Accepted Manuscript

Rejuvenation of the ageing upper lip and nose with suspension lifting

Prof. Maurice Y. Mommaerts, MD, DMD, PhD, FEBOMFS, FICS, FAACS, John
N.St.J. Blythe, FRCS(OMFS), FDS RCS(Eng), FRCS(Eng)

PII: S1010-5182(16)30016-6
DOI: 10.1016/j.jcms.2016.04.007
Reference: YJCMS 2333

To appear in: Journal of Cranio-Maxillo-Facial Surgery

Received Date: 29 December 2015

Revised Date: 22 February 2016
Accepted Date: 6 April 2016

Please cite this article as: Mommaerts MY, Blythe JNSJ, Rejuvenation of the ageing upper lip and nose
with suspension lifting, Journal of Cranio-Maxillofacial Surgery (2016), doi: 10.1016/j.jcms.2016.04.007.

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Rejuvenation of the ageing upper lip and nose with

suspension lifting

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Maurice Y. Mommaerts MD, DMD, PhD, FEBOMFS, FICS, FAACS, John N. St.

J. Blythe FRCS(OMFS), FDS RCS(Eng), FRCS(Eng),

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European Face Centre, Universitair Ziekenhuis Brussel, Brussels, Belgium

(Head: Prof. Maurice Y. Mommaerts)

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Corresponding author. Maurice Y. Mommaerts, European Face Centre,

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Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, B-

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1090 Brussels, Belgium. Tel.: +32 02 477 60 12, Fax: none, E-mail addresses:

maurice.mommaerts@uzbrussel.be, mauricemommaerts@me.com
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DISCLOSURE:
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The authors have no financial interest regarding the content of this article. No grants

have been attributed.

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Introduction

The youthful upper lip has a well-balanced pendulous form wrapped by flawless

skin. The rose petal curve of the white roll flows onto the ripe vermillion. The ideal lip

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length is 20mm (+/- 2mm), with a 1:2 ratio with the lower lip and chin. At rest the upper

lip should nearly completely drape a males upper incisors but reveal 4mm of incisal

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show in females (Mommaerts & Moerenhout, 2011). The beautiful ideal nasiolabial angle

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is between 95 - 105 degrees.

Upper lip ageing begins through a cascade of genetic and environmental factors.

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Solar radiation and smoking predisposes to pigmentation and rhytid formation. Perioral
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muscle and connective tissue atrophy leads to flattening and ptosis, while alveolar bone

resorption following incisor loss results in a sunken appearance and diminishes nasal
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tip support. Progressive reduction in the occlusal vertical dimension promotes vertical
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and transverse labial rhytides.

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There is an increasing demand for aesthetic procedures to rejuvenate the aged

upper lip. The media has focused mainly on non-surgical techniques, which has led to a
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dramatic rise in lip filling procedures. This has proven to be an excellent treatment for
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rejuvenating minor flaws, but overfilling has a detrimental effect on facial aesthetics.
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The upper lip has a pendulous form similar to a female breast. One of the key

aesthetic features is the upper lips ability to frame the front teeth in a manner similar to

the eyelids framing the eyes. There is a critical aesthetic 3D relationship between lip

position and amount of incisal show. The excessive administration of filler to recreate lip

volume risks detrimental lip droop and coverage of the upper incisors. This is counter-
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productive, looks un-natural and ages the patient. Hence surgical lip lifting may offer a

more favourable solution in certain circumstances.

There are a number of direct and indirect upper lip lifting procedures reported

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(Moragas et al. 2014). The main indication for lip lifting is lip droop or ptosis primarily

due to ageing or secondarily following inauspicious lip filling. Rarely is it seen in

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dochycephalic faces, when the extent of maxillary impaction in Le Fort I-type osteotomy

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is often limited by the upper lip position.

Surgical manipulation of this 3D structure should be approached with caution.

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Direct lifting violates the vermillion - philtrum complex, often resulting in unsightly
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scarring. Indirect lifting techniques avoid this complication but risk causing

disproportionate lifting. Often limited indirect techniques favour central lip lifting at the
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expense of the commissures, thus risking a 'pseudo-snarl'. Combining indirect lip lifting
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for the central portion and limited direct lip lifting at the corners of the mouth may be one
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alternative to create the beautiful ideal in both static and dynamic postures.

Following a small series of upper lip lifting procedures using the double duck
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technique (Cardin, 2013; Mommaerts 2013), the authors share their experience and
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describe an important modification to improve outcome. The double duck lip lift is an
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effective technique for lip lifting and provides concealed scars. However 2 important

complications need to be safeguarded against. The first is alar base ptosis. The classic

technique relies on suspending the weight of the lip to the periosteum alar regions. This is

a non-rigid nasal subunit and may descend under iatrogenic circumstances. The second is

relapse due to alar descent or deep suture failure. The authors have considered this
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problem, and through cadaveric studies have found a reliable technique to suspend the

upper lip, safeguard against alar ptosis and enhance the lifting effect on the ptotic nasal

tip. We describe the suspension lip lifting technique, a variant of the double duck (Fig.

1), which has not previously been described in the literature (Cardin, 2013; Mommaerts

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2013).

