Int. J. Oral Maxillofac. Surg.

2015; 44: 816–822

http://dx.doi.org/10.1016/j.ijom.2015.03.003, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Effects of two alar base suture C.Y.-H. Chen1,2,3, C.C.-H. Lin2,4,

E.W.-C. Ko1,2,3
1
Department of Craniofacial Orthodontics,

techniques suture techniques Chang Gung Memorial Hospital, Taipei,

Taiwan; 2Craniofacial Research Centre,
Chang Gung Memorial Hospital, Linkou,
Taiwan; 3Graduate Institute of Craniofacial

on nasolabial changes after and Oral Science, Chang Gung University,

Taoyuan, Taiwan; 4Department of Plastic and
Reconstructive Surgery, Chang Gung
Memorial Hospital, Taoyuan, Taiwan

bimaxillary orthognathic
surgery in Taiwanese patients
§
with class III malocclusions
C. Y. -H. Chen, C. C. -H. Lin, E. W. -C. Ko: Effects of two alar base suture techniques
suture techniques on nasolabial changes after bimaxillary orthognathic surgery in
Taiwanese patients with class III malocclusions. Int. J. Oral Maxillofac. Surg. 2015;
44: 816–822. # 2015 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. A randomized controlled trial was designed to assess the effectiveness of two
alar base cinch techniques on the changes in nasolabial morphology after bimaxillary
orthognathic surgery. Sixty patients requiring a Le Fort I osteotomy to correct skeletal
discrepancies were selected randomly to receive either conventional or modified alar
base cinching during the intraoral wound closure procedure. Conventional cinching
passed through nasalis muscle and anterior nasal spine. Modified cinching also passed
through dermis tissue to increase the anchorage. Postoperative hard and soft tissue
changes were evaluated using cone beam computed tomography and three-
dimensional stereophotogrammetry at predefined time points. Forty-eight patients
with a skeletal class III malocclusion were included. In the conventional group, there
was an increase of 0.31  1.31 mm in nasal width and an increase of 0.97  1.60 mm
in columellar length. In the modified group, there was an increase of 0.81  1.87 mm
Key words: alar base suture technique;
in the cutaneous height of the upper lip and a decrease of 0.76  1.56 mm in lower
nasolabial changes; orthognathic surgery;
prolabial width. Patients with an initial narrow nasal width, alar base width, and less three-dimensional stereophotogrammetry.
vertical nostril show were more susceptible to a greater degree of change after surgery.
Both alar base suture techniques are effective at controlling nasolabial form changes Accepted for publication 4 March 2015
resulting from class III dual-jaw orthognathic surgery. Available online 29 March 2015

§
Presented at the 71st Annual Meeting and Symposium of the American Cleft-Palate Craniofacial Association, Indianapolis, USA,
March 24–29, 2014.

0901-5027/070816 + 07 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Nasolabial changes by alar base sutures 817

