Modified Upper Lip Lift Technique: A Clinical Study to Evaluate Esthetic, Functional, and Scar Quality

1. INTRODUCTION

Lips play a pivotal aesthetic and functional role in shaping the overall impression of the face, as they are a key component of the facial “aesthetic triad” alongside the eyes and nose [1, 2]. Aesthetically, harmonious lip appearance is associated with vitality and attractiveness, with full, well-proportioned lips often considered a symbol of youth and freshness across many cultures. Functionally, lips are essential for speech, mastication, and nonverbal communication through facial expressions. However, various factors, such as aging, prior surgical interventions, or congenital deformities, can lead to undesirable changes in lip length, size, or symmetry. These alterations necessitate therapeutic approaches aimed at restoring their natural appearance and enhancing their aesthetic appeal [3-5].

In recent years, the field of lip aesthetics has seen significant advancements, with the development of both surgical and non-surgical techniques to address concerns related to lip length, volume, and positioning. Non-surgical options, such as injectable fillers, offer temporary enhancement with minimal downtime [6, 7]. In contrast, surgical techniques involve incisions and tissue modification to achieve more permanent changes in lip shape [7, 8]. While surgical methods provide long-lasting results, they may also carry risks such as visible scarring or loss of natural lip contours.

Among surgical approaches, the traditional direct lip lift remains a widely used procedure for correcting excessive upper lip length. This technique involves excising a strip of skin just below the nose, thereby elevating the upper lip and increasing visibility of the anterior teeth. Although effective, it can sometimes result in visible scarring or flattening of the vermilion border—particularly if patient selection is not optimal or anatomical considerations are overlooked—potentially compromising the final aesthetic outcome [9, 10].

The primary clinical indication for performing an upper lip lift is the aesthetic and functional deficit caused by a long upper lip, which results in insufficient display of the upper incisor teeth at rest and during animation [11, 12]. An aesthetically pleasing smile typically reveals 2-4 mm of the upper central incisors. A lip that drapes over the teeth, obscuring them completely, can impart an aged, stern, or less vibrant appearance [11, 13]. While the desire for increased vermilion volume is a significant factor, the fundamental goal of the procedure is to reposition the lip to its more youthful and functional position, thereby restoring the normal exposure of the anterior teeth and creating a harmonious balance between the lip, teeth, and overall facial aesthetics. This study's modified technique was specifically designed to address this insufficiency in tooth display while simultaneously enhancing lip volume and minimizing scar visibility [13, 14].

To address the limitations of traditional approaches, we developed and evaluated a modified upper lip lift technique [12-14]. This modification specifically refers to our emphasis on a deep-plane sub-SMAS dissection and suspension of the advanced lip flap to the stable pyriform ligament, rather than relying on a skin-only excision with high-tension closure [11-14]. This approach is designed to minimize visible scarring, prevent nasal base distortion, and ensure long-term stability of the result. It builds upon, but significantly refines, established techniques such as the “bullhorn” lip lift, which involves a central excision of skin beneath the nose, and the “subnasal” or “Italian” lift, which uses two separate lateral excisions. While these traditional methods effectively shorten the lip, they are often associated with a higher risk of an unnatural, “pulled” appearance or visible scarring if tension is not meticulously managed. Our modification aims to enhance both aesthetic and functional outcomes while minimizing these complications [11-14].

This study aims to evaluate the efficacy and safety of a modified upper lip lift technique by comprehensively assessing its impact on key aesthetic and functional parameters, including the reduction of upper lip height, the augmentation of vermilion thickness, and the improvement in upper anterior tooth exposure during smiling, all of which are measured quantitatively at standardized postoperative intervals over a six-month follow-up period to ensure stability of results. Concurrently, the study seeks to objectively document the evolution and final quality of the surgical scar using the Vancouver Scar Scale, thereby providing a rigorous assessment of the technique’s ability to minimize visible scarring through its design and closure method. Furthermore, the research endeavors to monitor and report any associated intraoperative or postoperative complications to establish a robust safety profile, while also contributing to the field by developing and validating a standardized surgical protocol and a set of objective, measurable criteria for outcome evaluation, ultimately facilitating its reliable adoption and comparison in future clinical practice.

2. METHODS

2.4. Surgical Procedure

The surgical procedure began with thorough preparation, including cleansing the facial area with an antibacterial solution, sterilizing surgical instruments, and using sterile gloves.

Local anesthesia was administered using a 1:100,000 solution of lidocaine with epinephrine to minimize bleeding and ensure effective numbing (Fig. 1). Once adequate anesthesia was achieved, the surgeon carefully marked the incision line using a sterile surgical pen. A modified bullhorn design was employed, which allows for better distribution of tensile forces and helps conceal the scar within the natural creases beneath the nose (Fig. 2).

