Cosmetic Surgery of the Lips

Bvian P. Maloney, M.D., F.A.C.S.

ABSTRACT Lips arc fllc c c ~ t r a lfeature it1 fllc lozucr third of tllcface. Wliefz flze!y are full a/1d mrll
dfirlcd, tllr!y impart a serlsc of!yolrtll, Iiealfh, and attractivcr~r~ss to fllc benrer. Thin,flnt lips, orl thc oflicr
Ilarld, iinply fragility atid srnilify. T l i ~character is ti^^ Of t11e l i ~ r~rss p o n s i b l ~ f i rfhesc qunlitics arc tlie
sliapc of C ~ ~ p i dbozu,
' s fhe rclativc length o f f h e upper lip, and the projection ov bulk o f t h c lips. Esfllrtic
guidelirzes arc p r e s c ~ f c dfor each of these chvacteristics, zullich 7uhen understood help the slrrcycorl

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forrir~~lafcall operatizlr p1n11.Lip a l r g r r l r ~ t a f i techniques
o~ llsing alrfogenous and alloplasfic niatcrials arc
prcscnfe~f.For p a f i ~ n f szuifli a 10~9lrpper lip, vcvirdiofi adva/iceii~enfafzd nasal base resccfiori arc
disclrssed i ~ zdetail. W i t h a look to tllefirture, a discussion cfpr~~lii?rinary cxpcriem-r with carbon dioxidc
lascr lip advnnce~ncnfcot~cllrdcstllc articlc.

A N A T O M Y A N D EMBRYOLOGY tion of the upper lip. Because of the paucity of mus-

culocutaneous attachments in the philtral groove,
The upper lip generally constitutes one-third of the lip tends to be thinner here. The upper lip is
the lower third of the face1(Fig. 1).The lower lip is defined by the central inverted W or Cupid's bow.
supported by the chin, and both together make up This appears to be the result of lifting action of the
two-thirds of the lower third of the face. The cutane- levator labii superioris inserting into the vermilion
ous portion of the upper lip extends to the nasal sill border at the philtral column and extending lat-
superiorly and to the nasal labial fold laterally. The erally. The highest point of the vermilion of the up-
lower lip shares the same lateral border as the upper per 11p should lie along the philtral columns with a
lip and is separated from the chin by the mentolabial central depression resulting in an inverted W shape.
sulcus. The lateral commissure of the lips should be The median tubercle of the upper lip 1s formed by
roughly in line with the medial limbus of the eyes. the vermilion attachment of the inferior margin of
Many of the undulations of the cutaneous portion the orbicularis oris muscle antagonistically oppo-
of the lip derive their origin from the underlying sing the levator labii superioris, resulting in a central
musculature during fetal development. The orbicu- protuberance.
laris oris muscle fibers of the upper lip from each The lower lip has the same tissue layers as the
side decussate in the midline and insert into the skin upper lip. The greatest area of vermilion show of the
of the opposite side lateral to the philtral groove2 lower lip should lie along parallel points with the
(Fig. 2). The philtral ridges represent the medial philtral ridges of the upper lip. Both upper and
borders of contralateral orbicularis oris muscle in- lower lips contain cutaneous and vermilion portions
sertion into the skin. The philtrum (Greek pliiltron, separated by a raised roll of skin commonly referred
"love charm") corresponds to the compact decussa- to as the sollrfc liile or roll. The purpose of the white
tion of the orbicularis oris muscle in the central por- line is u n k n o ~ n . It
~ -may
~ serve as a reservoir of

Department of Surgery, University of Alabama School o f Medicine, and McCollough, Grotting, and
Associates Plastic S ~ ~ r g e Clinic,
ry A MedPartiiers/Mullican Affiliate, Birmingham, Alabama