Surgical orthodontic treatment is com-

monly used to correct skeletal class III
malocclusion.1,2 Although, in the past,
skeletal class III malocclusion was treated
mainly by mandibular setback, bimaxil-
lary procedures have become more preva-
lent in recent years.3,4 Bimaxillary surgery
not only achieves a well-proportioned fa-
cial profile and symmetry, but also pro-
vides the same skeletal stability as that of
single-jaw osteotomies.5
However, the maxillary Le Fort I osteot-
omy can alter the soft tissue in the nasola-
bial region. The most significant changes
include an increase in the width of the alar
base of the nose, anterosuperior movement
of the nasal tip, and upper lip flattening.6–8
This finding is crucial for Asian popula-
tions, who tend to have wider noses, a
shorter columellar height, and a flatter ap-
pearance than Caucasians do.9,10 Numer-
ous studies have suggested that applying an
alar base cinch suture could minimize alar
base flaring.11–14 However, three-dimen-
sional (3D) studies have found that the alar
base width after surgery is still increased 2–
3 mm with or without cinch suture place- Fig. 1. Diagram illustrating the flow of participants through the randomized controlled trial,
ment.15,16 A modified alar base cinch suture including patients withdrawn and the number of participants completing the trial in each arm.
has been suggested to mitigate the detri-
mental effects of the maxillary Le Fort I eligible for inclusion in the study. Patients fixation involving plates and screws was
osteotomy on nasolabial aesthetics.15 with an associated syndromic diagnosis, applied to the medial and lateral but-
A new technique has been proposed for cleft of the lip or palate, dentofacial trau- tresses of the maxilla. No trimming of
improving the effectiveness of the alar ma, or previous nasal septum or nasal tip the anterior nasal spine (ANS), bony
cinch suture technique by increasing the operations were excluded. structures around the pyriform ring, or
anchorage of the alar cinch suture to the Informed consent was obtained from all nasal septum was done during the sur-
muscle and dermis tissue over the bilateral of the patients prior to surgery. The gery.
alar base. In contrast to extraoral patients were assigned randomly to either Before closure of the maxillary wound,
approaches,17,18 this technique could pre- the conventional group (group C) or mod- an alar base cinch suture without V–Y
vent temporary postoperative dimpling of ified group (group M). All of the cinch advancement was performed with 3–0
the alar base and sensitive nasal alar skin. suture operations were performed by a nylon. For group C, the suture began from
The aim of this study was to assess the single surgeon (CHL), who was informed the bilateral alar part of the nasalis muscle
effectiveness and resulting postoperative of the assigned grouping of the patient just and passed through a hole drilled in the
changes in the nasolabial region of two before orthognathic surgery by the re- ANS. For group M, the suture began from
alar base cinch suture techniques after search assistant; assignment was done the bilateral alar part of the nasalis muscle
orthognathic surgery. according to a randomized table. All of and dermis tissue over the alar base, and
the patients and the sole investigator then passed through a hole drilled in the
Patients and methods (YHC) were blinded to the grouping. ANS. The major difference between these
two methods was whether the additional
Protocol
anchorage sutures went through the der-
Interventions
This prospective randomized controlled mis tissue over the alar base or not (Fig. 2).
trial was conducted between September All of the patients underwent a standard During surgery, the surgeon repeatedly
2011 and February 2013. The study was Le Fort I osteotomy. Surgery was per- measured the alar width with the use of
approved by the Medical Ethics Commit- formed under general anaesthesia with callipers, both before incision and during
tee. The trial was registered at Clinical- nasotracheal intubation. The midface nasal cinch suturing. The surgeon
Trials.gov. The study was conducted degloving procedure was begun with attempted to maintain a consistent alar
according to the Consolidated Standards an incision along the bilateral upper buc- width by adjusting the tightness of the
of Reporting Trials standards for reporting cal sulcus, by cutting through mucosa sutures. Two-hand ties with four knots
randomized controlled trials (Fig. 1).19 and muscles to the anterior wall of the were used to ensure appropriate tightness.
maxilla. Nasalis muscles, originating
from the maxilla and connected to the
Sample collection Outcome measures
nasal bridge and alar cartilage, were sev-
All non-growing Taiwanese patients over ered and detached from the maxillary Two types of 3D stereophotogrammetry
18 years of age who underwent a Le Fort I surface. After satisfactory repositioning were conducted. Cone beam computed
maxillary osteotomy were considered of the maxillomandibular complex, rigid tomography (CBCT) data were obtained
818 Chen et al.

both before surgery and at 4–6 weeks

after surgery, and 3D digital photographs
were taken before surgery (T1) and at 6
months after surgery (T2). Fifteen an-
thropometric parameters were measured,
including baseline, nasal, and nasolabial
parameters (Table 1 and Fig. 3). The
sagittal and vertical movement of hard
tissue landmarks (the ANS, the midline
point at the innermost curvature point
from the maxillary ANS to the crest of
the maxillary alveolar process (A point),
and the midpoint of the upper incisor
edge (UI level)) and soft tissue land- Fig. 2. Diagrams illustrating (a) the conventional alar base cinch technique, and (b) the modified
marks (pronasale (prn), subnasale (sn), alar base cinch technique. The conventional alar base cinch suture began from the bilateral alar
and labiale superioris (ls)) were also part of the nasalis muscle and passed through a hole drilled in the anterior nasal spine. The
measured. modified alar base cinch suture began from the bilateral alar part of the nasalis muscle and
dermis tissue over the alar base, and then passed through a hole drilled in the anterior nasal spine.
m: alar part of the nasalis muscle; ANS: anterior nasal spine; D: dermis tissue over the alar base.

