Aging of the Upper Lip: Part II. Evidence-Based Rejuvenation of the Upper Lip—A Review of 500 Consecutive Cases

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.

9-point Injection Technique for Lip Augmentation and Lip Corner Lifting Using Sonographic Imaging of the Labial Artery Pathway

BACKGROUND

As lip enhancement with fillers has grown in popularity, practitioners have sought to identify injection methods that achieve aesthetically pleasing results while avoiding adverse events such as arterial injury due to intravascular injection.

OBJECTIVES

The primary objective of this study was to establish a safe injection technique for creating appealing, proportionate, and aesthetically pleasing lips while elevating the lip corners with filler.

METHODS

Before injection, the locations of the superior and inferior labial arteries were established by sonography and a 9-point injection technique (9-PIT) was devised to reliably achieve fashionable lips. Particle hyaluronic acid filler was administered to 50 patients by the 9-PIT and these patients were monitored for 3 months. The extent of lip corner elevation and the angle of lip corners were quantified by 3-dimensional analysis, while changes in the length and curvature along the upper peristomal lines were evaluated after 1 week.

RESULTS

The superior and inferior labial arteries originated from the deep lateral aspect of the lip and gradually traversed toward the midline in the superficial layer. Superficial arterial branches were identified in the submucosal layer near the midline. All patients expressed satisfaction with the lip shaping and corner elevation, without any adverse effects or vascular complications. The angle of lip corners decreased by 8.80%, and lip corners were lifted by 1.02 mm. The upper lip exhibited a more pronounced S-shape, with the upper lip line being elongated by 6.5%. This accentuated S-shape contributed to the appearance of lifted lip corners.

CONCLUSIONS

The 9-PIT facilitated safe and aesthetically pleasing lip volumization with corner elevation in a consistent manner, while elucidating vascular pathways. Lip corner elevation was achieved solely using HA filler.

LEVEL OF EVIDENCE: 3

Lip feminization: A review

Background

Facial feminization involves a broad array of procedures tailored to transgender women, with lip feminization emerging as a crucial element because of its significant impact on gender expression. Despite its importance, there is a dearth of studies singularly dedicated to lip feminization within this demographic.

Objectives

This review aimed to consolidate knowledge on various techniques (surgical and nonsurgical), outcomes, and patient satisfaction related to lip feminization, thereby highlighting its integral role in facial feminization and its significance in affirming transgender women's identity.

Methods

A systematic search of PubMed, MedLine, and Embase databases was conducted, focusing on studies published up to April 18, 2024. Inclusion criteria were centered on articles addressing the techniques and outcomes of lip feminization. A rigorous screening process was applied to identify relevant literature, which was then reviewed for data extraction on techniques, outcomes, complications, and patient satisfaction.

Results

Among the initial 28 publications, 21 articles remained. These studies provided insights into surgical and nonsurgical techniques for lip feminization and reported high-satisfaction rates within a broader scope of facial feminization surgeries. Notably, specific data on lip feminization were sparse and often extrapolated either from broader facial feminization research or studies on cisgender populations.

Conclusion

This review established that lip feminization is a crucial but under researched aspect of gender-affirming care. Recognizing the high-satisfaction rates reported for facial feminization, this study advocated for detailed, procedure-specific research to optimize outcomes for transgender women seeking lip feminization.

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.

Advancements in lip augmentation: A scoping review exploring novel techniques

Lip augmentation is among the most popular cosmetic procedures done today. Advancements in trustworthy techniques have made it feasible to alter the visual characteristics of the lips through the utilization of various injectable substances and surgical procedures. However, there is a lack of standardization in these techniques. The purpose of this review is to focus on novel dermal filler injection and surgical techniques for lip augmentation. We did a scoping review of the literature using PubMed, Embase, and the Google Scholar database to identify all original articles published up to June 2023, assessing new techniques that focus on lip augmentation. In our review, only two studies out of seven included studies were surgical whereas the other five studies were non-surgical. This suggests that injection of dermal fillers is currently the most opted technique performed. This review suggests that incorporating perioral rejuvenation into the plan for lower facial surgery can help to complete the youthful look sought by patients. Injectable fillers provide excellent but short-term benefits and additional options such as Modified upper lip lift and French kiss techniques exist that offer the patient permanent improvements at a low cost.

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.

