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Maxillary Augmentation Rhinoplasty Treatment & Management

  • Author: Michael Mercandetti, MD, MBA, FACS; Chief Editor: Mark S Granick, MD, FACS  more...
 
Updated: Dec 19, 2014
 

Surgical Therapy

Two common surgical approaches are the intranasal and intraoral routes.

The intranasal approach uses an incision made in the lateral vestibule that is brought down to the level of the nasal spine. The vertically oriented incision is located in the membranous portion of the septum and is the primary site of subperiosteal elevation underlying the alar bases.

The surgical approach via the intraoral modality commences with an incision through the gingivobuccal mucosa. The dissection is carried out in the subperiosteal pocket, allowing for adequate exposure of the implant site.

Different materials have been used to correct both premaxillary and maxillary hypoplasia.

Materials such as silicone silastic, cartilage,[15] disced or crushed cartilage[18] and/or bony autografts and/or homografts,[19] hydroxyapatite granules, Mersilene mesh,[19] acellular dermis, porous polyethylene, and, in the past, Proplast and Gore-Tex, have been used (see images below for examples). The choice of implant material used should be based on availability, biocompatibility, rate of extrusion, familiarity with the material, and previous surgical outcomes.

Various custom-shaped implants are also available.

Front view of Brink Peri-Pyriform (tm) silicone im Front view of Brink Peri-Pyriform (tm) silicone implant from Implantech.
Side view of Brink Peri-Pyriform (tm) silicone imp Side view of Brink Peri-Pyriform (tm) silicone implant from Implantech.
Fanous premaxillary silicone implant Fanous premaxillary silicone implant
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Preoperative Details

Appropriate assessment of the hypoplastic areas and the expected outcome must be reviewed thoroughly with the patient. The surgeon and patient then should decide on the desired degree of correction.

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Intraoperative Details

In either approach, care must be taken to avoid the infraorbital neurovascular plexus. Usually, this does not pose a problem because the subperiosteal dissection is not extended into this area unless the implants used are those described by Hinderer.[3]

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Postoperative Details

Postoperative antibiotics are administered routinely, and the patient is advised to avoid excessive manipulation of the area.

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Follow-up

Patients are usually observed the day after surgery, then at 1 week, 1 month, 3 months, 6 months, and 1 year postsurgery. These regimens are tailored as the surgeon sees fit.

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Complications

Complications related to the implant may arise.

If an autogenic implant is used, the possibility of donor site infection and scarring and autograft contamination exists.

Both synthetic and nonsynthetic grafts may extrude or become infected.

Patient dissatisfaction can also occur from an overcorrection or undercorrection or secondary to implant migration.

Paresthesias stemming from infraorbital nerve injury can result and persist indefinitely. Fortuitously, some paresthesias resolve within 6-12 months.

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Outcome and Prognosis

Most of the implant material is nonautogenous in nature. Silicone is relatively inert and has a long history of being well tolerated by the body. Infection can occur with any implanted material in the body. If this were to occur with the silicone implant, it would necessitate removal.

Slippage of the implant can also occur if the pocket is too large. Autogenous material such as cartilage is seldom used in this area. The increased effort to harvest this material and shave it is not often warranted. Septal cartilage can be fashioned into a maxillary onlay graft but "results in the long run may be less predictable than alloplastic correction.”[10]

The patient and surgeon ultimately decide which implant material to use.

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Future and Controversies

Newer imaging capabilities allowing for more readily available customizable implant creation will become more prevalent. This technology, coupled with newer implant materials, will lead to less traumatic surgical techniques and elevated patient and physician satisfaction levels.

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Contributor Information and Disclosures
Author

Michael Mercandetti, MD, MBA, FACS Private Practice

Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, Sarasota County Medical Society, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Coauthor(s)

Edward W Chang, MD, DDS, FACS Consulting Staff, Department of Cosmetic Services, Head and Neck Surgery, Kaiser Permanente of Northern California at Santa Rosa

Edward W Chang, MD, DDS, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American College of Surgeons, California Medical Association, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Adam J Cohen, MD Assistant Professor of Ophthalmology, Section Director of Oculoplastic and Reconstructive Surgery, Rush Medical College of Rush University Medical Center

Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, American College of Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: BioD, Poferious<br/>Serve(d) as a speaker or a member of a speakers bureau for: IOP<br/>Received income in an amount equal to or greater than $250 from: IOP for speaking.

