The name “lip lift” is a universal umbrella term for any procedure that may lift or even just produce the appearance of lifting a lip. Similarly, the term “upper lip lift” may be applied to any procedure used to lift any part of the upper lip, whether it be philtrum or vermillion, or even surgical vs. nonsurgical. The upper lip lift has a long history, dating back at least four decades. Traditional techniques have been criticized and avoided out of fear of scarring and effacement of the nasal base. The bullhorn subnasal lip lift was one of the first acceptable techniques, as described in 1971 by Cardoso and Sperli. Several renditions followed with the goal of reducing incision length, limiting scarring, and enhancing the amount of lifting. Unfortunately, most of these techniques have a tendency toward nasal base effacement and scarring that is difficult to repair. Along with the rise and improvements in facelift surgery, there’s been an increase in lip lift surgery. The modified upper lip lift, also referred to as the deep plane upper lip lift, is a powerful procedure that resolves and mitigates many of the issues seen with other types of lip lifts. The CUPID LIFT™ presents a mathematical design algorithm that may be applied to the deep plane upper lip lift to help maximize natural and balanced results in primary and revision surgeries.
This simple surgery has the ability to restore youth, sensuality, and balance to the entire face with natural and reproducible results, regardless of the patient’s gender, color, skin type, or age. This chapter seeks to elucidate and describe the surgery using the CUPID LIFT™ technique, as a deeper and more extensive form of the classic subnasal lip lift in the supra-SMAF (superficial muscular aponeurotic system) layer. Its design allows more uniform improvements along the length of the entire lip, treating both the subfacial and the subnasal lip.
INDICATION
Although lip lift has historically been reserved for elderly patients with significant rhytids, lighter and thinner skin, this procedure can now be used on patients of a wide variety of ages, ethnicities, genders, and skin types. The goal of lip lift is to achieve balance between the central and lateral upper lip along with exposure of the teeth and vermillion, with better facial harmony. The deep plane upper lip lift is a procedure that can be performed to improve upper lip height, volume, and character with or without modifying incisive tooth show to any significant extent. The most common presentations and complaints in the author’s practice are shown in Box 33.1 .
Box 33.1
Common Presenting Complaints for Patients Undergoing Lip Lift Surgery
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1.
Chronically long or heavy upper lip
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2.
Poor tooth show/dental hooding
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3.
Over-filled lips/poor filler results
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4.
Filler complications
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5.
Postsurgical drooping (rhinoplasty/orthognathic)
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6.
Poorly defined or thin upper lip
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7.
Asymmetry
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8.
Buried or drooping corners of the mouth
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9.
Upper lip incompetence
Generally, the threshold for potential candidates is lower when using the deep plane upper lift technique compared to other historic techniques. Patients often present with elongated and drooping upper lip length and lack of tooth show, which both portray an aged appearance. In recent years, there has been an increase in patients experiencing the negative effects of fillers (predominantly over-filling with or without dissolving). Patients with permanent fillers, or those with excessive filling, may benefit from an upper lip lift to re-elevate the lip to a higher position with improved eversion; although important to note that this cannot restore the lip to a normal state. Patients with a gummy smile are also potential candidates for deep plane lip lift surgery as the deep plane upper lip lift commonly decreases the gummy smile by mitigating strain with smiling.
Another common complaint is upper lip asymmetry concerns, including height disparities between cupid’s bow and oral commissure position. It is, however, important to differentiate between facial asymmetries which are not amenable to improvement from surgical lip lift. Neuromuscular dominance and dynamic play a major role in lip symmetry, function, and position. The character and function of the lip are also largely dependent on the underlying skeleton including upper and lower jaw, as well as the teeth. Iatrogenic upper lip drooping or lengthening is also an indication for surgery; this is commonly seen after rhinoplasty or orthognathic surgery. Maneuvers that destabilize the nasal base such as transfixion incisions are common culprits, as well as columellar struts that extend in front of the nasal spine.
TECHNIQUE
Lip lift surgery requires meticulous surgical planning and design. The surgical technique for the modified deep plane upper lip lift has been detailed previously by the primary author. The CUPID LIFT™ applied to the deep plane technique provides a centrally vectored advancement flap. Rather than focusing entirely on changes to incision design or placement, the key to a successful lip lift lies in a tension-free release, suspension, and closure. Of course, in the perioral region, despite a tension-free closure, dynamic tension from movement will always be a factor to consider in healing. The CUPID LIFT™ design uses a rotational advancement of lip skin toward the nose that is hinged around the apex of the incision at the lateral ala.
Markings
The First Step Is to Mark the Upper Incision
Markings must be made with the patient in the upright position. The upper mark goes across the entire nasal base in the natural alar-facial and alar-labial crease ( Fig. 33.1 ). The incision should not invade the sill and the lateral extent should not go past the superior or lateral extent of the alar-facial crease. Centrally, the marking peaks at the superior extent of the philtral column or at the divergence of the medial crural footplate around the nasal spine. This is known as the paramedian, peak, or “P” line ( Fig. 33.2 ). In the midline, the two paramedian peaks transition to a dip at the junction of the lip and the base of the columella. The marking in the middle of the columella and philtral dimple is designated by the “C” or central line. The columella and cupid’s bow trough ideally parallel each other, dipping roughly 2 mm in most patients.
