Premaxillary Augmentation Rhinoplasty

Updated: Oct 29, 2018
Author: Samuel J Lin, MD; Chief Editor: Arlen D Meyers, MD, MBA 



Premaxillary augmentation addresses the nasal base, upper lip, and nasolabial angle. Augmentation is typically achieved with implanted autogenous grafts, homografts, or alloplasts. However, rotational flaps have also been described in the literature. Insertion of an implant anterior to the nasal spine may address several aesthetic shortcomings. A premaxillary implant can increase tip projection, improve the nasolabial angle, and lengthen the upper lip. Implants may also be inserted over the central upper lip anterior to the maxilla to achieve maxillary augmentation in combination with the aforementioned changes to nasal appearance. Alternatively, when malocclusion exists, orthognathic work addresses the malocclusion while simultaneously correcting premaxillary retrusion.

This article reviews basic anatomy and aesthetic considerations of the nasal base/tip-lip complex, discusses the advantages and disadvantages of implants used for premaxillary augmentation, and offers surgical techniques to achieve the desired cosmetic result.

See the image below.

Premaxillary augmentation rhinoplasty. Ideal verti Premaxillary augmentation rhinoplasty. Ideal vertical dimensions of the face.


The premaxilla (also known as the incisive bone, intermaxillary bone, or Goethe bone) is the bony segment of the maxilla that lies between the lateral borders of the lateral maxillary incisors. It exists as a separate bone in the fetus and sometimes in the adult. If anatomic growth of this area is hindered by congenital anomalies (eg, cleft lip and palate, Binder syndrome), premaxillary retrusion is observed. The retruded maxillary segment is identified by a constellation of defects, including an acute nasolabial angle, nasal tip ptosis, and labial incompetence at rest. Part of this retrusion may be manifested by class III malocclusion, which orthognathic surgery should correct.

Pronounced ethnic differences of the premaxilla have been observed. The premaxilla is commonly in need of augmentation in the classic mesorrhine and platyrrhine noses. Of course, detailed anatomic evaluation of each patient helps identify the presence or absence of this finding.



The American Society for Aesthetic Plastic Surgery reports that rhinoplasty was the fourth most commonly performed aesthetic plastic surgery procedure in 2008.[1]


Besides congenital malformations and various individual differences that account for premaxillary retrusion, 2 types of noses exhibit a higher prevalence of this deformity: noses of aging individuals and noses of individuals of Asian or African descent.

As an individual ages, the nose undergoes several predictable changes, including nasal tip ptosis, maxillary bone resorption (with or without loss of maxillary dentition), and decrease in the vertical height of the upper lip vermilion. The overall appearance is an unpleasant acute nasolabial angle, loss of nasal projection, and lengthening of the upper lip. The first 2 unaesthetic features may be addressed by premaxillary augmentation. However, the lengthening of the upper lip may be exacerbated with a premaxillary implant. Flowers and Smith have described a method to correct this latter problem with a rotational flap (see Treatment).[2] Also, be particularly wary of inserting an alloplastic premaxillary implant into an edentulous patient who wears dentures because of eventual erosion into the implanted pocket.

The classic mesorrhine and platyrrhine noses are characterized by an acute nasolabial angle and underprojection of the nose, both of which may benefit from premaxillary augmentation. An analysis of the nasal/maxillary skeleton reveals these findings. The leptorrhine nose is characterized by a prominent anterior nasal spine and prognathic premaxilla. In contrast, the mesorrhine, or Asian, nose displays a more retruded premaxillary component and shorter nasal spine. The platyrrhine structure of the typical African nose exhibits retrusion of the premaxilla with an almost absent nasal spine. Premaxillary augmentation has served as a fundamental part of rhinoplasty in mesorrhine and platyrrhine noses. Of course, these generalizations may not apply to a specific patient; an exacting anatomic analysis is essential in every case.


Facial analysis

Ideally, the lower third of the face, from the subnasale to the menton, should occupy one third of the vertical dimension of the face. In aesthetic analysis, the remaining two thirds of the face may be equally divided from the trichion to the glabella and from the glabella to the subnasale. The lower third of the face may be further subdivided into an upper one third (subnasale to stomion) and lower two thirds (stomion to menton; see the image below). These ideal lengths should be kept in mind when performing premaxillary augmentation because the upper lip length is affected by this procedure.

