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Dr. Barry Eppley

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Posts Tagged ‘lip advancement’

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

Case Study: Upper Lip Advancement in a Man

Monday, April 14th, 2014


Background: There are many options for lip enhancement today of which injectable fillers is by far the most commonly used. But for a permanent change in size, surgical options must be considered. Two basic types of lip lifts exists done either from under the nose (subnasal lip lift)or from the edge of the top of the upper lip. (lip advancement) Each of these has their own advantage sand disadvantages but the very thin (pencil thin) upper lip can only be effectively treated by a lip or vermilion advancement.

The lip advancement procedure works because it physically moves the upper border of the pink portion (vermilion) of the lip upward. (in the case of the upper lip) By so doing, the vertical length of the lip is increased permanently which creates a bigger visible lip appearance. The lip advancement also has the advantage of being able to change and enhance the shape of the cupid’s bow of the upper lip, which frequently is flat in the lip with little vertical vermilion exposure.

While women are most commonly seen as having lip enhancement procedures, men occasionally do as well. Men usually consider lip augmentation for a very thin upper lip not necessarily to make an already decent sized upper lip just a little bigger. Men also do not usually want to have repeated procedures but would prefer a one time permanent result.

Case Study: This 40 year-old male wanted to have a permanent upper lip augmentation. He wanted have an upper lip that matched the size of his lower lip with better accentuation of the cupid’s bow. Interestingly, he had a full goatee that covered much of his upper lip perhaps as a camouflage for his perception of his upper lip size concerns.

Male Lip Advancement markings before surgery Dr Barry Eppley IndianapolisHis upper lip hairs were trimmed back to expose the amount of upper lip advancement to be done. With a calipers, a 4mm skin excision was marked (1/4 of the total philtral length)mwith a cupid’s bow highlight and lack of a taper near the corners of the mouth. Under vestibular local anesthetic blocks with direct upper lip infiltration, the skin was excised and the upper lip advanced along the line of the marks. The incision was closed with 6-0 plain sutures with a few deep 6-0 monocryl sutures. Antibiotic ointment was applied as the dressing.

Male Upper Lip Advancement result fronkt viewMale Upper Lip Advancement result side viewThe final lip advancement result with mature scars was seen four months later. While he still had a goatee, the upper lip scar was virtually undetectable and the increase in the size of the upper lip was doubled.

While there is always a concern about the scar from any lip advancement surgery, that concern is magnified in men. (because they do not ever use lipstick) But my experience in men has shown that the lip advancement scar heals well and is not more of a concern than when done in women.

Case Highlights:

1) Thin upper lip concerns in men, while not as common as in women, can be treated with the same types of lip enhancement techniques.

2) An upper lip or vermilion advancement offers a permanent solution to an improved lip size and shape.

3) Upper lip advancement scars heal well in men ( and perhap better than even in women) presumably due to the hair follicles in the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Lip Advancement for Lip Asymmetry

Sunday, October 27th, 2013


Background: The size and shape of the lips is controlled by many factors. But one of the most important is the pink part of the lip known as the vermilion. The size of the lips is largely controlled by the vermilion height of the vermilion. (lip line out to the skin edge or vermilion-cutaneous junction) How vertically long or short the vermilion is determines how one perceives the size of the lips.

Like size, the symmetry of the lips is similarly controlled by the vermilion. Any differences in the height of the vermilion along the lip line will create an obvious lip asymmetry. When it occurs closer to the corner of the mouth, as it most commonly does, it will make the lip look like it is curled inward. This is exaggerated when one smiles as the vermilion is naturally pulled thinner, sometimes making the asymmetry even more noticeable.

Case Study: This 19 year-old male was bothered by a lower lip asymmetry. His right lower lip near the corner was shorter or less full than the rest of the lip. This asymmetry became more obvious as he smiled as the lip pulled up and outward which naturally stretches the vermilion thinner. He was happy with the fullness of the rest of his lip.

The new lower level of the desired vermilion location was marked out to be even with the  vermilion-cutaneous junction of the rest of the lip.

Under local anesthesia, the skin was removed between the pen mark and the natural edge of the vermilion border. The vermilion edge was advanced out and closed to its new skin location with a two layer closure. (dissolveable sutures for the skin) It is usually advised to advance the vermilion out 1mm ore than desired to account for any amount of scar contraction.

Case Highlights:

1) Lip asymmetries caused by differences in vermilion show can be corrected by lip advancement or reduction of the vermilion-cutaneous junction.

2) Subtotal vermilion adjustments can be done under local anesthesia as an office procedure.

