Cosmetic Medicine

Aesthetic Surgery Journal

Preliminary Report 2019, Vol 39(12) NP474–NP483
© The Author(s) 2019. Published
by Oxford University Press on

Proposed Guide to Lip Treatment in Caucasian behalf of The Aesthetic Society. All
rights reserved. For permissions,

Women Using Objective and Measurable

please e-mail: journals.permis-
sions@oup.com
DOI: 10.1093/asj/sjz026
Parameters www.aestheticsurgeryjournal.com

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Giuseppe Sito, MD; Luana Consolini, MBiol; and Patrick Trévidic, MD

Abstract
Background: The lips are a focal point of the face; however, their aesthetic proportions and effect on perceived facial beauty remain poorly defined.
Perioral aging is highly individual, with several distinct and often simultaneous processes contributing to changes in lip contour and surface. These
processes can affect lip volume and length, shape, and the degree of vermilion inversion.
Objectives: We aimed to develop a treatment guide for Caucasian women that combined a complete analysis of the lips (including the effects of
aging) with consideration of the rheological characteristics of the products used to assist practitioners in tailoring rejuvenation treatment to individual
patients.
Methods: We reviewed existing literature to analyze the parameters that make the lips of Caucasian women “attractive” and investigated the
rheological characteristics of different hyaluronic fillers to provide guidance on the optimal treatment for each woman.
Results: Our numerical definition of the lips is based on 4 specific parameters: philtrum height, upper vermillion height, ratio between philtrum and
upper vermillion height, and golden ratio between upper and lower vermillion height. In our opinion, conserving the length of hyaluronic acid chains
results in dynamic fillers that may provide better results with lower risk of asymmetry compared with conventional products.
Conclusions: This new classification and associated treatment guideline aims to allow accurate assessment and enable practitioners to customize
treatment for individual patients.

Editorial Decision date: January 18, 2019; online publish-ahead-of-print February 4, 2019.

Numerous studies have been carried out to determine the
desired proportions between the different parts of the face
as well as the characteristics used to classify the “attractive-
ness” of the eyes1,2 and nose.3,4 The eyes, lips, and nose—
the “triangle of beauty”—are, in order of importance, the
anatomical areas that draw our attention5; however, some
research has shown how important the lips become when
smiling.6
The relative attractiveness of the lips is determined by a
combination of proportion, definition, and volume, and, as
explained by Hoefflin in the book chapter “The Definition
of Facial Beauty,”7 it is “a matter of just a few millimetres.”
Despite occupying only a small space, the lips play a central
role in the lower one-third of the face and comprise a series of
characteristic parameters that our aesthetic sensitivity defines
as “ideal”, causing us to see them as a focal area of beauty.8
The definition of the ideal lips has varied greatly
over the years. One of these definitions establishes that
Dr Sito is Master Scientific Director, Pegaso University of Naples,
Naples, Italy. Dr Consolini is a Clinical Manager for Teoxane Italy,
Bologna, Italy. Dr Trévidic is a plastic surgeon in private practice in
Paris, France.
Corresponding Author:
Dr Giuseppe Sito, Pegaso University, V. della Cavallerizza 14, 80121,
Naples, Italy.
E-mail: mail@giuseppesito.it
Sito et alNP475

the height of the “white lip”, also known as the upper

cutaneous lip or ergotrid, must not exceed the distance
between the lower lash rim and the supratarsal crease7
(Supplementary Figure 1). According to Perkins and
Sandel,9 the common denominator for “perfect” lips is
the volume of the labial mucous membrane. To be pre-
cise, the volume of the upper lip should be 75% to 80%
of the lower one (Supplementary Figure 2). Despite there
being a current tendency to emphasize the upper lip more
and more,10 the absence of precise corrective limits often
causes exaggerated aesthetic results, leaving the patient
dissatisfied.11

