change in nasolabial fold after maxill

Nasolabial Changes After Maxillary Advancement

Raffaele Rauso, MD, Gianpaolo Tartaro, MD, Umberto Tozzi, MD,Giuseppe Colella, MD, DMD, and Mario Santagata, MD, PhD

Background: Improving facial aesthetics has been shown to bea strong motivating factor in patients who decide to undergo orthog-nathic surgery. The nasolabial region is a keystone of facial aestheticsand thus is of central importance in planning and execution of orthog-nathic surgery. This article was performed to study modificationsof nasolabial area after maxillary advancement.Methods: Forty-two patients undergoing orthognathic surgery wereconsidered. In those patients, after Le Fort I osteotomy, only maxil-lary advancement was performed.Results: For each patient, several points in the nasolabial area weremarked, and the distances between these landmarks were measuredbefore and 6 months after surgery.Conclusions: The outcomes of this study show a general trend inthe widening of the alar base with an associated shortening of thecolumellar length and lengthening of the base of the nose.

Key Words: Nasolabial aesthetics, Le Fort I osteotomy,orthognathic surgery

(J Craniofac Surg 2011;22: 809Y812)

O rthognathic surgery attempts to correct underlying skeletaldeformities and improve function. In addition, it has the poten-

tial to significantly change the central aesthetic unit of the face, thenasolabial region. A key to achieve a good, functional, and aestheticresult involves both comprehensive surgical planning and an under-standing of the effects that orthognathic surgery of the maxilla willhave on the soft tissues within the nasolabial region.1 The Le Fort Iosteotomy, which is the mainstay of procedures used to correct de-fects of the maxilla, is well known to cause adverse changes in thelip and nasal region.2Y5

Maxillary orthognathic surgery comprises 4 basic cardinalmovements to correct the specific deformity and to restore function.This includes repositioning of the maxilla superiorly, inferiorly, pos-teriorly, or anteriorly. Each of these specific movements producespotential effects on the nasolabial region and is related to both thedirection and magnitude of the maxillary repositioning.6

Among all maxillary movements, anterior maxillary advance-ment has the most profound influence on nasolabial region.1 Withmaxillary advancement, the upper lip and the alar bases tend to

advance, and the columella is lowered. This results in widening ofthe alar bases, and supratip depression becomes much more pro-nounced because of the rise of the nasal tip and a more acute naso-labial angle.2 In addition, flattening and shortening of the upper lipoccur secondary to the retraction of the transacted nasolabial mus-culature and subsequent muscle shortening and lateral retractionwhen primary repair was not performed.2 Some techniques, includingalar base cinch suture and V-Y closure, can prevent some aestheticmodifications.6Y8 This study analyzes modifications of nasolabialarea after maxillary advancement.

MATERIALS AND METHODS

PatientsThis study was conducted as a clinical retrospective study.

Between January 2004 and January 2009, at the Department of Headand Neck Pathology, Oral Cavity and Audio-Verbal Communication,Second University of Naples, Naples, Italy, a total of 144 patients(56 female and 88 male subjects) with a dentoskeletal class III de-formity underwent orthognathic surgery. All patients were operatedon by the senior author (G.T.); a bimaxillary surgery with or withoutgenioplasty was performed in all patients. In this retrospectivestudy, only patients in whom after Le Fort I osteotomy a maxillaryadvancement was planned were included (42 patients: 30 womenand 12 men). The sample was composed of 42 patients, 30 womenand 12 men. The mean age of the patients was 34.5 years (range,18Y48 years). The age of female patients ranged from 19 to 40 years,and the median age was 24 years, whereas the age of male patientsranged from 19 to 38 years, and the median age was 26 years. Diag-nostic record includes measurements taken directly from the patient’sface. Patients were divided into 5 groups, based on the differentamount of maxillary advancement (3, 4, 5, 6, and 7 mm).

Soft-Tissue MeasurementsThe measurements includes length of the base of the nose,

subnasale-pronasale distance (sn-prn); alar width, distance from rightala to left ala (al-al); columellar length, subnasale-columella distance(sn-c); length of the upper lip, upper lipYstomion distance (ls-sto);height of the upper lip, subnasale-stomion distance (sn-sto); lengthof the philtrum, subnasaleYupper lip distance (sn-ls; Figs. 1 and 2).The distances were measured directly from the patient’s face beforeand 6 months after surgery.

