Aesth Plast Surg
https://doi.org/10.1007/s00266-023-03302-5
REVIEW
Different Techniques and Quantitative Measurements in Upper
lip lift: A Systematic Review
Hongli Zhao1 • Xiancheng Wang1 • Zhihua Qiao1 • Kai Yang1
Received: 28 December 2022 / Accepted: 7 February 2023
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2023
Abstract
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 mea-
surements of lifting efficiency.
Methods This study was conducted per PRISMA guide-
lines. 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
& Xiancheng Wang
wangxiancheng64@csu.edu.cn
1 vermilion, and covering of the teeth [20]. Actually, the
Department of Plastic and Aesthetic (Burn) Surgery, The
Second Xiangya Hospital of Central South University,
Changsha City, Hunan Province, People’s Republic of China
FACIAL SURGERY
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 con-
sistent 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.
Introduction
The perioral region is significant in conveying one’s age,
contributing to facial attractiveness and beauty [1–5], and is
gaining more interest during the COVID-19 pandemic [6]. A
youthful and attractive perioral region consists of a relatively
shorter upper lip with soft tissue projection [7, 8] whereas the
most significant senile alterations are upper lip lengthening
and shape deformities [9]. Furthermore, these aging traits
might occur on the lips of younger people due to hereditary
[10, 11], who may seek to change their appearance [12].
Detailed explanations of anatomy and function in con-
nection to aging and upper lip lengthening have been fre-
quently referenced [13–18]. The upper cutaneous lip, also
known as the ergotrid, is a trapezoidal region defined by
the upper vermilion border caudally, the nasal base
cephalad, and the nasolabial folds bilaterally [19]. Gravity
causes the upper lip to droop downward as a person ages,
resulting in an increased vertical height of the lip, flatting
of the philtrum, inversion of Cupid’s bow, thinning of the
upper lip is the only anatomical landmark in the centro-
facial area that sags, while all other anatomical landmarks
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remain in the same position [2, 21, 22]. Thus, reducing the
height from the nose to the vermilion border of the upper
lip can help restore a pleasant and youthful appearance
[23], and the impact of lip lift may be the highest on
younger-aged patients (35 years) [24].
Various techniques to lift the upper lip have been
described in the literature, which may consist of injecting
fillers [25] and lip lift surgical techniques [26], such as
simple subnasal skin excision, subnostril skin excision, or
even vermilion advancement [27, 28]. Filler materials were
first used to restore lip architecture and volume loss in the
1990s [29, 30], whereas surgical interventions to lift upper
lips began in the early 1970s, with a large series of cases
reported ten years later [20, 31]. Different excisions and
more methods with fewer scars have gained interest from
then on [32]. Typically, some studies believe that
injectable fillers do not produce long-term results due to a
lack of permanent fillers [33] while others think fillers
injected into the upper lip can produce clinical effects
equivalent to surgical lip lift operations [25, 34]. However,
it remains unclear whether they have the same effects, and
there is a lack of precise measurement evidence.
Furthermore, a study discovered that the average
decrease in philtrum length is not proportional to the
quantity of tissue removed. The lift of the upper lip was
greater than the amount of tissue excised [8]. Thus, a
quantitative measurement to evaluate the changes to the
upper lip after excision and closure is necessary. Some
studies have mentioned that laser [35] and facial serum
injections [36] can also shorten the upper lip, although the
precise efficacy of these treatments cannot be confirmed
due to the lack of quantitative evaluation. Even in research
with objective measurement data, measuring procedures
are not consistent [8, 29]. The lack of uniformity in out-
come reporting limited the evidence level to a higher one
[37], as Hassouneh et al stated that inconsistency in result
reporting was a significant impediment to the development
of effective systematic reviews and meta-analyses com-
paring multiple surgical interventions in facial plastic
surgery [38]. The standardization of outcomes and outcome
measurements can help to restrict incorrect outcomes,
avoid reporting bias, and facilitate data pooling in meta-
analyses [39].
Although Yamin et al [40] presented an overview of
surgical upper lip lifting methods in a recent systematic
review, this study did not analyze outcome metrics.
Therefore, the aim of this study was to systematically
assess both invasive and noninvasive upper lip lifting
techniques documented in the literature, while also taking
into account patient satisfaction, adverse effects, and, most
importantly, quantitative measurements of the lifting effi-
ciency. A quantitative measure method may help assist the
surgeon in developing better preoperative designs to
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Aesth Plast Surg
achieve a desirable result, such as the exact quantity of
tissue removed, and monitoring the durability of the post-
operative outcomes. Furthermore, quantifiable measure-
ments allow investigators to reliably compare the results of
various upper lip lifting treatments and will aid future high-
level evidence summaries in the form of systematic
reviews and meta-analyses.
Methods
Protocol and Registration
This systematic review was carried out in accordance with
the PRISMA guidelines [41]. A population, intervention,
comparison, outcome (PICO) framework was used to guide
the search strategy [42]. This study was not registered.
Inclusion and Exclusion Criteria
Studies were included when at least one surgical or non-
surgical procedure was used to lift the upper lip, or when
there was a reference to the effect of upper lip lift. Studies
were excluded when objective measurements of the upper
lip were not mentioned or in the case of cleft lip and palate
reconstruction. Studies that focused on orthodontic or
maxillary procedures or post-traumatic or post-oncologic
reconstructions were also excluded. Included studies were
limited to the English language and full text available.
(Table 1)
Search Strategy
MEDLINE (via PubMed), EMBASE (OvidSP), and
Cochrane Library database were searched from September
14, 2022, to October 12, 2022. Controlled terms (MeSH)
and keywords (Table 2) were combined for the search
strategy using ‘‘upper lip lift’’ OR ‘‘subnasal lip lift’’ OR
‘‘philtrum shorten.’’
Data Extraction
Two of the authors performed the search independently and
any disagreement was resolved by discussion. If dissimi-
larity occurred between the two authors, the senior author
made the ultimate decisions.
Completed data collection included study characteris-
tics, techniques, objective evaluation measurements, clini-
cal outcomes (degree of the lift), patient satisfaction,
adverse effects, and longevity of the lifting.
Aesth Plast Surg