The incision was then made along the pre-drawn line using a No. 15 surgical blade in a single, steady motion, deepened through the full thickness of the skin while avoiding damage to the underlying muscle. The skin flap was carefully elevated using microsurgical scissors and a periosteal elevator, with preservation of the SMAS layer to protect the superficial vascular network supplying the flap. Once the desired depth was reached, the orbicularis oris muscle was gently released from its adhesions, ensuring that its function remained intact and that no excessive tension was placed on the surrounding tissues, which could affect lip mobility. After completion of the incision, the excess skin flap was removed while carefully preserving the integrity of the underlying orbicularis oris muscle—crucial for achieving optimal functional and aesthetic outcomes (Fig. 3).

The outer skin layer was closed using 6/0 nylon sutures using an interrupted suturing technique to ensure precise apposition and minimal scarring (Fig. 4). Particular attention was paid to the mid-arch intersection during suturing, as accuracy in this area is essential for maintaining lip symmetry. At the conclusion of the procedure, a light dressing and antibiotic ointment were applied directly over the incision site.

Patients received detailed postoperative instructions, including gentle cleansing of the area and avoidance of direct sunlight or extreme heat during the early healing phase. A custom-designed compression bandage was also applied to maintain the lip in an optimal position without compromising blood flow. The bandage was designed to leave most of the lip exposed, allowing continuous monitoring of color and temperature as indicators of proper perfusion.

2.5. Clinical Analysis

The results were evaluated using a combination of objective measures and clinical assessments covering several key variables:

Scar: The Vancouver Scar Scale was used to measure scar grade based on color, texture, height, and elasticity. Results were graded from 0 (excellent scar) to 12 (poor scar) (Figs. 5-7).

Upper lip height: Upper lip height was estimated by measuring the distance between the inferior vermilion border and the vermilion border at rest using a fine ruler (Fig).

Red lip volume: The vertical distance from the vermilion border to the stomion inferius was measured at rest (Fig).

Upper anterior tooth exposure: Exposure was estimated during a normal, full smile using a fine ruler graduated in millimeters. The distance between the inferior lip border and the upper tooth margins was recorded (Fig. 10).

Evaluations were performed at specific time points: one week, three months, and six months postoperatively (Fig. 11).

3. RESULTS

4. DISCUSSION

Our current study represents an important step in evaluating the effectiveness of the modified upper lip lift technique. Its results demonstrated significant and stable improvements in several key variables, including upper lip height, vermilion volume, anterior tooth exposure, and scar quality. The study recorded an average reduction in upper lip length from 21.8 mm to 15.65 mm postoperatively, a significant increase in vermilion volume from 2.10 mm to 5.65 mm, and an improvement in anterior tooth exposure from 0.25 mm to 2 mm. Scar quality also improved, with a Vancouver Scale score decreasing from 5.10 to 2.40 over three months. These results reflect the precision of the surgical design and its effectiveness in achieving a balance between aesthetic and functional effects. In terms of improving the upper lip height, our results are consistent with those of similar surgical studies that have confirmed the effectiveness of surgical techniques in shortening a long lip. However, our study achieved faster stabilization of results, with no statistically significant changes observed between the third and sixth month measurements. This stability suggests that surgical modifications are more effective in stabilizing tissues compared to traditional techniques, which may exhibit some minor changes in the medium term due to tissue changes or internal tension.

Our modified technique builds upon the foundational “bullhorn” design first described by Cardoso and Sperli and later popularized by others [16, 17]. However, a key distinction lies in our approach to tissue handling and tension management. Traditional techniques often rely on skin excision and direct dermal closure, which can place excessive tension on the suture line, leading to visible scarring, widening, or even nasal base effacement, as critically noted by Talei [18]. Our technique, emphasizing a deep-plane sub-SMAS release, directly addresses this pitfall. By dissecting in a plane above the orbicularis oris and below the SMAS, we achieve a significant release of deep tissue tethers. This allows the advanced lip flap to be suspended under minimal tension to the stable pyriform ligament, a concept supported by anatomical studies [19]. This approach mirrors the principles of modern deep-plane facelift surgery, where release and re-suspension of structural layers yield more natural and durable results than skin-only techniques. Consequently, our high degree of scar satisfaction (VSS improving to 2.40) contrasts favorably with the “unacceptable aesthetic sequelae” and atrophic scarring that Talei associates with high-tension closures and techniques that violate the nasal sill [18].

With regard to increasing the volume of the red lip, our results are superior to those recorded in studies that relied on filler injections, as our technique achieved a more permanent increase without the need for repeated sessions [6, 10]. Furthermore, the absence of absorption of the injected material, as is the case with techniques such as autologous fat injection or silicone gel, makes the results more predictable, reducing the burden on the patient in terms of the number of visits and costs [20].

With regard to the extent of exposure of the anterior teeth, our results showed greater improvement compared to studies that used non-surgical techniques or less precise surgical techniques in determining the cleft location and force distribution. While some studies have reported increases of 1-1.5 mm using filler injections, our technique was able to achieve 2 mm, the desired exposure for most patients, without causing pathological deformities or unnatural changes in appearance [11, 21, 22].

