Lip Reduction 

Updated: Oct 29, 2018
Author: Rohit Seth, MD, PhD, MRCS(Edin); Chief Editor: Jorge I de la Torre, MD, FACS 

Overview

Background

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.

Reduction cheiloplasty, as performed through classically described techniques, has traditionally focused on reduction of lip volume through excision of a single strip or ellipse of tissue, with direct closure and a change in the posture of the lip.[1] However, lip reduction procedures are now placing more emphasis on the resultant contour of the lip and the volume relationship between the upper and lower lip.

"Bikini" lip reduction, introduced in 2007, is characterized by a restoration of an attractive labial contour. Using this technique, instead of an elliptical excision, authors describe bikini-shaped excisions: a "bikini top" excision in the upper lip, consisting of two cups and a middle strap, and a "bikini bottom" excision in the lower lip, in the shape of a triangle.[2]

There has been a "Brazilian" modification to the bikini lip reduction, featuring a bikini bottom excision on the lower lip that is less triangular and more curved; the upper excision is also more conservative.[3]

For patient education information, see the Aesthetic Medicine Resource Center.

Problem

The purpose of lip reduction is not always purely cosmetic. Macrocheilia, or excessively prominent lips, may interfere with oral function, with an inadequate seal between the upper and lower lips resulting in incompetence and drooling. It can also interfere with speech patterns and functionality and can alter self-perception and confidence, since the condition can sometimes be a source of ridicule and a target of bullying. Macrocheilia, which is more prevalent in certain ethnic groups, has multiple etiologies and can affect one or both lips. (See the image below.)

Frontal and profile view of a 45-year-old African Frontal and profile view of a 45-year-old African American woman seeking reduction of her upper lip.

Etiology

Macrocheilia can be due to normal ethnic variations, particularly in the Afro-Caribbean/American and Asian populations, as well as in other non-Caucasian groups. Other congenital causes of macrocheilia include "double lip" and labial "pits." In fact, the double lip can also be acquired; it most often occurs in the upper lip.[4]

Macrocheilia can also result from dentofacial deformities (pseudomacrocheilia), hemangiomas, inflammatory or lymphedematous infiltration, glandular hypertrophy, and generalized thickening of all tissues.[5, 6, 7] .

Port-wine (capillary) vascular malformations that enlarge the lips (port-wine macrocheilia) are a different category of lesions and have a different pathophysiology. They may require complex reconstruction.[7, 8]

Other causes of macrocheilia include infection, trauma, iatrogenic complications, neoplasms, and syndromes such as Melkersson-Rosenthal syndrome and Ascher syndrome. Miescher granulomatous macrocheilitis, a monosymptomatic presentation of Melkersson-Rosenthal syndrome, is characterized by granulomatous swelling of the lip.[9, 10]

Pathophysiology

As previously mentioned, macrocheilia is associated more commonly with certain ethnic groups and is a normal variation. Such ethnic variations demonstrate diffuse thickening of all lip structures and may require resection of muscle.

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 more 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.[5, 6]

Traumatic causes result in an inflammatory infiltration leading to fibrosis and subsequent lip enlargement, as shown below.

A. Face-on view of a 25-year-old male who sustaine A. Face-on view of a 25-year-old male who sustained facial trauma 1 year ago. He presents with persistent upper lip enlargement after all other facial edema subsided. B. Pursing of lips shows exaggerated eversion. C. Profile view.

The Melkersson-Rosenthal syndrome, a condition characterized by a 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.[5] Cheilitis granulomatosa produces a similar infiltrative process and lip enlargement.

Presentation

Clinical signs of macrocheilia include a protruding lip, which often stands out as the most prominent feature of the face, attracting undesirable attention. A proportion of patients present with oral dysfunction; functional difficulties such as labial incompetence interfere with speech, salivary control, and mastication. (See the image below.)

A. Child (age 6 years) with cerebral palsy who has A. Child (age 6 years) with cerebral palsy who has hypotonic upper and lower lips presents with lip incompetence and uncontrollable drool. B. Design of the lower lip full-thickness excision.

