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Archive for the ‘paranasal implants’ Category

OR Snapshots – ePTFE Premaxillary-Paranasal Implant

Monday, December 4th, 2017


Increasing the projection of the central midface at the base of the nose and upper lip involves augmenting the bony perimeter of the pyriform aperture. This anterior bony opening in the maxilla leads into the nose. At its more narrow end superiorly are the nasal bones. At its larger lower end the bone curves down and inward and meets in the middle to create the anterior nasal spine.

From an implant augmentation standpoint the pyriform aperture region has two distinct zones, the lateral paired paranasal regions and the central premaxillary region over the anterior nasal spine. The paranasal region has a flat or slightly concave surface while the premaxillary region is distinctly convex with a more V-shape projection to it. These anatomic central middle regions can be a augmented by three different styles of implants, paranasal, premaxillary and a combined premaxillary-paranasal implant.

Because of the tree different zones of potential augmentation and the very limited implant styles available, this is a very confusing area for surgeons and patients alike. The only preformed facial implant available is the peri-pyriform silicone implant. By its name and shape it is a premaxillary-paranasal implant since it covers all three zones. But it can be sectioned in the middle and turned into just paranasal implants if desired.

Another option to make a complete premaxillary-paranasal implant is to carve it out of an ePTFE block. Shaped almost like a moustache, the adaptability of this material allows it to be molded into placed over the central projecting spine and around the more concave sides into the maxilla. It may look large when positioned on the outside of the patient but it needs a lot of material to properly cover this central midface area.

The premaxillary-paranasal implant is placed through an intraoral incision under the upper lip. The key is to make the incision high enough on the lip side of the vestibule to maintain a good musculomucosavl cuff of tissue to close over the implant with a two layers of suture.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Screw Fixation of the Premaxillary-Paranasal Implant

Monday, March 28th, 2016


paranasal implant anatomy pyriform aperture dr barry eppley indianapolisAugmentation of the central midface can be done by placing an implant along the base and sides of the nose. Known as the pyriform aperture, it is the bony outline of the nasal cavity which makes a hole in the facial skeleton to the back of the throat. The soft tissue and cartilage structure of the nose sits on top or in front of it.

Peri-Pyriform Implant Dr Barry Eppley IndianapolsParanasal Implant placement Dr Barry Eppley IndianapolisThe pyriform aperture area can be augmented by a standard preformed implant known as the peri-pyriform implant. It has bilateral wings that augment the paranasal or sides of the pyriform aperture and a connecting center piece which crosses the premaxillary region along the bottom of the nose. Technically this implant should be called a premaxillary-paranasal implant. It is a versatile implant since it can be sectioned to just do paranasal augmentation or its wings can be removed to create just a premaxillary implant.

Paranasal Implant Placement Dr Barry Eppley IndianapolisThe premaxllary-paranasal implant is placed through a low anterior vestibular incision up under the upper lip. It is important to place the incision above the fixed mucoperiosteal to leave a cuff of tissue to create a good closure. Sunperiosteal dissection is done up to the anterior nasal spine and around the sides of the pyriform aperture. It is important to stay close to the edge of the bone but to not violate the nasal mucosal lining. The implant is placed snug up against the anterior nasal spine and along the sides of the pyriform aperture. Two 1.5mm screws are placed through the wings of the implant to secure it to the bone.

The premaxillary-paranasal implant is the only implant that can provide central face augmentation. It has a LeFort 1-like effect on the base and sides of the nose. Firm fixation to the bone by microcrews is a simple and effective method to ensure its postoperative placement and long-term stability

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Paranasal Implant

Sunday, February 21st, 2016


Background: Flatness in the midface occurs primarily due to natural development and occurs in certain ethnicities. The Asian face is well known to be broader with less anterior projection and it is most manifest in the appearance of the nose and the underlying maxillary support. But loss of maxillary support can also occur from trauma, loss of one’s upper teeth and part of the natural aging.

pyriform apertureAesthetic augmentation of the central midface is done by a paranasal implant, technically called the peri-pyriform implant. As the name implies, this facial implant wraps around the pyriform aperture or the anterior bony nasal aperture. By augmenting this area of the midface, the base of the nose is pushed forward including the nasolabial angle and the nostril attachments to the face.

The traditional paranasal implant is made of silicone and was originally designed to be used to complement a rhinoplasty procedure. But it is better perceived as a premaxillary implant and will have an effect on the nose and anterior facial projection that is very similar to LeFort 1 osteotomy advancement. It has anterior projections from 5 to 6.5mms.

Custom Paranasal Implant design Dr Barry Eppley IndianapolisCase Study: This 30 year-old male wanted to improve the projection of his midface and push the base of his nose further forward. Using a 3D model made from his own CT scan, a silicone elastomer moulage was used to design a custom fit paranasal implant that went further up along the pyriform aperture and had a central anterior nasal spine projection of 7mms.

