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

Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 756e763

Assessment of three-dimensional nasolabial response 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, USA b Dental Section, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi, Thailand

Received 13 January 2014; accepted 15 March 2014

KEYWORDS Le Fort I; Nasolabial; Three-dimensional; Anthropometric

Summary Background: Le Fort I advancement induces soft tissue changes to the nasolabial region. The correlation of sagittal skeletal movement to soft tissue alteration has been studied using 2D methods. However, the influence of maxillary advancement has not been adequately assessed using three-dimensional means. The purpose of this study is to analyze nasolabial changes 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 recorded. Nasolabial anthropometric measurements were performed using the corresponding 3D post-processing software (Mirror). Six month minimum follow-up elapsed before final evaluation. Results: Forty-four 3D photo data sets were included. Mean maxillary advancement was 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 the alar base, alar widths, nostril width, 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 significant (p < 0.05) increase of the nasal tip, columella and upper lip projection was seen. Philtral height showed no significant changes (p > 0.05) after maxillary advancement. No significant correlation (p > 0.05) between the degree of soft tissue changes and the amount of maxillary advancement was found. Conclusion: Le Fort I advancement significantly impacts the nasolabial soft tissue envelope. The 3D soft 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 and Aesthetic Surgeons.

* Corresponding author. Department of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT 06520, USA. Tel.: þ1 (203) 785 4559; fax: þ1 (203) 785 5714. E-mail addresses: [email protected], [email protected] (D.M. Steinbacher). http://dx.doi.org/10.1016/j.bjps.2014.03.023 1748-6815/ª 2014 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

3D nasolabial response to LeFort 1 advancement

Introduction Nasolabial symmetry, projection, and shape play a central role in facial aesthetics and expression.1 Due to the close relationship between these soft tissues and the underlying maxillary bone, Le Fort I advancement has a significant influence on these structures and, consequently, on overall facial proportions and balance.2e5 In addition, various soft tissue closure techniques following skeletal correction have been shown to significantly impact nasolabial configuration.2,6e9 Two-dimensional lateral cephalograms have been utilized for both presurgical planning, as well as postsurgical evaluation of outcomes. However, algorithms intended to predict soft tissue change from skeletal movement are limited to radiologic 2D shadow superimposition. Three-dimensional analysis and objective data is critical to properly define the type and extent of nasolabial change with Le Fort I. This information is useful for accurate planning, proper patient counseling, and optimization of esthetic outcomes. The purpose of this paper was to three-dimensionally assess and describe the nasolabial soft tissue changes following Le Fort I advancement. Additionally, we sought to evaluate the relationship between the amount of maxillary movement and nose/lip morphometrics. We hypothesize that significant three-dimensional nasolabial soft tissue alterations occur following Le Fort I advancement.

Patients and methods

757 Demographic information was tabulated including patients’ age, gender, and diagnosis. Peri-operative details including the amount of advancement and suture technique were documented. Pre- and postoperatively, all subjects were assessed using a 3D photogrammetric imaging technique. The postoperative interval was at least 6 months.

Imaging and data processing The three-dimensional photogrammetric data was acquired using the 3D VECTRA photosystem (Canfield, Fairfield, NJ). System calibration was performed before every capture process. Natural head position was chosen for data acquisition. Data sets were saved and calculated into a threedimensional model. Further data processing was performed using the corresponding imaging software (Mirror). Validity and reliability of the 3D photogrammetric tool for anthropometric measurements was confirmed in previous studies.10,11 Two blinded observers indicated the landmarks on each facial soft tissue image. The zoom and rotation tools were used to correctly identify and set the landmarks on the 3D surface (Table 1, Figures 1 and 2). To evaluate postoperative soft tissue changes, a paired two-sample t-test was used. An alpha level of 0.05 indicated a significant difference in scores. A cut-off of 5 mm was used to stratify the patients into two groups based on magnitude of maxillary advancement for additional analyses. An unpaired two-sample t-test was used for this evaluation.

