A modified alar cinch suture technique. Article (PDF Available) in European Journal of Plastic Surgery 32(6) · December with. Next, small amounts of the solution are injected beneath the alar bases and the nasolabial To control the width of the alar base, an alar cinch suture is used. Secondary changes of the nasolabial region after the Le Fort I osteotomy procedure are well known and include widening of the alar base of the nose, upturning.
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To prospectively analyze the amount of alar flare, factors contributing to alar sutue and efficacy of cinch suture as an adjunctive procedure for alar flare reduction.
Use of the alar base cinch suture in Le Fort I osteotomy: is it effective?
Thirty adult patients with vertical maxillary excess, who underwent Le Fort 1 impaction, were divided into 2 groups of 15 each. Alar cinch was performed as an adjunct procedure in group 2 patients and results were compared to group 1 which was the control group.
Measurements were made on the patients and on 1: Group 2 showed a near pre-operative alar position compared to group 1. The alar flare resulting from every millimeter of impaction was significantly less in group 2 compared to group 1. Alar cinch suture restores the normal alar width by preventing the lateral drift of the naso-labial muscle and thereby reducing the postoperative nasal flare significantly.
Le Fort 1 intrusion osteotomies are known to cause adverse effects on the oro-facial soft tissues such as broadening of the alar base, loss of vermillion show of the upper lip and down sloping of the commissure [ 1 ]. The Le Fort 1 osteotomy results in unpredictable soft tissue changes, which can be difficult to control because of considerable variation in their adaption.
The tip of the nose turns upwards, the naso-labial angle might increase and the maximal alar width increases. Soft tissue procedures on the nose, which can be performed simultaneously with a Le Fort 1 osteotomy, are the alar cinch suture, resection of the anterior nasal spine, wedge excision of the alar base, grinding of the paranasal area, and thinning of the columella [ 2 ].
Changes to the nose clearly occur after Le Fort 1 osteotomy superior repositioning. There was a statistically significant increase in post operative interalar width and inter-nostril width with maxillary movement. There are various adjunctive procedures but no evidence to suggest the efficacy of each adjunctive procedure advocated to minimize nasal changes. However, the alar flare, resulting as a consequence of superior repositioning of the maxilla, mars the objective of correcting VME and gummy smile.
This study highlights the factors contributing to the phenomenon of alar flare as a consequence of Le Fort 1 intrusion and the significance of alar cinch suture. Fifteen patients were subjected to endonasal intubation and underwent Le Fort 1 osteotomy with superior repositioning with no adjunctive procedure. Fifteen patients were subjected to endonasal intubation and underwent Le Fort 1 osteotomy with superior repositioning combined with cinch suturing.
The alar cinch suturing was preceded by changing the naso-endotracheal tube to oral route. The knot is based on the edge of the anterior nasal spine ANS bringing the naso-labial muscles closer to the nasal spine.
Preoperative interalar width was assessed by measuring the maximum convexity of the ala with the help of a vernier caliper Fig. The mean value of both the measurements was taken as pre-op interalar width.
Distance measured between the center of the maximum convexity of the ala using vernier caliper. Post-operative changes in alar flare following intrusion in 15 patients each of group 1 and group 2 measurements in mm. Based on the Pilot study of randomly selected 6 samples of group 2, the Pre test mean was The results from group 2 indicate that the amount of nasal flare was dictated by the kind of adjunctive procedure and not by the amount of maxillary intrusion carried out.
Group comparison using paired sample t test was found to be significant. Intergroup comparison was done by independent sample t test and it pronounced the following results:.
Mean and standard deviation of pre—post operative comparison in groups 1 and 2 and Paired sample t test in groups 1 and 2 to determine p value.
Use of the alar base cinch suture in Le Fort I osteotomy: is it effective?
For every unit increase of intrusion there was 0. The post-operative results in group 1, compared to pre-op, frontal and sub-nasal view, is depicted in Figs. The post-operative results in group 2 compared to pre-op, frontal and sub-nasal view, is depicted in Figs.
Many studies have reported secondary morphological changes in the nose, including alar flaring after a Le Fort 1 osteotomy.
The changes might be advantageous for patients with a narrow nose, but they can have a negative effect on the overall esthetics of the face in those with a wide nasal width [ 3 ]. Post surgical widening of the alar base after the maxillary Le Fort 1 procedure may be a favorable outcome in a patient with vertical maxillary hyperplasia and thin slit-like nares.
However, if a wide preoperative alar base is present, these same changes become undesirable, especially with anterior or superior repositioning of the maxilla. Bell and Profit suggested that at time of preoperative assessment, patients with a wide nose be warned that a rhinoplasty may be indicated in the near future [ 4 ]. During Le Fort 1 osteotomy with superior repositioning of the maxilla, we observed that there was a reduction in the depth of the nasal aperture.
This reduction in the depth of the nasal aperture does not provide adequate space for the alar base to occupy. This compromised space culminates in the naso-labial muscles being pushed laterally and thereby causing an increase in the inter-alar width resulting in post-operative nasal flare. Nasal widening, which is almost always observed after maxillary osteotomies, is only partially dependent on the amount of skeletal movement.
