Lifting of the upper lip: personal technique

Lip Feminization and Rejuvenation in Patients Assigned Male at Birth With Gender Dysphoria: Our 27-year Experience

Background

Despite the increasing demand, the combination of lip feminization and rejuvenation in patients assigned male at birth with gender dysphoria is rarely reported in the medical literature. We present our 27 years of experience performing these procedures in this patient population.

Methods

All patients assigned male at birth with gender dysphoria from 1997 to 2023 were included and grouped into 4 age categories. Combined surgical procedures were performed to achieve lip rejuvenation and feminization, with detailed descriptions of the techniques used. Results were evaluated three months postsurgery using the Global Aesthetic Improvement Scale and the Global Satisfaction Scale. Complications and outcomes were documented, and statistical analysis was conducted to compare the differences between the results obtained.

Results

During a 27-year period, 988 patients underwent 1789 procedures. Of these, 79.8% were younger than 50 years, with the largest group being between 20 and 35 years (47.6%). However, patients older than 65 had the highest average number of procedures (2.4 per patient). The results showed a high degree of improvement and satisfaction on both evaluated scales. There were only 2 hematomas, both resolved without incident. The main issues were volume loss after fat infiltration (14.3%) and poorly positioned scars in lip lifts (13.2%).

Conclusions

Surgical procedures to feminize and rejuvenate lips can be combined in patients assigned male at birth with gender dysphoria, achieving highly satisfactory results, high patient satisfaction, and few complications.

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.

The Proportional Relationship Among the Aesthetic Units of the Upper Lip: A 3-Dimensional Morphological Analysis of Young Adults

A deep understanding of the proportional relationship among the crucial aesthetic units of the upper lip is essential for lip treatment procedures, yet limited information can be found. The authors used 3-dimensional (D) photogrammetry to analyze the proportional features involving different lip structures. One hundred sixty volunteers (aged 18-35 y) were included, and standardized frontal view 3D images were obtained. A series of anthropometric parameters were measured, including linear, angular, and ratio parameters. The authors took the philtrum as one structure of particular concern. The philtrum was classified into 4 groups according to the shape of philtral columns, and philtrum depth was measured. The authors analyzed the correlations between the philtrum and the vermillion lip. They found significant differences in philtrum depth among different type groups. A significant negative correlation between philtral depth and philtrum length was found, which indicated that a long philtrum was more likely to be accompanied by a flat philtrum with shallow depth. The philtrum width was significantly correlated with the mouth width with a mean ratio of 0.25. The authors also found a significantly negative correlation between philtral depth and angle of Cupid's bow's peak (Achp), and a positive correlation between Achp and mouth width. This study used 3D photography to quantitatively analyze proportional characteristics among labial aesthetic units in young Chinese adults. The results showed that the philtrum and the vermillion lip morphology were closely related, providing helpful references in perioral procedures.

Investigation of the Relationship between Sagittal Skeletal Nasal Profile Morphology and Malocclusions: A Lateral Cephalometric Film Study

The aim of this study was to evaluate the relationship between skeletal sagittal nasal profile morphology and sagittal skeletal malocclusions. Regarding lateral cephalometric films, the study was conducted in a total of 135 individuals without any prior orthodontic treatment (mean age of 17.91 ± 1.91), including 49 males (mean age 17.91 ± 1.16) and 86 females (mean age 17.78 ± 1.91 years). The groups were divided into two groups as male and female according to gender, and three groups as skeletal Class 1, Class 2, and Class 3 according to the Steiner's ANB angle. In addition, skeletal groups were compared within groups by dividing into two groups of male and female. A total of eight parameters, three skeletal sagittal angular (SNA, SNB, and ANB angles), four nasal linear (R-A, N-A, N-ANS, and N-R distances) and one nasal angular (N1-N2/N2-R angle), were measured on each cephalometric film. The arithmetic mean and standard deviation of all measured nasal parameters were calculated. For statistical analysis, independent sample t-test and one-way analysis of variance (One-Way ANOVA) were used for normally distributed data, and Mann Whitney U and Kruskal Wallis tests were used for data that did not show normal distribution. For statistical analysis, p < 0.05 was considered significant. R-A, N-A, and N-ANS linear nasal parameters differed significantly between the male and female groups, which were evaluated regardless of the skeletal groups, with a higher rate in males (p < 0.05). N-R linear nasal parameter showed a statistically significant difference between skeletal malocclusion groups, which were evaluated regardless of gender. N-R distance was found to be significantly longer in skeletal Class 3 individuals than in Class 1 and 2 individuals (p < 0.05). There was no statistically significant difference in nasal bone concavity angle in all groups (p > 0.05). R-A and N-A linear nasal parameters showed statistically significant differences between male and female sex groups in all skeletal malocclusion classes (p < 0.05). At first, results showed that males had longer measurements than females in all linear nasal parameters. Second, longer measurements were found in all linear nasal parameters in skeletal Class 3 individuals than those in skeletal Class 1 and Class 2 individuals. Third, the nasal bone concavity angle was greater in skeletal Class 2 individuals than the others.

