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Archive for the ‘lip advancement’ Category

Techniques in Mouth Widening Surgery

Tuesday, January 30th, 2018


The mouth occupies the center of the face and is a prominent facial feature. The mouth is well is known to be a sensual structure whose perception is primarily influenced by the size of the lips, particularly in females. As a result, lip augmentation usually by injection is the most aesthetic procedure performed in the mouth area. Surgical lip manipulations include increasing or decreasing the vermilion show through subnasal lip lifts and advancement procedures.

The corner of the mouth is the smallest part of the lips but can still be surgically manipulated. This is usually for the aging mouth with downturned corners through a corner of the mouth lift. This is usually done in patients which, although often done in isolation, is also done during facelift surgery as well.

One other procedure done at the corner of the mouth is to adjust its width, the least commonly performed of all aesthetic mouth surgeries. Through adjustment of the position of the vermilion-cutaneous junction the mouth can be widened. From an aesthetic standpoint, the width of the mouth should be equal to or just within vertical lines dropped down from the inner edge of the iris of the eye. (although it is often closer to a vertical line dropped down from the pupil) From a facial proportion viewpoint the width of the mouth is described as being 1.6 times the width of the bottom of the nose as per the Golden Ratio.

In mouth widening surgery, the patient is first marked by establishing the target with a vertical line drawn down from the pupils of the eye. A horizontal line is the drawn from the vermilion-cutaneous junction at the mouth corners out to that line. This horizontal line often measures anywhere from 5 to 7mms. Triangles are drawn from the target width on each side of the horizontal line up to the vermilion border of the upper and lower lip.

An incision is first made from the mouth corner out to the desired width. The triangular skin segments (technically an hypotenuse) were next removed on each side. (total of 4 skin segments) To allow the mouth corner to move out to fill his created gap a wedge of orbiculares muscle is removed from each side.

Lastly the mouth corner is advanced out and a two-layer closure is done to complete the widened mouth corners.

Mouth widening surgery is a very effective procedure at opening up the small mouth.To have the best aesthetic result the advanced vermilion edges must be rolled outward with the widening and some muscle removed to create the space to do so. Fine line scars are the trade-off of mouth widening but they usually heal well and are acceptable. But some patients may require a small scar revision based on how well they heal.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transgender Vermilion Lip Advancements

Monday, December 11th, 2017


Background: The lips frame the mouth and are an important facial feature. What is seen on the lips is the dry vermilion with a little wet vermilion, known as the red part of the lips. The amount of vermilion seen determines the size of the lips. The junction of the vermilion and the skin, particularly the upper lip, determines their shape.

The lips are an important gender identifying feature. (even without makeup) As a general rule, desirable lips in women are fuller and have a more defined Cupid’s bow. It is not as important in men that lips necessarily be full. And most men do not have a well defined Cupid’s bow shape. While many women do have thin lips with little shape, often with aging, youthful feminine lips are associated with significant vermilion size and shape.

While there are many facial feminization surgery procedures, lip augmentation  is often a very important one. In achieving this change, a vermilion advancement is an effective and powerful procedure to do so. Changing the position of the vermilion-cutaneous junction through skin removal allows for much increased vermilion exposure. In the process the arc of the vermilion and the strength of the Cupid’s bow portion of the upper lip can be enhanced.

Case Study: This middle-aged male to female transgender patient was to undergo a fairly complete facial feminization procedure. The lips were thin (less than 7mms of exposed vermilion) and the mouth corners were turned down

As part of an overall nine hour facial feminization surgery, upper and lower lip advancements were performed. The size of the skin removed from the upper and lower lips was 3mms. The Cupid’s bow of the upper lip was sharpened. (stronger points) The two weeks result showed how dramatic such vermilion lip advancements can be.

Lip advancements may be a small in size facial feminization surgery procedure but its effects are significant. It does create a fine line scar at the vermilion-cutaneous junction but this heals extremely well particularly in genetic male facial skin that is naturally thicker with beard hairs.


1)The size and shape of the lips is a major feminine facial feature.

2) Vermilion advancements are the most powerful lip augmentation procedure because it can change both size and shape.

