1216569

research-article2023
ACSXXX10.1177/07488068231216569The American Journal of Cosmetic SurgeryFakih-Gomez et al

Technical Note
The American Journal of

Indirect Lip Lift With Modified Suspension Cosmetic Surgery

1­–14
© The Author(s) 2023
Technique to Pyriform Ligament Article reuse guidelines:
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https://doi.org/10.1177/07488068231216569
DOI: 10.1177/07488068231216569
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Nabil Fakih-Gomez, MD, MSc1 , Cristina Muñoz-Gonzalez, MD1,

David Dominguez-Medina, MD1, and Ibrahim Fakih-Gomez, MD1

Abstract
The lip lift procedure has witnessed a surge in popularity in recent years due to its remarkable ability to bring about a
substantial transformation in facial appearance through a minor surgical intervention. The primary objective of the procedure
is to diminish the height of the philtrum, consequently enhancing the visibility of the teeth while leaving behind a minimal
visible scar along the upper lip vermilion border. In this article, a series of refined modifications to the conventional subnasal
technique are introduced. The approach entails the removal of a skin strip while preserving a subcutaneous cuff. This method
incorporates central and laterally vectored deep-plane sub-superficial muscular aponeurotic system (SMAS) advancement
flaps, complemented by suspensions to the pyriform ligament. Furthermore, a sliding closure technique is introduced through
the cuffs, and an enhanced skin suturing method is implemented. These substantial enhancements to the procedure result
in a lasting elevation of the lip and a reduction in the visibility of unfavorable scarring. These modifications have emerged
through an evolutionary process, driven by the pursuit to improve scar outcomes. The surgical techniques applied in this
method effectively address the primary limitations of previous approaches, consistently yielding aesthetically pleasing results
over the long term.

Keywords
indirect lip lift, subnasal lip lift, pyriform ligament suspension, scar management

Introduction
The lips, a key focal point of the lower face, possess sex and
age-specific traits.1 An attractive face typically exhibits a
short philtrum, prominent and symmetrical philtral columns,
and a well-defined Cupid’s bow, creating the upper lip’s aes-
thetic unit.2,3 Over time, careful observation highlights that
the upper lip tends to lengthen and descend with age,1,4 result-
ing in a thinner appearance and the concealment of the upper
teeth, which were previously visible in younger women.4
Over the past years, lip lift procedure has been recom-
mended in the form of central lip lift, Austin-type lip lift, or
subnasal lip lift for patients who have a long upper lip.3,5 The
subnasal lip lift, was first described by Cardosa and Sperli
in 1971, and the first large series as an adjunct procedure to
face lift were published by Rozner in 1981. The most popular
modification of this technique was the wavy ellipse tech-
nique published by Austin 1986. The bullhorn pattern of
excision was a direct modification of Austin’s wavy ellipse
technique.3 Lip lift involves the excision of a strip of skin
and muscle from the upper lip immediately inferior to the
nasal base, as the tissue void is closed, the lip rotates and lifts
superiorly. This maneuver helps to shorten the distance from
the nasal base to the vermilion border using skin excision
and tissue advancement.
Traditional lip lift techniques have been criticized and
often avoided out of the fear of scarring; however, the mis-
take made by most practitioners is performing a simple der-
mal closure. We agree to the key of the upper lip lift is the
distribution of vectors in a deep-plane to get a flap without
tension in the skin. The superficial muscular aponeurotic
system (SMAS) must be suspended to redistribute tension
above the contracted orbicularis allowing proper, tension-
free, healing in a highly dynamic region.6,7
This article aims to present the author’s approach to the
indirect lip lift based on the Talei6 technique with deep-plane
release and suspension to pyriform ligament with some mod-
ifications. They include dissection technique, additional lat-
eral vector suspensions, deep closure sliding technique, and
1
Fakih Hospital, Khaizaran, Lebanon
Corresponding Author:
Nabil Fakih-Gomez, Chief, Department of Facial Plastic and Cranio-
Maxillo-Facial Surgery, Fakih Hospital, Khaizaran, 00000, Lebanon.
Email: info@drnabilfakih.com
2 The American Journal of Cosmetic Surgery 00(0)

improved superficial layered closure. These refinements

help to achieve a shorter upper lip with an aesthetically
pleasing scar.