Table 1. Definitions of landmarks and measurements in the assessment of 3D nasolabial changesa.

Parameter Anthropometric landmarks Abbreviation
Baseline parameter
(1) Inter-canthal distance Endocanthion R en–L en
Nasal parameters
(2) Nasal height Nasion, subnasale n–sn
(3) Nasal length Nasion, pronasale n–prn
(4) Nasal tip protrusion Subnasale, pronasale sn–prn
(5) Alar width The most lateral point on the curved base line of each ala, alar points R al–L al
(6) Alar base width Alar base points R alB–L alB
(7) Right vertical nostril show dimension Right vertical nostril show points q–r
(8) Left vertical nostril show dimension Left vertical nostril show points s–t
(9) Columellar length Labiale superioris, stomium ls–sto
Lip parameters
(10) Cutaneous height of upper lip Subnasale, highest point of columella sn–c
(11) Overall upper lip height Subnasale, labiale superioris sn–ls
(12) Vermilion height of upper lip Subnasale, stomium sn–sto
(13) Lower prolabial width Right and left crista philtrum R cphi–L cphi
(14) Upper lip protrusion Tragus, labiale superioris tr–ls
(15) Nasolabial angle (at MSR plane) Nasion, subnasale, labiale superioris NLA
3D, three-dimensional; MSR plane, mid-sagittal reference plane.
a
Anthropometric landmarks and measurements were defined according to Farkas (Farkas LG. Anthropometry of the head and face. New York:
Raven Press, 1994: 103–108, 112, 850).

Fig. 3. Outcome measures for 15 anthropometric parameters: (1) inter-canthal distance, (2) nasal height, (3) nasal length, (4) nasal tip protrusion,
(5) nasal width, (6) alar base width, (7) right and (8) left nostril show vertical dimension, (9) columellar length, (10) cutaneous height of the upper
lip, (11) overall upper lip height, (12) vermilion height of the upper lip, (13) lower prolabial width, (14) upper lip protrusion, and (15) nasolabial
angle (on midsagittal plane).
 Nasolabial changes by alar base sutures 819

Fig. 4. Standard head position was oriented to the reference planes in the 3D reconstructed CBCT hard tissue. The axial reference plane was
defined as the Frankfort horizontal plane (FH plane); the midsagittal plane was the plane perpendicular to the FH plane and passing through nasion;
the coronal reference plane was that perpendicular to both the axial and sagittal planes and bisecting the bilateral porions.

