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. [22, 23]
Surgical Therapy
The treatment of macrocheilia is varied but individualized to the etiology and patient's needs. Some general principles include the following: [19]
Correct underlying dento-osseous deformities.
Establish a balance between upper and lower lip tailored to the individual patient.
Do not reduce lips if excessive interlabial distance exists.
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. [24]
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. [25] 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. [25] 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 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 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, 19] 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]
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Frontal and profile view of a 45-year-old African American woman seeking reduction of her upper lip.
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Design of the wedge-shaped excision. Lateral extensions are necessary to eliminate dog ears.
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Frontal and profile views 2 months postoperatively. Note the better result seen in frontal view compared to profile view.
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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.
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A. Intraoperative view demonstrating clamping down on the vermilion with a side cutting bone cutter. B. Intraoperative result.
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A. 4 months postoperative view. B. Profile view.
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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.
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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.
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Lip reduction. Image from: Rees, T. Mentoplasty, prognathism and cheiloplasty. In Rees, Cosmetic Facial Surgery, 1st ed. Philadelphia, Pa: WB Saunders, 1973:550.