Extended Superolateral Cheek Lift With a Short Preauricular Scar: A Local Anesthesia-based Practicable Technique for the Correction of Moderate-degree Facial Aging Signs

An ideal technique applicable to middle-aged individuals with a moderate degree of facial aging signs has not yet been established. This study aimed to evaluate the utility of an extended superolateral cheek lift with a short preauricular scar technique for the correction of facial aging signs. A total of 200 female patients (mean age: 43 y, range 27-56 y) who underwent a local anesthesia-based extended superolateral cheek lift for the correction of facial aging signs confined to the malar and nasolabial area, lower eyelid, jawline, and neck were included. Data on the Global Aesthetic Improvement Scale, patient-reported outcomes, and complications were recorded at 1, 6, 12, and 24 months postoperatively. The Global Aesthetic Improvement Scale scores revealed exceptional improvement in 90% of patients along with no complications at month 24. None of the patients developed a depressed scar, skin necrosis, breaking of the superficial musculoaponeurotic system plication sutures, asymmetry, or facial nerve problems. At postoperative month 24, the appearance was reported to be very much improved by 90% of patients, and 94% of patients reported that they were very satisfied with the treatment and that they would recommend this treatment to friends and acquaintances. Our findings revealed the potential utility of an extended superolateral cheek lift with a short preauricular scar as a local anesthesia-based practicable technique for the correction of facial aging signs in middle-aged patients, offering a favorable postoperative outcome, lack of complications and high patient satisfaction in addition to invisible scars and a short-term postoperative recovery.

Different Techniques and Quantitative Measurements in Upper lip lift: A Systematic Review

BACKGROUND

The upper lip area is an important component of facial aesthetics, and aging produces an increase in the vertical height of the upper lip. Different upper lip lifting techniques are described in the literature.

OBJECTIVES

This systematic review aimed to assess both invasive and noninvasive upper lip lifting techniques with patient satisfaction, adverse effects, and quantitative measurements of lifting efficiency.

METHODS

This study was conducted per PRISMA guidelines. MEDLINE (via PubMed), EMBASE (OvidSP), and Cochrane Library database were searched from September 14, 2022, to October 12, 2022. Inclusion criteria were reporting on upper lip lift efficiency with quantitative measurements of the lifting degree.

RESULTS

Out of 495 studies through the search strategy, nine articles were included in the systematic review, eight for surgical procedures and one for nonsurgical. Surgical procedures seem to have better longevity than nonsurgical techniques. Reported patient satisfaction for both surgical and nonsurgical treatments was good with no severe complaints. The quantitative measures differ between researches and may be classified into two metrics: anatomy ratio computation using photographic analysis or direct height measurement with a caliper and precise parameters utilizing a three-dimensional method.

CONCLUSION

In general, surgical therapies seem to have a longer-lasting lifting effect on upper lip lifts with an inevitable scar, while nonsurgical techniques are minimally invasive but temporary. There was a lack of consistency in the measurements used to assess lifting efficiency. A consistent quantitative assessment can be beneficial for both clinical decision-making and high-level evidence research.

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 .

CUPID Lip Lift: Advanced Lip Design Using the Deep Plane Upper Lip Lift and Simplified Corner Lift

BACKGROUND

Upper lip lift is achieved with a variety of techniques but many questions remain about the benefits and drawbacks of each technique. The CUPID deep plane or modified upper lip lift procedure has recently been introduced to help mitigate risk and optimize outcomes.

OBJECTIVES

The aims of this study were: (1) to better characterize and simplify the complex and artistic decision-making process involved in upper lip lift and corner lip lift; (2) to present a mathematical guide to maintain the natural balance of the upper lip, optimizing muscle function, and to indicate when to add a corner lift; and (3) to elucidate design elements, aging, and future treatment considerations.

METHODS

A PubMed (United States National Library of Medicine, Bethesda, MD) search was performed in October 2021 for all journal articles published on upper lip lift and corner lip lifts. The search covered from 1950 to the present day in all languages and without exclusion criteria. Outcomes and the evolution of deep plane upper lip lift design over the last 6 years were analyzed.

RESULTS

By following the patterns demonstrated in over 2440 consecutive lip lifts, the authors have been better able to understand the nuances involved in proper design that will avoid acceleration of aging and exaggeration of appearance, and reduce the need for revision while maximizing results.

CONCLUSIONS

Upper lip lift design is more complex than most practitioners realize. The mathematical concept described herein makes it possible to obtain more aesthetically pleasing and consistent outcomes. This novel approach to lip lift design enables the practitioner to improve lip balance, facial harmony, and tooth show, and obtain adequate exposure of the lateral vermillion.

