Paranasal Augmentation

One of Dr. Zelken's favorite operations is the augmentation of the lower midface to soften or eliminate deep nasolabial folds and to enhance a flat midface on profile view.

Dr. Zelken has performed this procedure for nearly 10 years at the Our clinic in Newport Beach and has written on the subject.

Pyriform aperture augmentation is an increasingly popular procedure that can be performed in conjunction with rhinoplasty, facelift, or as a stand-alone procedure with your own tissue, filler, or implants.

Although mid-facial flatness- or concavity, is an age-indiscriminate cosmetic concern, pyriform aperture augmentation can benefit young patients as well as patients noticing age-related changes.

As an example, Queen Nefertiti is known for her sublime jawline but demonstrates subtle mid-facial flatness that may have benefited from paranasal augmentation.

WHO IS A CANDIDATE FOR PARANASAL AUGMENTATION?

You may be a candidate for pyriform augmentation if you are looking for a more permanent solution to “laugh lines”, also known as “smile lines”, which are layman’s terms for deep nasolabial folds. Patients with true skeletal insufficiency in this region may also demonstrate characteristics like:

• An acute columellar-labial angle
• Reduced “show” of the upper teeth
• Flattening or concavity of the lower midface on profile view
• A perceived (or actual) underbite

Dr. Zelken appreciates the greatest change in patients with visible hollowness just adjacent to the edge of the nostrils.

A profile view of Korean American actress Sandra Oh demonstrates features that might benefit from paranasal augmentation including a flat midface, deep nasolabial folds, and a gently under-projected nasal tip. A desire for a more convex midface seems more prevalent in ethnically Asian and black patients. Note: not a patient of the Jonathan Zelken, MD for Aesthetic Medicine.

PARANASAL AUGMENTATION PROCEDURE

There are many ways to augment the lower midface. Filler injection and fat grafting to the base of the nose is probably the most common, least expensive, and least invasive method of augmenting the lower midface. However, these methods probably do not qualify as “paranasal augmentation”, per se, because skeletal augmentation may not be the true intent of said procedures. There are several ways to skeletally augment or manipulate the midface to improve one’s appearance.

This falls into two broad categories: Orthognathic surgery and paranasal augmentation.

1. Orthognathic surgery is a significant and risky operation that relies on cutting, repositioning, and securing facial bones in an improved configuration. This is typically the domain of craniofacial plastic surgeons and oral maxillofacial surgeons and must not be taken lightly.

This is an appropriate operation, and the ideal operation, for persons with significant class III malocclusion (underbite) attributable to under projection and insufficiency of the maxilla (upper jaw). Correction of skeletally significant maxillary retrusion will confer important cosmetic and functional benefits. (Zelken JA, Davison SP. Postmaxillectomy prognathism. Plast Reconstr Surg. 2009 Feb;123(2):69e-71e. doi: 10.1097/PRS.0b013e318196bba8. PMID: 19182580.) When both the upper and lower jaw are suboptimally configured, double jaw surgery should be designed to address skeletal insufficiency in the midface as well.

Clinically significant midfacial retrusion such as the image shown above, resulting from cancer resection, cannot and should not be addressed with small implants alone. Note: not a patient of the Jonathan Zelken, MD for Aesthetic Medicine.

Because of the risks, costs, and unpredictability of orthognathic surgery, Dr. Zelken believes that a major operation should be avoided when it can. This probably applies to 95% of you who are reading this page and weighing your options.

2. Although paranasal skeletal augmentation cannot and will not influence the way your teeth align, it is a safe, affordable, and effective method to address paranasal hollows, deep smile lines, and mild setback of the maxilla (upper jaw). Paranasal augmentation is typically performed with bone or cartilage graft (also known as autogenous tissue), or implants (also known as alloplast).

Dr. Zelken believes that cartilage graft is the most readily available but least predictable option because much of it can be resorbed. Bone grafting is philosophically the superior option, as you augment bone with bone. Even though it can be difficult and unforgiving to sculpt bone graft, it can resorb, and it is relatively unforgiving as imperfections can lead to visible and palpable step-offs. So, that leaves us with alloplastic augmentation, which is known as peri pyriform (aperture) implants.

WHAT DO PERI PYRIFORM IMPLANTS LOOK LIKE?

Peri pyriform aperture implants are offered in many different shapes, sizes, and materials. The most common materials are porous polyethylene, PTFE (Gore-Tex), and silicone. Porous polyethylene, better known as Medpor, is rigid and the other materials are soft. Rigid implants are typically screwed into position while Gore-Tex and silicone are either sewn into position or placed in a tight pocket to prevent malposition or extrusion.

Dr. Zelken prefers silicone paranasal augmentation and either carves an implant from scratch using a silicone carving block or places an off-the-shelf, commercially available device and relies on meticulous pocket creation instead of sutures or screws to keep the implant in a stable position. A soft, malleable silicone implant enables Dr. Zelken to complete the procedure through 2 small incisions above your canines, minimizing the incision length and risk for implant extrusion.

Paranasal + premaxillary implants such as the Peri-Pyriform™ implant shown here by Implantech are commercially available and can be delivered as soon as one day after the order is placed. The appearance and intended anatomic position of the implant is shown above. According to the manufacturer, this implant is “a pre-maxillary implant designed to augment the peri-alar area around the pyriform aperture. As anterior projection to the premaxilla and provides a platform for the nasal base”.

