Analysis and Classification of the Upper Lip Aesthetic Unit:

Ethnic Considerations When Planning Lip Augmentation

Ideal standards of beauty including preferred lip characteristics vary between ethnicities. Although plump, well-defined lips are globally associated with youth, variation exists with regard to the perceived ideal lip volume and proportions between ethnicities. Proportions that may be assessed when planning lip augmentation include the upper-to-lower lip ratio, philtrum length, upper and lower vermilion heights, the ratio between the philtrum height and that of the upper vermilion, and the lip height-to-lip width ratio.It is important that accurate assessments of patients are made pre- and postaugmentation. However, many aesthetic assessment tools are based on Caucasian models with limited use in other ethnicities. We present a review of the ideal lip characteristics and assessment techniques accounting for ethnicity, with a view to providing practitioners an evidence-based approach to lip assessment and treatment planning for patients of all backgrounds.

The Concept of Ideal Lips of Caucasian Female: An Anthropometric Analysis of the Lower Third of the Face

BACKGROUND

The demand for lip-redefining procedures has been rising in recent years, thus creating the need for reliable and detailed reference sources on aesthetic female lips. This study investigates the morphology of the lower third of the face, including the lips and jawline, of attractive young Caucasian females.

METHODS

A semi-automatic photogrammetric analysis of the faces of professional female photograph models (n=400) of the Caucasian race aged 18-39 was performed. Angular, linear, and surface area parameters were evaluated. A graphical summarization of the average facial shape of all analyzed attractive females was generated as an average body contours (ABC) image.

RESULTS

The height of the lower third of the face equaled 0.32 ± 0.02 of the total facial height. The average lip width was 48.06 ± 3.34 mm. The upper vermilion height was found to be significantly lower than the lower vermilion height (6.47 ± 1.36 vs. 11.64 ± 1.46 mm, p < 0.01). The lip obliquity angle was found to be 1.05° ± 0.79°. The area surface of the upper lip vermilion was considerably smaller than the vermilion of the lower lip (p < 0.01).

CONCLUSIONS

This is one of the largest studies on attractive Caucasian females' lips and lower face morphology. The data it provides, including the graphical presentation of the aesthetic lower face as an ABC image, may provide physicians with valuable guidelines for lips rejuvenation and reconstruction procedures.

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 .

The Ideal Chinese Lip: Impact of Lip Contours and Proportions

BACKGROUND

The lips are one crucial determinant of facial attractiveness. Current studies investigating lip attractiveness were mostly conducted in Caucasians, and the results could not directly apply to Asians. Aside from lip proportions, lip contours play an important role in attractiveness but it is unclear how people perceive different lip contours. The aim of this study was to investigate the aesthetic perception of various lip shapes by Chinese to identify the most attractive lip morphology for women and men, respectively.

METHODS

303 Chinese participants were invited to rate the attractiveness of identical lip images with different contours and proportions in a young female and a young male. Stratified analyses were performed to assess the effect of gender, age and occupation on the preference of lip shapes.

RESULTS

The lips that were rated to be most attractive had a flat upper vermilion border, an M-shaped oral fissure and a U-shaped lower vermilion border in both genders. Most respondents considered an upper-to-lower vermilion proportion of 1:1 to be more attractive, regardless of the gender of the lip models, and the lip thickness-to-width proportions of 1:2 and 1:2.5 were perceived most attractive for female and male, respectively.

CONCLUSIONS

This study adds to our understanding of how lip contours contribute to attractiveness and that Chinese have distinctive aesthetic preferences for lip morphology, which possibly stem from racial characteristics and cultural differences. With such knowledge, practitioners may better tailor the treatment strategy when performing lip rejuvenation procedures.

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 .

Facial Anthropometric Measurements and Principles - Overview and Implications for Aesthetic Treatments

Facial anatomy is highly individual in each patient. Anthropometric measurements can be a useful tool to objectively analyze individual facial anatomy to allow for better comparability before and after treatments to ultimately improve standardization of facial procedures, both nonsurgical and surgical. The aim of this study was to provide a comprehensive overview over clinically relevant and feasible facial anthropometric measurements and principles for aesthetic medicine. A literature review was conducted to describe the most important and clinically relevant anthropometric measurements and principles for both the entire face and for three aesthetically relevant facial regions: the periorbital region, the nose, and the perioral region. A multitude of different anthropometric measurements and principles have been described in the literature for both the overall facial appearance and specific facial regions. Certain generally accepted anthropometric principles and proportions need to be respected to achieve aesthetic and harmonious results. For the overall facial appearance, a focus on symmetry, certain proportions, facial angles, and indices has been described. Principles and measurements were also described for the periorbital region, the nose, and the perioral region. Although attractiveness and aesthetic perception are subjective, objective evaluation of facial surface anatomy via anthropometric measurements can improve pre- and postinterventional analysis of the face and help the treating physician to individualize treatments, both nonsurgical and surgical.