Subjects

Results This retrospective analysis was performed in concordance with the Yale University Institutional Review Board (Protocol number: HIC# 1101007932). Patients who underwent single-piece Le Fort I advancement were included. Exclusion criteria were superior or inferior positioning of the maxilla and previous naso-maxillary surgery.

Table 1

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

Landmarks used for 3D nasolabial soft tissue assessment.

Landmark

Abbreviation

Definition

Glabella Nasion Alare Subalare Pronasale Collumella peak Subnasale Medial nostril base Lateral nostril base Lateral alar Soft triangle Midcolumella Lateral Crus Crista philtri superior Labiale superius Crista philtri inferior Chelion Tragus

G N Al SA Prn CP Sn mNb lNb LA ST MC LC Cphs Ls Cphi Che Tr

Most anteriorly projected point of the forehead within the midsagittal plane Most depressed midline point superior to the nasal bridge Most lateral point of the alar contour Labial insertion of each alar base Most anterior point of the nose Most superior point of the Columella Midpoint of the nasolabial angle at the columellar base Point on inner nostril where the columella meets the columellar crest Most inferolateral point of the nostril Point on inner nostril rim at its labial insertion Most superiormedial point of the nostril Medial nostril point at midcolumella height level Perpendicular to the columella, through the MC on the lateral crus Top of the philtral crest at the level of the subnasale Midpoint of the upper vermillion border Point of maximum vertical height of upper vermillion border (Cupid’s bow) Most lateral point of labial commissure Most anterior point of the tragus

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P. Metzler et al.

Figure 1

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

postoperative 3D photo capturing showed a mean of 7.8 months. 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 mm preoperatively while it was 125.2
11.7 mm (p Z 0.0353) postoperatively. Columella projection increased significantly (p Z 0.0163), showing respective means of 120.3
3.2 mm and 121.4
2.8 mm pre- and postoperatively. Preoperative mean nasal tip prominence was 30.1
3.2 mm, while the postoperative mean was 28.5
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) postoperatively. Mean preoperative alar width was 34.2
2.6 mm and increased to 37.0
3.7 mm postoperatively (p < 0.0001). Nostril height decreased significantly (p < 0.0001), showing respective means of 14.1
2.2 mm and 13.3
2.1 mm pre- and postoperatively. Mean nostril width increased postoperatively from 10.6
1.9 mm to 11.4
2.3 mm (p < 0.0001). The

combined bilateral sill width had a preoperative mean of 6.7
1.6 mm, which decreased to 5.9
1.3 mm postoperatively (p < 0.0001). Soft triangle angle measurements increased postoperatively from a mean of 70.6
10.0 to 80.3
9.2 (p < 0.0001). The lateral alar angle decreased significantly (p < 0.0001) showing a mean 110.2
13.9 preoperatively and 99.8
13.5 postoperatively. No significant differences (p > 0.05) could be seen pre- and postoperatively when comparing between the left and right nostril dimensions (Table 1). Subnasale projection showed a mean of 112.6
2.2 mm preoperatively and increased to 114.3
1.6 mm postoperatively (p Z 0.004), while lip projection showed a preoperative mean of 115.2
2.8 mm and increased to a postoperative mean of 117.8
2.6 mm (p Z 0.0005). Mean preoperative columella height was 11.4
1.6 mm, and this decreased to 10.8
2.0 mm postoperatively (p Z 0.0384). The upper philtrum width increased postoperatively from a mean of 11.7
2.1 mm to 12.6
2.2 mm (p Z 0.0007), and the lower philtrum width increased from a mean of 7.6
2.4 mm preoperatively to 12.6
2.2 mm postoperatively (p Z 0.0331). No significant changes were identified in the columella width and labial width postoperatively (p Z 0.6635 and p Z 0.2894, respectively). Percentages of soft tissue changes correlated with the absolute maxillary advancement are demonstrated in Table 1. We also stratified patients into groups to compare soft tissue changes after maxillary 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

Figure 2

Nasal landmarks for morphometric analysis.

