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The Modified Upper LipLift
Advanced Approach with Deep-PlaneRelease and Secure Suspension: 823-PatientSeries
Benjamin Talei, MD

KEYWORDS

� Modified upper lip lift � Philtrum � Reduction � Shortening � Augmentation

KEY POINTS

� Deep-plane release of the SMAS tissue in the upper lip permits a tension-free suspension to theligaments at the nasal base.

� Preoperative incision and vector markings provide a map for proper skin redistribution.

� Suspension suturing of the deep lip tissue allows proper, tension-free, healing in a highly dynamicregion.

� Immaculate closure is of utmost importance at the nasal base.

� Techniques crossing the nasal sill should be avoided.

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INTRODUCTIONThe Evolution of Lip Lifting

The upper lip lift has been performed for over 4 de-cades.1 The modified upper lip lift takes estab-lished principles used elsewhere in facial surgeryand applies them to upper lip rejuvenation toobtain superior results. Traditional lip lift tech-niques have been criticized and often avoidedout of the fear of scarring. To avoid problemsthat can be encountered at the nasal base, sur-geons have become increasingly creative withincision design, trying to maximize results anddecrease complications. Unfortunately, few ofthese techniques have provided esthetically natu-ral and reproducible results.

The bullhorn subnasal lip lift was one of the firstacceptable techniques, as described in 1971 byCardoso and Sperli.1 Several renditions followedwith the goal of reducing incision length, limiting

Disclosure Statement: The author has nothing to discloseFacial Plastic & Reconstructive Surgery, Beverly Hills CenteSuite 750, Beverly Hills, CA 90210, USAE-mail address: [email protected]

Facial Plast Surg Clin N Am 27 (2019) 385–398https://doi.org/10.1016/j.fsc.2019.04.0041064-7406/19/� 2019 Elsevier Inc. All rights reserved.

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scarring and enhancing the amount of lifting.2–6

Unfortunately, most of these techniques have atendency toward nasal base effacement and scar-ring that is difficult to repair according to the au-thor’s clinical experience (Figs. 1–4).

Our technique is based on the classic bullhornincision with modifications that have made a sig-nificant improvement in results and consistency.Rather than focus on changes in incision design,the key to our procedure is a deeper and moreextensive release of the upper lip and more defin-itive suspension. The modified upper lip lift is acentrally vectored deep-plane advancement flapfocused on releasing tension in the skin and uni-formly redistributing the skin once tethering isreleased. The preoperative radial vector markingsdesigned and depicted by the author are essentialto optimizing outcomes. We performed 823 upperlip lifts over the 4-year period from 01/01/2015 until

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Fig. 1. Atrophic scarring with nasal effacementfollowing “Italian Lip Lift.”

Fig. 3. Effacement of nasal base with labial skinpulled into the nose with loss of sill volume.

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the date of this article 10/31/2018. Review of ourresults reveals consistent outcomes with few com-plications when using our technique for the modi-fied upper lip lift.

PATIENT SELECTION

The modifications made to the bullhorn subnasallip lift technique have allowed a significantly widerapplication of this procedure. Previously reservedprimarily for elderly patients with light skin, thisprocedure can now be used on patients of awide variety of ages, skin types, genders, and eth-nicities. This procedure can also be used for pa-tients with already adequate tooth show whowish to improve upper lip height, character, andvolume. Even the most conservative upper lip liftcan change the slope and vector of the vermillionandmake the lip more receptive to filler augmenta-tion (Figs. 5–7).The most common presentations and com-

plaints in the author’s practice are shown in Box 1.Patients often present with excess lip length and

drooping, complaining of looking tired and aged.An elongated upper lip can lengthen the appear-ance of the entire midface. Lack of tooth show ex-aggerates the aged appearance and can

Fig. 2. Atrophic scarring with striations after verticallifting with extended lateral incisions.