Other clinical presentations include granulomatous conditions and syndromes. In Melkersson-Rosenthal syndrome, for example, the lip swelling can present on its own as granulomatous cheilitis, a subtype of orofacial granulomatosis.[11, 12] Granulomatous cheilitis is also a well-documented manifestation of Crohn disease.[13, 14]

Indications

In most cases of lip reduction, the surgery is performed at the patient's request, with a significant number of patients seeking the procedure because of concern about their looks. Other indications include functionality problems, such as excessive drooling due to labial incompetence, and the development of poor speech patterns.

Lip enhancement complications (eg, postoperative infection or overfilling with injectables) and trauma-related scar formation are additional indications for lip reduction.

Relevant Anatomy

The lips are the most prominent structures of the lower third of the face.[15, 16] 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.[17]

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.[18] The female lip is typically more protrusive than the male lip, except for the adolescent male, whose lip protrudes more than the female's.[15, 19, 18] 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.[16]

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.

 

Workup

Laboratory Studies

The lip and its relationship to other facial structures are evaluated by frontal and profile aesthetic views as well as possible cephalometric radiograph to assess the underlying dento-alveolus and facial skeleton. The lips must be assessed, as must the relationship of the lips to the nose and chin.[15, 19] Physical examination of the lip is conducted from the face-on view to evaluate the visible vermilion (vertical height) and the transverse lip excess.

From the profile view, the upper to lower lip relationship as well as the degree of lip eversion is also noted. Prominent lips may be the result not of lip volume but of lip ectropion or labial eversion.[6] Furthermore, the orbicularis musculature is assessed for its tone and the muscular ring for its competence. Once again, the nose-lip-chin relationship is critically evaluated. If needed, a lateral cephalogram is obtained to assess the underlying dento-alveolus and facial skeletal contribution to the lip deformity.

Imaging Studies

Lateral cephalometric evaluation is indicated to rule out dento-osseous causes of lip protrusion. It is used to assess osseous lip support, soft tissue thickness, and lip posture. For instance, maxillary retrusion with vertical deficiency and mandibular prognathism produces a pseudomacrocheilia of the lower lips, as shown below.[20]

A. Female (age 13 years) with midface deficiency s A. Female (age 13 years) with midface deficiency secondary to cleft lip and palate. The maxilla is hypoplastic and mandible is relatively prognathic with over closure. She has upper lip deficiency and lower lip prominence. B. After maxillary LeFort I advancement, the upper lip remains deficient and lower lip prominent. C. She underwent upper lip augmentation and lower lip reduction twice to achieve a harmonious facial profile.

Dento-osseous protrusion associated with microgenia can cause pseudomacrocheilia.[18] A useful cephalometric analysis consists of evaluating the linear distance from the lower incisor tip nasion B (NB) line, which is the same distance as the line from pogonion to NB line.[18] Alteration in this relationship suggests mandibular protrusion or microgenia. The normal chin and lip soft tissue thickness is approximately 12 mm in Caucasians and 15 mm in African Americans. Excessive lip incompetence could be the result of long face syndrome, open bite deformity, or muscular hypotonia.[18] Surgical-orthodontic therapy may eliminate the pseudomacrocheilia.

Other Tests

Preoperative evaluation of lip reduction surgery should include a psychological screening of the patient's expectations of the outcome of the surgery. Patients should be counseled in advance that additional touch-up surgery may be necessary.

 

Treatment

Medical Therapy

Medical therapy has limited usefulness in treating prominent lips but can help alleviate the underlying cause or associated anomalies. Steroid therapy, antibiotics, salazosulfapyridine, and radiation have shown limited success.

Lip reduction can also be achieved medically following augmentation with hyaluronic acid injections. If patients are dissatisfied with the results of the augmentation, it is possible to reverse them with the enzyme hyaluronidase (Hylase), which breaks down the hyaluronic acid.[21, 22]

Surgical Therapy

The treatment of macrocheilia is varied but individualized to the etiology and patient's needs. Some general principles include the following:[18]

  1. Correct underlying dento-osseous deformities.

  2. Establish a balance between upper and lower lip tailored to the individual patient.

  3. Do not reduce lips if excessive interlabial distance exists.

  4. Obtain optimal frontal rather than profile aesthetics.

Preoperative Details

The basic premise of lip reduction surgery is a transverse fusiform or elliptical incision between lateral commissures, as shown below. W- or Z-plasties may be added to prevent dog ears. When designing the incision, placing the anterior aspect of the incision posterior to the lip seal and wet line is imperative. Avoid the area of Cupid's bow as well. Cupid's bow should always be preserved during correction of a prominent upper lip since it is an important landmark of the lip. The labial artery is typically not encountered. The marking should be made prior to the use of local anesthetics, which tend to distort the lip architecture.[23]

Design of the wedge-shaped excision. Lateral exten Design of the wedge-shaped excision. Lateral extensions are necessary to eliminate dog ears.

