key: cord-0797856-i0h54z5s authors: Tosan, Foad; Esmaeelinejad, Mohammad; Ghorbani, Raheb title: Effects of open rhinoplasty on upper lip position in profile and frontal views date: 2020-08-15 journal: Br J Oral Maxillofac Surg DOI: 10.1016/j.bjoms.2020.08.012 sha: 6c7ea65a49489a90503c0d5bfe004c608c773618 doc_id: 797856 cord_uid: i0h54z5s Abstract Examining the upper lip position is a key indicator of facial beauty. This study aimed to examine the upper lip position following cosmetic rhinoplasty at the frontal and profile views. The medical records of 67 patients who underwent rhinoplasty with no history of any facial skeletal surgery were obtained from archives. Complete preoperative and postoperative photos including the profile view at rest and the frontal view at rest, were prepared and analyzed using Adobe Photoshop CC 2015 software. Interpupillary distances of two eyes in frontal views and Glabella to Pogonion (POG) distance in profile views were considered as fixed landmarks to calibrate the preoperative and postoperative photos. Upper lip length, subnasal area, and vermilion points were marked and compared between preoperative and postoperative photos. Data analysis was carried out using one-sample t-test and p<0.05% was considered as the significant level. Lip length (frontal view) was increased in 46 subjects. There were changes in the profile view of vermilion and subnasal positions in 56 patients and 53 patients, respectively. In surgical procedures on columella strut, maxillary augment, alar resection, spreader graft, columella retraction, and depressor septi muscle release, vermilion and subnasal protrusion in the profile view was statistically significant and lip length increased significantly in the frontal view. In tip rotation surgery techniques, the vermilion and subnasal position showed also significant protrusion. The depressor septi muscle cutting methods had only led to a significant protrusion of vermilion position and upper lip length. Despite all covariant interfering in rhinoplasty, this cosmetic surgery most often may increases maxillary lip length and helps that maxilla looks more protruded. Facial beauty as an important indicator has always been of human interest; however due to the ambiguous nature of beauty it is difficult to find a single definition for it. But the upper lip position is always considered as a determinant of beauty. 1 The ideal upper lip position in women is when 1 to 2 mm of gingiva is seen during maximum smile and this position is slightly lower than the above distance in men. 2 The most important muscles involved in the upper lip position include levator labi superioris alaeque nasi (LLSAN) and depressor septi nasi (DSN), which are manipulated usually in rhinoplasty. 3 Cosmetic nose surgery is one of the most popular cosmetic surgeries and plays a significant role in a change in facial aesthetic proportions. 4 rhinoplasty can affect the upper lip position and improve the patient's profile by using various grafts, such as premaxillary and other augmentation-based treatments. Therefore, examining the upper lip position as an influential indicator of facial and smile beauty as well as factors affecting its position are becoming more important. 6 On the other hand, the patient and, in turn, the surgeons are always worried about the surgical outcomes. 7 Therefore, potential dissatisfaction of the patients following rhinoplasty can be reduced by considering the upper lip position before the surgical procedure and the surgical effects on the lip position as an influential indicator on treatment outcomes. Attempts were made in the present study to investigate the effects of open rhinoplasty on the upper lip length and position simultaneously from the frontal and profile views. This historic cohort study was executed between December 2018 and July 2019. The medical records of 67 patients underwent open rhinoplasty more than 6 months ago without any facial skeletal surgery obtained from the archives. Participants were informed of the purpose and design of the investigation and signed an appropriate consent form. The procedures followed were in accordance with the ethical standards of the responsible committee of Semnan University of Medical Sciences with the ethical code of IR.SEMUMS.REC.1397.153. All calculations have been processed using Statistical Package for Social Science statistical software (version 23; SPSS Inc.). Descriptive statistics including tables and graphs have been applied to show the information. Onesample t test was used to determine the significant differences variables. A p-value of less than 0.05 has been considered statistically significant. Percentage of lip length changes (frontal view) was decreased in 21 patients and increased in other cases (46 cases). The upper lip length changes in the frontal view of different surgeries are given in Table 2 . These positive changes were statistically significant in columella strut (P <0.001), pre-maxillary augmentation graft (P = 0.001), alar resection (P <0.001), spreader graft (P = 0.001), columella retraction (P = 0.046), DSN release (P <0.001), and DSN removal (P = 0.005); however, they were not significant in other procedures it was not (P>0.05). Retrusion and protrusion accounted for subnasal position changes in 14 