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dramatically diminish sensuality. As the liplengthens, it also tends to display diminished func-tion while losing character and definition of the Cu-pid’s bow (Figs. 8–10).In recent years, there has been an emergence of

patients suffering the negative effects of fillers.Permanent fillers such as silicone, fat, and otherpolymers such as polymethylmethacrylate(PMMA) may cause perpetual damage to the up-per lip because of expansion, thickening, andeffacement. They may also dramatically inhibit lipfunction through muscular infiltration and/oredema. The upper lip lift cannot restore the lip toa normal state, but it can re-elevate the lip to ahigher position with improved eversion andimprove overall appearance (Figs. 11 and 12).Temporary injectables such as hyaluronic acid

(HLA) dermal fillers may have negative short-termoutcomes, as well as permanent sequelae. Themost notorious of these fillers to have a problemis Juvderm XC. Due to it being hydrophilic fromits high HLA concentration (24 mg/mL) and migra-tory in nature, it accounts for most problems seenwith HLA products in my practice. The tissue inte-gration and migration of this product can cause aspreading out of the filler in the subcutaneous

Fig. 4. Atrophic scarring and hypopigmentationfollowing upper lip lift performed with high tensionclosure.

ornia from ClinicalKey.com by Elsevier on May 04, 2020.pyright ©2020. Elsevier Inc. All rights reserved.

Fig. 5. Conservative excision on a patient withadequate tooth show improving lip accents.

Fig. 7. Conservative excision improving lip accent andappearance.

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tissue of the lip, beyond the vermillion borderwhere it was injected. The author has witnessedthe persistence of Juvederm in reactive regionsfor over 8 years. Given the issues witnessedfollowing injections of Juvederm XC, PMMA, sili-cone, and other polymers, the author has advisedagainst their use in the lips. Fat injections in the lipmay have similar consequences, and fat graftingshould not be done without prejudice. Thesemigratory, hydrophilic, and inflammatory fillersare most notably found within the 10-mm segmentabove the vermillion border months to yearsfollowing injection (Figs. 13–16). They are quitenoticeable on most patients, presenting with abulge, whitish discoloration, simian upper lip con-vexity, and limitation in smile. Dissolving HLA fillerabove the vermillion border is easy to do andshould be done before pursuing surgical interven-tion to increase precision and decrease postoper-ative inflammation.

Another presenting complaint is drooping orlengthening of the upper lip following surgical

Fig. 6. Lip eversion following modified upper lip liftproviding improved vermillion vectoring and display.


procedures such as rhinoplasty or orthognathicsurgery. Rhinoplasty can have a clear and directeffect on the position of the upper lip. Maneuversthat deproject the nasal tip, such as transfixion in-cisions or dissection around the nasal base, cancause the lip to lower immediately or shortly aftersurgery. This can be prevented, reversed, orimproved using a variety of resuspension tech-niques such as the “tongue-in-groove” maneuver,suspension to the nasal spine, or by performing anupper lip lift.

Another common presenting patient issue isasymmetry of the upper lip. Complaints typicallyinclude height disparities between Cupid’s bowpeaks, differences with smiling, and position ofthe oral commissures. Mild asymmetries at theCupid’s bow and along the adjacent vermillionmay be improved in some cases, but more lateralor more significant asymmetries are typicallybeyond the scope of an upper lip lift (seeFig. 16). Most lateral lip asymmetries are a conse-quence of facial asymmetries, which are notamenable to improvement from a proceduredone at the base of the nose.

Box 1Common complaints

1. Chronically long or heavy upper lip

2. Poor tooth show/dental hooding

3. Over-filled lips/poor filler results

4. Filler complications

5. Postsurgical drooping (rhinoplasty/orthognathic)

6. Poorly defined or thin upper lip

7. Asymmetry

8. Buried or drooping corners of the mouth

9. Upper lip incompetence


Fig. 8. Cupid’s bow definition and sensuality restored following modified upper lip lift.