Reprint requests: Llv. Maloney, 1600 20th St. South, Birmingham, AL 35205

Cop! rlglit ' 19Yh b\. I'li~rmrMrJ~c,ilI'ubl14wr\, Inc., 181 Park A \ w w South, Nc\v 'i'ork, NL' 10016. ,411 r ~ g h t sr r x w id
FACIAL PLASTIC SURGERY Volume 12, Number 3 July 1996
Figure 1. Esthetic proportions of the lower third of the
face. The lateral commissure of the lips should generally
extend in a vertical line to the medial limbus of the eyes.
skin, allowing the lips to perform complex motions
during talking and sucking. Possibly its greatest at-
tribute is the esthetic quality it imparts to the lips.
Young patients with full lips typically have a promi-
nent white line that frames and accentuates the ver-
milion. As a result of the aging process, the white
roll tends to flatten, contributing to the development
of an entropion of the upper lip and ectropion of the
lower lip. In other words, the vermilion show of the
upper lip tends to decrease and the central defining
points generally become blunted. The amount of
Figure 2. An,~tomic basis for the shape of Cupid's bow.
Orbicularis muscle fibers dccussate in the philtral groove
and insert along the opposite philtral ridge. The Ievator h b i i
superioris insertion onto the lip ciccounts for the adjacent
vernlilion elevation.
incisor show also decreases with time.6 These same
forces can cause the lower lip to fall away from the
lower teeth with increasing age. The underlying
supporting facial bones tend to decrease in size with
age, a process that can be accelerated in the eden-
tulous patient. The end result of the aging process is
most often a larger cutaneous envelope around the
mouth with poor vermilion definition.
EVALUATION O F THE LIPS
Twenty-seven muscles influence the periorbital
area. As the perioral musculature contracts, the up-
per lip tends to flatten and elongate; the lower lip
moves upward and the chin flattens. Since the goal
of surgery is to effect a change in the resting position
of the lips, it is important to have the patient evalu-
ated in a relaxed fashion to diagnose the lip condi-
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tion accurately.
Check the patient's occlusion, that is, the way the
maxillary teeth contact the mandibular teeth. Ab-
normalities in the patient's occlusion or anterior
teeth can have a significant effect on lip position. If
abnormalities exist, the surgeon should make the
patient aware of this and recommend the appropri-
ate orthodontic or orthognathic consultations.
Instruct the patient to bring the teeth together and
relax the lips; this can be difficult. Reflexes that
maintain an anterior lip seal may mask an underly-
ing lip malposition. To help overcome these reflexes,
have the patient sit upright and move the mandible
up and down several times with a thumb and fore-
finger to relax the musculature of the mandible and
lips. The patient is encouraged to relax during this
procedure so that all the movement is controlled by
the examiner. The amount of space between the lips
is checked when the teeth touch during elevation of
the mandible. The shape, definition, and any asym-
metry of the lip vermilion are noted and recorded.
The proportional lengths of the upper and lower lips
are also noted. Upper lip length is measured from
the subnasale (the point where the columella and lip
meet) to the stomion (the lowest point o f the upper
lip). The lower lip can be measured from the sto-
mion (the highest point of the lower lip) to the gna-
thion. Significant variation in lip length exists be-
tween sexes, with men generally having longer upper
lips than women.
A useful plane for evaluating the relative protru-
sion or retrusion of the lips is one connecting sub-
nasale and soft-tissue pogonion, that is, the most
anterior point of the chin (Fig. 3). Lip protrusion or
retrusion is measured as a perpendicular linear dis-
tance from the subnasale-pogonion plane to the
most prominent point on the upper and lower lips.
In a normal adolescent group, the upper and lower
lips fell forward of the subnasale-pogonion plane by
 COSMETIC SURGERY OF THE LIPS-Maloney

3.5 mm and 2.2 mm, re~pectively.~ Considerable

variation exists in malocclusion groups; therefore,
orthognathic consult generally is recommended for
these patients prior to lip surgery.
A small vertical space or interlabial gap is found
between the upper and lower lips in a relaxed posi-
tion; however, in malocclusions and facial dishar-
monies the gap may be large or completely lacking.
Older patients or those with congenitally long upper
lips generally have no interlabial gap.
Because of the multiplicity of muscular actions
around the mouth, the lip positions may be variable,
and repeating the examination several times may
yield a more detailed picture of the resting lip posi-
tion.

