The no-scar lip-lift: upper lip suspension technique

Lip Lifting: The Missing Link in Central Facial Rejuvenation

SUMMARY

The lip lift is a powerful yet finesse operation in the realm of facial rejuvenation. In an era of increased popularity of nonsurgical lip augmentation, the astute plastic surgeon must identify which patients will end up with an unnatural appearance should they receive volume enhancement alone in pursuit of central facial and perioral rejuvenation. In this article, the authors review the ideal youthful lip appearance, characteristics of the aged lip appearance, and indications for lifting. The authors present their preferred surgical technique, the underlying principles that it respects, and adjunct procedures to optimize results in central facial rejuvenation.

Nasal Sill Flap for Lip Lifting

BACKGROUND

 Over the years, different techniques have been developed to reduce the number of incisions and scars in subnasal lip lifting and to increase the amount of lifting. The aim of this study was to present a new technique to hide the scars at the nasal base in subnasal lip lifting procedures and to review the literature.

METHODS

 The file of patients who underwent subnasal lip lifting between January 2019 and January 2021 were examined. In all patients, the nasal sill flap that was designed was elevated, and the nasal sill flap that was prepared was adapted to its new location when the excision had been completed. Two different plastic surgeons evaluated the patients in the postoperative 12-month follow-ups. The scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height.

RESULTS

 The study included 26 patients. While 21 patients had no histories of lip lifting, five patients had had previous lip lifting history. The mean operation time was 37.11 minutes. Patients' skin types were determined as Type 3 in 18 patients and Type 4 in eight patients according to the Fitzpatrick classification. The mean follow-up period of the patients was 13.11 months. At the end of the 12-month period, the mean scar score of the patients was calculated as 11.15. The mean scar score of primary cases was 11.14, and the mean scar score of secondary cases was 11.20 (p = 0.983). There was no statistically significant difference in terms of complications among smokers (p = 0.356). The mean scar score was calculated as 12.17 in patients who had Type 3 skin and 8.88 in patients with Type 4 skin (p = 0.075).

CONCLUSIONS

 This technique is beneficial for patients because the scars are discrete and easier for patients to accept.

Lip-Shortening Surgery

BACKGROUND

Many changes are associated with the aging face. Upper lip lengthening with atrophy, lip thinning, and diminution of the lip margin are commonly seen.

METHODS

Lip-shortening surgery over a 32-year period by a single surgeon is reviewed. A direct surgical excision of the upper lip skin at the base of the nose with an irregular or curvilinear incision was used.

RESULTS

Facial aesthetics were improved with this direct surgical approach. A more youthful vermilion border and an increased lip projection were achieved. Lip asymmetry and an improvement in lip dynamics were also observed. A high rate of revision surgery (approximately 25%) was found in this series. The highly visible, delicate, central facial landmarks involved in lip shortening magnify small scar irregularities, and revision, although relatively minor, is often necessary. Patient satisfaction is high, as a subjective improvement in lip aesthetics is readily appreciated. Patients frequently request further shortening.

CONCLUSIONS

Surgeons need to review the exigent nature of this surgery with their patients and be willing to perform the associated revisions inherent in the procedure. Lip-shortening surgery reliably improves facial aesthetics and should be used by plastic surgeons when treating the aging face.

Lip Lift Techniques in Smile Design

The lips are the main aesthetic component of the facial lower third and simultaneously a substantial element for an ideally perceived smile. One of the most accepted and common procedures that is widely used to enhance the shape and contours of the upper lip is the lip lift. With a careful treatment plan and a professional surgery, a lip lift can reliably be used for the reduction of the philtrum height, enlargement of the upper vermilion, improvement of the dental show, restoration of facial aesthetic proportions, and creation of an enchanting smile.

An Overview of Maxillofacial Approaches to Smile Design

The oral and maxillofacial surgeon (OMS) has the knowledge and skills to make drastic skeletal changes in favor of a more cosmetic smile. OMS can alter intraoral and extraoral soft tissues to make subtle or significant changes in facial cosmesis. This article provides an overview of the scope of the OMS in smile design. The authors provide a cursory review of pertinent gross and surgical facial anatomy, discuss the role of orthognathic surgery and rhinoplasty in smile cosmesis, and describe the fundamentals of common cosmetic procedures ranging from gingivoplasty to lip lift and lip augmentation and the use of neurotoxins.

Lip Lift

The perioral area can be an important feature to convey femininity, particularly when speaking and smiling. A feminine lip has a shorter distance between the nasal sill and the vermillion border, fullness of the vermillion, and a few millimeters of tooth show with the mouth slightly open. The keys to a good outcome are incision design that respects the natural anatomy, placing the tension of the lift deep to the dermis to take tension off of the skin incision, determining the appropriate amount of lift for the patient's anatomy, and not violating the orbicularis oris.

Evaluation and treatment of facial feminization surgery: part II. lips, midface, mandible, chin, and laryngeal prominence

Facial feminization surgery (FFS) refers to a set of procedures aimed at altering the features of a masculine face to achieve a more feminine appearance. In the second part of this twopart series, assessment and operations involving the midface, mandible, and chin, as well as soft tissue modification of the nasolabial complex and chondrolaryngoplasty, are discussed. Finally, we provide a review of the literature on patient-reported outcomes in this population following FFS and suggest a path forward to optimize care for FFS patients.