Custom Paranasal Implant result side view Dr Barry Eppley IndianapolisCustomk Paranasal Implant result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, the custom paranasal  implant was placed through a maxillary vestibular incision limited to between the canine teeth. In a created subperiosteal  pocket, the implant was placed being careful to not violate the nasal mucosa. The custom paranasal implant was placed and secures with a single 1.5 x 5mm titanium screw on each side. The skeletal fit of the implant to the bone was perfect so screw fixation may not have been necessary but was done anyway. A double incision closure was done using resorbable sutures. A rhinoplasty procedure was also performed.

Custom Paranasal Implants result front view Dr Barry Eppley IndianapolisOf all the parasnasal implants I have placed, this custom paraansal or premaxillary implant is the best one I have ever seen done. The fit to the bone is far superior to the standard design because it was made to fit the concave shape of the pyriform aperture bone into the lateral canine fossa. With its feather edge, the shape of the implant allows for premaxillary and nasal base projection to be achieved without creating a noticeable ‘bump’ at the side of the nose over the face of the maxilla.


1) Aesthetic paranasal augmentation is traditionally done by the use of peri-pyriform implant.

2) The paranasal region of the midface is unique amongst facial augmentation sites as it is a concave region not a convexity.

3) A custom paranasal implant provides the greatest amount of midface projection and the smoothest transition into the surrounding maxillary bone.

Dr. Barry Eppley

Indianapolis, Indiana

New Paranasal Implant Design for Midface Augmentation

Saturday, June 21st, 2014


Of all the commercially available facial implants, one of the most obscure and least commonly used is that of the paranasal implant. Augmenting the base of the nose is historically associated with rhinoplasty surgery in an effort to add overall projection to the base of the nose. It was initially seen as a nose augmentation procedure not necessarily a facial skeletal implant to improve midface projection of the pyriform aperture region

paranasal implant anatomy pyriform aperture dr barry eppley indianapolisAnatomically the pyriform aperture refers to the anterior nasal aperture. This is a vertically oriented opening in the face with a wider base under the nostrils and a more narrow end superiorly just below a line between the eyes. From a bony standpoint it is bordered by the nasal bones superiorly and on the sides by the maxilla. At its lower end the maxillary bone curves centrally to join in the midline to create the anterior nasal spine prominence.

thAugmenting the paranasal region is currently done by using the well known peri- pyriform aperture silicone implant. While this design seems logical, its use in my experience has been plagued by too much fullness to the side of the nose creating an unaesthetic and uncomfortable ‘bump’. Patients often interpret this as misplacement/displacement of the implant from its desired location.Its shape does not really permit it to lie very close to the rim of the pyriform aperture and it frequently must be trimmed to do so. While the pyriform aperture area of the midface is not big, its proximity to the sensitive lips and base of the nose does not permit much forgiveness in terms of implant size and location.

Paranasal Implant Designs Dr Barry Eppley Indianapolissilicone paranasal implant designTo overcome the problems with current implant shapes, a new paranasal implant design has been developed. It has more of a triangular shape with a more tapered shape at its lateral and inferior edges. This allows its point of maximal projection (5mms) to lie directly under the nostrils and allows it to flow smoothly into the surrounding concave maxillary bone. This avoids any noticeable or palpable bump to the side of the nose and makes it undetectable from the outside. It is surprising the influence that a small amount of projection (5ms) has in just the right location.

silicone paranasal implant surgical placementThe paranasal implant is placed through a small 1 cm incision in the depth of the maxillary vestibule, just medial to a vertical line drawn up from the canine. A short dissection upward locates the lateral aspect of the pyriform aperture just under the base of the nose. Only a small pocket is needed. The paranasal implant is easily inserted and positioned. Because it is a small and tight pocket, no fixation is really needed. (although I almost always use it as I do with just about every facial implant but it can be argued it is not absolutely needed for this implant) A two-layer closure (muscle and mucosa) is done over the implants.

Paranasal implants add projection to the lower central third of the midface. They are used to augment a more flat midface profile with a sunken nasal base. This new design is more anatomically based, adds projection in the right location and can be easily placed without postoperative palpability. Its effectiveness and procedural simplicity should extend facial augmentation benefits to more patients.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Implants for Correction of Midface Deficiency

Monday, September 7th, 2009

Implants are very useful for producing three-dimensional facial changes. By extending the outer boundaries of bony prominences, the proportions and shape of the face can be changed dramatically. Implants essentially camouflage facial bony deficiencies or enhance a normal prominence. Traditional and well known facial implants are that of the chin, cheeks, or  nose. Jaw angle implants are also becoming more commonplace today.

Most facial implant use is for one region only (e.g., chin) even if the area of enhancement has two sides. (e.g., cheeks) Multiple sites of enhancement at one procedure can also be done and are associated with more significant facial changes. The use of combination cheek and chin augmentation or even chin, cheek and jaw angle augmentation are traditional implant duets and trios.

Another good facial implant combination is in the use of camouflaging a midface deficiency. Some midface hypoplasias are obvious, other are more subtle. Either way, there is an apparent flatter or less convex facial profile. In its severest form, the facial profile will actually be concave. The degree of midface underdevelopment is most evident by looking at one’s teeth or bite relationship. There may be an underbite or an edge-to-edge bite at the incisors. Someone may have had prior orthodontics so the ‘true’ bite relationship may have become obscured.