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SURGICAL TECHNIQUEDental and Facial Analysis

The threshold for patient candidacy is significantlylower when using the modified upper lip lift tech-nique. The exceptions are patients in whom a liplift would create imbalance or an exaggerated

Fig. 9. Youth and tooth show restored followingmodified upper lip lift.


appearance. A familiarity with minimum andmaximum excision amounts, as well as the neces-sary minimum height of lip to be left in situ is ofgreat importance. However, the true art of lip lifting

Fig. 10. Cupid’s bow definition tightened followingmodified upper lip lift.


Fig. 11. Modified upper lip lift combined with nasal base suspension and mucosal excision to improve silicone-caused deformities.


comes from a thorough facial analysis and an abil-ity to “eyeball” what would look good.

Overall facial balance must be considered,comparing soft tissue proportions, as well asdental or skeletal predominance. A primary goalof the lip lift for most patients and practitioners isto increase the incisive tooth show. There is atipping point that must be respected for each

Fig. 12. Upper lip weighing down from fillers now re-suspended following modified upper lip lift.


patient, where the sensuality and youthfulnessgained from increased tooth show transitions toa toothy or skeletonized appearance with exces-sive excision. There are no measurements or strict

Fig. 13. Front view. Top photo demonstrating simianappearance and heaviness from Juvederm. Bottomphoto after dissolver and lip lift.


Fig. 14. Corner view. Top photo demonstrating simianappearance and heaviness from Juvederm. Bottomphoto after dissolver and lip lift.

Fig. 16. Mild asymmetries improved with an asym-metric lip lift. Normal healing in Asian skin types.

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guidelines that would indicate this level or point. A3-mm tooth show on a patient with beautiful teethand normal projection may be lovely, whereas thesame amount of tooth show on a patient with astrong dental overjet (type II malocclusion), maloc-clusion, a gaunt facial appearance, or unappealingdentition may be excessive. Surprisingly, “gummy

Fig. 15. Lateral view. Top photo demonstrating simian apBottom photo after dissolver and lip lift.


smiles” are rarely affected or exaggerated with themodified upper lip lift, likely because this tech-nique has the ability to decrease the exertion orstrain on the upper lip with smiling (Fig. 17).

pearance, projection, and heaviness from Juvederm.


Fig. 17. A more relaxed smile noted in the bottomphoto after modified upper lip lift.

Fig. 18. The first step in marking is to find the naturalcrease between the nose and lip. The lateral-mostextent should be at the transition zone between awell-defined and blunted crease. Medially the peakoccurs where the medial crural footplate diverges.


Excessive tooth show, maxillary-mandibularimbalance, or unappealing dentition should notpreclude one from performing a lip lift. Either aconservative lip lift may be performed, in the 3-to 5-mm range of excision, or the patient may firstbe referred to a cosmetic dentist, orthognathicsurgeon, or orthodontist.

Relative soft tissue balance is also important.We learn to begin by analyzing the horizontal fifth’sand the vertical thirds of the face, but there aremany variables affecting what we perceive as apleasant harmony of the face. The proportionswe see on patients with thick skin or a full-roundface may be drastically different than that of a pa-tient with a thin or delicate face. Rather than mea-sure the proportions directly, the authorrecommends looking at the face as a whole andsimply envisioning the changes to be made. Theoverall intent is to make the lip fit appropriately inrelation to its surrounding structures, primarilythe nose, cheeks, and chin. For example, a widenasal base with fatty ala and flaring will not toleratethe appearance of a foreshortened upper lip.

Surgical Marking

The excision outline and radial reference markingsdesigned by the author are the most crucial part ofthis procedure. The markings are based on theclassic “bullhorn” lip lift. The excision and closureshould be treated as a centrally vectored advance-ment flap. The markings are made in a step-wiseand logical fashion to aid in the decision of theproper amount of upper lip excision and to makethe design as symmetric possible.


