Assessment of three-dimensional nasolabial response to Le Fort I advancement

Septal Extension Graft in Cleft Rhinoplasty: Patients with Secondary Unilateral Cleft Lip Nasal Deformity

BACKGROUND

Tip refinement procedures are still controversial in secondary unilateral cleft rhinoplasty. The aim of this study was to assess whether the septal extension graft improved nasal and tip deformity and achieved a normal profile with clinical and three-dimensional morphometric analyses.

METHODS

A consecutive series of 194 skeletally mature patients with unilateral cleft were included and analyzed. All had undergone secondary open rhinoplasty, performed by a single surgeon, with the use of the septal extension graft between 2013 and 2021. Clinical data were collected, and three-dimensional morphometric measurements were performed. An age-, sex-, and ethnicity-matched normal group was included for comparisons.

RESULTS

The authors' standard procedures included open approach combining reverse-U incision, septal extension graft, dorsal augmentation, lip revision, and vermilion augmentation. The postoperative outcome showed significantly increased numerical values (nasal bridge length, nasal height, nasal tip projection, nasal dorsum angle, columellar angle, columellar-lobule angle, nostril height ratio, nasal surface area, nasal volume) and decreased numerical values (alar width, tip/middle deviation, nasal tip angle, labial-columellar angle) compared with the preoperative morphology. The postoperative measurement showed significantly higher numerical values (nasal protrusion, tip/middle deviation, nasal dorsum angle) and lower numerical values (columellar-lobule angle, nostril height ratio, alar width ratio) compared with the control group.

CONCLUSIONS

This study revealed that the authors' secondary cleft rhinoplasty significantly improved the underprojected, up-rotated, deviated, and poorly defined tip and short nasal bridge deformities. The technique could result in the nose of the patients with cleft lip nasal deformity being closer to that of the normative profile.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Changes in three-dimensional nasal morphology according to the direction of maxillary movement during Le Fort I osteotomy

BACKGROUND

Le Fort I (LFI) osteotomy is commonly performed by orthognathic surgeons; however, postoperative changes in nasolabial morphology are of concern. Several factors influence such changes, but it is difficult to accurately predict the postoperative results. This study evaluated the three-dimensional (3D) morphological changes in the nasal region according to the different directions of maxillary movement during LFI osteotomy.

MATERIALS AND METHODS

Forty-one patients who underwent LFI osteotomies were included. All patients were divided into maxilla-up (Group U: 20 patients) and maxilla-forward (Group F: 21 patients) groups. Soft tissue morphologies were determined preoperatively and 3 or 6 months postoperatively using an optical 3D scanner. All datasets were evaluated in terms of volume changes in nine subregions and changes in linear measurements around the nasal area.

RESULTS

Both groups exhibited increased nasal volumes after surgery in the order of the three upper, three central, and three lower subregions. The change in volume of the central nasal region tended to be greater in Group U than that in Group F.

CONCLUSION

We evaluated 3D morphological changes in the nasal region according to the direction of maxillary movement during LFI osteotomy. Group U exhibited a large change in the volume of the central nasal region.

Comparative analysis of 3D tomography based soft tissue rendering and Proface facial scanning systems in orthognathic surgery

PURPOSE

This study aimed to investigate the linear and angular differences in the nasolabial soft tissue in patients who underwent bimaxillary orthognathic surgery using two different three-dimensional imaging methods. Furthermore, the advantages, disadvantages, and limitations of these methods were determined after comparing the data obtained from the imaging methods used in the study.

MATERIALS AND METHODS

Preoperative (T0) and 6-months postoperative (T1) cone-beam computed tomography (CBCT) and three-dimensional facial scanning (3DFS) data from 22 patients who underwent maxillary advancement surgery were examined. The DICOM (Digital Imaging and Communications in Medicine) data (CBCT group) and ".obj" format images (3DFS group) of the patients were analyzed using Dolphin software (Dolphin Imaging®, Version 12, Chatsworth, CA, USA). The linear and angular soft tissue measurements were calculated after determining the reference anatomical landmarks for both groups.

RESULTS

Measurements with CBCT and 3DFS imaging methods were compared at T0, T1, and all measurements (T0+T1). No statistically significant difference was observed between the CBCT and 3DFS groups for five measurements performed at T0 and T0+T1, but statistically significant differences were observed between the groups for the other seven measurements. There was no statistically significant difference between the CBCT and 3DFS groups for six measurements at T1, but there were statistically significant differences between the groups for the other six measurements. After reviewing the postoperative differences in the nasolabial soft tissue, a statistically significant increase in four linear and one angular measurement in the 3DFS group was observed, and there was a statistically significant increase in two linear and two angular measurements in the CBCT group. Upon comparison of postoperative differences in soft tissue alterations, no statistically significant difference between the 3DFS group and the CBCT group were observed in any of the soft tissue measurements.

CONCLUSION

Orthognathic surgery has significant effects on nose width and upper lip morphology. Although both 3DFS and CBCT methods can be used to evaluate such effects, the results of the present study revealed differences in sensitivity and limitations between the two methods. Thus, surgical outcomes should be evaluated in consideration of the abovementioned parameters.

Assessment of the Change in the Nasal Septum and Nasal Profile After Le Fort I With Cone Beam Computed Tomography

OBJECTIVE

This study aimed to determine the relationship between nasal changes and the amount of advancement, impaction, and downward movement of the maxilla after Le Fort I osteotomy.

METHODS

The study included 48 patients who underwent Le Fort I surgery and had pre- and postoperative cone-beam computed tomography records. Changes in the nasal septum were evaluated by measuring septal deviation angles and volumes. In addition, nasolabial angle and width of nasal and alar base were examined. Groups were determined according to the movement of point A (the deepest point on the curvature of the maxillary alveolar process), using a threshold of 1.5 mm for vertical movements and 4 mm for sagittal movements. This resulted in the comparison of 6 groups of 8 people each. Results are presented as mean and standard deviation or median and range depending on the data distribution. Significance level was accepted as P < 0.05.

