References

146

Upper Lip Lift as a Complementary

Technique in Facial Rejuvenation

Oscar M. Ramirez and Camilo O. Reyes

Introduction

The lip lift is a relatively easy and controlled surgical procedure that has a long-term effect and may be modified to each patient’s facial anatomy and aesthetic goals. The descent and enlargement of the upper lip depend on the gravitational effect, weakness of collagen bundles and elastic bers in the skin, and diminution of bone structure. In order to achieve a better result the lift lip can be combined with others complementary procedures such as a fat injection to obtain fullness and give the vermillion eversion and rolled dermis graft under the philtrum columns for height enhancement and illusion of narrowing. This procedure may be

performed under local anesthesia or as a part of full face lift.

Preoperative Markings

The preoperative markings are drawn before the injection of local anesthetic (Figure 146.1). We mark the important landmarks of the upper lip, which include the border of the lip, the philtrum columns and the midline. Based on those references, we mark the planned area of incision, which includes a curved linear incision from the implantation of the ala, close to the nasolabial fold going around the ala, continuing inside the nostril sill and the base of the columella. Symmetric marking of more or less the same length and shape is done on the contralateral side. Another symmetric marking of more or less the same length is done inferiorly into the upper lip. The lower incision marking is drawn to allow the maximal lateral elevation of the lip. This can be modified for a more central elevation depending of the patient’s desires and surgeon’s aesthetic goals.

Technique

The surgery is performed under local infiltration of 1% xylocaine with

1:100,000 epinephrine solution. About 5 cc of this is injected in the entire area. Using the #67 beaver blade, we proceed with excising the segment between the intervening lines down to the orbicularis oris muscle (Figure

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Chapter 146 Upper Lip Lift as a Complementary Technique in Facial Rejuvenation 453

146.2). The muscle is respected and kept intact. To avoid bunching up the tissues and allow eversion of the vermillion border, we proceed with undermining the skin off the orbicularis oris muscle for about 3 mm inferiorly. This also allows the eversion of the skin borders at the suture line. Hemostasis is done with bipolar cautery. To allow better reshaping of the cupid’s bow, we proceed with undermining with a blunt micro cannula the philtrum columns on the right and on the left. This produces an elevating effect of these structures. Fragments of dermis/fat graft are obtained from the undersurface of resected skin and introduced in the tunnels beneath the philtrum columns. We then proceed with closing the incision upon the advancement of the upper lip in two layers with 7-0 interrupted Prolene sutures for the deep subdermal layer and 6-0 Prolene sutures for the skin. We strongly recommend closing the opening of tunnels in order to keep in place the dermal grafts. The suture line is dressed with mastisol and micropore sterile tapes.

As a complementary procedure, if vermillion eversion and fullness is needed, micro fat injection can be done at the same time using “cell friendly” Ramirez micro cannula (Tulip Biomedical Company, San Diego CA).* An average of 4 cc of fat is injected into the upper lip. For aesthetic balancing fat can also be injected into the lower lip (6 cc as an average).

Discussion

We aim to have at least 3 mm of tooth show at rest. The exact amount resected will depend upon the vertical height of the maxilla and the length of the lip. Those that have a longer upper lip in youth and those that lose more maxillary vertical height with aging will need a larger amount of resection.

We have received requests using dermal graft taken from the same skin resected to increase the height of philtrum columns. It is important during the undermining of the tunnels to keep in mind always to do it in a conservative way, because the sockets must be fit to avoid the displacement of the dermal grafts. These tunnels must be closed in an independent way with a nonabsorbable suture, such as 6-0 or 7-0 prolene.

For augmentation of the lip volume, we prefer autologous tissue as opposed to alloplastic materials. Small amounts of fat are injected in the inner side of vermillion through puncture wounds in the corners of the mouth using the described micro cannula. If the fat graft is partially reabsorbed in the next few months, more fat can be reinjected later.

Conclusion

The lip lift provides an effective tool for correcting a natural tendency of the upper lip to cover the upper teeth during aging (Figures 146.3–146.6).

There is a dramatic improvement in the patient’s facial aesthetic appearance during the smiling and at rest. We strongly recommend this technique as a part of surgical armamentarium to achieve a youthful face.

* Dr. Ramirez is an Unpaid member of the Medical Advisory Board of Tulip Biomedical. He does not receive any royalties for these canulas.

454 O.M. Ramirez and C.O. Reyes

Figure 146.1. The shape of the resected skin resembles the horns of a bull. The width of the strip is about 5 mm as its narrowest and about 8 mm at its widest.

Figure 146.2. Front view in the same patient. Notice the strip of skin resected Observe that excision extents into the nostrils.

Chapter 146 Upper Lip Lift as a Complementary Technique in Facial Rejuvenation 455

Figure 146.3. Lateral view of the same patient. Notice the fullness and eversion of the vermillion. She has a more youthful appearance.

Figure 146.4. Frontal view. Observe the increase in the upper teeth showing at rest.