1. The first step is to mark the upper incision(Fig. 18). This mark goes across the entire nasalbase in the natural alar-facial and alar-labialcrease. The lateral extent of this is where thealar-facial crease tapers and ends caudally to-ward the alar groove. The incision should notgo past the superior or lateral extent of thewell-demarcated crease, which may end onthe inferior or lateral part of the ala. Extendingan incision beyond this point may cause distor-tion and scarring of the crease or even create apleat from the cheek to the nose and efface thenatural upper lateral extent of the upper lipesthetic unit. The incision continues under thenose, making sure not to invade the nasal sill.In hypotrophic nasal sills, a healthy amount oftissue must deliberately be left in situ. Pro-gressing centrally, the marking will reach apeak either at the superior extent of the philtralcolumn or at the divergence of the medial cruralfootplate around the nasal spine. It is importantto note that the line of the philtral column andthis peak do not always align. Moving furthercentrally, the 2 paramedian peaks then transi-tion into a dip at the junction of the lip to thebase of the columella. This crease may be lowand buried or high at the base of a rotatedcolumella.

2. Two reference markings are made on eachside, extending radially from the internal silland the external rim. The height of excision isthen demarcated (Fig. 19). The best startingpoint on most patients is on a horizontal creaseor line that the author deems a “line of declara-tion.” Most patients with an elongated lip have1 or 2 horizontal creases that form in lines oftension during strained smiling. If this is not pre-sent, the next step would be to find an area oftransition or inflexion on the upper lip followingthe base of the columella inferiorly. Most lips


Fig. 19. Radial reference markings are made to aideven distribution and advancement of flaps fromthe internal sill following the curve of the lip outwardas well as from the alar rim margin. The 2 paramedianpeaks are marked along with the center of the colu-mella. The ideal height is marked.

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look maximally appealing if they begin with avertical slope, transitioning anteriorly towardthe vermillion like a ski ramp (Figs. 20 and21). Once this point is chosen, the surgeonmust determine the ideal location for the bestlooking lip with an incision that would yield theideal excision for perfect tooth show. As a se-curity measure, mark the minimum amount ofremaining lip. For most patients, this would bearound 11 mm as measured from the Cupid’sbow peak superiorly while the lip is on stretch.Leaving less than 10 mm of residual upper lipheight is not recommended.

The amount of expected tooth show gainedfrom each excisional height is demonstrated in

Fig. 20. The upper lip looks most pleasant with an im-mediate transition from vertical to sloped.


Table 1. These measurements should only serveas guidelines. The amount to be excised typicallyranges between 4 and 11 mm, with most standardexcisions ranging between 5 and 7 mm. Excisionsaiming for notable tooth show are typically be-tween 7 and 9 mm. An excision of over 11 mm isnot advised, because this dramatically increaseshealing time and makes redistribution of skin diffi-cult for the average patient. There are many vari-ables that determine the actual changes in heightincluding skin thickness, skin laxity, muscle func-tion, and nasal base laxity. The lift obtained on pa-tients with thinner upper lips tends to be moreexaggerated than on those patients with thick orhyperelastic lips (see Table 1).Once the excision height is marked, a caliper is

used to measure the distance with the lip onstretch. The lower incision marking is then madeusing a caliper uniformly and in parallel to the up-per incision, until the first of the lateral radial mark-ings is encountered (Fig. 22). At this point, the dotsare connected between the internal rim referencemarking and the peak of the lateral upper incision.If there is a minor Cupid’s bow asymmetry, thiscan be corrected at this stage, with an asymmetricexcision. Lateral asymmetries cannot be correctedwith a surgery centered at the base of the nose.Once all the dots are connected, the remaining

reference markings are drawn, totaling 9 lines. Avertical marking is placed on each incision peakand 1 in the center. Intermediate markings arethen made between the peak marking and the in-ternal rim marking (Fig. 23). These points serveas closure points for the deep suspension suturesas well as even centralized redistribution markingsfor the advancement of the lower flap.