Table 1. Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria

Clinical trials Reviews

Comparative studies Letters to editor
Case reports No full text available
Full text available Non-English languages
Nonsurgical technique(s) to lift the upper lip No attention to an effect of the upper lip lift nor quantified patient
satisfaction
Surgical technique(s) to lift the upper lip Post-traumatic or post-oncologic reconstruction of the upper lip
Combination of surgical and nonsurgical technique(s) to lift the Orthodontic or maxillary surgical procedures
upper lip
Reference to the effect of upper lip lift in title or abstract Reconstruction of cleft lip and palate patients (UCLP).
No objective measurements of the upper lip lift.

Table 2. Specific search terms of databases

Database Search term

MEDLINE ((‘‘upper’’[All Fields] OR ‘‘uppers’’[All Fields]) AND (‘‘lip’’[MeSH Terms] OR ‘‘lip’’[All Fields]) AND (‘‘lifting’’[MeSH
(via PubMed) Terms] OR ‘‘lifting’’[All Fields] OR ‘‘lift’’[All Fields])) OR (‘‘subnasal’’[All Fields] AND (‘‘lip’’[MeSH Terms] OR
‘‘lip’’[All Fields]) AND (‘‘lifting’’[MeSH Terms] OR ‘‘lifting’’[All Fields] OR ‘‘lift’’[All Fields])) OR ((‘‘lip’’[MeSH
Terms] OR ‘‘lip’’[All Fields] OR ‘‘philtrum’’[All Fields]) AND (‘‘shorten’’[All Fields] OR ‘‘shortened’’[All Fields] OR
‘‘shortening’’[All Fields] OR ‘‘shortenings’’[All Fields] OR ‘‘shortens’’[All Fields]))
EMBASE (’upper lip’/exp OR ’upper lip’) AND (’lift’/exp
(OvidSP) OR lift) OR ’subnasal lip lift’ OR (subnasal AND
(’lip’/exp OR lip) AND (’lift’/exp OR lift)) OR
’philtrum shorten’ OR ((’philtrum’/exp OR
philtrum) AND shorten)
Cochrane (upper lip lift) OR (subnasal lip lift) OR (philtrum shorten)
Library

Summary Measures Results

Objective and quantitative outcome measures utilized to Included Studies

evaluate the lifting degree were organized and
summarized.
Risk of Bias of Individual Studies
Demographics of the included patients were collected. [43]
A total of 495 studies were identified through the search
strategy. After the removal of duplicates, 442 citations
were screened and 75 articles were selected for full-text
review. Nine articles finally matched the selection criteria,
reporting on upper lip lift techniques with quantitative
measurements of the lifting degree. (Figure 1)

Quality Control of Included Studies
The included studies were assessed employing the Oxford
Centre for Evidence-Based Medicine Levels of Evidence.
[44]
Study Characteristics
In total, 780 patients were enrolled in the nine studies.
[8, 12, 29, 33, 45–49] In eight studies that reported
descriptive gender data, 91.07% of the patients were
women(n=683), 7.33% were men(n=55) and 1.60% were
transgender(n=12). [8, 12, 29, 45–49] The mean age at

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Fig. 1 Flow diagram of study
selection
treatment was 46.01 years with a range of 21 to 83 years.
The mean time to follow-up was 31.48 months with a range
from 2 months to 10 years. Of the studies enrolled in this
systematic review, eight assessed an invasive technique to
lift the upper lip in 777 patients [8, 12, 29, 33, 46–49] and
one study assessed a noninvasive technique in three
patients [45]. All studies reported the quantitative mea-
surements of the upper lip, and five studies described dif-
ferences in ethnicity. No meta-analysis could be performed
because the metrics and outcomes were too diverse.
Techniques
As for invasive techniques to lift the upper lip [40], eight
studies were included that examined: (1) subnasal lip lift
with (a) a subnasal bull’s horn excision [8, 29, 46, 47], (b) a
subnasal wavy ellipse excision [33, 49], (c) two subnasal
incisions, sparing the philtral columns and groove [12],
(d) a subnasal bull’s horn excision with ‘‘T’’-shaped
muscle resection [48], and (2) lip advancement with ver-
million border gull wing excision [33]. Seven of the eight
studies included a follow-up period of at least 12 months
[12, 29, 33, 45–49]. A follow-up of 3 years or more was
described in five of the eight studies [29, 33, 46, 47, 49].
Jung et al showed a high degree in all patients [12], Pan
et al described a patient satisfaction rate of 96.1%(n=73)
[48], and Lee et al demonstrated that 186 patients (92.1%)
were satisfied with the aesthetic results according to a
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5-point scale questionnaire [29]. However, patient satis-
faction was not described in other studies.
As for noninvasive techniques to lift the upper lip, only
one study was included in three patients by injecting
botulinum toxin A in the upper lip [45]. The lift effects
lasted fewer than a month. Patient satisfaction was not
described in this study. Notwithstanding, the former studies
were all noncontrolled and nonblinded. (Table 3) (Sup-
plemental Table 1).
Quantitative Measurements
As for approximative measurements, anatomical ratios
were included in seven studies [12, 29, 33, 46–49]. The
most commonly used measurement was photographic
analysis using the (1) white-to-white corneal distance
[46, 47] or the (2) alar-medial canthus line [12, 33] as a
conversion factor to make all photographs comparable.
Nagy et al [46] used the white-to-white corneal distance as
a scale to measure the distance of the columella to Cupid’s
bow, bilateral columella to Cupid’s peak, bilateral mid-sill
to the vermillion border, bilateral lateral nasal ala to the
vermillion border, and upper red lip show from Cupid’s
bow to the mucosal edge of the upper lip, while Marechek
et al [47] used the same scale for philtrum length, ver-
million length, and alar width. Jung et al [12] calculated the
distance through the midphiltrum to the vermilion border
using the alar-medial canthus as a reference. Holden et al
Aesth Plast Surg