The goal should be removal of hypertrophied labial glands, fibrosis from an infiltrative process, or generalized thickened redundant tissue. In the upper lip, macrocheilia usually affects the lip in the vertical dimension. If the dry vermilion is not excessively large, the reduction surgery is designed as a transverse ellipse behind the wet line. However, if the entire vermilion is enlarged, then design of the excision may include the dry vermilion.

Intraoperative Details

With the patient upright, the amount of excision is estimated by pinching the mucosa until the desired vermilion show is obtained. The wedge-shaped excision removes mucosa, submucosa, submucosal glandular tissue, and occasionally, orbicularis muscle. The incision lines should be wavy, and the design of the excision should not compromise the oral circumflex artery. Therefore, the outer incision should be at least 5 mm above the inner lip angle. The future scar should be inconspicuous. The amount of excised tissue and the grade of planned inversion are determined individually for each case.[24] A useful technique of lip wedge excision is to first clamp down the amount to be excised with either a side cutting bone cutter or a Satinsky vascular clamp for approximately 5 minutes.

The clamp is released, and then the lip vermilion tissue is excised. While the incision remains stuck together, use resorbable 4.0 sutures to approximate lip tissues. Braided 4.0 sutures without swelling properties, either single or multiple, are used to close the mucosa. Such sutures, tied 5 or 6 times, preserve their integrity in the constantly wet and mobile environment for the required healing period of 7-9 days.[24] This technique is useful because of the bloodless surgical field, and no epinephrine solution is injected to distort the vermilion tissue. (See the image below.)

A. Intraoperative view demonstrating clamping down A. Intraoperative view demonstrating clamping down on the vermilion with a side cutting bone cutter. B. Intraoperative result.

A key upper lip feature, the central tubercle, must be preserved or recreated. A transverse excess of the upper lip is more difficult to address, mainly because this requires excision of a vertical segment of tissue that leaves visible scars on the lip. Therefore, some transverse excess is tolerated.

If the transverse lip dimension is excessive, a bilateral cleft lip repair can be designed to hide the scars in the philtral columns. This is rarely necessary. For the lower lip, the vertical and transverse dimensions are assessed. If vertical excess is the main concern, then transverse wedge excision is performed, keeping in mind that the lower lip vermilion is slightly fuller than the upper lip and is slightly posterior to the upper lip.

When a floppy, redundant lower lip is encountered, usually transverse lip excess, exaggerated lip eversion, and deficient muscular tone are present. In this instance, a vertical wedge excision of the lower lip is helpful to decrease the transverse redundancy and reestablish the structural sling of the lower lip sphincter. The incision should not extend beyond the labiomental fold. Instead, the design of the incision extends horizontally to hide the scar along the labiomental groove (see the image below). The vertical excision may be combined with the transverse wedge excision in the mucosa to obtain an optimum result.

A. Child (age 6 years) with cerebral palsy who has A. Child (age 6 years) with cerebral palsy who has hypotonic upper and lower lips presents with lip incompetence and uncontrollable drool. B. Design of the lower lip full-thickness excision.

Complications

Complications include hypertrophic scarring, hyperesthesia, and asymmetry.[5, 6, 18] Mucocele formation is possible, in theory, but rarely seen.

Outcome and Prognosis

Macrocheilia has various causes. The surgeon must be aware of the histopathologic causes to provide adequate treatment. The syndromic causes may require further medical therapy, as in the endocrine anomalies associated with Ascher syndrome. Be sure to recognize true macrocheilia versus pseudomacrocheilia and identify its cause. This requires anthropometric and cephalometric analysis as well as an aesthetic eye. Cheiloplasty is a simple procedure that produces a reliable, predictable result.[1]