ANESTHESIA

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Lip procedures are generally carried out under
local anesthesia with intravenous conscious seda- Figure 3. Evaluation of the projection of lips. The upper
tion. The choice rests with the surgeon, depending lip should lie roughly 3.5 mm anterior to a line connecting
the subnassle and pogonion. O n average, the lower lip
on patient preference and whether other procedures should be 2.2 mm anterior to the line.
are being performed concurrently. The sensory nerves
of the lips are branches of the infraorbital (V2) and
mental (V3) nerves. Viscous 4% lidocaine (Xylo-
caine) jelly is applied to the mucous membranes of sensitivities to this product, two skin tests performed
the upper and lower lips. Regional anesthetic blocks roughly 6 weeks apart are recommended prior to
consisting of a combination of 11% lidocaine with initiating treatment. Patient preparation consists of
1:100,000 epinephrine and 0.5% bupivacaine are oral analgesia and regional blocks. The implants can
placed appropriately through the oral mucosa. Lido- be used to augment the lip or treat perioral rhytids.
caine 1% with 1:100,000 epinephrine and hyaluroni- Zyderm is generally placed in the superficial der-
dase (Wydase) are mixed in a ratio of 10 mL to 1mL, mis. During augmentation of the lip, injection of the
respectively. This mixture is injected along the lips implant at the wet line of the lip is done by tunneling
as the needle is passed from o n e commissure to the in a superficial plane. Massaging the lip helps dis-
other. Only a limited amount of local anesthetic con- tribute the implant and reduce lumpiness. A benefit
taining epinephrine is injected directly into the lips of these materials is the absence of morbidity at the
to minimize distortion. This solution helps to de- donor site, and the fluid nature of the implant allows
crease intraoperative bleeding. the surgeon to augment areas very specifically. One
of the main disadvantages is the short duration of
effect, ranging from 2 to 6 months for many patients.
AUGMENTATION Silicone and Gore-Tex are not widely accepted for
lip augmentation at this time, primarily because of
Augmentation materials can be allografts of such the position of the Food and Drug Administration
materials as collagen, silicone, or Gore-Tex, or they (FDA) regarding their use.
may be autologous, namely, fat, dermis, superficial
musculoaponeurotic system (SMAS), or temporalis
fascia. Augmentation techniques are generally indi- Autologous Materials
cated for patients with upper lips of short or average
length, or those with well-defined upper lips lacking The use of autologous materials for lip augmenta-
projection or bulk. Thin lips can be congenital or tion, such as fat, dermis, SMAS, and fascia, has in-
acquired as a result of the aging process or trauma. creased recently. There is no risk for allergic reac-
tions, and the grafts are readily available in most
cases. A potential drawback is the additional mor-
Allografts bidity at a donor site if the augmentation is per-
formed as an isolated procedure.
Zyderm collagen".' is an enzyme-digested, puri- Fat has been used for lip augmentation for quite
fied bovine product. Because of the possible allergic some time. In the past, only limited amounts of the
FACIAL PLASTIC SURGERY Volume 12, Number 3 July 1996

fat would generally survive permanently and com-
monly leave the patient with yellowed lips. With
improved techniques of harvesting and washing the
fat, long-term survival seems to be improved and
yellowing of the lips minimized. Patients are gener-
ally counseled preoperatively that there may be con-
siderable resorption of the fat and that multiple pro-
cedures may be necessary to achieve the desired
augmentation. Patients often volunteer a plethora of
donor sites, only to learn that the amount to be
removed is so small as not to effect any significant
contour changes. The lower abdomen can be easily
accessed through an umbilical incision (Fig. 4A).
The submental region and hips are other common
donor sites. The areas are anesthetized with a solu-
tion of 0.5'4 lidocaine with 1:200,000 epinephrine.
After allowance is made for maximal hemostatic
effect, liposuctioning of the donor area is performed
using syringe suction. After harvesting roughly 10
mL of fat per lip to be augmented, the fat is washed
with sterile saline (Fig. 4B,C). After several wash-
ings, the fat appears as a distinct layer in between an
upper oily layer and saline below. The fat is saved
and the other layers are discarded. The fat can be
placed on a piece of Telfa to help remove some of the
excess saline (Fig. 4D). The graft is then placed in a
syringe. A 14- to 16-gauge needle is threaded through
a small stab incision in the oral commissure and
passed submucosally to the opposite commissure
(Fig. 4E-H). The fat is deposited as the trochar is