Table 3 Overview of studies

Reference Type of study Technique

Studies using invasive techniques

Patel et al [8] Case series Subnasal lift
Case series Subnasal lift with separation between skin and muscle
Nagy et al [42] Retrospective Subnasal lift
Marechek et al [47] Retrospective Subnasal lift
Jung et al [12] Retrospective Subnasal short scar lift
Pan et al [48] Retrospective Subnasal lift with orbicularis oris resection
Lee et al [29] Retrospective Subnasal lift
Raphael et al [49] Retrospective Endonasal lift
Holden et al [33] Retrospective Lip advancement
Retrospective Subnasal lift
Studies using noninvasive techniques
Li et al [45] Case report Botulinum toxin A

[33] recorded the same distance in the subnasal lip lift
group with additional measurements from the right alar rim
to the lateral vermilion border in the lip advancement
group. Also, a caliper was used to measure philtrum and
upper lip heights and then calculate the upper lip to lower
face ratio and philtral to labial height ratio [48]. In Lee’s
study, the philtrum length was measured face to face, and
the ratio of the philtrum to the height of the visible upper
vermilion was measured by photographs [29]. Repeal et al
[49] advocated a classification system [50] to categorize
patients into four types by labial and philtral height, a
philtral-labial score, and dental show. However, the way
how to measure was not described in the study.
As for exact measurements, 3D photographs and 3D
analysis were included in two studies [8, 45]. Patel et al [8]
took 3D photographs using the VECTRA H1 system, and
3D analysis was performed including vermillion height and
width, philtral height, sagittal lip projection, vermillion
surface area, and incisor show. Li et al [45] used the same
system to capture 3D photographs with different nasolabial
landmarks and eight linear distances, including philtrum
width, upper lip height, cutaneous upper lip height, upper
vermilion height, cupid’s bow height, right vermilion
margin lateral height and left vermilion margin lateral
height (Table 4).
downshift of the subnasal and increased exposure of the
nostril (2.05%,n=16), increased thickness of the philtrum,
and prominent vermilion tubercle (1.15%,n=9). Raphael
et al [49] demonstrated a subnasal wavy ellipse with
endonasal advancement flaps, thus reported adverse events
associated with such as localized wound separa-
tion(0.77%,n=6), under-correction(3.21%,n=25), alar dis-
tortion(4.87%,n=38), sill widening(3.72%,n=29) and sill
deformation(5.13%,n=40). For lip advancement, asymme-
try of the vermilion border was observed in 0.26% (n=2) of
all the patients [33]. For nonsurgical procedures, all three
patients complained about slight perioral muscular palsy
and mouth incompetence [45]. (Table 5)
Disclosure Agreements [43]
Only one of the nine studies was provided with a disclosure
agreement of support by the university (Table 6). There-
fore, there was no conflict of interest.
Quality Control of Included Studies [43]
Seven of the nine included studies were Level of Evidence
IV studies, and two studies were Level of Evidence V
studies (Table 7).

Adverse Effects
No severe adverse events were described for both surgical
and nonsurgical lip lifting procedures. For subnasal lip lift
procedures, the most common short-term complication was
minor adverse such as redness [12], swelling [12], dehis-
cence caused by hematoma [29] (0.64%, n=5), and asym-
metric upper lip [29] (0.64%, n=5). The most common
long-term complications were obvious incisions scar
[12, 29, 48, 49](4.36%, n=34). Pan et al [48] described a
Discussion
This is the first systematic review to identify both tech-
niques and outcome measures employed within the upper
lip lift literature. Both surgical and nonsurgical procedures
could show a lifting effect on the subnasal lip with good
patient satisfaction. Surgical procedures, with a mean fol-
low-up length of 31.48 months (range: 2 months to 10
years), have more longevity than nonsurgical procedures,

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 Aesth Plast Surg

Table 4 Schematic representation of different techniques and quantitative measurements

Reference Technique Quantitative measure method

Studies using invasive techniques

Patel et al [8]

