CASE REPORT

Upper lip shortening combined with Lefort 1 maxillaryintrusion: a novel approach to correct the long face syndrome

Anthony T. Macari & Naji Abou Chebel

Received: 11 July 2013 /Accepted: 27 September 2013# Springer-Verlag Berlin Heidelberg 2013

Abstract Lip lengthening is a common characteristic of agingcaused by the weakening of the fascial attachments and de-crease of lip volume. We report a comprehensive combinedplastic-orthognathic surgery of a long face syndrome unchar-acteristically associated with a long upper lip in a 37-year-oldCaucasian woman. The deformity comprised increased lowerface height, vertical maxillary excess, and increased gingivaldisplay upon smiling. The long lip (30.7 mm; norm, 20.1+2 mm) constituted a limitation to the routine maxillary Lefortimpaction because of the expected deficient display of maxil-lary teeth at rest and during smile. Lip shortening (5 mm)through a crescent flap was combinedwith maxillary impaction(6 mm), mandibular advancement (8 mm), and genioplasty(8 mm). Post-treatment results revealed normal relations be-tween the upper lip and both the lower facial features and thedentition, at rest and during smile. Research should explore thepredictability of the observed hard and soft tissue changes insimilar dysmorphologies.Level of Evidence: Level V, therapeutic study.

Keywords Lip lift . Maxillary intrusion . Long facesyndrome . Gingival smile

Introduction

Lip lengthening is a common characteristic of aging caused bythe weakening of the fascial attachments and decrease of lipvolume [1]. In addition, loss of lip architecture followingatrophy of the orbicularis oris and levator labii superioris caninduce shortening of the vermillion border and flattening ofthe philtral columns and the cupid bow [2, 3].

Different surgical approaches have been described to short-en a long upper lip when indicated. These techniques includedirect surgical excision of the nasal base skin [4–7] andintranasal incision with no visible scar [8, 9].

The relationship between lip line at rest and during smile isa critical diagnostic component of facial esthetics that impactson treatment planning and outcome in orthodontics andorthognathic surgery. In rest position, young individuals dis-play on average one third of the maxillary incisors. With age,lip lengthening, and loss of lip architecture result in a non-esthetic reduction of the dental display at rest or upon smiling[10]. When present in young adults, a long upper lip deviatingfrom established norms (20.1±2 mm in young adult femaleaccording to Farkas) [11] represents a constitutional variation.

Upper lip length is normal in a typical hyperdivergentpattern [12] associated with an increased lower facial height(LFH). Yet, surgical impaction of the maxilla in the treatmentof maxillary vertical excess associated with the long facesyndrome [13, 14] leads to shortening of the upper lip(approximately 20 %) [15]. The appearance of a long lip,usually in conjunction with a short face syndrome, is oftenadjusted with the downward movement of the maxillary boneand teeth [16]. Therefore, the problems related to the hardtissues are often treated without the possibility to control theirimpact on the upper lip. Lip surgery, particularly lip lift (or lipshortening), commonly performed in plastic surgery, is notcombined with orthognathic surgery.

Our aim is to illustrate such combination in the treatment ofan adult female whose surgical treatment for a long facesyndrome would have concealed the maxillary incisors cov-ered by a long upper lip, and affected her facial estheticsnegatively, particularly during smile.

Case report

The patient, a healthy 37-year-old Caucasian female,complained of mandibular retrognathism. Her symmetrical

A. T. Macari (*) :N. Abou ChebelDivision of Orthodontics and Dentofacial Orthopedics,Department of Otolaryngology‐ Head and Neck Surgery,American University of Beirut,Beirut, Lebanone-mail: am43@aub.edu.lb

Eur J Plast SurgDOI 10.1007/s00238-013-0899-z

face was characterized by increased LFH and a longupper lip, both features aggravating the appearance of along face syndrome. A gingival display of nearly 3 mmupon smiling conferred the “gummy smile” look, magni-fied by the short clinical crowns of the maxillary anteriorand posterior teeth (Fig. 1).

Analyses of facial proportions demonstrated an increasedLFH to total facial height (TFH) measured on hard (58.24 %)and soft (62.44 %) tissues both beyond the normal 55 %. Theupper lip, measured form the base of the nose (subnasale) tothe contact point between the lips (stomion), showed anexcess both in length (30.7 mm) and in its ratio to the LFH(39.20 %). Given an average lip in adult females of20.1±2.0 mm, and accounting for a normal range includingthe standard deviation, the patient's excess lip length wasabout 8.6 mm.