Excision

The procedure is performed using local anesthesiaand with the surgeon at the head of the bed. Thelower incision is made first, with a 15 blade scalpelperpendicular to skin, extending to the junction ofthe fat and the muscle. The upper incision is thenmade parallel to the lower incision (Fig. 24). Theskin and subcutaneous flap is then excised in aplane over the orbicularis, leaving a thin glossylayer of fat intact. This glossy layer is where mostof the vasculature lays deep to the superficialmuscular aponeurotic system (SMAS). Thelarger-caliber vessels in the field are the inferioralar arteries, which are buried under the ala andalar sill, running parallel to them (Fig. 25).

Dissection

Once the excision is performed, the labial flap isthen elevated in a deep sub-SMAS plane. This


Fig. 21. The upper lip convexity in the before photo causes an aged, simian appearance.


dissection releases the labial SMAS from the un-derlying orbicularis oris. The extent of this dissec-tion is at the discretion of the surgeon, as moreextensive dissection may mitigate tension butalso causes a dramatic increase in postoperativeswelling. Taller excisions typically require a greaterdegree of release, as do patients who requirerelease and rolling of the lateral vermillion to avoida subsequent corner lift. The average patient willrequire release in the deep plane half-way downthe central philtrum. Full central dissection isavoided because of possible effacement of theCupid’s bow (Figs. 26 and 27). Laterally, thedissection is carried as far out as necessary to

Table 1Estimated lift based on excision height––variable

Excision(mm)

3 4 5 6 7 8 9 10 11

Toothshow(mm)

0 0–1 1–2 2–3 2–4 3–5 4–6 5–7 6–8


obtain a palpable release of the labial flap thatwould allow a minimal tension closure. For mostpatients the dissection approaches or extends tothe vermillion anywhere lateral to the philtral col-umns and stops just before the nasolabial fold.Care must be taken to stay in a directly sub-SMAS plane to avoid excessive bleeding or dam-age to any of the labial elevator complex. Carefulhemostasis must be achieved, preferably with abipolar cautery (Fig. 28). Although a hematoma isnot typically a risk in classic lip lifts, it is a consid-eration with a modified upper lip lift given theextensive dissection and dead space created.

Suspension and Closure

The mistake made by most practitioners is per-forming a simple dermal closure. As we havelearned from endoscopic brow lifting andadvanced forms of face lifting, the best lift isachieved by performing adequate release of teth-ering and then by suspension of dense tissue up-ward to a fixed location. When this is performedin the upper lip, the released skin/SMAS flap isthen able to roll over and redistribute tensionabove the contracted orbicularis.


Fig. 22. Castro-Viejo angles caliper is used to mark theheight of excision with the lip on stretch. Equalheights are marked between the internal sill refer-ence markings.

Fig. 24. Perpendicular incisions are made through theskin, fat, and SMAS to the level of the orbicularislayer. Upper and lower incisions are made in parallelto aide in proper approximation.

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The dermis at the base of the nose is not firmlyattached. The periosteum or overlying pyriform lig-ament are the only firm structures that can providea strong base for suspension. Suturing to the peri-ostium produces an over exaggerated tacking ofthe labial flap. The pyriform ligament is a densenetwork of fibrous tissue overlying the periosteumthat spans the pyriform aperture and is perfect forengagement of suspensory sutures.7

A 5-0 PDS suture on a P-3 needle is used ateach of the central 7 reference markings. The nee-dle is passed into the junction of the nasal and oralmusculature and then carried deep to grab thepyriform ligament but not the periosteum. The nee-dle exits deep to the alar dermis with care not toincorporate the dermis (Fig. 29). The needle isthen passed inferiorly through the SMAS on theunderside of the labial flap (Fig. 30). The SMASof the upper lip is a discrete tissue layer with sub-stantial strength that is located just deep to thereticular dermis.8,9

Suturing to the SMAS instead of the dermis al-lows the skin to approximate without tension or

