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 Summary Background: Le Fort I advancement induces soft tissue changes to the nasolabial
Le Fort I; region. The correlation of sagittal skeletal movement to soft tissue alteration has been studied
Nasolabial; using 2D methods. However, the influence of maxillary advancement has not been adequately
Three-dimensional; assessed using three-dimensional means. The purpose of this study is to analyze nasolabial
Anthropometric 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 re-
corded. 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 sig-
nificant (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 corre-
lation (p > 0.05) between the degree of soft tissue changes and the amount of maxillary advance-
ment 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: derek.steinbacher@yale.edu, derek.steinbacher@gmail.com (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 757

Introduction Demographic information was tabulated including pa-

Nasolabial symmetry, projection, and shape play a central role
in facial aesthetics and expression.1 Due to the close rela-
tionship between these soft tissues and the underlying
maxillary bone, Le Fort I advancement has a significant influ-
ence 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 evalua-
tion 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 in-
formation 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 al-
terations occur following Le Fort I advancement.
Patients and methods
Subjects
This retrospective analysis was performed in concordance
with the Yale University Institutional Review Board (Proto-
col number: HIC# 1101007932). Patients who underwent
single-piece Le Fort I advancement were included. Exclu-
sion criteria were superior or inferior positioning of the
maxilla and previous naso-maxillary surgery.
tients’ 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 tech-
nique. 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 acqui-
sition. Data sets were saved and calculated into a three-
dimensional model. Further data processing was performed
using the corresponding imaging software (Mirror). Validity
and reliability of the 3D photogrammetric tool for anthro-
pometric 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 post-
operative 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 un-
paired two-sample t-test was used for this evaluation.
Results
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

Table 1 Landmarks used for 3D nasolabial soft tissue assessment.

Landmark Abbreviation Definition
Glabella G Most anteriorly projected point of the forehead within the midsagittal plane
Nasion N Most depressed midline point superior to the nasal bridge
Alare Al Most lateral point of the alar contour
Subalare SA Labial insertion of each alar base
Pronasale Prn Most anterior point of the nose
Collumella peak CP Most superior point of the Columella
Subnasale Sn Midpoint of the nasolabial angle at the columellar base
Medial nostril base mNb Point on inner nostril where the columella meets the columellar crest
Lateral nostril base lNb Most inferolateral point of the nostril
Lateral alar LA Point on inner nostril rim at its labial insertion
Soft triangle ST Most superiormedial point of the nostril
Midcolumella MC Medial nostril point at midcolumella height level
Lateral Crus LC Perpendicular to the columella, through the MC on the lateral crus
Crista philtri superior Cphs Top of the philtral crest at the level of the subnasale
Labiale superius Ls Midpoint of the upper vermillion border
Crista philtri inferior Cphi Point of maximum vertical height of upper vermillion border (Cupid’s bow)
Chelion Che Most lateral point of labial commissure
Tragus Tr Most anterior point of the tragus
758
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 signifi-
cantly (p Z 0.0163), showing respective means of
120.3
3.2 mm and 121.4
2.8 mm pre- and post-
operatively. 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) post-
operatively. Mean preoperative alar width was
34.2
2.6 mm and increased to 37.0
3.7 mm post-
operatively (p < 0.0001). Nostril height decreased signifi-
cantly (p < 0.0001), showing respective means 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
Figure 2 Nasal landmarks for morphometric analysis.
P. Metzler et al.
combined bilateral sill width had a preoperative mean of
6.7
1.6 mm, which decreased to 5.9
1.3 mm post-
operatively (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 post-
operatively (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 post-
operatively (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 advance-
ment are demonstrated in Table 1. We also stratified pa-
tients 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
Le Fort 1 advancement is known to have beneficial effects
on the facial profile, especially within the nasolabial re-
gion. However, adverse side-effects including widening of
the alar bases, increasing nasal tip projection, and flat-
tening, 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 759