Anatomical Considerations
The vertical height of the upper lip, measured from the
nasal base to the central upper vermilion border, ranges
between 12 and 14 mm. At midline, the height of the upper
vermilion lip is typically between 7 and 8 mm, with the
peaks of the Cupid’s bow being 3 to 5 mm higher than the
vermilion’s central point, oriented in a superior and lateral
direction to it.8 Figure 1. Measurement of lip length varies from 12 to 13 mm in
In general, the overall height of the upper lip, measured the central area, 16 mm in the middle of the hemi-lip, and 19 mm
from sub-nasale to stomion, is longer in males 23.6 mm at the corner of the mouth. The Cupid’s bow is positioned
than females 20.6 mm. As a result, females tend to have 3 to 5 mm higher than the central point of the vermilion.
a greater ideal upper incisor show in repose, approximately
4 mm, compared with males, which is around 2 mm.1 It has
been described that there is a proportional correlation
between the skin excision height and degree of tooth show
in millimeters.6

Surgical Technique
The measurement of lip length is taken from the sub-nasale to
the vermillion line. A natural height within the range of 12 to
13 mm is typically recommended (Figure 1). The markings
are methodically and systematically applied to facilitate the
determination of the appropriate extent of upper lip excision.
The choice of incision design can follow an external
approach, which is based on the classic bullhorn lip lift, or an Figure 2. External approach design with the 9 vertical references.
endonasal approach.9 For patients with hypertrophic nasal
sills, it is advisable to opt for the external incision design to
prevent the need for amputation of the nasal sill (Figure 2).
On the contrary, individuals with flat nasal sills make excel-
lent candidates for the endonasal incision design, which
allows for the concealment of the incision within the nostrils
(Figure 3).
In the case of an endonasal lip lift, the superior incision is
delineated beneath the nose, extending across the entire nasal
base. The lateral boundary of this incision corresponds to the
point where the alar-facial crease tapers and terminates
beneath the nasolabial fold. When marking along the nasal
sills, it is essential to carefully encroach upon them by enter-
ing the nostril marginally, ensuring that the incision remains
concealed within the nostril. Typically, the marked endonasal Figure 3. Endonasal approach design with the 9 vertical references.
points are situated approximately 2 to 3 mm above the sill
entrance.
Vertical radial reference markings are created to facilitate The determination of the inferior incision line is guided
the even distribution of flap advancement. These markings by the required measurement, assisted by a Castroviejo
are placed at the internal lateral rim, and 2 intermediate are caliper if necessary. Care is taken to ensure that this incision
added between the peaks of the internal rim and the internal line runs parallel to the upper marking incision. The rest of
lateral rim. In addition, a center columellar line is marked the inferior marking is created by gradually tapering from the
bringing the total number of markings to 9 (Figures 2 and 3).6 marking at the internal sill upward.
Fakih-Gomez et al
Figure 4. Superficial incision using an 11-blade scalpel.
Figure 5. Excision of the marked skin leaving the subcutaneous layer beneath untouched.
The initial step involves making the lower incision using an
11-blade scalpel. This incision is made superficially, penetrat-
ing only the skin, imitating the process of marking the resec-
tion borders with the scalpel (Figure 4). Following this, the
upper incision is crafted, using a 15-blade scalpel, removing
only the skin within the delineated resection area while leav-
ing the subcutaneous layer beneath intact (Figure 5).
3
A monopolar electrocautery is employed to carefully
penetrate the subcutaneous layer at the center (Figure 6),
reaching the SMAS to establish superior and inferior cuffs
comprising skin, subcutaneous tissue, and SMAS layers
(Figure 7). These cuffs primarily aid in the dissection beneath
the SMAS, extending to the vermilion line border on both
lateral sides (Figures 8 and 9). In cases of reduced tension for
4 The American Journal of Cosmetic Surgery 00(0)

Figure 6. Monopolar electrocautery is employed to carefully penetrate the subcutaneous layer at the center.

