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Figure 1.
The Goode Ratio and the Z Angle
The Goode Ratio and the Z Angle

The profile line is tangent to the pognion and the anterior-most point of the upper lip. When this line is extended until it intersects with the Frankfort horizontal line, the Z angle is created.

Figure 2.
Closed Rhinoplasty With Decrease in Z Angle
Closed Rhinoplasty With Decrease in Z Angle

A woman in her 20s underwent a closed rhinoplasty in which tip projection was increased by the placement of a columellar strut. The Z angle decreased by 3°, creating a noticeable projection of the upper lip.

Figure 3.
Treatment With Premaxillary Injection of Hyaluronic Acid
Treatment With Premaxillary Injection of Hyaluronic Acid

A woman in her 50s treated with a premaxillary injection of hyaluronic acid to aid in perioral rejuvenation, resulting in a significant change in upper lip position.

1.
Toutounchi  JS, Biroon  SH, Banaem  SM, Toutounchi  NS, Nezami  N, Salari  B.  Effect of the depressor septi nasi muscle modification on nasal tip rotation and projection.  Aesthetic Plast Surg. 2015;39(3):294-299.PubMedGoogle ScholarCrossref
2.
Benlier  E, Balta  S, Tas  S.  Depressor septi nasi modifications in rhinoplasty: a review of anatomy and surgical techniques.  Facial Plast Surg. 2014;30(4):471-476.PubMedGoogle ScholarCrossref
3.
Janeke  JB, Wright  WK.  Studies on the support of the nasal tip.  Arch Otolaryngol. 1971;93(5):458-464.PubMedGoogle ScholarCrossref
4.
Anderson  JR.  A reasoned approach to nasal base surgery.  Arch Otolaryngol. 1984;110(6):349-358.PubMedGoogle ScholarCrossref
5.
Kridel  RW, Scott  BA, Foda  HM.  The tongue-in-groove technique in septorhinoplasty: a 10-year experience.  Arch Facial Plast Surg. 1999;1(4):246-256.PubMedGoogle ScholarCrossref
6.
Powell  N, Humphreys  B.  Proportions of the Aesthetic Face. New York, NY: Thieme-Stratton; 1984:21.
7.
Merrifield  LL.  The profile line as an aid in critically evaluating facial esthetics.  Am J Orthod. 1966;52(11):804-822.PubMedGoogle ScholarCrossref
8.
Holdaway  RA.  A soft-tissue cephalometric analysis and its use in orthodontic treatment planning: part I.  Am J Orthod. 1983;84(1):1-28.PubMedGoogle ScholarCrossref
9.
Richardson  MA, Rousso  DE, Replogle  WH.  Long-term analysis of lip augmentation with superficial musculoaponeurotic system (SMAS) tissue transfer following biplanar extended SMAS rhytidectomy.  JAMA Facial Plast Surg. 2017;19(1):34-39.PubMedGoogle ScholarCrossref
10.
Penna  V, Stark  GB, Voigt  M, Mehlhorn  A, Iblher  N.  Classification of the aging lips: a foundation for an integrated approach to perioral rejuvenation.  Aesthetic Plast Surg. 2015;39(1):1-7.PubMedGoogle ScholarCrossref
11.
Wollina  U.  Perioral rejuvenation: restoration of attractiveness in aging females by minimally invasive procedures.  Clin Interv Aging. 2013;8:1149-1155.PubMedGoogle ScholarCrossref
12.
Penna  V, Stark  GB, Eisenhardt  SU, Bannasch  H, Iblher  N.  The aging lip: a comparative histological analysis of age-related changes in the upper lip complex.  Plast Reconstr Surg. 2009;124(2):624-628.PubMedGoogle ScholarCrossref
13.
Gunn  DA, Rexbye  H, Griffiths  CEM,  et al.  Why some women look young for their age.  PLoS One. 2009;4(12):e8021.PubMedGoogle ScholarCrossref
14.
Vent  J, Lefarth  F, Massing  T, Angerstein  W.  Do you know where your fillers go? an ultrastructural investigation of the lips.  Clin Cosmet Investig Dermatol. 2014;7:191-199.PubMedGoogle ScholarCrossref
15.
Pessa  JE.  An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity.  Plast Reconstr Surg. 2000;106(2):479-488.PubMedGoogle ScholarCrossref
16.
Zimbler  MS, Kokoska  MS, Thomas  JR.  Anatomy and pathophysiology of facial aging.  Facial Plast Surg Clin North Am. 2001;9(2):179-187, vii.PubMedGoogle Scholar
17.
Mendelson  B, Wong  CH.  Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation.  Aesthetic Plast Surg. 2012;36(4):753-760.PubMedGoogle ScholarCrossref
18.
Mendelson  BC, Hartley  W, Scott  M, McNab  A, Granzow  JW.  Age-related changes of the orbit and midcheek and the implications for facial rejuvenation.  Aesthetic Plast Surg. 2007;31(5):419-423.PubMedGoogle ScholarCrossref
19.
Shaw  RB  Jr, Kahn  DM.  Aging of the midface bony elements: a three-dimensional computed tomographic study.  Plast Reconstr Surg. 2007;119(2):675-681.PubMedGoogle ScholarCrossref
20.
Rohrich  RJ, Hollier  LH  Jr, Janis  JE, Kim  J.  Rhinoplasty with advancing age.  Plast Reconstr Surg. 2004;114(7):1936-1944.PubMedGoogle ScholarCrossref
21.
Iblher  N, Kloepper  J, Penna  V, Bartholomae  JP, Stark  GB.  Changes in the aging upper lip—a photomorphometric and MRI-based study (on a quest to find the right rejuvenation approach).  J Plast Reconstr Aesthet Surg. 2008;61(10):1170-1176.PubMedGoogle ScholarCrossref
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Original Investigation
Jul/Aug 2017

