Association of Increasing Nasal Tip Projection With Lip Position in Primary Rhinoplasty

The Incidence of Nasal Tip and Upper Lip Malposition in Primary Rhinoplasty

BACKGROUND

For an optimal aesthetic plan for correction of nasal tip disharmony, it is crucial to note lip and tip disproportions.

OBJECTIVES

In this study we sought to investigate the incidence of preoperative upper lip malposition in primary rhinoplasty patients.

METHODS

In total, 150 consecutive primary rhinoplasty patients were included. The position of the upper lip was measured during smiling relative to the incisors and gum line, and categorized as ideal, inadequate incisor show, or excessive gum show. Nasal length was categorized based on soft tissue cephalometic analysis of life-size photographs as long, ideal, or short. Tip projection was categorized as overprojected, ideal, or underprojected. The columella was categorized as hanging, ideal, or retracted.

RESULTS

Standardized photographs of 139 primary rhinoplasty patients met inclusion criteria. Forty-seven (34%) patients had an ideal upper lip position, 83 (61%) inadequate incisor show, and 7 (5%) excessive gum show. Sixteen (12%) had a short nose, 45 (33%) ideal length, and 76 (55%) a long nose. Fourteen (10%) had an underprojected tip, 38 (28%) had an ideal tip projection and 85 (62%) an overprojected tip. None of the nasal parameters were predictive of upper lip position. Tip overprojection (odds ratio [OR] 3.03, P = .02) and hanging columella (OR 2.97, P = .001) were predictive of a long nose. Tip underprojection was predictive of short length (OR 35, P < .0001).

CONCLUSIONS

There is a high incidence of upper lip malposition in patients undergoing primary rhinoplasty. It is vital for the rhinoplasty surgeon to identify it preoperatively and plan the surgical maneuvers accordingly to prevent exacerbating an insufficient incisor show or excessive gum show.

LEVEL OF EVIDENCE: 4

Incisor Show-based Selection of Tip Augmentation Rhinoplasty Technique

Our recent studies show that the majority of patients seeking rhinoplasty have inadequate incisor show. Furthermore, some rhinoplasty maneuvers, such as a columella strut, can alter the lip position and consequently the incisor show. We report the senior author's (B.G.) algorithm for tip augmentation technique based on our previous studies and 44 years of keen observation in the field of rhinoplasty. The 5 most common scenarios are described. When there is a short columella with inadequate incisor show, bilateral extended spreader grafts and columella strut with a tapered posterior portion are recommended, serving as a reliable midline septal extension graft supporting the medial crura in a more anterior position with sutures and a positive effect on incisor show. When there is an optimal lip-incisor relationship, a columella strut with a tapered posterior end fixed to the septum, with or without extended spreader grafts, is a better choice to prevent a change in smile. If there is excessive gum show, the optimal tip augmentation technique is a columella strut without tapering or even wider posterior end, with fixation of the columella strut to the septum, with or without extended spreader grafts that will push the upper lip caudally. The remaining scenarios are described in detail. Tip augmentation maneuvers in rhinoplasty can have a significant influence on upper lip position, which is often detrimental to the smile. The preoperative position of the upper lip during smile should play an integral role in the selection of tip augmentation technique.

LEVEL OF EVIDENCE: 5

Impact of Tongue-in-Groove Technique on Smile and Lip Position: A Comparative Analysis with and without Septal Extension Graft

This study was conducted to compare the outcomes of the tongue-in-groove (TIG) technique with and without septal extension graft (SEG) on smile and lip position in rhinoplasty. Fifty-eight rhinoplasty patients, treated at a tertiary referral center between 2020 and 2022, underwent preoperative and 12-month postoperative evaluations, using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) and the visual analog scale (VAS). The preoperative and 12-month postoperative photographs were analyzed using Adobe Photoshop to assess changes in lip and smile positions. The study included 38 patients in the TIG with SEG group and 20 patients in the TIG without SEG group. The participants, with an average age of 32.12 ± 7.97 years, comprised 81% females. In terms of surgical outcomes, postoperative evaluations revealed significant improvements in the VAS aesthetic score, SCHNOS-O score, and SCHNOS-C score compared with preoperative scores (p < 0.001) for both groups. Notably, both groups demonstrated significant improvements in the upper lip length, nasolabial angle (NLA), columellar inclination (CI) angle, and smile NLA. Patients in the SEG group exhibited markedly superior SCHNOS-O results, as well as distinctions in smile NLA and smile CI, compared with the group without SEG. The impact of rhinoplasty techniques on lip and smile remains complex requiring further evaluation. Both of the TIG techniques, with and without SEG, resulted in positive outcomes in terms of improving lip and smile positions, with the use of SEG demonstrating greater stability during a smile.

Growth patterns of the nasolabial region following unilateral cleft lip primary repair

Surgical correction is the optimal way of repairing a congenital cleft lip. Patients with this condition often undergo initial surgical treatment at an early age and achieve an acceptable outcome. However, their levels of satisfaction will decrease in later stages of life as facial growth and development will inevitably cause changes in long-term outcomes, especially in the nasolabial region. Therefore, it is important for surgeons to understand nasolabial development after primary treatment and tailor their surgical techniques appropriately. This review focuses on the growth patterns of the nasolabial region after primary repair, so as to provide references for operative strategy.