3) In the transgender male to female patient changing the mouth area with a surgical lip augmentation is a small but important facial change.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Mouth Widening in Scar Contractures

Sunday, July 23rd, 2017


The width of the mouth and the flexibility of the lips are important for food intake and oral hygiene. They not only permit the lower jaw to open fully but also allow mobility of the adjacent facial soft tissues with expression. Having a ‘loose’ oral sphincter is taken for granted until one doesn’t have that normal stretch of the lips.

Tight or contracted mouth corners occur for a variety of reasons but the most common is that of trauma. Burns, avulsive tissue loss and surgery can create scarring around the lips which can cause banding or tightness across the once flexible mouth corners. No matter how soft the rest of the lips are, loss of stretch at the corners where the upper and lower lips meet will limit oral opening and access.

Opening up or releasing the mouth corners is a surgical procedure known as a commissuroplasty. But its name does not convey exactly how it is done. There are a variety of mouth releasing procedures but most are based on scar contracture release just as is done anywhere on the body. The most well known of these would be the z-plasty,  the transposition of two triangular skin flaps. The incisions are designed to create a Z shape with the central line of it being placed with the part of the scar that needs lengthening.

In the contracted mouth corner, however, the line of tightness is not straight. It occurs at angled intersection of the junction of the upper and lower lip lines. This requites a modification of the classic z-plasty to include a backcut at the center of the ‘central’ limb along the line that the mouth corner need to be extended out laterally.

With the cutting of these flaps, the lower vermilion-mucosal flap is transposed out into the most lateral extent of the newly created corner position. The superior skin flap is then rotated along the vermilion-cutaneous line of the lower lip. Some trimming of this skin flap is usually needed. This creates an increased mouth corner position of 1 cm or more ion each side.

This type of mouth widening procedure is used in scar contracture releases. It its not the technique that would be used in cosmetic mouth widening or commissure lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Lower Lip Advancement for Subtotal Hemangioma Excision

Monday, July 17th, 2017


Background: The lips are composed of both wet and dry tissue known as vermilion. Known as the pink or red part of the lips its presence and size determines whether the size of the lips is interpreted.

But the one red tissue one does not want on their lips is a hemangioma. Hemangiomas are benign blood vessel tumors that develop in the first few months of life. They can grow rapidly, appear bright red and distort the tissues wherein they lie. Once they reach their maximum size they remain stable in size and then undergo a phase of involution. (shrinking) Many hemangioma will almost completely go away but in their wake they often leave distorted skin which is stretched and discolored.

Hemangiomas often occur on the lips and can involve both the lip proper (vermilion) and the adjacent skin. Removing the sequelae of a hemangioma around the lips can be tricky since you do not want to distort the lips in the process of removing any mottled skin.

Case Study: This 40 year-old female had a hemangioma that involved the lower lip as a child. While most of the hemangioma shrunk down there always remained distortion of the lower lip from damaged tissues. Because of the discoloration and tissue distortions the upper lip always looked  somewhat bigger than the lower lip. (more vermilion exposure) Most of the tissue distortions were beyond the vermilion-cutaneous margins into the skin below the lip.

The natural vermilion edge of the lower lip was marked and two options for excision were planned. (subtotal vs complete) It could be seen that complete excision of the abnormal tissues would create too big of a lower lip with the resultant lower lip advancement. A line that removed 50% of the distorted skin was chosen. Under local anesthesia, a strip of lower lip skin was removed and the vermilion edge of the lower lip brought out to close it.

A vermilion or lower lip advancement is typically an aesthetic procedure to make the lips look bigger. (more vermilion exposure) But in tumor resections it can be used to improve lip symmetry and size even if it does not result in complete removal of all abnormal tissue.


  1. While hemangiomas shrink in most children, they often leave behind redundant discolored skin.
  2. In removing residual hemangioma from the lip and lip margin, a vermilion advancement can achieve a subtotal reduction of it and improved upper and lower lip symmetry.
  3. Lip advancements, regardless of why they are performed, should not be overdone since they are irreversible.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Extreme Upper and Lower Lip Advancements with Mouth Corner Lifts

Sunday, April 30th, 2017


Background: Lip augmentation is one of the most popular non-surgical facial enhancement procedures. Done primarily by synthetic injectable fillers the size of the lips can be increased for the duration of the filler’s persistence. When skillfully done injectable fillers can create a myriad of perioral effects from lip size increase, correction of lip asymmetries and corner of the mouth lifts.