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.

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.

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 .

Proposed Guide to Lip Treatment in Caucasian Women Using Objective and Measurable Parameters

BACKGROUND

The lips are a focal point of the face; however, their aesthetic proportions and effect on perceived facial beauty remain poorly defined. Perioral aging is highly individual, with several distinct and often simultaneous processes contributing to changes in lip contour and surface. These processes can affect lip volume and length, shape, and the degree of vermilion inversion.

OBJECTIVES

We aimed to develop a treatment guide for Caucasian women that combined a complete analysis of the lips (including the effects of aging) with consideration of the rheological characteristics of the products used to assist practitioners in tailoring rejuvenation treatment to individual patients.

METHODS

We reviewed existing literature to analyze the parameters that make the lips of Caucasian women "attractive" and investigated the rheological characteristics of different hyaluronic fillers to provide guidance on the optimal treatment for each woman.

RESULTS

Our numerical definition of the lips is based on 4 specific parameters: philtrum height, upper vermillion height, ratio between philtrum and upper vermillion height, and golden ratio between upper and lower vermillion height. In our opinion, conserving the length of hyaluronic acid chains results in dynamic fillers that may provide better results with lower risk of asymmetry compared with conventional products.

CONCLUSIONS

This new classification and associated treatment guideline aims to allow accurate assessment and enable practitioners to customize treatment for individual patients.

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.

Central Lip Lift as Aesthetic and Physiognomic Plastic Surgery: The Effect on Lower Facial Profile

BACKGROUND

A central lip lift was introduced to Westerners in 1980s. However, no studies have been conducted on the facial aesthetic and physiognomic perspectives of a central lip lift in the Asian population.

OBJECTIVES

The authors presented the central lip lift as aesthetic and physiognomic treatment in Asians and explained its effect on lower facial profile.

METHODS

A retrospective chart review was performed in 202 cases of asians. The authors analyzed patient age, cause of long philtrum, purpose of the treatment, and postoperative satisfaction. The authors then performed an anthropometric assessment and a photographic analysis.

RESULTS

The vertical disproportion of the lower face was improved after the treatment, and there was significant shortening of the philtrum length (P < .001) and an increase in a visible upper vermilion (P < .001). In Westerners, a long philtrum was mainly caused by the aging process. Aging patients (range, 40-59 years) underwent the central lip lift for upper lip rejuvenation. In contrast, in Asia, a long philtrum was primarily caused by bone retraction after an orthognathic surgery or orthodontic procedure. Young patients (range, 20-39 years old) underwent the central lip lift to correct a relatively lengthened philtrum after 2-jaw surgery. Furthermore, about half of the patients (52.0%) underwent the central lip lift for facial physiognomic improvement.

CONCLUSIONS

In today's multiracial society, plastic surgeons planning a central lip lift in Asian patients should consider both aesthetic and physiognomic perspectives. Regardless of the aesthetic outcome, the surgeon should strive to maximize patient satisfaction.

LEVEL OF EVIDENCE

4 Therapeutic.

Classification of the Aging Lips: A Foundation for an Integrated Approach to Perioral Rejuvenation

BACKGROUND

Although perioral aging is highly individual with several distinct processes taking part simultaneously, there is scarce systematic information which helps to indicate the right rejuvenation approach among the multitude of proposed procedures. Existing data about perioral aging has not yet been transformed into a consistent therapeutic concept. The intention of this study was to provide a simple, yet reproducible classification and to offer appropriate rejuvenation approaches.

METHODS

To identify reliable and constant landmarks of the ongoing process of perioral aging, 462 perioral photo documentations were morphometrically analyzed. Based upon the identified landmarks a two-dimensional classification was developed. The classification was validated by three plastic surgeons. Inter- and intra-rater reliability was calculated using Cohen's kappa coefficient.

RESULTS

Perioral aging can be broken down into changes of the lip shape and changes of the lip surface. Both processes can be classified into three stages each: Lip shape according to the shape in profile view, the lip length in relation to the frontal incisors, and the degree of vermilion inversion. Lip surface according to the presence and degree of radial wrinkles and the visibility of the structural elements Cupid's bow, philtrum, and white roll. Inter-observer reliability was rated very good (kappa values between 0.819 and 0.963) and perfect for intra-observer reliability (1.0).

