Lip Reduction:Sometimes Needles are Not Enough
A lot of attention gets paid to lip enlargement but there are a large number of patients that aren’t interested!
Contemporary cosmetic surgeons and practitioners are well aware of the art and science of lip enhancement using injectable fillers. For those of us who have been doing this longer than 10 years, we remember the old days of bovine collagen. That was a tough time for fillers as we basically had two choices; Zyplast and Zyderm. Allergy testing and minimal longevity made this a less than desirable option. Fast forward to 2002 and the first hyaluronic acid fillers received FDA approval. This began a filler revolution that gave cosmetic injectors a non allergenic product that did not require over correction, was much longer lasting and (of utmost importance) could be reversed. These hyaluronic acid fillers have become the dominating force in contemporary lip enhancement. Numerous other types of injectable fillers have also been FDA approved providing the cosmetic surgeon with numerous safe, and long-lasting options.
Although filler injection is one of the most commonly requested cosmetic procedures, not all patients can benefit from larger or fuller lips. Some patients (primarily ethnic patients) request smaller lips and other patients have congenital or age related morphologic conditions that require more than a simple filler injection to improve. The remainder of this article will deal with several surgical solutions to accommodate this segment of the cosmetic surgery population.
Subcutaneous Lip Lift
Astute cosmetic practitioners realize that all lips are not created equal and in fact they are probably more like snowflakes in that no two patients present with the exact same situation for correction. The youthful lip has many unique characteristics. These include volume that provides plumpness, a shorter length than the aging lip which provides pout and allows for several millimeters of upper incisor show. In addition, the aesthetic youthful lip displays well defined anatomic structures that include the “white roll” which is the light reflex at the vermilion/cutaneous junction of Cupid’s Bow (figure 1A). A well developed Cupid’s Bow that generally has a “lazy M” shape in the upper lip. The lower lip vermilion/cutaneous junction is more curvilinear. Other desirable features include a well defined philtrum and philtral columns. The upper lip is consistent with the Golden Ratio (also called Devine Proportion) ratio of 1:1.6, which means that the upper lip contains about 1/3 of the total lip volume while the lower lip contains about 2/3’s of the total lip volume (figure 2).
Figure 1. This image shows the volume and form of the youthful lip (left) versus the loss thereof in the senescent lip (right).
Figure 2. This image illustrates the aesthetic anatomy of female lip.
The senescent lip undergoes many changes when compared to the youthful lip. A generalized loss of volume occurs that affects all associated tissues. The lip skin is affected from actinic damage and vertical lip rhytids, the lip muscle, fat and salivary glands also becomes atrophic. The supporting teeth and alveolar bone also undergo atrophic changes which lead to decreased lip position and support. The sum of all of these changes results in a longer lip in older individuals (figure1B) with loss of volume and definition. The longer lip also hides the upper incisor show.
The subcutaneous lip lift (SLL) is designed to shorten the lip as well as “roll it out and up” to restore volume and extend vermilion and upper incisor show. Candidates for this procedure must have a lip length of at least 20 mm from the columella to the vermilion, as shortening a lip that is already short can lead to anaesthetic results that are difficult to correct. Using a fine line marker, a very geometric line is drawn at the base of the columella, moving laterally along the bilateral alar bases. These lines should represent the full anatomic curvature of the nasal base structures. Next, a reciprocal line is drawn to complete the “bull horn” or “mustache” anatomy. The lower portion of the incision is 5-7 mm from the top line in the average patient and tapers into the alar bases (figure 3).
Figure 3. The subcutaneous lip lift is sometimes referred to as the “bull horn” procedure because of the geometric outline of the excess upper lip skin below the nasal sill.
Local anesthesia is injected subcutaneously around the marked incision and using a 15 scalpel blade, the incision is made, keeping in mind the curvature of the incision. The incision can include skin or skin and orbicularis muscle depending upon how much outward roll our pout is desired. If muscle is included, the incision can be “V” shaped in cross-section. The marked skin is then excised and cauterization performed for hemostasis (figure 4). Subcutaneous 5-0 gut sutures are used to reinforce the closure and a running 6-0 nylon suture is used for final closure (figure 5).
A patient is shown before and after subcutaneous lip lift (figure 6). Notice the difference between the length and pout of the lip as well as the amount of incisor show in the after picture.
Figure 4. The excised upper lip excess is shown in this figure after hemostasis.
Figure 5. The final 6-0 nylon suture closure is shown one week after the procedure.
Figure 6. This patient is shown before and after subcutaneous lip lift. Not the shorter and fuller lip. The patient also has more upper tooth.
