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Augmentation of the central midface refers to building out the skeletal margins that surround the pyriform aperture. While such augmentation can be done by injectable fillers and fat as well as implants, the most assured outcomes come from placing a permanent material on the bone. Such materials around this area have been given various names such as paranasal, premaxillary and peri-pyriform implants. While seemingly sounding similar, and although the central midface area is not that big, they actually represent different regions within the U-shaped pyriform aperture region.

The paranasal region specifically refers to an augmentation that is done on the sides of the pyriform aperture. Externally this lies right under the sides of the nostrils and may evened further up along the sides of the nose. (hence the name ‘paranasal’) It does not cross under the base of the nose nor connect the two sides. Thus it is usually done in a bilateral or paired manner with the specific objective of adding volume to the sides of the nose.

The history of such implant use comes from rhinoplasty surgery as a complementary procedure to it and, as a result, is traditionally done through an intranasal approach or a skin incision at the alar-facial junction. The implants were usually placed in a subcutaneous location. While there may be some merit to this approaches, it is better today to think of paranasal implants as a subperiosteal skeletal augmentation procedure. Such placement avoids all of the problems that have historically been associated with them including upper lip stiffness and restriction of smile.

By using two small intraoral incisions high up into the vestibule under the upper lip, access is direct and comes below all facial musculature. Subperiosteal dissection allows for wide elevation of the entire paranasal region for a wider-based and more natural implant augmentation.

One key to paranasal implant augmentation is to get the implant up snug under the nostrils. If it gets too lateral using standard implants but will appear and feel like a bump to the side of the nose. How high up along the pyriform aperture the implant needs to go depends how flat the central midface is. Like all bilateral facial implants getting ideal symmetry between the two sides is not always easy.

Standard paranasal implants provide direct augmentation to the lateral nasal base. If more extended augmentation is needed out last the canine fossa and out onto the lateral maxilla, a custom paranasal implant design will be needed.

Dr. Barry Eppley

Indianapolis, Indiana

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