The M odified Upper Lip

Lift
Advanced Approach with Deep-Plane
Release and Secure Suspension: 823-Patient
Series
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 the
ligaments 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 dynamic
region.
 Immaculate closure is of utmost importance at the nasal base.
 Techniques crossing the nasal sill should be avoided.

INTRODUCTION scarring and enhancing the amount of lifting.2–6

The Evolution of Lip Lifting Unfortunately, most of these techniques have a
tendency toward nasal base effacement and scar-
The upper lip lift has been performed for over 4 de-
ring that is difficult to repair according to the au-
cades.1 The modified upper lip lift takes estab-
thor’s clinical experience (Figs. 1–4).
lished principles used elsewhere in facial surgery
Our technique is based on the classic bullhorn
and applies them to upper lip rejuvenation to
incision with modifications that have made a sig-
obtain superior results. Traditional lip lift tech-
nificant improvement in results and consistency.
niques have been criticized and often avoided
Rather than focus on changes in incision design,
out of the fear of scarring. To avoid problems
the key to our procedure is a deeper and more
that can be encountered at the nasal base, sur-
extensive release of the upper lip and more defin-
geons have become increasingly creative with
itive suspension. The modified upper lip lift is a
incision design, trying to maximize results and
centrally vectored deep-plane advancement flap
decrease complications. Unfortunately, few of
focused on releasing tension in the skin and uni-
these techniques have provided esthetically natu-
formly redistributing the skin once tethering is
ral and reproducible results.
released. The preoperative radial vector markings
The bullhorn subnasal lip lift was one of the first
designed and depicted by the author are essential
acceptable techniques, as described in 1971 by
to optimizing outcomes. We performed 823 upper
facialplastic.theclinics.com

Cardoso and Sperli.1 Several renditions followed

lip lifts over the 4-year period from 01/01/2015 until
with the goal of reducing incision length, limiting

Disclosure Statement: The author has nothing to disclose.

Facial Plastic & Reconstructive Surgery, Beverly Hills Center for Plastic & Laser Surgery, 465 North Roxbury Drive,
Suite 750, Beverly Hills, CA 90210, USA
E-mail address: drtalei@beverlyhillscenter.com

Facial Plast Surg Clin N Am 27 (2019) 385–398

https://doi.org/10.1016/j.fsc.2019.04.004
1064-7406/19/Ó 2019 Elsevier Inc. All rights reserved.
386 Talei

Fig. 1. Atrophic scarring with nasal effacement Fig. 3. Effacement of nasal base with labial skin
following “Italian Lip Lift.” pulled into the nose with loss of sill volume.

the date of this article 10/31/2018. Review of our dramatically diminish sensuality. As the lip
results reveals consistent outcomes with few com- lengthens, it also tends to display diminished func-
plications when using our technique for the modi- tion while losing character and definition of the Cu-
fied upper lip lift. pid’s bow (Figs. 8–10).
In recent years, there has been an emergence of
patients suffering the negative effects of fillers.
PATIENT SELECTION Permanent fillers such as silicone, fat, and other
polymers such as polymethylmethacrylate
The modifications made to the bullhorn subnasal
(PMMA) may cause perpetual damage to the up-
lip lift technique have allowed a significantly wider
per lip because of expansion, thickening, and
application of this procedure. Previously reserved
effacement. They may also dramatically inhibit lip
primarily for elderly patients with light skin, this
function through muscular infiltration and/or
procedure can now be used on patients of a
edema. The upper lip lift cannot restore the lip to
wide variety of ages, skin types, genders, and eth-
a normal state, but it can re-elevate the lip to a
nicities. This procedure can also be used for pa-
higher position with improved eversion and
tients with already adequate tooth show who
improve overall appearance (Figs. 11 and 12).
wish to improve upper lip height, character, and
Temporary injectables such as hyaluronic acid
volume. Even the most conservative upper lip lift
(HLA) dermal fillers may have negative short-term
can change the slope and vector of the vermillion
outcomes, as well as permanent sequelae. The
and make the lip more receptive to filler augmenta-
most notorious of these fillers to have a problem
tion (Figs. 5–7).
is Juvderm XC. Due to it being hydrophilic from
The most common presentations and com-
its high HLA concentration (24 mg/mL) and migra-
plaints in the author’s practice are shown in Box 1.
tory in nature, it accounts for most problems seen
Patients often present with excess lip length and
with HLA products in my practice. The tissue inte-
drooping, complaining of looking tired and aged.
gration and migration of this product can cause a
An elongated upper lip can lengthen the appear-
spreading out of the filler in the subcutaneous
ance of the entire midface. Lack of tooth show ex-
aggerates the aged appearance and can