The Rhino-Lip-Lifting: A Novel Proposal for Midface Profileplasty Performed as a Single Surgical Procedure

As facial aging occurs, aesthetic changes of the nasal tip and the senile upper lip include tip ptosis, increase in skin length, loss of vermillion height and Cupid's bow, and vertical wrinkles.Regardless of the rejuvenation procedure, the lips are not to be considered as a single anatomical entity, instead they should be placed in a strong correlation with the nose. The aim of this study is therefore to demonstrate the effectiveness of the association of primary closed rhinoplasty together with indirect subnasal lip-lifting technique.A total of 45 patients were enrolled in this study and underwent primary closed rhinoplasty with indirect subnasal lip-lifting. The result showed an overall average nasolabial angle width reduction of 10.9% and lip length shortening of 23.5%, as assessed 1 year after the surgical procedure. When comparing before and after photographs and using the Subjective Global Aesthetic Improvement Scale (sGAIS), the overall satisfaction was rated 4.4 on 5, as "much improved."The authors show that lips should not be considered as a single anatomical entity but that they indeed must be placed in a strong correlation with the nose since a droopy nasal tip is likely to be considered unattractive and is often associated with the appearance of a long nose with covered philtrum and upper lip.Tip rotation to a normal nasolabial angle width could grant a beneficial impact on overall nose aesthetics; however, it may not fully balance the midface profile as it is the "lip position-to-incisal show" ratio that defines beauty, whereas the balance among forehead, nasal tip, upper lip, and chin is what defines the contour of harmonious profiles.This is the first patient series to show that the combination of closed rhinoplasty and indirect lip-lifting is a highly effective, safe, and reliable procedure to address profile rejuvenation.

Aesthetic Surgical Enhancement of the Upper Lip: A Comprehensive Literature Review

BACKGROUND

The recent rise in popularity of minimally invasive facial aesthetic procedures has resulted in the overall heightened patient interest in lip rejuvenation. There is a variety of techniques and modifications for surgical upper lip enhancement described in the literature but no single method is considered optimal. The aim of this literature review is to provide a comprehensive analysis of the studies dealing with surgical upper lip enhancement and evaluate their short- and long-term outcomes, as well as complication profiles.

METHODS

A comprehensive review of the published literature through July of 2019 was performed. The PUBMED and Cochrane databases were searched for all English language articles on aesthetic surgical enhancement of the upper lip. Only articles dealing with the aesthetic aspect of the upper lip subunit were included. Preoperative assessment, patient selection and technique execution were assessed. Data were abstracted on all postoperative complications and outcomes.

RESULTS

Overall, 52 articles were screened for inclusion, of which 17 met the inclusion criteria. The total number of patients treated in these studies was 2265. The average follow-up period was 30 months. The most commonly used surgical method across the studies was the subnasal lip lift (93.6%). The bull's horn excision pattern was utilized to perform the subnasal lip lift in 71.7% of the cases, and the wavy ellipse excision was used in 18.1% of patients. Lip advancement by vermillion border excision pattern was the technique of choice for 49 patients (2.2%). Across all patients the most common complication was a non-aesthetically appealing result or adverse scarring with a mean incidence of 7.23%. Overall, the studies reported improvement in the aesthetic appearance of the upper lip after surgical enhancement, along with few but promising reports of high patient satisfaction. There is a relative paucity of high-quality data regarding complication profiles, patient selection, indications and contraindications.

CONCLUSIONS

This review provides an overview of several techniques and modifications for upper lip enhancement. It highlights the paucity of high-quality data on their application and optimizing patient selection. Promising satisfaction rates and relatively low complication rates suggest a more prominent role for surgical cheiloplasty in facial rejuvenation.

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 .

Perception of upper lip augmentation utilizing simulated photography

BACKGROUND

No head to head comparison is available between surgical lip lifting and upper lip filler injections to decide which technique yields the best results in patients. Despite the growing popularity of upper lip augmentation, its effect on societal perceptions of attractiveness, successfulness and overall health in woman is unknown.

METHODS

Blinded casual observers viewed three versions of independent images of 15 unique patient lower faces for a total of 45 images. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses.

RESULTS

Two hundred and seventeen random observers with an average age of 47 years (standard deviation, 15.9) rated the images. The majority of observers were females (n=183, 84%) of white race (n=174, 80%) and had at least some college education (n=202, 93%). The marginal mean score for perceived attractiveness from the natural condition was 1.5 points (95% confidence interval [CI], 0.9-2.18) higher than perceived attractiveness from the simulated upper lip filler injection condition, and 2.6 points higher (95% CI, 1.95-3.24) than the simulated upper lip lift condition. There was a moderate to strong correlation between the scores of the same observer.

CONCLUSIONS

Simulated upper lip augmentation is amenable to social perception analysis. Scores of the same observer for attractiveness, successfulness, and overall health are strongly correlated. Overall, the natural condition had the highest scores in all categories, followed by simulated upper lip filler, and lastly simulated upper lip lift.