In terms of scar quality, our study demonstrated significant improvement across time periods, with the overall scar score decreasing from 5.10 after one week to 2.40 after three months. This improvement reflects the effectiveness of the surgical modifications in concealing the surgical line within the natural subnasal creases, as well as the use of absorbable sutures to reduce tension on the wound. Compared to traditional techniques, which often score higher on the Vancouver Scale, our technique offers a more effective solution in reducing scarring complications [11, 12, 23, 24].

In addition, the results showed significant stability over the medium term (6 months), supporting the idea that this technique provides a permanent solution compared to non-surgical options that require periodic maintenance. The absence of major complications such as infection or permanent deformities also enhances the safety aspect of the technique, a key factor in determining the appropriate procedure for patients [12-14].

Compared to other studies that used different techniques, such as autologous fat transfer or the use of sutures, our modified technique provided more consistent and stable results, with a significant reduction in the need for subsequent interventions. Furthermore, complete control over lip shape and volume during surgery gives the surgeon greater freedom to design the final outcome compared to techniques that rely on tissue interaction with the injected material [11, 22, 12, 25].

The stability of our results at the 6-month follow-up underscores the durability of this technique. By fixing the advanced soft tissue to the stable pyriform ligament, we mitigate the effects of gravity and tissue relaxation over time, providing a long-lasting solution that non-surgical options cannot match. Furthermore, the modified upper lip lift should not be viewed as an isolated procedure but as an integral component of holistic perioral and midface rejuvenation [17]. As Winslow emphasizes, addressing the aging lip is crucial for a complete lower facial rejuvenation, as rhytidectomy alone does not correct lip elongation, volume loss, or rhytids [26]. Our technique can be effectively combined with other procedures such as facelifts, rhinoplasty, or skin resurfacing (e.g., laser or peels) to address the multifaceted nature of facial aging comprehensively, maximizing patient satisfaction.

While our study focused on the aesthetic and functional improvements of a modified upper lip lift in a cosmetic context, it is crucial to acknowledge that the parameters we measured, specifically, upper maxillary gingival display, are not merely aesthetic concerns but are also critical functional and diagnostic indicators in the field of orthognathic surgery. Excessive maxillary gingival display, often termed a “gummy smile,” is a well-established clinical finding that can signify underlying skeletal discrepancies, such as vertical maxillary excess [27]. However, we excluded these severe skeletal deformities [15] from our study sample as management may require orthognathic surgery. According to the Index of Orthognathic Functional Treatment Need (IOFTN) [28], significant maxillary gingival display is a validated criterion that can indicate a high priority for orthognathic surgical intervention to correct the underlying dentofacial deformity and restore functional harmony. Therefore, while our technique effectively and safely enhances tooth exposure for aesthetic purposes in patients with appropriate indications, it is not a substitute for orthognathic surgery in cases where the underlying etiology is skeletal. Surgeons must exercise careful patient selection to ensure that a lip lift is performed for the correct indications, avoiding its use as a camouflage for a condition that requires definitive skeletal correction. This distinction is vital for achieving optimal long-term functional and aesthetic outcomes for the patient [29].

The most significant limitations of this study are its relatively small, unmatched sample size (n=20) and its short-term follow-up period of six months. The limited cohort restricts the generalizability of our findings to a broader population, as it may not fully capture the range of anatomical variations and potential complications. Furthermore, while the six-month data demonstrates promising stability, it is insufficient to evaluate the truly long-term outcomes of the procedure, as well as the perennial evolution of scar quality, and the potential for late tissue relaxation, considering the fact that upper lip length tends to increase with age [30]. Therefore, a longer observation period, extending to one year or more, would be necessary to conclusively confirm the durability of the surgical modifications [1, 2].

Despite these constraints, our study has notable strengths, including its prospective design and the use of objective, validated measurement tools to quantify outcomes. The multiple, standardized follow-up points provide a robust dataset for analyzing the dynamic healing process within the studied timeframe. Future research should prioritize more diverse patient cohorts, include detailed facial skeletal discrepancy assessment, and extended follow-up periods to validate these preliminary findings and establish the technique's long-term efficacy and safety profile.

CONCLUSION

Based on present findings, using the modified upper lip lift technique, the upper lip height was accurately shortened from an average of 21.8 mm to 15.65 mm postoperatively, with clear stability over the six-month follow-up period. A significant increase in vermilion lip volume was also observed, from 2.10 mm to 5.65 mm, contributing to improved lip fullness and aesthetic appearance. Additionally, the exposure of the upper anterior teeth improved from 0.25 mm to 2.00 mm, which is considered a desirable range from an aesthetic and functional perspective.

In terms of scarring, the results showed a gradual improvement in scar quality, with the Vancouver Scar Scale score decreasing from 5.10 after one week to 2.40 after three months, with no unacceptable scarring or permanent deformity. The microincision design within the natural subnasal creases significantly reduced the scar. Overall, the technique has proven highly effective and safe, with high patient satisfaction, making it a reliable and preferred option compared to traditional techniques or non-surgical procedures in terms of stability and long-term results. However, longer-term follow-ups and a more diverse sample would be recommended for future studies.

REFERENCES