A vertical excess of nearly 4.5 mm in the middle facereflected a downward position of the maxilla. Alveolar hyper-plasia was demonstrated with increased distances to the pala-tal plane of the maxillary central incisor tip (+7.5 mm) and the

first molar cusp (+5 mm). Other cephalometric linear andangular measurements, also shown in Table 1, along withthe clinical findings further support the diagnosis of long facesyndrome, and the need to address the following problems:

1. The convex profile, retrognathic mandible, and deficientextension of the chin

2. The increased lower facial height and upper lip length3. The short clinical crowns and the excessive gingival

display upon smiling

The patient's oronasal functions were within normal rangeincluding normal mastication, speech, and nasal mode ofrespiration.

Treatment objectives and planning

The patient's initial complaints were related to her facialesthetics. Given the severe skeletal discrepancy between thejaws, management of the malocclusion required a treatment

Fig. 1 Pretreatment facial andprofile photographs showing thelong face syndrome and the lipline at rest displaying normalheight of the clinical incisors'crowns (3 mm), despite the longupper lip length

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combining orthodontics and orthognathic surgery to achievethe objectives that corresponded to the list of problems:

1. Improve the projection of the mandible and the chin2. Restore optimal facial vertical proportions3. Optimize the height of the clinical crowns

Despite the fact that this patient had a long face syndromewith vertical maxillary excess, she deviated from the classicallong face appearance because the long upper lip camouflagedthe maxillary hyperplasia at rest, the lip line resting at 3 mmfrom the incisal edges (Fig. 1), as well as the “gummy smile”during smile. Though the gingiva could be reduced to elon-gate the short crowns and correct the gummy smile, it will notcorrect the maxillary hyperplasia.

A maxillary hyperplasia is usually corrected by a maxillaryimpaction. However, given our patient's individual character-istics, intruding the maxilla is limited by the amount of gingi-val shown at full smile and the exposure of maxillary incisorsat rest (esthetic interaction between the upper lip and theanterior teeth in dynamic and static relationships). Yet, theexcessive length of the upper lip (30.7 mm; Table 1) justifiedaddressing the maxillary hyperplasia through surgical Lefort 1impaction coupled with a lip shortening.

Therefore, we decided on the following treatment protocol:

1. Presurgical orthodontic preparation to normalize the in-clination of mandibular incisors and increase the overjetfor optimal mandibular advancement.

2. Crown lengthening through gingivectomy to optimizecrowns' height.

3. Lip lifting: 5 mm shortening of the upper lip to increaseupper incisors' exposure

4. Le Fort 1 osteotomy for maxillary impaction of 6 mm andmandibular advancement of 8 mm coupled with agenioplasty of 8 mm.

5. Postsurgical orthodontic completion of treatment.

Surgical technique

First, the upper lip was shortened to provide additional expo-sure of the maxillary incisors at rest. A crescent of skin wasoutlined under each nostril, and the calculated amount (5 mm)of skin and subcutaneous tissue were excised, leaving themuscle intact (Fig. 2a). The closure was done in two layers.The incision was hidden in the nasolabial crease [17]. Teethexposure was increased to full crown visibility (Fig. 2b),

Table 1 Anthropometricmeasurements

T1 initial pretreatment, T2presurgical, T3 post-treatmenta Norms for age and gender fromFarkas LG. Anthropometricanalyses

T1 T2 T3 Norms

Soft tissuea

TFH (Nasion-Gnathion) (mm) 125.4 126.8 121.8 111.4±4.8

LFH (Subnasale-Gnathion) (mm) 78.3 78.8 71.9 64.3±4

Upper lip (Subnasale-Stomion) (mm) 30.7 30.7 25.4 20.1±2

LFH/TFH 62.44 % 62.14 % 58.07 % 57.7 %

UL/LFH 39.20 % 38.95 % 35.32 % 33.33 %

Fig. 2 Per-operative pictures of athe crescent outline of the skinflap under both nostrils. b Thefull height of incisors' crownsshowing after completion of thelip lift. c Normal 2–3 mm ofincisors' crown height showingafter performance of Lefort 1maxillary intrusion. d Cut belowthe nasal spine preserving themuscular attachment to the nasalspine. e Drawing of modified LeFort 1 osteotomy: a combinedlateral and nasal floor resection

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allowing for a Lefort 1 impaction that would restore the properrelation between lip and incisors at rest.

Then, the corrective double jaw surgery placed the jaws inthe planned position: 8 mm mandibular advancement throughbilateral sagittal split osteotomy, 6 mm maxillary impactionthrough a modified Lefort 1 osteotomy (MLO) leaving ANSintact, through its attachment to the septum, and the musclesattached to it undisturbed to avoid lip shortening as a sideeffect of the impaction (Fig. 2c–d), and 8 mm advancementgenioplasty. Accordingly, 3 mm of the maxillary incisorcrowns were visible at rest, restoring the relationship betweenlip and incisors to normal levels (Fig. 2e). The surgeon co-author (NAC) had introduced the MLO (Fig. 2c–d) to avoidthe side effects of ANS movement on nose, subnasal attach-ment, and upper lip.