RESULT

There were no significant differences for each group on its own septal deviation volume or angle values pre/postoperatively. Groups 3 and 5, which both had at least 1.5 mm of impaction, showed significant changes in both deviation angle and volume between the preoperative and postoperative measurements. Nasolabial angle did not show significant changes between groups. Alar base width and nasal width increase was significantly highest in Group 1, which has more than 4 mm sagittal movement and less than 1.5 mm vertical movement.

CONCLUSIONS

Le Fort I osteotomy may lead to undesirable changes in the spatial positioning of the nasal septum. The results of this study suggest that maxillary advancement does not significantly impact septal deviation, whereas maxillary impaction increases the amount of deviation. In addition, nasal width and alar base width tended to increase, and the nasolabial angle tended to decrease slightly, regardless of the direction of movement of the maxilla after orthognathic surgery.

CLINICAL RELEVANCE

Surgeons should consider increased nasal septal deviation risks when planning impaction of the maxilla. The soft tissue changes in the nose vary according to different directions and amounts of Le Fort I surgery.

Maxillary advancement surgery with vertical component: Impact on the nasolabial aesthetics

The aim of this study is to evaluate the changes in nasolabial soft tissues following Le Fort I osteotomies, focusing on the impact of maxillary vertical repositioning. This retrospective study included 39 patients with a history of Le Fort 1 osteotomy between 2013 and 2021. Patients were grouped based on their maxillary movement into three categories: pure advancement (group A), advancement with impaction (group B), and advancement with downward repositioning (group C). Preoperative and postoperative CBCT (Cone Beam Computed Tomography) data were analyzed to measure the changes in nasolabial soft tissues. The current study utilized Mimics Suite 20.0 for measuring linear and angular variables. The evaluated variables included intercanthal distance, nasal dorsal length, tip protrusion, mouth width, alar width, upper lip height, nostril dimensions, and angles of nasolabial, alar base, and upper lip. Among them intercanthal distance, nasal dorsal length, or tip protrusion showed no statistical difference (p > 0,05). Mouth width, alar width, alar base angle were increased and upper lip angle was decreased significantly (p < 0.001). Changes in upper lip height and nasolabial angle differed among the groups of the study. While upper lip height increased significantly in groups A and C (p < 0.05), there was a slight decrease in Group B with no significance (p > 0.05). Nasolabial angle decrased significantly on Groups A and B (p < 0.05). The results of this study revealed changes in several soft tissue parameters, some of which occurred regardless of vertical repositioning of the maxilla. Within the limitations of the study, maxillary advancement surgery can affect the aesthetics of the nasolabial region and cause specific changes in related soft tissues. Understanding these changes is essential to establish realistic patient expectations and achieve optimal functional and aesthetic outcomes.

Three-Dimensional Morphological Study on the Effectiveness of Expanded Polytetrafluoroethylene Prosthesis in the Paranasal Augmentation

BACKGROUND

The paranasal depression is a common facial feature of Oriental populations. One of the most wildly used method to improve it was paranasal augmentation using expanded polytetrafluoroethylene (ePTFE). The effectiveness of it should be tested by three-dimensional morphological measurements.

METHODS

Patients who underwent paranasal augmentation using ePTFE between January 2017 and December 2022 were recruited in the study. The preoperative and postoperative clinical variables and three-dimensional measurement of patients were also collected. The satisfaction outcome were assessed.

RESULTS

By establishing a coordinate system based on the Frankfurt plane, 16 landmarks including nasal alar crest, subnasal point, upper lip, pogonion, glabella, sub-cheek, orbitale, tragion in left and right side of faces were marked. Five segments, 4 ratios, and 3 angles were measured based on it. The significant increase of segments, ratios, and angles indicated that paranasal augmentation could increase the protrusion of paranasal area, both in absolute value and relative proportion. The significant decrease of other data indicated that the protrusion difference between paranasal base and upper lip, forehead, and chin, respectively, were shortened after surgery. The average size of implant was 6.54 ± 1.02 mm, and the average increase of paranasal height was 4.38 ± 1.04 mm postoperatively. This indicates that two-thirds of its height will ultimately be reflected effectively in the sagittal elevation of the paranasal base.

CONCLUSIONS

Paranasal augmentation using ePTFE could effectively increase paranasal height and improve subunits relationships, and the ePTFE prosthesis should be designed and carve considering the 1/3 loss of height after implantation.

LEVEL OF EVIDENCE III

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 .

Does Le Fort I Osteotomy Influence Nasal Septum Deviation?

BACKGROUND

Le Fort I osteotomy is a technique for surgically correcting the maxillary position. Le Fort I osteotomy may affect the nasolabial structures since a very close relationship exists between the maxilla and the nose.

PURPOSE

This study aimed to investigate the effect of different maxillary movements on the nasal septum after Le Fort I osteotomies with cone beam computed tomography (CBCT) images. We hypothesized that nasal septal angle changes after maxillary impaction and advancement movements.

STUDY DESIGN, SETTING, AND SAMPLE

This retrospective cohort study involved patients who underwent Le Fort I osteotomy to correct the maxillary position at Erciyes University, Oral and Maxillofacial Surgery Hospital. This study included patients who had CBCT images before (T0) and ≥12 months after (T1) surgery. Patients with a history of septoplasty or rhinoplasty before orthognathic surgery, congenital deformities, or posttraumatic deformities were excluded.

PREDICTOR VARIABLES

Its predictor variable was the direction and magnitude of the maxilla's vertical and horizontal movements.

MAIN OUTCOME VARIABLE

Change in septal deviation (in degrees) was the main outcome of the study.

COVARIATES

Age, sex, operation (Le Fort I alone or double jaw surgery), cartilage reduction, and anterior nasal spine reduction during surgery were covariates.

DATA ANALYSIS

Angle values were compared with independent samples t test or the Mann-Whitney U test in two-category variables. The Kruskal Wallis test was used to compare the angle values according to the movement. A P value of < .05 was considered statistically significant.

