About 99 percent of the time lip enhancement involves making lips bigger, usually with fillers. But for a significant number of patients, making the upper lip smaller via a lip lift is actually the more appropriate aesthetic procedure.

Much of what we consider female beauty concerns the amount of the central incisor teeth that show when the mouth is at rest and during various animations. In a normal situation, an attractive female shows several millimeters of incisal edge in repose. In the same situation, however, this patient would show several millimeters of gingiva when smiling. Patients who do not show any incisor at rest or gingiva when smiling realize that their aesthetics are skewed but are not sure why.

A lip lift procedure can improve lip and smile aesthetics in several ways. First and foremost, it shortens the lip. Younger patients usually have shorter lips that are plump and curvaceous, while older patients frequently have elongated upper lips and tend to lose volume in their lips with advancing age. This elongation and volume loss is a result of maxillary and mandibular bony changes, atrophy of the skin, mucosa, perioral musculature, and parenchymal glandular tissue, as well as attrition of the teeth.

The goal of the lip lift procedure is to shorten the upper lip and evert the vermilion, which results in a more volumized “rolled-out” lip. When measuring the lip from the bottom of the philtrum to the top of the vermilion, excessive length is generally considered more than 20mm.

Lip Lifting: Marking Matters

The actual lip lift procedure takes about 30 minutes and can be performed with local anesthesia, although I usually operate with IV or general anesthesia. The crux of this procedure is to remove excessive upper lip skin just beneath the nose. As the incision is larger in the center and tapers out for blending on the lateral edges, a specific geometric pattern is used. This pattern resembles a “bullhorn,” “Angel Wing,” or “Mustache,” and the procedure is sometimes named after one of these.

It is very important to draw this outline with a marking pen that will not fade with surgical prep, etc., as it will serve as the precise template for excision. It is also important to mark the pattern before any anesthesia and with the patient in the upright position.

I have seen some surgeons use a simple elliptical incision for this procedure, which does not heal as well as the precise geometric incision. The preferred incision corresponds to the lower nasal anatomy and gently tapers out to the lateral nostril. It is also important to make the incision just at the nasal sill and not extend into or too far above or below the nostrils. Again, marking is everything in this procedure.

The maximum amount of skin resection is commensurate with the length of the lip. In general, I usually remove 5-8mm of skin, which can represent up to one-third of the total lip length as measured from philtrim to vermilion (Figure 1). Novice surgeons should remain conservative in determining how much skin to remove.

Figure 1. This image shows both the “bullhorn” pattern of excision and an approximate one-third reduction of upper lip skin as marked.

The Procedure

A small amount of local anesthesia is injected to provide hemostasis, but not to excessively distort the tissues. Using a #11 blade, the intricate pattern is incised then removed. Although some surgeons remove skin and orbicularis muscle, I generally do not remove muscle, as I have seen abnormal animation occur in excessively operated patients from other surgeons.

A full thickness skin excision is performed using the fine tip of the #11 blade (Figure 2). This is an adjustable procedure as at this point, the surgeon can estimate the amount of incision show and remove more skin if desired.

Figure 2. The #11 blade is used to outline the excision pattern to enable a full thickness skin removal.

Figure 3. The left image shows the full thickness excision and the right image shows the wound approximated with subcutaneous gut suture.

After this skin is excised, hemostasis is performed with microbipolar cautery, as the upper lip is a vascular area. Next, subcutaneous sutures are placed using 5-0 gut suture (Figure 3). This is important to bolster the strength of the repair, as this area is subject to a lot of animation. These subcutaneous sutures also help align the precise pattern between the proximal and distal skin margins.

Final closure is performed with alternating 5-0 and 6-0 gut sutures or the surgeon's choice (Figure 4). Sutures are left in place about one week. Patients are asked to refrain from significant animation for the first week and to avoid foods that would aggravate the area or require excessive lip movement.

Figure 4. This image shows the final closure and the excised skin overlying the operative site.

Figure 5. This patient is shown before and after lip lift. Note the shorter and everted lip and aesthetic scar.

Figure 6. The same patient is shown in the lateral view illustrating increased incisor exposure

Figure 7. This image shows a patient before and after lip lift, illustrating the shortening of the lip and increased incisor show.

A True Aesthetic Concern

Although the average patient heals with a very acceptable scar, I tell all patients that I can laser the scar at six weeks for superior blending and include this in the cost of the procedure.

Patients report high satisfaction with the results of this procedure, as it addresses their true aesthetic concerns and makes a pronounced difference in their facial appearance, when in repose and when smiling.