Figure 7. Superior and inferior cuffs comprising skin, subcutaneous tissue, and SMAS layers.
SMAS = superficial muscular aponeurotic system.

closure, the dissection may be halted midway, preserving the
subcutaneous layer between the philtrum columns (Figure 10).
Laterally, the dissection extends to the nasolabial folds,
facilitating a palpable release of the labial flap, which, in
turn, allows for a minimal-tension closure.
Below the entire length of the superior border incision
and at the entrances to the nasal sills, sub-SMAS undermin-
ing is performed in a beveled manner (Figure 11). Following
the undermining process, the superior cuff is reduced at the
boundary of the cutaneous incision (Figure 12).
Fakih-Gomez et al 5

Figure 8. Performing sub-SMAS undermining below the superior border incision and at the entrances to the nasal sills.
SMAS = superficial muscular aponeurotic system.

Figure 9. The cuff aids in the dissection beneath the SMAS, extending to the vermilion line border on both lateral sides.
SMAS = superficial muscular aponeurotic system.

Regarding the inferior border, it involves the labial flaps horizontal resection limited to the superficial layer of the
that extend into the nasal sills. At these levels, the subcuta- subcutaneous cuff. This approach ensures that the stag-
neous layer is cut in a staggered fashion, with a careful gered inferior cuff fills the beveled resected sub-SMAS
6 The American Journal of Cosmetic Surgery 00(0)
layer beneath the entrances to the nasal sills (Figures 13
and 14). In the remaining portions of the inferior border, the
subcutaneous cuff is reduced, leaving a length of approxi-
mately 1 to 2 mm.
The suspensions should be approached as central and
laterally vectored advancement flap (Figure 15). A single
central suspension is created using a 4-0 Monocryl suture. It
enters superiorly between the nasal and labial muscle layers,
penetrates deeply to grasp the pyriform ligament, and exits
just beneath the dermis inferiorly. Two lateral suspension
sutures are crafted using 4-0 Monocryl, with entry from the
inside of the nose superiorly (at the internal lateral part of the
Figure 10. Dissection on both lateral sides of the lip.
Note. Central region is not dissected.
Figure 11. Sub-SMAS undermining in a beveled manner below the entire length of the superior border incision and at the entrances to
the nasal sills.
SMAS = superficial muscular aponeurotic system.
nasal sill). These sutures pass deep, capturing the orbicularis
oris muscle, and exiting just deep to dermis (Figure 16).
The subcutaneous layer is closed using 5-0 Monocryl
sutures. To optimize the closure, the subcutaneous layer of
the upper incision is grasped in a full-thickness manner, and
the lower incision is grasped in a partial-thickness manner
(Figure 17). This step ensures better alignment of the inci-
sion borders (Figure 18).
For the superficial closure, a double-layer approach is
employed: two 5-0 nylon intradermal running sutures are
used, both starting from lateral to medial and forming a knot
between them at the central part (Figure 19). In addition,
6-0 nylon simple sutures are used for the skin (Figure 20).
Our recommendation is to clean the wound consistently,
approximately 3 times a day during the first 5 days, using
betamethasone or sodium fusidate ointment to prevent clot
accumulation.
Patient Results
A total of 41 patients underwent this technique between
August 2021 and August 2023, with 40 (97.5%) being
women and 1 (2.5%) being men. Mean (range) age was
38.5 (25-52) years old. The postoperative follow-up time
ranged from 6 to 22 months, with a mean of 14 months.
The mean (range) of lip resection was 8 mm (5-11 mm).
Overall patient satisfaction was high, a stable and long-
lasting result was observed during the follow-up period
Fakih-Gomez et al 7

Figure 12. Reduction of the superior cuff at the incision boundary.