Premaxillary augmentation rhinoplasty. Ideal verti Premaxillary augmentation rhinoplasty. Ideal vertical dimensions of the face.

When evaluating a patient for possible premaxillary augmentation, assessing the upper lip position both in repose and in animation, particularly smiling, is important. As premaxillary deficiency can lead to excessive and unaesthetic gum exposure (so-called gummy smile), the patient should be asked to smile to determine whether such a condition exists. If the patient has very little upper gingival showing or even partial overhang of the upper lip onto the incisors, the surgeon should be wary about pursuing premaxillary augmentation as dental show may be further lessened. This preoperative assessment and related patient counseling cannot be overemphasized.

Relevant Anatomy

Nasal base

A fundamental focus of aesthetic analysis of the nose is the nasal base. Often, terms used to describe this area are used imprecisely; for example, the term lobule may apply only to the tip of the nose or to the entire inferior portion of the nose, including the alae laterally. In this article, the term lobule refers specifically to the region of the nose medial to the alae and anterior to the nostrils, ie, the tip of the nose.

Vagueness in definition also affects the nasal base. Some authors define the nasal base as the area of the paired lower lateral cartilages, whereas others use the term to describe an area that is limited to the point at which the columella meets the upper lip (see the image below).

Premaxillary augmentation rhinoplasty. The nasal b Premaxillary augmentation rhinoplasty. The nasal base: lobule, alae, and columella.

The nasal base is defined in this article as the entire triangular area from alar-facial crease to alar-facial crease and including the nasal tip. The anteroposterior dimension from nasal tip to base of the columella may be ideally subdivided into equal thirds: (1) from tip to anterior nostril rim, (2) from anterior nostril rim to anterior border of medial crural footplates, and (3) from anterior medial crural footplate to the base of the columella (see the image below). The width of the nasal base, from lateral alar margin to lateral alar margin, should equal the intercanthal distance and 70% of the length.

Premaxillary augmentation rhinoplasty. Ideal dimen Premaxillary augmentation rhinoplasty. Ideal dimensions of the nasal base.

On lateral view, the nostril aperture should approximate an oval. The ideal width of the oval should be approximately 2-4 mm without excessive columellar/alar show or retraction. In addition, the columella should display a double break, with the break at the mid columella.

Nasolabial angle

The nasolabial angle, or, more precisely, the columellar-labial angle, is defined by the angle the columella makes with the upper lip. Ideally, the columellar-labial angle should be 95-115° for females and 90-100° for males. However, the individual face must be taken into account, and different facial configurations may benefit from a different columellar-labial angle. For example, a smaller or more acute columellar-labial angle is preferable in taller patients. However, a relatively more obtuse columellar-labial angle is aesthetically preferable in shorter patients. In general, the male nose may tolerate more variation in the columellar-labial angle than that of the female.


The lengthening of the upper lip produced by aging may be exacerbated with a premaxillary implant. Be particularly wary of inserting an alloplastic premaxillary implant into an edentulous patient who wears dentures because of eventual erosion into the implanted pocket.

As mentioned before, observation of the patient during forceful smiling is important in order to evaluate the safety of implant placement, as it concerns lengthening of the upper lip. For a patient with very little upper gum showing, a risk exists of pulling the lip so far down as to hood over the incisors. Another important consideration that concerns larger alloplastic implants involves the possibility for patients to feel the implant during smiling or animation, which can be quite troublesome. This possible outcome should be explained. Typically, smaller autogenous grafts do not cause this problem, but larger alloplasts can cause this problem.[3]



Surgical Therapy

Premaxillary augmentation may be achieved with surgical implants. Many implants are approved for use in nasal reconstruction; these may be classified as autografts, homografts, and alloplasts. However, no ideal implant currently exists.