Fig. 4. Atrophic scarring and hypopigmentation

Fig. 2. Atrophic scarring with striations after vertical following upper lip lift performed with high tension
lifting with extended lateral incisions. closure.
 The Modified Upper Lip Lift 387

Fig. 5. Conservative excision on a patient with Fig. 7. Conservative excision improving lip accent and
adequate tooth show improving lip accents. appearance.

tissue of the lip, beyond the vermillion border procedures such as rhinoplasty or orthognathic
where it was injected. The author has witnessed surgery. Rhinoplasty can have a clear and direct
the persistence of Juvederm in reactive regions effect on the position of the upper lip. Maneuvers
for over 8 years. Given the issues witnessed that deproject the nasal tip, such as transfixion in-
following injections of Juvederm XC, PMMA, sili- cisions or dissection around the nasal base, can
cone, and other polymers, the author has advised cause the lip to lower immediately or shortly after
against their use in the lips. Fat injections in the lip surgery. This can be prevented, reversed, or
may have similar consequences, and fat grafting improved using a variety of resuspension tech-
should not be done without prejudice. These niques such as the “tongue-in-groove” maneuver,
migratory, hydrophilic, and inflammatory fillers suspension to the nasal spine, or by performing an
are most notably found within the 10-mm segment upper lip lift.
above the vermillion border months to years Another common presenting patient issue is
following injection (Figs. 13–16). They are quite asymmetry of the upper lip. Complaints typically
noticeable on most patients, presenting with a include height disparities between Cupid’s bow
bulge, whitish discoloration, simian upper lip con- peaks, differences with smiling, and position of
vexity, and limitation in smile. Dissolving HLA filler the oral commissures. Mild asymmetries at the
above the vermillion border is easy to do and Cupid’s bow and along the adjacent vermillion
should be done before pursuing surgical interven- may be improved in some cases, but more lateral
tion to increase precision and decrease postoper- or more significant asymmetries are typically
ative inflammation. beyond the scope of an upper lip lift (see
Another presenting complaint is drooping or Fig. 16). Most lateral lip asymmetries are a conse-
lengthening of the upper lip following surgical quence of facial asymmetries, which are not
amenable to improvement from a procedure
done at the base of the nose.

Box 1
Common 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
Fig. 6. Lip eversion following modified upper lip lift 9. Upper lip incompetence
providing improved vermillion vectoring and display.
388 Talei

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

SURGICAL TECHNIQUE appearance. A familiarity with minimum and

Dental and Facial Analysis maximum excision amounts, as well as the neces-
sary minimum height of lip to be left in situ is of
The threshold for patient candidacy is significantly
great importance. However, the true art of lip lifting
lower when using the modified upper lip lift tech-
nique. The exceptions are patients in whom a lip
lift would create imbalance or an exaggerated

Fig. 9. Youth and tooth show restored following Fig. 10. Cupid’s bow definition tightened following
modified upper lip lift. modified upper lip lift.
 The Modified Upper Lip Lift 389

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- patient, where the sensuality and youthfulness
ity to “eyeball” what would look good. gained from increased tooth show transitions to
Overall facial balance must be considered, a toothy or skeletonized appearance with exces-
comparing soft tissue proportions, as well as sive excision. There are no measurements or strict
dental or skeletal predominance. A primary goal
of the lip lift for most patients and practitioners is
to increase the incisive tooth show. There is a
tipping point that must be respected for each

Fig. 13. Front view. Top photo demonstrating simian

Fig. 12. Upper lip weighing down from fillers now re- appearance and heaviness from Juvederm. Bottom
suspended following modified upper lip lift. photo after dissolver and lip lift.
390 Talei

Fig. 14. Corner view. Top photo demonstrating simian

appearance and heaviness from Juvederm. Bottom
photo after dissolver and lip lift.