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

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Illinois at Chicago
  • 2The Facial Plastic Surgery Center, University of Illinois at Chicago, Chicago, Illinois
JAMA Facial Plast Surg. 2017;19(4):323-326. doi:10.1001/jamafacial.2017.0070
Key Points

Question  Do common rhinoplasty techniques that increase tip projection, such as a columellar strut and tongue-in-groove maneuver, affect the upper lip position?

Findings  In this case series, a long-lasting causal association between the upper lip and the nasal tip was discovered; as nasal tip projection is increased, upper lip projection is also increased.

Meaning  Using the correlation between upper lip projection and nasal tip projection, we describe a new technique for perioral rejuvenation where hyaluronic acid filler is placed in the premaxillary region.

Abstract

Importance  The effects of rhinoplasty maneuvers on adjacent facial features are an important component in preoperative planning and patient counseling. Tip projection modifications are commonly performed in both cosmetic and reconstructive rhinoplasty.

Objective  To evaluate the subsequent change in lip projection that results from increasing nasal tip projection.

Design, Setting, and Participants  In this case series, 20 patients underwent primary rhinoplasty with the objective of increasing tip projection during the period from October 1, 2014, to September 25, 2015. Preoperative and postoperative photographs were evaluated.

Main Outcomes and Measures  The increased tip projection was verified using the Goode ratio. Upper lip projection was calculated by the Z angle, which is based on the intersection between the Frankfort horizontal plane and the profile line. Vermilion height was also assessed.

Results  Of the 20 patients in the study (19 females and 1 male; mean [SD] age, 26.8 [10.2] years; range, 16-52 years) 18 (90%) demonstrated an increase in upper lip projection when the tip projection was increased by either a columellar strut or tongue-in-groove maneuver. The Z angle demonstrated a statistically significant decrease of 2.7° (95% CI, 1.5°-3.9°; P < .001). Although the vermilion height did not change a significant amount, there was a trend toward an increase in mean height of 0.051 (95% CI, –0.00515 to –0.10685; P = .09).

Conclusions and Relevance  Increasing nasal tip projection causes a measurable increase in upper lip projection. This new causal association has been applied to our filler injection armamentarium as an alternative way to achieve the desired result of a more youthful upper lip.