The effectiveness of fillers in the lip is based on having enough vermilion height so it can be expanded superiorly as well as outward. When the lips are very thin with a small amount of vermilion show, the push of the fillers is going to more outward than upward. This creates the dreaded ‘ducklip’ effect in which the lips are disproportionately balanced between their projection and height.

With poor responses to fillers in thin lips, changing the location of the vermilion border is the most effective approach. This his known as a lip advancement procedure and can be done on both the upper and lower lips. It is particularly effective in vermilion height asymmetries due to the ability to precisely change the location of the vermilion-skin border line.

Case Study: This 35 year-old female wanted bigger lip but also correction of her natural upper lip asymmetry. She previously had a congenital nevus removed from the left side of her upper lip which further contributed to her natural lip asymmetry. She had injectable fillers placed into her lips numerous times in the past but didn’t want to continue with that recurring expense.

Under local anesthesia with infraorbital and mental nerve blocks, lip advancements were performed. A 3mm lower lip advancement and an asymmetric 5/3.5mm upper lip advancement were performed combined with corner of the mouth lifts through a triangular skin excision. At the end of the procedure, the instantaneous size increase and improved lip symmetry could be seen. Between the use of local anesthetic and swelling, the lips looked enormous in size at the completion of the procedure but this will recede to a more normal appearance in 10 to 14 days later.


  1. Lip advancements are the most powerful surgical form of lip augmentation as they affect the whole lip from corner to corner.
  2. Lip advancements are the most effective form of lip asymmetry correction whether it is a partial or complete advancement.
  1. Upper and lower lip advancements done together create the most dramatic effects even at 3mm to 4mms of advancement per lip.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Lip Advancements for Permanent Lip Liner Removal

Saturday, December 24th, 2016


Background: The size and shape of the lips has taken on great aesthetic significance over the past two decades. Many makeup, injectable and surgical methods have been devised and are available to enhance one’s lips. The usual goals are to make the lips look bigger with increased vermilion show and projection as well as a more defined upper lip cupid’s bow shape.

Cosmetic tattooing of the lips (also known as micropigmentation) is a well established technique to enhance their color and shape. Colored metallic pigments are implanted into the dermis of the skin or mucosa with an extremely fine needle or cluster of needles. Because it is not surgery or temporary fillers, it is extremely popular as it eliminates the daily use of pencils to outline, fill-in, or reshape lip borders. The permanent color that it provides also decreases the need to reapply lipstick or lip gloss.

One technique of lip tattooing is that of a blended lip liner. This is done by  placing a liner on the lip border which is then shaded inward so it appears as if the person’s lipstick has faded. Some women find this lip tattooing method more appealing than a plain line lip liner which can appear unnatural and very distinct.

Despite its many benefits, lip micropigmentation places pigments that are permanent. Should one later want to remove the lip liner, this can prove difficult to do. The use of a q-switched laser can be used to remove unwanted lip liner. It requires multiple treatments and is not always completely successful.

lip-liner-lips-beforeCase Study: This 24 year-old female had permanent lip liner placed that she ultimately decided she did not like. She did not prefer its color nor the way in which it was placed. (plain line) She wanted the lip liner surgically removed but also wanted her lips bigger at the same time.

lip-advancement-markings-for-lip-liner-removal-dr-barry-eppley-indianapolisPresurgical markings were made for lip advancements that would incorporate the inner border of the lip lines as well as an outer rim of skin for removal. Given that the lip advancements included some vermilion for the lip liner removal, the amount of skin marked to be removed was less than normal.

lip-advancement-marking-and-results-dr-barry-eppley-indianapolislip-advancements-for-lip-liner-removal-result-dr-barry-eppley-indianapolisUnder local anesthesia the undesired vermilion lip liner and marked skin were removed. The remaining vermilion was advanced to the outer edge of the excised skin on the upper and lower lips and closed with 6-0 plain sutures.

Lip advancements are a well known surgical method of lip enhancement. It is a powerful technique because it relocates the vermilion-cutaneous border which makes the lips look bigger and more shapely. It does so with the trade-off of a fine line scar at the vermilion-cutaneous border. But in the properly selected patient that aesthetic trade-off may be worthwhile. Removal of permanent lip liner can be one of those patient groups where it has the advantage of an immediate and assured removal of lip pigment as well as that of larger lips.