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Figure 4. A: Syringe liposuction device on draped um-

bilical site. Once inserted, a lock at the end of the syringe
secures the plunger and maintains the vacuum. 6 : Stratifica-
tion of syringe contents immediately after suctioning. From
top to bottom: oil layer, fat, and serosanguineous layers.
C: Coupling device that facilitates washing the fat with sa-
line. Washing is performed several times until the implant is
yellow-white. D: Washed fat implant is drained of excess
saline and placed in a syringe. Notice the intact nature of the
implant. (Figure continued on the next page.)
 COSMETIC SURGERY OF THE LIPS-Maloney

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G
Figure 4. (Continued). E: The fat can be delivered
through a syringe and trochar. F: An alternative device for
delivering the fat. This allows for depositing a quanta of
implant with each compression of the trigger. G: The fat
implant is being inserted into the lateral commissure of the
lip of a patient immediately following upper and lower lip
advancement. H: Same patient 3 months after the proce-
dure. Notice the slight yellowing of the lips.

withdrawn. The small commissure incision is closed
with an absorbable suture. The donor site is closed
with a absorbable suture, and pressure garments are
not generally applied unless a change in body con-
tour is desired. Procedures can often be repeated in
the same donor area without significant contour
changes.
A strip of SMAS can make an excellent implant.
Most commonly it is harvested at the same time a
faceliftprocedure is performed (Fig. 5A). The SMAS

A B
Figure 5. A: Harvesting a strip of SMAS during a facelift operation. The length of the implant can be extended
by excising above or below as needed. Care should be taken not to go deeper than the parotid fascia. B: Lip
implants are commonly soaked in an antibiotic solution prior to insertion. Photo depicts a strip of SMAS in
gentamicin solution. (Figure continued on the next page.)
FACIAL PLASTIC SURGERY Volume 12, Number 3 July 1996
is tailored to the desired shape and then soaked in a
gentamicin solution (Fig. 58).An incision is made in
the vermilion of both lateral commissures and a
submucosal tunnel is created (Fig. 5C). Care should
be taken in developing the tunnel, as the tendency is
to create a tunnel that lies more posteriorly than the
desired position (Fig. 5D). An alligator forceps is
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Figure 5. (Continued). C: The commissure incision gen-
erally involves the mucosa and not the cutaneous portion of
the lip. One incision in each commissure can often be used
for augmenting both upper and lower lips. D: Blunt-tipped
scissors can be used to create a submucosal pocket. One
needs to be careful not to let the scissors drift posteriorly
when creating the pocket. One of the main goals of augmen-
tation procedures is generally anterior projection, and the
placement of the submucosal pocket i s paramount to ac-
complishing this. E: An alligator forceps can be inserted
through the submucosal pocket and used to pull the implant
through to the desired position. F: The commissure incisions
are closed with an absorbable suture. G: Distended appear-
ance of patient immediately after upper SMAS lip augmenta-
tion. Most postoperative edema resolves generally within 2
weeks; however, patients commonly notice lip tightness for
up to 2 months.
inserted into one of the commissure incisions and
passed through the tunnel to the opposite commis-
sure incision (Fig. 5E). The forceps grasp the end of
the SMAS graft and pull it through the subrnucosal
tunnel until its desired position is achieved. A dis-
solvable suture attached to the trailing end of the
SMAS can be used to shimmy the graft back and

