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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4387_Библиотеки_им_академика_М_И_Перельмана
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Chapter 9 Malar
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A
B
D
E
C
Fig. 9.15 The patient shown in Fig. 9.8 underwent revision surgery to correct her facial imbalance. Her brow was repositioned, her submalar
implants were removed, a subperiosteal midface lift was performed, the depressions at the chin osteotomy sites were bridged with porous
polyethylene implants, and her chin pad was resuspended. Preoperative: (A) frontal, (B) lateral, and (C) oblique views. Postoperative: (D)
frontal, (E) lateral, and (F) oblique views. (G) Intraoperative view during revision surgery shows submalar position of implant responsible for
undesired midface contour.
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F
G
REFERENCES
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1. Perrett DI, May KA, Yoshokawa S. Facial shape and judgment of female attractiveness. Nature
1994;368:239–42.
2. Yaremchuk MJ. Secondary malar implant surgery. Plast Reconstr Surg 2008;121(2):620–8.
3. Farkas LG, Hreczko TA, Katic MJ. Craniofacial norms in North American Caucasians from
birth (one year) to adulthood. In: Farkas LG, editor. Anthropometry of the head and face. 2nd
ed. New York: Raven Press; 1994, Appendix A.
4. Hinderer UT. Malar implants for the improvement of facial appearance. Plast Reconstr Surg
1975;56:157–65.
5. Silver WE. The use of alloplastic material in contouring the face. Facial Plast Surg 1986;3:81–
98.
6. Wilkinson TS. Complications in aesthetic malar augmentation. Plast Reconstr Surg
1983;71(5):643–9.
7. Powell NB, Riley RW, Lamb DR. A new approach to evaluation and surgery of the malar
complex. Ann Plast Surg 1988;20:206–14.
8. Prendergast M, Schoenrock LD. Malar augmentation. Arch Otolaryngol Head Neck Surg
1989;115:964–9.
9. Whitaker LA. Aesthetic augmentation of the malar-midface structures. Plast Reconstr Surg
1987;80(3):337–46.
10. Terino EO. Alloplastic contouring by zonal principles of skeletal anatomy. Clin Plast Surg
1992;19(2):487–510.
11. Yaremchuk MJ. Making concave faces convex. Aesth Plast Surg 2005;29(3):141–7.
12. Binder WJ. Submalar augmentation. An alternative to face-lift surgery. Arch Otolaryngol Head
Neck Surg 1989;115:797–801.
References
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Video 9.1 Malar implant. This video demonstrates placement of a porous polyethylene
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implant placed through eyelid and intraoral incisions. The implant was modied
intraoperatively to t the needs of the patient.
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Chapter 10
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Pyriform aperture
A relative deficiency in lower midface projection may be congenital or
acquired, particularly after cleft surgery and maxillary fractures. Since the
majority of white faces are convex, midface concavity is often considered less
attractive. Fig. 10.1 shows the average midface inclination of white North
Americans as determined by Farkas.1 Patients with satisfactory occlusion and
lower midface concavity can have their aesthetic desires satisfied with skeletal augmentation. Augmentation of the pyriform aperture area is usually
performed to move the lower midface profile from one of concavity to relative convexity.
Implantation of alloplastic material in the pyriform aperture area can simulate the visual effect of Le Fort I advancement and other skeletal manipulations.1 It 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. Fig. 10.2 shows
the average nasolabial angle in white North Americans as determined by Farkas.1 It also tends to efface the nasolabial fold of the overlying soft tissue
envelope.
The implant design and surgical techniques described here are extensions
of others’ previous efforts to improve paranasal aesthetics. Severe cases of
nasomaxillary deficiency, seen with Binder’s syndrome, have been treated
with bone and cartilage grafts alone or together with ostesotomies.
midface deficiency has also been treated with cartilage grafts or silicone
implants as adjuncts to aesthetic rhinoplasty.
2,3
11–14
4–10
Lower
SURGICAL ANATOMY (FIG. 10.3)
The surface of the maxilla is very irregular. 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.
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g
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g
Is
0°
–3.1° mean
(+ 3.5°)
A
Is
1.6° mean
(+ 2.5°)
B
0°
Fig. 10.1 The inclination of the midface, i.e., glabella (g) to upper lip (ls), in men and women. (A) In men g–ls is 1.3 ± 3.5 degrees. (B) In
women g–ls is 1.6 ± 2.5. Data from Farkas etal. 1994,1 with permission.
g
g
99.8° mean
(+ 11.8°)
104.2° mean
(+ 9.8°)
–3.1° mean
(+ 3.5°)
A
Fig. 10.2 The nasolabial angle in men and women. (A) In men the nasolabial angle is 99.8 ± 11.8 degrees. (B) In women the nasolabial angle
is 104.2 ± 9.8 degrees. Data from Farkas etal. 1994,1 with permission.
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0°
0°
B
1.6° mean
(+ 2.5°)
Nasalis m.
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Levator labii superioris
alaeque nasi m.
Infraorbital n.
The implant
Orbicularis oculi m.
Levator labii superioris alaeque
nasi m. (origin)
Levator labii superioris m. (origin)
Zygomatico-facial n.