3) With animation (smiling) the adjusted lip asymmetry may or may not reappear. Subtotal lip vermilion adjustment are static-based procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Surgical Rejuvenation of the Aging Mouth

Wednesday, October 16th, 2013


Background: Aging affects all parts of the face and the mouth area is no exception. The changes of the lips and the perioral tissues are classic and include thinning of the lips, downturning of the corners of the mouth and the development of vertical lip lines. These central facial aging changes are unaffected by more peripheral procedures like a facelift. Rather they require a direct approach to their treatment and are not uncommonly done as part of a facelift to provide a more complete facial rejuvenation effect.

While injectable fillers are the mainstay of younger lip and mouth enhancements, the older aging mouth is less responsive to just pure plumping effects. It needs more help with actual mini-lifting prcedures that are designed just for the lips.

Case Study: This 62 year-old female was bothered by the constant frown of her mouth and the thinning of her upper lip. While she had always had a thinner upper lip, it had gotten even thinner as she has gotten older. Her goal was not to have really big lips but an upper lip that matched the size of her lower lip. But what really bothered her was the downturned corners of her mouth. This made he look mad all the time when she really wasn’t.

A lip rejuvenation plan was marked out that included an upper lip (vermilion) advancement, corner of the mouth lifts and fat injections into her marionette lines.

Under local anesthesia which included infraobital nerve blocks and direct local infiltration into the upper lip, a 3mm vermilion lip advancement was initially done with making the cupid’s bow area more accentuated. The tail ends of the vermilion advancements were left open in preparation for the corner of the mouth lifts. Corner of the mouth lifts were done by making an outward line of 7mms from the corners toward the tragus and turning that into a triangle as it curved toward open end of the lip advancement. Finally, fat was harvested from her abdomen from inside her bellybutton, concentrated and then injected from the bottom end of the marionette lines upward, placing 4ccs of fat per side.

There are many options for turning an aging or unhappy mouth area into a more rejuvenated one. While the most common technique that comes to mind are injectable fillers, they usually are inadequate for older lip and mouth area as the exclusive treatment option. To make lips fuller or to change the smile line in older patients requires skin removal and lifting techniques.

Case Highlights:

1) Lip and perioral aging is often accompanied by a combined thinning of the upper lip and downturning of the corners of the mouth.

2) Corner of the mouth lifts combined with an upper lip advancement creates a more complete lip rejuvenation effect.

3) Most perioral rejuvenation procedures can be performed under local anesthesia as an office procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Revision of Lip (Vermilion) Advancements

Sunday, September 15th, 2013


Background: While injectable fillers are the most common form of lip augmentation, there are limits as to the lip changes they can achieve. While fillers add volume, they have a limited ability to significantly increase the vertical height of the lip. The vertical or visible size of the lip vermilion is what all forms of lip augmentation are designed to achieve. If too much injectable filler or if the vertical height of the lip vermilion is small, the lip will be pushed out horizontally but not enough vertically. This creates the classic injectable filler deformity known as ‘duck lips’.

If the lip is very thin (small amount of vertical vermilion height), a surgical approach rather than an injectable filler will produce a better result. One of the surgical lip augmentation choices is a vermilion or lip advancement. By removing a strip of skin above the whole length of the lip, the vermilion edge can be up (for the upper lip) or down. (for the lower lip) By moving the edge of the vermilion, a powerful change in the size of the lip can be seen.

Lip advancements are relatively straightforward office procedures done under local anesthesia. On the surface, they seem simple and uncomplicated…and they are. But they require create precision in their execution to have an even lip edge from one mouth corner to the other and a meticulous design and alignment of the cupid’s bow of the upper lip. Being off fractions of a millimeter can easily result in obvious lip distortions and an unnatural look. Poor suturing or suture reactions at the vermilion-cutaneous border can result in visible scar.

Case Study: This 40 year-old female had an upper and lower lip advancement procedure done one year previously. She was very unhappy with her result even from the beginning as the cupid’s bow position was off to the side and one side of the lower lip vermilion was smaller than the other. As it healed and the scars matured, the immediate distortions of the lips seen after surgery did not improve.

Under local anesthesia, a new position of the cupid’s bow was marked as well as more symmetrical vermilion-cutaneous edges. Skin was removed to allow shifting of the vermilion positions to create a symmetric looking cupid’s bow and even upper and lower lip edges. This is did not significantly increase the size of her lips as no more than one to two millimeters was removed from any one area. It is important for patients to remember that the early lip advancement result (initial or revisional) procedure will have the lips look ‘overdone’. This relaxes and looks more natural with healing time.

Revisions of lip advancements can be successfully done through careful identification of the lip asymmetries and excision of small skin segments for realignment. In some cases the entire scar lines must excised to get the best result.

Case Highlights:

1) Lip advancements require great precision in their execution or lip distortions, asymmetries and visible scarring can result.