forth to confirm its position. The commissure inci-
sions are closed with a dissolvable suture (Fig. 5F,G).
The long-term augmentation results are similar to
those with fat grafts. Therefore, it is best to inform
the patient that effects will be temporary.
Temporalis fascia is readily available at the time a
facelift is performed, or it can be harvested sep-
arately through a vertical incision over the tempo-
ralis fossa. The fascia is easily identified as the im-
mobile layer beneath the loose areolar fascia. The
superficial layers will slide back and forth; however,
the temporalis fascia remains stationary. The width
of the lip is measured and a rectangular piece of
fascia equal to this distance is harvested (Fig. 6A,B).
If additional bulk is necessary, some of the underly-
ing temporalis muscle can be harvested with the
fascia. The fascia is then folded or rolled to the de-
sired bulk (Fig. 6C). Sutures are not usually neces-
sary to maintain the desired shape of the implant.
The fascia is inserted through a tunnel, as previously
described for SMAS grafts (Fig. 7).
If the patient has any scars, preferably on the
abdomen, back, or upper extremities, where the skin
tends to be thicker, the deeper dermis can be har-
vested and used for lip augmentation. The epi-
COSMETIC SURGERY OF THE LIPS-Maloney
dermis and papillary dermis can be removed with a
dermabrader or carbon dioxide laser. Dermal grafts
tend to be thicker than fascia grafts and are treated
similarly to the SMAS grafts. Dermal cysts can oc-
cur, most likely from buried superficial dermis. This
is an unusual complication that can generally be
easily treated by local excision.
Technique
A v-y advancement of the mucous membranes or
augmentation chei10plasty~~J can be used to in-
crease the bulk or projection of the lips (Fig. 8A,B).
The undersurface of the lip is outlined to create flaps
that, when advanced, it is hoped will result in the
desired fullness (Fig. 9A-D). The flaps are devel-
oped in a submucosal plane and advanced. Absorb-
able sutures are used to secure the flaps in their new
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positions. When the flaps are designed, incisions
should be done intraorally as much as possible to
decrease the possibility of their being visible. Dissec-
tion should not generally involve the orbicularis
muscle, as this may result in a more protracted re-
covery period.
Figure 6. A: Measurement of the horizontal length of the
lip i s necessary prior to lip augmentation to facilitate harvest-
ing an adequately sized implant. B: Temporal incision with
the temporal fascia identified and donor area outlined. If
additional bulk is necessary, some of the underlying tempo-
ralis muscle can be harvested in continuity with the over-
lying fascia. C: A temporalis fascia implant grasped by the
alligator forceps. The implant does not generally require any
sutures to maintain its shape.
 FACIAL PLASTIC SURGERY Volume 12, Number 3 July 1996
Figure 7. Comparison of SMAS and temporalis fascia
grafts. When significant bulk is necessary, SMAS grafts gen-
erally are bulky and plentiful. Temporalis fascia grafts are
more often thinner, and although muscle can be harvested
with them, they tend to be better suited for small-to-medium
augmentation.
Postoperative Instructions for Lip
Augmentation
Iced compresses should be applied to the lips for
36 hours. A cool, soft diet is recommended. Lip ac-
tivity (talking and chewing) should be limited for 2
weeks. A broad-spectrum antibiotic is commonly
prescribed for 5 days. If the patient has a history of
fever blisters, acyclovir capsules are prescribed.
Pressure dressings may be applied overnight to the
donor areas, with the common exception of body
A B
Figure 8. A: Photo of a young girl bitten by a dog in the distant past. She has scarring of the Cupid's bow area
and loss of her upper lip on the left side, which has left her with some dental show. B: Same patient 6 months after
undergoing upper lip advancement to improve the scarring in the Cupid's bow and v-y advancement of the mucous
membranes on the left side of the upper lip.
liposuction sites, which are generally left undressed.
Incisions are cleaned with hydrogen peroxide and
an antibiotic ointment four to six times a day. Pa-
tients with a history of herpes simplex labialis are
given prophylaxis with acyclovir 200-mg capsules
six times a day. If herpes simplex vesicles develop,
acyclovir 5% ointment is appliec' to the vesicles.
REDUCTION OF THE LONG LIP
Patients with an average or long lip may be se-
lected for either a vermilion advancement12-l5or na-
sal base resection.16J7 If the goal is to obtain more
definition of the Cupid's bow area, the lip advance-
ment is generally preferred. To shorten a well-defined
but long upper lip, a nasal base resection or a lip
advancement can be performed. The lip may appear
fuller because of the increase in vermilion show;
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however, projection is usually not significantly en-
hanced. For patients in whom additional bulk or
projection is needed, the previously discussed aug-
mentation techniques can be used in combination
with either of these lip reduction procedures. Deep
chemical peeling has also been performed concur-
rently with these procedures to improve perioral
rhytids.
Vermilion Advancement
The surgeon can gain an appreciation of the de-
gree of lip show that the patient desires with the aid
of mirrors, photos, or a computer imager. With the
 COSMETIC SURGERY OF THE LIPS-Maloney

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Figure 9. A: Preoperative photograph of a patient desiring lip enhancement without implants. Patient has a
long upper lip with moderatedefinition of the central upper lip but little lip bulk. B: Preoperative lateral photograph
of the same patient. The upper lip i s consistent with senile entropion of the lip, that is, the lips have poor projection
and a flat appearance. C: Same patient after undergoing upper and lower lip advancement to reduce the relative
lengths of the lips and increase the vermilion definition. To increase the projection of the upper lip, multiple v-y
advancements are outlined. D: Postoperative photograph of patient after upper and lower lip advancement and v-y
advancement of the upper lip.