RESULTS

This study evaluated 154 CBCT images of 77 patients (44 [57.1%] females and 33 [42.9%] males), of which 68 (88.3%) had double jaw surgery and nine (11.7%) had single Le Fort I surgery. The average nasal septum angle was significantly smaller preoperatively (166.2° [157.1° to 172.15°]) than postoperatively (168.7° [131.5° to 180.0°]) across subjects (P = .031). The septal angle decreased in 28 patients, and the rate of postoperative angular change was higher in patients with both advancement and impaction during the surgery (P = .014).

CONCLUSION AND RELEVANCE

Septum deviation can occur in 37% of cases after Le Fort I surgery. Therefore, Le Fort osteotomies are associated with changes in nasal appearance.

Soft and Hard Tissue Changes and Facial Rejuvenation of Anterior Maxillary Segmental Osteotomy: A Three-Dimensional Cephalometric Study

OBJECTIVE

To explore the efficacy of anterior maxillary segmental osteotomy (AMSO) in reliving maxillary protrusion and better analyze the three-dimensional (3D) morphological changes of the postoperative nasolabial region using computed tomography (CT) and evaluate the trend of facial rejuvenation.

MATERIALS AND METHODS

Forty-five patients who underwent AMSO from January 2017 to December 2021 were retrospectively included. CT and oriented photography were performed before and 10 months after the treatment. The mimics17.0 software was used to reconstruct the 3D CT scan results before and after the operation, measure the data of each anatomical index, and systematically evaluate the soft tissue changes in the nasolabial region. The patients themselves, the plastic surgeons, family members, or friends of patients use the Face-Q Age Appraisal Visual Analogue Scale (VAS) to evaluate the changes in patients' visual age before and after the operation.

RESULTS

Forty-five cases of maxillary protrusion were alleviated. Seen from the side, the protruding degree of the upper lip is obviously reduced. In the front view, ∠Cont-Sbal-F, the width of alar base, and alae nasi all increased significantly. Contrary to traditional perceptions, the protrusion and height of the nose tip actually increased rather than decreased after AMSO. The visual age score improved positively, and patients obtained facial rejuvenation. No serious complications occurred; after 10-month follow-up, we achieved a high degree of satisfaction.

CONCLUSION

AMSO can significantly improve the maxillary protrusion, and it can increase the protrusion and height of the nose tip. Also, patients can get a younger appearance. Comprehensive preoperative evaluation and postoperative nasolabial morphology with maxillary protrusion patients are helpful for correct clinical decision-making. At the same time, the operation suggests a new choice of facial rejuvenation for patients with maxillary protrusion.

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.

Analysis of Gull in Flight Appearance and Related Parameters Following Le Fort I Osteotomy

ABSTRACT

The present study aimed to investigate how "Gull in Flight" appearance and alar-columellar relationship change following maxillary surgery. Thirty-three patients who underwent Le Fort I osteotomy with or without mandibular osteotomy were included in this retrospective study. Measurements which were angle of columella triangle, alar-rim angle, columella lobular angle, and distance of points forming "Gull in Flight" appearance were evaluated on pre and postoperative frontal and lateral photos of patients. Data was submitted to statistical analysis and significance level was determined as 0.05. Following Le Fort I surgery, distance of points forming "Gull in Flight" appearance with respect to canthus was decreased significantly (P < 0.05). Positions of these points to each other were not changed (P > 0.05). Every 1 mm maxillary impaction led to 0.58 mm reduction in y3 (the distance from the point that illustrates Gull's body) (P = 0.032). There was a decrease in angle of columella triangle, alar-rim angle and increase in columella lobular angle. However, these changes were not found significant (P > 0.05). Angle of columella triangle was increased 2.51 degree for every 1 mm maxillary advancement (P = 0.028). In conclusion, maxillary surgery had an impact on nasal region from frontal view. However, "Gull in Flight" appearance which is one of the aesthetic parameters in nose was not changed following maxillary surgery.

Three-dimensional nasolabial changes after maxillary advancement osteotomy in class III individuals: a systematic review and meta-analysis

Background Class III malocclusions with maxillary retrognathia are commonly treated with single jaw Le Fort I maxillary advancement. The three-dimensional (3D) effects of surgery on the nasolabial region varies among the clinical studies. Quantifying these changes is of great importance for surgical planning and obtaining valid consent. Objectives To investigate the 3D relationship between soft tissue and skeletal changes secondary to Le Fort I maxillary advancement surgery in skeletal class III patients.Search methods Comprehensive search of multiple electronic databases supplemented by a manual and grey literature search were undertaken from inception to 9 June 2020.Selection criteria Studies that evaluated the 3D soft tissue changes of patients before and after maxillary advancement surgery alone.Data collection and analysis Study selection, data extraction and risk of bias assessment were performed independently by two reviewers, with disputes resolved by a third reviewer. A quantitative synthesis of the data was pre-planned for pooling similar outcome measures.Results Four studies were included in the final review and meta-analysis, with a total of 105 patients (mean age 16.7 + 33.9 years). The mean maxillary advancement of the included studies was 5.58 mm (95% CI 5.20-5.96). The sagittal effects of surgery on nose tip projection and prominence were insignificant (P >0.05, two studies); however, subnasal projection (MD 1.7 mm, two studies) and upper lip projection (MD 2.90 mm, four studies) increased significantly in a forward direction after surgery (P <0.05). Le Fort I osteotomy widens the upper philtrum width (MD 0.84 mm, two studies) (P <0.05). Inconsistencies among the included studies were identified; therefore, the results should be interpreted with caution.Conclusions There is weak evidence based on quantitative assessments that Le Fort I maxillary advancement significantly affects the nasolabial soft tissue envelope mainly in a sagittal dimension. These changes are concentrated around the central zone of the nasolabial region. Future prospective studies on maxillary advancement osteotomy with a standardised method of assessment, taking into consideration the confounding factors, are required.