Upper lip characteristics and associated excessive gingival display etiologies in adults: Race and sex differences

BACKGROUND

This cross-sectional study aimed to examine upper lip (UL) and smile characteristics and soft tissue excessive gingival display (EGD) etiologies (hypermobile upper lip [HUL], altered passive eruption [APE], and short upper lip [SUL]) in a nondental adult population and to analyze interracial (Black and White) and intersex differences.

METHODS

Community participants, non-Hispanic Blacks (NHB) and non-Hispanic Whites (NHW), were recruited and examined for UL vertical dimensions at rest and maximum smile and for HUL, APE, and SUL. Associations between gingival display (GD) or EGD and UL anatomical characteristics, HUL, APE, and SUL were analyzed.

RESULTS

Participants included 66 NHB and 65 NHW adults. Ergotrid height (greater among NHW; p = 0.019) averaged 14.0 mm. Upper lip vermilion length (ULVL), total UL length, internal lip length, total UL length during smile, and UL mobility averaged 8.6, 22.5, 23.1, 16.6, and 5.9 mm, respectively (all significantly greater in NHB; p ≤ 0.012). SUL prevalence was 4.6%, found only among NHW. Lip length change from rest to smile (LLC) averaged 26.2% (significantly greater in females; p = 0.003). HUL prevalence was 10.7% (NHB 13.1%, NHW 3.5%; p = 0.024). NHB had significantly greater GD (p ≤ 0.017). EGD and APE prevalence (6.9% for both) showed significant interracial and intersex differences (p ≤ 0.014). Multivariate logistic regression analyses indicated that LLC and HUL were the most consistently significant EGD determinants.

CONCLUSIONS

UL anatomical and functional characteristics and soft tissue-related EGD etiologies exhibit significant interracial and intersex differences, with UL mobility/hypermobility being the most consistently significant determinant of GD.

Facial Aesthetic Ideals: A Literature Summary of Supporting Evidence

BACKGROUND

To achieve the goal of enhancing facial beauty it is crucial for aesthetic physicians and plastic surgeons to have a deep understanding of aesthetic ideals. Although numerous aesthetic criteria have been proposed over the years, there is a lack of empirical analysis supporting many of these standards.

OBJECTIVES

This aim of this review was to undertake the first exploration of the empirical evidence concerning the aesthetic ideals of the face in the existing literature.

METHODS

A comprehensive search in MEDLINE, Embase, Scopus and CENTRAL databases was conducted for primary clinical studies reporting on the classification of the facial aesthetic units as per the Gonzales-Ulloa facial aesthetic unit classification from January 1962 to November 2022.

RESULTS

A total of 36 articles were included in the final review: 12 case series, 14 cohort studies, and 10 comparative studies. These described the aesthetic ideals of the following areas: forehead (6 studies; mean level of evidence, 3.33); nose (9 studies; mean level of evidence, 3.6); orbit (6 studies; mean level of evidence, 3); cheek (4 studies; mean level of evidence, 4.07); lips (6 studies; mean level of evidence, 3.33); chin (4 studies; mean level of evidence, 3.75); ear (1 study; level of evidence, 4).

CONCLUSIONS

The units that were most extensively studied were the nose, forehead, and lip, and these studies also appeared in journals with higher impact factors than other subunits. Conversely, the chin and ear subunits had the fewest studies conducted on them and had lower impact factors. To provide a useful resource for readers, it would be prudent to identify and discuss influential papers for each subunit.

LEVEL OF EVIDENCE: 3

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.

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 .

Exploration of surgical approach to reconstruct smile-like lip shape in East-Asian women

BACKGROUND

To investigate the clinical effects of surgical treatment to improve the lip morphology for a smile-like appearance (joy and happiness) in East-Asian women.

METHODS

From October 2016 to April 2020, 63 patients who had received surgery to lift the commissure of the mouth and adjust the shape of the upper red lip to form a smile-like shape were analyzed and evaluated.

RESULTS

The lip shape of enrolled patients was improved to a certain extent after surgery without any obvious scar hyperplasia, and the satisfaction rate of people after the surgery was 85.71%.

CONCLUSION

For East-Asian women with thin and flat lips, surgical approach can be used to improve the shape of lip, such that the appearance of the lip is in a smile-like shape, which can enhance affinity and also exhibit the aesthetic characteristics of East-Asian women. This treatment can be used for clinical reference.

LEVEL OF EVIDENCE

Level IV.

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.

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.

Analysis of upper lip appearance after surgical lip augmentation procedure "VY in VY": Progress of results

INTRODUCTION

Many materials and techniques were used for lip augmentation, whereas in the last years all attention is paid for filling material, and long-lasting surgical techniques were ignored.

MATERIALS AND METHODS

This study includes 12 candidate patients for upper lip augmentation; all are females, their age range 21-24 years. Standardized anterior and lateral photographs of each subject were taken at: preoperative, 2, 4, and 12 months later, and were analysed using digital imaging software to quantify postoperative changes. We used t-test of correlated samples to detect any statistical significance and Interclass correlation coefficient test (ICC) for reliability that proved the reliability and reproducibility of our method.