Edward H Farrior, MD, FACS Affiliate Associate Professor, Voluntary Faculty, Department of Otolaryngology-Head and Neck Surgery, University of South Florida Health Sciences Center; Visiting Clinical Associate Director, Department of Otolaryngology, University of Virginia

Edward H Farrior, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Florida Medical Association

Disclosure: Nothing to disclose.

Donald R Laub, Jr, MD, MS, FACS Professor, Departments of Surgery and Pediatrics, University of Vermont College of Medicine; Medical Director, Vermont State Cleft Palate-Craniofacial Center; Medical Director, Children's Upper Extremity Center at Fletcher-Allen Health Care

Donald R Laub, Jr, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Cleft Palate-Craniofacial Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, Vermont Medical Society, AO Foundation, American Association of Pediatric Plastic Surgeons, Northeastern Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George Peck, MD 

George Peck, MD is a member of the following medical societies: American Society for Aesthetic Plastic Surgery

Disclosure: Nothing to disclose.

Chief Editor

Mark S Granick, MD, FACS Professor of Surgery, Chief, Division of Plastic Surgery, Rutgers New Jersey Medical School

Mark S Granick, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, Phi Beta Kappa, Northeastern Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Waterjel, Inc.; Reconstat, LLC; DSM<br/>Serve(d) as a speaker or a member of a speakers bureau for: Novadaq<br/>Received none from Waterjel Inc. for board membership; Received none from Reconstat LLC for board membership; Received none from Open Science Co., LLC for board membership.

Additional Contributors

Frederick J Menick, MD Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Facial and Nasal Reconstructive Surgeon, Tucson, Arizona

Frederick J Menick, MD is a member of the following medical societies: American Society of Maxillofacial Surgeons, Canadian Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

References
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  9. Converse JM, Horowitz SL, Valauri AJ, Montandon D. The treatment of nasomaxillary hypoplasia. A new pyramidal naso-orbital mazillary osteotomy. Plast Reconstr Surg. 1970 Jun. 45(6):527-35. [Medline].

  10. Flowers RS. Augmentation maxilloplasty. Terino EO, Flowers RS, eds. The Art of Alloplastic Facial Contouring. Mosby: St Louis; 2000. 129-150.

  11. Romo T 3rd, Shapiro AL. Aesthetic reconstruction of the platyrrhine nose. Arch Otolaryngol Head Neck Surg. 1992 Aug. 118(8):837-41. [Medline].

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  14. Bottini DJ, Gentile P, Cervelli G, et al. Changes in nasal profile following maxillomandibular osteotomy for prognathism. Orthodontics (Chic.). 2013. 14(1):e30-8. [Medline].

  15. Kim WS, Kim CH, Yoon JH. Premaxillary augmentation using autologous costal cartilage as an adjunct to rhinoplasty. J Plast Reconstr Aesthet Surg. 2010 Sep. 63(9):e686-90. [Medline].

  16. Mertens C, Decker C, Seeberger R, Hoffmann J, Sander A, Freier K. Early bone resorption after vertical bone augmentation - a comparison of calvarial and iliac grafts. Clin Oral Implants Res. 2012 Mar 27. [Medline].

  17. Guerrerosantos J, Sterzi C. Interpositional cartilage grafts to improve vertical length of the face. J Craniofacial Surg. Nov 2012. 21(6):1666-9. [Medline].

  18. Cochran CS, Ducic Y, DeFatta RJ. Restorative rhinoplasty in the aging patient. Lartngoscope. May 2007. 117(5):803-7. [Medline].

  19. Foda HM. Mersilen mesh in premaxillary augmentation. Aesthetic Plast Surg. may-Jun 2005. 29(3):169-73. [Medline].

  20. Cochran CS, Ducic Y, DeFatta RJ. Restorative rhinoplasty in the aging patient. Laryngoscope. 2007 May. 117(5):803-7. [Medline].

  21. Fanous N, Yoskovitch A. Premaxillary augmentation for central maxillary recession: an adjunct to rhinoplasty. Facial Plast Surg Clin North Am. 2002 Nov. 10(4):415-22. [Medline].

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  24. Nassif PS, Kokoska MS. Aesthetic Facial Analysis. Facial Plast Surg Clin of North Am. November 1999. 7(1):4.

 
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Skeleton of the head. Superiofrontal view showing maxilla and premaxilla.
View of head skeleton from below showing incisive foramen, palate, and premaxilla.
Front view of Brink Peri-Pyriform (tm) silicone implant from Implantech.
Side view of Brink Peri-Pyriform (tm) silicone implant from Implantech.
Fanous premaxillary silicone implant
 
 
 
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