Eur J Plast Surg
DOI 10.1007/s00238-017-1293-z
ORIGINAL PAPER
Prevalence of transverse upper labial crease
Gertrude M. Beer 1 & Mirjana Manestar 1
Received: 15 January 2017 / Accepted: 10 February 2017
# Springer-Verlag Berlin Heidelberg 2017
Abstract
Background The presence or hyperactivity of the depressor
septi nasi muscle has been proposed to cause a visible crease
in the upper labial region that is esthetically disturbing to
patients. The objective of this paper was to determine how
often an upper labial crease is evident in women and to find
a straightforward treatment. Muscular creases can be amelio-
rated with botulinum toxin. However, weakening the depres-
sor septi nasi muscles with botulinum toxin did not eradicate
existing upper labial creases at rest or during facial animation.
Therefore, we proposed that a complex interplay exists be-
tween the upper labial muscles, and we sought to determine
which of these muscles are responsible for the existence of the
upper labial crease.
Methods A total of 100 consecutive female volunteers who
visited a plastic surgery clinic were prospectively examined.
The presence and localization of the upper labial crease were
assessed at rest and during animation prompted with the
Bsmile test^ and during snuffling. Additionally, the appearance
and symmetry of the upper labial crease were assessed and
correlated with the type of smile to identify the dominant
muscles involved.
Results In total, 38% of women older than 40 years presented
with an upper labial crease at rest, and 70% presented with a
crease during animation. Only one third of the women were
aware that they had such a crease when they smiled. When the
crease was present, it was bilateral in 98% of the women.
* Gertrude M. Beer
gertrude.beer@access.uzh.ch
1
Institute of Anatomy, Department of Macroscopic Anatomy,
University Zürich-Irchel, Winterthurerstrasse 190,
8057 Zürich, Switzerland
When it was asymmetrical, which was the case for 10% of
women, the fold was longer, shorter, or less visible on one half
of the upper lip. The localization was highly variable and
ranged from the base of the columella to the caudal third of
the upper lip. When an upper labial crease was present at rest
and/or during facial animation, it was associated with a type B
smile, i.e., the Bcanine^ smile, due a dominant levator labii
superioris muscle.
Conclusions This study showed that upper labial creases are
present more often than women are aware of them. The injec-
tion of botulinum toxin into the levator labii superioris mus-
cles can eradicate an upper labial crease.
Level of Evidence: Level IV, risk / prognostic study.
Keywords Transverse upper labial crease . Depressor septi
nasi muscle . Mimetic muscles . Botulinum toxin . Levator
labii superioris muscle . Canine smile
Introduction
The transverse upper labial crease, when present, is located in
the mid-philtral area below the nose. It may be visible both at
rest and during animation or only during facial animation. The
anatomical basis for the formation of this crease is thought to
be the insertion of the two depressor septi nasi muscle fibers
into the overlying skin [1]. These small muscles originate at
the medial crural footplate and are located on either side of the
caudal part of the nasal septum and the anterior nasal spine.
Rohrich [1] identified the following three types of presenta-
tion for these muscles: type I is primarily responsible for the
upper labial crease (62% of cases) and inserts into and inter-
digitates fully with the orbicularis oris muscle, type II (22% of
cases) inserts into the periosteum of the maxillary bone and is
incomplete or missing in the orbicularis oris muscle, and type
 Eur J Plast Surg

Fig. 1 The three types of smile defined and illustrated by Rubin in 1974 the dominant action of the levator labii superioris muscles, type B. right
[12]. left The BMona Lisa^ smile, with the dominant action of the The Bfull denture^ smile, in which all muscles are equally dominant and
zygomaticus major muscles, type A. middle The Bcanine^ smile, with all teeth are exposed, type C

III (16% of cases) shows either an absence of or rudimentary muscles, and we sought to identify the muscles that are
depressor septi nasi muscles. jointly responsible for the existence of an upper labial
The actions of these muscles have been assumed to cause crease. Additionally, we sought to determine how often
or accentuate a drooping nasal tip, elevate and shorten the
upper lip, and lead to an upper labial crease in both the static
and dynamic face. Cachay [2] summarized these symptoms as
part of the Brhino-gingivolabial syndrome of the smile,^ and
Cetinkale [3] named this syndrome Bsmiling deformity.^ To
correct this deformity, Rohrich [1] recommended the dissec-
tion and transposition of the depressor septi nasi muscles as an
adjunct to rhinoplasty. Other authors have recommended the
resection of these muscles [4, 5].
In contrast, Toutounchi [5] and Kosins [6] recently
questioned the beneficial role of nasal tip rotation and projec-
tion and the shortening of the upper lips by cutting or reposi-
tioning the depressor septi nasi muscles. Rarely one of these
reports has given specific attention to the eventual improve-
ment of an existing upper labial crease.
With increasing age, this crease can become visible
and unsightly even when the face is at rest, and it is
esthetically disturbing to patients. As botulinum toxin is
well known to ameliorate dynamic muscle creases [7,
8], Redaelli [9] and Maio [10] suggested injecting small
doses of botulinum toxin into the depressor septi nasi
muscles just below the nasal tip at the beginning of the
columella. In our practice, this therapy did not eradicate
existing upper labial creases. Therefore, we anticipated
that a complex interplay exists among the upper labial