Zygomaticus major m.
Zygomaticus minor m.
Levator labii superioris m.
Levator anguli oris m.
Orbicularis oris m.
Depressor septi m. (origin)
Levator anguli oris m. (origin)
Nasalis m. (origin)
Buccinator m. (origin)
Fig. 10.3 Midface skeletal, nervous, and muscular anatomy.
THE IMPLANT
Pyriform aperture (or paranasal) implants are available from Matrix Surgical
Inc. (Atlanta, GA) as Omnipor and from Stryker (Kalamazoo, MI) as Medpor.
They are designed as right and left crescents and come in two sizes. The smaller
implant is 27 mm long by 25 mm high and provides 4.5 mm of projection. The
larger implant, which is 30 mm long by 28 mm high, provides 7 mm of projection. These implants are designed to be tailored to the patient’s particular aesthetic needs. The implant is positioned to sit flush on the bone. Patient anatomy
will determine whether the entire crescent or just the horizontal or vertical limb
of the crescent are used (Fig. 10.4).
Zygomaticus minor m. (origin)
Zygomaticus major m. (origin)
Infraorbital foramen
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A
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C
Fig. 10.4 Porous polyethylene paranasal implants are designed to augment both the lateral and inferior aspects of the
pyriform aperture. Implants can be carved to allow selective augmentation. Screw xation prevents movement of the
implant and allows in-place contouring. (A) Implant augments pyriform aperture skeleton (maxilla lateral to the pyriform
aperture and alveolus). (B) Implant contoured and positioned to selectively augment alveolus. (C) Implant contoured and
positioned to selectively augment maxilla lateral to the pyriform aperture.
B
OPERATIVE TECHNIQUE (FIG. 10.5)
Paranasal augmentation can be done under local or general anesthesia.
After sterile preoperative preparation and draping, a local anesthetic with
1:200,000 epinephrine is infiltrated at the surgical site. An upper gingivobuccal sulcus incision is made just lateral to the pyriform aperture to avoid
placing incisions directly over the implant. The incision is made at least 1 cm
above the sulcus to provide an adequate cuff of mucosa inferiorly to allow
layered closure. The lip elevators can be seen after the mucosa is incised.
These muscles are not divided but, rather, retracted during the exposure of
the maxilla.
Subperiosteal dissection exposes the area to be augmented. The levator
anguli oris (caninus) and maxillary origins of the buccinator are separated
from the maxilla during implant placement. The lip elevators and the infra-
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orbital nerve are retracted to provide exposure. The borders of the pyriform
aperture, the infraorbital nerve, and the root of the canine tooth should be
PEARL
Avoid making the incision directly
over the area to be augmented.
Fig. 10.5 Diagrammatic overview of paranasal implant surgery. The
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incision is made on the labial side of the buccal sulcus and lateral
to the area to be augmented. The grey area indicates the area of
subperiosteal dissection. Note the proximity of the infraorbital nerve.
Note that the root of the canine tooth lies below the area to be
augmented. It must be avoided during screw immobilization of the
implant.
Clinical examples
identified during surgery. Defining the bony edges of the pyriform aperture provides bony landmarks facilitating precise and symmetric implant
placement. The implant may compromise the nasal airway if positioned
beyond the bony edge of the aperture. Identification of the nerve avoids
inadvertent retractor or implant damage to the structure. The root of the
canine tooth will be visible as a distinct bulge just lateral to the pyriform
aperture. The implant will, in part, lie directly over it. The surgeon must
avoid damaging these structures if screw fixation is used to immobilize the
implant.
The deeply located levator anguli oris (caninus), dilator naris, and depressor septi, as well as portions of the maxillary origins of the buccinators, are
separated from the maxilla during implant placement. The lip elevators and
the infraorbital nerve are retracted to provide exposure. As a result of these
manipulations there is usually temporary dysfunction of these structures postoperatively. The incision is closed in layers. Because of the relatively small area
of dissection, no drains are used.
CLINICAL EXAMPLES
A deficiency in lower midface projection is common in patients with surgically
corrected clefts. Both the alteration of soft tissue skeletal relationships during surgical repair and the growth-retarding forces of scarring are believed to
restrict palatal and maxillary growth after cleft repair. As shown diagrammatically in Fig. 10.6 and clinically in Fig. 10.7, augmentation of the alveolus and
lower lateral paranasal area will improve lip and nasal relationships and overall
facial balance.
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Fig. 10.6 The impact of an implant relative to
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prole and nasolabial angle. (A) Prole view of a
patient with lower midface concavity and acute
nasolabial angle. (B) Prole view showing that
augmentation of the pyriform aperture area creates
a convex prole and opens the nasolabial angle.
A B
Fig. 10.7 A 31-year-old woman, after remote cleft lip
repair, cleft palate repair, and two rhinoplasties, underwent
rhinoplasty with a tip graft, alar base repositioning, and a
paranasal augmentation. A larger implant was placed on the
cleft side. (A) Preoperative frontal view. (B) Postoperative
frontal view. (C) Preoperative lateral view. (D) Postoperative
lateral view.
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A
C
B
D
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