Postoperative Periorbital Edema and Ecchymosis After External Lateral Osteotomy "Comparing Conventional Osteotome and Piezo Scalpel in Rhinoplasty".

The piezo surgery was reported to cause minimal trauma to the soft tissue. The aim of this study was to compare the periorbital edema and ecchymosis after transcutaneous lateral osteotomy in rhinoplasty using 2-mm osteotome versus Piezo scalpel respectively. In a randomized clinical trial and split-mouth-design, we performed primary rhinoplasty in 15 patients (7 men, 8 women; age 18-35 years, mean age 26.6 ± 5.7 years). Transcutaneous lateral osteotomy was performed using a 2-mm osteotome on the one side and a piezo scalpel on the opposite side. We took digital photographs of the face on 1, 3, 7 and 14 postoperative days. Three examiners used a standard 5-point Kara-Gokalan scale to assess the early postoperative periorbital edema and ecchymosis on each side. We found more difficult to use the piezo scalpel via only one incision and found easier to use two stab incisions for inserting the piezo scalpel. The time spend for each osteotomy was similar (P > 0.05). The inter-observer agreement was high (> 0.676). The postoperative edema showed to be significantly different on day 1, 3 and 7 (P-value < 0.05), ecchymosis was much less on piezo side but not significantly. It was more difficult to use piezo scalpel via only one incision. The piezo scalpel showed to reduce the postoperative edema significantly and improved the ecchymosis. Swelling and bleeding could have crossed the midline and blurred the comparison of two sides. However, this is the best design to achieve the highest similarity in study condition. Level of Evidence Level I, therapeutic study.

Evaluating the length, diameter, and stenosis of deep circumflex iliac artery and neighboring arteries based on digital subtraction angiography.

BACKGROUND: The vascularized iliac bone crest flap offers excellent usable bone in terms of volume and quality. Its nourishing vessel, the deep circumflex iliac artery (DCIA), although relatively short, is reliable vessel. Digital subtraction angiography presents still the gold standard for diagnostic purpose. However, computed tomography (CT) and magnetic resonance imaging (MRI) angiography is used for preoperative planning with low morbidity. The purpose of this study is to evaluate the gainable information using digital subtraction angiography (DSA) as compared to other imaging modalities. MATERIALS AND METHODS: We evaluated information gainable from standard DSA of 130 consecutive patients (average age was 69.5 years [range 18-90 years]) concerning topography, dimension, and condition of the vessel wall. We looked for differences considering gender and side. RESULTS: DCIA could not be followed in the periphery constantly in all cases due to the small, illustrated field. Arteriosclerotic changes showed to be very low in DCIA as compared to the neighboring vessels. Diabetes mellitus and smoking had a significant impact on vessel condition. DCIA branched off into its main two branches early after 40 mm (11%), after 40-60 mm (30%), or late after 60 mm (59%). DCIA showed to be least affected by different risk factors that reported to affect the vessel condition. CONCLUSIONS: We present additional detailed topographic anatomy of DCIA and its variation that can be used intraoperative guide to harvest the flap and teaching purpose. Standard DSA delivers valuable preoperative data regarding stenosis in addition to the topographic anatomy of the flap pedicle. However, imaging of the distal parts of the DCIA, nourishing the skin paddle is limited by the detector field used. For a full imaging of both DCIAs from the origin to the perforators, the intraarterial injection of contrast medium, as applied in DSA, could be combined with different imaging modalities like CT-angiography.

Comparison of Bone Formation After Sinus Membrane Lifting Without Graft or Using Bone Substitute "Histologic and Radiographic Evaluation".

PURPOSE: Sinus floor elevation without using autogenous bone graft or bone substitute will eliminate donor site morbidity and reduce the cost and the risk of infection. We evaluated the bone gain after sinus membrane elevation without graft or using bone substitute in the same maxilla. Dental implants were inserted simultaneously as a 1-stage procedure. PATIENTS AND METHODS: In a split-mouth design, we conducted a randomized double-blinded clinical trial performing sinus lifts and simultaneous implant insertion in 10 healthy patients (n = 20). On the 1 site, we performed graft-less sinus lift (group 1) and on the other site Cerabone was used as bone substitute (group 2), respectively. The quantity and quality of bone gained in each sinus were evaluated and compared radiologically and histomorphometrically. RESULTS: After 6 months, the average gain of bone height was 6.21 and 9.58 mm in group 1 and 2, respectively, as measured radiologically (P < .001, P < .001). Histomorphometric examination showed significantly higher thickness of trabeculae and bone formation in group 1 (P = .003 and P = .002). However, the neovascularization was higher, but not significantly (P = .288). CONCLUSIONS: Radiological bone gain was similar in both groups. However, histomorphometric examination showed superior bone formation in graft-less group as compared to the Cerabone group. The blood clot seems to be an adequate filler and excellent medium for bone formation. More studies in split-mouth design are needed to compare different bone substitutes.