Le Fort 1 advancement is known to have beneficial effects on the facial profile, especially within the nasolabial region. However, adverse side-effects including widening of the alar bases, increasing nasal tip projection, and flattening, thinning, and shortening of the upper lip have previously been described.3,4,12e18 Previous studies suggest that soft tissue changes due to maxillary advancement

3D nasolabial response to LeFort 1 advancement Table 2

759

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

Measurement Nose Nasofrontal angle Nasolabial angle Nasal projection Alar base width Alar width Sill width right Sill width left Nostril height right Nostril height left Nostril width right Nostril width left Soft triangle angle right Soft triangle angle left Lateral alar angle right Lateral alar angle left Columella width Columella heigtht Columella projection Lip Subnasale projection Lower philtrum width Upper philtrum width Philtrum height Lip width Labiale superius projection

Abbreviation

Definition

NFA NLA NP ABW ACW SWr SWl NHr NHl Nwr NWl STAr STAl LAAr LAAl CW CH CP

Angle between G-N-Prn Angle between CP-Sn-Ls Distance between Tr-Prn Distance between SA (l)-SA (r) Distance between Al (l)-Al (r) Distance between mNb-lNb (r) Distance between mNb-lNb (l) Distance between LA-ST (r) Distance between LA-ST (l) Distance between MC-Al (r) Distance between MC-Al (l) Angle between MC-ST-LC (r) Angle between MC-ST-LC (l) Angle between lNb-LC-ST (r) Angle between lNb-LC-ST (l) Distance between MC (r)-MC (l) Distance between Sn-CP Distance between Tr-CP

SnP LPW UPW PH LW LSP

Distance Distance Distance Distance Distance Distance

occur inconsistently, complicating reliable hard-to-soft tissue predictions. Nasal tip advancement has been reported to increase between 30% and 60% of the total amount of maxillary advancement.19e21 The columellar base was touted to advance to a greater extent than the nasal tip, secondary to the anterior movement of the maxilla, but this phenomenon was also inconsistently reproduced.7 The alar width was found to consistently increase after maxillary advancement but a wide range has been described.2,12,22 The change in upper lip morphology is reported to have the most direct response to maxillary/ incisor advancement - representing values up to 140% of maxillary advancement.2,8 Postoperative two-dimensional soft tissue changes as a result of maxillary movements have been described in the literature and variably reported to be used as a reference for current prediction planning. However, these predictions are inherently biased from overlapped structures and do not accurately represent the three-dimensional changes that occur within the overlying soft tissue.13,23,24 Indeed, the most objective analysis strategy is 3D morphometric analysis (see Table 3). Multiple methods have been described for threedimensional soft tissue assessment following orthognathic surgery. Attempts including direct anthropometric, moire ´, laser, and volumetric computed tomography measurements were shown to be limited due to poor surface texture and resolution. Less detailed information considerably hinders reproducibility and reliability of measurements, allowing only rough quantitative measurements and coarse evaluation. 3D photo technology overcomes these drawbacks by

between between between between between between

Tr-Sn Cphi (r)-Cphi (l) Cphs (r)-Cphs (l) Ls-Sn Che (r)-Che (l) Tr-Ls

providing real three-dimensional and detailed anthropometric data.10,11,25 However, as in every facial morphometric assessment, changes in facial expression have the potential to bias study results. Therefore, during picture capturing our patients were instructed to keep their facial expression neutral pre- and postoperatively (see Figure 3). To the authors’ knowledge, no study exists focusing on three-dimensional nasolabial soft tissue changes after Le Fort I advancement using 3D photo technology at this level of detail. We hypothesized that more complex threedimensional nasolabial soft tissue changes are imparted following maxillary advancement than have been previously shown using 2D means (see Table 4). In our cohort, the nasolabial soft tissue changes were compared with the actual bony movements measured intraoperatively. An average projection increase of the nasal tip, as measured from the tragus, was about 10% of the total maxillary movement but is of questionable clinical relevance. However, the nasal tip prominence (measured from the alar groove to the tip) significantly decreased by about 32% of the total maxillary advancement. So, although actual tip projection increased, compared to the posterior face, the relative tip prominence (the proportion of the nasal tip in front of the upper lip) decreased. This finding was likely due to the more obtuse alar relationship secondary to advancement and widening of the ala as the piriform came forward. The widened, obtuse ala pulled the tip back, following the tripod theory, despite an increase in nasal projection relating to the face.26,27 In other words, intrinsic nasal tip projection decreased e relative to the

