assessment of three-dimensional nasolabial response to le fort i advancement

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e8

Assessment of three-dimensional nasolabialresponse to Le Fort I advancement

Philipp Metzler a, Erik J. Geiger a, Christopher C. Chang a,Irin Sirisoontorn b, Derek M. Steinbacher a,*

a Department of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven,CT 06520, USAb Dental Section, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University,Nonthaburi, Thailand

Received 13 January 2014; accepted 15 March 2014

KEYWORDSLe Fort I;Nasolabial;Three-dimensional;Anthropometric

* Corresponding author. DepartmentTel.: þ1 (203) 785 4559; fax: þ1 (203

E-mail addresses: derek.steinbach

Please cite this article in press as: MJournal of Plastic, Reconstructive &

http://dx.doi.org/10.1016/j.bjps.2014.01748-6815/ª 2014 Published by Elsevier

Summary Background: Le Fort I advancement induces soft tissue changes to the nasolabialregion. The correlation of sagittal skeletal movement to soft tissue alteration has been studiedusing 2D methods. However, the influence of maxillary advancement has not been adequatelyassessed using three-dimensional means. The purpose of this study is to analyze nasolabialchanges following Le Fort I advancement using 3D photometric measurements.Methods: Patient demographic information and their amount of advancement were tabulated.Pre- and postoperative 3D photographs (3D VECTRA photosystem, Canfield, Fairfield, NJ) were re-corded. Nasolabial anthropometric measurements were performed using the corresponding 3Dpost-processing software (Mirror). Six month minimum follow-up elapsed before final evaluation.Results: Forty-four 3D photo data setswere included. Meanmaxillary advancementwas 5.5 (�1.9)mm. Male/female ratio was 0.7 with a mean age of 16.7 years. Significant increases (p < 0.0001)were seen in thealar base,alarwidths, nostrilwidth, and in the soft triangle and lateral alar angles.Significant decreases (p< 0.0001) were noted in the nasofrontal angle and in nostril height. A sig-nificant (p < 0.05) increase of the nasal tip, columella and upper lip projection was seen. Philtralheight showed no significant changes (p> 0.05) aftermaxillary advancement. No significant corre-lation (p> 0.05) between the degree of soft tissue changes and the amount of maxillary advance-ment was found.Conclusion: LeFort I advancement significantly impacts thenasolabial soft tissueenvelope. The3Dsoft tissue changes are predictable and similar for any advancement up to 10 mm.ª 2014 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive andAesthetic Surgeons.

of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT 06520, USA.) 785 [email protected], [email protected] (D.M. Steinbacher).

etzler P, et al., Assessment of three-dimensional nasolabial response to Le Fort I advancement,Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.03.023

3.023Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

mailto:[email protected]

mailto:[email protected]

http://dx.doi.org/10.1016/j.bjps.2014.03.023



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Introduction

Nasolabial symmetry, projection,and shapeplayacentral rolein facial aesthetics and expression.1 Due to the close rela-tionship between these soft tissues and the underlyingmaxillary bone, Le Fort I advancement has a significant influ-ence on these structures and, consequently, on overall facialproportions and balance.2e5 In addition, various soft tissueclosure techniques following skeletal correction have beenshown to significantly impact nasolabial configuration.2,6e9

Two-dimensional lateral cephalograms have been utilizedfor both presurgical planning, as well as postsurgical evalua-tion of outcomes. However, algorithms intended to predictsoft tissue change from skeletal movement are limited toradiologic 2D shadow superimposition. Three-dimensionalanalysis and objective data is critical to properly define thetype and extent of nasolabial change with Le Fort I. This in-formation is useful for accurate planning, proper patientcounseling, and optimization of esthetic outcomes.

The purpose of this paper was to three-dimensionallyassess and describe the nasolabial soft tissue changesfollowing Le Fort I advancement. Additionally, we sought toevaluate the relationship between the amount of maxillarymovement and nose/lip morphometrics. We hypothesizethat significant three-dimensional nasolabial soft tissue al-terations occur following Le Fort I advancement.