Subnasal Lip Lifting in Aging Upper Lip: Combined Operation with Nasal Tip Plasty in Asians

BACKGROUND

The objective of this study was to illustrate a novel technique for lifting of the aging upper lip with nasal tip plasty in Asians. With this procedure, a shortening of the philtrum, an increase of the vermilion, and a natural and nicer mouth can be obtained, with increase of the tip of the nose simultaneously.

METHODS

Thirty patients were the subjects of this study. Incisions were made bilaterally beginning at the alar fold, entering nostrils, and rising medially on the skin below the lower margin of the medial crura. Excess skin of the philtrum was eliminated in two separate pieces and the muscle was suspended to the base of the nose with interrupted stitches.

RESULTS

All patients expressed a high degree of satisfaction. The average ratio between the L1 reference line and the height of the upper lip measurement preoperatively was 0.43 ± 0.05. This ratio was improved postoperatively to an average of 0.32 ± 0.05. The nasolabial angle was 91.31 ± 4.19 degrees before surgery and 105.62 ± 5.04 degrees after surgery. The angle of the upper lip was 48.97 ± 2.41 degrees before surgery and 38.21 ± 3.34 degrees after surgery.

CONCLUSIONS

Lip lift is an effective tool for correcting a natural tendency of the upper lip to cover the upper teeth during aging. There is a dramatic improvement in the patient's facial aesthetic appearance during smiling and at rest. The authors strongly recommend this technique as part of the surgical procedure to achieve a youthful face.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Lip Lift

The male upper lip has a distinctly longer cutaneous height from the nasal base to the upper vermilion border than its female counterpart. The subnasal indirect lip lift using the bullhorn technique or its modifications allows for shortening of this height to feminize the lower face, creating a more aesthetically pleasing upper lip secondary to increased vermilion height and lip pout. Patient selection is critical, taking into account lip height, vermilion height, alar base width, skin type, upper incisal show, and maxillary height. Precise measurements, controlled excision of the planned resection, and meticulous reapproximation of skin provide an aesthetic result, while minimizing visible scarring.

Correction of a Long Face: Simultaneous Reduction of the Upper Lip Using a Modified Endonasal Technique and Le Fort I Osteotomy Superior Impaction

BACKGROUND

Although Le Fort I osteotomy superior impaction during bimaxillary surgery is beneficial for patients with a long face, achieving satisfactory results can be challenging due to the redundant upper lip. However, upper-lip reduction has rarely been performed during or following bimaxillary surgery because of the difficulty in estimating the required amount of cutaneous resection needed and the apparent horizontal scars left behind. Therefore, no simultaneous cutaneous upper-lip reduction with orthognathic surgery has been reported. The authors present successful clinical outcomes using a modified endonasal upper-lip reduction technique performed with orthognathic surgery.

METHODS

A total of 33 patients underwent simultaneous cutaneous upper-lip reduction with orthognathic surgery. Of those, 15 patients were statistically analyzed. The amount of skin excised was individualized depending on the amount of Le Fort I osteotomy superior impaction and the aesthetic goal. Postoperative changes in upper-lip length were assessed with lateral cephalography.

RESULTS

Most patients had satisfactory results without serious complications. Overall lip contours, especially lip height, were greatly improved. The scar was hidden intranasally, aside from inconspicuous scarring in the subalar area. Regarding Le Fort I osteotomy, the amount of superior impaction averaged 3.26 mm (range, 0-6.0). The amount of upper-lip reduction averaged 3.42 mm (range, 3.0-6.0). Upper-lip length decreased from 25.27 ± 0.94 mm preoperatively to 21.22 ± 0.94 mm postoperatively (P < 0.05).

CONCLUSIONS

Upper-lip reduction is essential for achieving desired results during orthognathic surgery for patients with a long face. Our method enables simultaneous maxillary height and cutaneous upper-lip reduction without a continual, visible cicatrix.

Rejuvenation of the ageing upper lip and nose with suspension lifting

There are growing number of patients attending aesthetic consultations and requesting the rejuvenation of ageing upper lips. Often these patients also have nasal tip ptosis. There are a number of direct and indirect upper lip lifting procedures. We describe a novel technique, which combines upper lip and nasal tip rejuvenation through hidden incisions and the use of suspension micro-screws.

The endonasal lip lift: personal technique

Given the shortcomings of current methods to shorten the cutaneous upper lip, the senior authors modified the traditional subnasal lip lift with endonasal flaps, performing 311 such lifts over a 15-year period. Ideal surgical candidates are adults with tall philtra, negligible dental show, and no maxillary abnormalities. Benefits of the procedure include improved scar appearance and pout, absence of tension in visible areas, increased dental and vermilion display, and minimal scar migration (ie, loss of lift). Moreover, caudal rhinoplasty procedures are facilitated via the same incision sites. Undercorrection, sill widening, and alar distortion are mostly avoidable (or at least corrigible) complications. Nasal sill disruption, however, remains an inevitable drawback that may be minimized through meticulous technique.