Three horizontal levels determine the excision height and residual or final height of the lip. The relaxed skin tension lines guide the vector of lifting and final shape of the lip.
CPID title designation to the RSTLs; C (Center); P (Peak); I (Intermediate); D (Diagonal); O (Outer), NLF (Nasolabial Fold).
The vector of aging in the upper lip appears to follow the same course as the Relaxed Skin Tension Lines (RSTL), drooping around the upper alveolus with the medial markings experiencing a more of an effective vertical lift than the lateral radial markings, which have a more diagonal vector. These lines can be placed by following the RSTLs and radial angulation of the pores of the upper lip.
Diagonal/Radial Internal Sill Markings
Two reference markings are made on each side, extending radially from the sill at its internal recurvature point laterally. This is known as the Diagonal or “D” line. The portion of philtrum and red lip between the two D lines is known as the “subnasal” lip, while the lip lateral to the “D” line is termed “subfacial” lip. This “D” line marks the lateral extent of the subnasal lip, and the lateral extent of the subnasal lip lift on the vermillion border. The subnasal lip is suspended from the nose, is treated by a subnasal lip lift, and contains a white roll above the vermillion border. The subfacial lip hangs from the face, may be treated with a corner lip lift, has less eversion, ages more rapidly, and is typically void of the white roll above the vermillion.
Intermediate Line
An intermediate or “I” line is drawn between the “P” and “D” lines, extending to the vermillion border. Note that excessive pull on the “I” line may result in an angry or snarled appearance to the upper lip.
Determine Height of Central Excision
The height of central lip excision is determined by considering the incisive display, lip height, and overall balance. Patients with elongated upper lips sometimes display a “line of declaration,” a horizontal crease across the central philtrum when smiling, that can be used if present. As a security measure, mark the minimum amount of remaining lip. For most patients, this would be around 11 mm as measured from the Cupid’s bow peak superiorly while the lip is on stretch. Leaving less than 10 mm of residual upper lip height is not recommended. It is important to note that there is no proper lip height for patients and that the height remaining should only be considered when producing a functional lip within a balanced face. For this reason, we advise against the belief that an ideal lip height exists.
Box 33.2 provides a general estimation of incisive tooth show change to expect in relation to excision height. This should only be used as an estimate, as the actual change varies depending on skin quality, skin type, elasticity, etc. Incisive display is measured as the difference in height between the border of the two central incisors and the lower vermillion wet-dry border at the stomion.
Box 33.2
Estimated Lift Based on Excision Height 2 *
| Excision (mm) | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
| Tooth show (mm) | 0 | 0–1 | 1–2 | 2–3 | 2–4 | 3–5 | 4–6 | 5–7 | 6–8 |
Upon examination, a lower lip raising reflex may be noted in some patients when the upper lip is raised manually on examination which may suggest that patients may not benefit from large excisions and that the patient may develop mouth closure strain following a lip lift.
In cases where more tooth show is needed but greater excision heights would lead to exaggeration or soft tissue imbalance, we recommend performing orbicularis suspension/imbrication to achieve the needed more incisive display than can be obtained from skin excision alone.
The height of the residual lip at the “C” and “P” lines should be equivalent, so as long as the columella has a 2 mm dip, this will retain or create a 2 mm dip from the cupid’s bow peak to trough ( Fig. 33.3 ). The nasal base and lip may both possess asymmetries, so symmetry can be improved by varying the excision design from side to side. For instance, if an asymmetry of philtral column height exists, markings may be made by measuring the residual height of the desired side and applying the same marking to the contralateral side.
The Residual CUPID measurements determine the final shape and slope of the vermillion border. A 2 mm slope between P, I, and D provides a continuous line. Sharp or blunt Cupid’s troughs can be altered by making the C and P line equal in height.
Lateral Markings and Slope
The primary author has observed that the most pleasant appearance for most lips would result in a height difference along the vermillion border of 2 mm between each point in the horizontal plane and the adjacent point along the PID line when measuring the residual vector line height ( Fig. 33.3 ). For example, a residual “P” height of 14 mm would correspond to an “I” height of 16 mm and a “D” height of 18 mm. Although “C” and “P” both would measure 14 mm, the cupid’s bow trough at the “C” line would be 2 mm lower than the peak of the cupid’s bow at the “P” line as this mirrors the 2 mm dip in the columella on most patients.
In many patients with pre-existing central exaggeration, a buried lateral vermillion, angular depression around the commissure, low chelion height relative to the stomion, or a predisposition to exaggeration following a lip lift, a laterally biased lip lift must be performed. If the lateral portion and corners of the lip aren’t proportionately lifted, the angular depression around the mouth will become substantially worse.
Once the excision height is marked, the lower incision marking is then made using a caliper uniformly and in parallel to the upper incision.