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Just like any other area of the face, the lips are sub-
ject to a constant aging process. Photoaging, genetics,
maxillo-mandibular bone reabsorption, smoking, and
other factors make the lips thinner, with progressive flat-
tening and lengthening of the philtrum, and reduction of
the Cupid’s bow and the natural protrusion of the upper
lip12,13 (Supplementary Figure 3). This is joined by a char-
acteristic fading of the color of the vermilion and softening
of the lip contour.11 A complete treatment approach must
consider all of these aspects combined.
In the literature, numerous measurement scales and
algorithms based on separate analysis of the lip and white
lip are used to determine treatments aimed at skin reju-
venation of the perilabial areas.14-18 As highlighted by
Raphael et al,19 the ideal lip correction treatment is based
on an analytical approach to the labial area between the
base of the nose and the stomion. By measuring specific
parameters (height of the philtrum and the upper lip, and
the proportion between them), Raphael et al developed a
numerical lip classification for Caucasian women (ie, pale-
skinned women of European origin).19
This article proposes a more complete analysis, which,
as well as the parameters reported by Raphael et al,19 also
contemplates the aging of the philtrum, and the upper and
lower lip ratio in Caucasian women. All of these elements
have been combined to form a treatment guide, which,
together with consideration of the rheological character-
istics of the products used, aims to assist practitioners in
tailoring treatment to individual patients.
METHODS
To obtain a detailed understanding of lip anatomy and
what are considered to be ideal lip parameters in Caucasian
women, we conducted an initial search of the existing
literature in May 2017. The PubMed and Google Scholar
databases were searched and the screening of abstracts and
article titles was performed by author L.C. based on the
following inclusion criteria: (1) articles from January 1960
to December 2017 for a general overview on the aesthetic
parameters of beauty; (2) primary articles published in the
Figure 1. Macroscopic anatomical structure of the lips.
(1) Nasolabial folds; (2) philtrum columns; (3) philtrum;
(4) Cupid’s bow; (5) white roll; (6) upper vermilion with
median and lateral tubercles; (7) lower vermilion; (8) lateral
commissures.
last 10 years (from January 2007 to December 2017) on
lip parameters and scales of measurement, as well as
guidelines for lip treatment products; and (3) the article
was published in English.
Relevant articles meeting the agreed criteria, published
up to January 2018, were also considered by the authors.
All search results were reviewed and confirmed by the
authors G.S. and P.T.; there were no disagreements on the
results.
Key Features
The upper and lower lips have distinct anatomical
features. The upper lip extends from the base of the nose
(above) to the lateral nasolabial folds (area 1 in Figure 1)
and the border of the lower vermilion (area 7). There is a
cutaneous portion of the upper lip, the white lip (trapezium
delimited above by the nasal base, below by the border of
the upper vermilion [area 6], and laterally by the right and
left nasolabial folds) also defined as the upper cutaneous
lip or ergotrid, which determines a more or less evident M
shape in the Cupid’s bow (area 4). The cutaneous portion
of the upper lip has a median depression, the philtrum, in
NP476
Figure 2. The golden ratio. G-K point, Glogau-Klein points
of the Cupid's bow.
the center (area 3), delimited at the sides by the philtrum
columns (area 2), which then slope down towards the
sides of the white lip. The lower lip extends from the
lower vermilion to the lateral commissures (area 8) and
the mandible (below). Around the border of the upper
vermilion, a delicate and paler cutaneous area, the white
roll (area 5), marks the contour between the vermilion and
the upper cutaneous lip.
In the literature, harmonious lips are presented with
certain specific features. Lips that are considered attractive
and proportionate have determined indices: a well-defined
Cupid’s bow and labial profile, a thinner upper lip protru-
sion compared with the larger lower lip, and a philtrum
characterized by a specific height and shape.7,11
The parameters that appear to be essential for a com-
plete definition of lip aesthetics are: philtrum height, upper
vermilion height, proportion between philtrum and upper
vermilion height, and the golden ratio (Figure 2) between
upper and lower vermilion heights. Thanks to the numer-
ical characterization of each parameter, it is now possible
to classify lips not only on a photographic basis but also on
a numerical basis.7,19-21
Philtrum Height
The lips are part of an aesthetic unit that comprises the
mouth and the perilabial tissue that surrounds it. The
white lip area in particular tends to gradually sag due to
gravity, bone retraction, elastosis, and a weakening of the
ligaments.9
The ideal dimensions of the philtrum indicated in the
literature are a width of 10 to 11 mm7 and a length of
12 to 15 mm20 (Supplementary Figure 4). The length in
particular is strongly influenced by aging, which causes
a progressive increase with time. As we age, regardless
Aesthetic Surgery Journal 39(12)
of the anatomical conformation of the face, the phil-
trum becomes longer, passing from an optimal range of
12 to 15 mm (or thereabouts) to mean values of 18 to
20 mm.20,22,23 A study by Zankl et al,20 which assessed