Effect of Tongue-in-Groove Technique on Upper Lip Slope in Rhinoplasty

BACKGROUND

Several surgical techniques used for rhinoplasty can change the upper lip form over the long term. By eliminating the membranous septum and causing dysfunction of the depressor septi nasi muscle and performing other maneuvers, the tongue-in-groove (TIG) technique can exaggerate changes in the upper lip shape, length, and slope.

METHODS

This study was conducted to compare the effects of the TIG technique with and without a septal extension graft (SEG) on lip slope and aesthetic angles on the profile view. A retrospective review was performed on 367 patients who underwent primary rhinoplasty using the TIG technique from 2016 to 2020. The upper lip angle (ULA), the nasolabial angle (NLA), and the columellar facial angle (CFA) were measured for comparison pre-and post-operatively.

RESULTS

Of 367 patients, 209 underwent TIG, while the rest underwent TIG over SEG (TIG+SEG). Comparison of pre-and post-operative ULAs showed significant changes in both groups. Although mean ULAs increased in both groups, some of the patients in each group experienced a decrease in ULA. The percentage of the patients with increased post-operative ULA significantly grow with increase in the pre-operative NLA (p < 0.05). However, no significant correlation was found between pre-operative CFA and post-operative ULA.

CONCLUSION

The present study suggests that TIG with and without SEG can change the lip slope on the profile view, possibly due to the shift of the subnasal point superiorly and posteriorly.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of open rhinoplasty on upper lip position in profile and frontal views

Examining the upper lip position is a key indicator of facial beauty. This study aimed to examine the upper lip position following cosmetic rhinoplasty at the frontal and profile views. The medical records of 67 patients who underwent rhinoplasty with no history of any facial skeletal surgery were obtained from archives. Complete preoperative and postoperative photos including the profile view at rest and the frontal view at rest, were prepared and analysed using Adobe Photoshop CC 2015 software. Interpupillary distances of two eyes in frontal views and Glabella to Pogonion (POG) distance in profile views were considered as fixed landmarks to calibrate the preoperative and postoperative photos. Upper lip length, subnasal area, and vermilion points were marked and compared between preoperative and postoperative photos. Data analysis was carried out using one-sample t-test and p<0.05% was considered as the significant level. Lip length (frontal view) was increased in 46 subjects. There were changes in the profile view of vermilion and subnasal positions in 56 patients and 53 patients, respectively. In surgical procedures on columella strut, maxillary augment, alar resection, spreader graft, columella retraction, and depressor septi muscle release, vermilion and subnasal protrusion in the profile view was statistically significant and lip length increased significantly in the frontal view. In tip rotation surgery techniques, the vermilion and subnasal position showed also significant protrusion. The depressor septi muscle cutting methods had only led to a significant protrusion of the vermilion position and upper lip length. Despite all covariants interfering in rhinoplasty, this cosmetic surgery most often may increases maxillary lip length and helps that maxilla look more protruded.

Hyaluronic Acid Filler in the Treatment for Drooping Tip: Anatomical Concepts and Clinical Results

The plunging nasal tip is a challenging condition because, although it is predominantly a dynamic deformity which occurs during smiling, it also indicates a structural problem. When a person smiles, the paired depressor septi nasi muscles pull the tip caudally at the same time as the levator labii superioris alaeque nasi muscles pull the alar base and lateral lip cephalically. This movement causes straightening of the alar rim. Even though surgical rhinoplasty is the gold standard to restore nasal appearance, the procedure may fail to treat the dynamic cause of the drooping tip. This article outlines the anatomical concepts that lead to a drooping tip and presents a technique that can treat both the dynamic and structural causes of the drooping tip using hyaluronic acid filler. Cases are also presented that illustrate these concepts. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Premaxillary Injection for Perioral Rejuvenation and Lip Enhancement

BACKGROUND

This is the first study to evaluate the effect of premaxillary filler injection on nasal tip projection, upper lip projection, and upper lip vermilion height.

OBJECTIVES

The primary objective of this study was to analyze the change in nasal tip projection (measured by the Goode ratio) and the change in upper lip projection (measured by the Z angle) following premaxillary hyaluronic acid injection. A secondary objective was to measure the change in upper lip vermilion height. We hypothesized that treated subjects will show an increase in nasal tip projection, upper lip projection, and upper lip vermilion height.

METHODS

Twenty volunteer patients with signs of perioral aging or poor upper lip projection were enrolled in this prospective cohort study and underwent premaxillary hyaluronic acid filler injection between November 2017 and June 2018. Nasal tip projection, upper lip projection, and upper lip vermilion height were assessed from baseline and posttreatment photographs based on the Goode ratio, Z angle, and lip vermilion height ratio, respectively.

RESULTS

No significant change was noted between pre- and posttreatment Goode ratio measurements (P = 0.841). There was a significant decrease in Z angle and therefore significant increase in upper lip projection with treatment (P < 0.001). The lip vermilion height ratio demonstrated a trend of increased upper lip vermilion height but this did not achieve statistical significance (P = 0.561).

CONCLUSIONS

Premaxillary filler treatment resulted in a significant increase in upper lip projection. Premaxillary filler injection when performed in a safe manner is a valuable treatment option for perioral rejuvenation.

LEVEL OF EVIDENCE: 4