You are in: eMedicine Specialties > Plastic Surgery > NOSE Rhinoplasty, Maxillary AugmentationArticle Last Updated: Apr 2, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota Michael Mercandetti is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, 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, and Sarasota County Medical Society Coauthor(s): Adam J Cohen, MD, Assistant Professor, Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Consulting Surgeon, Myers Wyse Center for the Eye; Director, Center for Facial Rejuvenation; Founding Partner, HC Consulting, Inc; Edward W Chang, MD, DDS, Consulting Staff, Department of Cosmetic Services, Head and Neck Surgery, Kaiser Permanente of Northern California at Santa Rosa; Edward Farrior, MD, Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of South Florida Health Sciences Center; Donald R Laub Jr, MS, MD, FACS, Associate Professor of Surgery and Pediatrics, University of Vermont College of Medicine; Interim Chief, Plastic and Reconstructive Surgery, Fletcher Allen Health Care Editors: Fred Menick, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; George Peck, Jr, MD, Consulting Staff, Department of Plastic Surgery, St Barnabas Hospital of New Jersey; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center Author and Editor Disclosure Synonyms and related keywords: maxillary augmentation, premaxillary augmentation, maxillary retrusion, maxillary hypoplasia, craniofacial anomalies, Apert syndrome, Crouzon syndrome, rhinoplasty, midfacial retrusion, midface retrusion, lower jaw, prognathic, prognathic profile, columella-labial angle correction, maxillary bone, underdeveloped maxilla, maxilla, maxilla development, maxilla correction, intranasal approach, intraoral approach INTRODUCTIONSection 2 of 12
  Maxillary augmentation denotes the genre of reconstructive surgeries that address the correction of maxillary hypoplasia. Maxillary hypoplasia results from the underdevelopment of the maxillary bones and produces midfacial retrusion, creating the illusion of protuberance of the lower jaw. As a result the profile appears prognathic. History of the ProcedureCinelli provided one of the earliest descriptions of correcting maxillary hypoplasia in 1958.1 Correction of the premaxillary segment of a patient with an acute columella-labial angle and an overly long nose was undertaken by rotating a caudal septal cartilage flap onto the maxilla. ProblemMaxillary hypoplasia can affect different subunits of the maxillary bone. If the entire maxilla is hypoplastic, it is termed maxillary micrognathia, while premaxillary hypoplasia refers to the part of the maxillary bone between the lateral maxillary incisor fissures. Many authors refer to this area when speaking of maxillary hypoplasia in relation to rhinoplasty. The anterior spine of the maxilla can be hypoplastic, requiring augmentation with a maxillary spine graft. Hypoplasia in the area of the alar-facial junction may also occur, while Byrd and Hobar defined perialar hypoplasia as a deficiency of the nasal base skeleton.2 This deficiency results in ptosis and a diminished projection of the nasal tip. With an acute columella-labial angle, an edentulous appearance can be appreciated along with deepening of facial folds and posterior displacement of the alar base in relation to the cheek. Hinderer described para-alar implants for the correction of deep alar and nasolabial grooves.3 Medial maxillary hypoplasia, also known as nasomaxillary hypoplasia, can create a "dishpan face" appearance.2 Hinderer described this as maxillary body hypoplasia resulting in a depression of the paranasal mid face. Hypoplasia of the maxillary bone in the medial inferior orbital region can result in a tear-trough deformity, occasionally observed with malar (zygoma) hypoplasia. At times, various authors interchange premaxillary with maxillary and perialar hypoplasia when referring to the same hypoplastic area. FrequencyOften, maxillary hypoplasia is observed in various ethnic groups, but it may not be appreciated as a cause of facial deformity if subtle. EtiologyCongenital, acquired, or developmental maxillary hypoplasia can occur. PathophysiologyCraniofacial anomalies, Apert syndrome, and Crouzon syndrome include maxillary and cranial hypoplasia. More localized anomalies, such as Binder syndrome, refer to congenital maxillary hypoplasia. In Binder syndrome, also referred to as maxillonasal dysplasia, anterior nasal spine, nasal bone, and anterior maxillary hypoplasia are found. These patients have a concave mid face with a C-shaped profile, a blunted, short nose, and an acute columella-labial angle.4 Cleft palate and labial deformities are often coupled with premaxillary hypoplasia,5 resulting in an acute columella-labial angle, ptosis of the nasal tip, and upper labial retraction, with possible exposure of the upper gingiva. Etiologies of acquired hypoplasia are often from trauma or from malposition of the maxillary bone following surgery. Converse et al have postulated that during childhood, trauma can have a retarding effect on facial development.6 Developmental hypoplasia may be a sequela to dental extraction, with failure of the maxillary bone to properly mature and expand. ClinicalPatients of Northern European ancestry, including English descendants, can have maxillary hypoplasia.7 Premaxillary hypoplasia is often observed in patients of Hispanic, African American, and Asian (mesorrhine) heritage. Platyrrhine (African American) noses can also appear flared with widened alae, insufficient dorsal nasal support, and underprojection of the nasal tip.8 INDICATIONSSection 3 of 12