Patients and methods

Subjects

This retrospective analysis was performed in concordancewith the Yale University Institutional Review Board (Proto-col number: HIC# 1101007932). Patients who underwentsingle-piece Le Fort I advancement were included. Exclu-sion criteria were superior or inferior positioning of themaxilla and previous naso-maxillary surgery.

Table 1 Landmarks used for 3D nasolabial soft tissue assessme

Landmark Abbreviation Definition

Glabella G Most anteriorlyNasion N Most depressedAlare Al Most lateral poiSubalare SA Labial insertionPronasale Prn Most anterior poCollumella peak CP Most superior poSubnasale Sn Midpoint of theMedial nostril base mNb Point on inner nLateral nostril base lNb Most inferolaterLateral alar LA Point on inner nSoft triangle ST Most superiormeMidcolumella MC Medial nostril pLateral Crus LC Perpendicular tCrista philtri superior Cphs Top of the philtLabiale superius Ls Midpoint of theCrista philtri inferior Cphi Point of maximuChelion Che Most lateral poiTragus Tr Most anterior po

Please cite this article in press as: Metzler P, et al., Assessment of tJournal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://

Demographic information was tabulated including pa-tients’ age, gender, and diagnosis. Peri-operative detailsincluding the amount of advancement and suture techniquewere documented. Pre- and postoperatively, all subjectswere assessed using a 3D photogrammetric imaging tech-nique. The postoperative interval was at least 6 months.

Imaging and data processing

The three-dimensional photogrammetric data was acquiredusing the 3D VECTRA photosystem (Canfield, Fairfield, NJ).System calibration was performed before every captureprocess. Natural head position was chosen for data acqui-sition. Data sets were saved and calculated into a three-dimensional model. Further data processing was performedusing the corresponding imaging software (Mirror). Validityand reliability of the 3D photogrammetric tool for anthro-pometric measurements was confirmed in previousstudies.10,11

Two blinded observers indicated the landmarks on eachfacial soft tissue image. The zoom and rotation tools wereused to correctly identify and set the landmarks on the 3Dsurface (Table 1, Figures 1 and 2). To evaluate post-operative soft tissue changes, a paired two-sample t-testwas used. An alpha level of 0.05 indicated a significantdifference in scores. A cut-off of 5 mm was used to stratifythe patients into two groups based on magnitude ofmaxillary advancement for additional analyses. An un-paired two-sample t-test was used for this evaluation.

Results

Forty-four pre- and postoperative 3D photo data sets couldbe included in this study. Male/female ratio was 0.7 with amean age of 16.7 years. A maxillary advancement wasexclusively performed in this study population, showing amean value of 5.5 (�1.9) mm. Latency time for

nt.

projected point of the forehead within the midsagittal planemidline point superior to the nasal bridgent of the alar contourof each alar baseint of the noseint of the Columellanasolabial angle at the columellar baseostril where the columella meets the columellar crestal point of the nostrilostril rim at its labial insertiondial point of the nostriloint at midcolumella height levelo the columella, through the MC on the lateral crusral crest at the level of the subnasaleupper vermillion borderm vertical height of upper vermillion border (Cupid’s bow)nt of labial commissureint of the tragus

hree-dimensional nasolabial response to Le Fort I advancement,dx.doi.org/10.1016/j.bjps.2014.03.023

Figure 1 Overview of the used nasolabial landmarks for 3D photometric analysis.

3D nasolabial response to LeFort 1 advancement 3

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postoperative 3D photo capturing showed a mean of 7.8months.

Mean preoperative nasofrontal angle was 144.7 � 6.3�

and decreased to 141.2 � 6.8� postoperatively(p < 0.0001). Mean nasal tip projection was 124.5 � 3.1 mmpreoperatively while it was 125.2 � 11.7 mm (p Z 0.0353)postoperatively. Columella projection increased signifi-cantly (p Z 0.0163), showing respective means of120.3 � 3.2 mm and 121.4 � 2.8 mm pre- and post-operatively. Preoperative mean nasal tip prominence was30.1 � 3.2 mm, while the postoperative mean was28.5 � 2.9 mm (p Z 0.0014).