patients and 53 patients, respectively. The mean±standard deviation (SD) of changes in different surgical procedures is presented in Table 3 . These incremental changes were statistically significant in columella strut (P <0.001), premaxillary augmentation (P <0.001), alar resection (P <0.001), spreader graft (P = 0.001), columella retraction (P <0.001), DSN release (P = 0.006), and tip rotation (P = 0.044), but they were not significant in other procedures (P> 0.05). Changes in vermilion position were of retrusion type in 11 individuals and protrusion in 56 individuals. The mean±SD of changes in different surgical procedures is given in Table 4 . These protrusion changes were statistically significant in columella strut (P <0.001), premaxillary augmentation (P <0.001), alar resection (P <0.001), spreader graft (P <0.001), columella retraction (P <0.001), DSN release (P <0.001), DSN removal (P = 0.009), and tip rotation (P = 0.047), but they were not significant in other procedures (P>0.05). Facial muscles move in harmony while daily activities such as smiling and talking. According to the philosophical notion that facial beauty is not merely the coordination of static anatomical structures and that facial dynamics are concerned with facial beauty. After cosmetic surgeries, defects that were noticeable only at the start of a smile and static facial positions were of more interest; however, the so called "facial expression surgery" or "dynamic surgery" are nowadays used to remove many defects. This technique is used not only to improve the nose shape but also to enhance the patient's smile. 8 In current study it was decided to investigate the upper lip position 6 months following open rhinoplasty from frontal and profile views. The human smile is a short and coordinated activity of the imitation muscles, which is mainly associated with a large ascent movement of the upper lip and the lip corners in the vertical vector. 9 It is possible that the transection of the pulling muscles and ligaments decrease the vertical smile forces, which in turn overcomes non-vertical forces, reduces lip upward movement, and increases lip length, and leads to lip protrusion. Another cause of upper lip protrusion and subnasal and vermilion points repositioning in this study was premaxillary augmentation graft. Obviously, protrusion increased by the addition of bone and soft tissue to the maxilla. Although most nasal changes in rhinoplasty are associated with increased or decreased bone and sub-cartilage structure, soft tissue modification has an important contribution to the final result. 10 Sometimes rhinoplasty is performed regardless of dynamic muscular function. When patients recover from postoperative muscle function and begin to use their past imitations, such as smiling, the damaged dynamic forces may lead to nasal tip descent in a subtle way over a long period of time, which is related to their preoperative performance. To prevent this from happening, it is essential to carefully examine the facial muscles and preoperative smile patterns. 11 Consistent with our study, in a review study on the effects of interventions on DSN muscle in rhinoplasty, Sinno S et al. (2015) showed that treatment of DSN muscle, which involves transection or displacement of the muscle, results in improved aesthetic outcomes in rhinoplasty. 12 Transection or displacement of this muscle improves the position of the nose tip and increases the smile line and enhances the beauty of the face. A study executed by Ho et al. (2014) revealed that DSN muscle transection is not predictable but has little effect on high lip length. 13 In another study, Kalantar Hormozi A. et al (2014) concluded that there was no statistically significant difference between DSN muscle transection or displacement at high lip length changes. 14 As mentioned The key point of the findings of the current study is the appropriate decision made by the surgeon to combine several rhinoplasty maneuvers to prohibit increasing of upper lip following surgery. Furthermore, if the patient's lip is already longer than normal, the surgeon may suggest the patient a lip lift surgery a few months after rhinoplasty. The limitations of this study are, although there is collective lip length increase, it is difficult to pinpoint which of the adjuvant procedures are of more dominant in producing the final outcome. In this study, different rhinoplasty maneuvers were performed according to the patient's needs, and the final result of upper lip position was the outcome of several surgical maneuvers. Therefore, the result was not merely related to a surgical maneuver and could possibly have an effect on the results. Also, some surgical maneuvers were performed less frequently due to the small number of specimens and this made some of them became insignificant. Procedures involved in rhinoplasty including columella strut graft, premaxillary augmentation graft, alar resection, The procedures followed were in accordance with the ethical standards of the responsible committee of Semnan University of Medical Sciences with the ethical code of IR.SEMUMS.REC.1397.153. Participants were informed of the purpose and design of the investigation and signed an appropriate consent form. 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