Subnasal bull’s horn excision 3D VECTRA H1 assess the whole upper lip area
Subnasal bull’s horn excision 3D VECTRA H1 assess the whole upper lip area
Nagy et al [42]

Subnasal bull’s horn excision

Subnasal bull’s horn excision
Anatomic rao calculang by the white-to-white
cornea distance
Anatomic ratio calculating by the white-to-white cornea
distance
Marechek et al
[47]

Subnasal bull’s horn excision

Subnasal bull’s horn excision
Anatomic rao calculang by the white-to-white
cornea distance
Anatomic ratio calculating by the white-to-white cornea
distance
Jung et al [12]

Two subnasal incisions, sparing the

philtral columns and groove
Two subnasal incisions, sparing the philtral columns and Anatomic rao calculang by the ala-to-medial
groove canthus distance
Anatomic ratio calculating by the ala-to-medial canthus
distance

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Aesth Plast Surg

Table 4 continued
Reference Technique Quantitative measure method

Pan et al
[48]

Two subnasal incisions, sparing the Philtrum and upper-lip heights were measured by
philtral columns and groove a caliper to calculate the philtral to labial height
Two subnasal incisions, sparing the philtral rao
columns and groove
Philtrum and upper lip heights were measured by a caliper to calculate the
philtral to labial height ratio
Lee et al
[29]

Subnasal bull’s horn excision The philtrum length was measured face to face,
Subnasal bull’s horn excision and the ratio of the philtrum to the height of the
visible upper vermilion was measured by
photographs.
The philtrum length was measured face to face, and the ratio of the philtrum to
the height of the visible upper vermilion was measured by photographs.
Raphael,
et al,
[49]

Subnasal wavy ellipse with endonasal Calculate the philtral-labial score without
advancement flaps menon how to measure
Subnasal wavy ellipse with endonasal Calculate the philtral-labial score without mention how to measure
advancement flaps
Holden
et al [33]

Vermillion border Gull wing excision

Vermillion border Gull wing excision
Anatomic rao calculang by the ala-to-medial
canthus distance
Anatomic ratio calculating by the ala-to-medial canthus distance

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 Aesth Plast Surg

Table 4 continued
Reference Technique Quantitative measure method

Subnasal wavy ellipse excision

Subnasal wavy ellipse excision
Anatomic rao calculang by the ala-to-medial
canthus distance
Anatomic ratio calculating by the ala-to-medial canthus
distance
Studies using noninvasive techniques
Li et al
[45]

A total of 4U BTA injecon at the 3D VECTRA H1 assess the whole upper lip area
vermilion border of the upper lip 3D VECTRA H1 assess the whole upper lip area
A total of 4U BTA injection at the vermilion border of the upper
lip

Table 5 Summary of complications of different techniques

Technique Complications Numbers of patients (%)

Short-term complication
Subnasal lip lift Redness and swelling of the incision 3(0.39)
Dehiscence caused by hematoma 2(0.26)
Asymmetric upper lip 5(0.64)
Long-term complication
Visible scar 34(4.36)
Downshift of the subnasal and increased exposure of nostril 16(2.05)
Increased thickness of the philtrum and prominent vermilion tubercle 9(1.15)
Localized wound separation 6(0.77)
Under-correction 25(3.21)
Alar distortion 38(4.87)
Sill widening 29(3.72)
Sill deformation 40(5.13)
Upper lip advancement Asymmetry of the vermilion border 2(0.26)
Botulism toxin A injection Slight perioral muscular palsy 3(0.39)
Mouth incompetence 3(0.39)

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Table 6 A disclosure agreement of support by the manufacturer

Reference Financial interests or support

Studies using invasive techniques

Patel et al [8] None reported/Funding: The authors received no financial support for the research, authorship, and publication of this
article.
Nagy et al [42] No funding was received for this article.
Marechek et al Not published
[47]
Jung et al [12] The authors have no financial interest to declare in relation to the content of this article.
Pan et al [48] None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
Lee et al [29] This article was supported by the 2014 Yeungnam University Research Grant.
Raphael et al [49] The authors received no financial support for the research, authorship, and publication of this article.
Holden et al [33] None reported.
Studies using noninvasive techniques
Li et al [45] The authors report no conflict of interest.