2500 individuals, determined the elongation curve of the
philtrum as it ages and confirmed the findings of previous
studies.24-26 In specific terms, if we exclude a first peak in
growth during adolescence, followed by a reduction upon
reaching adulthood, the philtrum presents a constant and
characteristic elongation.
Considering the classification proposed by Fitzpatrick
and collaborators27 for photoaging of the face and the
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perioral area (light to moderate, advanced, severe photo-
aging), we can identify 3 different classes of age on the
philtrum elongation curve presented in the study by Zankl
et al.20 The first class can be identified between the ages
of 25 and 45 years, the second between 45 and 65 years,
and the final class in individuals aged over 65 years. The
first class presents a light to moderate elongation of the
philtrum between 16 and 17 mm, the second, an advanced
elongation between 17 and 19 mm (Supplementary Figure
5A), and the third class presents severe elongation, with
the philtrum exceeding 19 mm (Supplementary Figure 5B).
Height of the Upper Vermilion
The ideal lips should be full, with a specific proportion
between the upper and lower lips and a well-defined
vermilion border.12,28 Aesthetically speaking, they should
have an approximate length of 57 to 62 mm, an upper
vermilion height of 8.5 to 9 mm, and a lower vermilion
height of 9.5 to 10 mm,7 increasing by a few millimeters
at the level of the lower lateral tubercles29 (Supplementary
Figure 4).
The literature contains numerous descriptions of aging
and the changes that affect the upper lip with age.23,30-33
A study carried out by Farkas et al in 199234 used mor-
phometric data to establish that growth stops in early
childhood. Aging causes a significant elongation and
visible thinning of the upper lip, with an increase of the
prolabium.35 The reduction of the vermilion seems to
be caused mainly by a thinning of the border, which is
responsible for an inversion in the overall conformation of
the upper lip. However, contrary to earlier theories,31,33,36
there is no loss of volume of the labial mucous membrane,
but instead a redistribution between lip length (which
increases) and vermilion height (which diminishes).35
Growing demand for lip redefining treatments has led
to the development and publication of numerous pho-
tographic classification scales. Scales may range from
1 to 5 (eg, the Lip Fullness Grading Scale,37 the Overall
Lip Index,38 the Lip Fullness Scale, and the Medicis Lip
Fullness Lip Scale—an implementation of the Lip Fullness
Sito et alNP477
Figure 3. Definition of the upper cutaneous lip area (green).
Measurement points (black). ls, upper lip; sn, subnasal; st,
stomion.
Scale17—or 1 to 9.39 All of these scales classify the lips
(upper and/or lower) as very thin, thin, normal, full, and
fleshy.
Ratio Between the Philtrum and Upper
Vermilion
Dissatisfaction with the appearance of our lips stems
mainly from the combination of an elongated philtrum and
thin lips.11,40,41 The causes of these undesirable features can
be congenital or acquired.9,23 In particular, the reduction
of the Cupid’s bow, the inversion of the vermilion, or the
elongation of the philtrum are recognized indicators of lip
and perilabial aging.42,43 These indicative parameters are
part of a characteristic anatomical region that comprises
the white lip (ergotrid) and the upper vermilion. Here, we
can identify 3 points: the nasal base (sn), the upper border
of the vermilion (ls), and the central part of the labial rim,
the stomion (st) (Figure 3). These points define 2 specific
vertical measurements: the height of the philtrum and
that of the upper vermilion, which are connected by a
proportion known as the philtral labial score (PLS).
The PLS represents the ratio between the height of the
philtrum and that of the upper lip (Figure 4).19 On the
basis of the PLS, Raphael et al defined a new numerical
lip classification system, known as the labral classification
system (LCS), which conveys objectivity to photographic
classification systems.19 The LCS was based on a retro-
spective analysis of records (including before and after
photographs, PLS, and dental show values) for 200 mainly
Caucasian women aged 25 to 75 years. This confirmed that
the PLS can be used to classify lips according to the fol-
lowing 4 types.19
• Type 0: characterized by lips considered to be normal
and free from defects; PLS 1.2 to 2.3. No treatment is
recommended
• Type 1: presents a thin upper vermilion, an absence
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or reduced appearance of radial wrinkles; PLS 3 to
5. Increase in the volume of the upper lip is recommended
• Type 2: presents an elongated philtrum, with flattened
philtrum columns, an increase in the distance between
them, and an inversion of the upper lip; PLS 3 to
5. Lifting of the upper lip is recommended
• Type 3: presents both defects (thin upper vermilion and
elongated philtrum), generally evident radial wrinkles;
PLS >5. Combine treatments (volume and lifting are
recommended)
The LCS is based on numerical proportions and heights
recognized in neoclassical aesthetics and by state-of-
the-art photometric analysis programs. Lips with a short
philtrum, full lips, or a combination of both features are not
considered, because these lip types are rarely the subject of
aesthetic treatments. The LCS includes recommendations
for the most appropriate corrective treatment for each
type, based on restoring the PLS to optimal proportions to