RESULTS

there were statistically significant improvements in al parameters that characterize the fullness of the upper lip. These changes was observed from the 2^nd month (P<0.05) and continued improving until the 4^th month (P<0.05), after that they appeared to be stable (P>0.05). These changes were at the 12^th month postoperative in: upper white lip (-9%), upper red lip (53%), upper red lip area (63%), protrusion (41%) and nasolabial angle (-7%). There was no statistical significance in the change of Cupid's bow curvature (P-value = 0.104 > 0.05).

CONCLUSIONS

VY in VY for upper lip augmentation improves the parameters that define the youthful and fully appearance of the upper lip and the progress of results may be predictable. These improvements appear to be stable from the 4th month. Also, it doesn't change the Cupid's bow curvature.

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.

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.

Surgical Management of the Superior Lip as a Complement in Facial Features Remodeling Surgery

The lower 3rd of the face is an essential area to pay attention to achieve excellent results in facial features remodeling surgery (FFRS). Because of its importance in facial remodeling surgery, special care has been taken in upper lip procedures. A combination of treatments has been used for the upper lip, which include surgical and nonsurgical procedures, depending on the patient assessment. The authors use a subnasal lip lift when surgery is required. This study describes the use of lip lift in combination with FFRS.

Aging of the Upper Lip: Part I: A Retrospective Analysis of Metric Changes in Soft Tissue on Magnetic Resonance Imaging

BACKGROUND

In scientific literature, numerous theories on the mechanism of facial aging can be found. The debate about facial sagging versus deflation is still ongoing. In this study, the metric changes in perioral soft tissue were demonstrated. These data can contribute to a better understanding of physical changes in the aging perioral area.

METHODS

Upper lip measurements were performed on cranial magnetic resonance images of 200 Caucasian subjects (100 men and 100 women). The study population was aged between 20 to 30 and 65 to 80 years. The upper lip length and soft-tissue thickness were measured on sagittal and parasagittal section. Cross-section surface area of the upper lip was measured in the sagittal section to represent volume. The data were analyzed with a t test and results were considered significant at p < 0.01.

RESULTS

The upper lip in the old age group differed significantly in length (19.24 percent in women and 18.24 percent in men), thickness (up to -40.55 percent in women and -32.74 percent in men), and volume (-20.89 percent in women and -17.40 percent in men). Soft-tissue thickness at the alar nasolabial fold was significantly thinner in the old age group (-25 percent in women and -25.7 percent in men) and showed significantly greater tissue loss than elsewhere in the upper lip (p < 0.001).

CONCLUSIONS

These results suggest that the aging perioral area is affected with a combination of soft-tissue lengthening, thinning, and volume loss. The clinical implications of this study on perioral rejuvenating strategies will be explained in part II.

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.

Digitalized analysis of philtral anatomy for planning individual treatment

OBJECTIVE

Restoration of the philtral region following traumatic, cleft, and tumor surgeries is often difficult due to influence of this feature to whole facial beauty. The aim of this study is to investigate the types and measurements of the philtrum and its relationship with the upper lip using a software.

METHODS

Standard personal photographs of the philtral region were obtained from 200 young adults participated in this study. Linear analyses (the lengths of philtral column and dimple; the philtral width) and angular analyses (apex and central angles of Cupid's bow) were measured as reference points. As for the shape of the philtral column, it was categorized as four distinct types: parallel, triangular, concave, and unclear type.

RESULTS

The philtral width was 11.37 ± 1.9 mm in males, 10.21 ± 1.80 mm in females. The length of the philtral dimple was 18.16 ± 3.6 mm in males, 18.16 ± 3.6 mm in females. Compared with women, both of the measured average philtral reference lengths displayed a significantly greater value in men. In the meanwhile, compared to women, the angular measurements of Cupid's bow (i.e., the apex and central angle of Cupid's bow) were smaller in men. It was 127.47 ± 12.74° mm in males, 134.1 ± 11.38° mm in females. The triangular and concave types were associated with a substantial fraction in men, whereas the triangular and parallel types were predominant in women. There were significant gender differences in the esthetic rankings of philtral column shapes.

CONCLUSIONS

These results suggest digitalized reference values relative to the philtral column which may increase the success of the individual reconstructive treatment of the surgical procedures and reduce possible asymmetrical appearance. With the help of certain software, this research has made possible to investigate the ideal parameters of philtral construction in defining the best surgical solution for the patient.

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.

Five-year Experience with Perma Facial Implant

SUMMARY

Augmentation cheiloplasty is becoming an increasingly popular aesthetic procedure despite current methodologies having met with disappointment among surgeons and patients. The goal of this study was to examine the benefits and drawbacks of 1 device in particular-Perma Facial Implant (PFI). The senior authors (P.R. and S.W.H.) performed 832 consecutive PFI lip augmentations with excellent results based on photographic documentation, patient satisfaction surveys, unbiased surgeon ratings, and low complication rates. In addition to augmenting thin lips, PFIs hide excess dentition and improve vermilion rhytids and pout. Contrary to alternatives, they are both permanent and reversible. However, they do not level out asymmetries or benefit razor-thin lips without prior lifting or mucosal advancement.

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.