guidelines that would indicate this level or point. A Fig. 16. Mild asymmetries improved with an asym-
3-mm tooth show on a patient with beautiful teeth metric lip lift. Normal healing in Asian skin types.
and normal projection may be lovely, whereas the
same amount of tooth show on a patient with a smiles” are rarely affected or exaggerated with the
strong dental overjet (type II malocclusion), maloc- modified upper lip lift, likely because this tech-
clusion, a gaunt facial appearance, or unappealing nique has the ability to decrease the exertion or
dentition may be excessive. Surprisingly, “gummy strain on the upper lip with smiling (Fig. 17).

Fig. 15. Lateral view. Top photo demonstrating simian appearance, projection, and heaviness from Juvederm.
Bottom photo after dissolver and lip lift.
 The Modified Upper Lip Lift 391

1. The first step is to mark the upper incision

(Fig. 18). This mark goes across the entire nasal
base in the natural alar-facial and alar-labial
crease. The lateral extent of this is where the
alar-facial crease tapers and ends caudally to-
ward the alar groove. The incision should not
go past the superior or lateral extent of the
well-demarcated crease, which may end on
the inferior or lateral part of the ala. Extending
an incision beyond this point may cause distor-
tion and scarring of the crease or even create a
pleat from the cheek to the nose and efface the
natural upper lateral extent of the upper lip
esthetic unit. The incision continues under the
nose, making sure not to invade the nasal sill.
In hypotrophic nasal sills, a healthy amount of
tissue must deliberately be left in situ. Pro-
gressing centrally, the marking will reach a
peak either at the superior extent of the philtral
Fig. 17. A more relaxed smile noted in the bottom column or at the divergence of the medial crural
photo after modified upper lip lift. footplate around the nasal spine. It is important
to note that the line of the philtral column and
Excessive tooth show, maxillary-mandibular this peak do not always align. Moving further
imbalance, or unappealing dentition should not centrally, the 2 paramedian peaks then transi-
preclude one from performing a lip lift. Either a tion into a dip at the junction of the lip to the
conservative lip lift may be performed, in the 3- base of the columella. This crease may be low
to 5-mm range of excision, or the patient may first and buried or high at the base of a rotated
be referred to a cosmetic dentist, orthognathic columella.
surgeon, or orthodontist. 2. Two reference markings are made on each
Relative soft tissue balance is also important. side, extending radially from the internal sill
We learn to begin by analyzing the horizontal fifth’s and the external rim. The height of excision is
and the vertical thirds of the face, but there are then demarcated (Fig. 19). The best starting
many variables affecting what we perceive as a point on most patients is on a horizontal crease
pleasant harmony of the face. The proportions or line that the author deems a “line of declara-
we see on patients with thick skin or a full-round tion.” Most patients with an elongated lip have
face may be drastically different than that of a pa- 1 or 2 horizontal creases that form in lines of
tient with a thin or delicate face. Rather than mea- tension during strained smiling. If this is not pre-
sure the proportions directly, the author sent, the next step would be to find an area of
recommends looking at the face as a whole and transition or inflexion on the upper lip following
simply envisioning the changes to be made. The the base of the columella inferiorly. Most lips
overall intent is to make the lip fit appropriately in
relation to its surrounding structures, primarily
the nose, cheeks, and chin. For example, a wide
nasal base with fatty ala and flaring will not tolerate
the appearance of a foreshortened upper lip.

Surgical Marking
The excision outline and radial reference markings
designed by the author are the most crucial part of
this procedure. The markings are based on the
classic “bullhorn” lip lift. The excision and closure
should be treated as a centrally vectored advance- Fig. 18. The first step in marking is to find the natural
ment flap. The markings are made in a step-wise crease between the nose and lip. The lateral-most
and logical fashion to aid in the decision of the extent should be at the transition zone between a
proper amount of upper lip excision and to make well-defined and blunted crease. Medially the peak
the design as symmetric possible. occurs where the medial crural footplate diverges.
392 Talei

