Lip Reduction 

Although full lips are currently a desirable feature sought by many people, excessively prominent lips may interfere with oral function, and "fat lips" can become a source of ridicule. Macrocheilia (prominent lips) has multiple etiologies that affect one or both lips.

Most commonly, prominent lips are features associated with ethnic races other than Caucasian (see the image below). Congenital origin is a less common cause and acquired conditions such as trauma are a rare cause. Patients typically seek correction for aesthetic reasons. The goals of lip reduction surgery are to achieve a harmonious relationship between the upper and lower lips that is in balance with the entire face as well as to attain normal lip competence. For information on aesthetic procedures, including news and CME activities, visit Medscape’s Aesthetic Medicine Resource Center.

Congenital etiologies include double lip, labial "pits," neoplasm, and ethnic variations. Acquired causes include trauma, infections, neoplasms, and syndromes such as Melkersson-Rosenthal syndrome and Ascher syndrome. Miescher granulomatous macrocheilitis is a mono-symptomatic presentation of Melkersson-Rosenthal syndrome that is characterized by granulomatous swelling of the lips.^[1] Port-wine (capillary) vascular malformations that enlarge the lips (port-wine macrocheilia) are a different category of lesions that have a different pathophysiology and may require complex reconstruction.

Pathologically, lip enlargement demonstrates multiple etiologies including inflammatory or lymphedematous infiltration, glandular hypertrophy, and generalized thickening of all tissues.^{[2, 3]} The double lip deformity occurs because of the persistence of the transverse sulcus between the inner pars villosa and the outer pars glabra, resulting in glandular hypertrophy along with redundant labial mucosa. The excess tissue forms an accessory lip, which is apparent during smiling. The underlying orbicularis oris muscle is not involved. Ascher syndrome is identical to double lip deformity with associated blepharochalasis and endocrine disorders.

Another example of hypertrophy is cheilitis glandularis simplex, a sarcoidlike condition.^{[2, 3]} Traumatic causes result in an inflammatory infiltration leading to fibrosis and subsequent lip enlargement, as shown below. The Melkersson-Rosenthal syndrome, a condition characterized by the triad of facial paralysis, facial edema, and lingua plicata (furrowed tongue), similarly results in an infiltrative process of the lips.

Migraine headaches are frequently associated with this syndrome. Over time, the recurrent bouts of edema render the tissue indurated.^[2] Cheilitis granulomatosa produces a similar infiltrative process and lip enlargement. The ethnic variation of macrocheilia demonstrates diffuse thickening of all lip structures and may require resection of muscle.

The patient presents to report prominent lips or facial disproportion. The protruding lip often stands out as the most prominent feature of the face, attracting undesirable attention. Functional difficulties such as labial incompetence interfere with speech, salivary control, and mastication.^[3] Lip reduction surgery is often performed as an adjunctive procedure in rhinoplasty performed on those other than Caucasians to achieve facial harmony.^[4] See the image below.

The lips are the most prominent structures of the lower third of the face.^{[5, 6]} They are an important element in conveying emotion and attractiveness. In the "normal" lip position, the commissures lie between the pupils and are slightly wider than the ala of the nose. In profile, the lips should be slightly parted and the lower lip should lie only just posterior to the upper lip. The upper lip ideally covers two thirds of the incisors. Normally, slightly more lower lip vermillion is exposed than the upper. In profile, excessive protrusion of either lip is considered unaesthetic.

The upper lip extends from the base of the nose superiorly to the nasolabial folds laterally and to the free edge of the vermilion border inferiorly. The lower lip extends from the superior free vermilion edge superiorly, to the commissures laterally, and to the mandible inferiorly. Around the circumferential vermilion-skin border, a fine line of pale skin accentuates the color difference between the vermilion and normal skin. See Lips and Perioral Region Anatomy for more information.

The nose, chin, and lips have an aesthetic relationship. To evaluate the nose-chin-lip relationship, a vertical line tangent to the upper lip (normal projection) typically has the lower lip passing posterior (2 mm) to this line and chin posterior to the lower lip (in men it is slightly stronger). A horizontal line from nasal tip to the ala cheek junction should have 50–60% of the line anterior to this vertical line. This defines the ideal tip projection.^[7]

A second aesthetic relationship, a line from the subnasale tangent to the pogonion, has the upper lip protruding 2-5 mm and the lower lip 1-4 mm beyond the line.^[8] The female lip is typically more protrusive than the male lip, except for the adolescent male, whose lip protrudes more than the female's.^{[5, 9, 8]} Vermilion height norms vary in different ethnicities; for example, on average, African American males have 13.3-mm upper lips and 13.2-mm lower lips, and African American females have 13.6-mm upper lips and 13.8-mm lower lips. North American Caucasian vermilion height norms of upper and lower lip for males and females are 8.0 and 8.7 mm and 9.3 and 9.4 mm, respectively. Consider ethnic variations of anthropometric norms when planning reduction surgery.^[6]

Contraindications to reduce lip size include pseudomacrocheilia, acute inflammation, and psychological instability. If dento-osseous abnormalities are not recognized, lip reduction is inappropriate and causes loss of normal lip volume. Avoid operations during the acute inflammatory phase of Melkersson-Rosenthal syndrome or cheilitis granulomatosa, as the inflammation makes the procedure extremely difficult. Multiple surgeries may be required, and the patient should have realistic expectations of the outcome. Patients perceived as psychologically unstable should not undergo reduction surgery.