Mean alar base width preoperatively was 29.2 � 3.2 mm,which increased to 31.9 � 4.0 mm (p < 0.0001) post-operatively. Mean preoperative alar width was34.2 � 2.6 mm and increased to 37.0 � 3.7 mm post-operatively (p < 0.0001). Nostril height decreased signifi-cantly (p < 0.0001), showing respective means of14.1 � 2.2 mm and 13.3 � 2.1 mm pre- and postoperatively.Mean nostril width increased postoperatively from10.6 � 1.9 mm to 11.4 � 2.3 mm (p < 0.0001). The

Figure 2 Nasal landmarks for morphometric analysis.


combined bilateral sill width had a preoperative mean of6.7 � 1.6 mm, which decreased to 5.9 � 1.3 mm post-operatively (p < 0.0001). Soft triangle angle measurementsincreased postoperatively from a mean of 70.6 � 10.0� to80.3 � 9.2� (p < 0.0001).

The lateral alar angle decreased significantly(p < 0.0001) showing a mean 110.2 � 13.9� preoperativelyand 99.8 � 13.5� postoperatively. No significant differences(p > 0.05) could be seen pre- and postoperatively whencomparing between the left and right nostril dimensions(Table 1).

Subnasale projection showed a mean of 112.6 � 2.2 mmpreoperatively and increased to 114.3 � 1.6 mm post-operatively (p Z 0.004), while lip projection showed apreoperative mean of 115.2 � 2.8 mm and increased to apostoperative mean of 117.8 � 2.6 mm (p Z 0.0005). Meanpreoperative columella height was 11.4 � 1.6 mm, and thisdecreased to 10.8 � 2.0 mm postoperatively (p Z 0.0384).The upper philtrum width increased postoperatively from amean of 11.7 � 2.1 mm to 12.6 � 2.2 mm (pZ 0.0007), andthe lower philtrum width increased from a mean of7.6 � 2.4 mm preoperatively to 12.6 � 2.2 mm post-operatively (p Z 0.0331).

No significant changes were identified in the columellawidth and labial width postoperatively (p Z 0.6635 andp Z 0.2894, respectively). Percentages of soft tissuechanges correlated with the absolute maxillary advance-ment are demonstrated in Table 1. We also stratified pa-tients into groups to compare soft tissue changes aftermaxillary advancements of less than and more than 5 mm.Subsequent evaluation revealed no significant differences(p > 0.05) between the two groups (Table 2).

Discussion

Le Fort 1 advancement is known to have beneficial effectson the facial profile, especially within the nasolabial re-gion. However, adverse side-effects including widening ofthe alar bases, increasing nasal tip projection, and flat-tening, thinning, and shortening of the upper lip havepreviously been described.3,4,12e18 Previous studies suggestthat soft tissue changes due to maxillary advancement


Table 2 Parameters (direct distances and angles) used for 3D nasolabial soft tissue assessment.

Measurement Abbreviation Definition

NoseNasofrontal angle NFA Angle between G-N-PrnNasolabial angle NLA Angle between CP-Sn-LsNasal projection NP Distance between Tr-PrnAlar base width ABW Distance between SA (l)-SA (r)Alar width ACW Distance between Al (l)-Al (r)Sill width right SWr Distance between mNb-lNb (r)Sill width left SWl Distance between mNb-lNb (l)Nostril height right NHr Distance between LA-ST (r)Nostril height left NHl Distance between LA-ST (l)Nostril width right Nwr Distance between MC-Al (r)Nostril width left NWl Distance between MC-Al (l)Soft triangle angle right STAr Angle between MC-ST-LC (r)Soft triangle angle left STAl Angle between MC-ST-LC (l)Lateral alar angle right LAAr Angle between lNb-LC-ST (r)Lateral alar angle left LAAl Angle between lNb-LC-ST (l)Columella width CW Distance between MC (r)-MC (l)Columella heigtht CH Distance between Sn-CPColumella projection CP Distance between Tr-CPLipSubnasale projection SnP Distance between Tr-SnLower philtrum width LPW Distance between Cphi (r)-Cphi (l)Upper philtrum width UPW Distance between Cphs (r)-Cphs (l)Philtrum height PH Distance between Ls-SnLip width LW Distance between Che (r)-Che (l)Labiale superius projection LSP Distance between Tr-Ls