CBCT capture and image processing the paired t-test results to validate the Movements of hard and soft tissue
image measurements and landmark regis- landmarks
CBCT was performed using an i-CAT
tration. No significant difference was
scanner (Imaging Sciences International, The sagittal and vertical movements of the
found (P = 0.247 and P = 0.345).
Hatfield, PA, USA) with 14-bit grey-scale hard tissue landmarks (ANS, A point, and
resolution and a voxel size of 0.4 mm3. UI level) in both groups were not signifi-
The CBCT data were constructed into 3D Results cantly different and were less than 4.0 mm
CBCT models. The head position was then (Table 2). The difference in sagittal and
Participant flow and follow-up
oriented to the reference planes (Fig. 4). vertical movement of the pronasale and
Bone tissue and skin tissue surface images Sixty patients requiring a Le Fort I osteot- labiale superioris between the two groups
were segmented according to different omy to correct skeletal discrepancies were was also non-significant. The sagittal and
thresholds of Hounsfield units and then selected randomly to receive either con- vertical movements of the subnasale were
superimposed. After the superimposition ventional or modified alar base cinching significantly different between the two
of the bone tissue surface images before during the intraoral wound closure proce- groups: in group C, the subnasale moved
and after orthognathic surgery, directional dure. Ten non-Class III patients were ex- backward and downward; in group M, the
movements of the maxilla were measured cluded to enhance sample consistency and subnasale demonstrated significant for-
in the x, y, and z planes. 3D CBCT image two patients refused to take part in the ward and upward movements (Table 3).
rendering, registration, superimposition, study. The sample size was reduced to 48
and skeletal measurements were con- patients. There were 24 patients each in
Outcome measures
ducted using Vultus software (3dMD, group C and group M, with a similar sex
Atlanta, GA, USA). distribution in the two groups (7 male and All of the differences in the 15 outcome
17 female patients in group C, and 8 male measures in group C were non-significant,
and 16 female patients in group M). The except for columellar length, which in-
3D digital photography capture and mean age of the patients was 23.78 years creased significantly by 0.97  1.60 mm
image processing in group C (range 18–34 years) and 24.13 (P = 0.008, a = 0.05) (Table 4). In group
3D digital photography capture using com- years in group M (range 19–57 years). No C, the percentage of nasal widening great-
mercial stereophotogrammetry devices significant difference was observed be- er than 2 mm was 8.33% (2/24) and the
(3dMD) contained 4000–20,000 3D points. tween the two groups regarding age, percentage of alar base widening greater
The rendering, registration, and superimpo- sex, or the 15 nasolabial parameters than 2 mm was 12.50% (3/24). Nasal
sition of 3dMD images, as well as measure- (P > 0.05). width in group C increased by
ment of soft tissue movement, were
performed using Vultus software and Table 2. Maxillary dentoskeletal movements in both groups ( in millimetres).
3dMD patient software (3dMD). The
Group Cb Group Mb
imported 3dMD facial images were regis- Inter-group difference,
tered and superimposed on the oriented 3D Axisa Mean SD Mean SD paired t-test, P-value
CBCT images (Fig. 4). A surface-based best ANS x 0.50 1.09 0.95 1.29 0.098
fit registration method was used, and the y 0.32 2.82 0.95 2.10 0.389
root mean square (RMS) error was main- z 0.71 2.73 0.50 2.35 0.780
tained under 0.5 mm. Each image was man-
A point x 0.22 1.50 0.58 1.22 0.054
ually annotated using 19 landmarks. y 0.95 2.29 1.58 1.94 0.323
z 1.83 2.97 1.11 2.43 0.371
Statistical analysis UI level x 0.30 1.44 0.86 1.53 0.011*
y 0.58 2.40 1.08 1.82 0.426
The statistical analysis was performed z 2.42 3.95 1.91 2.88 0.621
using IBM SPSS Statistics for Windows,
SD, standard deviation; ANS, anterior nasal spine; UI, upper incisor edge.
version 19.0 (IBM Corp., Armonk, NY, a
x-axis defined as the transverse dimension (a positive direction for the x-axis is right); y-axis
USA). Intra- and inter-group differences defined as the vertical dimension (a positive direction for the y-axis is up); z-axis defined as the
were analyzed using the Student’s t-test sagittal dimension (a positive direction for the z-axis is forward).
and a paired t-test. Hypothesis testing was b
The mean maxillary movement in groups C (conventional) and M (modified) in the sagittal
two-sided at a level of 0.05. Repeated and vertical dimensions were forward and downward, without significant difference.
*
measurement sets were compared with P-value < 0.05.
820 Chen et al.

Table 3. Changes in soft tissue landmarks in 3D planes (in millimetres). significant decrease in lower prolabial
Group Cb Group Mb width by 0.76  1.56 mm (P = 0.029,
Inter-group difference, a = 0.05), and a significant decrease in
Axisa Mean SD Mean SD paired t-test, P-value upper lip protrusion by 1.88  3.26 mm
Pronasale x 0.14 1.23 0.35 1.70 0.275 (P = 0.011, a = 0.05) (Table 4). The per-
y 0.12 1.62 0.29 1.42 0.361 centage of nasal widening greater than
z 0.08 1.43 0.48 1.04 0.284 2 mm in group M was 20.83% (5/24), and
Subnasale x 0.05 1.13 0.67 1.88 0.119 the percentage of alar base widening
y 0.62 1.32 0.21 0.97 0.019* greater than 2 mm in group M was
z 0.03 1.55 1.08 1.89 0.034* 29.17% (7/24). The inter-group differ-
Labiale superioris x 0.00 1.64 0.74 2.02 0.422 ences of all 15 outcome measures were
y 0.90 1.78 0.03 2.09 0.177 non-significant (Table 4).
z 0.42 2.06 0.03 2.09 0.133 The reported negative correlation be-
3D, three-dimensional; SD, standard deviation. tween initial and 6-month postoperative
a
x-axis defined as the transverse dimension (a positive direction for the x-axis is right); y-axis changes in nasal width, alar base width,
defined as the vertical dimension (a positive direction for the y-axis is up); z-axis defined as the and mean vertical nostril show were
sagittal dimension (a positive direction for the z-axis is forward). statistically significant (Table 5). The
b
The only significant movement between groups C (conventional) and M (modified) was the change in nasal width was not correlated
sagittal and vertical dimension of subnasale. Subnasale in group C moved backward and to the change in NLA (P = 0.946),
downward, whereas subnasale in group M moved forward and anteriorly. but the change in alar base width was
*
P-value < 0.05. correlated to the change in NLA
(P = 0.026).
0.31  1.31 mm, but this was not signifi- significant increase in cutaneous height
cantly different. of the upper lip by 0.81  1.87 mm
Most of the differences in the 15 out- (P = 0.049, a = 0.05), a significant in- Discussion
come measures in group M were non- crease in the nasolabial angle (NLA) Surgical movements of the maxilla may
significant, except for the following: a by 3.25  7.258 (P = 0.043, a = 0.05), a affect nasolabial aesthetics after surgery.13