patient in a sitting position, the central three defin-
ing points of Cupid's bow are highlighted at the
vermilion-cutaneous junction. Similar points are
marked for the lower lip. Points parallel to these are
marked superiorly on the upper lip and inferiorly on
the lower lip, depending on the degree of advance-
ment desired, usually 3 to 5 mm. Generally, 1mm of
lip recoil should be expected and the surgical exci-
sion extended by this margin. These central points
are connected to points approximately 5 mm medial
to the oral commissure. The edge of the vermilion is
outlined, completing the fusiform portion of peri-
oral skin to be excised (Fig. 10A).
The lip is stabilized against the underlying teeth
by having an assistant apply gentle traction at the
outer corners of the mouth. A partial-thickness inci-
 FACIAL PLASTIC SURGERY Volume 12, Number 3 July 1996

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E
Figure 10. (Figure continued on the next page.)
 COSMETIC SURGERY OF THE LIPS-Maloney

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Figure 10. (Continued). A: Preoperative markings for
upper and lower lip advancement. B: The lip is immobilized
by applying downward pressure on the lips against the un-
derlying teeth. Alternatively, skin hooks can be placed in the
corners of the mouth and outward traction applied. C: While
the lip is stabilized by an assistant, the ellipse of skin i s
removed with sharp scissors in a deep dermal plane. The
orbicularis muscle should not be visualized. D: A similar
procedure is performed for the lower lip. E: Notice the ap-
pearance of upper and lower lips after partial-thickness exci-
sion of the skin. F: The three defining sutures of Cupid's bow
are placed in a vertical mattress fashion to maximize wound
eversion. C: Cross-section of a lip showing the beveling of
the skin edges, split-thickness excision of the skin, and
placement of the vertical mattress suture. H: Cross-section of
lip showing the recreation of the white roll as the vertical
mattress suture i s tightened. I: Immediate postoperative ap-
pearance of upper and lower vermilion advancement. A
running locking 6-0 absorbable suture is used for additional
wound edge approximation.

sion is made along the vermilion, care being taken to
bevel the incision away from the fusiform piece of
skin to be excised (Fig. 10B). The outer edge of the
fusiform is incised in a similar fashion. The incisions
are carried to a point 3 to 5 mm from the commissure.
The fusiform portion of skin to be removed is
excised in a deep dermal plane with sharp dissect-
ing scissors (Fig. 10C,D).Care should be taken not to
expose the underlying orbicularis muscle. Under-
mining of the skin edges is generally not necessary
except when large fusiform pieces of skin are ex-
cised (Fig. 10E).The three defining points of Cupid's
bow are reconstructed with vertical mattress sutures
of 6-0 fast-absorbing gut (FAG-Ethicon PC-1 needle)
(Fig. 10 F-H). A running subcuticular 5-0 prolene
suture is used for wound approximation. Additional
6-0 fast-absorbing gut simple sutures are used for
fine tuning wound edge approximation when neces-
sary (Fig. 101).
If additional augmentation is planned, it is gener-
ally performed after the vermilion advancement
(Fig. 11A-D).
FACIAL PLASTIC SURGERY Volume 12, Number 3 July 1996

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C D
Figure 11. A, B: Preoperative photos of patient with significant facial asymmetry. Notice the difference in
widths of the two halves of her face and the effect on lip position. Also, there i s considerable vermilion from side to
side. Profile of same patient (B) with long upper lip. Upper lip also lacks projection. C, D: Three-year postoperative
photographs of patient after upper and lower vermilion advancement. Upper lip length has been reduced
significantly. The vermilion advancement has not significantly increased lip projection, though.