Surgical Procedure

MaxillaAfter nasotracheal intubation, mepivacaine hydrochloride with

1:200,000 units of adrenaline was infiltrated into the mucobuccalfold of the maxilla and mandible. Attention was first turned towardthe maxilla, where an incision was made in the upper gingivobuccalsulcus down to the bone. The periosteum was elevated, exposing thenasal spine, piriform aperture, and the face of the maxilla. After theinfraorbital nerve was identified, to avoid injury, a maxillary Le Fort Iosteotomy was performed and down fractured, which allowed this

ORIGINAL ARTICLE

The Journal of Craniofacial Surgery & Volume 22, Number 3, May 2011 809

From the Maxillofacial Surgery, Head and Neck Department, Second Uni-versity of Naples, Naples, Italy.

Received March 29, 2010.Accepted for publication September 14, 2010.Address correspondence and reprint requests to Raffaele Rauso, MD, Centro

Polispecialistico Santa Apollonia, via Martiri del Dissenso, 47, 81055Santa Maria Capua Vetere, Caserta, Italy; E-mail: [email protected]

The authors report no conflicts of interest.Copyright * 2011 by Mutaz B. Habal, MDISSN: 1049-2275DOI: 10.1097/SCS.0b013e31820f3663

Copyright © 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

segment to be manipulated forward, backward, upward, and/or down-ward. The mobile maxillary segment was subsequently placed at itspredetermined position and secured with the use of a miniYLuhrplating system. A 3Y0 polyglactin suture was used to cinch the alarbase. A midline V-Y extension was also performed with a 0.5-cmvertical limb. The mucosa was subsequently closed with 3Y0 poly-glactin sutures.

MandibleA bilateral sagittal split osteotomy was undertaken to allow

the mandible to advance. This, along with the predicted autorotation,corrected anteroposterior discrepancy and established class I incisalrelationship. An advancement genioplasty was carried out in case ofchin correction. Traditional titanium miniplates were used to stabilizethese movements. During the surgical procedures, the positions ofmaxillary segments were located using an intermediate bite wafer,with a final wafer to site the mandible in the new occlusal position.

RESULTSIn all the cases, a good, aesthetic, and functional result was

reached; there were no big complications. Table 1 shows the lengthsof maxillary advancement, the number of patients, the significance(P value) for every distance, and the average and SD, before and6 months after surgery. The general trend is a widening of the alarbase with an associated shortening of the columellar length andlengthening of the base of the nose. There is no general trend for theupper lip.

DISCUSSION AND CONCLUSIONSIn performing maxillary surgery, it is imperative for the sur-

geon to understand the preoperative aesthetic facial relationshipsand anticipate the potential effects that the surgical procedure mayproduce on the nasolabial region, so that potential adverse anestheticchanges can be minimized or avoided.1 Maxillary surgery, more spe-cifically Le Fort I osteotomy, results in significant nasal and labialchanges.5,9 Widening of the alar bases, increasing the prominence ofthe alar groove, upturning of the nasal tip, opening of the nasolabialangle, and shortening and thinning of the upper lip have been notedvariably in patients who underwent Le Fort I osteotomies performedvia a conventional circumvestibular incision.7,10,11 Among all max-illary movements, anterior maxillary repositioning has the greatestinfluence on nasal morphology in the tip and alar base regions.1

The upper lip and alar bases tend to advance, and the columella islowered. The alar bases widen markedly, and the supratip depressionbecomes more pronounced because of the rise of the nasal tip.3,11

The upper lip becomes shorter and thinner.8 Other changes in soft-tissue morphology after combined orthodontic and surgical therapymay or may not accompany the maxillary surgery and depend onseveral factors. These include surgical procedure, method of wound

closure, the new spatial arrangement of the skeletal and dental ele-ments, the adaptive qualities of soft tissues, orthodontic vectors oftooth movement, lip thickness, lip tonus, lip area, lip contact (com-petence), lip strength, interlabial gap, amount of overjet, amount offatty tissue and musculature, and postoperative edema.5,12Y18 Allthese changes are secondary to alterations in the regional anatomyassociated with surgical repositioning.3,19,20

Collins and Epker6 recommended an alar cinch procedureto prevent such widening; otherwise, other techniques to avoid thisphenomenon have been described.21Y24 Schendel25 was the first toshow a technique for repositioning the nasolabial musculature inconjunction with a V-Y mucosal closure, when widening of the alarbases or shortening and thinning of the upper lip are undesirable.