Effect of Le Fort I Maxillary Repositioning on Three-Dimensional Nasal Tip Rotation: A Comparative Study with Implication for the Asian Nose

BACKGROUND

Le Fort I maxillary repositioning influences nasal morphology. In Asian cultures, upward nasal tip rotation with increased nostril exposure is considered aesthetically unpleasant and can have psychosocial consequences. This three-dimensional imaging-based study evaluated the effect of different Le Fort I maxillary movements on nasal tip rotation.

METHODS

Consecutive patients who underwent two-jaw orthognathic surgery (n = 107) were enrolled. To achieve a standard head orientation, preoperative and 1-week and 12-month postoperative cone-beam computed tomography-derived three-dimensional craniofacial models were superimposed. Tip rotation angle was calculated according to the Frankfort horizontal plane for all three-dimensional digital models. The final tip rotation angle change was defined as 12-month postoperative value minus preoperative value. Translational maxillary movement types (advancement versus setback and intrusion versus extrusion), postoperative maxillary segment locations (anterosuperior, anteroinferior, posterosuperior, or posteroinferior), and actual linear maxillary changes were noted.

RESULTS

Advancement (1.79 ± 5.20 degrees) and intrusion (2.23 ± 4.96 degrees) movements demonstrated significantly larger final tip rotation angle changes than setback (-0.88 ± 5.15 degrees) and extrusion (0.09 ± 5.44 degrees) movements (all p < 0.05). Postoperative anterosuperior location (2.95 ± 4.52 degrees) of the maxillary segment demonstrated a significantly larger final tip rotation angle change than anteroinferior (0.48 ± 5.65 degrees), posterosuperior (-1.08 ± 4.77 degrees), and posteroinferior (-0.64 ± 5.80 degrees) locations (all p < 0.05). Translational maxillary movement and actual linear maxillary change were not correlated with final tip rotation angle change.

CONCLUSION

Effects of Le Fort I maxillary repositioning on nasal tip rotation depend on movement types and maxillary segment location.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Impact of the Different Types of Le Fort I Maxillary Surgical Movement on Nasal Width Changes: A Photogrammetric Analysis

BACKGROUND

Le Fort I maxillary movements affect nasal width, but nasal width changes with specific movement types have not been formally addressed to date.

OBJECTIVES

The purpose of this study was to analyze and compare the changes in nasal width with different maxillary movements.

METHODS

A retrospective study was performed among consecutive patients who underwent bimaxillary orthognathic surgery (n = 138) and who were grouped based on the type of maxillary movement (ie, maxillary advancement with intrusion [MAI], maxillary advancement with extrusion [MAE], and maxillary setback with intrusion [MSI]). Preoperative and 12-month postoperative nasal widths were analyzed photogrammetrically by 2 blinded evaluators.

RESULTS

Maxillary advancement with intrusion and MAE presented a significantly (P < 0.05) higher alar base widening than MSI did, with no significant (P > 0.05) differences between MAI and MAE. Maxillary advancement movements (MAI and MAE) showed significantly (P < 0.05) higher alar base widening than maxillary setback movement (MSI). However, no significant (P > 0.05) difference was observed between maxillary intrusion (MAI and MSI) and maxillary extrusion (MAE) movements.

CONCLUSIONS

This study shows that the nasal width varies distinctly depending on the type of Le Fort I maxillary surgical movement.

Type of maxillary segment mobilization affects three-dimensional nasal morphology

BACKGROUND

Surgical mobilization of the maxillary segment affects nasal morphology. This study assessed the impact of the type of maxillary mobilization on the three-dimensional (3D) nasal morphometry.

METHODS

Pre- and postsurgery cone beam computed tomography-derived facial image datasets of consecutive patients who underwent two-jaw orthognathic surgery were reviewed. Using preoperative 3D facial models as the positional reference of the skeletal framework, 12-month postoperative 3D facial models were classified into four types of maxillary mobilizations (advancement [n = 83], setback [n = 24], intrusion [n = 55], and extrusion [n = 52]) and four types of final maxillary positions (anterosuperior [n = 44], anteroinferior [n = 39], posterosuperior [n = 11], and posteroinferior [n = 13]). Six 3D soft tissue nasal morphometric parameters were measured, with excellent intra- and interexaminer reliability scores (ICC>0.897) for all the measurements. The 3D nasal change for each nasal parameter was computed as the difference between postoperative and preoperative measurement values.

RESULTS

The intrusion maxillary mobilization resulted in a significantly (all p<0.05) larger 3D nasal change in terms of alar width, alar base width, and nostril angle parameters, and a smaller change in terms of the nasal tip height parameter than the extrusion maxillary mobilization; however, no significant (all p>0.05) difference was observed between advancement and setback maxillary mobilizations. The anterosuperior and posterosuperior maxillary positions had a significantly (all p<0.05) larger 3D nasal change in terms of the alar base width and nostril angle than the anteroinferior and posteroinferior maxillary positions.

CONCLUSION

The type of maxillary mobilization affects the 3D nasal morphometry.

The Effects of Maxillary Movements on Nasal Aesthetics Following Orthognathic Surgery

Improvement of the harmony between facial subunits is the ultimate goal of orthognathic surgery and surgeons must accurately make soft tissue projections for planned bony movements. Yet, few studies have examined the effects' of orthognathic surgery on aesthetic parameters of nasolabial area on a thorough basis.This retrospective study included 61 patients that underwent orthognathic surgery. Demographic data, evaluation period, and surgical details were analyzed. Superficial topographical analysis of intercanthal distance, alar width, nasal height, nasal length, nasal tip protrusion, upper lip height, nasal bone angle, supratip break angle, nasal dorsum angle, nasal tip angle, columellar-lobular angle, columellar-labial angle, upper lip angle, and tip-to-midline angle was recorded before and after surgery. Postoperative changes in these parameters and their correlation to maxillary movements were analyzed.Alar width, upper lip height, columellar-labial angle, supratip break angle, nasal dorsum angle, and upper lip angle increased postsurgery, whereas tip-to-midline angle decreased. Upper lip height and columellar-labial angle were significantly correlated with clockwise/counter-clockwise rotation and anterior re-positioning. Columellar-labial angle increased 2° for each 1 mm of anterior movement and decreased 4° for each 1 mm of counter-clockwise rotation. Novel parameters, such as columellar-lobular angle and tip-to-midline angle, were not associated with any maxillary movement postsurgery.Orthognathic surgery primarily affected the lower third of the nose and changed alar width, upper lip height, supratip break angle, nasal dorsum angle, columellar-labial angle, upper lip angle, and tip-to-midline angle in this region; however, only columellar-labial angle and upper lip height were found to be correlated solely with maxillary movements.