Patient-Specific Topographic Anatomy of the Deep Circumflex Iliac Artery Flap: Comparing Standard and Modified Computed Tomographic Angiography.

PURPOSE: Computed tomographic angiography (CTA) is reported to give insight into patient-specific anatomy of the flap pedicle preoperatively. We compared information available from standard CTA (s-CTA) with that gained by modifying the conventional CTA technique (modified CTA [m-CTA]). Dissected cadavers served as the control group. MATERIALS AND METHODS: We evaluated 16 s-CTA scans (32 deep circumflex iliac arteries [DCIAs]) and 12 m-CTA scans (17 DCIAs) using 3-dimensional software (Vesalius; ps-medtech, Amsterdam, The Netherlands). We dissected 17 cadavers (n = 34 DCIAs) to serve as the control group. The positions of 4 landmarks (anterior superior iliac spine, origin of DCIA, origin of ascending branch, and crossing of horizontal branch and iliac crest) were defined in a 3-dimensional coordinate system. RESULTS: We found significant differences concerning the distances from the origin of the DCIA to the femoral bifurcation (P < .05) and the anterior superior iliac spine to the crossing point of the horizontal branch with the iliac crest (P < .05) between CTA scans and cadaveric studies. The imaging quality of the m-CTA scans was shown to be more consistent than and superior to that of the s-CTA scans. The visible length of the DCIA was longer on m-CTA scans (mean, 134.32 mm) than on s-CTA scans (mean, 73.62 mm). We could evaluate the branching off of perforators and the relation of the pedicle to the surrounding bone and soft tissue in more detail on m-CTA scans. Standard CTA allowed the bilateral evaluation of the pedicle, whereas m-CTA allowed the evaluation of the injected side only. CONCLUSIONS: The quality and quantity of information available from CTA could be improved by modifying the s-CTA examination by injection as close as possible to the target vessel. Standard CTA delivered information about both sides, whereas m-CTA may need an additional injection for contralateral-side imaging.

Tooth-borne distraction osteogenesis versus conventional Le Fort I in maxillary advancement of cleft lip and palate patients.

BACKGROUND: Distraction osteogenesis (DO) is rapidly becoming a mainstream surgical technique for correction of maxillary deficiency. The aim of this study was to compare the effectiveness of a newly designed tooth-borne osteogenic distraction device with conventional Le Fort 1 osteotomy in maxillary advancement of cleft lip and palate patients. METHODS: The DO group consisted of 10 subjects (7 males, 3 females) with a mean age of 21.2 (SD 4.2) years. In these patients, the newly designed distraction device which exerted force anteroposteriorly was cemented after mobilization of the maxilla. After a latency period of 7 days, the distractor was activated twice daily by a total amount of 0.5 mm per day. The activation was continued for 3 weeks. After an 8-week consolidation period, the distraction appliance was removed. Cephalograms of DO patients were obtained at the start of distraction and at the end of consolidation. The Le Fort 1 group consisted of 11 subjects (6 males, 5 females) with a mean age of 22.3 (SD 3.7) years. Pre and postsurgery lateral cephalograms were obtained. t-test and paired t-test were used to evaluate the data. RESULTS: At the end of treatment, the SNA angle of Le Fort 1 patients increased by 5.5° (SD 2.3) (P<0.001) and the SNA angle of DO patients increased by 3.4° (SD 2) (P<0.001). CONCLUSIONS: Current evidence suggests that both conventional Le Fort 1 and tooth-borne osteogenic distraction device can effectively advance the maxilla forward in patients with cleft lip.

Three-Dimensional Analysis of the Ear Morphology.