Table 1. These measurements should only serve

as guidelines. The amount to be excised typically
ranges between 4 and 11 mm, with most standard
excisions ranging between 5 and 7 mm. Excisions
aiming for notable tooth show are typically be-
tween 7 and 9 mm. An excision of over 11 mm is
not advised, because this dramatically increases
healing time and makes redistribution of skin diffi-
cult for the average patient. There are many vari-
ables that determine the actual changes in height
including skin thickness, skin laxity, muscle func-
Fig. 19. Radial reference markings are made to aid tion, and nasal base laxity. The lift obtained on pa-
even distribution and advancement of flaps from tients with thinner upper lips tends to be more
the internal sill following the curve of the lip outward exaggerated than on those patients with thick or
as well as from the alar rim margin. The 2 paramedian hyperelastic lips (see Table 1).
peaks are marked along with the center of the colu- Once the excision height is marked, a caliper is
mella. The ideal height is marked. used to measure the distance with the lip on
stretch. The lower incision marking is then made
using a caliper uniformly and in parallel to the up-
look maximally appealing if they begin with a
per incision, until the first of the lateral radial mark-
vertical slope, transitioning anteriorly toward
ings is encountered (Fig. 22). At this point, the dots
the vermillion like a ski ramp (Figs. 20 and
are connected between the internal rim reference
21). Once this point is chosen, the surgeon
marking and the peak of the lateral upper incision.
must determine the ideal location for the best
If there is a minor Cupid’s bow asymmetry, this
looking lip with an incision that would yield the
can be corrected at this stage, with an asymmetric
ideal excision for perfect tooth show. As a se-
excision. Lateral asymmetries cannot be corrected
curity measure, mark the minimum amount of
with a surgery centered at the base of the nose.
remaining lip. For most patients, this would be
Once all the dots are connected, the remaining
around 11 mm as measured from the Cupid’s
reference markings are drawn, totaling 9 lines. A
bow peak superiorly while the lip is on stretch.
vertical marking is placed on each incision peak
Leaving less than 10 mm of residual upper lip
and 1 in the center. Intermediate markings are
height is not recommended.
then made between the peak marking and the in-
The amount of expected tooth show gained ternal rim marking (Fig. 23). These points serve
from each excisional height is demonstrated in as closure points for the deep suspension sutures
as well as even centralized redistribution markings
for the advancement of the lower flap.

Excision
The procedure is performed using local anesthesia
and with the surgeon at the head of the bed. The
lower incision is made first, with a 15 blade scalpel
perpendicular to skin, extending to the junction of
the fat and the muscle. The upper incision is then
made parallel to the lower incision (Fig. 24). The
skin and subcutaneous flap is then excised in a
plane over the orbicularis, leaving a thin glossy
layer of fat intact. This glossy layer is where most
of the vasculature lays deep to the superficial
muscular aponeurotic system (SMAS). The
larger-caliber vessels in the field are the inferior
alar arteries, which are buried under the ala and
alar sill, running parallel to them (Fig. 25).

Dissection
Fig. 20. The upper lip looks most pleasant with an im- Once the excision is performed, the labial flap is
mediate transition from vertical to sloped. then elevated in a deep sub-SMAS plane. This
 The Modified Upper Lip Lift 393

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

dissection releases the labial SMAS from the un- obtain a palpable release of the labial flap that
derlying orbicularis oris. The extent of this dissec- would allow a minimal tension closure. For most
tion is at the discretion of the surgeon, as more patients the dissection approaches or extends to
extensive dissection may mitigate tension but the vermillion anywhere lateral to the philtral col-
also causes a dramatic increase in postoperative umns and stops just before the nasolabial fold.
swelling. Taller excisions typically require a greater Care must be taken to stay in a directly sub-
degree of release, as do patients who require SMAS plane to avoid excessive bleeding or dam-
release and rolling of the lateral vermillion to avoid age to any of the labial elevator complex. Careful
a subsequent corner lift. The average patient will hemostasis must be achieved, preferably with a
require release in the deep plane half-way down bipolar cautery (Fig. 28). Although a hematoma is
the central philtrum. Full central dissection is not typically a risk in classic lip lifts, it is a consid-
avoided because of possible effacement of the eration with a modified upper lip lift given the
Cupid’s bow (Figs. 26 and 27). Laterally, the extensive dissection and dead space created.
dissection is carried as far out as necessary to
Suspension and Closure
The mistake made by most practitioners is per-
Table 1 forming a simple dermal closure. As we have
Estimated lift based on excision height–– learned from endoscopic brow lifting and
variable advanced forms of face lifting, the best lift is
achieved by performing adequate release of teth-
Excision 3 4 5 6 7 8 9 10 11
ering and then by suspension of dense tissue up-
(mm)
ward to a fixed location. When this is performed
Tooth 0 0–1 1–2 2–3 2–4 3–5 4–6 5–7 6–8 in the upper lip, the released skin/SMAS flap is
show
then able to roll over and redistribute tension
(mm)
above the contracted orbicularis.
394 Talei