2) Revisions of lip advancement complications can be done through cupid’s bow realignment, vermilion line adjustments and hypertrophic scar excisions.

3) Lip advancement revisions, like the original procedure, can be done under local anesthesia in an office setting.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know: Lip Vermilion and Bigger Lips

Sunday, January 13th, 2013


The visible lip is composed of a special tissue known as vermilion. It is the pink or red part of the lip. Its vertical height determines the size of the lip that is seen. Vermilion is uniquely different than the surrounding skin being thinner, much more pliable and capable of substantial stretch. This is a valuable property when it comes to opening one’s mouth and allowing food to pass through. Its elasticity is also why injectable fillers work so well to make the lip bigger, they push the flexible vermilion up and outward creating a fuller lip. But there is a limit as to how much the vermilion can stretch and without adequate vermilion height the push of an injectable filler can only make the vermilion come forward rather than up. This is why women with very thin lips that receive injectable fillers can have the ‘duck lip’ look, too much vermilion movement forward and not enough upward. With thin lips more natural vermilion show may be achieved by actually moving its location. This is known as a vermilion or lip advancement procedure that changes the location of the vermilion-cutaneous border by removing skin and advancing the vermilion border outward. This is a powerful procedure that creates a dramatic change in lip size and is permanent.

Durability of Excisional Lip Lifts

Thursday, November 1st, 2012

Excisional methods of lip rejuvenation, known as lip lifts, are an historic treatment. While pushed aside with the introduction and widespread adoption of injectable fillers, they are making a comeback with the realization that fillers can not solve all insufficient or aging lip problems. They are beginning to reappear in publications and at meetings as a viable method for making lips bigger by increasing vermilion show and decreasing the vertical lip distance between the base of the nose and the upper lip.

Like any form of lifting, a good question is how long does it last? This is most relevant to the true upper lip lift known as the subnasal or bullhorn upper lip lift because it pulls the lip upward. The vermilion advancement also known as the gull wing lip lift involves less pull to create its effect although its sustained results are still relevant.

In the September 2011 issue of the Archives of Facial Plastic Surgery, a study was published in the long-term analysis of surgical correction of the senile upper lip. This was a retrospective review of 30 patients who had either a lip lift or a lip advancement performed for an aging upper lip. (15 lifts, 15 advancements) Digital imaging analysis was used to standardize each patient’s before and after results. The mean follow-up of the patients was just over four years. The revision rate was 7% with all revisions occurring in the vermilion advancement patients and none in the subnasal lip lift patients. Interestingly, all revision occurred in patients who were smokers. Besides significant improvement in lip appearance in all patients, both types of lip lifts showed sustained results out to the duration of the study.

Unlike synthetic injectable fillers and even fat, permanent lip augmentation is elusive. Lip lift and advancements are well known to offer significant improvement and this study supports the observation that those results are sustained and thus permanent. I do find it interesting that the study did not show a difference between subnasal lip lifts vs vermilion advancements as lip lifts have historically been known to have some degree of ‘relapse’ and secondary relaxation lengthening of the result. Based on this study and the technique used (no muscle manipulation or suturing) there is no need to overcorrect a lip lift since significant loss of the result is not seen.

Despite the durability of lip lifts, they still play a minor role in lip rejuvenation. Because of the scar burden that they create and the volumetric benefits of fillers, lip lifts are reserved as a salvage procedure for failed lip rejuvenation attempts by other methods. Even in a patient who has a very thin lip regardless of age and seems like a good candidate for a lip lift, I want them to try fillers first to prove that surgical modification of the lip is desired.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Extreme Lip Augmentation with Vermilion Advancements

Monday, August 2nd, 2010

Background:  Lip augmentation is a very common office-based cosmetic procedure that is done by commercially-available injectable fillers. Despite the immediate and dramatic effects of injectable fillers in the lips, their results are not permanent. These lip treatments must be repeated if the results are to be maintained. There are some patients who tire of these repeated treatments or can not get the lip results they want with injections alone.

The lip (vermilion) advancement is a permanent alternative to lip injections. Fuller or larger lips are evident when more of the vertical height of the vermilion (pink portion of the lips) is seen. Injections accomplish this by pushing from the inside out. Lip advancements achieve this by moving the border of the vermilion further out through skin removal.

Case Study: This is a 40 year-old female who has received injectable fillers into her lips for years. She tired of the discomfort and cost of the repeated injection sessions. While her lips could not be construed as thin to begin with, she sought a very full lip look. She felt that even the injections did not get them large enough. In these before surgery pictures, the lines (mounds) of her existing fillers can be seen around her lips.

