a subperiosteal location. This is well below the lip muscles and soft tissue so as to not interfere with lip and mouth movement. (otherwise it can cause a blocking effect to the lip when one smiles) This also gives the opportunity to create more of a ‘LeFort I’ or maxillary advancement effect to the base of the nose if the implant design and size is sufficient.
Dr. Barry Eppley
Q: Dr. Eppley, I had a rhinoplasty done about a year ago to extend and derotate my tip and columnella. In the process I also had a premaxillary implant which was inserted in the nasal spine area through an incision through the inside of my upper lip. All of these were rib cartilages.
Whatever the cause, my smile has been warped for the worst. Before surgery, when I smiled, my upper lip used to be mobile, flip up, and thick and my columnella and tip would also droop down resulting in a nice natural smile that wasn’t tense. Now my smile is frozen looking. My upper lip is thin, tense and my nose tip and columnellar are also wooden looking and do not move with my smile the way it used to. It looks off and disturbing according to many of my friends. I am very upset with this. Is this my tip and columnella rib work that is doing this or is it a result of my premaxillary graft? I would certainly like to remove my premax graft if this will fix my smile. Thank you very much.
A: When you add a lot of rib cartilage grafts to the tip of the nose and the underlying pyriform aperture/nasal spine area, there is the possibility of stiffening how the upper lip moves. While it is possible that it is the combination of the effects of all the cartilage grafts (I have no idea as to teh details of where they were placed exactly and their size), the most likely culprit is the premaxillary graft. Its removal would be a good place to start and would also not affect to any significant degree the rhinoplasty result. Whether it will produce a complete normalization of your smile can not be predicted and it is not known if that could ever be achieved even with removal of all of the rib cartilage grafts.
Dr. Barry Eppley
Q: Dr. Eppley, I am trying to find solutions to reconstruct my face after permanent teeth extracted for braces. I have attached some photographs. hope it helps. What I want to achieve is more fullness and proyection to my face, like I used to have before the extractions. If you can give me any suggestion I’ll appreciate it.
A: Thank you for sending your pictures. Knowing that you probably had your maxillary bicuspids extracted for orthodontics would indicate that you have some paranasal flattening and even some premaxillary deprojection as well as a more obtuse nasolabial angle. All of this would have resulted from pulling the anterior maxilla back into the extraction spaces. That could be improved by the placement of a combined premaxillary-paranasal implant, adding about 5 to 7ms anterior projection of the maxilla and the base of the nose, thus pulling this middle part of the face forward.
Dr. Barry Eppley
Q: Dr. Eppley, There is no much information out there on paranasal implants. You are such treasure trove of knowledge so I will ask you this question. Someone on realself asked me whether my paranasal implants were uncomfortable, and I told her that they aren’t. This got me wondering, what exactly is the difference between a paranasal and premaxillary implant? Is the reason why my paranasal implants feel comfortable because they don’t sit on the nasal base?
A: Paranasal implants sit on the side of the nose under the nostrils along the side of the bony pyriform apertures. A premaxillary implant goes across the base of the nose under the columella and below the bony anterior nasal spine. In some cases a premaxillary implant can include the paranasal area as well or can be limited to just under the anterior nasal spine area. If properly placed at the bone level and not oversized, a premaxillary implant should be no more uncomfortable than paranasal implants. Premaxillary implants are placed by some surgeons through the nose into the soft tissues above the bone, potentially creating abnormal fullness and stiffness of the upper lip when smiling. This is not my recommended tissue location for a premaxillary implant.
Dr. Barry Eppley
Q: Dr. Eppley, Can a combination premaxillary implant and paranasal implant be done?
A: A premaxillary implant is different that a paranasal implant as your question implies. A premaxillary implant goes under the base of the nose in front of the anterior nasal spine. It opens up the nasolabial angle and provides some augmentation of the upper lip. Paranasal implants are different in that they go along the side of the nose to add volume to the flatter or more deficient midface or maxilla. This is above the alveolar level and to the side of the nose. Both implants are used for similar overall facial profile indications…for the patient with a flatter or retrusive midface. These implants actually exist most commonly in silicone are are done as a combined premaxillary and paranasal implant known as the peri-pyriform implant. It can be used to wrap around the entire nasal based or can be cut to be used as separate premaxillary and paranasal implants.
Dr. Barry Eppley
Q: Dear Dr. Eppley, I had a submaxillary Gore-Tex implant placed at the same time as a rhinoplasty over fifteen years ago. It was done to elevate the area below my nose to improve the shape of the angle between my lip and nose. Later it was determined by an oral surgeon that I needed upper jaw surgery but that would be extremely difficult as this implant sticks to the bone and therefore he would not operate on me. I can live with all of the above; however, this implant is annoying as on the right side it continues to dig down into my right upper gum area. I have been told that this type of implant can be very difficult to remove and that it would be best to just leave it alone. What is your opinion on getting it removed?
A: To clarify the issues in regards to your Gore-tex facial implant, here is what I think:
1) To be exact, it is a premaxillary implant not a submaxillary implant. Because it is Gore-Tex and placed during a rhinoplasty, it was inserted through a nostril base incision initially. It was done to open up the nasolabial angle.
2) Gore-tex does not adhere to the bone and is the one of the least ‘sticky’ implants to remove. It is smooth and the body places a capsule around it.
3) Because it was placed long ago, it is likely a multi-stranded Gore-tex implant rather than a solid one-piece implant composition. This makes it a little more difficult to remove but certainly far from impossible.
4) Your premaxillary implant can be removed through an incision inside the mouth as that is just as close as going through a nasal base incision.
Dr. Barry Eppley
Q: I went in for a rhinoplasty consultation and, during the course of discussion, the plastic surgeon brought up the idea of combining it with a premaxillary implant. I had never heard of that type of facial implant before. I can understand that it pushes out the base of the nose but I am concerned as to what it may due to my upper lip. Does a premaxillary implant change the appearance of the upper lip in any way?
A: The premaxillary implant is one of the uncommonly used of all the facial implants. The benefit of its use comes when one’s facial profile or midface is a little recessed or retruded. With this facial skeletal pattern, the nasolabial angle is usually too acute (less than 90 degrees) and contributes to a hanging or downturned nasal tip appearance. Bringing out the nasal base can be aesthetically helpful in midfacial hypoplasia whether one is having a rhinoplasty or not. The premaxillary implant builds out the paranasal and the anterior nasal spine area using an implant which spans across the entire lower pyriform aperture region. (nasal base) This will usually result in a very mild vertical lip lengthening although that will not occur in everyone based on their anatomy. At the least, it will cause the upper part of the lip to be more full/protrusive. This will also change the nasolabial angle, the angle between the columella of the nose and the upper lip, which is the primary objective of this type of facial implant.
Dr. Barry Eppley