Table 4. Intra- and inter-group differences in nasolabial changes in both groups.

Group Ca Group Ma
T2–T1 T2–T1
Intra-group Intra-group Inter-group
Mean SD difference, P-value Mean SD difference, P-value difference, P-value
1 Inter-canthal distance 0.62 2.35 0.218 0.04 0.82 0.804 0.211
2 Nasal height 0.80 3.91 0.336 0.78 2.27 0.114 0.102
3 Nasal length 0.81 2.88 0.192 0.38 2.41 0.457 0.136
4 Nasal tip protrusion 0.46 1.42 0.135 0.11 0.92 0.565 0.113
5 Nasal width 0.31 1.31 0.277 0.13 2.25 0.781 0.115
6 Alar base width 0.26 1.85 0.505 0.62 2.08 0.164 0.535
7 R nostril show vertical dimension 0.27 1.21 0.299 0.19 1.52 0.554 0.850
8 L nostril show vertical dimension 0.13 1.87 0.738 0.20 1.42 0.508 0.891
9 Columellar length 0.97 1.60 0.008* 0.38 1.92 0.358 0.262
10 NLA 2.92 8.28 0.104 3.25 7.25 0.043* 0.888
11 Cutaneous height of upper lip 0.38 1.11 0.116 0.81 1.87 0.049* 0.344
12 Overall upper lip height 0.25 1.86 0.528 0.63 1.50 0.057 0.451
13 Vermilion height of upper lip 0.55 1.64 0.123 0.55 1.35 0.062 0.995
14 Lower prolabial width 0.40 1.61 0.250 0.76 1.56 0.029* 0.440
15 Upper lip protrusion 0.41 5.12 0.706 1.88 3.26 0.011* 0.078
SD, standard deviation; T1, before surgery, T2, 6 months after surgery; R, right; L, left; NLA, nasolabial angle (8).
a
Group C, conventional; group M, modified; all measurements in millimetres, except NLA.
*
P-value < 0.05.

Table 5. Correlation between the initial nasal form and the surgical changes in nasal width, alar base with, and mean nostril show vertical
dimension.
T0 and DT2–T0
Nasal width Alar base width Mean nostril show vertical dimension
** *
Group C r= 0.538 r= 0.414 r= 0.173
Group M r= 0.224 r= 0.541** r= 0.737**
Overall r= 0.182 r= 0.501** r= 0.515**
Group C, conventional; group M, modified. Results showed statistically significant differences.
*
P < 0.05; Pearson’s correlation coefficient.
**
P < 0.01; Pearson’s correlation coefficient.

