Introduction
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.
Problem
Most commonly, prominent lips are features associated with ethnic races other than Caucasian (see Image 1). 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.
Etiology
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.
Pathophysiology
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 (see Image 4). 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.
Presentation
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 (see Image 8).3 Lip reduction surgery is often performed as an adjunctive procedure in rhinoplasty performed on those other than Caucasians to achieve facial harmony.4
Indications
See above.
Relevant Anatomy
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 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
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.
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References
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Pitanguy I, Gonzalez R, Brentano J, et al. Surgical treatment of macrocheilia. Head Neck Surg. May-Jun 1988;10(5):309-18. [Medline].
Habel G, O'Regan B. Surgical management of macrocheilia of the lower lip. Br J Oral Maxillofac Surg. Oct 1990;28(5):295-8. [Medline].
Stucker FJ Jr. Reduction cheiloplasty. An adjunctive procedure in the black rhinoplasty patient. Arch Otolaryngol Head Neck Surg. Jul 1988;114(7):779-80. [Medline].
Ellis DA, Rubin AM, Shemen LJ. University of Toronto teaching rounds. Esthetic evaluation of the lips and cosmetic reconstructions. J Otolaryngol. Jun 1982;11(3):221-5. [Medline].
Farkas LG. Anthropometry of the Head and Face in Medicine. NY: Elsevier Science; 1981.
Gunter PJ. Facial analysis for the rhinoplasty patient. Presented at: Dallas Rhinoplasty Symposium. 1999:17-28.
Epker BN, Wolford LM. Reduction cheiloplasty: its role in the correction of dentofacial deformities. J Maxillofac Surg. Jun 1977;5(2):134-41. [Medline].
Stucker FJ Jr. Profile contouring including cheiloplasty. Arch Otolaryngol. Nov 1979;105(11):680-3. [Medline].
Pensler JM, Mulliken JB. The cleft lip lower-lip deformity. Plast Reconstr Surg. Oct 1988;82(4):602-10. [Medline].
Cederna PS, Fiala TGS, Smith DJ Jr, et al. Melkersson-Rosenthal syndrome: reduction cheiloplasty utilizing a transmodiolar labial suspension suture. Aesthetic Plast Surg. Mar-Apr 1998;22(2):102-5. [Medline].
Field LM. Macrocheiloplasty. Principles and techniques. J Dermatol Surg Oncol. Jun 1992;18(6):503-7. [Medline].
Niechajev I. Lip enhancement: surgical alternatives and histologic aspects. Plast Reconstr Surg. Mar 2000;105(3):1173-83; discussion 1184-7. [Medline].
Dedic A, Masic I, Pasalic A, et al. [Therapy of the Melkersson-Rosenthal syndrome with kenalog]. Med Arh. 2000;54(2):119-20. [Medline].
Matory EW. Lip thinning. In: E Courtiss, ed. Male Aesthetic Surgery. 2nd ed. St. Louis: Mosby; 1991:180-1.
Puri N, Pradhan KL, Chandna A, et al. Biometric study of tooth size in normal, crowded, and spaced permanent dentitions. Am J Orthod Dentofacial Orthop. Sep 2007;132(3):279.e7-14. [Medline].
Trussler AP, Kawamoto HK, Wasson KL, et al. Upper lip augmentation: palmaris longus tendon as an autologous filler. Plast Reconstr Surg. Mar 2008;121(3):1024-32. [Medline].
Further Reading
Keywords
lip reduction, lip surgery, full lips, lips too full, lip reduction surgery, lip lift, lip treatments, prominent lips, fat lips, big lips, large lips, cheiloplasty, oral function, macrocheilia, Melkersson-Rosenthal syndrome, Ascher syndrome
Overview: Lip Reduction