As stated earlier, not all patients desire larger lips. In my personal experience it is mostly African-American patients that seek lip reduction although I have performed the procedure on Caucasian patients. The lip lift procedure is designed to reduce the amount of vermilion show and outward roll of the lips by removing a strip of mucosa and or muscle posterior to the wet/dry line. Patients that have significant class II occlusion (buck teeth) or significant incisor show are not candidates, as this procedure also shortens the lip and excess tooth show would be a complication.
Like many procedures, pre op markings are very important to control the result of the procedure. The patient is marked by estimating the amount of excess or desired reduction. The patient is asked to retract their lips while looking the mirror to the point of reduction desired. The lips should be wiped with alcohol before marking to all better adherence of the marking. A mark is made at this position on the lips (figure 7A). Next, the patient is asked to relax their lips and a mark is made on the vermilion at this point (figure 7B). The difference between the marks (usually 5-7 mm) is the amount of anticipated reduction (figure 7C). This reduction will be completed posterior to the wet/dry line. For the novice surgeon it is better to error on the conservative side as more reduction can always be completed later. After marking the lips, a dry gauze is placed between the lips to prevent markings from smudging.
Figure 7. The patient is shown with lips relaxed (A), the lips pursed (B) and the differences between these positions (C). This is used to estimate the amount of skin to be removed posterior to the wet/dry line.
Important to the success of the procedure is making the incision posterior to the wet/dry line to keep it hidden. Failure to do so will produce a visible incision. The lips are infiltrated with local anesthesia in all planes. Due to the vascularity of the lips, a simultaneous incision/coagulation such as electrosurgery, radiowave surgery, or CO2 laser is preferable (figure 8).
Figure 8. This image shows the Ellman high frequency radiowave micro needle used to incise the lip (8A) and used in the coagulation mode to excise the excess mucosa with simultaneous hemostasis.
Experienced surgeons will often remove 1.5 to 2.0 times the estimated skin. If the pre op markings require a 5 mm position difference, 10-12 mm of skin is removed to compensate for the elasticity of these tissues. This should be approached with caution by novice surgeons.
After the skin is excised, the orbicularis oris muscle and minor salivary glands are visible. For patients that desire significant reduction it is not uncommon to remove a wedge of these deeper tissues. After the proper amount of mucosa and deep tissue is removed, absolute hemostasis is performed and several 5-0 gut key sutures are placed to strengthen the closure. This is followed by a running 5-0 silk suture (figure 9). Although other suture materials can be used, silk is the most patient friendly.
Figure 9. The final closure with 5-0 silk running suture is shown.
This procedure is always followed by significant swelling and patients are frequently placed on a steroid regimen. The suture line may initially be visible due to the swelling, but will retract as swelling resolves. Patients must be warned that in some cases swelling can last for a number of weeks. Figure 10 shows a patient before and after lip reduction.
Figure 10. This patient is shown before and after surgical lip reduction of the upper and lower lips.
Up till about 5 years ago, lip implants were a common procedure in my practice. Due to the advances in HA fillers, the procedure has waned, but is still an option for some patients. Although most cosmetic patients have accepted the process of injectable fillers, there is a segment that disdains needles or the need for continual maintenance. Lip implants can be a suitable option for this segment of the cosmetic population. Contraindications for this procedure include smokers or patients that use their lips to make a living (woodwind instrument players). Patients must understand that the implant may be visible with extreme animation and that it will also be palpable.
I have used numerous materials over the years for lip implantation and although several of these are biocompatible, they do not look or feel natural. At this point in time, the only lip implant I use is a soft, stretchy, tapered implant made by SurgiSil (Plano, TX).
The patient’s lips are measured pre op to determine the proper implant size. This procedure is easily performed with local anesthesia which is infiltrated in all planes of the lip. A “stab” incision is made just shy of each commissure and a dissector is advanced through one incision and out the other incision (figure 11).
Figure 11. A tendon passer is threaded through stab incisions in the center of the lip and the implant is pulled through the central lip into position.
Figure 12. This patient is shown before and after lip implant placement in both lips.
It is important to remain in a straight line in the center of the lip throughout the entire dissection or the implant will not sit naturally. I generally use a tendon passer to perform the dissection, then pull one end of the implant through the incision, center it and close the incisions. Experienced surgeons can perform this procedure in about 5 minutes. Patients are asked to limit oral function for several days and ice as applied as much as possible. Figure 12 shows a before and after picture of a patient with upper and lower lip implants.
For most cosmetic surgeons, injectable fillers can satisfy the majority of their patients. Some patients, however, present with inherited, developmental, or age related lip problems that are not amenable to filler injection. For this population, procedures such as the subcutaneous lip lift, lip reduction and lip implants may have benefit.
To find out more about lip enhancement options and other cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia visit www.lovethatface.com
Joe Niamtu, III DMD
Cosmetic Facial Surgery