760 Table 3

P. Metzler et al. Morphometric evaluation before and after maxillary advancement.

Measurement (mm, ) Nose Nasofrontal angle Nasolabial angle Nasal tip projection Nasal tip prominence Alar base width Alar width Sill width right Sill width left Nostril height right Nostril height left Nostril width right Nostril width left Soft triangle angle right Soft triangle angle left Lateral alar angle right Lateral alar angle left Columella width Columella height Columella projection Lip Subnasale projection Lower philtrum width Upper philtrum width Philtrum height Mouth width Labiale superius projection

T1

T2

DT2T1

CI

p-value

D T/Adv (%)

144.7
6.3 124.9
11.3 124.5
3.1 30.1
3.2 29.2
3.2 34.2
2.6 6.9
1.5 6.5
1.6 13.9
2.2 14.2
2.1 10.6
2.0 10.9
1.9 70.8
11.6 71.0
8.6 110
16.5 109.3
13.4 6.7
1.3 11.4
1.6 120.3
3.2

141.2
6.8 125.2
11.7 125.3
3.0 28.5
2.9 31.9
4.0 37.0
3.7 6.1
1.1 5.8
1.3 13.0
1.8 13.4
2.3 11.2
2.4 12.0
2.2 79.8
10.4 81.5
7.6 100.3
14.4 97.2
15.2 6.5
0.8 10.8
2.0 121.4
2.8

3.5
1.7 0.4
8.3 0.8
1.9 1.6
1.6 2.8
1.9 2.9
2.0 0.8
0.8 0.6
0.8 0.9
0.8 0.8
0.4 0.6
0.9 1.1
0.9 9.0
4.8 10.5
6.1 9.7
6.4 12.1
7.5 0.2
1.3 0.6
1.0 1.0
1.5

4.5 to 2.6 4.2 to 5.0 0.2 to 1.8 2.5 to 0.7 1.7 to 3.8 1.7 to 4.0 1.2 to 0.4 1.1 to 0.2 1.4 to 0.4 1.0 to 0.5 0.1 to 1.1 0.6 to 1.6 6.3 to 11.7 7.1 to 13.9 13.2 to 6.2 16.2 to 8.0 0.9 to 0.6 1.1 to 0.04 0.2 to 1.9

<0.0001* 0.0353 0.0031* 0.0014* <0.0001* <0.0001* 0.0011* 0.0061* 0.0011* <0.0001* 0.0221* 0.0004* <0.0001* <0.0001* <0.0001* <0.0001* 0.6635 0.0384* 0.0163*

66.8Y 2.1Y 10.2[ 31.8Y 54.0[ 54.5[ 14.1Y 10.6Y 16.5Y 15.9Y 12.7[ 20.9[ 181.4[ 201.3[ 198.9[ 226.3[ 2.9Y 9.9Y 16.1[

0.004* 0.0007* 0.0331* 0.4894 0.2894 0.0005*

28.8[ 19.6[ 18.7[ 6.6[ 17.6[ 51.2[

112.6 11.7 7.6 14.6 49.3 115.2









2.2 2.1 2.4 3.4 2.8 2.8

114.3 12.6 8.5 14.9 50.1 117.9









1.6 2.2 2.6 3.1 4.2 2.6

1.7 0.9 0.9 0.3 0.8 2.7









1.9 0.9 1.5 1.6 2.7 2.3

0.6 to 2.7 0.5 to 1.4 0.1 to 1.7 0.6 to 1.2 0.7 to 2.3 1.4 to 4.0

T1 preoperative. T2 postoperative. CI Confidential Interval. DT (T2T1)/&uarr. [ Increase. Y Decrease.