BACKGROUND: For surgical treatment of the face, detailed surgical planning is necessary to avoid later unaesthetic results. Most of the studies in the literature concentrate on the ears' anatomy during childhood and adolescence. Nearly no study evaluates the anatomy of ears of people aged 50 or older. It was our aim to measure and evaluate the ear's anatomy in Caucasians between the ages of 21 and 65. METHODS: Three-dimensional scans of 240 volunteers were taken. The subjects were divided into groups of males and females and each of them into three groups by age (21-35, 36-50, 51-65). Landmarks were placed in these scans. Distances, relations and angles between them were recorded. RESULTS: The distance between the subaurale and superaurale significantly increases (p < 0.001) during the aging process in males and females. Also, the width of the ear, measured between the preaurale and postaurale, significantly increased (p = 0.007) with advancing age. When the length of the ear is divided into four parts by anatomical landmarks, it extended the most in the lower quadrant with increasing subject age. CONCLUSION: The ear of Caucasians does not stop changing its shape during adulthood. Even after the body has stopped growing, the ear still does. With the measured values in this study, it should be possible for the surgeon to plan the operation in advance and achieve satisfactory aesthetic outcomes. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of the Effect of Dexamethasone and Tranexamic Acid, Separately or in Combination on Post-Rhinoplasty Edema and Ecchymosis.

BACKGROUND: Dexamethasone and tranexamic acid are used to decrease post-rhinoplasty periorbital edema and ecchymosis. We compared the impact of each medication separately or in combination in this regard. METHODS: A prospective, randomized triple-blinded study was undertaken on 60 patients who underwent primary open rhinoplasty. They were divided into four groups: Group D (n = 15) received 8 mg dexamethasone, group T (n = 15) received 10 mg/kg tranexamic acid, group DT (n = 15) received both 8 mg dexamethasone and 10 mg/kg tranexamic acid, and group P (n = 15) received neither medication and served as the placebo control group. The medications were given intravenously (IV) 1 h before and three doses every 8 h postoperatively. Digital photographs were taken on the first, third and seventh postoperative days. One expert examiner blinded to the study evaluated the periorbital edema and ecchymosis on a scale of 0-4. Periorbital edema and ecchymosis were examined in all groups. RESULTS: In group D, group T and group DT, periorbital edema and ecchymosis ratings were significantly lower compared with the control group (p < 0.01). No statistically significant difference was seen in preventing or decreasing both periorbital edema and ecchymosis among group D, group T and group DT. CONCLUSION: Tranexamic acid and dexamethasone, separately or in combination, had similar effects in reducing periorbital edema and ecchymosis in open rhinoplasty. Combined application did not show a significantly higher beneficial effect in this regard. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A non-language-specific speech test to evaluate the speech of cleft patients from different language and cultural backgrounds - A pilot study.

Cleft speech tests are not universally available. We developed a tool to fill this gap, especially in the context of a cleft mission setting. We performed a pilot study to evaluate the test's ability to differentiate between the speech of cleft patients and healthy individuals from three different language backgrounds. We used 78 made-up, nonsensical syllables to evaluate hypernasality, nasal emissions, and consonant errors. Cleft (n = 41) and non-cleft (n = 39) individuals from three countries were included in this study. Two speech and language pathologists, blinded to the examination, rated the audio recording independently. Patients from Germany (n = 12; mean age 15.2), Iran (n = 14; mean age 7), and India (n = 15; mean age 14.7 years) were evaluated. We observed a significant difference in each category (p < 0.05) between patients and control subjects of the same language and cultural background. Hypernasality was affected the most. The test proved to possess the correct phonetic characteristics to reveal and provoke relevant cleft speech pathologies independent of cultural and language backgrounds. The test sounds posed no articulatory difficulties to non-cleft individuals, with some exceptions regarding non-specific consonant errors. A comparison with other existing tests will further illuminate its value as a speech test.

Family history and risk factors for cleft lip and palate patients and their associated anomalies.