Fig. 23. The remainder of the inferior marking ismade by tapering from the internal sill markings up-ward. The corresponding reference markings aremade, as well as 2 intermediate reference markingsto total 9 markings.


dimpling. This provides a major advantage bypushing the dermal edges together. The incisionis closed sequentially from central to lateral(Fig. 31). Once the knots are tied, the skin edgesshould be closely approximated. At the lateral-most reference marking, a 4-0 Vicryl on a PS-2needle is passed from inside the pyriform comingout radially to grab the SMAS, and then returnedback into the nose to complete a mattress suture(Fig. 32). The inferior alar artery should be identi-fied and avoided, if possible. The skin is then reap-proximated with a plethora of vertical mattress andinterrupted 6-0 nylon sutures, with the end pointbeing resolution of any step-offs from the lowerto upper skin flaps (Figs. 33 and 34). This area isunforgiving and meticulous suturing technique isrequired.

POSTOPERATIVE COURSEPostoperative Care

The incisions must be kept moist with ointment atall times in the first several weeks. Patients aregiven a surgical mask to so they do not feel self-

Fig. 25. The marked skin, fat, and SMAS are excisedleaving a thin, glossy fat layer intact to avoid damageof vessels and the inferior alar artery marked in thephoto.


Fig. 26. Deep-plane/sub-SMAS elevation is performeddirectly over the muscle layer.

Fig. 28. Hemostasis is obtained using bipolar electro-cautery to minimize risk of hematoma.


conscious. Sutures are typically removed partiallyat day 3 and completely at day 5 (Fig. 35). Tapingis neither affective nor necessary. Patients areforewarned that swelling may appear extremeand that the appearance of the lip typically takes3 months to return to normal. Relative to others,this technique produces significantly moreswelling in this area because of the disruption ofbilateral lymphatic drainage pathways as well asmuscle trauma causing a postoperative myositis.The stiffness and swelling in the first 3 monthsmay benefit incisional healing by limiting move-ment at the incision line. Patients are seen at 3-week intervals for reassurance and potential injec-tion of 5-fluorouracil 50mg/cc into a firm orbicula-ris patch. The nasal base is also quite responsiveto fractionated CO2 laser, should that be required.Most patients receive this routinely at 60 and120 days at a low setting.

Potential Sequelae

The most commonly encountered sequelae of anupper lip lift are scarring and widening of the nasalbase. For this reason, most practitioners whoperform the lip lift procedure do so on elderly pa-tients with light skin. Issues can arise with any

Fig. 27. Sub-SMAS dissection is continued half-waydown the central philtrum. Lateral dissection is typi-cally carried to the same level or greater.


technique. However, when using the bullhorn inci-sion, even if unsightly scarring occurs, it can mostoften be easily and significantly improved with scarmodulation therapies. Off-label use of 5-fluoro-uracil 50mg/cc can help flatten hypertrophic inci-sions. CO2 laser can improve hypertrophic,atrophic, and other types of scarring.

Alternative techniques that involve more com-plex types of incisions, such as the philtral stretch-ing variations of the upper lip lift, L-shapedphiltrum lift, extended incision lip lift, Greenwaldincision, double duck suspension, and the Italiantechnique, may result in greater amounts of scar-ring and changes to the nasal base that are difficultto reverse. Atrophic scarring is quite common, aswell as skeletonization or effacement of the nasalbase. Incisions extending into the nasal sill inher-ently cut away healthy mass and volume at thenasal base while advancing the skin of the lip in-side the nose where it does not naturally reside.

Distortion or effacement of the nasal base canoccur with untoward tension on compliant por-tions of the nasal base. When tension is combinedwith excision of portions of nasal sill, the distortioncan become more prominent. If the central lip islifted or excised more than the lateral portions,

Fig. 29. 5-0 PDS suture enters between the nasal andlabial muscle layers, passes deep grabbing the pyri-form ligament, and exits just deep to the dermis.


Fig. 30. The 5-0 PDS is passed deep to the dermis tograb the SMAS layer only.