Paranasal + premaxillary implants such as the Peri-Pyriform™ implant shown here by Implantech are commercially available and can be delivered as soon as one day after the order is placed. The appearance and intended anatomic position of the implant is shown above. According to the manufacturer, this implant is “a pre-maxillary implant designed to augment the peri-alar area around the pyriform aperture. As anterior projection to the premaxilla and provides a platform for the nasal base”.

This is an example of a Gore-Tex device manufactured by Implantech that is designed to correct deep nasolabial folds without supporting or changing the shape of the base of the nose. Because there are 2 smaller parts, Dr. Zelken prefers to secure these implants with sutures or screws to prevent malposition and uses this device less frequently than the Peri-Pyriform implant. According to the manufacturer, “the ePTFE paranasal implant increases the projection of the nostril base and decreases the depth of the upper nasolabial folds”.

position through larger incisions. (source: Yen CI, Chen RF, Zelken J, Chang CS, Yang SY, Chen HC, Chang SY, Yang JY, Chuang SS, Hsiao YC. The Influence of Paranasal Augmentation on the Measurement of the Nose for the Treatment of Midfacial Concavity. Aesthet Surg J. 2018 Feb 15;38(3):241-251. doi: 10.1093/asj/sjx166. PMID: 29401214.) Note: not a patient of the Our clinic for Aesthetic Medicine.

ARE THERE CUSTOM PARANASAL AND PREMAXILLARY IMPLANTS?

For patients with post-traumatic deformities and congenital differences that lead to skeletal asymmetries or configurations that are not amenable to commercially available, off-the-shelf implants, custom devices can be sculpted from a silicone carving block, prefabricated implants can be carved to accommodate individual anatomies, and custom implants can be manufactured.

In-house implant manufacture is available at the Our clinic for Aesthetic Medicine using polyether ether ketone (PEEK) but requires a CT scan for the planning phase which can be obtained easily with a cone beam CT scanner (lower radiation, lower cost, lower quality image but sufficient) or a formal CT with prescription.

WHY DON’T MORE SURGEONS OFFER PARANASAL AUGMENTATION?

Because photographic and photogrammetric changes are measurable, but subtle, whereas other implant procedures like cheek and chin augmentation are not. Paranasal augmentation simply has not turned the attention of these other procedures. In other words, many surgeons simply do not know about paranasal augmentation or how to successfully perform the procedure.

But, that is not to say the procedure is not commonly performed. For example, many injectors knowingly or unknowingly perform paranasal augmentation when they fill so-called “smile lines”.

For the past 10 years, the “lift and fill” facelift that relies as much on structural fat grafting as it does on lifting the skin and soft tissue includes the pyriform apertures as one of the most effective fat grafting recipient sites in the face. While fillers and fat grafting can address soft tissue and bony features, these alternatives may be more subtle and less permanent than an implant. Although paranasal augmentation with an implant seems extreme, in the hands of an experienced surgeon, the procedure often takes 30 minutes or less to complete.

BEFORE AND AFTERS OF PARANASAL AUGMENTATION IN NEWPORT BEACH PATIENTS

There are many before and after photographs available of patients who underwent paranasal augmentation. Because this procedure is typically performed as an adjunct to rhinoplasty, buccal fat pad removal, facelift, and corrective procedures of the upper lip, the rationale for and desired outcome of paranasal augmentation should be considered.

Several years ago, Dr. Zelken co-authored a scientific paper investigating the influence of paranasal augmentation as a standalone procedure on facial appearance. Although facial measurements did change, the measurable changes were enough to enhance beauty and patient satisfaction meaningfully but subtly, and this is consistent with Dr. Zelken’s own experience.

A 30-year-old woman in the augmentation group with (A, C, E, G, I, K) preoperative and (B, D, F, H, J, L) 12-month postoperative outcome. Source: Cheng-I Yen, MD, Ruei-Fong Chen, MD, Jonathan Zelken, MD, et. al., The Influence of Paranasal Augmentation on the Measurement of the Nose for the Treatment of Midfacial Concavity, Aesthetic Surgery Journal, Volume 38, Issue 3, March 2018, Pages 241–251. Note: not a patient of the Our clinic for Aesthetic Medicine.

RISKS ASSOCIATED WITH PYRIFORM APERTURE AUGMENTATION

The risks associated with paranasal augmentation are significantly reduced when you work with a board-certified facial plastic and reconstructive surgeon. These risks include:

• Implant migration
• Bone absorption
• Nasal bleeding
• Infection

Following your surgeon’s pre-and post-operative instructions will greatly aid in your recovery and successful results.

CONSULT DR. ZELKEN FOR PARANASAL AUGMENTATION IN NEWPORT BEACH, CA

Your surgeon’s experience, technique, and skill are critical to ensure safety and ideal results are achieved in all plastic surgery procedures. Dr. Zelken is board-certified and graduated at the top of his class at Tufts University and went on to complete his microsurgery fellowship under the guidance of one of the world’s most respected microsurgeons in Taiwan.

Dr. Zelken’s consistently pleasing, and beautiful results, reflect his surgical technique and eye for detail. Call the Our clinic at (949-432-4730) to schedule an appointment and find out how he can help you achieve your desired cosmetic goals.