LEVEL OF EVIDENCE: 4

Determination of the Anthropometric Measures of the Lips by Age Groups in the Mestiza Population

Measurements from a certain population may show a similar pattern that allows an alteration to be easily recognized and enable a better surgical approach. In our population, the changes in the anthropometric measurements of the lips are unknown, so our objective is to determine the variations in these measurements by decades of age to achieve a better aesthetic and reconstructive surgical approach. Anthropometric measurements of the lips were taken with a vernier in relation to the previously marked anatomical points. The sample consists of 174 patients who came for care not related to labial pathologies with ages between 20 and 80 years with Mexican nationality. We use the sample calculation formula to estimate an average, with an alpha error of 0.5 and a tolerance of 2 mm of the data for the measurements of the height of the lower face with an average measurement of 56.2 mm and a SD of 8.87 mm of the Marzena's article. Wyganowska-Świątkowska and colleagues Average measurements were obtained, where a progressive longitudinal increase in measures: al-ch, sbl-cph, sn-Is, li-sto, cph-Is, li-sl, ch-li, li-pg according to aging is confirmed. In contrast, the ch-cph and ch-sbl measures, remain the same despite the aging, showing greater changes in the sagittal plane than in the parasagittal. The study only shows measures of length, so caring out a magnetic resonance imaging study to also measure the volume and perform it with a larger sample to have the optimal standard is further needed.

Three-Dimensional Perioral Assessment Following Subnasal Lip Lift

BACKGROUND

The subnasal lip lift is a surgical technique that elevates the "lip line" (interface between vertical maxillary incisor height and upper lip) to achieve a more youthful aesthetic.

OBJECTIVES

The authors sought to offer the first ever definition, to their knowledge, of 3-dimensional (3D) changes to the upper lip due to subnasal lip lift.

METHODS

A lip lift procedure was performed (on cadaveric samples) in a sequential manner from 2.5- to 5.0-mm intervals (n = 13). 3D photographs were taken with the VECTRA H1 system (Canfield Scientific, Fairfield, NJ), and 3D analysis was performed including vermillion height and width, philtral height, sagittal lip projection, vermillion surface area, and incisor show. A subset of samples (n = 9) underwent a modification of the technique by undermining the upper lip subcutaneous tissue off the underlying muscular fascia.

RESULTS

Vermillion surface area (baseline range, 1.45-5.52 cm2) increased by an average of 20.5% and 43.1% with 2.5-mm and 5.0-mm lip lift, respectively. Anterior projection of the vermillion increased in all cases by an average of 2.13 and 4.07 mm at 2.5 and 5.0 mm, respectively. Philtral height decreased in all cases by an average of 3.37 and 7.23 mm at 2.5 and 5.0 mm, whereas incisal show increased on average of 1.9 and 4.09 mm, respectively.

CONCLUSIONS

This study is the first to our knowledge to define the 3D morphometric changes to the upper lip following subnasal lip lift. Quantifying these changes aids the surgeon in preoperative planning and guiding patient expectations.

Applications of 3D photography in craniofacial surgery

Three-dimensional (3D) photography is becoming more common in craniosynostosis practice and may be used for research, archiving, and as a planning tool. In this article, an overview of the uses of 3D photography will be given, including systems available and illustrations of how they can be used. Important innovations in 3D computer vision will also be discussed, including the potential role of statistical shape modeling and analysis as an outcomes tool with presentation of some results and a review of the literature on the topic. Potential future applications in diagnostics using machine learning will also be presented.

Rejuvenating the Aging Upper Lip: The Longevity of the Subnasal Lip Lift Procedure

Objective: This study sought to retrospectively analyze the longevity of the subnasal lip lift procedure on the aging upper lip by determining if the amount of skin resected was maintained. Methods: Patients who underwent subnasal upper lip lift procedure of 5-mm resection with the senior author (S.W.P.) from 2006 to 2020 were identified for a total of 52 patients who met inclusion criteria. Pre- and postoperative measurements of nasal base to upper lip vermillion border and vermillion height were taken. Longevity of results were measured through percentage retention of 5-mm lift and percentage improvements of lip show. Results: The percentage retention of the 5-mm lift and percentage improvement of lip measurements were maintained over time with a slow decline. The average percentage improvement of lip show was 48.2%. Patients <5 years out from surgery had 50.1% improvement compared with 40.3% for those ≥5 years out (p = 0.569). Conclusions: The subnasal lip lift procedure shortens the vertical height of the elongated upper lip and gives increased vermillion show with predictable results.