1) Lip liner is permanent and can not always be completely removed except by surgical excision.

2) A lip advancement can be done to both simultaneously excise the undesired lip liner and increase the size of the lips.

3) The amount of skin that can be removed for a lip advancement when lip liner is being excised will be less than normally done.

Dr. Barry Eppley

Indianapolis, Indiana

Cupid’s Bow Reduction of the Upper Lip

Wednesday, June 29th, 2016


cupid's bowUnlike the lower lip the shape of the upper lip is marked by the cupid’s bow area. Occupying the central third of the upper lip, its two raised peaks at the end of the philtral columns create a double bow effect. This lip feature is well known and has the cupid’s bow name because its shape resembles that of the bow of Cupid the Roman god of love.

Having a visible or enhanced Cupid’s bow area is usually seen as a desired upper lip feature. Whether done by injection materials or an actual vermilion advancement a more pronounced Cupid’s bow can be obtained in many women.

But not every women considers a prominent Cupid’s bow a desireable lip feature. A few women desire the central lip area to be more rounded and not have two distinct curves to it. This can be achieved by a small procedure known as a Cupid’s Bow Reduction.

Cupid's Bow Reduction markings Dr Barry Eppley IndianapolisCupid's Bow Excision intraop Dr Barry Eppley IndianapolisBy excising an elliptical segment of skin between the two peaks of the Cupid’ bow the vermilion of the lip is advanced. This will always reduce the prominence of the bow and in some cases eliminate it completely based on the stretch of the upper lip vermilion. This will then given the vermilion line of the upper lip one single continuous long curve as opposed to a double curve effect.

Cupid's Bow Excision before and after results Dr Barry Eppley IndianapolisCupid’s bow reduction surgery can be done in the office under local anesthesia and has an immediate effect. The fine line scar as its trade-off usually heals in a near inconspicuous fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Subnasal Lip Lift with Lateral Vermilion Advancements

Saturday, January 23rd, 2016


Background: Rejuvenation of a long upper lip can only be reliably done by removing skin somewhere between the nose and the upper lip. The most common procedure to do so is known as the subnasal lip lift. It is more popular and commonly done than its cousin the upper lip advancement due to the less risky scar location along the base of the nose.

But the subnasal lip lift is often misunderstood at to its effect on the upper lip. It is important to realize that this is a central lip enhancement procedure. It will have no effect on the size or shape of the upper lip outside of the cupid’s bow region. This is understandable as the horizontal length of the skin excision at the base of the nose is no wider than the width of the nostrils.

This limited subnasal lip lift effect must be appreciated before surgery to prevent a vermilion fullness imbalance developing across the upper lip. While the height of the vermilion at the cupid’s bow region is always higher than that at the sides, thin lateral upper lips may look even thinner when the central upper lip vermilion becomes fuller.

Case Study: This 44 year-old female wanted to shorten her long upper lip, give the cupid’s bow more of a pout and show a little more upper teeth. But in demonstrating the effect of the upper lip lift, it was a revelation to her that the sides of the upper lips did not change. A concurrent strategy of increasing the height of the vermilion directly at the sides of the upper lip with the lip lift was planned.

Subnasal Lip Lift with Lateral Vermilion Advancement markings dr barry eppley indianapolisHer upper lip enhancement procedure was done under infraorbital nerve blocks with direct local anesthesia infiltration into the base of the nose and the sides of the lips. A subnasal lip lift was done that reduced the skin distance of the upper lip from 18mm to 13mm along the length of the philtral columns. This was combined with a 4mm lateral vermilion advancements from the corner of the mouth to almost the cupid’s bow.

Subnasal Lip Lift with Lateral Vermilion Advancements result front view Dr Barry Eppley IndianapolisSubnasal Lip Lift with Lateral Vermilion Advancements result side view Dr Barry Eppley IndianapolisHer immediate result showed a total lip enhancement effect of shortening her long upper lip and increasing the vermilion show at the sides of the lip

A subnasal lip lift can not change the sides of the upper lip no matter how it is designed. A simple but often overlooked strategy for a more complete upper lip effect when doing a subnasal lip lift is the lateral vermilion advancement. This avoids a scar along the vermilion-cutaneous junction across the cupid’s bow area where it can be potentially more noticeable.


