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About Face

Chapter Seven The Lips The Shape What Can Be Done Chin Surgery Lip Surgery The Paris Lip

Lip Surgery

Now that you know how we view the lips - as an integral part of the lower third of the face - it might help to look at a few site-specific situations, when only the lips are affected. If the problem involves muscle defects, we’ll work on those before doing anything with the soft tissue. As I said in the chapter on linear scarring, sometimes a lip scar will show up when a patient smiles because the muscle hasn’t been properly repaired after an accident. We might have to reopen the scar and close the wound with a deep dermal stitch to produce a finer, less visible scar. This is particularly important if scarring mars the vermilion border, making it so noticeable.

If the problem is a paralyzed lower lip, it most often is due to damage to the “ramus mandibularis,” the branch of the facial nerve that affects the lip. This nerve gives function to the group of muscles that pulls down or depresses the lower lip. Without this function, people who naturally have a full dental smile suffer the most. When they smile, it looks like a corner of their bottom lip is being pulled by an invisible fish hook because the paralyzed side does not move. But there is an effective technique we can use to almost restore a natural, balanced smile.

We start by cutting out a wedge of the lower lip, which immediately improves the situation by tightening the lip into a straighter horizontal line. (Often, a paralyzed lower lip hangs loosely, due to loss of muscle tone.) This wedge-shaped wound, made near the corner of the mouth, is sewn up with a deeply placed stitch that closes up the muscle to minimize scarring. But before sewing it up, we give the lip a “sling” by suturing it to the groove between the upper lip and the cheek. This exerts a permanent, upward pull that counteracts the slackness in the paralyzed area.

This technique is an exacting form of surgery because it involves a couple of procedures that require experience and some finesse on the part of the surgeon. For example, because the lip is pulled toward the corner of the mouth, the fullest part of the lip moves away from the center of the mouth. As a result, we have to surgically “thin” part of the red segment of the lip so that it looks natural in its new position. And the “sling” itself must be sutured to the muscle of the lip, then slung around the corner of the mouth and attached through an incision to the lip-cheek groove.

Happily, not all patients arrive at a cosmetic surgeon’s office in need of such extensive repair work to the lips. Some want to improve the appearance of their lips for cosmetic reasons alone. A fairly typical example is the patient who, as a youngster, got whacked in the mouth by a hockey stick or a set of handlebars in a tricycle accident. This can lead to a scar inside the upper lip, on the lubricating or mucous membrane. The scar thickens and it begins to push down so that a small part of the membrane shows, particularly when the patient smiles. The procedure to correct this is a straightforward excision; we cut out most of the thickened scar and sew up the membrane to produce a finer scar that will heal more evenly.

Young patients who have had surgery to correct the birth deformity of a shortened philtral area, usually referred to as a “harelip,” often end up with no tubercle. We can correct this with collagen injections, but a more permanent solution would be to insert a piece of Gore-Tex into the red segment of the upper lip. This would create the appearance of a natural tubercle.

As with any other cosmetic procedure, it is our task to make sure that the limitations of lip surgery are understood. A cosmetic surgeon can work with only the basic equipment a patient brings to the operation; if you have lips as thin as a monkey’s (“simian” lips), don’t wave a magazine photo of an actress famous for her pout under the surgeon’s nose. Thin lips can be made to look fuller than they are to begin with, but simple genetics are a limiting factor. Patients with very full lips, for example, can expect cosmetic surgery to produce lips that are less full - but they likely will never manage to have thin lips. A percentage of my patients are blacks who want an overly protuberant lower lip reduced in size, and again, I have to take the time to explain the limitations of surgery.

A patient’s age will also determine what a cosmetic surgeon can reasonable hope to accomplish. I’ve described previously how the circular muscle surrounding the mouth, the “orbicularis oris,” is attached directly to the skin in that area. With age, the muscle shortens, or shrinks a bit, and this causes vertical lines to appear around the lips. This situation can be improved upon with a chemical peel of the upper lip and/or collagen injections every six months to make the lines nearly invisible.

Aging might also create problems in the lip area if the patient has had teeth removed over the years. This can result in a loss of bone above the upper teeth, which causes the mouth to “sink” or cave in a little, which in turn, brings down the tip of the nose. In a case like this, I’d be inclined to combine several surgical and nonsurgical techniques to correct the problem: perhaps some Rhinoplasty (surgery of the nose) to bring up the tip, along with a chemical peel or collagen injections around the mouth, and maybe even an assessment as to whether a face-lift would help by generally tightening up the lower third of the face.

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