Postoperative Instructions cators saturated with hydrogen peroxide and coated

In addition to the steps outlined for postoperative with an antibiotic ointment. This routine is carried
care of patients undergoing lip augmentation, the out four to six times daily.
following will generally facilitate wound healing. Early postoperative observations may include
The incisions are cleaned with cotton-tipped appli- milia, herpes simplex, and temporary anesthesia.
 COSMETIC SURGERY OF THE LIPS-Maloney

Dryness of the newly advanced mucosa may be
ameliorated with lip balm. With time, favorable
metaplasia occurs, minimizing the dryness.
Late observations generally include tightness in
the lips and an unnatural feeling while smiling for
2 to 3 months. As the swelling resolves, smiles re-
turn to normal. This process and scar maturation
seem to occur more slowly in younger patients. Lo-
calized edema may respond to local injection of tri-
amcinolone (5 mg/mL). Dermal cysts are a potential
complication; these manifest as localized swelling
and erythema and can be treated with local excision.
Excision of the fusiform piece of skin should be
performed in the deep dermal plane to decrease the
chance of cyst formation.
Nasal Base Resection
tures are placed in the subcutaneous layer. Approx-
imation of the skin is performed with vertical mat-
tress and simple fast-absorbing gut sutures.
Carbon Dioxide Laser Lip Advancement
The carbon dioxide laser can be used as a tool to
rejuvenate facial rhytids. In addition to the stimula-
tion of new collagen synthesis and realignment of
the skin layers, a thermal phenomenon termed col-
lngeiz shvinknge is thought to occur.18Whether this is a
temporary immediate histologic finding or an actual
long-term benefit is uncertain. Clinically, the surgeon
notices a contracture of the tissues being lasered. To
effect collagen shrinkage, the carbon dioxide laser
set at 18 W, 360 mJ is used to outline the vermilion-
cutaneous junction and an adjacent ellipse of skin, as
in the vermilion advancement technique described

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This technique can be used to shorten a long lip previously (Fig. 13A-C). To effect more of the de-
that has good central definition. It also corrects en- sired histologic changes, a larger ellipse is lasered
tropion of the upper lip, but it has minimal effect on than if one were performing an excision technique.
lip projection. With the patient in a sitting position, Two passes are generally used at this setting. The
the ellipse of skin at the nasal base is outlined (Fig. settings are decreased, and feathering is performed
12A,B). The upper border of the ellipse follows the around the edges. When the lasering is performed
curves of the nasal base. Slight overcorrection of in a defined fashion, the vermilion can be selectively
around 2 mm is helpful to achieve the desired result. advanced to accentuate the central portion. Lido-
The ellipse of skin is incised; the incision is beveled caine ointment 4% is applied the first night to the
away from the central ellipse. Sharp dissecting scis- lasered areas. Beginning the next day, the patient
sors are used to remove the skin in a subcutaneous showers two times a day and uses a moist dressing
plane. Limited undermining of the lower lip skin technique with a bland ointment. An additional ben-
edge may allow for easier wound closure. Several efit is that associated perioral rhytids are softened.
buried interrupted 5-0 polyglycolic acid (Dexon) su-

CONCLUSION

Whether they are a result of the aging process,

Figure 12. A, 8 : Frontal and lateral views of the nasal
base resection. The striped ellipse denotes the area to be
cxc ised.
trauma, or congenital factors, thin lips impart an
"old look" to the individual. Patients with lips that
are short or of average length may benefit from
augmentation. Temporalis fascia and SMAS are the
two augmentation materials the author utilizes most
commonly, although younger patients often choose
fat augmentation. A more permanent solution is the
v-y mucosal advancement; however, the healing
time can be longer than in augmentation proce-
dures. Patients with an average or long upper lip
who desire more lip definition may benefit from the
vermilion advancement. Care should be taken to
remove only split-thickness skin in order to main-
tain a raised area around the lips. Healing after a
vermilion advancement generally takes significantly
longer in younger patients than in patients over 40
years of age.
The nasal base resection can be a useful procedure
for shortening the upper lip. The potential for a
visible scar may be unappealing to patients. The
FACIAL PLASTIC SURGERY Volume 12, Number 3 July 1996

Downloaded by: University of British Columbia. Copyrighted material.

Figure 13. A: Preoperative photo of patient. B: Advance-
ment patterned eschar from first pass of carbon dioxide laser.
C: Three-month postoperative result after only laser lip ad-
vancement. An increase in vermilion show has occurred,
however; blunting of Cupid's bow has also occurred.

scars from vermilion advancement, when notice-
able, can be covered with lipstick or permanent cos-
metics. The carbon dioxide laser is an exciting new
tool with some vermilion advancement capabilities.
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