Level of Evidence  4.

Introduction

Tip modification is an integral part of rhinoplasty. It is arguably the most difficult and complex part of the procedure owing to the many variables that can be altered. Besides changing the shape of the nasal tip, several of the maneuvers in rhinoplasty involve changing the tip location, whether that is projection and/or rotation. These alterations are used during both cosmetic and functional rhinoplasty. Although several studies have focused on evaluating how tip modifications affect other regions of the nose along with its overall appearance, the data assessing how these maneuvers affect adjacent facial structures are more limited.1,2

The 2 most common techniques to increase tip projection are placement of a columellar strut and performing a tongue-in-groove maneuver. The columellar strut graft is a tailored piece of cartilage that is placed between the medial crura of the lower lateral cartilages and spans from the premaxilla to the nasal tip.3 According to the tripod theory of nasal tip support by Anderson,4 it can be visualized how this graft pushes the tip outward and how the rest of the nose responds. This maneuver is usually performed when the patient’s septal length is within the normal limits. If a patient has a longer septum, however, the medial crura can be set back and sutured onto the septum. In doing so, the placement of this suture will dictate the location of the tip. The technique of suturing the medial crura to the caudal septum is called a tongue-in-groove maneuver.5 If the patient has a shorter septum, a caudal septal extension graft can be placed, followed by a similar tongue-in-groove maneuver.

While evaluating patients’ postoperative rhinoplasty photographs, the senior author (S.H.D.) noted that the upper lip projection appeared to be increased when the tip projection was increased. After recognizing this trend in multiple patients, we hypothesized that there is a causal association between the two (ie, nasal tip projection and lip position). The aim of this study is to evaluate if increasing tip projection, by either a columellar strut placement or tongue-in-groove technique, results in an increase in the upper lip projection.

Methods

A retrospective medical record review was performed of patients undergoing primary rhinoplasty with an objective of increasing tip projection between October 1, 2014, and September 25, 2015. All the patients were treated in a private practice setting that specializes in cosmetic surgery. Of the 85 patients, 20 met the following inclusion criteria: (1) the patient was undergoing primary rhinoplasty, (2) no lip enhancement procedures or chin augmentation procedures were performed, (3) standardized preoperative and postoperative photographs were available for review, (4) tip projection was increased and verified on postoperative photographs by calculating the Goode ratio, (5) detailed operative reports were available outlining the operative maneuvers, and (6) the senior author (S.H.D.) was the only operating surgeon. Other than those not having adequate photographic documentation, patients were excluded if they had other facial surgery, including perioral or orthognathic procedures, and if they underwent modification of the radix, which could also interfere with calculating tip projection. The photographs used for evaluation were the preoperative profile and the 12-month postoperative profile. The study was performed in compliance with the University of Illinois at Chicago’s institutional review board.

Given that there is inherent variability even in standardized portrait photography, the decision was made to perform measurements that included facial landmarks and distance ratios. The values then would not be influenced by changes in lighting, camera angle, facial orientation, and camera distance. The primary author (E.W.C.) performed all measurements and calculations to avoid any potential bias that could be created by the operating surgeon participating in this step. For tip projection, the Goode ratio was used. This value is defined as the nasal height over the nasal length. The nasal height is measured from the alar-facial groove to the tip-defining point, and the nasal length is measured from the root of the nose, or nasion, to the tip-defining point.6 These calculations were performed both preoperatively and postoperatively to ensure an increase in tip projection.

Upper lip projection was measured by a method outlined by Merrifield7 in 1966. As described, a profile line was drawn tangential to the soft tissue of the chin and to the most anterior point of the upper lip. This line was then extended upward to the Frankfort horizontal plane. The angle at which these 2 lines intersect is called the Z angle (Figure 1).7,8 A change in the Z angle to a more acute value on postoperative photographs would indicate an increase in upper lip projection. This method was chosen because it is calculated independent of any postoperative nasal changes. Therefore, any residual nasal swelling would not affect the resulting measurements. Secondarily, the ratio of upper lip vermilion height to lower lip vermilion height was also evaluated. Statistical analysis was conducted using a paired 2-tailed t test. P < .05 was considered significant.