alar groove e as the ala splayed, while extrinsic tip projection 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 seen in all patients. We demonstrated a significant width increase of landmarks within the ala and alar base region, demonstrating mean transverse widening of about 50% of the corresponding amount of maxillary advancement. These findings were consistent in all patients, independent of the extent of the skeletal advancement (See Figure 4). Nostril dimensions (nostril height, nostril width, sill width) and shape (soft triangle and lateral alar angles) were significantly changed by the maxillary advancement. Postoperatively, the nostril width increased, while the vertical dimension decreased, both significantly. At the same time, the soft triangle angle became more obtuse while the lateral alar angle became more acute postoperatively. Clinically, this alteration of the alar-columellar relationship resulted in an increased lateral nostril display. This occurs due to a combination of columellar caudal buckling, secondary to the osseous advancement, and the alar retraction/upward rotation from soft tissue degloving. Interestingly, the columella width did not change significantly.

The labial superius showed an advancement of 50% of the total maxillary movement. The nasolabial angle did not demonstrate a predictable trend after maxillary advancement. Although the philtrum height remained stable, significant upper lip widening (including both upper and lower philtral widths) was noted, again secondary to the more forward bony position and resultant increase in soft tissue tension and drape. Comparing nasolabial changes in 2 groups based on magnitude of advancement one <5 mm (mean Z 4.4 mm) and one >5 mm (mean Z 7.0 mm), no significant differences in morphometrics could be found. In other words, a 5 mm advancement will result in the changes described above, and these do not proportionally increase with increasing amounts of advancement, based on our findings. Our study does demonstrate that more complex threedimensional soft tissue changes occur following Le Fort I advancement than previously described using 2D studies. This objective anthropometric analysis demonstrates predictable and similar changes in nasolabial soft tissue anatomy after maxillary advancements up to 10 mm, which can be helpful for future soft tissue prediction planning. This of course does not minimize the fact that each patient is unique and requires tailored approaches and discussion,

3D nasolabial response to LeFort 1 advancement

761 Table 4 Soft tissue changes according to the amount of advancement. Measurement (mm, )

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

with consideration of gender, ethnicity, and goals of treatment. A multitude of techniques have been described to control undesired morphologic soft tissue changes after orthognathic surgery. The presence or absence of the anterior nasal spine was reported to have less of an effect on postoperative nasal morphology than one might intuit.28 However, our clinical experience reveals, and our understanding of anatomic relationships suggests, that the ANS does impact on subnasal projection, nasolabial angle, and nasal tip movement and projection, when considered in light of variables such as the amount of advancement, underlying anatomic variation, nasolabial morphology and skin thickness.29 The modeling ostectomy within the lateral piriform aperture of the Le Fort I segment, which reduces or smoothens the step between the upper portion of the bilateral nasal buttresses and the lower portion of the anteriorly moved Le Fort I segment, reduces alar base projection and widening. This procedure should be considered, especially in larger maxillary advancements. Further, the classic Le Fort I osteotomy line represents a superiorly inclined plane in reference to the Frankfort horizontal plane. An anterior advancement within this

Nose Nasofrontal angle Nasolabial angle Nasal tip projection Nasal tip prominence Alar base width Alar width Sill width right Sill width left Nostril height right Nostril height left Nostril width right Nostril width left Soft triangle angle right Soft triangle angle left Lateral alar angle right Lateral alar angle left Columella width Columella height Columella projection Lip Subnasale projection Lower philtrum width Upper philtrum width Philtrum height Mouth width Labiale superius projection

<5 mm >5 mm D > 5 mm p-value  < 5 mm 3.4 3.7 0.3 2.2 4.3 2.2 0.3 1.5 1.1 1.0 2.4 1.4 3.1 2.2 1.0 2.9 2.8 0.1 0.6 1.2 0.6 0.3 1.1 0.8 0.7 1.2 0.6 0.9 0.6 0.2 0.7 0.4 0.3 1.2 0.9 0.3 7.8 10.8 3.0 8.6 10.3 1.7 8.7 11.2 2.5 10.7 12.6 1.9 0.2 0.7 0.9 0.4 0.9 0.5 0.7 1.6 0.9 1.3 1.1 1.1 1.3 1.0 2.8