Table 7 Quality assessment of included studies according to the referable aesthetic criteria, Heidekrueger et al discovered
Oxford Centre for Evidence-Based Medicine Criteria that the ideal proportions to define an attractive lip might
Reference Level of evidence be influenced by multiple sociocultural and demographic
factors [53]. Although the desired perioral aesthetic criteria
Studies using invasive techniques may differ across different ethnic and geographic back-
Patel et al [8] Therapeutic, IV. grounds, it is widely acknowledged that the ratio of cuta-
Nagy et al [42] Therapeutic, IV. neous skin height to upper vermilion height should be less
Marechek et al [47] Therapeutic, IV. than 3 [50]. Age-related changes to the upper lip, including
Jung et al [12] Therapeutic, V. soft tissue descent and deflation, lead to an extended and
Pan et al [48] Therapeutic, IV. thin upper lip with diminished maxillary incisor show,
Lee et al [29] Therapeutic, IV. affecting these optimum ratio [15, 17]. Consideration of
Raphael et al [49] Therapeutic, IV. these ideal ratios during the treatment planning will sig-
Holden et al [33] Therapeutic, IV. nificantly improve lip lift outcomes [54]. Through skin
Studies using noninvasive techniques excision and advancement of the soft tissue complex, the
Li et al [45] Therapeutic, V. surgical procedure can effectively shorten the distance
between the nasal base and the vermilion border of the
upper lip, thereby improving the philtrum to upper ver-
milion proportions [55]. Nonsurgical procedures, such as
while an incision scar is inevitable. The quantitative out- lip fillers, generally improve the ratio of the philtrum to the
come measurements vary a lot and reveal salient discrep- vermilion by restoring volume to the lip [25].
ancies across the upper lip lift literature. Different surgical techniques to lift the upper lip have
It is necessary to capture the aesthetic characteristics of been summarized in the literature [56]. In general, the
the perioral region. The components of the perioral aes- surgical treatment typically referred to as the lip lift
thetic include both soft tissue and skeletal elements which operation is a method of correcting the aging upper lip that
include the dimensions of the philtrum and upper lip skin, was first described by Cardosa and Sperli in 1971 and has
the vermillion, perioral fat compartments, as well as den- subsequently undergone various modifications
tition and cephalometric relationships [8]. There is exper- [29, 49, 57–60]. Commonly, the procedure entails the
imental agreement that a greater vermilion show, a shorter excision of a section of the upper lip with the purpose of
philtrum, and symmetric and prominent philtral columns decreasing the cutaneous top lip height and boosting the
are more appealing [51, 52]. According to research, the maxillary incisor display. The excision pattern is often a
philtrum to upper vermilion ratio should ideally be between ‘‘bullhorn’’ or a ‘‘wavy ellipse’’-shaped wedge resection
2 and 2.9, and the upper-to-lower vermilion ratio should be with the scar buried in the nasal crease. There is also
between 0.75 and 0.8 [50]. Despite the availability of another option, lip advancement procedures, in which the
incision is made along the vermillion border to generate a