The amount of subperiosteal dissection performed, which involves the total surface of the maxilla, seems to play a major role. Indeed, periosteal elevation disinserts the facial muscles from the naso-labial area and the anterior nasal spine. Other contributing factors include detachment of muscle insertion from its origin and the muscle tends to reattach at a shortened length because of contraction.
This lateral retraction results in flaring, widening and elevation of the base of the nose, which is frequently not symmetric [ 5 ]. Maurice [ 6 ] describes important information stating that rotation of the palate does have significant effect on the soft tissue of the naso-labial region, also stating that changes in the lateral position of the pyriform aperture have significant effect on the soft tissue of the nasal base. This adds to the significance of the study.
We also observed that resection of the siture of the nasal septum while superiorly repositioning the maxilla reduces the height of the nasal septum thereby losing finch tip projection and contributing to alar flare. These alterations in the skeletal anatomy cause undesirable soft tissue response, which more often is clinically unacceptable. Different movements of the maxilla have distinct effects on the nasal suhure. Superior repositioning of the maxilla causes elevation of the nasal tip, widening of the alar bases, and a decrease in the naso-labial angle [ 4 ].
According to a study conducted by Harvey Rosen, increase in alar rim width accompany superior and anterior repositioning of the maxilla [ 7 ]. In our study we observed that for every unit increase in the intrusion there is 0. Several methods can be found in slar literature and can be used in combination with each other: The suture did reduce alar flaring but it also increased the naso-labial angle. The suture did not significantly influence nasal tip projection.
Our study suyure these findings to some extent. They also suggested that a modified cinch suture may result in greater stability. Our results showed a better stability in group 2 attributed to the method of suturing the nasolabial muscle to ANS that we follow. The use of submental intubation facilitated accurate measurement of the changes in nasal width produced by the osteotomy and the cinch suture.
Their study concluded that a mean increase in the width of the base of wlar nose of 3. We observed that there was a lateral drift in the naso-labial musculature immediately after the incision and also after osteotomy thereby increasing the flare.
We also noticed cinch suturing was effective in mitigating the alar flare increase following the intrusion.
In our study the Regression analysis clearly suggested that the there is a significant reduction in the alar flare in group 2 compared to group 1. We conclude that Le Fort 1 osteotomy superior repositioning leads to a widening of alar region of the nose, especially the alar base.
The alar cinch suture brought in a significant reduction in alar flare when compared to group 1 where superior reposition was done without any adjuvant procedure especially when the suture is passed through the anterior nasal spine. It is a simple procedure that minimizes the option of a second surgery. Cinch suture as an adjuvant procedure does not eliminate post-operative alar flare completely because it does not address the other contributing factors like the loss of pyriform depth and septal resection, which needs further evaluation.
Appreciation is extended to Mrs. National Center for Biotechnology InformationU. J Maxillofac Oral Surg. Published online Dec MustafaFatima Shehzanaand H. Author information Article notes Copyright and License information Disclaimer. Hari Kishore Bhat, Email: Received Apr 28; Accepted Oct This article has been cited by other articles in PMC. Abstract Objectives To prospectively analyze the amount of alar flare, factors contributing to alar flare and efficacy of cinch suture as an adjunctive procedure for alar flare reduction.
Study Design Thirty adult patients with vertical maxillary excess, who underwent Le Fort 1 impaction, were divided into 2 groups of 15 each. Results Group 2 showed a near pre-operative alar position compared to group 1. Conclusion Alar cinch suture restores the normal alar width by preventing the lateral drift of the naso-labial muscle and thereby reducing the postoperative nasal flare significantly.
Alar flare, Le Fort 1 impaction, Alar cinch suture. Introduction Le Fort 1 intrusion osteotomies are known to cause adverse effects on the oro-facial soft tissues such as broadening of the alar base, loss of vermillion show of the upper lip and down sloping of the commissure [ 1 ].
Aims and Objectives To assess the amount of alar flare. Materials and Methods Inclusion Criteria Patients diagnosed with the following conditions: Exclusion Criteria All orthognathic procedures not performed on maxilla. Open in a separate window. Points marked to measure the maximum convexity of the ala and alar base. Distance measured between the center of the alar bases using vernier caliper. Intergroup comparison was done by independent sample t test and it pronounced the following results: Regression Analysis Regression Equation for Group 1 For every unit increase of intrusion there was 0.
Discussion Many studies have reported secondary morphological changes in the nose, including alar flaring after a Le Fort 1 osteotomy. Conclusion We conclude that Le Fort 1 osteotomy superior repositioning leads to a widening of alar region of the nose, especially the alar base.
Acknowledgments Appreciation is extended to Mrs. Compliance with Ethical Standards Conflict of interest None. A prospective study on the effect of modified alar cinch sutures and VY closure versus simple closing sutures on nasolabial changes after Le Fort I intrusion and advancement osteotomies.
J Oral Maxillofac Surg. Nasal changes after surgical auture of skeletal correction of skeletal Class III malocclusion in Koreans. A modified alar cinch suture technique.