CONCLUSION

A better understanding of perioral aging leads to a simple classification for the aging lips. Using the classification helps to tailor an appropriate treatment to the individual patient and aids to achieve a natural rejuvenation result.

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

BACKGROUND

Addressing the long upper lip has been a complex problem for some time. Methods such as the subnasal skin excision and the vermillion advancement technique have been described, but both leave a visible scar. A no-scar lip-lift technique is necessary for a subset of patients who have a long upper lip and will not accept a visible scar.

METHODS

The upper lip is shortened via an intranasal incision and suspension suture that elevates the upper lip and anchors it to the anterior nasal spine. A retrospective review of 92 patients who had undergone upper lip-lift with the no-scar suspension technique was performed. Three plastic surgeons assessed the pre- and postoperative results and determined the presence of improvement in four categories: lip shortening, lip projection, incisor show, and vermillion show.

RESULTS

The lip parameters improved, with 85% of the patients showing noticeable lip shortening, 79% showing increased sagittal projection, 74% exhibiting increased incisor show, and 25% exhibiting increased vermillion show. All the patients had improvement in at least one of the four categories. Complications were experienced by two patients with a suture abscess and one patient with an unraveled suture.

CONCLUSION

The overall lip contours improved after the lip suspension technique, most noticeably in terms of lip height and sagittal projection, and the scar was hidden intranasally.

Laser burn wound healing in naso-labial region of fetal and neonatal mice

OBJECTIVE

To investigate the characteristics of wound healing in the mouse naso-labial region in both the fetal and neonatal stages, histological and immunohistochemical analyses were performed using a newly established laser burn wound healing system.

MATERIALS AND METHODS

Fetal mice at embryonic day 14 (E 14) were wounded as a model of fetal wound healing. To compare it, neonatal mice at day 5 after birth (d 5) were adopted as a model of neonatal wound healing. The healing process was examined by van Gieson staining and immunohistochemistry for fibronectin and tenascin.

RESULTS

Relatively large damage remained after wound healing even in fetal mice. In both types of wound healing, rapid regeneration of muscle tissues were observed. Fibronectin and tenascin immunostaining was detected not only in wound healing region, but also in the endomysium of regenerating muscle tissues. Especially, tenascin showed a restricted expression pattern.

CONCLUSIONS

Rapid regeneration of muscle tissues in the naso-labial region in both the fetal and neonatal mice seemed to leave relatively large damage even in the fetal wound healing. Contracted force exerted by muscle tissues may be a reason for this phenomenon. Fibronectin and tenascin were closely related to the wound healing process including muscle regeneration in this region.

The relationship between craniofacial structures and the nose in Anatolian Turkish adults: a cephalometric evaluation

INTRODUCTION

The aim of this study was to evaluate the relationship between the facial skeletal and the nasal profile in Anatolian Turkish adults. This prospective study was conducted at Gazi University, Faculties of Dentistry and Medicine, in Ankara, Turkey.

METHODS

The sample included 262 Turkish adults (167 women, 95 men), aged 18 to 30 years. Fifteen facial skeletal parameters and 12 nasal parameters (10 soft tissue and 2 nasal skeletal) were measured on lateral cephalograms. Analysis of variance, Duncan test, and Pearson correlation analysis were used for statistical analysis.

RESULTS

The anteroposterior and vertical classifications were found to be significant with analysis of variance in certain parameters such as nasolabial angle (P < .05), nasomental angle (P < .001), and soft-tissue facial convexity (P < .001). Sex was also found to be significant for nasal length (P < .001), nasal depths (P < .05, P < .001), and hump (P < .01), in addition to soft-tissue facial convexity (P < .01). The results also showed correlations between the skeletal and nasal parameters. Facial heights, lengths, and the anteroposterior/vertical position of the maxilla and mandible were found to be correlated to nasal length and form.

CONCLUSIONS

Nasal length, prominence, and form are associated with height and length of the maxilla and the mandible. Posterior-inferior development of the face results in a convex nasal profile, whereas anterior development produces a straight or concave nasal profile.

Facial Rejuvenation

Nonsurgical facial rejuvenation is often used as an alternative to more invasive procedures. Topical agents improve cell maturation and cell turnover, chemical peels and microdermabrasion improve poorly textured skin and pigment anomalies. Surgical facial rejuvenation provides dramatic changes but requires more recovery time.