Table 2 Parameters (direct distances and angles) used for 3D nasolabial soft tissue assessment.
Measurement Abbreviation Definition
Nose
Nasofrontal angle NFA Angle between G-N-Prn
Nasolabial angle NLA Angle between CP-Sn-Ls
Nasal projection NP Distance between Tr-Prn
Alar base width ABW Distance between SA (l)-SA (r)
Alar width ACW Distance between Al (l)-Al (r)
Sill width right SWr Distance between mNb-lNb (r)
Sill width left SWl Distance between mNb-lNb (l)
Nostril height right NHr Distance between LA-ST (r)
Nostril height left NHl Distance between LA-ST (l)
Nostril width right Nwr Distance between MC-Al (r)
Nostril width left NWl Distance between MC-Al (l)
Soft triangle angle right STAr Angle between MC-ST-LC (r)
Soft triangle angle left STAl Angle between MC-ST-LC (l)
Lateral alar angle right LAAr Angle between lNb-LC-ST (r)
Lateral alar angle left LAAl Angle between lNb-LC-ST (l)
Columella width CW Distance between MC (r)-MC (l)
Columella heigtht CH Distance between Sn-CP
Columella projection CP Distance between Tr-CP
Lip
Subnasale projection SnP Distance between Tr-Sn
Lower philtrum width LPW Distance between Cphi (r)-Cphi (l)
Upper philtrum width UPW Distance between Cphs (r)-Cphs (l)
Philtrum height PH Distance between Ls-Sn
Lip width LW Distance between Che (r)-Che (l)
Labiale superius projection LSP Distance between Tr-Ls

occur inconsistently, complicating reliable hard-to-soft
tissue predictions. Nasal tip advancement has been re-
ported 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 in-
crease 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 three-
dimensional soft tissue assessment following orthognathic
surgery. Attempts including direct anthropometric, moiré,
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 evalua-
tion. 3D photo technology overcomes these drawbacks by
providing real three-dimensional and detailed anthropo-
metric data.10,11,25 However, as in every facial morpho-
metric assessment, changes in facial expression have 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 three-
dimensional 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 sec-
ondary 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 P. Metzler et al.

Table 3 Morphometric evaluation before and after maxillary advancement.

Measurement (mm, ) T1 T2 DT2T1 CI p-value D T/Adv (%)
Nose
Nasofrontal angle 144.7
6.3 141.2
6.8 3.5
1.7 4.5 to 2.6 <0.0001* 66.8Y
Nasolabial angle 124.9
11.3 125.2
11.7 0.4
8.3 4.2 to 5.0 0.0353 2.1Y
Nasal tip projection 124.5
3.1 125.3
3.0 0.8
1.9 0.2 to 1.8 0.0031* 10.2[
Nasal tip prominence 30.1
3.2 28.5
2.9 1.6
1.6 2.5 to 0.7 0.0014* 31.8Y
Alar base width 29.2
3.2 31.9
4.0 2.8
1.9 1.7 to 3.8 <0.0001* 54.0[
Alar width 34.2
2.6 37.0
3.7 2.9
2.0 1.7 to 4.0 <0.0001* 54.5[
Sill width right 6.9
1.5 6.1
1.1 0.8
0.8 1.2 to 0.4 0.0011* 14.1Y
Sill width left 6.5
1.6 5.8
1.3 0.6
0.8 1.1 to 0.2 0.0061* 10.6Y
Nostril height right 13.9
2.2 13.0
1.8 0.9
0.8 1.4 to 0.4 0.0011* 16.5Y
Nostril height left 14.2
2.1 13.4
2.3 0.8
0.4 1.0 to 0.5 <0.0001* 15.9Y
Nostril width right 10.6
2.0 11.2
2.4 0.6
0.9 0.1 to 1.1 0.0221* 12.7[
Nostril width left 10.9
1.9 12.0
2.2 1.1
0.9 0.6 to 1.6 0.0004* 20.9[
Soft triangle angle right 70.8
11.6 79.8
10.4 9.0
4.8 6.3 to 11.7 <0.0001* 181.4[
Soft triangle angle left 71.0
8.6 81.5
7.6 10.5
6.1 7.1 to 13.9 <0.0001* 201.3[
Lateral alar angle right 110
16.5 100.3
14.4 9.7
6.4 13.2 to 6.2 <0.0001* 198.9[
Lateral alar angle left 109.3
13.4 97.2
15.2 12.1
7.5 16.2 to 8.0 <0.0001* 226.3[
Columella width 6.7
1.3 6.5
0.8 0.2
1.3 0.9 to 0.6 0.6635 2.9Y
Columella height 11.4
1.6 10.8
2.0 0.6
1.0 1.1 to 0.04 0.0384* 9.9Y
Columella projection 120.3
3.2 121.4
2.8 1.0
1.5 0.2 to 1.9 0.0163* 16.1[
Lip
Subnasale projection 112.6
2.2 114.3
1.6 1.7
1.9 0.6 to 2.7 0.004* 28.8[
Lower philtrum width 11.7
2.1 12.6
2.2 0.9
0.9 0.5 to 1.4 0.0007* 19.6[
Upper philtrum width 7.6
2.4 8.5
2.6 0.9
1.5 0.1 to 1.7 0.0331* 18.7[
Philtrum height 14.6
3.4 14.9
3.1 0.3
1.6 0.6 to 1.2 0.4894 6.6[
Mouth width 49.3
2.8 50.1
4.2 0.8
2.7 0.7 to 2.3 0.2894 17.6[
Labiale superius projection 115.2
2.8 117.9
2.6 2.7
2.3 1.4 to 4.0 0.0005* 51.2[
T1 preoperative.
T2 postoperative.
CI Confidential Interval.
DT (T2T1)/&uarr.
[ Increase.
Y Decrease.