achieve “ideal” lips.
The ratio between specific heights in the lower third
of the face was also used by Farkas et al44 to analyze the
following distance ratios: upper cutaneous lip (sn – ls) /
total upper lip (sn – sto) and upper vermilion (ls – st) /
total upper lip (sn – st) in a young Caucasian population
(Figure 5).
Lips are considered “normal” with an upper vermilion
height that is 25% of the overall lip dimension, which is
equivalent to a PLS of <3 in the study by Raphael et al.19
The experimental values of the PLS support previous stud-
ies on the elongation of the philtrum with age22,23 and the
ideal dimension of the upper vermilion.29,32
Ratio Between the Upper and Lower
Vermilion
During the past 2000 years, research into the proportions
that make up pleasing facial features has supported
the existence of a specific proportion associated with
harmonious shapes recognized as beautiful. This index,
known as the golden ratio or divine ratio, is identified
NP478
Figure 4. Components used in calculation of the philtral
labial score (PLS). L, height of upper lip; ls, upper lip; P,
height of philtrum; sn, subnasal; st, stomion.
by the symbol φ (phi) and is an irrational number that
approximates to 1.618. Thanks to its ubiquitarian nature
and the close relationship with aesthetics,45-47 the golden
ratio has been the key consideration of facial harmony
since the days of the Ancient Greeks. The concept of
mathematical models48 has enabled the construction
of “phi masks” to determine the ideal measurements of
a face, from which any individual characteristics can be
optimized and made ideal. In specific terms, a study that
assessed the lips of young Caucasian females considered
the lips to be “perfect” when they presented with a φ ratio
between the lower and upper vermilion heights21 (Figure 2).
The ideal volume of the lower lip has to be 1.618 times that
of the upper one.
The same ratio also governs the labial profile. In ideal
lips, the straight line that runs through 2 precise points,
subnasal and pogonion, should identify a mean projection
of the upper lip of 3.5 mm compared with a lower lip pro-
jection of 2.2 mm, with a ratio of 1.618:1. Therefore, the
ideal upper lip should protrude about 2 mm beyond the
Aesthetic Surgery Journal 39(12)
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Figure 5. Linear vertical measurements of the lower third
of the face. Heights of the upper lip: o, upper cutaneous;
*, upper vermilion; #, total measurement. ls, upper lip; sn,
subnasal; st, stomion.
lower one9 (Figure 6). In contrast, an exaggeration of this
proportion creates unnatural looking “duck” lips, with an
undesirable pout.11
RESULTS
Based on the previous classifications and measurements
discussed above, we propose a nonsurgical treatment
guide aimed at achieving the “ideal” lips for Caucasian
women. The guide incorporates the following features:
• Specific intervals of philtrum elongation with age20
• Numerical lip classification—the LCS19: PLS and its
ideal value (to be achieved with treatment)
• Photographic lip classification—the Lip Fullness Grading
Scale37: from very thin to fleshy
• The golden ratio between the upper and lower lips21
The guide is illustrated in Figure 7 and documented in
Table 1.
Sito et alNP479
Figure 6. Comparison of ideal protrusion of the upper lip compared to the lower one (left side) compared with excessive
protrusion of the upper lip compared with the lower one, with an unnatural aesthetic result (right side).
Positioning and Injection of
Hyaluronic Acid
Various reabsorbing and permanent fillers are used to
correct and enhance the lips. Thanks particularly to the
results achieved and the excellent level of safety, hyaluronic
acid is the reabsorbing substance most frequently used.11
Because there is no fatty tissue in the lips, hyaluronic acid
can be injected at surface level (mid-derma) or deep down
(deep derma or submucosal level, above the orbicularis
oris muscle), depending on the specific viscoelasticity of
the gel.
The filler can be injected in 3 different positions.38,49
• Injection into the body of the vermilion, to increase vol-
ume without the risk of overcorrection and in the lateral
commissures. As highlighted by Sarnoff and Gotkin,11
to achieve a harmonious result, it is important for the
correction to respect the natural curve of the lips created
by the tubercles of the upper lip (1 medial and 2 lateral)
and the lower lip (2 medial)
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• Injection along the border of the vermilion, as far as
the Glogau-Klein points of the Cupid’s bow, positioned
between the red lip and the white roll (about one-third
of the way up the height of the white-roll), to redefine
the labial profile
• Injection along the philtrum columns for a redefinition
of the structure of the philtrum and a reduction of the
length perceived
In young patients, the treatment of thin lips usually
envisages an increase in volume of the central one-
third of the body of the vermilion. The injection can be
performed employing different techniques, including
the retrograde linear, which is preferable, or the serial
puncture techniques. The correct level is deep. Often
a lack of fullness in lips depends on the flattening or
elongation of the philtrum rather than on the fact that
the lips themselves are thin. In these cases, the injection
is performed closer to the surface, in the border of the
vermilion and/or in the philtrum columns, utilizing the
retrograde linear technique, which improves the eversion
NP480 Aesthetic Surgery Journal 39(12)