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Technique

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Initially lip form and relationship to the maxillary incisors are recorded. The
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height of tissue to be excised (beak length) can be calculated by measuring the

difference between the ideal lip show and the position of the stomion superioris with the
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patient sitting with a relaxed lip posture. 1 mm should be added to the calculated beak

length to compensate for potential relapse. Sub-alar duck beak shaped excisions are
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marked out, extending from lateral to medial aspects of the alar implantation, followed by
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two ellipse excisions (3-4 mm in height) on both sides of the membranous septum. On

one side of the septum the ellipse should be made below the medial crural footplate, and
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above on the contralateral side. The alar-septal excision zones are joined by a curvilinear
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line, which passes from the alar region over the nostril sill and vertically into the
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membranous septum (Figs. 1 & 2). The upper lip, alar and columella was infiltrated with

6 ml 1% XylocaineR with 1:200.000 adrenaline (AstraZeneca, Brussels, Belgium). The

incision is made superficial to muscle (Fig. 3). Limited undermining can be performed

before 2-0 PDS (Ethicon, Johnson and Johnson, USA) is passed through the caudal

septum halfway between the spine and septal angle before harnessing subcutaneous tissue
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of the upper philtrum at a distance matching the planned lift. This is the first of three key

suspension sutures. The septal suspension suture supports the central upper lip and lifts

the tip of the nose. Subsequently blunt dissection can be performed above the lip

musculature underneath the alae until the inferior-lateral bony margin of the piriform rim

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is reached. A 3-0 PDS suture is threaded through the 'eye' of the 5 mm self-tapping

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titanium anchor screw (Surgi-Tec NV, Sint-Denijs-Westrem, Belgium) and the screw

inserted into the bone (Figs. 4 and 5). The subcutaneous tissue at the lower ends of the

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'beak' excisions are sutured and suspended to the rigid screw. There is also the option of

placing an intranasal alar cinch suture. Although not used in this case, we have found

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excellent results with this modification in transgender and transracial lip lifting. Skin
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closure of the skin can be performed with 5-0 Ethilon (Ethicon, Johnson and Johnson,

USA) and mucosal closure with 4-0 Vicryl Rapide (Ethicon, Johnson and Johnson,
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USA). Suture removal at one week is advised, as well as patient follow up at 1 month and
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3 months. A major advantage lies in the fact that there is no horizontal scar crossing the
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base of the columella (Mommaerts, 2013; Moragas, 2014; Fig. 6).

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Discussion
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The suspension indirect lip lift has five benefits. The first is a hidden scar. The

second is minimal access with preservation of philtrum skin. The alternative bullhorn

technique leaves a scar at the nasolabial angle (Echo et al. 2011). Thirdly, this technique

preserves orbicularis oris, preventing muscle atrophy (Austin, 1986). In addition, the lift

reduces labial rhytides and allows lip eversion. The latter gives an augmentation effect.
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The technique also promotes minor nasal tip elevation. The magnitude of tip elevation

has not been validated but we expect 1mm rise in the nasal tip for 3-4 mm of labial

excision. We have found the lift predictable with an excision: lift ratio of 1:1. There is the

option of suspending the lip from the piriform aperture periosteum rather than a

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suspension screw. In several of our early cases solely using periosteal suspension only

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increased the risk of alar ptosis. This may be due to dynamic forces in the lip during

mastication and facial expression, which may increase suspension suture periosteal

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detachment. The disadvantages may include a minor nostril sill step deformity and screw

complications. These might include infection or failure of osseointegration. However we

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have not found this in our practice. A pilot hole using a 1.0 or 1.3 mm drill may be
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required to accommodate the screws in dense bone. The micro-screw has a low profile

and cannot be palpated at the skin surface.

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Conclusion

The suspension lip lift provides an effective and reliable method of lip
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rejuvenation. The scars are concealed and suspension screws prevent alar ptosis or early
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relapse.
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REFERENCES

Austin HW. The lip lift. Plast Reconstr Surg 77: 990-94, 1986

Cardin VLN, Dos Santos A, Lucas R, De Faria R, De Souza JO, De Lima A. Double

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duck nasolabial lifting. Rev Bras Cir Plast. 26: 466-471, 2011

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Mommaerts MY, Moerenhout BAMMI. Reliability of clinical measurements used in the

determination of facial indices. J Craniomaxillofac Surg. 39, 107-110, 2011

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Mommaerts MY. The surgical art of facial makeover planning and operative techniques.

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Subnasal lip lift. Sint-Martens-Latem: Orthoface R&D, 291-294, 2013
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Moragas JSM, Vercruysse HJ, Mommaerts MY. Non-filling procedures for lip
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augmentation: A systematic review of contemporary techniques and their outcomes. J

Craniomaxillofac Surg 42: 943-952, 2014

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Echo A, Momoh AO, Yuksel E. The no-scar lip-lift: upper lip suspension technique.
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Aesthetic Plast Surg. 35: 617-23, 2011

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Captions to the figures

Figure 1 The double duck skin and nasal mucosa markings; the central lip suspension

to the septal cartilage is shown as well.

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Figure 2 Pre operation. The ptotic lip excessively drapes over the upper incisors

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providing only 1mm of incisal show at rest.

Figure 3 Intra-operative appearance following the excision of the skin and mucosal

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islands and wide undermining. A 2/0 PDS suture has been passed through the caudal part

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of the septum and subcutaneous tissue of the philtrum. This will form the central labial
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suspension suture. The ptotic lip excessively drapes over the upper incisors providing no

incisal show at rest.

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Figure 4 5-mm titanium suspension / anchor microscrew with external and internal
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pentagon screw head design ( Surgi-Tec, Sint-Denijs-Westrem, Belgium) attached to the

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micro-screwdriver and incorporating a 2/0 PDS suture through the eye of the screw.

Figure 5 A model skull demonstrating the placement of a titanium suspension / anchor

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microscrew. Note the position in relation to the nasal floor and incisal roots.
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Figure 6 Three months post operation. Hidden scar and shorter upper lip.
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