Nasolabial angle and nasal tip elevation changes in profile view following a Le Fort I osteotomy with or without the use of an alar base cinch suture: a long-term cohort study

OBJECTIVES

Cinch sutures attempt to counteract alar base widening but may lead to unintended increases in the nasolabial angle and nasal tip elevation. The aim of this investigation was to assess nasolabial angle changes after maxillary osteotomies with and without alar base cinch sutures in the short and long terms.

STUDY DESIGN

Seventy-eight patients were assessed, with 51 in the cinch group (38 females, 13 males; age range 16-39 years) and 27 in the no-cinch group (12 females, 15 males; age range 17-27 years). The upper component (nasal tip elevation), lower component (lower lip inclination), and the overall nasolabial angle were measured on preoperative, postoperative, and long-term follow-up lateral cephalometric radiographs.

RESULTS

The overall nasolabial angle (P = .006) and its upper component (P < .001) increased significantly in the cinch group immediately postoperatively but resolved by 6 to 12 months for the overall nasolabial angle and by 12+ months (up to 5.7 years) for the upper component. There were no significant changes in the no-cinch group.

CONCLUSIONS

In the short term, the alar base cinch suture increases nasal tip elevation and the overall nasolabial angle. In the long term, there was no significant difference, suggesting that the initial nasal tip elevation resolves over time and that the cinch suture may have a limited effect on nasal tip elevation in the longer term.

Primary Rhinoplasty Does Not Interfere with Nasal Growth: A Long-Term Three-Dimensional Morphometric Outcome Study in Patients with Unilateral Cleft

BACKGROUND

Primary rhinoplasty has not been universally adopted because the potential for nasal growth impairment remains an unsolved issue in cleft care. This study's purpose was to assess the long-term effects of primary rhinoplasty performed by a single surgeon in a cohort of patients with a unilateral cleft lip nose deformity.

METHODS

Three-dimensional nasal morphometric measurements (linear, angular, proportional, surface area, and volume) were collected from consecutive patients (cleft group, n = 52; mean age, 19 ± 1 year) who had undergone primary rhinoplasty with the use of the Noordhoff approach between 1995 and 2002 and reached skeletal maturity. Normal age-, sex-, and ethnicity-matched subjects (control group, n = 52) were identified for comparative analyses.

RESULTS

No significant differences (all p > 0.05) were observed for most measures, including nasal height, alar width, nasal dorsum angle, columellar angle, columellar-labial angle, nasal tip/height ratio, nasal index, alar width/intercanthal distance ratio, nasal surface area, and nasal volume. The cleft group displayed significantly (all p < 0.05) lower nasal bridge length and nasal tip projection, and greater nasal protrusion, tip/midline deviation, nasal tip angle, nasal tip protrusion width index, and alar width/mouth ratio values than the control group.

CONCLUSIONS

Primary rhinoplasty does not interfere with nasal growth as measured by three-dimensional photogrammetric analysis. Further imaging studies are required for the assessment of development in other anatomical nasal structures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A machine learning framework for automated diagnosis and computer-assisted planning in plastic and reconstructive surgery

Current computational tools for planning and simulation in plastic and reconstructive surgery lack sufficient precision and are time-consuming, thus resulting in limited adoption. Although computer-assisted surgical planning systems help to improve clinical outcomes, shorten operation time and reduce cost, they are often too complex and require extensive manual input, which ultimately limits their use in doctor-patient communication and clinical decision making. Here, we present the first large-scale clinical 3D morphable model, a machine-learning-based framework involving supervised learning for diagnostics, risk stratification, and treatment simulation. The model, trained and validated with 4,261 faces of healthy volunteers and orthognathic (jaw) surgery patients, diagnoses patients with 95.5% sensitivity and 95.2% specificity, and simulates surgical outcomes with a mean accuracy of 1.1 ± 0.3 mm. We demonstrate how this model could fully-automatically aid diagnosis and provide patient-specific treatment plans from a 3D scan alone, to help efficient clinical decision making and improve clinical understanding of face shape as a marker for primary and secondary surgery.

Three-Dimensional Nasal Alterations in Le Fort I Advancement: Linear Measurements, Angles, Nasal Indices, and Volume Differences

The maxillary advancement obtained by the Le Fort I osteotomy can also generate significant changes in the soft tissue of the nose and lips. The aim of this study was to compare the alterations in the soft tissue of the nose following the Le Fort I osteotomy maxillary advancement technique in a population of young adults submitted to orthognathic surgery. Seven men and 8 women aged between 23 and 45 underwent orthognathic surgery using the Le Fort I osteotomy and bilateral mandibular sagittal osteotomy. Sixty 3-dimensional images were analyzed (Vectra M3, Canfield, NJ) after labeling landmarks on the face and determining linear and angular measurements, proportion, and volume difference indices at the following intervals: preoperatively (baseline), then 2 months, 6 months, and 1 year after surgery. Following Le Fort I, there was an increase in the alar base, and reduction of nasal tip protrusion, nasal angles, and the nasal tip protrusion index (P < 0.05). There were no differences in the facial thirds, the nasal index, and angles of nasal and mentolabial convexity (P > 0.05). There was a difference in the volume of the nose only 2 months after surgery. The Le Fort I osteotomy caused significant alterations in linear, angular, and nasal proportion measurements. The volume differences were reversible in the early postoperative period and probably associated with edema. The possibility of variations in the size and shape of the nose should be presented to prospective patients preoperatively.