At the time of the procedure, the position of the desired new edge of the vermilion was initially lined with a marker. Since the upper lip is usually smaller than the lower lip in most patients, the upper lip line is about 4 to 5mms above the existing vermilion edge and about 3mms below the lower lip vermilion edge. Dental blocks (infraorbital nerve upper and mental nerve lower) were initially performed. This provided anesthesia so that a next set of injections could be done directly along the line of the lip cutouts for absolute comfort and control of any bleeding during the procedure. The previously marked skin was removed along the upper and lower lips as marked. A two-layer closure was then done. For patients that live close, I use very fine 7-0 sutures to be removed a week later. For faraway patients, fine dissolveable 6-0 plain sutures are used. Antibiotic ointment is the only dressing. Some significant lip swelling will initially be seen, accentuated by the previous injection of the local anesthetic.There are no dietary or oral hygiene restrictions. Lipstick may be applied after one week.

Her lip advancement results were very satisfactory to her. She achieved the more extreme lip augmentation result that she had long desired. Her lip scars were very fine and not easily seen even on close inspection.

Case Highlights:

1)      Permanent lip augmentation can only be achieved with a lip or vermilion advancement. The trade-off for this permanency is a fine line scar.

2)      How much vermilion any particular patient wants increased is marked before surgery with their approval. Like drawing lip liner, the exact result can be known before surgery.

3)      Lip advancements should be reserved for those patients who have previously tried injectable fillers or have very thin lips that do not respond well to injections.

Dr. Barry Eppley


Nips and Tucks for the Aging Mouth

Thursday, May 6th, 2010

The mouth area is not spared as the rest of the face ages. Most women focus on changes in the neck and jowls as well as around the eyes. And while there are some well known procedures that make great improvements in these facial areas (facelift, blepharoplasty), how to improve the mouth area is not so standard and well known.

The mouth looks older as a result of  numerous anatomic changes. The upper lip will get longer and thinner. The corners of the mouth start to turn downward. From the downturned corners, grooves extend towards the jaw line creating marionette lines. The nasolabial folds or lip-cheek grooves which ‘parenthesize’ the mouth become more pronounced and deeper. Vertical wrinkles develop on both the upper and lower lip running into the pink (vermilion) of the lip, often resulting in lipstick which bleeds into them.

While wrinkle reduction around the mouth can be done with various laser methods and injectable fillers, improvement in that alone is often not enough to make an overall youthful change. Like the rest of the face, the mouth area can benefit from various ‘nips and tucks.’

There are some small but very effective perioral (mouth) procedures that can create some subtle but significant lifting and upturning of the lips. Youthful changes come from having more exposed vermilion and a more even or horizontal smile line. (mouth corner to corner line) These perioral rejuvenation procedures include lifts of the lip, corner of the mouth, and smile lines.

A long upper lip can be shortened with an upper lip lift, often known as a subnasal or bullhorn lip lift. It is done to primarily shorten the aged long lip, but a small amount of increased upper teeth may result when the lips are slightly open. By using a wavy or bullhorn-shaped ellipse of skin under the nose, the central part of the lip is upturned. The key to this procedure is to remove skin only. If one removes any of the deeper muscle, the upper lip will get tight and look unnatural when smiling. There will be a few millimeters or relapse over the first six months after the lift.

 Rather than done under the nose, lip advancements are done lower at the actual border of the upper lip. It creates a different and more complete upper lip lift because it effects the entire horizontal width of the upper lip. Lip advancement achieves improved exposure of the vermilion and eliminates the bottom end of the vertical lip lines. A small strip of skin abobe the lip line is removed to make the whole upper lip look bigger as well as shortens upper lip length.

The corner of the mouth lift is the ‘cutest’ of the perioral procedures because it removes such a small amount of skin to achieve its effect. Its intent is to elevate the down turned corners of the mouth so that the smile line (lips at rest) becomes more horizontal. This makes one’s mouth appearance more perky. This is done by removing a small triangle or heart-shaped piece of skin above each corner which changes the location and angulation of the sides of the mouth.

Beyond the corners of the mouth, folds of skin may drape downward. This loose skin can be improved somewhat by a facelift but some patients may not want to invest that much effort for improvement. These “parachute” folds of skin can be removed, placing a fine line scar in the lower end of the cheek-lip groove. It also creates a small amount of  lifting of the corners of the mouth as well.

One of the great benefits to these procedures is that they can be done in an office setting under local anesthesia. This keeps the cost down compared to more extensive surgery. They can be combined with injectable procedures such as Botox and fillers as well as laser and light skin treatments. They are a great compliment to be done with a facelift, either before or after.

Nips and tucks of the mouth area will result  in some small scars as a trade-off for their rejuvenating effects. Minor scar revision and touch-ups may occasionally be needed as the margin of error or forgiveness of any scar abnormality is quite small in the very visible mouth 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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