Midface deficiency is marked by flatter cheekbones and a ‘sunken’ base to the nose, known as the paranasal region. The entire midfacial skeleton is recessed from below the eyes down to the upper teeth. This bony position will have an impact on other facial areas making the nose and chin look bigger and the upper lip look smaller and thinner.

In young patients or more severe midfacial deficiencies, one should consider moving part or all of the midfacial bones. Traditional LeFort osteotomy patterns in conjunction with orthodontics is the standard approach. For patient’s with less significant deficiencies or who are not desirous of making that degree of surgical effort, augmenting the deficient bone is another option.

The combination of cheek and paranasal implants is a good facial augmentation combination for this problem. Using four implants (two cheek and two paranasal) placed through two incisions under the upper lip, the midface area can be brought out for greater facial convexity. It is important to secure these implants to the cheek and maxilla with small screws to prevent movement or migration after surgery.  The choice of implant material is not important but good sizing and placement position is.

With an improved midfacial profile, the nose will appear smaller and may not require any alteration. For others, changing the shape of the nose through a rhinoplasty may be simultaneously beneficial. This can be determined before surgery through computer prediction imaging.

 Dr. Barry Eppley
Indianapolis, Indiana


Maxillary, Premaxillary and Paranasal Implants for Facial Augmentation

Tuesday, August 11th, 2009

Facial implants remain a good and simple way to highlight existing or deficient facial anatomy. While everyone  knows the most common facial implants, such as cheeks and chins, there are numerous other areas of the face that can implanted.

In the midface, there are the standard implants of the cheeks and nose. These areas represent convex facial areas that are more commonly implanted because their lack of prominence is well recognized and aesthetically more obvious.

The midface also has areas of concavities that can benefit from bony augmentation. These areas are less well recognized because they are cancavities to begin with. As such, the benefits of their expansion or augmentation are not as apparent.

These midfacial areas are known as the maxillary, pre-maxillary, and paranasal areas. To some degree, these three areas all run together and are contiguous. But they are separate implants for each ‘subarea’. They all address areas of flatness or excess concavity to the midfacial area.

The paranasal implant addresses flatness underneath the base of the nose. This can occur from a congenital problem such as cleft lip and palate but most commonly is just the natural development of one’s face. The midface is flatter overall and one will frequently have cheek deficiencies as well. Most noticeable is that the nose is less pronounced and the base of the nose is positioned behind the projection of the upper front teeth in profile.

Premaxillary implants help bring out the entire base of the nose. They bring projection to the entire nasal base, most prominently the anterior nasal spine area. By using an implant across this area, the nasolabial angle is opened up by being brought forward. This can also give the illusion of increased nasal tip projection as well.

 The maxillary implant is the least used facial implant of them all. It is really an extended paranasal implant which extends back along the maxilla above the roots of the upper teeth. It can also be used for paranasal or base of the nose augmentation but adds more fullness to the entire lower midface as well. Their effects are somewhat similar to what a LeFort I advancement osteotomy (2 to 4mms) may do.

 Like all midface implants, they can be placed through an intraoral approach through a high vestibular incision. The periosteum needs to be elevated and the implants should be secured to the bone with screw fixation.

There are no definite methods of assessment that can determine the indications for these types of facial implants. Their use is based on an artistic or aesthetic sense of facial balance and the results can not be well predicted based on some form of computer analysis or prediction. In my Indianapolis plastic surgery practice, I find that their use is most commonly done with other facial procedures such as rhinoplasty, chin and cheek augmentation and mid- and lower facelifts.   

Dr. Barry Eppley
Indianapolis, Indiana


Paranasal Implants – The Facial Implant You Never Heard Of

Friday, September 26th, 2008

One type of facial implant, and a facial area that can be augmented, is the paranasal area which most have never heard of. The paranasal region is the area just to the side of your nose at the wings of the nostrils.  This is an area that is supported by the bone above the front and canine teeth. I became very familiar this area in treating cleft patients where on the side of the cleft the paranasal region was always deficient and sunken in. I frequently built this area back up with bone grafts or implants as an older child or teenager when I did their reconstructive rhinoplasty (nose ) surgery.  From this experience, I observed how building out this area affected the face.

Cosmetically, some patients have an overall middle of the face deficiency as the upper jaw is a little short and they have flatter cheeks. Other patients have more ideal facial bone development but, as they age, the overlying nasolabial folds become ‘deeper’ as the cheek tissue descends and falls over the more fixed upper lip tissue. In either case, the use of paranasal implants may be aesthetically helpful.

Paranasal imoplants are very small implants, about the size of a quarter, that are placed on the bone right up against the pyriform aperture through a small incision up under the lip. What is the pyriform aperture you ask? If you look at a skull, you will see the nasal passages in the middle of the face. The lower end of this large opening down near the upper teeth is known as the pyriform aperture. You can easily see the bone right next to them which slopes away. By building up this area, you increase the fullness under the side of the nose.

Paranasal implants, while not commonly done, can be useful as an overall strategy with cheek implants to build out the middle of the face or to help soften the deepest end of the nasolabial fold near the nose.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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