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more radial vector of lift [9, 33]. The key to a good out-
come in surgical methods is incision design that respects
the natural anatomy, placing the tension of the lip deep to
the dermis to alleviate tension off the skin incision, iden-
tifying the proper amount of lift for the patient’s anatomy,
and not violating the orbicularis oris [32]. Apart from the
volume contribution of the orbicularis oris muscle, the
superficial musculoaponeurotic system (SMAS) of the
upper lip is the principal support mechanism for the skin’s
youthfulness. Noticeably, the SMAS layer thins with age,
making rhytids in the upper lip more visible [60]. Talei
et al developed a modified cupid lift procedure that focuses
on releasing the SMAS in the patient’s perioral region and
provided extensive details of patient selection and upper lip
excision design [60]. Despite the fact that the surgical
procedure has been in use for four decades and is widely
accepted [3, 20, 31], only eight articles met the inclusion
criteria. The limited number of studies included was due to
a lack of quantitative measurements in many of them. The
reported mean follow-up period was 31.48 months, show-
ing a satisficed longevity of the lifting effect. Anyhow, for
surgical procedures, scarring is generally the patient’s main
concern and has been reported in 4.36% of cases. To
decrease scarring, Lee et al injected botox into the orbic-
ularis oris muscle following precise wound closure [29],
and Marechek et al used CO2 laser to blend the incision site
[47]. Almost all research included in this systematic review
that discussed such procedures reported excellent patient
satisfaction; however, most studies failed to analyze patient
satisfaction using validated questionnaires. The most
common and longest-standing procedure is the subnasal lip
lift with a bull’s horn excision, which is appropriate for
most patients except those with a drooping lip corner
[8, 29, 46, 47]. By localizing tension deep within the nasal
vestibule onto relatively immobile tissue, the endonasal lip
lift technique with a wavy excision can produce enhanced
stability, intranasally hidden scar, and camouflage at the
nasolabial junction49. Candidates are patients who have a
tall philtral height with normal or short labial height (the
philtral-labial score [ 3) and 0-mm dental show. Notice-
ably, to avoid nasal sill disruption, the surgery must be
performed with great precision. Lip advancement with
vermillion border gull wing excision has limitations in use
because the scar around the vermillion may influence
anatomic function [33], while techniques utilizing two
subnasal incisions are minimally invasive and may benefit
younger cosmetic patients as well as Asian patients [12].
Noninvasive treatments for rejuvenating perioral tissues
or lifting the upper lip include injecting fillers [25], laser
[35], serums [36], or a combination of these, as aging
causes not only volume loss, but also perioral wrinkles on
the lip [61]. However, the former reports lacked quantita-
tive measurements or failed to pay attention to the upper lip
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Aesth Plast Surg
lifting efficiency and thus were excluded from our research.
Only one study utilizing Botulinum toxin A (BTA) met the
inclusion criteria [45]. The aim of applying botox to lift the
upper lip is to inhibit the contraction of the orbicularis oris
muscle, a circular muscle that resides around the lip. It is
made up of deep and superficial fibers that serve many
purposes. The deep fiber is a constrictor muscle that aids in
the retention of food and fluids while eating, whereas the
superficial fiber is a retractor muscle that aids in speaking
and facial expressions when working with other muscles
[62]. Botox can inhibit acetylcholine release at the
myoneural junction, resulting in a paralyzed effect of the
orbicular oris muscle. As a result, the lip gets more everted,
leading to an augmented upper lip and a shortened phil-
trum. There are just minor short-term complaints regarding
slight perioral muscular palsy and month incompetence.
However, the lifting effect lasted less than a month, with no
mention of patient satisfaction, and no comparison with
surgical treatments could be conducted due to the diverse
measure metrics and outcomes.
Quantitative measurements are significant for both
clinical decision-making and future high-level evidence
analysis. As for clinical choice, Patel et al used three-di-
mensional technique metrics to provide quantifiable results
indicating the average decrease in philtral length, and the
amount of tissue resected do not have a line relationship
[8]. The study reported that a 2.5-mm resection reduced
philtral length by 3.37 mm on average, whereas a 5-mm
resection reduced philtral length by 7.25 mm on average.
Since the philtrum to upper vermilion ratio, which should
ideally range from 2 to 2.9 [50], is calculated by comparing
the heights of the cutaneous skin and the upper vermilion,
small inaccuracies in the postoperative philtrum height
may cause changes in the ratio and produce results that are
significantly different from the desired ratio value. There-
fore, a quantitative assessment is essential for proper pre-
operative design as well as for determining the precise
longevity of lifting efficiency. In terms of study quality, the
literature on lip lifting often has a not high level of evi-
dence (LOE), and the lack of uniformity across the studies
may lead to a number of issues. Usually, a successful
systematic review and meta-analysis are considered the
highest LOE, while they require consistent outcome
reporting to be effective [37]. The heterogeneity limits the
comparison between articles and outcomes, thus limiting