Table 1 Frequency of upper labial crease at rest and during animation

in two groups of women (aged <40 vs. > 40 years)

Crease present <40 years, n = 21 >40 years, n = 79 n = 100

At rest 0 30 (38%) 30 Fig. 2 Different localizations of the upper labial crease at rest. a A short
Laughing 5 (24%) 51 (65%) 56 upper labial crease near the columellar base in a 45-year-old woman. b A
slightly asymmetric upper labial crease in the mid-philtral area in a 65-
Snuffling 9 (43%) 60 (76%) 69
year-old woman. c An upper labial crease in the caudal part of the upper
Asymmetry 0 10 (13%) 10 lip in a 50-year-old woman. The two women in b, c do not have a
drooping nasal tip at rest
Eur J Plast Surg
Fig. 3 Upper labial crease in a 56-year-old woman with a Bcanine^ smile.
a The levator labii superioris muscles pull the alar crease extraordinarily
high, and the upper lip crease becomes very prominent. b The same upper
labial crease at rest
an upper labial crease is evident in women at rest and
during animation of the face and to identify visible var-
iations of this crease.
Patients and methods
A total of 100 consecutive female volunteers who visited a
plastic surgery clinic were prospectively examined for this
study. The women were divided into two groups according
to age (younger or older than 40 years). The study was carried
out in compliance with the Helsinki Declaration and was ap-
proved by the ethics committee of the Cantonal Coordination
Office for Human Research (KOFAM). Informed consent was
obtained from all women. When one of them was younger
than 18 years, informed consent was also obtained by a parent.
Fig. 4 a The levator labii superioris muscle with partial insertion into the
connective tissue near the nostril base (arrow), shown in a dissected
cadaver. The skin on the left cheek has been removed to reveal the
muscle fibers along the wall of the nose (arrowheads). Some of the
lateral bundles of the angular head continue between bundles of the
Only women who had undergone previous operations on or
around the nose and mouth, especially rhinoplasty and
septoplasty, or who had previously received botulinum toxin
and/or hyaluronic acid injected into the muscles near the nose
or the mouth were excluded from the study. Otherwise, con-
secutive enrollment was strictly followed.
The presence and localization of the upper labial crease
were assessed at rest and while smiling (the Bsmile test^
[11]) and snuffling. Additionally, the appearance and symme-
try of the upper labial crease were assessed. To better visualize
the crease, and in contrast to many other reports, we took
photos of the patients from a frontal view instead of a lateral
view.
During the smile test, the type of smile was also recorded.
According to Rubin [12], the three basic smile types include
the BMona Lisa^ smile (67%), the Bcanine^ smile (31%), and
the Bfull denture^ smile (2%; Fig. 1).
Statistical analysis was performed using SPSS version 15
(SPSS Inc., Chicago, IL, USA). Variables are expressed as
frequencies and percentages for qualitative data and as the
means ± standard deviation for quantitative data.
Results
The youngest woman was 16 years old, and the oldest woman
was 80 years old. The mean age was 50 years (±14 years).
Twenty one of the women (1/5) were younger than
40 years.
The presence of an upper labial crease in the two groups at
rest and during facial animation is described in Table 1. Only
one third of the women were aware of having such a crease
during facial animation.
When present, the crease was bilateral in 98% of the wom-
en. When the crease was asymmetrical, as was the case in 10%
orbicularis oris muscle medially as far as the philtral region, inserting
into the philtral skin. b The connective tissue base of the levator labii
superioris muscle near the nostril base often becomes visible and appears
string-like when the individual smiles (arrow)
 Eur J Plast Surg

of the women, it was either longer, shorter, or less visible on

one half of the upper lip. The crease never appeared in two
separate parts.
The localization of the crease was highly variable and
ranged from the base of the columella to the caudal third of
the upper lip (Fig. 2). When an upper labial crease was present
both at rest and during animation, it was associated with a
more or less pronounced type B smile, i.e., the canine smile.