2.3 0.7 0.6 0.9 0.4 2.5

1.0 0.4 0.6 0.4 0.7 0.3

0.1723 0.1624 0.2558 0.0830 0.3662 0.9242 0.1517 0.0519 0.1956 0.3018 0.588 0.5425 0.2596 0.937 0.4715 0.8246 0.2054 0.3861 0.239 0.3362 0.3781 0.5038 0.4282 0.6651 0.7967

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

plane will consequently lead to a compromised nasal septum, resulting in morphologic and functional nasal changes. The leveling of the nasal crest to prevent any septo-maxillary interference is often sufficient to maintain the septal midsagittal position. Depending on the septal and maxillary morphology, a surgical shortening of the posterior septal angle may be required. Correction of the septal interface with the ANS and maxillary crest is easily performed following “down fracture” as an excellent exposure is achieved. One must recognize the impact of improper handling of the septum, with over-resection resulting in potential loss of tip projection and underresection risking caudal septal deflection and deviation. Both of these results may jeopardize optimal nasal morphology, function, and esthetic outcome. Surgical osteotomy below the anterior nasal spine has been introduced, but risks the dentition and did not result in preventing the adverse soft tissue effects.30 (See Figure 5). Soft tissue closure after Le Fort I advancement does also play a role in optimizing nasolabial form, or at least preventing any untoward response. We recognize that surgical approach frees the insertions of the nasolabial muscles and separates the attachment of the alar base from the underlying bone. This dissection alone impacts nasolabial

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

morphology and the alarefacial interface. This relationship is altered further with maxillary advancement and movement, with subsequent redraping of the nasolabial tissue. Techniques have been devised therefore to influence desired or “proper” redraping of the nasal base and upper lip. The alar cinch suture is an attempt to narrow, or control excess widening of, the alar base, and takes some form of an inter-alar suture on the deep surface. The “VeY” lip mucosal closure entails recruiting lateral mucosa inferiorly and medially, to increase lip pout and possibly length. Some suggest that the combination of both techniques simultaneously garner esthetic benefits by controlling the nasolabial fibro-muscular structures.2,6e9,31 Others have touted performance of definitive correction of alar and sill via a formal rhinoplasty at a later date, following soft tissue settling.4 Concurrent rhinoplasty is also a possibility, but in the setting of a Le Fort I, the degloved alar base cannot be accurately judged, and it is best to wait for interval soft tissue swelling and contraction to resolve.32 It is clear that a range of desired and undesired nasolabial consequences may be experienced following Le Fort I, depending on the skeletal movement, host soft tissue

variables, and techniques for closure and redraping of the soft tissue. However, our data suggests that, in a straightforward Le Fort I, these changes are predictable and reproducible. These should be anticipated and emphasized during the planning session to the patient as either a desired consequence, or as an untoward result of the procedure that may be temporarily controlled during the closure, or more likely, definitively addressed at a later time.32 Accurate understanding and quantification of the 3D soft tissue response to Le Fort I is essential to achieve the most accurate treatment plan and esthetic result. Also, as previously mentioned, when undesired consequences are expected, this permits proper patient counseling and the proscription of intraoperative controls or future procedures to be implemented. Future efforts will be geared to investigating a variety of skeletal movements, the influence of age, gender and ethnicity, and the presence or absence of common craniofacial syndromes on nasolabial results. These studies will permit more reliable 3D planning, accurate predictions of surgical outcomes, and the eventual achievement of the most esthetic results.

Figure 5 Frontal view showing 3D transverse nasolabial changes before (grey surface) and after (3D mesh) surgery. A significant 3D transverse enlargement of the lateral nasal structures after maxillary advancement is visible.

3D nasolabial response to LeFort 1 advancement

Conclusion Nasolabial soft tissue changes following Le Fort I advancement are more complex than previously described. Morphometric changes, including: increased inter-alar widening, tip rotation, and lateral nostril display, occurred in a consistent reproducible fashion for a Le Fort I advancement up to 10 mm. This objective 3D understanding will permit accurate planning, counseling, and help optimize eventual esthetic outcomes.

Acknowledgments The authors do not have any source of funding or conflicts of interest to declare for this project. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

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