Adverse reactions associated with perioral rejuvenation using laser, fat and hyaluronic acid: systematic review

Perioral rejuvenation is carried out by surgical and non-surgical tools. The common procedures are laser resurfacing and volumanisation using alloplastic fillers or autogenous fat. Nonetheless, any such procedures are associated with complications. To evaluate a concise presentation of complications and safety associated with different perioral rejuvenation treatments including laser ablation, fat grafting and hyaluronic acid injections. A systematic literature review of all the relevant studies and case reports on complications and adverse reactions associated with the laser ablation, administration of fillers and fat for the rejuvenation of perioral region. Twelve articles passed the inclusion criteria (as per PRISMA guidelines) and were scrupulously analysed. Four publications evaluated complications associated with laser resurfacing, 5 were related to filler augmentation and 3 were related to fat administration. The results concluded that all three aesthetic treatments are associated with mild to moderate complications. Severe complications are rare but can arise. Clinicians should be mindful of possible complications and able to recognise adverse events so that remedies could be executed with minimal delay. Training and supervision are essential components of ensuring provision of safe aesthetic treatment, and lack of regulation is a concern.

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 .

Upper Lip Horizontal Line: Characteristics of a Dynamic Facial Line

Background: Upper lip appearance received major attention with the introduction of diverse treatment modalities, including lip augmentation, rhinoplasty surgery, and dental treatment designed to support the upper lip. Our objectives were to define the prevalence and characteristics of the upper lip horizontal line (ULHL), which is a dynamic line appearing during a smile, in relation to gender, malocclusions, aging, and facial morphology. Methods: First, the prevalence and gender distribution of ULHL was examined from standardized en-face imaging at full smile of 643 randomly selected patients. Second, cephalometric and dental cast model analyses were made for 97 consecutive patients divided into three age groups. Results: ULHL appears in 13.8% of the population examined, and prevailed significantly more in females (78%). The prevalence of ULHL was not related to age nor to malocclusion. Patients presenting ULHL showed shorter upper lip and deeper lip sulcus. The skeletal pattern showed longer mid-face, shorter lower facial height and greater prevalence of a gummy smile. Conclusions: Female patients with short upper lip, concavity of the upper lip, and gummy smile are more likely to exhibit ULHL. The ULHL is not age-related and can be identified in children and young adults. Therefore, it should be considered when selecting diverse treatment modalities involving the upper lip.

Stereophotogrammetry to reveal age-related changes of labial morphology among Chinese women aging from 20 to 60

Background

The lip is of important aesthetic value and highly subjected to aging. Collecting anthropometric baseline data and understanding age‐related changes of labial morphology can help with diagnosis of deformity, assessment of aging, and planning of cosmetic procedures. Many studies have focused on Caucasians, while there is a lack of anthropometric data on Chinese women.

Methods

A total of 169 women were enrolled in this cross‐sectional study and divided into four consecutive age groups. Linear distances, angles, and surface area data were obtained via stereophotogrammetry. Intergroup comparisons between different age groups were performed to find age‐related differences.

Results

Lip width significantly increased with age while philtrum width seemed to show no obvious change. Cutaneous upper and lower lip height increased, lengthening the lip in the vertical dimension. Decrease of upper vermilion height and changes in angles indicated that aging process shortened the upper vermilion and flattened the vermilion border. Surface area also showed age‐related changes. Intergroup comparison showed no statistical significance in most variables between 20s and 30s or 30s and 40s, while age‐related changes in some variables were significant between 40s and 50s.

Conclusion

This study provided anthropometric data of labial morphology across a wide age range. Aging process affected a variety of labial anthropometric variables. Age‐related changes accelerated after 40 among Chinese women.

Surgical Method of a Corner Mouth Lift

Background:

The mouth and perioral area play a primary role in emotional expression, and these are among the most important areas projecting youth and attractiveness. A downturned corner of the mouth presents negative feelings such as sadness, depression, and tiredness. A corner mouth lift (CML) may restore more attractive and youthful appearance, which can favorably affect first impression, self-esteem, and the quality of life in patients.

Methods:

From December 2016 to September 2018, 498 patients underwent a CML. There were 434 women and 64 men. The mean age was 38.99 years (19–63 years) and 34.19 years (21–67 years) in female and male patients, respectively. A total of 432 cases (86.7%) were primary surgical cases, whereas 66 (13.3%) were secondary cases. There were 178 patients (35.7%) who only underwent CML, whereas the remaining patients (64.3%) underwent the CML contemporarily with other perioral surgery such as subnasal lift.

Results:

Most patients were satisfied with the results. However, some patients showed unsatisfactory outcomes such as hypertrophic scar, asymmetry, persistent swelling, or undercorrection. The most common complaints immediately after surgery were swelling and bruise, which were improved spontaneously within 1–2 weeks. Postoperative scar and undercorrection were the most common complications that required revision surgery.

Conclusions:

CML showed reliable and satisfactory outcomes in most patients. It could be a good option for patients who desire CML regardless of their age.