Long-Term Nasal Growth after Primary Rhinoplasty for Bilateral Cleft Lip Nose Deformity: A Three-Dimensional Photogrammetric Study with Comparative Analysis

Nasal deformity is associated with congenital cleft lip and palate. Primary rhinoplasty for reconstruction of the nasal deformity at the time of bilateral cleft lip repair is a controversial issue in cleft care due to traditional teaching concerning the potential impairment of nasal growth. This study assessed long-term nasal growth in patients with bilateral cleft lip and palate who underwent primary rhinoplasty by a single surgeon between 1995 and 2002 and reached skeletal maturity (n = 39; mean: 19 ± 2 years). Normal age-, gender-, and ethnicity-matched subjects (n = 52) were enrolled for comparative analyses. Three-dimensional nasal photogrammetric measurements (10 linear, 4 angular, 6 proportional, 1 surface area, and 1 volume parameter) were collected from patients with bilateral cleft lip and palate and normal subjects. Patients who underwent rhinoplasty presented with significantly (all p < 0.05) smaller nasal tip projection and nasal tip angles, but greater values for nasal dorsum length, nasal protrusion, alar width, columellar height, dome height, columellar angle, labiocolumellar angle, nasal tip height ratio, nasal index, alar width/intercanthal distance ratio, and alar width/mouth width ratio compared to normal subjects. There were no differences (all p > 0.05) in nasal height, tip/midline deviation, nasal dorsum angle, dome-to-columella ratio, columella height/alar width ratio, area surface, and volume parameters between the two groups. This study shows that primary rhinoplasty performed in patients with bilateral cleft lip and palate during infancy does not result in deficiency of the nasal dimensions relative to controls.

The use of Medpor implants for midface contouring in cleft patients

Three-dimensional midfacial deficiency in cleft patients is common and is frequently connected to impairment of the aesthetic facial appearance. Different approaches to augment relevant facial regions are available. Alloplastic facial implants have been established as a viable alternative to autologous tissue augmentation in various circumstances. However, in cleft patients, the application of facial implants has rarely been reported. This retrospective study aimed to evaluate the use of Medpor implants for midfacial contouring in cleft patients. Fifty-one patients with orofacial clefts were assessed with regard to defined parameters. A range of Paranasal, Malar and Nasal Dorsum Medpor implants had been used. Unilateral cleft lip and palate (UCLP) represented the most common indication, followed by bilateral cleft lip and palate (BCLP). Bilateral implant insertion was performed as a general rule with few exceptions. Insertion of implants was frequently combined with other cleft-related surgical procedures. Even after orthognathic surgery, midfacial augmentation was implemented to specifically address residual volume deficiency, particularly in the malar region. The complication rate amounted to 4.9% (6/122 implants). Based on our findings, Medpor implants are reliable and long-term stable materials to successfully augment paranasal, subnasal and malar areas as well as a solid nasal dorsum material with few complications in cleft patients.

Three dimensional evaluation of soft tissue after orthognathic surgery

Background

To evaluate the nasolabial soft tissue change three-dimensionally after orthognathic surgery, using a structured light scanner.

Methods

Thirty-two malocclusion patients, who underwent orthognathic surgery, were evaluated. CBCT and 3D facial scans were obtained before surgery and 3 months after surgery. The 3D changes in the 26 landmarks, and the relative ratio of the soft tissue movement to the bony movement, were evaluated.

Results

In the Le Fort I advancement patients, the nasal tip moved 17% forward, compared to the maxillary bony movement, but the nasal prominence decreased 15%. The alar width increased 4 mm after the advancement, and the width decreased 4.7 mm after Le Fort I setback. The relative ratio of the soft tissue movement to the bony movement after bilateral sagittal split osteotomy was about 66% at the Li point in the anteroposterior direction, and it was 21% in the Le Fort I advancement and 14% in Le Fort I setback at the Ls point.

Conclusion

Alar cinch suturing may not be sufficient to overcome the effect of the maxilla advancement compressing the nasal complex. Alar width widening was prevented in Le Fort I setback. However, it is uncertain that the alar cinch suturing was solely responsible. The soft tissue around the mandible tends to accompany the bony movement more than the maxillary area. In addition, structured light scanning system proved to be a useful tool to evaluate the nasolabial soft tissue.

Long-term outcomes of bimaxillary surgery for treatment of asymmetric skeletal class III deformity using surgery-first approach

OBJECTIVES

Although several studies have reported the advantages of the surgery-first approach for orthognathic correction of Class III deformity, there are few reports of the success of this approach for patients with facial asymmetry. Therefore, the purpose of this study was to evaluate the outcome of bimaxillary surgery for asymmetric skeletal Class III deformity using a surgery-first approach.

MATERIALS AND METHODS

Sixty-five patients who consecutively underwent at least a combined Le Fort I and a bilateral sagittal split osteotomy for asymmetric skeletal Class III deformity were identified in the authors' patient database. Standardized frontal photographs were used to measure the change in midface, intercommissural line, chin from midface, and chin deviation angles as well as upper, middle, and lower contour deviation angles. The facial midline symmetry index, facial contour symmetry index, and overall facial symmetry index were also calculated. Self-reported questionnaires regarding overall appearance and satisfaction with facial areas were administered at least 1 year post-surgery.

RESULTS

Forty-six patients had genioplasty. There was a statistically significant improvement in the deviation angles measured and the facial midline, facial contour, and overall facial symmetry index. Self-reported questionnaires, completed at least 1 year post-surgery, showed that patient satisfaction was high.

CONCLUSIONS

These findings demonstrate that the surgical-orthodontic treatment with surgery-first approach can successfully maintain or improve facial symmetry.