Fig. 32. The 7 central reference markings are closedwith the deep layer of 5-0 PDS sutures. The 2 mostlateral markings are closed using a 4-0 Vicryl enteringfrom the inside of the nose, passing externally be-tween the orbicularis muscle and nasal ala to grabthe SMAS layer then exit through the nose by passingthrough the nasolabial junction.

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this can also produce an unnatural and dispropor-tionate postoperative appearance to the lip thatfurther exaggerates a suboptimal outcome. Cen-tral lip lifts are rarely indicated andmost commonlyproduce an exaggerated upturn of the central lip.This often results in relative worsening of theappearance of lateral lip hooding. It is importantto remember that there are limits to what a proced-ure at the nasal base can achieve. The intent tochange the character of the lip significantly shouldbe avoided.

Avoiding Sequelae

The first way to assure a superior result is properincision design, following the principles of the bull-horn lip lift. This means avoiding cutting into anddamaging the nasal sill by carrying incisions insidethe nose. Most techniques that involve hidden in-cisions inherently require that healthy sill skin isexcised and replaced with skin from the lip. Labialskin does not naturally occur within the nasal silland it should not be placed there during a strictlycosmetic procedure. Once the sill is removedand scarring occurs, the sill cannot be replacedand the atrophic skin that replaces it is quite diffi-cult to repair.

Fig. 31. A 5-0 PDS is tightened with a single knot, fol-lowed by a slip knot, then a locking knot.


Problematic healing also seems to arise frominadequate incision length and insufficient deeptissue release. Making smaller incisions, whethersingle in the center or bilateral incisions underthe nasal sills, tend to increase complications aswell. Smaller incisions may limit the proper releaseof tension and redistribution of skin, while also pre-senting the potential for disproportionate lifting.This means that, although incisions are limited,there may be higher tension placed on each inci-sion point, resulting in poor healing. Uniform redis-tribution avoids irregularities and skin bunching byspreading the tension evenly along the length ofthe entire incision. The perioral region is extremelydynamic, and all possible efforts to relieve tensionat the incision should be performed. Properrelease of the deep structures to reduce closuretension, coupled with adequate deep suturing, fol-lowed by intricate superficial suturing, will enhanceresults. The practitioner should be aware that thenasal base is an unforgiving area with regard to

Fig. 33. Superficial closure is performed with a combi-nation of 6-0 nylon vertical mattress and interruptedsutures.


Fig. 34. Closure using enough sutures to avoid anystep-offs or irregularities.


irregularities and scarring. Although it may notseem so, longer incisions tend to heal better thanshorter ones.

Some lip lifting techniques rely on muscle sus-pension, excision, or plication to relieve tensionon the skin.6,10 This ideology may theoreticallybe supported by muscle-tightening proceduresperformed during facelift surgery; however,mimetic muscles are not routinely suspended dur-ing rhytidectomy. Rather, the SMAS-platysmacomplex is tightened, which carries no mimeticfunction. A dense SMAS fascia definitively existsin the upper lip just deep to the dermis and super-ficial to the orbicularis oris muscle. The SMAS-skinflap may be released and used for lifting similar todeep-plane lifting in the face. The orbicularis oris isa mimetic muscle that is extremely dynamic andsensitive to trauma. From the author’s experience,muscle binding has a higher probability of causingfibrosis at the plicated region and may actuallyhave a tendency to pull the nasal base in a down-ward direction. Still, muscle plication or imbrica-tion may serve a purpose in some patientsduring various lip lifting procedures including themodified upper lip lift. When binding is performedduring this procedure, it is typically limited to theuppermost 2 mm of the orbicularis muscle. The

Fig. 35. Sutures are typically removed at days 3 and 5.This photos was taken 5 days postoperatively.


upper orbicularis is taken and suspended to thepyriform ligament using 5-0 PDS sutures to limitpotential damage to the muscle and nasal base.Experienced practitioners may use muscle-binding techniques routinely with high successrates, but amount of muscle trauma in the handsof the novice surgeon should be limited.