Surgical correction of dentofacial anomalies such as class IIIdeformities aims to improve both the function and the aestheticappearance of the patient. Both aspects are equally important inachieving optimal results. When planning the surgery, the surgeonmust understand the possible effects of maxillomandibular manip-ulation not only on the soft tissues that overlie the maxilla andmandible but also on other structures that play a significant role inthe overall aesthetic balance of the face, such as the nose and thelip.4 The patient needs to be informed of these possible changesand may need to be aware that future nasal surgery may be neces-sary to create a cosmetically pleasing result.

From this study, it is possible to note that maxillary anteriorrepositioning has a great effect on the nose and the upper lip. Thismovement precipitates widening of the alar base with an associatedshortening of the columellar length and lengthening of the base ofthe nose, although there is no general trend for the upper lip. It ispossible that it is the result of the use of the alar cinch suture andthe V-Y closure, during the surgical procedure. The length of thebase of the nose decreases by 0.04 to 0.05 mm for each millimeterof maxillary advancement; the alar width increases by 0.05 to0.08 mm for each millimeter of maxillary advancement; the colu-mellar length decreases by 0.03 to 0.06 mm for each millimeter ofmaxillary advancement; the length of the upper lip decreases by0.01 to 0.02 mm for each millimeter of maxillary advancement,but this change is not constant; the height of the upper lip decreasesby 0.02 to 0.06 mm for each millimeter of maxillary advancement,but this change is not constant; and the length of the philtrum de-creases by 0.02 to 0.08 mm for each millimeter of maxillary ad-vancement, but this change is not constant. About the length of the

FIGURE 1. Alar width: right alaYleft ala distance (al-al).

FIGURE 2. Length of the base of the nose,subnasale-pronasale distance (sn-prn); columellar length,subnasale-columella distance (sn-c); length of the upperlip, upper lipYstomion distance (ls-sto); height of the upper lip,subnasale-stomion distance (sn-sto); length of the philtrum,subnasaleYupper lip distance (sn-ls).

Rauso et al The Journal of Craniofacial Surgery & Volume 22, Number 3, May 2011

810 * 2011 Mutaz B. Habal, MD


base of the nose, the alar width, and the columellar length, thedifference between the average observed is significant for P G 0.05(significance value 995%) in 3- and 4-mm maxillary advancementand for P G 0.01 (significance value 999%) in 5-, 6-, and 7-mmmaxillary advancement. It is not the same for the upper-lip mea-surements, because in some cases, the difference between the aver-age observed is significant for P G 0.05 (significance value 995%);in other cases, the difference between the average observed is sig-nificant for P G 0.01 (significance value 999%), but in most cases,the difference between the average observed is not significant forP G 0.05 (significance value G95%), although the values tend todecrease.

Finding out the relationship between changes of the naso-labial region and the maxillary advancement can become an easyand not an expensive way to have an idea of how, during maxil-lary advancement, the nasolabial region could change. The result

of this finding is important because patients must be properly in-formed of this possible change that can affect the overall aestheticsof the face, keeping in mind that further surgery may need to beperformed.

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TABLE 1. Length of Maxillary Advancement, the Number of Patients, the Significance (P Value) for Every Distance, and theAverage and SD, Before and 6 Months After Surgery

Distances P Average Before and After Surgery, mm SD Before and After Surgery

Maxillary advancement: 3 mm (n =14)sn-prn 0.0205 2.2143, 2.0857 0.1460, 0.1292al-al 0.0387 2.7071, 2.9500 0.2921, 0.2981sn-c 0.0132 1.3571, 1.1571 0.2138, 0.1828ls-sto 0.0448 0.9000, 1.0214 0.1617, 0.1424sn-sto 0.8500 2.2643, 2.2857 0.3455, 0.2381sn-ls 0.9036 1.5143, 1.5214 0.2070, 0.0699





The Journal of Craniofacial Surgery & Volume 22, Number 3, May 2011 Changes After Maxillary Advancement

* 2011 Mutaz B. Habal, MD 811


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change in nasolabial fold after maxill

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