Regarding the outcome measures, sagittal
and vertical movements of the soft tissue
corresponding to the maxilla were found.
Recent studies have supported the hypoth-
esis that maxillary advancement, rather
than maxillary impaction, plays the most
crucial role in movement in all direc-
tions.20,21 A 3D CBCT study showed that
postoperative NLA increased significantly
when maxilla advancement was more than
4.0 mm.20 In our study, the sagittal and
vertical movements of the maxilla were all
less than 4.0 mm, which minimized the
postoperative response of the soft tissue to
skeletal movement. No significant corre-
lation between skeletal (ANS, A point, and
UI level) and soft tissue (prn, sn, and ls)
movement was reported in the current
study (x2 analysis, all P > 0.213). Thus,
skeletal movement in our study could be
considered a controlled factor, and its
effectiveness in comparing different alar
base cinch sutures could be evaluated.
Regarding the 15 outcome measures,
the significant change in group C was
increased columellar length; in group M,
the significant changes were increased
NLA, increased cutaneous height of the
upper lip, decreased lower prolabial width,
and decreased upper lip protrusion. The
mean position of the subnasale moved
slightly backward and downward in group
C, whereas in group M it moved slightly
forward and upward. The similar direc-
tional movement of the pronasale and
labiale superioris and statistically different
opposite directional movement of the sub-
nasale explain why the NLA and cutane-
ous height of the upper lip increased
significantly in group M. The mild Le Fort
I maxillary advancement could also ac-
count for the increased NLA in both
groups.21,22 A correlation was determined
between the change in alar base width and
the change in NLA when an alar base
suture was used. This finding suggests that
because the alar base cinch suture reduces
alar flaring, the technique could increase
NLA.23
A total of 15.22% (7/46) and 21.74%
(10/46) of the patients had more than
2 mm of both nasal widening and alar base
widening; for all of these patients, the
initial nasal width and initial alar base
width were lower than average. Further-
more, patients with a narrower nasal
width, alar base width, and mean vertical
nostril show tended to have greater wid-
ening of the nose and alar base with an
increase in mean vertical nostril show at 6
months after surgery. This is in concor-
dance with the results of Chung et al.,10
who concluded that female Korean
patients with a narrow initial nose were
Nasolabial changes by alar base sutures
more susceptible to alar widening than
those with a broad nose. The nasal forms
in patients with initial narrow nasal and
alar width, as well as less vertical show,
would be expected to become normal, and
additional rhinoplasty might be needed if
the changes are greater than expected.
Soft tissue swelling after surgery makes
the evaluation of postsurgical soft tissue
changes difficult. Most studies have used
images taken at least 3 months post-sur-
gery, with some extending this to 6 months
or 1 year.24 However, Moss et al.25 de-
scribed little facial soft tissue change oc-
curring from 3 months to 1 year post-
surgery. Kau et al.26 reported that the facial
morphology returned to approximately
90% of the baseline facial scan at 3 months
post-surgery. Oh et al.27 also found that the
soft tissue remained stable at 6 months after
surgery and suggested that this would be
appropriate for assessment. Thus, in the
present study, the post-surgical 3D digital
photographs were obtained a minimum of 6
months after surgery.
The postoperative CBCT data were not
obtained simultaneously with the 3D dig-
ital photographs in this study. The CBCT
data obtained before and at 4–6 weeks
after surgery were required to assess the
3D maxillary movement of the Le Fort I
osteotomy. Although the stability of the
surgical movements also contributes to the
soft tissue outcome for the nose and lips,
bimaxillary orthognathic surgery has been
shown to be a relatively stable treatment
procedure during the 1 year after sur-