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occur inconsistently, complicating reliable hard-to-softtissue predictions. Nasal tip advancement has been re-ported to increase between 30% and 60% of the totalamount of maxillary advancement.19e21 The columellarbase was touted to advance to a greater extent than thenasal tip, secondary to the anterior movement of themaxilla, but this phenomenon was also inconsistentlyreproduced.7 The alar width was found to consistently in-crease after maxillary advancement but a wide range hasbeen described.2,12,22 The change in upper lip morphologyis reported to have the most direct response to maxillary/incisor advancement - representing values up to 140% ofmaxillary advancement.2,8 Postoperative two-dimensionalsoft tissue changes as a result of maxillary movementshave been described in the literature and variably reportedto be used as a reference for current prediction planning.However, these predictions are inherently biased fromoverlapped structures and do not accurately represent thethree-dimensional changes that occur within the overlyingsoft tissue.13,23,24 Indeed, the most objective analysisstrategy is 3D morphometric analysis (see Table 3).

Multiple methods have been described for three-dimensional soft tissue assessment following orthognathicsurgery. Attempts including direct anthropometric, moire,laser, and volumetric computed tomography measurementswere shown to be limited due to poor surface texture andresolution. Less detailed information considerably hindersreproducibility and reliability of measurements, allowingonly rough quantitative measurements and coarse evalua-tion. 3D photo technology overcomes these drawbacks by


providing real three-dimensional and detailed anthropo-metric data.10,11,25 However, as in every facial morpho-metric assessment, changes in facial expression have thepotential to bias study results. Therefore, during picturecapturing our patients were instructed to keep their facialexpression neutral pre- and postoperatively (see Figure 3).

To the authors’ knowledge, no study exists focusing onthree-dimensional nasolabial soft tissue changes after LeFort I advancement using 3D photo technology at this levelof detail. We hypothesized that more complex three-dimensional nasolabial soft tissue changes are impartedfollowing maxillary advancement than have been previouslyshown using 2D means (see Table 4).

In our cohort, the nasolabial soft tissue changes werecompared with the actual bony movements measuredintraoperatively. An average projection increase of thenasal tip, as measured from the tragus, was about 10% ofthe total maxillary movement but is of questionable clinicalrelevance. However, the nasal tip prominence (measuredfrom the alar groove to the tip) significantly decreased byabout 32% of the total maxillary advancement. So, althoughactual tip projection increased, compared to the posteriorface, the relative tip prominence (the proportion of thenasal tip in front of the upper lip) decreased. This findingwas likely due to the more obtuse alar relationship sec-ondary to advancement and widening of the ala as thepiriform came forward. The widened, obtuse ala pulled thetip back, following the tripod theory, despite an increase innasal projection relating to the face.26,27 In other words,intrinsic nasal tip projection decreased e relative to the


Table 3 Morphometric evaluation before and after maxillary advancement.

Measurement (mm,�) T1 T2 DT2�T1 CI p-value D T/Adv (%)

