What Type Of Premaxillary Augmentation Do I Need?

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