the clinical choice. Within the upper lip lifting literature,
our systematic review identified two metrics: anatomy ratio
calculation through photographic analysis or direct height
measurement using a caliper, and precise parameters using
a three-dimensional approach. The photographic analysis is
the most practical method and particularly well-suited for
retrospective studies since preoperative and postoperative
photographic data for facial aesthetic surgery are typically
Aesth Plast Surg
well documented. The conversion factor to calculate the
anatomy ratio of the philtrum consists of the white-to-white
corneal distance [46, 47] and the alar-medial canthus dis-
tance [12, 33]. We properly recommend the former as a
reference because it is more accurate since the two inner
canthi are two spots with certain anatomical sites. The alar,
on the other hand, is an area with a more ambiguous
anatomical position, which might lead to erroneous infor-
mation. Three-dimensional measuring is a more precise
and comprehensive approach that can measure not only
philtrum length, but also sagittal projection and the size of
the overall upper vermillion surface. However, such a
machine may be not available in every research team,
restricting its usage and popularity in the upper lip lifting
metrics.
There are some limitations to this evaluation. For star-
ters, this search was confined to English language papers;
so, relevant outcomes and outcome measures in non-Eng-
lish journals may have been missed. Furthermore, despite
the fact that this study used a comprehensive electronic
database technique, no search of the gray literature was
conducted, and pertinent papers may have been overlooked
accidentally. Additionally, only nine papers satisfied the
inclusion criteria for this review out of the 495 articles
discovered following database screening. The main reason
for the small number of articles is that most of them do not
employ quantitative data to evaluate lifting efficacy. Fur-
thermore, the reported ethnic characteristics vary greatly,
making it impossible to compare the aesthetic variations
and surgical outcomes of upper lip lifting in different
ethnic groups with certain. And because the reported ages
were predominantly in senior citizens, with a mean age of
46.01 years (range: 21 to 83 years), it may not be appli-
cable to young persons with a congenital lengthened upper
lip.
Systematic reviews and meta-analyses have the highest
level of evidence, while the quality of these studies and the
outcomes they assess depend primarily on the data on
which the analysis is based [37]. Nevertheless, they cannot
be employed successfully in the upper lip lift literature
since most research has reported non-quantitative results or
diverse outcomes. As a result, the majority of published
clinical research on this topic (as well as other procedures)
cannot contribute to better quality evaluation and analysis.
To further study the success of a surgical or nonsurgical
upper lip lifting procedure, we propose that future research
include quantitative measures to evaluate the upper lip
lifting outcomes, which can be beneficial for both clinical
decision-making and high-level evidence research.
Conclusion
This is the first research to systematically evaluate both
surgical and nonsurgical upper lip lifting techniques,
accounting for patient satisfaction, adverse effects, and,
most critically, quantitative measurements of lifting
effectiveness. Overall, surgical therapies appear to provide
a higher and longer-lasting lifting influence on upper lip lift
with an inevitable scar, whereas nonsurgical techniques
look to be minimally invasive but conservative. The vari-
ability in the results used to assess lifting efficiency
necessitates greater uniformity in quantitative measure-
ments to support clinical decision-making and future high-
level evidence analysis.
Supplementary Information The online version contains
supplementary material available at https://doi.org/10.1007/s00266-
023-03302-5.
Acknowledgments This work was supported by the Hunan Provin-
cial Natural Science Foundation (No.2021JJ30034).
Declarations
Conflict of interest None of the authors has a financial interest in
any of the products, devices, or drugs mentioned in this article.
References
1. Wollina U (2013) Perioral rejuvenation: restoration of attrac-
tiveness in aging females by minimally invasive procedures. Clin
Interv Aging 8:1149–1155
2. Tonnard PL, Verpaele AM, Ramaut LE, Blondeel PN (2019)
Aging of the Upper Lip. Plast Reconstr Surg 143:1333–1342
3. Felman G (1993) Direct upper-lip lifting: a safe procedure.
Aesthetic Plast Surg 17:291–295
4. Bashour M (2006) History and Current Concepts in the Analysis
of Facial Attractiveness. Plast Reconstr Surg 118:741–756
5. Fitzgerald R, Graivier MH, Kane M et al (2010) Facial aesthetic
analysis. Aesthet Surg J 30:25S-27S
6. Trinh LN, Safeek R, Herrera D, Gupta A (2022) Has the COVID-
19 Pandemic Impacted Interest in Cosmetic Facial Plastic Sur-
gery? A Google Trends Analysis. Facial Plast Surg 38:285–292
7. Ramaut L, Tonnard P, Verpaele A et al (2019) Aging of the upper
lip: part i: a retrospective analysis of metric changes in soft tissue
on magnetic resonance imaging. Plast Reconstr Surg
143:440–446
8. Patel AA, Schreiber JE, Gordon AR et al (2022) Three-Dimen-
sional Perioral Assessment Following Subnasal Lip Lift. Aesthet
Surg J 42:733–739
9. Fanous N (1984) Correction of Thin Lips. Plast Reconstr Surg
74:33–41
10. Knize DM (2004) Lifting of the upper lip: Personal technique.
Plast Reconstr Surg 113:1836–1837
11. Guerrissi JO, Sanchez LI (1993) An Approach to the Senile
Upper Lip. Plast Reconstr Surg 92:1187–1191
12. Jung J-A, Kim K-B, Park H et al (2019) Subnasal Lip Lifting in
Aging Upper Lip. Plast Reconstr Surg 143:701–709
123