Results

Of the 20 patients who were included, 19 were female and 1 was male, with a mean (SD) age of 26.8 (10.2) years (range, 16-52 years). Seventeen patients received a closed, endonasal rhinoplasty, and the remaining 3 underwent an open approach. Despite the different approaches, there were only 2 methods of increasing tip projection: placement of a columellar strut and performing a tongue-in-groove maneuver; these methods were almost equally divided, with 11 columellar strut placements and 9 tongue-in-groove maneuvers.

Upper lip projection was increased for 18 patients (90%). The Z angle demonstrated a statistically significant decrease of 2.7° (95% CI, 1.5°-3.9°; P < .001). The mean change in the Z angle was 3.2° when the 2 patients who did not exhibit a change were excluded (Figure 2). The ratio of lip height was less predictable; however, there was a trend toward an increase in mean upper lip vermilion height of 0.051 (95% CI, –0.00515 to –0.10685; P = .09). The 2 patients who did not have an increase in upper lip projection did demonstrate an increase in upper lip height.

Discussion

The present study is the first, to our knowledge, to demonstrate a causal association between nasal tip projection and upper lip projection. As the tip is projected anteriorly, the upper lip shifts in a predictable manner in the same direction. The correlation persists despite the technique used to increase tip projection. Although there was a measurable trend toward an increase in upper lip height, the difference was less predictable and less noticeable to the trained eye. Further study is recommended to see if this increasing trend is a true correlation.

The new data have resulted in the senior author expanding on his filler injection armamentarium by incorporating this association. By use of hyaluronic acid filler in the premaxilla, the nasal tip is projected, resulting in the subsequent lip alteration. The increased upper lip projection, along with a less acute nasolabial angle, is characteristic of a more youthful appearance (Figure 3).9

The perioral aging process has been well described in the literature; however, the treatment options have remained limited. As the patient ages, there is flattening of the Cupid’s bow and loss of definition of the philtral columns. The resulting appearance is a thin and elongated upper lip.10,11 Histologically on a deeper level, the orbicularis oris muscle atrophies, and the muscle curvature, which once contributed to the vermilion border delineation, relaxes, forming a less-acute angle and adding to the overall increase in the lip length.12 In 2009, an observational twin study in Denmark highlighted the importance of the upper lip length as a defining feature of perceived advancing age.13 A mean of 71 assessors evaluated 102 Danish female twins and found upper lip height to be significantly and independently associated with perceived aging, along with skin wrinkling and hair graying. These findings were confirmed with a similar study of 162 British women.13 Traditionally, these patients were treated by restoring volume back into the lips. Various techniques and materials have been described, with the objective of redefining the vermilion border and filling the underlying muscle to aid in everting the upper lip.11,14

Besides the vermilion changes, many other transformations occur with age. Other perioral findings include deepening of the nasolabial and labiomental creases, development of perioral rhytids, downturning of the oral commissures, and jowling.15,16 The combination of all of these changes emphasizes that a more structural change is occurring. Specifically, selective bony resorption is happening in specific areas of the facial skeleton.17 The maxilla has been found to undergo significant retrusion in dentulous patients, and in 2007, Mendelson et al18 quantified the change over time, with the maxillary angle decreasing by about 10° between young (<30 years of age) and old (>60 years of age) individuals. In addition, the piriform aperture gradually widens with age, contributing to the soft-tissue changes that occur with the nose, such as an increased nasal length, drooping of the tip, and posterior displacement of the columella.19,20

The premaxillary injection adds a new tactic for addressing perioral aging. Because the aging process is multidimensional, we advocate for a multidimensional treatment. By restoring the underlying bone loss of the premaxilla, the overlying soft tissue is projected back to its original location. In 2008, Iblher et al conducted a magnetic resonance imaging–based comparative study evaluating upper lip changes and concluded that “contrary to most earlier descriptions of upper lip aging, we could show that there is no absolute volume loss but rather a redistribution from thickness towards length.”21(p1175) The authors also commented that since volume deficiency is not the primary cause, procedures aimed at lip augmentation would result in an unnatural, “blown up” appearance. On further examination of their findings and magnetic resonance images, it was found that the nasolabial angle is deepened in the older population, which suggests that the premaxillary volume loss is a significant contributing factor.