Discussion

This study showed that only one third of women who

had an upper labial crease during facial animation were
aware of it. In younger patients, the crease was present
only during animation, whereas in patients older than
40 years, it was increasingly present both during anima-
tion and at rest. Interestingly, this finding was always
correlated with a certain type of smile, i.e., the canine
smile. The canine smile occurs when the levator labii
superioris muscles are the dominant upper lip muscles.
When the individual with this type of smile laughs, the
levator labii superioris muscles contract first, exposing
the canine teeth and pulling the alar base superiorly in a
significant manner. The corners of the mouth contract
only secondarily to finally pull the lips upward and
outward [12]. The significant rise of the alar crease
during such a smile leads to a disproportionate move-
ment of the alar crease of the nose upward and the
illusion that the nasal tip is plunging [6]. This further
leads to compression of the mediocranial parts of the Fig. 5 Frontal views of a 45-year-old woman. a Upper labial crease
located near the columellar base that is barely visible at rest. The spots
upper lip and thus contributes to the presence of an
where the botulinum toxin injection was planned are indicated with
upper labial crease (Fig. 3). The more the alar crease arrows. b When the individual smiles, the crease becomes very
rises above the nasal tip in the canine smile and the more prominent, the alar creases move superiorly, and the upper parts of the
under-rotated and acute the nasal tip appears at rest, the nasolabial fold become very deep. The smile is a Bcanine^-type smile. c
After the injection of 2 u of botulinum toxin into the levator labii
more the nose appears to plunge and the deeper the upper
superioris muscle at each of the two nasal alar junctions, the smile
labial crease becomes. Kosins [6] prospectively measured became softer, the alar bases moved less superiorly, the upper lip was
changes in these parameters in 25 women before and dur- not shortened as much, and the upper labial crease disappeared. d Some
ing smiling in lateral-view photographs. Whereas the alar of these changes, especially the elongated upper lip, were even visible at
rest
crease was disproportionally elevated by 3.7 mm, the na-
sal tip dropped only negligibly by 0.9 mm. Instead of
leaving a positive impression when smiling, this type of place cartilage at the transection site [15]. Other authors
smile often causes an unsightly appearance and leaves an question the effectiveness of these procedures [5]. The
unpleasant impression [13, 14]. authors of the present study would not readily resect
Surgeons [2, 15] who consider the depressor septi sections of important muscles such as the orbicularis
nasi muscles to be the main contributor to this smiling oris muscle, which is associated with a risk of losing
deformity recommend excision of these muscles, some- some upper lip fullness, just to eradicate a dermal
times along with portions of the orbicularis oris and crease. Generally, it is doubtful that the small and short
nasalis muscles [2]. To prevent the reattachment of the depressor septi nasi muscles would have the power to
two muscles, additional attempts have been made to accentuate a drooping nasal tip and to contract against
Eur J Plast Surg
the underlying medial crus of the major alar cartilage
and thus cause an upper labial crease. Even if the de-
pressor septi nasi muscle interdigitates with the
orbicularis oris muscle (type 1), it is more likely that
it elevates as the orbicularis oris contracts in a circular
manner and thus shrinks during smiling. Moreover, no
reported rhinoplastic studies have determined the degree
to which the depressor septi nasi muscle contributes to
the drooping of the nasal tip and eliminates an upper
labial crease as a result of simultaneous rhinoplasty ma-
neuvers that elevate the nasal tip per se. Additionally,
these evaluations have always occurred only after a pro-
cedure and not before [5]. Because the depressor septi
nasi is an independent muscle, its contribution to smil-
ing cannot be directly measured. Although Kalantar-
Hormozi [14] noticed an upper labial crease reduction
from 61 to 30% after the release of the depressor septi
nasi muscles, the literature does not offer sufficient ev-
idence to support the use of depressor septi nasi muscle
surgery to treat an upper labial crease.
As our study determined, the upper labial crease is
correlated with the canine smile type, indicating that the
levator labii superior muscles (Fig. 4) and not the de-
pressor septi nasi muscles play a dominant role in short-
ening the upper lip and contributing to an upper labial
crease.
We also noticed that in the other two smile types, in
which the levator labii superioris muscle is not as dom-
inant, the alar crease also rises, but it fails to rise above
the nasal tip [6]. The upper lip is therefore not elevated
to the same degree, and an upper labial crease does not
appear.
If our hypothesis was correct, weakening the levator
labii superioris muscles with botulinum toxin would
cause the upper labial crease to disappear. As surgery
with the dissection of the levator labii superioris mus-
cles was not an option for us, we began to inject small
doses (2 u) of botulinum toxin into the levator labii
superioris muscle at both alar creases of the nose. At
such small doses, the well-known side effects of botuli-
num toxin on the perioral area and the smile can be
prevented. With this uncomplicated treatment, the upper
lip elongated, the prominent proximal nasolabial fold
flattened, and the perioral expression softened. We ex-
perienced that the attractiveness of the smile improved,
and the upper labial crease disappeared (Fig. 5). Yet,
women should also be informed about possible side ef-
fects of botulinum toxin. Local, general side effects
from the injection such as swelling, hematoma, or in-
fection are very rare. The most feared specific side
effect is the inadvertent weakening of the cranial parts
of the orbicularis oris muscle with temporary changes in
speaking, drinking, and eating. The other specific side
effects such as the elongation of the upper lip with
reduced visibility of the frontal upper teeth and the
change in the facial expression by a flattened upper
nasolabial fold and a different type of smile are inevi-
table and should be considered in the decision-making
process for the eradication of the transverse upper labial
crease with botulinum toxin.
Compliance with ethical standards
Conflict of interest Gertrude M. Beer and Mirjana Manestar declare
that they have no conflict of interest.
Funding This study was not funded by anyone.
Ethical approval All procedures performed in this study were in ac-
cordance with the ethical standards of the national research committee
and with the 1964 Helsinki declaration and its later amendments or com-
parable ethical standards.
Patient consent Patient consent was obtained from all individual par-
ticipants included in the study. Additional consent was obtained for the
use of their images.
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