Skeletal deficiency in the central midface impacts nasal aesthetics. This lack of lower face projection can be corrected by alloplastic augmentation of the pyriform aperture. Creating convexity in the deficient midface will make the nose seem less prominent. Augmentation of the pyriform aperture is, therefore, often a useful adjunct during the rhinoplasty procedure. Augmenting the skeleton in this area can alter the projection of the nasal base, the nasolabial angle, and the vertical plane of the lip. The implant design and surgical techniques described here are extensions of others’ previous efforts to improve paranasal aesthetics.
Key points
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Pyriform aperture augmentation increases the convexity of the lower midface.
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Increasing the convexity of the midface makes the nose seem less prominent.
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Pyriform aperture augmentation increases the projection of the nasal base and nasal tip.
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Pyriform aperture augmentation opens the nasolabial angle and effaces the nasolabial fold.
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Avoid making the intraoral incision directly over the area to be augmented.
Skeletal deficiency in the central midface impacts nasal aesthetics. This lack of lower face projection can be corrected by alloplastic augmentation of the pyriform aperture. Creating convexity in the deficient midface will make the nose seem less prominent. Augmentation of the pyriform aperture is often a useful adjunct during the rhinoplasty procedure. Augmenting the skeleton in this area can alter the projection of the nasal base, the nasolabial angle, and the vertical plane of the lip.
The implant design and surgical techniques described here are extensions of others’ previous efforts to improve paranasal aesthetics. Severe cases of the nasomaxillary deficiency, seen with Binder syndrome, have been treated with bone and cartilage grafts alone or together with ostesotomies. Lower midface deficiency has also been treated with cartilage grafts or silicone implants as adjuncts to aesthetic rhinoplasty.
Preoperative evaluation
Anthropometric Data
Midface concavity is often considered less attractive. Augmentation of the pyriform aperture area is usually performed to move a flat or concave lower midface profile to relative convexity.
When used as an adjunct to rhinoplasty, augmentation later to the pyriform aperture will increase the projection of the nasal base. Augmentation of the maxillary alveolus below the pyriform aperture will increase the nasolabial angle and the vertical plane of the lip ( Fig. 1 ).
Pyriform aperture augmentation increases the convexity of the lower midface and improves the projection of the nasal base, thereby opening the nasolabial angle.
Preoperative evaluation
Anthropometric Data
Midface concavity is often considered less attractive. Augmentation of the pyriform aperture area is usually performed to move a flat or concave lower midface profile to relative convexity.
When used as an adjunct to rhinoplasty, augmentation later to the pyriform aperture will increase the projection of the nasal base. Augmentation of the maxillary alveolus below the pyriform aperture will increase the nasolabial angle and the vertical plane of the lip ( Fig. 1 ).
Pyriform aperture augmentation increases the convexity of the lower midface and improves the projection of the nasal base, thereby opening the nasolabial angle.
Surgical anatomy
The anterior or facial surface of the maxilla is very irregular ( Fig. 2 ). Inferiorly, this is due to a series of eminences and corresponding depressions reflecting the apices of the teeth. The incisive fossa is the depression above the prominent incisors. This depression gives rise to the origin of the depressor septi. The canine tooth forms a vertical ridge that separates the incisive fossa from the canine fossa, which is deeper and larger than the incisive fossa. The canine fossa gives rise to the levator anguli oris. The infraorbital foramen is located just above the canine fossa. It allows exit of the infraorbital nerve and vessels. They travel beneath the levator superioris and above the levator anguli oris. The infraorbital nerve supplies the skin of the lower lid, the side of the nose, most of the cheek, and upper lip. Medial to the infraorbital foramen is the nasal notch, which is a concavity whose margin gives rise to the dilator naris as it ends below as the anterior nasal spine.