The location of the premaxillary injection provides patients with facial rejuvenation that appears natural. Because the aging process affects both the nose and the upper lip, these patients receive a significant benefit, both aesthetically and cost-effectively, from the single filler injection. Extreme caution is advised when performing this procedure because the area of operation contains large vessels that are at risk for intravascular injection. The senior author advocates for the use of 22-gauge cannulas to help minimize the risk of vascular injury. Further research in this area can help define how best to integrate this new approach and when to use it for the most effective result for all patients.

Limitations

Possible limitations of this study include a slight variation of the portrait photography, differences in the surgical maneuvers with each patient, and persistent edema that has yet to resolve. Although the photography studio is standardized, there are minor differences in lighting, camera distance, camera angle, and facial orientation that can affect the measurements. To minimize this bias, all measurements were performed by one person (E.W.C.) and were based on facial landmarks and distance ratios. In addition, while only 2 surgical techniques were studied, each patient’s rhinoplasty consisted of an array of supplementary maneuvers including open vs closed approach. All these surgical maneuvers can cause varying degrees of edema. Although many agree that the swelling is resolved by 1 year, several others believe that the edema can persist even longer.

Conclusions

Our study highlights a correlation between nasal tip projection and upper lip projection. For both cosmetic and functional rhinoplasty, the association is important in preoperative planning, patient counseling, and expected outcomes. The correlation adds to the growing area of research emphasizing the importance of approaching rhinoplasty with consideration of the nose’s relationship and function with the rest of the face, and not just as an operation for an isolated structure. In addition, this new finding can be incorporated into facial rejuvenation procedures, specifically perioral rejuvenation. When altering facial features, particularly in cosmetic surgery, it is paramount that the relationships between the adjacent structures are thoroughly understood.

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Article Information

Corresponding Author: Eric W. Cerrati, MD, The Facial Plastic Surgery Center, University of Illinois at Chicago, 60 E Delaware Pl, Ste 1422, Chicago, IL 60611 (ecerrati@gmail.com).

Accepted for Publication: December 15, 2016.

Published Online: April 13, 2017. doi:10.1001/jamafacial.2017.0070

Author Contributions: Dr Cerrati had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Cerrati.

Drafting of the manuscript: Cerrati.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Cerrati.

Study supervision: Dayan.

Conflict of Interest Disclosures: Dr Dayan reported receiving honoraria from Allergan/Actavis, Merz, Valeant, Galderma, PCA, Revance, and Zeltiq. No other disclosures were reported.

Additional Contributions: We thank the patients for granting permission to publish this information.