Figure 13. Reduction of the superior cuff at the incision boundary.

(Figures 21-24). Thirty-nine of the patients (95%) con­ underwent a revision surgery, revealing hypertrophy of the
sidered their scar optimal and barely visible. However, 1 epidermis/dermis, and is currently undergoing low-dose
patient (2.5%) developed a unilateral nodule fibrosis, pri- cortisone injections for management. Another patient
marily due to excessive bipolar coagulation. This patient (2.5%) experienced a non-ideal cosmetic scar due to surgical
8 The American Journal of Cosmetic Surgery 00(0)

Figure 14. The labial flap is cut in a staggered fashion, with a careful horizontal resection limited to the superficial layer of the
subcutaneous cuff.
Note. This approach ensures that the staggered inferior cuff aligns with and fills the beveled resected sub-SMAS layer beneath the entrances to the
nasal sills. In the remaining portions of the inferior border, the subcutaneous cuff is reduced, leaving a length of approximately 1 to 2 mm (The blue line
corresponds to the subcutaneous layer without the dermal layer, whereas the green line corresponds to the incision border.).

Figure 15. Central and lateral suspensions of the advancement flap using 4-0 Monocryl suture.
Fakih-Gomez et al 9

Figure 16. Repositioned tissue without skin tension.

Figure 17. Closure of the subcutaneous layer with 5-0 Monocryl sutures.
Note. The subcutaneous layer of the upper incision is grasped in a full-thickness manner, and the lower incision is grasped in a partial-thickness manner.

infection, which led to wound dehiscence and second clo- Discussion

sure healing. This patient underwent a corrective revision
surgery at 12 months. No other complications were identi- To date, 20 indirect lip lift techniques have been docu-
fied along the incision line. mented in the literature. 2,5-7,9-23 Therefore, a comprehensive
10
Figure 18. Proper alignment of the incision borders.
Figure 19. Intradermal closure with 5-0 nylon running sutures.
understanding of the intricacies and proper execution of
these techniques is crucial when choosing the most suitable
one. However, it is worth noting that the literature does not
provide a clear description of the applicability of these tech-
niques in addressing various ethnic backgrounds and ana-
tomical variations.3
The American Journal of Cosmetic Surgery 00(0)
The majority of subnasal lip lift techniques primarily
target the central upper lip and are less effective on the
lateral aspects.1 This modified technique, however, intro-
duces a central6 and lateral vectored deep-plane advance-
ment flap. The latter modification provides the added
benefit of achieving a certain degree of lateral lifting
Fakih-Gomez et al 11

Figure 20. Closure of skin with 6-0 nylon simple sutures.

Figure 21. (A) Frontal view of a 25-year-old female patient with an upper lip length of 21 mm before surgery. (B) Result at 1 month
after resection of 7 mm. (C) Result at 1 year.

effect. The key to achieving this desired result lies in the
deeper sub-SMAS dissection, primarily on the lateral
regions, reaching down to the vermilion. In addition, this
deep-plane dissection extending into the nasolabial folds
laterally helps elevate the corners of the lip to some extent.
In the central area, full vertical dissection down to the ver-
milion is avoided to prevent the erasure of the Cupid’s
bow.6 Restricting the dissection in the central part of the
upper lip is crucial for achieving elevation while maintain-
ing oral competence.7
12 The American Journal of Cosmetic Surgery 00(0)

Figure 22. (A) Frontal view of a 41-year-old female patient with an upper lip length of 18 mm before surgery. (B) Result at 1 month
after resection of 5 mm. (C) Result at 1 year.

Figure 23. (A) Frontal view of a 50-year-old female patient with an upper lip length of 22 mm before surgery. (B) Result at 1 month
after resection of 9 mm. (C) Result at 1 year.