BACKGROUND AND AIMS: Several environmental and genetic issues have been suspected as risk factors for oral clefts; and many studies have been conducted in this regard; however, large socioeconomic impacts of cleft lip and or palate (CL/P) justifies the need for further multifactorial researches. Current study aimed to assess parental risk factors for CL/P and its associated malformations. MATERIAL AND METHODS: Hospital records of 187 consecutive syndromic and non-syndromic children with cleft lip and or palate (103 boys and 84 girls) with a mean age of 1.7 (SD 2.2) years and 190 consecutive non-cleft children (103 boys and 87 girls) with a mean age of 2.8 (SD 2.2) years formed this study. Parental risk factors and abnormalities and physical problems and anomalies were evaluated in all subjects. RESULTS: Family history of clefts (OR 7.4; 95% CI), folic acid consumption (OR 7.3; 95% CI) and consanguineous marriage (OR 3.2; 95% CI) were quite strongly associated with increased risk of CL/P. In addition, all congenital abnormalities and physical problems had significantly higher incidence in CL/P patients. CONCLUSIONS: The findings of this study suggest that expecting mothers of consanguineous marriage and families with a history of CL/P should be extra cautious about the occurrence of CL/P.

Evaluation of the accuracy of a mobile and a stationary system for three-dimensional facial scanning.

PURPOSE: Numerous three-dimensional (3D) facial scanners have emerged on the market; however, publications evaluating their accuracies are sparse. In this study, the accuracy of two 3D scanners used in facial scanning was evaluated. MATERIALS AND METHODS: A test specimen was attached at the right cheek and the forehead of 41 volunteers. These volunteers were scanned with Artec EVA® and FaceScan3D®. The acquired data were aligned to a 3D model of the test specimen for comparing the mean error, original length and width and angles to the measured values. RESULTS: The mean error in Best Fit alignment is significantly lower using Artec EVA (p < 0.001) for both test specimens. The deviation from the original length and width is significantly lower for the test specimens (p < 0.01) when measured with Artec EVA. The aberration of the angles measured between the front plane and the side plane is significantly lower when measured with Artec EVA (p < 0.001). Captured with Artec EVA the discrepancy between the original angle and the angle measured between the side planes to each other is significantly lower (p < 0.01). CONCLUSIONS: Scanning with Artec EVA leads to more accurate 3D models as compared to scanning with FaceScan3D. The exactness achieved by both scanners is comparable to other scanners mentioned in literature.

The use of mobile 3D scanners in maxillofacial surgery.

There are many possibilities for the use of three-dimensional (3D) scanners in maxillofacial surgery. This study aimed to investigate whether the bundling and syncing of two 3D scanners has advantages over single-scanner acquisition in terms of scan quality and the time required to scan an object. Therefore, the speed and precision of 3D data acquisition with one scanner versus two synced scanners was measured in 30 subjects. This was done by analyzing the results obtained by scanning test objects attached to the forehead and cheeks of the subjects. Statistical methods included the Student t test for paired samples. Single-scanner recording resulted in significantly lower mean error of measurement than synced recording with two scanners for length (P < 0.001), all frontal/lateral plane angles (P = 0.034, P < 0.001, P = 0.002, P = 0.003), and side/side plane angles (P = 0.014, P < 0.001, P = 0.015, P = 0.011) of the test object on the cheek. Likewise, the single-scanner method resulted in a significantly lowermean error of measurement than the two-scanner method for frontal/lower plane angles (P < 0.001), right/lower plane angles (P < 0.001), and left/lower plane angles (P = 0.002). Conversely, synced recording of data with two scanners resulted in a significant reduction of scanning time (P < 0.001). Compared to data acquisition with a single 3D scanner, the bundling of two 3D scanners resulted in faster scanning times but lower scan quality.

Regions of ilium and fibula providing clinically usable bone for mandible reconstruction: "A different approach to bone comparison".

A variety of donor sites are available for mandibular reconstruction. We present here a different way of comparing two commonly-used bone flaps. The lengths of the usable parts in a total of 241 coxal bones, 91 mandibles and 60 fibulas were measured. The mandible was measured from condyle-to-condyle and the harvestable bone length (HBL) and usable (UBL) bone lengths in fibula and ilium were also measured. The bone thickness (BT) in 60 iliac crests was measured in two parallel lines from the anterior superior iliac spine (ASIS) along the iliac crest. The mandible was 32.17 mm shorter in females than in males. The total ilium UBL was 171.12 mm in females and 178.80 mm in males. The mean HBL of the fibula was 22.6 mm shorter in females than in males. However, in some fibulas in both females and males, only 4.2% and 21.1% of the HBL respectively could be used if the ultimate goal was to insert dental implants. We found significant correlations between BT and gender in both fibula and ilium (P≤ 0.05). The ilium offers constant BT throughout the usable bone area with a similar bone length to the fibula. In contrast, the fibula showed variable bone dimensions, so not all of it is clinically usable. This should especially be considered in females when a mandibular reconstruction is planned with the goal of occlusal rehabilitation. Clin. Anat. 29:773-778, 2016. © 2016 Wiley Periodicals, Inc.

Acellular Dermal Graft in Secondary Cleft Lip Deficiencies: Assessment of Results With a Reproducible Quantitative Technique.

PURPOSE: Considering the little evidence around acellular dermal graft application in secondary lip reshaping, this study is aimed to quantitatively examine the effect of acellular dermal graft in combination with Z-plasty technique in secondary defects of cleft lip. METHODS: In this clinical investigation, patients with secondary unilateral cleft lip deformity were selected. Standard photographs were prepared for each patient. Subsequent to scar revision, submucosal tunneling and Z-plasty, implantable human acellular dermal graft was placed and fixed in submucosal pocket. Quantitative parameters included angle of symmetry , dimension of symmetry (DS), defect height (DH), parallel lines, and lip thickness were measured presurgically and 1 year after treatment. Pre and post-operative pictures were compared and the changes were documented according to the criteria. P value less than 0.05 were considered as significant. RESULTS: Eighteen patients were included in this study. The difference of "DS" between normal side and cleft side was 3.1 ± 1.5 mm presurgically and 1.1 ± 1.8 mm postsurgically. The change was significant (P value < 0.05). The difference between pretreatment and posttreatment measures of "DS", "DH", and "Lip Thickness" were 2.75 ± 4.55, 3.43 ± 4.82, and 2.66 ± 3.04 mm, respectively. The results were significant (P value<0.05). CONCLUSIONS: Based on the results, acellular dermal graft in combination with Z-plasty was able to improve lip deformity in patients with secondary defects of cleft lip. Further studies are recommended regarding the application of this technique in patients with bilateral cleft lip and severe "DH."

Two-Step Reconstruction of Non-Marginal Auricular Defects.

PURPOSE: Auricular reconstruction is an extensively discussed topic in facial reconstructive surgery and poses an immense challenge to the reconstructive surgeon. This report describes a 2-stage technique to repair non-marginal full-thickness defects of the auricle. MATERIALS AND METHODS: Thirteen patients underwent surgery after partial to complete loss of the auricular concha using an improved and refined method. Tissue from the pre- and retroauricular regions was used to replace nonhelical auricular tissue loss in 2 surgical steps. All procedures were performed in an ambulatory setting using local anesthesia. RESULTS: All 13 patients (age range, 37 to 82 yr; mean age, 68 yr; 4 women and 9 men) had excellent esthetic outcomes with low surgical morbidity and were satisfied with the achieved results. No flap necrosis was observed. Auricular vertical and horizontal dimensions changed minimally (0 to 4 mm). A tension-free closure of the donor-site defects could be achieved primarily. CONCLUSION: The present method uses 2 separate donor sites to reconstruct centrally located full-thickness defects of the auricle. It is straightforward to perform, minimizes the surgical steps required, shows excellent outcomes, and allows easier closure of the donor site because of the distribution of the harvested tissue.

Histopathological Differences of the Pedicle Artery in Commonly Used Free Flaps: The Influence of Age, Gender, and Side.

PURPOSE: The increasing use of vascularized free flaps has increased the demand for a specified flap selection. This study investigated histologic differences in the arterial wall of the pedicle for commonly used free flaps and the effect of age, gender, and anatomic side on these differences. MATERIALS AND METHODS: Light microscopic examinations of vessel walls were performed on 245 specimens of the nourishing artery of commonly used free vascularized flaps in preserved cadavers. The peroneal artery (PA), radial artery (RA), inferior epigastric artery (IEA), deep circumflex iliac artery (DCIA), and circumflex scapular artery (CSA) were examined. Differences of histologic changes in the arterial wall and the effect of age, gender, and body side were investigated. RESULTS: All examined vessel specimens (age range, 62 to 98 yr; mean age, 83 yr; 15 female and 12 male) displayed mostly Class II changes. PA showed the greatest atherosclerotic changes, followed by the RA, IEA, DCIA, and CSA. Age had a meaningful effect on PA and RA. Anatomic side was important for PA and DCIA, whereas gender had a minor influence on vessel condition. CONCLUSION: The vessel wall of different flaps showed different atherosclerotic changes depending on age, anatomic side, and gender. These differences should be considered in flap selection.