Autografts are derived from the patient's own body and include bone (rib, iliac crest, septal, calvarial) and cartilage (septal, conchal, rib). Homografts are obtained from another human donor and include irradiated cadaveric rib and dermis (AlloDerm). Alloplasts are semisynthetic or synthetic materials; examples include silicone, Gore-Tex or polytetrafluoroethylene (PTFE), hydroxyapatite, and titanium.[4]


Many plastic surgeons consider autografts the preferred implant material because of their biocompatibility and low infection and extrusion rates. However, disadvantages should be mentioned, including donor site morbidity, need for additional operative time, limited supply, and the potential for resorption. In the premaxilla, the 2 main autologous graft materials used are cartilage and bone.

Cartilage may be harvested from the septum, which is stronger and straighter than conchal cartilage. These attributes make septal cartilage easier to carve and shape. Alternatively, the concha yields approximately 5 cm of cartilage for grafting and may be particularly useful for onlay grafts to the alae, which have a similar curvature. Conchal cartilage should be harvested from the more pronounced ear (because excessive conchal removal may medialize the ear somewhat), from the ear that is not used on the telephone, or from the ear that the patient does not sleep on at night. Costal cartilage, usually taken from the fifth, sixth, or seventh rib, may also be used. Harvesting costal cartilage should be avoided in the elderly population because the cartilage is most likely calcified, making carving almost impossible. Harvesting rib cartilage has several distinct disadvantages: (1) higher resorption rate, (2) risk of pneumothorax, and (3) postoperative pain.

Bone may also be used to reconstruct nasal defects. Split calvarial bone grafts of membranous bone origin may be less likely to resorb than iliac crest grafts of endochondral bone. In addition, removal of iliac crest may cause more postoperative pain. Costal bone may also be used for nasal reconstruction. The main drawbacks of bone grafts are the higher resorption rate, difficulty shaping the graft, and malposition over time.


Homografts are used less frequently than autografts and are associated with a higher rate of resorption. Acellular dermis (AlloDerm) has been used successfully as a camouflaging and soft tissue contouring material, which is especially helpful in thin-skinned individuals, and it may be combined with cartilage or rib grafts. However, it also may resorb over time.


An advantage of allografts is their "off-the-shelf" availability. No additional operative time is required for graft harvest, and no donor site morbidity occurs. A disadvantage is the risk of infection and extrusion that may occur at any time during the patient's life.

Synthetic implants have different properties that are important in tissue reactivity and bio-integration. Porosity allows tissue ingrowth but also bacterial entry, which can be countered by macrophage ingress if the pore size exceeds 50 µm. If pore size is greater than 100 µm, then bony and fibrous ingrowth may occur to increase graft stability. For example, Medpor has pores ranging from 100-250 µm, which allows for significant tissue ingrowth. Some implants that lack pores, such as solid silicone, prevent tissue ingrowth and bacterial entry. By virtue of silicone's nonporous nature, the infection rate is lower compared to other allografts, and stabilization is achieved via capsule formation. If the capsule becomes thick, the surrounding tissues may be adversely deformed. Silicone is also relatively inert and biocompatible by virtue of its close proximity to carbon on the periodic table.

Polymer implants

Polymers are composed of a long chain of repeating subunits. The length of chains and the amount of cross-linking of branches directly influence the stability of the polymer, an important property for implant materials. Commonly used polymers are silicone, Gore-Tex or PTFE, and Medpor. Surgical-grade silicone is composed of a methylated silicone polymer. It may come as a liquid gel or as a solid rubber. The latter is used in nasal reconstruction and is particularly useful in premaxillary augmentation. As mentioned, silicone is nonporous and hence does not permit tissue ingrowth. Gore-Tex is a polymer of fluorine and carbon with small pores (22 µm); Gore-Tex permits some limited tissue ingrowth for increased stability and has been accepted in a wide variety of uses in rhinoplasty. Medpor, a high-density polyethylene polymer, has large pore size (100-250 µm) and is very rigid.

Ceramic implants

Hydroxyapatite is the principal member of this group of implants and has been used in rhinoplasty, including premaxillary augmentation. Hydroxyapatite granules (Interpore 200) form an adherent paste that may be inserted adjacent to hard tissue but should not be used in a soft tissue pocket. Hydroxyapatite also does not resist compression and should not be considered a rigid supportive element.