  1. A subnasal lip lift shortens the vertical distance between the base of the nose and the central upper lip only.
  2. A subnasal lip lift does not increase the height of the vermilion at the sides of the lip.

3. Lateral vermilion advancements are needed with a super lip lift to create a total lip enhancement effect.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Techniques for Mouth Asymmetry

Friday, November 6th, 2015


Asymmetry of the mouth is not rare and consists of differences in the size and shape of the vermilion and/or the corner of the mouth. One side of the upper lip may be smaller than the other side or the corners of the mouth may be at different horizontal levels. Some patients affected by mouth asymmetry have had it since they were born while others have developed it with aging. Certain medical conditions that affect facial nerve function can also create mouth asymmetry with decreased muscular movement on one side.

The most effective method of improvement in mouth asymmetry, not caused by a nerve dysfunction, is a direct one. Moving the location of the vermilion-cutaneous junction through skin excision is the most visually effective technique. Lifting the skin from distant locations is not going to lift the mouth or improve lip symmetry. No form of a facelift or midface lift is going to affect the mouth area. This is well known in facelift where efforts to lift up drooping corners of the mouth is not successful.

Direct excision for improvements in mouth asymmetry are simple variants of the well known procedures of lip or vermilion advancements and corner of the mouth lifts. These direct excisional methods have been around for decades. Their effectiveness at cosmetic enhancements of the lip and mouth area can not be denied but they have never been widely popular due to the risk/concern of scarring.

Mouth Asymmetry Surgery result Dr Barry Eppley IndianapolisFor upper lip asymmetries a smaller side of the lip can be advance upward by a partial vermilion advancement that only goes as far as the cupid’s bow on that side of the lip. This can be combined with an extension into a corner of the mouth lift to create a complete elevation of the lower or hanging side of the mouth. While fine line scars are always a trade-off, they usually heal well when well executed even in high risk patients with intermediate pigment types. (e.g., Hispanics, Asians)

While not appropriate for everyone with mouth asymmetry, utilization of simple and direct procedures such as vermilion advancements and corner of the mouth lifts can be both effective and have acceptable scar lines.

Dr. Barry Eppley

Indianapolis, Indiana

Cupid’s Bow Lift of the Upper Lip

Monday, August 17th, 2015


Augmentation of the upper lip is one of the most commonly done non-surgical facial enhancement procedures. This can usually be successfully done through the use of a variety of different hyaluronic acid-based injectable fillers. Despite their popularity and frequency of use, however, injectable fillers can not solve all aesthetic upper lip concerns. A thin upper lip with little vermilion height often does not respond well to volume addition alone and is prone to result in the dreaded ‘duck lip’ look where most of the filler volume comes horizontally forward rather than increasing vertical vermilion height.

Surgical lip augmentation offers a better result in the thin upper lip because it can alter the location of the vermilion-cutaneous junction…the one anatomic feature by which lip size and shape is mainly judged. This can be done by an ‘upper’ lip procedure known as a subnasal lip lift or a ‘lower’ upper lip procedure known as a vermilion advancement. While very close by location the effects of these two surgical lip procedures can be dramatically different.

One way that they differ is in the effects on the cupid’s bow area. An aesthetically important feature of the upper lip, the cupid’s bow or tubercle, is a double curve of the lip which resembles a bow laid on its side. The peaks of the bow coincide with the vertical philtral columns coming down from the nose giving a prominent bow appearance to the upper lip. While a subnasal lip lift will pull up on the central cupid’s bow area it will really reshape or ‘sharpen up‘ its shape. Only a vermilion advancement can create that change since it changes it directly by skin excision.

Cupid's Bow Augmentation Surgery Technique Dr Barry Eppley IndianapolisCupid's Bow Upper Lip Augmentation Surgery Dr Barry Eppley IndianapolisA cupid’s bow lift can be created as an isolated procedure (in an upper lip with adequate volume) or can be combined with other lip enhancement procedures such as injectable fillers or a subnasal lip lift. Removing a few millimeters of skin can really change the cupid’s bow appearance even if it is just limited to the peaks of the cupid’s bow alone.

While cupid’s bow augmentation does create a fine line scar at the new vermilion-cutaneous junction it typically heals very well as it is not under undue tension due to the limited resection area.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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