Fig. 22. Castro-Viejo angles caliper is used to mark the Fig. 24. Perpendicular incisions are made through the
height of excision with the lip on stretch. Equal skin, fat, and SMAS to the level of the orbicularis
heights are marked between the internal sill refer- layer. Upper and lower incisions are made in parallel
ence markings. to aide in proper approximation.

The dermis at the base of the nose is not firmly dimpling. This provides a major advantage by
attached. The periosteum or overlying pyriform lig- pushing the dermal edges together. The incision
ament are the only firm structures that can provide is closed sequentially from central to lateral
a strong base for suspension. Suturing to the peri- (Fig. 31). Once the knots are tied, the skin edges
ostium produces an over exaggerated tacking of should be closely approximated. At the lateral-
the labial flap. The pyriform ligament is a dense most reference marking, a 4-0 Vicryl on a PS-2
network of fibrous tissue overlying the periosteum needle is passed from inside the pyriform coming
that spans the pyriform aperture and is perfect for out radially to grab the SMAS, and then returned
engagement of suspensory sutures.7 back into the nose to complete a mattress suture
A 5-0 PDS suture on a P-3 needle is used at (Fig. 32). The inferior alar artery should be identi-
each of the central 7 reference markings. The nee- fied and avoided, if possible. The skin is then reap-
dle is passed into the junction of the nasal and oral proximated with a plethora of vertical mattress and
musculature and then carried deep to grab the interrupted 6-0 nylon sutures, with the end point
pyriform ligament but not the periosteum. The nee- being resolution of any step-offs from the lower
dle exits deep to the alar dermis with care not to to upper skin flaps (Figs. 33 and 34). This area is
incorporate the dermis (Fig. 29). The needle is unforgiving and meticulous suturing technique is
then passed inferiorly through the SMAS on the required.
underside of the labial flap (Fig. 30). The SMAS
of the upper lip is a discrete tissue layer with sub- POSTOPERATIVE COURSE
stantial strength that is located just deep to the Postoperative Care
reticular dermis.8,9
Suturing to the SMAS instead of the dermis al- The incisions must be kept moist with ointment at
lows the skin to approximate without tension or all times in the first several weeks. Patients are
given a surgical mask to so they do not feel self-

Fig. 23. The remainder of the inferior marking is

made by tapering from the internal sill markings up- Fig. 25. The marked skin, fat, and SMAS are excised
ward. The corresponding reference markings are leaving a thin, glossy fat layer intact to avoid damage
made, as well as 2 intermediate reference markings of vessels and the inferior alar artery marked in the
to total 9 markings. photo.
 The Modified Upper Lip Lift 395

Fig. 26. Deep-plane/sub-SMAS elevation is performed Fig. 28. Hemostasis is obtained using bipolar electro-
directly over the muscle layer. cautery to minimize risk of hematoma.

