Q: Dr. Eppley, I have quite significant nasal deviation and also maxillary retrusion from unilateral cleft lip and palate. To create fullness in that area I have inquired about orthognathic surgery and was told that the removal of teeth when I was younger makes that almost impossible. I was wondering if theoretically it is possible to put premaxillary implants in with a deviated septum that needs correcting. Does the premaxillary implants stabilize the septum?
A: When a Lefort I or maxillary advancement is not possible, onlay facial implants can provide a similar aesthetic effect. (with the exception of the effect on the upper lip by the anterior tooth movement) Midface augmentation could include premaxillary, paranasal, maxillary and/or cheek augmentation. These are all different types of facial implants to augment various areas of the midface. An entire custom midface implant can also be made from a 3D CT scan. Placing any of these implants is not influenced by any form of septal correction. Septal straightening is needed in every cleft patients and how it is straigthened and its stability is not changed or influenced if a premaxillary implant is done at the same time.
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’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 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 had implants for submalar augmentation placed through mouth on September 2nd and then had them removed one month later. I also had a small premaxillary implant put in through the nose. I removed them because they were too big and the premaxillary implant changed the way my nose looked. The implants have been out for one week. I know that some of the undesirable effects were swelling and that I didn’t give them a real chance. But the anxiety they were causing me on a daily basis was too much. I can’t find any information as to why my nose looks different still after removal, it is wider and the nostrils look rounder and slightly more upturned. Is it possible it won’t go back to pre op look? Could scar tissue have formed that quickly or is it just swelling and if so when should I expect it to truly resolve. The cheeks and lower face are still very swollen also, will this eventually return to pre op look also given that they were in and out so quickly? When can I expect to look like me again? My muscles are a bit tight but overall seem to be functioning without any issues to the nerves and I can smile. Thanks and I look forward to your response.
A: Certainly one week after implant removal, there will be residual swelling and facial distortions. By your own admission you know this and it will take several months before you can judge the final outcome. I would have no doubt that the cheeks area will return completely to normal. Whether the nasal base will is unknown. In placing premaxillary implants the attachments to the nose around the pyriform aperture and the anterior nasals spine are disrupted. This may cause the nostrils to end up slightly wide than before but this is a possibility not a certainty.You must wait three months after facial implant surgery, either after their placement or removal, before seeing the final results.
Dr. Barry Eppley
Q: Dr. Eppley, I had a rhinoplasty several years ago that changed the angle of my nose from convex to acute. I would like to have this corrected with a premaxillary implant. Do you prefer silicone, mersilene mesh or hydroxyapatite?
A: Thank you for your inquiry and good question. While arguments can be made for any of the materials you have mentioned, and I have used them all, I prefer mersilene mesh in the premaxillary/pyriform aperture area. While I don’t use this material for most other facial areas, it has several advantages under the base of the nose including easy shaping and fabrication, no need for implant fixation, rapid tissue ingrowth with firm fixation and minimal palpability to the touch. Silicone implants tend to be a little firm and placing them under the thin mucosa of the maxillary vestibule makes them prone to future problems of tissue thinning, exposure as well as palpability. Hydroxyapatite granules is another reasonable alternative as a good long-term facial implant material. Its only problem is that one does not have ideal control over the placement of the material and the granules do settle out so the amount of premaxillary augmentation may not be enough or may be uneven or irregular.
Dr. Barry Eppley
Q: i am interested in changing the bottom front part of my nose. i believe it is called the columella. I think this is where the skin between the nostrils meets the upper lip. In my case, that angle is too small. It should be more open. I have read that an implant can create that effect. If an implant is placed there will it also lift up the tip of my nose? I have attached pictures which show what changes I want.
A: In doing assessment of the ‘columellar implant’ in your desired image look, there are three changes I see that you have made: 1) opening up/fullness of the nasolabial angle, 2) change in the angulation of the columella to the lip, and 3) nasal tip narrowing and lifting. It is important to note that to really achieve these changes an open tip rhinoplasty with an implant needs to be done. I would use cartilage for an implant in the columella rather than a synthetic implant. The columellar skin is not very thick and less potential problems will occur from a graft from your own body. That is so for the following reasons:
1) a premaxillary implant will push out the columellar base (open up the nasolabial angle) but will not push up the tip of the nose.
2) A true columellar implant will push out the columellar skin but will not, in and out itself, narrow and lift the lip of the nose.
The concept here is that a columellar implant or strut is an adjunct to a tip rhinoplasty but not a substitute for it.