alar groove e as the ala splayed, while extrinsic tip pro-
jection increased as the piriform and anterior nasal spine
(ANS) pushed the entire nasal complex forward.
Further, a general decrease of the nasofrontal angle,
representing the upward rotation of the nasal tip, was seen
in all patients. We demonstrated a significant width in-
crease of landmarks within the ala and alar base region,
demonstrating mean transverse widening of about 50% 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 signif-
icantly changed by the maxillary advancement. Post-
operatively, 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 colu-
mella 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 advance-
ment. Although the philtrum height remained stable, sig-
nificant 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 differ-
ences 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 three-
dimensional soft tissue changes occur following Le Fort I
advancement than previously described using 2D studies.
This objective anthropometric analysis demonstrates pre-
dictable and similar changes in nasolabial soft tissue anat-
omy after maxillary advancements up to 10 mm, which 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, ) <5 mm >5 mm D > 5 mm p-value
 < 5 mm
Nose
Nasofrontal angle 3.4 3.7 0.3 0.1723
Nasolabial angle 2.2 4.3 2.2 0.1624
Nasal tip projection 0.3 1.5 1.1 0.2558
Nasal tip prominence 1.0 2.4 1.4 0.0830
Alar base width 3.1 2.2 1.0 0.3662
Alar width 2.9 2.8 0.1 0.9242
Sill width right 0.6 1.2 0.6 0.1517
Sill width left 0.3 1.1 0.8 0.0519
Nostril height right 0.7 1.2 0.6 0.1956
Nostril height left 0.9 0.6 0.2 0.3018
Nostril width right 0.7 0.4 0.3 0.588
Nostril width left 1.2 0.9 0.3 0.5425
Soft triangle angle right 7.8 10.8 3.0 0.2596
Soft triangle angle left 8.6 10.3 1.7 0.937
Lateral alar angle right 8.7 11.2 2.5 0.4715
Lateral alar angle left 10.7 12.6 1.9 0.8246
Columella width 0.2 0.7 0.9 0.2054
Columella height 0.4 0.9 0.5 0.3861
Columella projection 0.7 1.6 0.9 0.239
Lip
Subnasale projection 1.3 2.3 1.0 0.3362
Lower philtrum width 1.1 0.7 0.4 0.3781
Upper philtrum width 1.1 0.6 0.6 0.5038
Philtrum height 1.3 0.9 0.4 0.4282
Mouth width 1.0 0.4 0.7 0.6651
Labiale superius 2.8 2.5 0.3 0.7967
Figure 3 Superimposing of 3D photos before and after Le projection
Fort I advancement showing significant 3D nasolabial changes.
<5 mm maxillary advancement (mean values).
Due to retrogenia, a genioplasty was additionally performed in
>5 mm maxillary advancement (mean values).
this patient.

with consideration of gender, ethnicity, and goals of
treatment.
A multitude of techniques have been described to con-
trol 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 under-
standing 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, un-
derlying 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
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 under-
resection 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 intro-
duced, but risks the dentition and did not result in pre-
venting the adverse soft tissue effects.30 (See Figure 5).
Soft tissue closure after Le Fort I advancement does also
play a role in optimizing nasolabial form, or at least pre-
venting 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 un-
derlying bone. This dissection alone impacts nasolabial
762 P. Metzler et al.

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 move-
ment, 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 con-
trol 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 simulta-
neously garner esthetic benefits by controlling the nasola-
bial 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 naso-
labial 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 straight-
forward 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 pro-
cedure 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 pre-
viously mentioned, when undesired consequences are ex-
pected, 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, accu-
rate 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 advance-
ment 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 opti-
mize 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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