A B

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C D

Figure 7. Lip classification based on measurable parameters: philtrum height and philtral labial score (PLS) ratio between
philtrum and upper lip. (A) Type 0, ideal lips. (B) Type 1, intermediate lips. (C) Type 2, elongated lips. (D) Type 3, very
elongated lips.

of the upper lip and reduces the perceived length of the
philtrum.49
Most requests for volume-related treatments come from
elderly patients, where the choice of the right injection
level is critical to achieving a natural and harmonious
result. With time, the lips tend to elongate and gradually
become atrophic35; deep injection throughout the entire
body of the vermilion is recommended, which also encour-
ages a reduction of the vertical labial wrinkles that are
frequently associated. The greater the atrophy, the greater
the risk of an unnatural aesthetic result. In senescent lips,
it can be helpful to reduce the amount of hyaluronic acid
injected into the body of the vermilion, resulting in a less
deep redefinition of the labial profile and the philtrum
columns.50
Rheological Characteristics of
Hyaluronic Acid
When assessing the best treatment for the patient, in
addition to the technique and the right injection level, it
is essential to consider the rheological characteristics of
the filler. The ideal rejuvenation of the lips is based on 2
factors: an increase in the volume of the vermilion, the
definition of its profile, and the philtrum height.
To increase the volume, as required particularly in
patients who are older or who have thin lips, the filler
must be able to maintain the shape and projection con-
veyed, resisting degradation as well as the forces of elon-
gation and compression caused by the natural dynamism
of the lips. From a rheological point of view, this translates
into a filler with an elastic modulus G’ and intermediate
cohesivity to resist the degradation and forces of compres-
sion produced by the contraction of the underlying labial
muscle.11,51 To avoid perception of the implant, the correct
position is at the deep level.
To improve the labial profile, which is more frequently
desired in young patients with normal to fleshy lips or in
older patients to complement volumetric correction,11,50
the filler is positioned closer to the surface. A filler posi-
tioned in the superficial derma must have different rheo-
logical properties from one that is injected deeper down to
add volume; the frequency and intensity of the different
stimuli (cutaneous, muscular, or fatty deposit) to which
the filler is subjected are more variable in this area. From
the rheological point of view, the gel has to have lower G’
and cohesivity, because there is an increase in the forces
of contraction or stretching in this area (elongation/short-
ening), whereas the compression forces are reduced. It
also must present high levels of malleability, minimum
Sito et alNP481

