The Incidence of Nasal Tip and Upper Lip Malposition in Primary Rhinoplasty

Abstract

Rhinoplasty, one of the most demanding plastic surgery procedures, remains among the most commonly performed procedures, with approximately 200,000 cases performed per year in the United States.¹ One of the cardinal factors that make rhinoplasty so enigmatic is the dynamic interplays of different maneuvers. Each move can deliver the intended goals but also result in multiple unintended changes. These interplays have long been the topic of interest and investigation for the senior author (B.G.).^2-8 An understanding of these dynamic effects is crucial to appropriately plan and execute a rhinoplasty that improves facial harmony and produces more predictable outcomes.

The upper lip is considered 1 of the key indicators of facial aesthetics.^7,9 Based on B.G.’s 40-plus years of experience and several published studies, it is known that rhinoplasty affects the upper lip position, including lip height and projection, incisor/gingival show, vermilion, and subnasale positions, as well as the overall smile profile.^6,7,10-15 Some of these changes may be beneficial, whereas others may result in undesirable changes and patient dissatisfaction.

There is a paucity of literature on the incidence of preoperative upper lip malposition, because it is largely underrecognized and underestimated. The position of the upper lip should be integral to preoperative surgical planning. Similarly, there is no report on the incidence of nasal tip and columella malposition in this population. In this study we aimed to investigate the incidence of upper lip and nasal tip malposition.

METHODS

A retrospective chart review of B.G.’s most recent 150 consecutive patients presenting for primary rhinoplasty in the years 2022 and 2023 was performed. The sole inclusion criterion was presentation for primary rhinoplasty. Patients with any history of septorhinoplasty, nasal surgery, or orthognathic or lip surgery were excluded. The preoperative photographs in frontal and profile views, including life-size photographs, were analyzed with soft tissue cephalometric analysis. The parameters of focus were nasal length, tip projection, the columella, amount of gingival show, and upper lip position in relation to the central incisors. The lateral view was utilized for nasal parameters. The frontal view during smiling served for upper lip parameters. The definition of ideal nasal parameters was based on B.G.’s soft tissue cephalometric methodology of nasal analysis according to individualized facial proportions and measurements (Figure 1).¹⁶ All noses were analyzed with the same standardized methodology to determine the ideal dimensions according to each patient's face. The nasal length was categorized as short, ideal, or long. The tip projection was categorized as underprojected, ideal, or overprojected. The columella was categorized as retracted, ideal, or hanging.

Figure 1.

Photographic example of 37-year-old female patient showing preoperative planning with patient-specific ideal nasal profile tracing.

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The ideal upper lip position during smile was based on the well-accepted description of full incisor show and <1 mm of maxillary gingival show at the central incisors.^17,18 The upper lip position was analyzed during smile only and categorized as inadequate incisor show, ideal, or excessive gum show (Figure 2). All photographs were taken by the same professional photographer in the same location with standardized lighting and parameters as well as life-size scale to facilitate measurements.

Figure 2.

Photographs of (A) a 24-year-old female patient showing upper lip measurements with excessive gum show; and (B) a 32-year-old female patient showing measurements with inadequate incisor show.

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Statistical analyses were performed with JMP software.¹⁹ Continuous and categorical variables were compared with the Mann–Whitney U test and analysis of variance (ANOVA), respectively. Multiple logistic analyses were then performed to assess for correlation among the variables. P values less than .05 were considered statistically significant. Measurements on life-size photographs were taken digitally with Photoshop CS6.²⁰

All patient information was deidentified and patient consent was obtained for all photographs included. This study was considered institutional review board (IRB) exempt because the data was obtained retrospectively and no interventions were studied. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

RESULTS

Of the 150 patient charts reviewed, 137 met the inclusion criteria. A total of 115 (84%) patients were female. The age of patients ranged from 22 to 54 years, with an average of 34 years. Forty-seven (34%) patients had an ideal upper lip position, 83 (61%) had inadequate incisor show during smile, and 7 (5%) patients had excessive gum show during smile (Table 1). In patients with an ideal upper lip position, the central incisor height (2 to 3) was 8.8 ± 1.2 mm. The majority of these patients had an asymmetric lip position at the level of the lateral incisors, with only 12 (26%) having equal upper lip positions from right side to left side at the level of the lateral incisors, without statistical significance (P = .13). In patients with inadequate incisor show, the central incisor show (1 to 3) was measured to be 5.9 ± 2.1 mm. In patients with excessive gum show, the amount of gum show (1 to 2) was 1.2 ± 0.9 mm, and the central incisor height (2 to 3) was measured at 9.8 ± 1.5 mm. The central incisor height (2 to 3) was greater in patients with excessive gingival show, with a trend toward significance (P = .06).

Considering nasal parameters (Table 1), 16 patients (12%) had a short nose, 45 (33%) had an ideal nasal length, and 76 (55%) had a long nose compared to the ideal dimensions obtained from the individualized preoperative nasal analysis. Fourteen (10%) patients had an underprojected tip, 38 (28%) had an ideal tip projection, and 85 (62%) had an overprojected nasal tip compared to the ideal dimensions. Fifty-six patients (41%) had a retracted columella, 34 (25%) had an ideally positioned columella, and 47 (34%) had a hanging columella.