NoseNasofrontal angle 144.7 � 6.3 141.2 � 6.8 3.5 � 1.7 �4.5 to �2.6 <0.0001* 66.8YNasolabial angle 124.9 � 11.3 125.2 � 11.7 0.4 � 8.3 �4.2 to 5.0 0.0353 2.1YNasal tip projection 124.5 � 3.1 125.3 � 3.0 0.8 � 1.9 0.2 to 1.8 0.0031* 10.2[Nasal tip prominence 30.1 � 3.2 28.5 � 2.9 1.6 � 1.6 �2.5 to �0.7 0.0014* 31.8YAlar base width 29.2 � 3.2 31.9 � 4.0 2.8 � 1.9 1.7 to 3.8 <0.0001* 54.0[Alar width 34.2 � 2.6 37.0 � 3.7 2.9 � 2.0 1.7 to 4.0 <0.0001* 54.5[Sill width right 6.9 � 1.5 6.1 � 1.1 0.8 � 0.8 �1.2 to �0.4 0.0011* 14.1YSill width left 6.5 � 1.6 5.8 � 1.3 0.6 � 0.8 �1.1 to �0.2 0.0061* 10.6YNostril height right 13.9 � 2.2 13.0 � 1.8 0.9 � 0.8 �1.4 to �0.4 0.0011* 16.5YNostril height left 14.2 � 2.1 13.4 � 2.3 0.8 � 0.4 �1.0 to �0.5 <0.0001* 15.9YNostril width right 10.6 � 2.0 11.2 � 2.4 0.6 � 0.9 0.1 to 1.1 0.0221* 12.7[Nostril width left 10.9 � 1.9 12.0 � 2.2 1.1 � 0.9 0.6 to 1.6 0.0004* 20.9[Soft triangle angle right 70.8 � 11.6 79.8 � 10.4 9.0 � 4.8 6.3 to 11.7 <0.0001* 181.4[Soft triangle angle left 71.0 � 8.6 81.5 � 7.6 10.5 � 6.1 7.1 to 13.9 <0.0001* 201.3[Lateral alar angle right 110 � 16.5 100.3 � 14.4 9.7 � 6.4 �13.2 to �6.2 <0.0001* 198.9[Lateral alar angle left 109.3 � 13.4 97.2 � 15.2 12.1 � 7.5 �16.2 to �8.0 <0.0001* 226.3[Columella width 6.7 � 1.3 6.5 � 0.8 0.2 � 1.3 �0.9 to 0.6 0.6635 2.9YColumella height 11.4 � 1.6 10.8 � 2.0 0.6 � 1.0 �1.1 to �0.04 0.0384* 9.9YColumella projection 120.3 � 3.2 121.4 � 2.8 1.0 � 1.5 0.2 to 1.9 0.0163* 16.1[LipSubnasale projection 112.6 � 2.2 114.3 � 1.6 1.7 � 1.9 0.6 to 2.7 0.004* 28.8[Lower philtrum width 11.7 � 2.1 12.6 � 2.2 0.9 � 0.9 0.5 to 1.4 0.0007* 19.6[Upper philtrum width 7.6 � 2.4 8.5 � 2.6 0.9 � 1.5 0.1 to 1.7 0.0331* 18.7[Philtrum height 14.6 � 3.4 14.9 � 3.1 0.3 � 1.6 �0.6 to 1.2 0.4894 6.6[Mouth width 49.3 � 2.8 50.1 � 4.2 0.8 � 2.7 �0.7 to 2.3 0.2894 17.6[Labiale superius projection 115.2 � 2.8 117.9 � 2.6 2.7 � 2.3 1.4 to 4.0 0.0005* 51.2[

T1 preoperative.T2 postoperative.CI Confidential Interval.DT (T2�T1)/&uarr.[ Increase.Y Decrease.


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alar groove e as the ala splayed, while extrinsic tip pro-jection increased as the piriform and anterior nasal spine(ANS) pushed the entire nasal complex forward.

Further, a general decrease of the nasofrontal angle,representing the upward rotation of the nasal tip, was seenin all patients. We demonstrated a significant width in-crease of landmarks within the ala and alar base region,demonstrating mean transverse widening of about 50% ofthe corresponding amount of maxillary advancement.These findings were consistent in all patients, independentof the extent of the skeletal advancement (See Figure 4).

Nostril dimensions (nostril height, nostrilwidth, sillwidth)and shape (soft triangle and lateral alar angles) were signif-icantly changed by the maxillary advancement. Post-operatively, the nostril width increased, while the verticaldimension decreased, both significantly. At the same time,the soft triangle angle becamemore obtuse while the lateralalar angle became more acute postoperatively. Clinically,this alteration of the alar-columellar relationship resulted inan increased lateral nostril display. This occurs due to acombination of columellar caudal buckling, secondary to theosseous advancement, and the alar retraction/upwardrotation from soft tissue degloving. Interestingly, the colu-mella width did not change significantly.


The labial superius showed an advancement of 50% ofthe total maxillary movement. The nasolabial angle did notdemonstrate a predictable trend after maxillary advance-ment. Although the philtrum height remained stable, sig-nificant upper lip widening (including both upper and lowerphiltral widths) was noted, again secondary to the moreforward bony position and resultant increase in soft tissuetension and drape.

Comparing nasolabial changes in 2 groups based onmagnitude of advancement one <5 mm (mean Z 4.4 mm)and one >5 mm (mean Z 7.0 mm), no significant differ-ences in morphometrics could be found. In other words, a5 mm advancement will result in the changes describedabove, and these do not proportionally increase withincreasing amounts of advancement, based on our findings.

Our study does demonstrate that more complex three-dimensional soft tissue changes occur following Le Fort Iadvancement than previously described using 2D studies.This objective anthropometric analysis demonstrates pre-dictable and similar changes in nasolabial soft tissue anat-omy after maxillary advancements up to 10 mm, which canbe helpful for future soft tissue prediction planning. This ofcourse does not minimize the fact that each patient isunique and requires tailored approaches and discussion,


Figure 3 Superimposing of 3D photos before and after LeFort I advancement showing significant 3D nasolabial changes.Due to retrogenia, a genioplasty was additionally performed inthis patient.

Table 4 Soft tissue changes according to the amount ofadvancement.

Measurement (mm,�) <5 mm >5 mm D > 5 mm� < 5 mm

p-value

NoseNasofrontal angle �3.4 �3.7 0.3 0.1723Nasolabial angle 2.2 4.3 2.2 0.1624Nasal tip projection 0.3 1.5 1.1 0.2558Nasal tip prominence �1.0 �2.4 1.4 0.0830Alar base width 3.1 2.2 1.0 0.3662Alar width 2.9 2.8 0.1 0.9242Sill width right �0.6 �1.2 0.6 0.1517Sill width left �0.3 �1.1 0.8 0.0519Nostril height right �0.7 �1.2 0.6 0.1956Nostril height left �0.9 �0.6 0.2 0.3018Nostril width right 0.7 0.4 0.3 0.588Nostril width left 1.2 0.9 0.3 0.5425Soft triangle angle right 7.8 10.8 3.0 0.2596Soft triangle angle left 8.6 10.3 1.7 0.937Lateral alar angle right �8.7 �11.2 2.5 0.4715Lateral alar angle left �10.7 �12.6 1.9 0.8246Columella width 0.2 �0.7 0.9 0.2054Columella height �0.4 �0.9 0.5 0.3861Columella projection 0.7 1.6 0.9 0.239LipSubnasale projection 1.3 2.3 1.0 0.3362Lower philtrum width 1.1 0.7 0.4 0.3781Upper philtrum width 1.1 0.6 0.6 0.5038Philtrum height 1.3 0.9 0.4 0.4282Mouth width 1.0 0.4 0.7 0.6651Labiale superius

projection2.8 2.5 0.3 0.7967

<5 mm maxillary advancement (mean values).>5 mm maxillary advancement (mean values).

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with consideration of gender, ethnicity, and goals oftreatment.

A multitude of techniques have been described to con-trol undesired morphologic soft tissue changes afterorthognathic surgery. The presence or absence of theanterior nasal spine was reported to have less of an effecton postoperative nasal morphology than one might intuit.28

However, our clinical experience reveals, and our under-standing of anatomic relationships suggests, that the ANSdoes impact on subnasal projection, nasolabial angle, andnasal tip movement and projection, when considered inlight of variables such as the amount of advancement, un-derlying anatomic variation, nasolabial morphology andskin thickness.29

The modeling ostectomy within the lateral piriformaperture of the Le Fort I segment, which reduces orsmoothens the step between the upper portion of thebilateral nasal buttresses and the lower portion of theanteriorly moved Le Fort I segment, reduces alar baseprojection and widening. This procedure should beconsidered, especially in larger maxillary advancements.Further, the classic Le Fort I osteotomy line represents asuperiorly inclined plane in reference to the Frankforthorizontal plane. An anterior advancement within this