CLINICAL RELEVANCE

The surgery-first approach for improving facial asymmetry using the guidelines described for setups of the models is a feasible alternative to the classic orthodontic-first approach for bimaxillary orthognathic surgery.

Orthognathic Surgery and Rhinoplasty: Simultaneous or Staged?

BACKGROUND

Orthognathic surgery can significantly impact the nasolabial envelope, and at times requires an adjunctive rhinoplasty. The purpose of this study was to evaluate nasal morphology in orthognathic patients, focusing on predictive variables, and the need for and timing of definitive rhinoplasty. Based on these data, an algorithm for the implementation of adjunctive rhinoplasty is proposed.

METHODS

A review of cases over a 3-year period was completed. Information regarding demographic, diagnostic, and operative details; nasal morphology; and use of rhinoplasty was compiled. Three-dimensional images were used to quantify anatomical variables.

RESULTS

Over 589 patients were reviewed during this period. Of these, 163 fulfilled inclusion criteria for this study. The mean age was 23.3 years. In total, 41.7 percent of orthognathic cases underwent adjunctive rhinoplasty. Of these, 82.4 percent were staged and 17.6 percent were simultaneous. The average time between staged procedures was 208 days. When simultaneous, 16.7 percent of the orthognathic procedures had significant maxillary movement (advancement >4 to 5 mm, impaction >2 mm, alar base excisions); in comparison, 92.9 percent of staged cases had significant maxillary movement (p < 0.0001). All patients had self-reported satisfaction with functional and aesthetic results during the follow-up period.

CONCLUSIONS

Nasal and jaw deformities are intricately interlinked. In this series, the authors identified patterns requiring adjunctive rhinoplasty in the setting of orthognathic surgery. The authors present an algorithm to extensively treat the nasomaxillofacial relationship using orthognathic surgery alone, orthognathic surgery in concert with rhinoplasty, or orthognathic surgery followed by staged rhinoplasty.

The Influence of Paranasal Augmentation on the Measurement of the Nose for the Treatment of Midfacial Concavity

BACKGROUND

A concave midface with its associated deep nasolabial folds is more aesthetically displeasing than a convex midface. Midfacial concavity may be addressed with autologous tissue and implants.

OBJECTIVES

The aim of this study was to determine the effect of paranasal augmentation on photogrammetric parameters.

METHODS

Between July 2013 and August 2016, 12 patients underwent paranasal augmentation to address midface concavity. Augmentation was performed with autologous rib cartilage, autologous mandibular bone, or preshaped porous polyethylene (PPE). All operations were performed through the upper gingivobuccal approach. Twelve patients who underwent malar reduction using the same approach acted as a control group to account for the influence of the approach on soft tissue change. Preoperative and postoperative measurements were made photogrammetrically.

RESULTS

The average follow-up period was 12.8 months (range, 5-30 months) for both groups. The mean thickness of augmentation grafts was 5.18 mm (range, 3-7 mm). Alar width and alar base width increased 4.84% (P = 0.01) and 7.66% (P = 0.01), respectively. The nasolabial angle increased from 97.2°to 103.6° and the columellar inclination increased from 116.0° to 119.1° but neither were statistically significant. Photogrammetric parameters did not change significantly in the control group. Partial wound dehiscence occurred in one case. There was greater postoperative increase in alar width (P = 0.020), alar base width (P = 0.024), and nasolabial angle (P = 0.033) in the experimental group compared to the control group.

CONCLUSIONS

Paranasal augmentation using PPE or autologous material generates measurable soft tissue changes designed to enhance paranasal aesthetics.

LEVEL OF EVIDENCE 3

Virtual Surgical Planning: The Pearls and Pitfalls

Objective

Over the past few years, virtual surgical planning (VSP) has evolved into a useful tool for the craniofacial surgeon. Virtual planning and computer-aided design and manufacturing (CAD/CAM) may assist in orthognathic, cranio-orbital, traumatic, and microsurgery of the craniofacial skeleton. Despite its increasing popularity, little emphasis has been placed on the learning curve.

Methods

A retrospective analysis of consecutive virtual surgeries was done from July 2012 to October 2016 at the University of Montreal Teaching Hospitals. Orthognathic surgeries and free vascularized bone flap surgeries were included in the analysis.

Results

Fifty-four virtual surgeries were done in the time period analyzed. Forty-six orthognathic surgeries and 8 free bone transfers were done. An analysis of errors was done. Eighty-five percentage of the orthognathic virtual plans were adhered to completely, 4% of the plans were abandoned, and 11% were partially adhered to. Seventy-five percentage of the virtual surgeries for free tissue transfers were adhered to, whereas 25% were partially adhered to. The reasons for abandoning the plans were (1) poor communication between surgeon and engineer, (2) poor appreciation for condyle placement on preoperative scans, (3) soft-tissue impedance to bony movement, (4) rapid tumor progression, (5) poor preoperative assessment of anatomy.

Conclusion

Virtual surgical planning is a useful tool for craniofacial surgery but has inherent issues that the surgeon must be aware of. With time and experience, these surgical plans can be used as powerful adjuvants to good clinical judgement.

Review of nasal changes with maxillary orthognathic surgery

This article reviews the literature on nasal changes with maxillary orthognathic surgery. Understanding such changes is vital for surgical planning and for obtaining appropriate informed consent, and there are medico-legal implications. During orthognathic surgical planning a prediction of the effects of the different surgical movements is possible and this forms part of the basis of the planning stage. The predicted changes need to be identified and their desirability or not for each individual patient determined. Some techniques for managing undesirable nasal changes are discussed, including adjunct measures to minimize these potential effects (e.g. cinch sutures), and additional surgical procedures to manage the undesired nasal changes once they are produced.