In subanalysis of the various permutations in presentation (Table 2), noses with underprojected tips most commonly had short nasal length (71%) and poor incisor show during smile (64%). Noses with an ideal tip projection most commonly had either an ideal nasal length (47%) or a long nose (47%) and inadequate incisor show (66%). Noses with an overprojected tip most commonly also had a long nose (67%) and inadequate incisor show (58%).

DISCUSSION

Studies on the dynamics of rhinoplasty are a consistently growing tenet in nasal surgery, garnering profound recognition over the last 30 years due to B.G.’s deep interest and ardent belief that this knowledge is required to reduce the unpredictability of results.^2-4 Even though this concept is now well recognized in the literature, certain effects of rhinoplasty on surrounding facial features remain to be studied and appreciated. One of these effects is the position of the upper lip. The literature has historically expounded on the influence of nasal musculature, most notably the levator labii superioris alaeque nasi and the depressor septi nasi, on the orientation and dynamic deformation of the upper lip and nasal tip.^{6,7,12,15,17,21} Recent work by B.G.’s team demonstrated that specific rhinoplasty techniques directly impacted the position of the upper lip.¹¹

However, to most effectively apply this knowledge clinically, the surgeon must recognize the preoperative position and characteristics of both the nose and upper lip. There is literature on postoperative patient complaints in primary vs secondary rhinoplasty, as well as on preoperative concerns in secondary rhinoplasty.^22,23 However, there are no published studies on preoperative concerns in primary rhinoplasty. The goal of this study was to fill that knowledge gap.

The most commonly presenting upper lip position was found to be inadequate incisor show (61%), and the least common was excessive gum show (5%). This is prodigious because 1 of the most common maneuvers in rhinoplasty is placement of a columella strut graft. In our studies we have unwaveringly demonstrated that placement of a columella strut will result in reducing the incisor show.¹¹ The most commonly presenting nasal features were a long nasal length (55%) and an overprojected tip (62%). The columella presentation was near evenly split between retracted (41%) and hanging (34%). Not surprisingly, statistical analysis demonstrated that a long nose was associated with an overprojected tip and a hanging columella. Conversely, a short nose was associated with an underprojected tip, but had no association with the columella. However, the upper lip position did not demonstrate any statistical correlation to any of the nasal features. In other words, none of the nasal parameters were predictive of the upper lip position. This highlights the importance of a complete facial analysis before rhinoplasty. The surgeon cannot assume where the upper lip is positioned based on presenting nasal parameters and must assess it separately during repose and smiling.

As previously reported, it is common to encounter underlying osseous deformities in primary rhinoplasty patients involving the midface skeleton, dentofacial relationships, and chin position.^5,14,24,25 Nevertheless, most patients present solely for rhinoplasty and are frequently not interested in having orthognathic surgery. Yet it remains vital to recognize underlying maxillary excess or deficiency. Especially if it is directly causing upper lip malposition, it will facilitate preoperative counseling regarding surgical limitations. Similarly, recognizing excess upper lip soft tissue can introduce the need for lip lift into discussion. As shown in our study, the majority of patients seeking primary rhinoplasty present with insufficient incisor show, whether osseous or related to soft tissue in etiology.

Regarding nasal features, the most common presentation was, not surprisingly, a long and overprojected nose. This was consistent with previous studies in which the most common presenting complaint for primary rhinoplasty was found to be a “large nose.”²² In these cases, the rhinoplasty surgeon must attempt to avoid lowering the lip too much when reducing the size of the nose, particularly if there is inadequate incisor show to begin with. In cases of short, underprojected noses, which most commonly present in the Asian population, care must be taken during nasal augmentation to avoid worsening a preexisting excessive gum show, if one exists.

Although mere incidence rates may not directly help individual patients, the goal is to bring more attention to these nuances and improve the surgeon's preoperative analysis and outcomes. Several limitations to the study need to be mentioned. First, it is nearly impossible to ensure uniform smiling efforts between patients during photography. Even though the photographer in this study was professionally trained and the settings and positions were standardized, some patients inevitably placed a bigger effort during smile than others, potentially skewing the measurements in upper lip position. Second, no underlying osseous cephalometrics were utilized, mainly because this was not the goal of the study. Finally, it is possible the study was underpowered to detect any correlation with the least common presentations, namely excessive gum show with the various nasal features. Notwithstanding the shortcomings, this study proves B.G.’s clinical observation related to the frequency of incisor show flaws and underscores its seminal role in deciding which technique to select for correction of tip disharmonies.

CONCLUSIONS

Despite the lack of recognition, there is a high incidence of upper lip suboptimal position in patients presenting for primary rhinoplasty, the most common being insufficient incisor show. Preoperative nasal tip and upper lip malposition must be identified and incorporated in both patient counseling and the surgical plan. It is vital for the rhinoplasty surgeon to execute maneuvers that will not exacerbate an inadequate incisor show or excessive gum show, when present. B.G.’s algorithm to guide selection of the appropriate tip augmentation technique to avoid ill effects on the smile will be the subject of the following report.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes