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Surgical Lip Enhancement: Lip Lift and Lip Reduction


Lip Anatomy and Histology

The lips serve many functions, such as eating, drinking, speaking, mimetic animation, kissing, and serving as a valve for the terminal oral airway. Lips are among the most vascular structures on the face and are supplied by the superior and inferior labial branches of the facial artery as it branches from the external carotid artery. The labial artery lies in the posterior third of the lip at about the incisor level ( Fig. 11.1 ). The depth of this artery is an important landmark to keep in mind, but fortunately it is deep to most lip-reduction procedures.

Fig. 11.1, The labial artery lies in the posterior one-third of the lip and is generally away from the surgical field in most procedures.

The anatomy of the lip is very unique in that there is a triple transition from hair-bearing skin to vermilion tissue to oral mucosa. The hair-bearing skin terminates at the cutaneous/vermilion junction. The vermilion tissue consists of a very thin, keratinized, stratified squamous epithelium with extensive interdigitations with the underlying dermis ( Fig. 11.2 ). The vermilion is devoid of hair follicles, sweat glands, and sebaceous glands (although they may be sparsely present). The lack of sebaceous glands causes the vermilion to dry and crack, hence the lips must remain moistened with saliva. The vermilion derives its color from the rich vascular plexus in the underlying dermis. This area is also highly sensitive as a result of its rich sensory innervation.

Fig. 11.2, The vermilion tissue lacks hair follicles, sweat glands, and sebaceous glands (which can be sparsely present). D , dermis; E , epithelium.

The thin, keratinized, stratified squamous epithelium of the exposed vermilion transitions into a thick, nonkeratinized, stratified squamous epithelium and becomes the intraoral mucosa. Under this thicker epithelium lies a submucosa containing numerous accessory salivary glands, including serous, mucous, and mixed seromucous glands.

The bulk of the lip volume is made up of the circumoral orbicularis oris muscle, which blends laterally into the complex modiolus, a convergence of the perioral mimetic muscles. The orbicularis muscle lies more to the posterior region of the lip, and it curls over the vermilion surface and ends at the vermilion/cutaneous junction ( Fig. 11.3 ). Fig. 11.4 shows the lip structures in cross-section.

Fig. 11.3, Facial skin surrounding the lips contains hair follicles and sweat and sebaceous glands (A). The vermilion portion of the lip consists of thin, keratinized, stratified squamous epithelium (B) and transitions to the thick, nonkeratinized, stratified squamous epithelium of the oral mucosa (C). The submucosa of the intraoral mucosa contains numerous minor salivary glands (D). The orbicularis oris muscle is seen underlying these structures and constitutes the bulk of the lip (E). The vermilion is almost in contact with the orbicularis oris muscle anteriorly.

Fig. 11.4, Transverse section through the lower lip shows the dermis (D) , fat (F) , the orbicularis oris muscle (OOM) , vermilion (V) , and oral mucosa (M) . Note that the orbicularis muscle is situated closer to the oral surface of the lip than the facial surface and also terminates as it curves around the vermilion cutaneous junction.

Surgical Lip Lift

From time to time, patients come to the cosmetic surgery practice for lip enhancement but anatomically are not great filler candidates. A lengthened upper lip presents numerous cosmetic problems. First and foremost, the elongated upper lip is unaesthetic; younger patients have short, curvaceous lips with adequate volume. The aging lip becomes elongated, undergoes volume loss, and loses its curvature ( Fig. 11.5 right sided picture). In addition, a long lip can cover the upper teeth and give the patient a “denture” appearance. An attractive smile shows several millimeters of incisor edge exposure in repose and more in smile. Patients who do not show an incisal edge appear older or have an unbalanced smile.

Fig. 11.5, The youthful lip is short, curvaceous, and full (left) . The senescent lip is longer, devoid of curvature, and hypovolemic (right) .

The lip lift procedure (also known as a subnasal lift, angel wing lift , and bullhorn lift ) produces several aesthetic improvements. It shortens the elongated lip to a more youthful, shorter lip and rolls the lip superiorly, which increases the vermilion border similar to fillers and provides a more voluminous lip posture ( Fig. 11.6 ). In many patients, it also allows several millimeters of incisor to show at rest and several millimeters of gingiva to show at full smile, which is considered a pleasing attribute.

Fig. 11.6, The lip-lift procedure vertically shortens the lip for a more aesthetic appearance and increased upper-incisal show. It also rolls the lip posteriorly, which creates a rounder, plumper lip.

The basis of the subnasal lift is to excise a mustache or bullhorn-shaped piece of skin from within the delicate curves of the subcolumellar region. When the tissue is excised and the incision is closed, the lip is not only shortened (lifted), but the vermilion border is rolled upward and forward. This procedure is only performed on patients with enough vertical lip excess to accommodate reduction without overshortening. This is important because performing this procedure on a patient with a short lip will expose excessive incisal show and may prevent the patient from being able to put the lips together. The width of the excision is commensurate with the amount of desired lift, and 6–10 mm of skin excision is usually required to aesthetically elevate the lip without overcorrection. Shortening the lip more that 15 mm can create overcorrection, although in selected cases I have reduced an upper lip to 10 mm with positive aesthetics. This estimation of skin excision is an arbitrary measurement, and other factors must be considered for a balanced appearance. Most cases are performed as a “skin-only” excision, but some surgeons advocate orbicularis oris excision for severe cases. I have seen numerous cases from other surgeons with dysfunction and appearance problems after muscle excision, so this procedure should be left to surgeons who are experienced with lip lifting.

Different surgeons or articles measure lip length from different anatomic points. In this chapter, total lip length is measured from the columella to the most inferior tip of the vermilion border.

Prediction

In general, I shy away from surgical predictions and instead have people examine my before-and-after photos, which I believe are graphically representative of the variety of results. One way the surgeon and patient can estimate the result of a lip lift is to draw the surgical outline with the proposed incision distance and manually elevate the lip until the superior and inferior lines touch ( Fig. 11.7 ). This is a “guestimate” but can indicate whether excessive incisal show is present or in general how the result may look.

Fig. 11.7, An approximate postsurgical prediction can be performed by drawing the proposed incision outline on the patient and elevating the lip until the superior and inferior lines touch. Although there is not necessarily a 1:1 direct relationship with excision and elevation, this maneuver gives the surgeon and patient an idea of a possible result. It also greatly assists in pointing out to nonsurgical candidates that they would have excessive incisal exposure.

Contraindications

Contraindications to the surgical lip lift include patients who would exhibit excessive incisal show. This is a common “deal breaker” for many consults that I see. A patient wants a shorter lip but would show excessive incisor tooth structure. An additional contraindication are patients with unrealistic expectations. It is not uncommon for young female patients to see a lip lift procedure on social media and desire to have it performed thinking it will be transformative. Inflated expectations or body dysmorphic tendencies are a definite contraindication. A lip lift is not an easy procedure to reverse, so careful patient selection is critical.

Procedure

This procedure can be performed with local anesthesia, but intravenous sedation may provide a more relaxed patient when operating literally under the patient’s nose. The success of this procedure largely relies on the accuracy of the marking. In this case, it is not only the measurements of the marking but also the delicate and intricate curves and tapers. A curvilineal line under the nose is an invitation for a poor aesthetic outcome. The architecture of the alae, columella, and nares requires a delicate, curvaceous, tapered incision of the upper extent and a corresponding reciprocal incision on the bottom portion of the incision. Understanding this incision is integral. It is actually simple as it simply follows the curvilineal anatomy of the lateral alae, the columella, and the nasal sill. I have seen patients who were treated with a simple “smile face” curved incision that did not follow the nasal topography, and the incisions are vary apparent. Tracing the superior limb of the incision is relatively straightforward. The more difficult part is to duplicate the curves of the upper incision on the lower incision. In effect, it is a mirror image. I have performed this procedure many times, but I frequently end up drawing the lower incision and wiping it off and redrawing it until it is perfect. Besides the outline of the incision, it must also be consistent with the amount of skin to be removed. Finally, it must taper laterally to a fine point at the lateral alae ( Fig. 11.8 ). The incision should not cross into the nostril. For the novice surgeon, referring to a photo of an ideal angel wing diagram before marking ensures that the proper contours are replicated.

Fig. 11.8, Drawings for a 6-mm excision (left) and a 10-mm excision (right) are shown.

The excision is relative to the amount of lip length, and generally 6–10 mm of skin is excised ( Figs. 11.9 and 11.10 ). After local anesthesia infiltration, the actual incision is made with a #11 or #15C scalpel. Is important to incorporate the delicate outlines of the wings ( Fig. 11.11 ). After the incision is made, I prefer a bloodless modality like CO 2 laser or radiofrequency microneedling to dissect the skin off of the subcutaneous tissue ( Fig. 11.12 ). As stated, I do not usually remove the orbicularis oris muscle unless it is hypertrophic.

Fig. 11.9, This patient has a preoperative lip length of almost 22 mm. The proposed excision was 6 mm, which would leave a net lip length of 15 mm.

Fig. 11.10, An immediate postoperative view shows a 6-mm reduction, leaving a 15-mm lip length.

Fig. 11.11, The angel wing outline is made to the level of the subcutaneous tissue with a scalpel blade. The completed excision is shown (left) and subcutaneous dissection is performed using fine-tipped radiofrequency bipolar forceps (right) .

Fig. 11.12, After skin excision, the wound margins are approximated to validate the correct amount of incisor exposure. It is possible to remove more skin if necessary, but this should be done with caution. Generally, a 6- to 8-mm excision is adequate.

After the skin is excised, the inferior edge can be lifted with forceps to approximate the wound while viewing the amount of incisal show. If insufficient tooth structure is visible, more skin can be trimmed (see Fig. 11.12 ). This is a rare event in my experience. If more skin is removed, it must be done with caution as edema, local anesthesia, and general anesthesia can all make a difference in the true lip posture. Generally, a 6- to 8-mm skin excision is sufficient to make a positive cosmetic change.

After the skin is excised and hemostasis obtained, the procedure is basically finished except for the suturing. The peaks and troughs of the incision outline will allow the surgeon to precisely line up the incision edges, and this is secured with several subcutaneous 5-0 gut sutures ( Figs. 11.13 and 11.14 ). After the subcutaneous suture, a running 6-0 nylon suture is used ( Fig. 11.15 ).

Fig. 11.13, After the skin excision and hemostasis is completed, a subcutaneous closure is performed with 5-0 gut suture. It is easier to begin in the midline and move laterally, suturing corresponding peaks and troughs.

Fig. 11.14, The full thickness skin excision (left) and the wound after subcutaneous closure (right) are shown. This should be a smooth approximation without step-off of the approximated edges to achieve maximum aesthetics.

Fig. 11.15, The final closure and the excised skin specimen.

I tell all patients that I will perform complimentary laser resurfacing of the scar at 4–6 weeks, but most patients do not require this. I have seen several cases of minor wound dehiscence that healed uneventfully. Fig. 11.16 shows a typical incision at 1 week. Figs. 11.17–11.25 show selected before and after images for the surgical lip lift.

Fig. 11.16, A typical lip-lift incision scar at 7 days.

Fig. 11.17, This patient is shown in frontal view before (left) and 8 weeks after (right) surgical lip lift. Note the shorter upper lip.

Fig. 11.18, The same patient shown in Fig. 11.17 is shown in three-quarter view. Note shorter lip and increased vermilion show of upper lip.

Fig. 11.19, The same patient shown in Figs. 11.17 and 11.18 with improved incisor exposure with the mouth partially open.

Fig. 11.20, The same patient shown in Figs. 11.17–11.19 is shown with improved incisor exposure at full smile. This case represents the power of this procedure for facial and dental aesthetics.

Fig. 11.21, This case illustrates the ability of a surgical lip lift to improve incisal show.

Fig. 11.22, A patient before surgery (left) and after surgery (right) . These photos illustrate the power of this simple procedure to not only shorten the lip but to increase projection and vermilion show.

Fig. 11.23, This patient is shown before and 3 months after lip lift. Note the shorter and fuller upper lip.

Fig. 11.24, This three-quarter view shows a patient before and after lip lift. A shorter lip with increased pout is shown (right) . This scar is a candidate for CO 2 laser revision.

Fig. 11.25, This denture patient had poor upper incisor exposure, and the lip lift greatly improved her smile.

Complications

Complications have been rare with this procedure. Accurate diagnosis and patient selection are important for predictable outcomes. Wound dehiscence can occur from oral function ( Fig. 11.26 ). The patient is reminded to “rest” the lip, and the dehiscence generally fills in without problems to aesthetics. Steroid injection or scar revision may be required for regions of large dehiscence.

Fig. 11.26, Minor wound dehiscence such as pictured here can occur and generally heals without further intervention.

Although most patients have acceptable incision aesthetics, I have experienced 3–4 patients with ungraceful scarring that benefited from steroid or 5-fluorouracil injection or CO 2 laser resurfacing to blend the scar ( Figs. 11.27 and 11.28 ). Undercorrection can be addressed with revision surgery. Overcorrection can be very problematic, and I have never experienced this problem. As stated earlier, I have seen several patients operated on by other surgeons who removed significant orbicularis oris muscle leaving dysfunctional animation.

Fig. 11.27, A patient with a typical well-healing lip lift incision at 1 month (left) . A patient who developed hypertrophic scarring from a lip lift (right) was treated with intralesional steroids and CO 2 laser resurfacing.

Fig. 11.28, This patient presented with an unaesthetic scar 8 weeks after lip lift surgery and was treated with two passes of aggressive, full-coverage CO 2 laser resurfacing.

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