Orthognathic Surgery and Rhinoplasty to Address Nasomaxillary Hypoplasia

The treatment of nasomaxillary hypoplasia is challenging. The phenotype of Binder "syndrome" includes the following: midfacial hypoplasia, class III malocclusion, small or absent anterior nasal spine, flattened nose, horizontal nostrils, short columella, acute nasolabial angle, and a flat frontonasal angle. A staged approach is used, with orthognathic surgery to achieve vertical maxillary length and sagittal advancement, followed by rhinoplasty aimed to increase nasal tip projection, rotation, and columellar length. This article details the diagnosis and treatment of nasomaxillary hypoplasia, demonstrating the senior author's (D.M.S.) preferred approach and technical steps.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Long-term stability of limiting nasal alar base width changes with a cinch suture following Le Fort I osteotomy with submental intubation

The aim of this study was to assess the effectiveness of the nasal alar base cinch suture following Le Fort I osteotomy at long-term follow-up. One hundred and forty participants (89 female, 51 male) aged between 16 and 51 years underwent Le Fort I osteotomy with submental intubation. Anthropometric measurements of the nose were taken intraoperatively, immediately postoperative, and for up to 3 years postoperative: the maximum lateral convexity of the alae (Al-Al) and the lateral extremity of the alar base curvature at the alar groove (Ac-Ac). The use of a cinch suture was recorded. The results were analysed using a linear mixed-effects model analysis. One hundred and six participants had cinch sutures and 34 had no cinch sutures. Following Le Fort I osteotomy, there were significant increases in Ac-Ac (by 4.29mm) and Al-Al (by 3.70mm) (both P<0.0001). Cinch sutures significantly reduced the widths back to preoperative values (P<0.0001). Alar width remained stable over 3 years, with an increase of 0.36mm for Al-Al (P>0.05) and 1.03mm for Ac-Ac (P<0.05) compared to the postoperative measurement. In conclusion, a cinch suture was helpful in reducing the unwanted alar base width changes, which were found to be relatively stable at 3 years.

Three-dimensional Nasolabial Morphologic Alterations Following Le Fort I

BACKGROUND

Le Fort I osteotomy imparts significant changes to the nasolabial region. Past studies have relied on 2-dimensional data and have not delineated differences among various Le Fort I subtypes. The purpose of this study is to 3-dimensionally analyze Le Fort I-induced nasal and lip changes comparing advancement alone versus widening alone [surgically assisted maxillary expansion (SAME)] versus advancement and widening. We hypothesize that the combination of maxillary advancement with widening will result in the most profound changes.

METHODS

A retrospective cohort study was performed. Included Le Fort I patients were grouped as: (1) nonsegmental straight advancement, (2) widening without advancement, and (3) segmental advancement and widening. Pre- and postoperative 3-dimensional photogrammetry (Canfield) were analyzed. Anthropometric landmarks were placed and measured by 2 independent observers. Statistics involved both paired and unpaired t tests (significance = P < 0.05).

RESULTS

One hundred eight photogrammetric data sets were analyzed, including 46 single-piece, 26 SAME, and 36 segmental. Significant postoperative nasal changes were observed within each intragroup analysis. The most dramatic changes were seen after segmental Le Fort I with advancement and widening, which included alar base width, alar width, nostril width, and soft triangle angle, all P < 0.05.

CONCLUSIONS

Le Fort I osteotomy results in significant alteration of the nasolabial morphology. This is the first study to 3-dimensionally analyze nasal changes that occur comparing maxillary advancement alone versus widening alone (SAME) versus advancement with widening. These objective data permit improved patient counseling and surgical planning.

State-of-the-art three-dimensional analysis of soft tissue changes following Le Fort I maxillary advancement

We describe the comprehensive 3-dimensional analysis of facial changes after Le Fort I osteotomy and introduce a new tool for anthropometric analysis of the face. We studied the cone-beam computed tomograms of 33 patients taken one month before and 6-12 months after Le Fort I maxillary advancement with or without posterior vertical impaction. Use of a generic facial mesh for dense correspondence analysis of changes in the soft tissue showed a mean (SD) anteroposterior advancement of the maxilla of 5.9 (1.7) mm, and mean (SD) minimal anterior and posterior vertical maxillary impaction of 0.1 (1.7) mm and 0.6 (1.45) mm, respectively. It also showed distinctive forward and marked lateral expansion around the upper lip and nose, and pronounced upward movement of the alar curvature and columella. The nose was widened and the nostrils advanced. There was minimal forward change at the base of the nose (subnasale and alar base) but a noticeable upward movement at the nasal tip. Changes at the cheeks were minimal. Analysis showed widening of the midface and upper lip which, to our knowledge, has not been reported before. The nostrils were compressed and widened, and the lower lip shortened. Changes at the chin and lower lip were secondary to the limited maxillary impaction.

Is the Pyriform Ligament Important for Alar Width Maintenance After Le Fort I Osteotomy?

PURPOSE

To determine whether identification and incorporation of the pyriform ligament in the alar cinch results in decreased alar base widening compared with standard alar cinch techniques.

MATERIALS AND METHODS

This was a retrospective case series and the sample was composed of patients undergoing Le Fort I osteotomy. Intraoperatively, the pyriform ligament was identified and incorporated in the alar cinch suture. Greatest alar width (GAW) measured immediately after closure was compared with GAW measured at least 5 months postoperatively. The change in alar base width was compared with that reported in the literature using other alar cinch techniques. Two case examples are reported.

RESULTS

The sample was composed of 15 patients (mean age, 27.1 yr; 27% female). The mean postoperative change in GAW was 1.0 ± 0.6 mm (2.59 ± 1.59%). Postoperative change in alar base width reported in the literature ranged from 0.5 to 10.8%.

CONCLUSION

The pyriform ligament is easily identified during exposure of the maxilla and pyriform aperture and can be used to control widening of the alar base after Le Fort I osteotomy.

Quantifying Asymmetry and Scar Quality of Children With Repaired Cleft Lip and Palate Using Symnose 2

The Symnose semiautomated assessment of outcome of the appearance of the repaired cleft lip and nose was developed to measure asymmetry. Symnose 2 has been further developed to include quantification of the extent of scar color, intensity, and contour and midline dehiscence, underexpressed in the measurement of asymmetry.