gery.28 Therefore, it could be assumed
that no significant adverse bony relapse
occurred during the 6-month study peri-
od.20 Besides, the postoperative soft tissue
changes occurring at 2–6 months are the
result of remodelling of the surrounding
structures or muscles, rather than hard
tissue relapse.27 Furthermore, if we had
taken one more CBCT at 6 months after
surgery, the patients would have been
exposed to additional CBCT radiation
(137.4 mSv).29 Lastly, the ANS was not
trimmed during surgery, so it would be
clear to landmark the positional change of
the ANS before and 4–6 weeks after sur-
gery. On the other hand, ANS might be-
come less identifiable at 6 months after
surgery due to remodelling.
A recent systematic review30 reported
that modified extraoral alar base cinch
sutures17,18 could control nasal width
and alar base width more effectively after
surgery in different ethnic groups, such as
Brazilians, Italians, and Indians. However,
further research is necessary to draw more
solid conclusions by providing data from
participants of different races, sexes, and
821
with various underlying skeletal move-
ments. The prospective, randomized, con-
trolled, and double-blind nature of our
study minimized the opportunity for bias.
The controls of our study design included
random assignment of patients, standard-
ized surgical procedures performed by a
single surgeon, and generally consistent
maxillary movement.
Although patient-reported quality of
life was not assessed, according to the
clinical charts and the clinicians’ interac-
tions with patients, none of the patients
included in the study complained of unex-
pected nasolabial changes during the 6
months after orthognathic surgery.
The findings of the current study indi-
cate that both alar base suture techniques
(conventional and modified approaches)
during orthognathic surgery can control
postoperative nasolabial changes effec-
tively in Taiwanese class III patients, as
observed for at least 6 months after sur-
gery. The conventional approach was
more effective at increasing columellar
length. By contrast, the modified approach
had a greater effect on the increased NLA
in response to underlying skeletal move-
ment in the ANS, as well as a greater upper
lip-lengthening effect.
Funding
None.
Competing interests
None declared.
Ethical approval
This study was approved by the Institu-
tional Review Board and Medical Ethics
Committee at Chang Gung Memorial Hos-
pital (CGMH-100-1653A3).
Patient consent
Written patient consent was obtained.
References
1. Bailey LJ, Haltiwanger LH, Blakey GH,
Proffit WR. Who seeks surgical-orthodontic
treatment: a current review. Int J Adult
Orthodon Orthognath Surg 2001;16:280–92.
2. Espeland L, Hogevold HE, Stenvik A. A 3-
year patient-centred follow-up of 516 con-
secutively treated orthognathic surgery
patients. Eur J Orthod 2008;30:24–30.
3. Bailey LT, Proffit WR, White Jr RP. Trends
in surgical treatment of Class III skeletal
relationships. Int J Adult Orthodon Orthog-
nath Surg 1995;10:108–18.
822 Chen et al.
4. Johnston C, Burden D, Kennedy D, Harra-
dine N, Stevenson M. Class III surgical-
orthodontic treatment: a cephalometric
study. Am J Orthod Dentofacial Orthop
2006;130:300–9.
5. Jakobsone G, Stenvik A, Sandvik L, Espe-
land L. Three-year follow-up of bimaxillary
surgery to correct skeletal Class III maloc-
clusion: stability and risk factors for relapse.
Am J Orthod Dentofacial Orthop 2011;139:
80–9.
6. Mitchell C, Oeltjen J, Panthaki Z, Thaller
SR. Nasolabial aesthetics. J Craniofac Surg
2007;18:756–65.
7. Milliard Jr DR. The alar cinch in the flat,
flaring nose. Plast Reconstr Surg 1980;65:
669–72.
8. O’Ryan F, Schendel S. Nasal anatomy and
maxillary surgery. I. Esthetic and anatomic
principles. Int J Adult Orthodon Orthognath
Surg 1989;4:27–37.
9. Farkas LG, Katic MJ, Forrest CR, Alt KW,
Bagic I, Baltadjiev G, et al. International
anthropometric study of facial morphology
in various ethnic groups/races. J Craniofac
Surg 2005;16:615–46.
10. Chung C, Lee Y, Park KH, Park SH, Park
YC, Kim KH. Nasal changes after surgical