plane will consequently lead to a compromised nasalseptum, resulting in morphologic and functional nasalchanges. The leveling of the nasal crest to prevent anysepto-maxillary interference is often sufficient to maintainthe septal midsagittal position. Depending on the septaland maxillary morphology, a surgical shortening of theposterior septal angle may be required. Correction of theseptal interface with the ANS and maxillary crest is easilyperformed following “down fracture” as an excellentexposure is achieved. One must recognize the impact ofimproper handling of the septum, with over-resectionresulting in potential loss of tip projection and under-resection risking caudal septal deflection and deviation.Both of these results may jeopardize optimal nasalmorphology, function, and esthetic outcome. Surgicalosteotomy below the anterior nasal spine has been intro-duced, but risks the dentition and did not result in pre-venting the adverse soft tissue effects.30 (See Figure 5).

Soft tissue closure after Le Fort I advancement does alsoplay a role in optimizing nasolabial form, or at least pre-venting any untoward response. We recognize that surgicalapproach frees the insertions of the nasolabial muscles andseparates the attachment of the alar base from the un-derlying bone. This dissection alone impacts nasolabial


Figure 4 Lateral view showing the complex pattern of 3D nasolabial changes after orthognathic surgery. A superior rotation ofthe nasal tip and the increase of nasal tip, subnasal and upper lip projection before (grey surface) and after (3D mesh) maxillaryadvancement can be seen.


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morphology and the alarefacial interface. This relationshipis altered further with maxillary advancement and move-ment, with subsequent redraping of the nasolabial tissue.Techniques have been devised therefore to influencedesired or “proper” redraping of the nasal base and upperlip. The alar cinch suture is an attempt to narrow, or con-trol excess widening of, the alar base, and takes some formof an inter-alar suture on the deep surface. The “VeY” lipmucosal closure entails recruiting lateral mucosa inferiorlyand medially, to increase lip pout and possibly length. Somesuggest that the combination of both techniques simulta-neously garner esthetic benefits by controlling the nasola-bial fibro-muscular structures.2,6e9,31 Others have toutedperformance of definitive correction of alar and sill via aformal rhinoplasty at a later date, following soft tissuesettling.4 Concurrent rhinoplasty is also a possibility, but inthe setting of a Le Fort I, the degloved alar base cannot beaccurately judged, and it is best to wait for interval softtissue swelling and contraction to resolve.32

It is clear that a range of desired and undesired naso-labial consequences may be experienced following Le FortI, depending on the skeletal movement, host soft tissue

Figure 5 Frontal view showing 3D transverse nasolabial changes3D transverse enlargement of the lateral nasal structures after ma


variables, and techniques for closure and redraping of thesoft tissue. However, our data suggests that, in a straight-forward Le Fort I, these changes are predictable andreproducible. These should be anticipated and emphasizedduring the planning session to the patient as either adesired consequence, or as an untoward result of the pro-cedure that may be temporarily controlled during theclosure, or more likely, definitively addressed at a latertime.32

Accurate understanding and quantification of the 3D softtissue response to Le Fort I is essential to achieve the mostaccurate treatment plan and esthetic result. Also, as pre-viously mentioned, when undesired consequences are ex-pected, this permits proper patient counseling and theproscription of intraoperative controls or future proceduresto be implemented. Future efforts will be geared toinvestigating a variety of skeletal movements, the influenceof age, gender and ethnicity, and the presence or absenceof common craniofacial syndromes on nasolabial results.These studies will permit more reliable 3D planning, accu-rate predictions of surgical outcomes, and the eventualachievement of the most esthetic results.

before (grey surface) and after (3D mesh) surgery. A significantxillary advancement is visible.


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Conclusion

Nasolabial soft tissue changes following Le Fort I advance-ment are more complex than previously described.Morphometric changes, including: increased inter-alarwidening, tip rotation, and lateral nostril display,occurred in a consistent reproducible fashion for a Le Fort Iadvancement up to 10 mm. This objective 3D understandingwill permit accurate planning, counseling, and help opti-mize eventual esthetic outcomes.

Acknowledgments

The authors do not have any source of funding or conflictsof interest to declare for this project. None of the authorshas a financial interest in any of the products, devices, ordrugs mentioned in this manuscript.

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assessment of three-dimensional nasolabial response to le fort i advancement

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