Aesthetic considerations The middle third of the face is the area delineated by a horizontal line connecting the lateral canthi to a horizontal line tangentially placed at the upper edge of Cupid's bow of the lip.9 More common descriptions denote the middle third of the face to encompass from the glabella to the subnasale9 or from the brow to the base of the nose.10 While certain aspects of facial beauty or facial handsomeness transcend culture, ethnicity, and time, other aspects are particular to one or more of these conditions. Facial features that are considered beautiful in today's world can differ not only between Eastern and Western cultures, but from age to age within a given culture. Maxillary augmentation is indicated when any part of the maxilla is hypoplastic and creates an aesthetic or functional deficiency. Maxillary augmentation in the context discussed herein denotes an adjunctive procedure used during rhinoplasties. If malocclusion exists, surgeries that create osteotomies, such as Le Fort I-type fractures, anterior maxillary displacement, and other orthognathic procedures, can be employed. RELEVANT ANATOMYSection 4 of 12
Each of the two maxillary bones is pyramidal and consists of 4 legs or processes: the zygomatic process, the frontal process, the alveolar process, and the palatine process. These processes emanate from the body of the maxillary bone. The premaxilla is found between the lateral maxillary incisor fissures anterior to the incisive foramen (see Image 2). The premaxilla includes the 4 incisor teeth and the nasal spine. Within the body of the maxillary bone is the maxillary sinus. The orbital floor serves as the roof of the maxillary sinus and transmits the infraorbital neurovascular structures via the infraorbital groove and canal. These structures exit at the infraorbital foramen, superior to the canine fossa. The frontal surface of the maxillary bone forms the anterior wall of the maxillary sinus and contains the infraorbital foramen. The lateral nasal wall forms the medial wall of the maxillary sinus and the alveolar and palatine processes form the floor of the sinus. The alveolar process houses the teeth, and the palatine process forms most of the hard palate. The zygomatic process of the maxilla joins the zygoma, forming the infraorbital rim and most of the floor of the orbit. Lastly, the frontal process of the maxilla extends superiorly and joins with the nasal bone, the lacrimal bone, and the frontal bone. The maxillary bone is composed of 4 vertical buttresses. One buttress is the lateral buttress, which is also referred to as the zygomaticomaxillary buttress; the anterior buttress is referred to as the nasomaxillary buttress. The posterior buttress is also referred to as the pterygomaxillary buttress. The final buttress, the median buttress, is also referred to as the frontoethmoidovomerian. The first 3 buttresses are dual or paired whereas the last buttress is single. CONTRAINDICATIONSSection 5 of 12
A major contraindication is an allergy to implant materials. A relative contraindication is presented by patients who have extremely thin skin, making implant camouflage challenging. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Surgical TherapyTwo 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 and/or bony autografts and/or homografts, hydroxyapatite granules, Gore-Tex, acellular dermis, porous polyethylene, and, in the past, Proplast have been used. 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. Preoperative DetailsAppropriate 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. Intraoperative DetailsIn 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 Postoperative DetailsPostoperative antibiotics are administered routinely, and the patient is advised to avoid excessive manipulation of the area. Follow-upPatients 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. COMPLICATIONSSection 8 of 12
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. OUTCOME AND PROGNOSISSection 9 of 12
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.”7 The patient and surgeon ultimately decide which implant material to use. FUTURE AND CONTROVERSIESSection 10 of 12
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. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Rhinoplasty, Maxillary Augmentation excerpt Article Last Updated: Apr 2, 2008 | ||||||||||||||||||||||||||||||||||||||||