conscious. Sutures are typically removed partially technique. However, when using the bullhorn inci-
at day 3 and completely at day 5 (Fig. 35). Taping sion, even if unsightly scarring occurs, it can most
is neither affective nor necessary. Patients are often be easily and significantly improved with scar
forewarned that swelling may appear extreme modulation therapies. Off-label use of 5-fluoro-
and that the appearance of the lip typically takes uracil 50mg/cc can help flatten hypertrophic inci-
3 months to return to normal. Relative to others, sions. CO2 laser can improve hypertrophic,
this technique produces significantly more atrophic, and other types of scarring.
swelling in this area because of the disruption of Alternative techniques that involve more com-
bilateral lymphatic drainage pathways as well as plex types of incisions, such as the philtral stretch-
muscle trauma causing a postoperative myositis. ing variations of the upper lip lift, L-shaped
The stiffness and swelling in the first 3 months philtrum lift, extended incision lip lift, Greenwald
may benefit incisional healing by limiting move- incision, double duck suspension, and the Italian
ment at the incision line. Patients are seen at 3- technique, may result in greater amounts of scar-
week intervals for reassurance and potential injec- ring and changes to the nasal base that are difficult
tion of 5-fluorouracil 50mg/cc into a firm orbicula- to reverse. Atrophic scarring is quite common, as
ris patch. The nasal base is also quite responsive well as skeletonization or effacement of the nasal
to fractionated CO2 laser, should that be required. base. Incisions extending into the nasal sill inher-
Most patients receive this routinely at 60 and ently cut away healthy mass and volume at the
120 days at a low setting. nasal base while advancing the skin of the lip in-
side the nose where it does not naturally reside.
Potential Sequelae Distortion or effacement of the nasal base can
The most commonly encountered sequelae of an occur with untoward tension on compliant por-
upper lip lift are scarring and widening of the nasal tions of the nasal base. When tension is combined
base. For this reason, most practitioners who with excision of portions of nasal sill, the distortion
perform the lip lift procedure do so on elderly pa- can become more prominent. If the central lip is
tients with light skin. Issues can arise with any lifted or excised more than the lateral portions,

Fig. 27. Sub-SMAS dissection is continued half-way Fig. 29. 5-0 PDS suture enters between the nasal and
down the central philtrum. Lateral dissection is typi- labial muscle layers, passes deep grabbing the pyri-
cally carried to the same level or greater. form ligament, and exits just deep to the dermis.
396 Talei

Fig. 30. The 5-0 PDS is passed deep to the dermis to Fig. 32. The 7 central reference markings are closed
grab the SMAS layer only. with the deep layer of 5-0 PDS sutures. The 2 most
lateral markings are closed using a 4-0 Vicryl entering
from the inside of the nose, passing externally be-
this can also produce an unnatural and dispropor- tween the orbicularis muscle and nasal ala to grab
tionate postoperative appearance to the lip that the SMAS layer then exit through the nose by passing
further exaggerates a suboptimal outcome. Cen- through the nasolabial junction.
tral lip lifts are rarely indicated and most commonly
produce an exaggerated upturn of the central lip.
Problematic healing also seems to arise from
This often results in relative worsening of the
inadequate incision length and insufficient deep
appearance of lateral lip hooding. It is important
tissue release. Making smaller incisions, whether
to remember that there are limits to what a proced-
single in the center or bilateral incisions under
ure at the nasal base can achieve. The intent to
the nasal sills, tend to increase complications as
change the character of the lip significantly should
well. Smaller incisions may limit the proper release
be avoided.
of tension and redistribution of skin, while also pre-
senting the potential for disproportionate lifting.
Avoiding Sequelae This means that, although incisions are limited,
The first way to assure a superior result is proper there may be higher tension placed on each inci-
incision design, following the principles of the bull- sion point, resulting in poor healing. Uniform redis-
horn lip lift. This means avoiding cutting into and tribution avoids irregularities and skin bunching by
damaging the nasal sill by carrying incisions inside spreading the tension evenly along the length of
the nose. Most techniques that involve hidden in- the entire incision. The perioral region is extremely
cisions inherently require that healthy sill skin is dynamic, and all possible efforts to relieve tension
excised and replaced with skin from the lip. Labial at the incision should be performed. Proper
skin does not naturally occur within the nasal sill release of the deep structures to reduce closure
and it should not be placed there during a strictly tension, coupled with adequate deep suturing, fol-
cosmetic procedure. Once the sill is removed lowed by intricate superficial suturing, will enhance
and scarring occurs, the sill cannot be replaced results. The practitioner should be aware that the
and the atrophic skin that replaces it is quite diffi- nasal base is an unforgiving area with regard to
cult to repair.