Postsurgical phase

The postsurgical orthodontic finishing stage was initiated1 month after the operation. The orthodontic appliances wereremoved 8 months after the surgery (Fig. 3), nearly 2 yearsafter treatment initiation.

Discussion

The treatment of this long face syndrome was unique becauseof its combination with a soft tissue plastic surgery that wasnecessary to maintain basic esthetic proportions. The typicalincreased height of the lower facial third in long face syn-dromes is frequently related to maxillary hyperplasia,

Fig. 3 Postsurgical facial andprofile photographs

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mandibular steepness, and anterior open bite. These featuresare usually associated with lip incompetence at rest, and oftenwith a short upper lip.

The untypical long upper lip in our patient engendered thepresented approach because the classical surgery, limited to aLefort 1 intrusion, would have embedded the maxillary ante-rior teeth in an unesthetic relationship with the surroundingsoft tissues. The resulting look is characteristic of aging:hidden maxillary teeth and exposure of mandibular teethduring speech. Otherwise, to avoid the disproportional rela-tionship between a long upper lip and the maxillary incisors,the amount of maxillary impaction would be limited,compromising the ideal correction of the long face syndrome

Given the doubled-faceted nature of this surgical approach,outcome predictability is important to be addressed during thetreatment planning phase. On the basis of orthognathic stud-ies, the range of upper lip shortening ranges from 20 to 40 %.Assuming an average of 30 % [18], lip shortening pursuant tothe Lefort impaction (6mm) would have amounted to 1.8 mm,which when added to the lip lifting of 5 mm would amount tototal lip shortening of 6.8 mm. However, the actual differencebetween pre and post-treatment lip length was 5.3 mm, nearlycoincident with the actual lip lifting. The modified Lefort 1osteotomy that left ANS intact through its attachment to theseptum avoided lip shortening as a side effect of the impac-tion. Ongoing research should shed more light on this proce-dure, particularly in comparison with other orthognathic im-paction protocols.

While upper lip elongation is commonly observed in olderpatients, it can also be developmental in young individuals as isthe case of our patient. A long upper lip will hide the maxillaryteeth. Lip lifting is recommended to correct this elongation:resecting skin and subcutaneous tissue from the upper part ofthe lip will shorten the outer part of the lip, the overall length ofthe upper lip, and will create an upper lip pout.

We recommend normalizing (lifting) the upper lip prior tointruding the maxilla. This will create an increased exposureof the upper incisors and will allow the possibility of intrudingthe upper jaw the amount needed to correct the maxillaryvertical excess responsible for the long face syndrome.

The patient's oronasal functions recovered to pretreat-ment normalcy, which was in line with reported functionaladaptation following orthognathic surgery. In this context,two areas of focus warrant discussion: nasal resistance andspeech. Postsurgical rhinomanometric studies on patientswho underwent maxillary Lefort 1 impaction, inferior po-sitioning or sagittal movement, indicated either no changesor improvement of nasal flow [19, 20]. Postoperative re-duction of the nasal airway resistance might be explainedby of the opening of the nasal valve following the increasein the alar base width [19].

Similarly, most of the studies evaluating the effect oforthognathic surgery on speech did not depict any deterioration

in articulation [21, 22]. Yet, available studies on postsurgicalchanges in speech have methodological limitations, includingsmall samples, warranting further research before a clear cutconclusion is drawn [23]. Certain malocclusions (class III—diastema, increase in overjet, presence of open and deep bite,asymmetry) are more associated with speech impairment thanothers (class II—protrusion of maxillary incisors, posteriorcross bite) [24]. Our patient fell in the latter category and thesurgery did not disturb her normal speech. Future investigationshould focus on the type of malocclusion and the presence ofpresurgical speech disturbance. The type of surgery is probablyless relevant than the pretreatment condition, as the sameprocedure (e.g., maxillary impaction) may be used to correctan anterior open bite with dyslalia resulting in speech improve-ment, but also to eliminate a “gummy” smile with no impact onspeech in a patient who does not have an open bite.

Conclusion

The correction of long face syndrome in the presence ofan increased upper lip length necessitates a deviationfrom routine orthognathic surgical approach. To avoidthe unpleasant and non-esthetic coverage of the maxil-lary teeth at rest after Lefort 1 maxillary impaction, theupper lip was shortened surgically resulting in a remark-able improvement of facial esthetics and achieving op-timal relations between upper lip and maxillary teeth atrest and during smile.

While lip lifting is commonly described in facial plastics,its combination with orthognathic surgery helped create bal-ance between hard and soft tissues.

Acknowledgments We thank Dr. Joseph G. Ghafari for his valuablereview of this manuscript.

Conflict of Interest None

Patient consent Patient provided written consent for the use of herimages.

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