References
1.
Toutounchi  JS, Biroon  SH, Banaem  SM, Toutounchi  NS, Nezami  N, Salari  B.  Effect of the depressor septi nasi muscle modification on nasal tip rotation and projection.  Aesthetic Plast Surg. 2015;39(3):294-299.PubMedGoogle ScholarCrossref
2.
Benlier  E, Balta  S, Tas  S.  Depressor septi nasi modifications in rhinoplasty: a review of anatomy and surgical techniques.  Facial Plast Surg. 2014;30(4):471-476.PubMedGoogle ScholarCrossref
3.
Janeke  JB, Wright  WK.  Studies on the support of the nasal tip.  Arch Otolaryngol. 1971;93(5):458-464.PubMedGoogle ScholarCrossref
4.
Anderson  JR.  A reasoned approach to nasal base surgery.  Arch Otolaryngol. 1984;110(6):349-358.PubMedGoogle ScholarCrossref
5.
Kridel  RW, Scott  BA, Foda  HM.  The tongue-in-groove technique in septorhinoplasty: a 10-year experience.  Arch Facial Plast Surg. 1999;1(4):246-256.PubMedGoogle ScholarCrossref
6.
Powell  N, Humphreys  B.  Proportions of the Aesthetic Face. New York, NY: Thieme-Stratton; 1984:21.
7.
Merrifield  LL.  The profile line as an aid in critically evaluating facial esthetics.  Am J Orthod. 1966;52(11):804-822.PubMedGoogle ScholarCrossref
8.
Holdaway  RA.  A soft-tissue cephalometric analysis and its use in orthodontic treatment planning: part I.  Am J Orthod. 1983;84(1):1-28.PubMedGoogle ScholarCrossref
9.
Richardson  MA, Rousso  DE, Replogle  WH.  Long-term analysis of lip augmentation with superficial musculoaponeurotic system (SMAS) tissue transfer following biplanar extended SMAS rhytidectomy.  JAMA Facial Plast Surg. 2017;19(1):34-39.PubMedGoogle ScholarCrossref
10.
Penna  V, Stark  GB, Voigt  M, Mehlhorn  A, Iblher  N.  Classification of the aging lips: a foundation for an integrated approach to perioral rejuvenation.  Aesthetic Plast Surg. 2015;39(1):1-7.PubMedGoogle ScholarCrossref
11.
Wollina  U.  Perioral rejuvenation: restoration of attractiveness in aging females by minimally invasive procedures.  Clin Interv Aging. 2013;8:1149-1155.PubMedGoogle ScholarCrossref
12.
Penna  V, Stark  GB, Eisenhardt  SU, Bannasch  H, Iblher  N.  The aging lip: a comparative histological analysis of age-related changes in the upper lip complex.  Plast Reconstr Surg. 2009;124(2):624-628.PubMedGoogle ScholarCrossref
13.
Gunn  DA, Rexbye  H, Griffiths  CEM,  et al.  Why some women look young for their age.  PLoS One. 2009;4(12):e8021.PubMedGoogle ScholarCrossref
14.
Vent  J, Lefarth  F, Massing  T, Angerstein  W.  Do you know where your fillers go? an ultrastructural investigation of the lips.  Clin Cosmet Investig Dermatol. 2014;7:191-199.PubMedGoogle ScholarCrossref
15.
Pessa  JE.  An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity.  Plast Reconstr Surg. 2000;106(2):479-488.PubMedGoogle ScholarCrossref
16.
Zimbler  MS, Kokoska  MS, Thomas  JR.  Anatomy and pathophysiology of facial aging.  Facial Plast Surg Clin North Am. 2001;9(2):179-187, vii.PubMedGoogle Scholar
17.
Mendelson  B, Wong  CH.  Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation.  Aesthetic Plast Surg. 2012;36(4):753-760.PubMedGoogle ScholarCrossref
18.
Mendelson  BC, Hartley  W, Scott  M, McNab  A, Granzow  JW.  Age-related changes of the orbit and midcheek and the implications for facial rejuvenation.  Aesthetic Plast Surg. 2007;31(5):419-423.PubMedGoogle ScholarCrossref
19.
Shaw  RB  Jr, Kahn  DM.  Aging of the midface bony elements: a three-dimensional computed tomographic study.  Plast Reconstr Surg. 2007;119(2):675-681.PubMedGoogle ScholarCrossref
20.
Rohrich  RJ, Hollier  LH  Jr, Janis  JE, Kim  J.  Rhinoplasty with advancing age.  Plast Reconstr Surg. 2004;114(7):1936-1944.PubMedGoogle ScholarCrossref
21.
Iblher  N, Kloepper  J, Penna  V, Bartholomae  JP, Stark  GB.  Changes in the aging upper lip—a photomorphometric and MRI-based study (on a quest to find the right rejuvenation approach).  J Plast Reconstr Aesthet Surg. 2008;61(10):1170-1176.PubMedGoogle ScholarCrossref
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