The suspensions outlined in our technique emphasize the suspension differs slightly from the approach proposed by
significance of the pyriform ligament, which serves as a Echo et al,7 where the suspension relies on the soft tissue sur-
robust and ideal structure for securing suspensory sutures as rounding the anterior nasal spine or the inferior anterior sep-
described in Ben Talei’s technique.6 This structure-specific tal cartilage. Echo’s suspension method avoids the need for
Fakih-Gomez et al
Figure 24. (A) Right three-quarter view of a 50-year-old female patient with an upper lip length of 22 mm before surgery. (B) Result at
1 month after resection of 9 mm. (C) Result at 1 year.
direct excision techniques, potentially requiring adjustments
to the lower third of the nose.
It is essential to note that patients with a wider anatomical
alar base will experience a more effective lateral lift when
the excisions extend to the perialar creases. Conversely,
those with a narrower base width may only attain satisfactory
central lift.1 In simpler terms, the lateral reach of the lateral
suspensions is constrained by the width of the nasal base, and
they offer enduring support for the lateral lift. However, the
extent of this suspended lateral lift will not be as significant
as that achieved with a proper corner lip lift. With this con-
cept firmly understood, there is no necessity to extend the
excision design laterally or superiorly beyond the alar-facial
crease to achieve greater lateral lift. Doing so may result in
crease distortion and scarring.6
The creation of tissue cuffs at the incision borders repre-
sents a significant innovation in this technique. This serves to
prevent the skin surface from being traumatized during dis-
section. Furthermore, it enhances the contact surfaces of the
tissues and improves their distribution when suturing.
The most commonly encountered sequelae are scarring
and widening of the nasal base. Several studies have reported
rates of adverse scarring ranging from 1% to 5%.3-6 In addi-
tion, subnasal lift techniques have been associated with
adverse scarring rates of 6.7% to 10.5%.3 To mitigate scar-
ring issues that may arise at the nasal base, surgeons have
increasingly employed creative incision designs in an effort
to maximize results and minimize complications.6,7
13
However, through the implementation of this technique
and leveraging the deep-plane sub-SMAS release, suspen-
sions, and meticulous double-layer closure, it has been inten-
tionally minimized the risk of unacceptable scar formation
and poor aesthetic outcomes. The most critical factor influ-
encing the development of a high-quality scar is the execu-
tion of a meticulous double-layer superficial closure. Simple
sutures are removed as early as the third day to prevent them
from leaving marks on the skin. In contrast, intradermal
sutures are left in place for a longer duration to prevent any
muscular distortion of the sutured incisions during the heal-
ing phase. This precaution is essential because, during this
phase, there is tension and movement in the area due to facial
muscle activity and the act of eating.
Based on our clinical experience over 1 year in this tech-
nique, involving visual photographic analysis of all cases
treated, we have observed that in the long term, this method
successfully shortens the philtrum. However, it is worth not-
ing that its ability to achieve upper lip eversion is somewhat
limited. We acknowledge this visual effect as a potential
limitation of the technique, regardless of the suspension
employed.
Conclusions
The modified indirect lip lift technique is a safe, consistent,
reproducible, and widely applicable method. This technique
effectively addresses the primary limitations of previous
14
approaches, consistently yielding aesthetically pleasing
results over the long term with a low rate of complications.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Nabil Fakih-Gomez https://orcid.org/0000-0003-4464-8258
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Author Biographies
Nabil Fakih-Gomez, MD, MSc, Department of Facial Plastic
and Cranio-Maxillo-Facial Surgery, Fakih Hospital, Khaizaran,
Lebanon.
Cristina Muñoz-Gonzalez, MD, Department of Facial Plastic
and Cranio-Maxillo-Facial Surgery, Fakih Hospital, Khaizaran,
Lebanon.
David Dominguez-Medina, MD, Department of Facial Plastic
and Cranio-Maxillo-Facial Surgery, Fakih Hospital, Khaizaran,
Lebanon.
Ibrahim Fakih-Gomez, MD, Department of Facial Plastic and
Cranio-Maxillo-Facial Surgery, Fakih Hospital, Khaizaran,
Lebanon.