13. Guyuron B, Rowe DJ, Weinfeld AB et al (2009) Factors con-
tributing to the facial aging of identical twins. Plast Reconstr Surg
123:1321–1331
14. Raschke GF, Rieger UM, Bader R-D et al (2014) Perioral aging–
an anthropometric appraisal. J Cranio-Maxillo-fac Surg Off Publ
Eur Assoc Cranio-Maxillo-fac Surg 42:e312-317
15. Penna V, Stark G-B, Eisenhardt SU et al (2009) The aging lip: a
comparative histological analysis of age-related changes in the
upper lip complex. Plast Reconstr Surg 124:624–628
16. Pensler JM, Ward JW, Parry SW (1985) The superficial muscu-
loaponeurotic system in the upper lip: an anatomic study in
cadavers. Plast Reconstr Surg 75:488–494
17. Mally P, Czyz CN, Wulc AE (2014) The Role of Gravity in
Periorbital and Midfacial Aging. Aesthet Surg J 34:809–822
18. Ponsky D, Guyuron B (2011) Comprehensive surgical aesthetic
enhancement and rejuvenation of the perioral region. Aesthet
Surg J 31:382–391
19. Becker S, Lee MR, Thornton JF (2011) Ergotrid flap: a local flap
for cutaneous defects of the upper lateral lip. Plast Reconstr Surg
128:460e–464e
20. Austin HW (1986) The Lip Lift. Plast Reconstr Surg 77:990–994
21. Rohrich RJ, Pessa JE, Ristow B (2008) The youthful cheek and
the deep medial fat compartment. Plast Reconstr Surg
121:2107–2112
22. Lambros V (2007) Observations on periorbital and midface
aging. Plast Reconstr Surg 120:1367–1376
23. Flowers RS Jr, EMS, (1999) Technique for Correction of the
Retracted Columella, Acute Columellar-Labial Angle, and Long
Upper Lip. Aesthetic Plast Surg 23:243–246
24. Gordon AR, Schreiber JE, Tortora SC, et al (2021) Turning back
the clock with lip lift: quantifying perceived age reduction using
artificial intelligence. Facial Plast Surg Aesthetic Med
fpsam.2020.0560.
25. Rho N-K, Goo BL, Youn S-J et al (2022) Lip lifting efficacy of
hyaluronic acid filler injections: a quantitative assessment using
3-dimensional photography. J Clin Med 11:4554
26. Waldman SR (2007) The Subnasal Lift. Facial Plast Surg Clin N
Am 15:513–516
27. Moragas JSM, Vercruysse HJ, Mommaerts MY (2014) ‘‘Non-
filling’’ procedures for lip augmentation: a systematic review of
contemporary techniques and their outcomes. J Cranio-Maxillo-
fac Surg Off Publ Eur Assoc Cranio-Maxillo-fac Surg
42:943–952
28. Georgiou CA, Benatar M, Bardot J et al (2014) Morphologic
variations of the philtrum and their effect in the upper lip lift.
Plast Reconstr Surg 134:996e–997e
29. Lee DE, Hur SW, Lee JH et al (2015) Central Lip Lift as Aes-
thetic and Physiognomic Plastic Surgery: The Effect on Lower
Facial Profile. Aesthet Surg J 35:698–707
30. Alster TS, West TB (2000) Human-derived and new synthetic
injectable materials for soft-tissue augmentation: current status
and role in cosmetic surgery. Plast Reconstr Surg 105:2515–3252
31. Rozner L, Isaacs GW (1981) Lip lifting. Br J Plast Surg
34:481–484
32. Sturm A (2022) Lip lift. Otolaryngol Clin North Am 55:835–847
33. Holden PK (2011) Long-term analysis of surgical correction of
the senile upper lip. Arch Facial Plast Surg 13:332
34. Ghannam S, Bageorgou F (2022) The lip flip for beautification
and rejuvenation of the lips. J Drugs Dermatol JDD 21:71–76
35. McDaniel DH, Lord J, Ash K, Newman J (1999) Combined CO2/
erbium:YAG laser resurfacing of peri-oral rhytides and side-by-
side comparison with carbon dioxide laser alone. Dermatol Surg
Off Publ Am Soc Dermatol Surg Al 25:285–293
36. Moy M, Diaz I, Lesniak E, Giancola G (2022) Peptide-pro
complex serum: investigating effects on aged skin. J Cosmet
Dermatol. https://doi.org/10.1111/jocd.14992
123
Aesth Plast Surg
37. Hassan Y, Leveille CF, Gallo L et al (2020) Reporting outcomes
and outcome measures in open rhinoplasty: a systematic review.
Aesthet Surg J 40:135–146
38. Hassouneh B, Brenner MJ (2015) Systematic review and meta-
analysis in facial plastic surgery. Facial Plast Surg Clin N Am
23:273–283
39. Waltho D, Gallo L, Gallo M et al (2020) Outcomes and outcome
measures in breast reduction mammaplasty: a systematic review.
Aesthet Surg J 40:383–391
40. Yamin F, McAuliffe PB, Vasilakis V (2021) Aesthetic surgical
enhancement of the upper lip: a comprehensive literature review.
Aesthetic Plast Surg 45:173–180
41. Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting
items for systematic reviews and meta-analyses: the PRISMA
statement. PLoS Med 6:e1000097
42. Schardt C, Adams MB, Owens T et al (2007) Utilization of the
PICO framework to improve searching PubMed for clinical
questions. BMC Med Inform Decis Mak 7:16
43. van der Sluis N, Gülbitti HA, van Dongen JA, van der Lei B
(2022) Lifting the mouth corner: a systematic review of tech-
niques, clinical outcomes, and patient satisfaction. Aesthet Surg J
42:833–841
44. OCEBM Levels of Evidence Working Group. The Oxford Levels
of Evidence 2. Oxford Centre for Evidence-Based Medicine.
2011.https://www.cebm.ox.ac.uk/resources/ levels-of-evidence/
ocebm-levels-of-evidence
45. Li Y, Chong Y, Yu N et al (2021) The use of botulinum toxin A
in upper lip augmentation. J Cosmet Dermatol 20:71–74
46. Nagy C, Bamba R, Perkins SW (2022) Rejuvenating the Aging
Upper Lip: The Longevity of the Subnasal Lip Lift Procedure.
Facial Plast Surg Aesthetic Med 24:95–101
47. Marechek A, Perenack J, Christensen BJ (2021) Subnasal lip lift
and its effect on nasal esthetics. J Oral Maxillofac Surg
79:895–901
48. Pan B-L (2017) Upper lip lift with a ‘‘T’’-shaped resection of the
orbicularis oris muscle for Asian perioral rejuvenation: a report of
84 patients. J Plast Reconstr Aesthetic Surg JPRAS 70:392–400
49. Raphael P, Harris R, Harris SW (2014) The endonasal lip lift:
personal technique. Aesthet Surg J 34:457–468
50. Raphael P, Harris R, Harris SW (2013) Analysis and classifica-
tion of the upper lip aesthetic unit. Plast Reconstr Surg
132:543–551
51. Suryadevara AC (2008) Update on perioral cosmetic enhance-
ment. Curr Opin Otolaryngol Head Neck Surg 16:347–351
52. Penna V, Fricke A, Iblher N et al (2015) The attractive lip: a
photomorphometric analysis. J Plast Reconstr Aesthetic Surg
JPRAS 68:920–929
53. Heidekrueger PI, Szpalski C, Weichman K et al (2017) Lip
attractiveness: a cross-cultural analysis. Aesthet Surg J
37:828–836
54. Fallahi HR, Keyhan SO, Bohluli B et al (2022) Lip lift techniques
in smile design. Dent Clin North Am 66:443–457
55. Salibian AA, Bluebond-Langner R (2019) Lip Lift. Facial Plast
Surg Clin N Am 27:261–266
56. Júnior LCA, da Silva Cruz NT, de Vasconcelos Gurgel BC, et al
(2022) Impact of subnasal lip lift on lip aesthetic: a systematic
review. Oral Maxillofac Surg.
57. Talei B (2019) The modified upper lip lift. Facial Plast Surg Clin
N Am 27:385–398
58. Li YK, Ritz M (2018) The modified bull’s horn upper lip lift.
J Plast Reconstr Aesthet Surg 71:1216–1230
59. Ramirez OM, Khan AS, Robertson KM (2003) The upper lip lift
using the ‘‘bull’s horn’’ approach. J Drugs Dermatol JDD
2:303–306
Aesth Plast Surg
60. Talei B, Pearlman SJ (2022) CUPID Lip Lift: advanced lip design
using the deep plane upper lip lift and simplified corner lift.
Aesthet Surg J 42:1357–1373
61. Paes EC, Teepen HJLJM, Koop WA, Kon M (2009) Perioral
wrinkles: histologic differences between men and women. Aes-
thet Surg J 29:467–472
62. Nicolau PJ (1983) The orbicularis oris muscle: a functional
approach to its repair in the cleft lip. Br J Plast Surg 36:141–153
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