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

Overview

Planning tip correction requires noting how the nose and lip relate, since operating on one affects the other. The authors measured upper lip position during smiling in consecutive primary rhinoplasty patients, categorizing it against the incisors and gum line, and separately categorized nasal length, tip projection and columella position from life size photographs.

Sections of note

• Design: measurement study of 150 consecutive primary rhinoplasty patients; 139 met photographic inclusion criteria.
• Upper lip position when smiling: 47 patients, 34 percent, ideal; 83, 61 percent, showed inadequate incisor show; 7, 5 percent, showed excessive gum.
• Nasal length: 16 short, 45 ideal, 76 long. Tip projection: 14 underprojected, 38 ideal, 85 overprojected.
• No nasal measurement predicted upper lip position.
• Tip overprojection predicted a long nose, odds ratio 3.03, p equal to 0.02, as did a hanging columella, odds ratio 2.97. Tip underprojection strongly predicted a short nose, odds ratio 35, p less than 0.0001.
• Stated conclusion: upper lip malposition is common and must be identified before surgery to avoid worsening it.

What it means for a patient

• How much upper tooth shows when you smile is a separate feature from the nose, and two thirds of these patients showed less than ideal.
• Tip surgery can pull the upper lip and change the smile, which is why lip position is assessed before the operation.
• Because nothing about the nose predicts lip position, it must be measured separately rather than inferred.
• Limits: 139 patients, one practice, categories assigned from photographs rather than by patient report, and no outcome data on whether surgery changed lip position.

Why this paper matters

The smile is judged in motion while rhinoplasty is planned from still photographs, so an effect on the smile is easily missed until afterward. Quantifying how common suboptimal lip position is at baseline makes the case for checking it routinely. How often rhinoplasty actually worsens the smile is not measured here.

Terms

• Incisor show: how much of the upper front teeth is visible when smiling.
• Gummy smile: excessive gum visible above the upper teeth when smiling.
• Tip projection: how far the nasal tip stands out from the plane of the face.
• Hanging columella: the strip between the nostrils sitting lower than the nostril rims.
• Odds ratio: how much more likely an outcome is in one group than another.