Fig. 33. Superficial closure is performed with a combi-

Fig. 31. A 5-0 PDS is tightened with a single knot, fol- nation of 6-0 nylon vertical mattress and interrupted
lowed by a slip knot, then a locking knot. sutures.
 The Modified Upper Lip Lift 397

upper orbicularis is taken and suspended to the

pyriform ligament using 5-0 PDS sutures to limit
potential damage to the muscle and nasal base.
Experienced practitioners may use muscle-
binding techniques routinely with high success
rates, but amount of muscle trauma in the hands
of the novice surgeon should be limited.
Direct vermillion excisions tend to cause a blur-
ring of the vermillion and a visible scar with a
potentially unnatural appearance that almost al-
ways requires lip liner camouflage. Once the
vermillion is distorted, it cannot be recreated. In
Fig. 34. Closure using enough sutures to avoid any
step-offs or irregularities.
the author’s opinion, the only indication for an inci-
sion at the vermillion border is the rare patient who
requires a corner of the mouth lift.11 Corner lift in-
irregularities and scarring. Although it may not cisions are limited and seldom cause issues; how-
seem so, longer incisions tend to heal better than ever, we perform them rarely because the
shorter ones. modified upper lip lift has the ability to treat this re-
Some lip lifting techniques rely on muscle sus- gion on most patients.
pension, excision, or plication to relieve tension
on the skin.6,10 This ideology may theoretically
Complications
be supported by muscle-tightening procedures
performed during facelift surgery; however, A chart review of 823 consecutive lip lifts from
mimetic muscles are not routinely suspended dur- January 2015 to October 2018 in the author’s pri-
ing rhytidectomy. Rather, the SMAS-platysma vate practice was performed. Histories were
complex is tightened, which carries no mimetic reviewed for any complications seen past the 3-
function. A dense SMAS fascia definitively exists month mark. Of note, there were no patients
in the upper lip just deep to the dermis and super- demonstrating any limitation in movement or
ficial to the orbicularis oris muscle. The SMAS-skin smile. Five patients required revision to obtain
flap may be released and used for lifting similar to further lifting or further lifting and symmetry. Two
deep-plane lifting in the face. The orbicularis oris is patients developed dermal atrophy and telangiec-
a mimetic muscle that is extremely dynamic and tasias following injection with triamcinolone.
sensitive to trauma. From the author’s experience, Because of this, the author no longer injects triam-
muscle binding has a higher probability of causing cinolone postoperatively in these patients. Two
fibrosis at the plicated region and may actually patients complained of vague changes in char-
have a tendency to pull the nasal base in a down- acter of the nostrils, which were difficult to depict
ward direction. Still, muscle plication or imbrica- in photos. Two patients experienced minor hema-
tion may serve a purpose in some patients tomas, which were limited by tamponade. Two pa-
during various lip lifting procedures including the tients had prolonged edema extending to the 4-
modified upper lip lift. When binding is performed month mark, which then resolved. Both of these
during this procedure, it is typically limited to the patients had previous silicone injections and an
uppermost 2 mm of the orbicularis muscle. The 11-mm excision. Ten patients developed a rash
from antibiotic ointment. Two patients presented
with a 1-mm rim of eschar/epidermolysis of un-
known cause around the lateral nostril base that
healed without incidence. Although many patients
received scar modulation with injections of 5-fluo-
rouracil 50mg/cc and/or CO2 laser treatments on
the incisions, none were bothered by their inci-
sions. There were no patients found to have
increasing asymmetry. There were no incidents
of infection.
Forty-five patients had a simultaneous lip lift
with rhinoplasty with no adverse sequelae. Alar-
plasty was performed at a separate time on all
Fig. 35. Sutures are typically removed at days 3 and 5. but 2 patients to avoid lateral scarring. Sixty-two
This photos was taken 5 days postoperatively. patients had simultaneous lip lift with rhytidectomy
398 Talei

with no adverse sequelae. Sixty-eight patients had with an exceedingly low complication rate. The
simultaneous mucosal lip reductions mostly to need for such a procedure is under-recognized in
reduce polymer-related abnormalities. Fifteen patients of all ages. The modified upper lip lift is
received simultaneous dermis or SMAS grafts to a safe, consistent, reproducible, and widely appli-
augment lip volume and there were no adverse ef- cable technique for any gender, ethnicity, and skin
fects. One patient requested a subsequent corner type.
lift. The remainder of the patients seeking corner
lifting before surgery received an adequate degree REFERENCES
from the modified upper lip lift.
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