Influence of Connecting Two Standalone Mobile Three-Dimensional Scanners on Accuracy Comparing with a Standard Device in Facial Scanning.

OBJECTIVES: In this study is investigated if bundling of two scanners leads to better accuracy in recording faces than a standard face-scanning device. MATERIAL AND METHODS: In a group of 28 volunteers, two test specimens were attached to their faces: one on their forehead and one turned 90° on their cheek. Each volunteer was scanned by FaceScan3D® and two bundled Artec EVA® scanners. The scans were aligned to a three-dimensional model of the test specimen, and the mean error was recorded. Length, width and angles between the test specimen's planes were compared. RESULTS: The mean deviation is significantly lower for the cheek test specimen in alignment (P < 0.001), length and width (P < 0.001) but not for the forehead test specimen in alignment and length and width (P > 0.05) using FaceScan3D®. The aberration from the original angle between two sides of the test specimen is significantly lower measured with Artec EVA® for the angle between the front and the bottom plane of both test specimens (P < 0.01). Besides the angle between the right plane and the bottom plane as well as the top plane of the test specimen mounted to the cheek, the deviation of the angle between the other side planes to each other is significantly lower (P > 0.05) scanned with Artec EVA®. CONCLUSIONS: Compared to FaceScan3D®, two bundled Artec EVA® scanners provide different accuracies depending on the location of the measured parameters. The accuracy measured for both scanners is inside the range found in the literature.

Use of anterior maxillary distraction osteogenesis in two cleft lip and palate patients.

Distraction osteogenesis (DO) has become a mainstream surgical technique for patients with jaw deformities. The aim of this study was to report the effect of DO done by a hyrax screw incorporated in an acrylic plate in the treatment of two maxillary deficient cases with cleft lip and palate. Two patients, a 24-year-old female and a 29-year-old male who suffered from maxillary deficiency and cleft lip and palate, were treated by DO. After making vertical cuts between the premolars on both sides and horizontal cuts similar to Le Fort 1, a hyrax screw was mounted on an acrylic plate for the slow anteroposterior expansion of maxillary arch. The expansion was achieved by turning the hyrax screw 0.8 mm per day after the latency period. Treatment was discontinued after achieving satisfactory over jet and occlusion. This study showed that anterior maxillary distraction is a reliable technique for correction of midfacial deformity arising out of cleft lip and palate. Incidences of complications are negligible compared to total maxillary distraction.

Forehead flap in maxillofacial surgery: Our experiences.

The forehead flap is a commonly used technique to reconstruct the deep and large nasal defects. It can be conveniently performed under local or general anesthesia and provides a very good color and texture matching to the nasal skin, which makes it a suitable graft harvesting site for nasal reconstruction. It has only single disadvantage disadvantagethat it is a two-stage procedure and "finishing" surgeries are needed occasionally for best surgical and cosmetic outcome. In this paper, we describe three different applications of forehead flaps.

Effect of maxillary advancement on the change in the soft tissues after treatment of patients with class III malocclusion.

The aesthetic outcome of treatment has become increasingly important to patients having orthognathic surgery. The aim of this observational cohort study based on clinical records was to evaluate the effect of maxillary advancement on changes to the soft tissues. We studied 53 patients with class III malocclusion (29 women and 24 men, mean (SD) age 28 (11) years). We identified all patients treated between 1 January 2002 and 30 December 2013 who could be monitored postoperatively for 6 months. To study the effect of maxillary advancement on changes to the soft tissue we distinguished between patients who had had less than 6mm, and those with 6mm advancement or more. In those who had had less than 6mm, we found no significant changes in the soft tissue in the region of the nasolabial angle. However, the lip-chin- throat angle (p=0.016), cervical length (p=0.002), lower lip (p=0.007) and upper lip distance (p=0.0001) from the aesthetic line changed significantly. On the other hand, the changes to the soft tissue in the submental and nasolabial regions were significant in patients with 6mm advancement or more, and indicated a clear improvement in the aesthetic outcome of this region. This aesthetic change for the good in the submental and nasolabial regions after maxillary advancement of 6mm or more should be considered when planning treatment, and reduction in the mandibular setback will reduce the risk of development of a double chin.