Metallic implants

Metallic implants are rarely used in nasal reconstruction but are mentioned for completeness. Metallic implants may be classified into those that osseointegrate with adjacent bone to form a molecular bond (eg, titanium) and those that instead form a capsule, which in turn may impair stability.

Intraoperative Details

Insertion of implants

Many different implants are available for nasal reconstruction. These implants may be placed strategically into various anatomic sites to achieve different cosmetic goals. Implants may be placed between the anterior maxillary spine and the posterior end of the medial crura as a plumping graft to enhance nasal projection and to improve the nasolabial angle. Alternatively, a columellar strut may be inserted to increase projection, provide more structural support, and possibly alter the columellar-alar relationship.[5] The surgeon should take care not to make the strut too long; it should end just above the nasal spine. Otherwise, it may shift to the side, leading to nasal deviation and even a clicking sensation that the patient may find disconcerting.

If the entire maxillary segment between the nose and the upper lip is retrusive, a larger block may be inserted for augmentation. This should, in turn, favorably alter nasal appearance. These implants may be inserted via many different incisions. For example, a plumping graft may be inserted via an intranasal incision, external rhinoplasty incision, or sublabial incision. A larger maxillary implant may be inserted through an extended subnasal or sublabial incision.

Rotational flaps

Rotational flaps have been used less frequently for premaxillary augmentation. Adamson and McGraw describe separating the intracrural soft tissue from the medial crura through an open rhinoplasty incision (see the image below). The posteriorly based flap of intracrural tissue is then bunched up in front of the maxillary spine to achieve 3 mm of added projection. The authors report no resorption in 7 patients who underwent this technique over a 3-year period. However, they caution that this flap does not add significant projection and may be used in conjunction with other methods of augmentation.

Premaxillary augmentation rhinoplasty. Rotational Premaxillary augmentation rhinoplasty. Rotational intracrural flap. Intracrural flap is pedicled posteriorly and bunched along the anterior maxillary spine.

Flowers and Smith advocate marking out an area immediately inferior to the nasal base along the upper lip as the donor site for the premaxillary augmentation (see the image below). This flap is raised with its base medially located, de-epithelialized, and pulled through anteriorly within a columellar pocket. They contend that this particularly benefits elderly individuals because the upper lip is shortened as the nasolabial angle is increased.

Premaxillary augmentation rhinoplasty. Rotational Premaxillary augmentation rhinoplasty. Rotational subnasal flap. The de-epithelialized flap is tunneled anteriorly in a columellar soft pocket.

Orthognathic surgery

As an alternative to a maxillary implant for a retruded premaxilla, a Le Fort I osteotomy may be performed to address both the retruded premaxilla and malocclusion, if this condition exists. Advancing the entire maxilla may variably affect nasal appearance. Poor et al reported that 50% of patients undergoing Le Fort I advancement perceived worsening of nasal appearance after surgery. Unlike a plumping graft, which advances the columella and not the alae (see the image below), advancement of the whole maxilla pushes the entire nasal base forward, which may cause the alae to widen and the nasolabial angle to become more acute. Patients who undergo maxillary orthognathic surgery may require rhinoplasty.

Premaxillary augmentation rhinoplasty. Example of Premaxillary augmentation rhinoplasty. Example of a silicone premaxillary implant.


See Contraindications.

Future and Controversies

Techniques for premaxillary augmentation are part of the arsenal of the facial plastic and reconstructive surgeon. The tip-lip complex is a critical part of every rhinoplasty analysis and deserves special consideration in patients who are aging, those with congenitally malformed noses, and patients of specific ethnic descent (see Pathophysiology).

Implants remain a mainstay for premaxillary augmentation, and the surgeon must carefully weigh the advantages and disadvantages of the type of implant selected. Premaxillary implants serve to address several deformities at once: an acute nasolabial angle, underprojected nose, and short upper lip. If the entire upper lip is underdeveloped, a large implant or orthognathic surgery may be required to correct both nasal and premaxillary deficiencies. The facial plastic surgeon must use aesthetic judgment to decide the need for surgical intervention in this anatomic region critical to overall nasal and facial cosmesis.[6]