Direct vermillion excisions tend to cause a blur-ring of the vermillion and a visible scar with apotentially unnatural appearance that almost al-ways requires lip liner camouflage. Once thevermillion is distorted, it cannot be recreated. Inthe author’s opinion, the only indication for an inci-sion at the vermillion border is the rare patient whorequires a corner of the mouth lift.11 Corner lift in-cisions are limited and seldom cause issues; how-ever, we perform them rarely because themodified upper lip lift has the ability to treat this re-gion on most patients.

Complications

A chart review of 823 consecutive lip lifts fromJanuary 2015 to October 2018 in the author’s pri-vate practice was performed. Histories werereviewed for any complications seen past the 3-month mark. Of note, there were no patientsdemonstrating any limitation in movement orsmile. Five patients required revision to obtainfurther lifting or further lifting and symmetry. Twopatients developed dermal atrophy and telangiec-tasias following injection with triamcinolone.Because of this, the author no longer injects triam-cinolone postoperatively in these patients. Twopatients complained of vague changes in char-acter of the nostrils, which were difficult to depictin photos. Two patients experienced minor hema-tomas, which were limited by tamponade. Two pa-tients had prolonged edema extending to the 4-month mark, which then resolved. Both of thesepatients had previous silicone injections and an11-mm excision. Ten patients developed a rashfrom antibiotic ointment. Two patients presentedwith a 1-mm rim of eschar/epidermolysis of un-known cause around the lateral nostril base thathealed without incidence. Although many patientsreceived scar modulation with injections of 5-fluo-rouracil 50mg/cc and/or CO2 laser treatments onthe incisions, none were bothered by their inci-sions. There were no patients found to haveincreasing asymmetry. There were no incidentsof infection.

Forty-five patients had a simultaneous lip liftwith rhinoplasty with no adverse sequelae. Alar-plasty was performed at a separate time on allbut 2 patients to avoid lateral scarring. Sixty-twopatients had simultaneous lip lift with rhytidectomy


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with no adverse sequelae. Sixty-eight patients hadsimultaneous mucosal lip reductions mostly toreduce polymer-related abnormalities. Fifteenreceived simultaneous dermis or SMAS grafts toaugment lip volume and there were no adverse ef-fects. One patient requested a subsequent cornerlift. The remainder of the patients seeking cornerlifting before surgery received an adequate degreefrom the modified upper lip lift.

SUMMARY

A variety of lip lift techniques have been createdover time with the intent of diminishing scarringand poor outcomes. A great deal of energy hasbeen misdirected toward compensatory measuressuch as changes in incision design rather thansimply improving the manner in which the lip islifted. The modified upper lip lift is a sub-SMASrelease and suspension technique that simplifiesprocedural steps and minimizes risks of adverseoutcomes. Furthermore, it permits a wider applica-tion of an often-needed technique to all ages, eth-nicities, genders, and skin types. We have learneda great deal from other facial cosmetic surgeries,such as brow lifts, upper blepharoplasty, anddeep-plane rhytidectomy. As guided by the evolu-tion of upper blepharoplasty, muscle preservationis essential for maintaining proper function andvolume. Face-lifting techniques have demon-strated a much greater efficacy when tension isadequately released then resuspended to a firmor fixed structure, such as is seen with deep-plane facelifts.The upper lip lift has the ability to produce a high

yield change on the face with a single, small pro-cedure. It can produce a younger and moresensual appearance by shortening the perceivedheight of the midface, as well as by increasingtooth show and oral visibility. The nasolabial foldin most patients appears softer and shortened aswell. This easily reproducible technique hasrepeatedly demonstrated consistent outcomes


with an exceedingly low complication rate. Theneed for such a procedure is under-recognized inpatients of all ages. The modified upper lip lift isa safe, consistent, reproducible, and widely appli-cable technique for any gender, ethnicity, and skintype.

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