correction of skeletal Class III malocclu-
sion in Koreans. Angle Orthod 2008;78:
427–32.
11. Betts NJ, Vig KW, Vig P, Spalding P, Fon-
seca RJ. Changes in the nasal and labial soft
tissues after surgical repositioning of the
maxilla. Int J Adult Orthodon Orthognath
Surg 1993;8:7–23.
12. Collins PC, Epker BN. The alar base cinch: a
technique for prevention of alar base flaring
secondary to maxillary surgery. Oral Surg
Oral Med Oral Pathol 1982;53:549–53.
13. Mansour S, Burstone C, Legan H. An evalu-
ation of soft-tissue changes resulting from
Le Fort I maxillary surgery. Am J Orthod
1983;84:37–47.
14. Radney LJ, Jacobs JD. Soft-tissue changes
associated with surgical total maxillary in-
trusion. Am J Orthod 1981;80:191–212.
15. Howley C, Ali N, Lee R, Cox S. Use of the
alar base cinch suture in Le Fort I osteotomy:
is it effective. Br J Oral Maxillofac Surg
2011;49:127–30.
16. Ubaya T, Sherriff A, Ayoub A, Khambay B.
Soft tissue morphology of the naso-maxil-
lary complex following surgical correction
of maxillary hypoplasia. Int J Oral Maxillo-
fac Surg 2012;41:727–32.
17. Ritto FG, Medeiros PJ, De Moraes M,
Ribeiro DP. Comparative analysis of two
different alar base sutures after Le Fort I
osteotomy: randomized double-blind con-
trolled trial. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2011;111:181–9.
18. Nirvikalpa N, Narayanan V, Wahab A,
Ramadorai A. Comparison between the clas-
sical and a modified trans-septal technique of
alar cinching for Le Fort I osteotomies: a
prospective randomized controlled trial. Int J
Oral Maxillofac Surg 2013;42:49–54.
19. Begg C, Cho M, Eastwood S, Horton R,
Moher D, Olkin I, et al. Improving the
quality of reporting of randomized con-
trolled trials: the CONSORT statement.
JAMA 1996;276:637–9.
20. Ryckman MS, Harrison S, Oliver D, Sander
C, Boryor AA, Hohmann AA, et al. Soft-
tissue changes after maxillomandibular ad-
vancement surgery assessed with cone-beam
computed tomography. Am J Orthod Dento-
facial Orthop 2010;137:S86–93.
21. Vasudavan S, Jayaratne YS, Padwa BL.
Nasolabial soft tissue changes after Le Fort
I advancement. J Oral Maxillofac Surg
2012;70:270–7.
22. Honrado CP, Lee S, Bloomquist DS, Larra-
bee WF. Quantitative assessment of nasal
changes after maxillomandibular surgery
using a 3-dimensional digital imaging sys-
tem. Arch Facial Plast Surg 2006;8:26–35.
23. Shoji T, Muto T, Takahashi M, Akizuki K,
Tsuchida Y. The stability of an alar cinch
suture after Le Fort I and mandibular osteo-
tomies in Japanese patients with Class III
malocclusions. Br J Oral Maxillofac Surg
2012;50:361–4.
24. Bailey LJ, Collie FM, White Jr RP. Long-
term soft tissue changes after orthognathic
surgery. Int J Adult Orthod Orthognath Surg
1996;11:7–18.
25. Moss JP, McCance AM, Fright WR, Linney
AD, James DR. A three-dimensional soft
tissue analysis of fifteen patients with Class
II, Division 1 malocclusions after bimaxil-
lary surgery. Am J Orthod Dentofacial
Orthop 1994;105:430–7.
26. Kau CH, Cronin A, Durning P, Zhurov AI,
Sandham A, Richmond S. A new method for
the 3D measurement of postoperative swell-
ing following orthognathic surgery. Orthod
Craniofacial Res 2006;9:31–7.
27. Oh KM, Seo SK, Park JE, Sim HS, Cevi-
danes LH, Kim YJ, et al. Post-operative
soft tissue changes in patients with man-
dibular prognathism after bimaxillary sur-
gery. J Craniomaxillofac Surg 2013;41:
204–11.
28. Bailey LJ, Cevidanes LH, Proffit WR. Sta-
bility and predictability of orthognathic sur-
gery. Am J Orthod Dentofacial Orthop
2004;126:273–7.
29. Ludlow JB, Davies-Ludlow LE, Brooks SL,
Howerton WB. Dosimetry of 3 CBCT
devices for oral and maxillofacial radiology:
CB Mercuray, NewTom 3G and i-CAT. Den-
tomaxillofac Radiol 2006;35:219–26.
30. Liu X, Zhu S, Hu J. Modified versus classic
alar base sutures after Le Fort I osteotomy: a
systematic review. Oral Surg Oral Med Oral
Pathol Oral Radiol 2014;117:37–44.
Address:
Ellen Wen-Ching Ko
Department of Craniofacial Orthodontics
Chang Gung Memorial Hospital
6F 199 Tung-Hwa North Road
Taipei 105
Taiwan
Tel: +886 2 27135211x3533;
Fax: +886 2 25148846
E-mail: ellenko.wc@msa.hinet.net