Table 1. Proposed Treatment Guidea

Type Height of P, mm Classification of L, mm PLS (P/L) Ratio between lower lip and L Recommended treatment

0 Ideal (12–15 mm) Very thin, thin 3-5 ≥1.618 Increase in the volume of the upper lip

<1.618 Increase in the volume of the lips (upper + lower)

Normal, full, fleshy <3 (1.2-2.3) ≥1.618 None

<1.618 Increase in the volume of the lower lip

1 Intermediate (16–17 mm) Very thin, thin >5 ≥1.618 Increase in the volume of the upper lip

<1.618 Increase in the volume of the lips (upper + lower)

Normal, full, fleshy 3-5 ≥1.618 Redefinition of the upper lip (increased projection)

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<1.618 Redefinition of the lips (upper + lower)

2 Elongated (17–19 mm) Very thin, thin >5 ≥1.618 Increase in volume of L

<1.618 Increase in volume of lips

Normal, full, fleshy 3-5 ≥1.618 Redefinition of P columns

<1.618 Redefinition of P columns and lower lip

3 Very elongated (>19 mm) Very thin, thin >5 ≥1.618 Increase in volume of L

<1.618 Increase in volume of lips (upper + lower)

Normal, full, fleshy 3-5 ≥1.618 Redefinition of P columns

<1.618 Redefinition of P columns and lower lip

aThe guide is based on the height of the philtrum, classification of the upper lip, ratio between height of the philtrum and the upper lip (PLS), and the ratio between height of the lower and upper
lips. L, upper lip; P, philtrum; PLS, philtral labial score.

values, lower G’, high tissue integration) could repre-

sent an interesting possibility for this type of correction.
The specific rheology of dynamic fillers depends on the
conservation of the natural links of the hyaluronic acid
molecule, impossible up to now employing classic meth-
ods.52,53 Studies of dynamic rheology54,55 have shown
that it is the conservation of the length of the chains of
hyaluronic acid that guarantees a lesser breakdown of
the gel in a hydrophilic and hydrophobic environment,
guaranteeing an excellent safety profile and lower risk of
asymmetry.

DISCUSSION

Video 1. Watch now at https://academic.oup.com/asj/

article-lookup/doi/10.1093/asj/sjz026.
projection, and maximum capacity to follow facial move-
ments.51 The lower viscoelasticity of the gel together with
extensive stretching will increase incorporation into the
dermic matrix, stabilizing the position and favoring a nat-
ural correction.
The availability of new fillers with a dynamic rhe-
ological profile (medium to high stretch and strength
The guide that we have developed is designed to help
practitioners customize and optimize augmentation
procedures for lips, thus minimizing the risk of hypo-
and hypercorrections. By combining our findings on lip
anatomy and the different types of fillers available for
lip treatment, we aim to help standardize augmentation
procedures for the lips and increase patient satisfaction.
Limitations of our treatment guide are that it is only for
Caucasian women and it is unsuitable for patients with
strongly asymmetrical lips. The guide has not been
validated; a logical next step would be a clinical trial in
NP482
women requiring lip augmentation powered to assess the
validity of guide.
We also have developed an app based on our proposed
guide, which combines all the discussed parameters (phil-
trum, upper vermilion, and lower vermillion height) and
provides treatment indications for practitioners. The app,
which is available on Apple and Android platforms, shows
the area of the lip needing treatment (upper or lower ver-
million), the type of treatment required (lip volume or
labial profile), and advice on optimal filler choice (demon-
strated in Video 1).
CONCLUSIONS
There is no single prescription for “perfect” lips, and
treatment must be tailored to the needs of the individual.
The proposed classification and guide for treatment (Table 1)
could enable the practitioner to better tailor treatment to
individual patients by considering individual variability
and the physiological changes linked to aging in Caucasian
women. We have been developing software that expertly
combines all the discussed parameters and provide
treatment indications for practitioners. This software,
which will be available on Apple and Android platforms,
will also provide advice about the optimal filler choice.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
Acknowledgments
The authors kindly acknowledge the creation of the figures
by Davide Gamberini (Grafica Biomedica Illustrazioni
Medico Scientifiche, Italy), who has provided permission
to use these figures. The authors also thank MedSense,
Ltd. for providing editorial assistance.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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