Asian Facial Cosmetic Surgery

257
Tip Projection
Autologous cartilage grafts are used for the nasal tip.
Columellar Strut
A columellar strut is placed between the medial crura
through an external approach (Figure 24-1, A). Even
without direct contact with the anterior nasal spine, the
strut strengthens tip support and adds significant projec-
tion when used together with a shield or cap graft. The
columellar strut does not span the entire length of the
columella in a tent-pole fashion; rather, it is positioned in
the midportion of the columella to preserve mobility.1
Although septal cartilage is preferred, auricular or costal
Nasal Tip Augmentation for
Asians
Dong Hak Jung
cartilage may be used. Before suture fixation, temporary
fixation with a 26-gauge needle helps maintain precise align-
ment (see Figure 24-1, B). If symmetry is not achieved, tilting
or deviation of the columella may occur (Figure 24-2).2
Transdomal Suture
Transdomal suture fixation is made in a horizontal
mattress fashion using #5.0 polydiaoxane suture (PDS
suture). The suture begins in the center, and the knot is tied
between the dome. The suture loop is positioned slightly
cephalic to the center of the dome to enhance the tip-
defining points (TDPs). It is crucial to maintain the
symmetry (Figures 24-3 and 24-4).
24
A
B
Figure 24-1
A, Placement of columellar strut. B, Intraoperative view.

NASAL TIP AUGMENTATION FOR ASIANS
258
Shield Graft
A shield-shaped septal cartilage graft with a 8- to 12-mm
upper edge defines the TDPs (Figure 24-5). On frontal
view, TDPs are generally less than 10 mm apart. These are
the reflections of light at the junction between the domes
(Figure 24-6). The edges of the cartilage are tapered to
provide a smooth surface contour. A longer graft not only
adds projection but can also lengthen the nose. A shorter
graft tends to fall back cephalically, giving rotation in
addition to projection (Figure 24-7).1 When the graft
projects more than 1 to 3 mm or the graft material is weak,
a buttress graft is added for posterior reinforcement. The
surgeon must keep in mind that the flat nature of the graft
may lead to the loss of natural infratip lobular contour.
Figure 24-2
Asymmetric strut fixation causes a columellar deviation.
Figure 24-3
A,Transdomal suture. B and C, Intraoperative views.
Continued
A
B
C

COLUMELLAR STRUT
259
D
E
F
G
H
I
J
K
Figure 24-3, cont’d.
D to G. Interoperative views. H and J, Preoperative views. I and K, Postoperative views.

NASAL TIP AUGMENTATION FOR ASIANS
260
Figure 24-4
A, An alternative method to the transdomal suture is to suture each dome individually and then tie the two domes together. B, Preoperative view.
C, Postoperative view.
A
B
C
A
B
Figure 24-6
Preoperative view (A) and postoperative view (B) after placement of shield grafts.
A
B
Figure 24-5
Shield graft. A,The graft is 8 to 12 mm wide and projects 1 to 3 mm above the existing domes. B,The graft is fixed with four to six interrupted 6-0 PDS sutures.

COLUMELLAR STRUT
261
Cap Graft (Onlay Graft)
The cap graft is a simple method to enhance the TDPs. The
8- to 12-mm wide grafts are stacked in layers. Fixation
is done with two to four interrupted 6-0 PDS sutures. It is
better to place a columellar strut when a cap graft is
planned (Figures 24-8 and 24-9).
Plumping Graft
The use of plumping graft at the feet of the columella adds
projection and improves the nasolabial angle (Figure 24-10).
This graft is more effective when used in combination with
other techniques.
A
B
C
Figure 24-7
A, Long shield graft augmenting the nasal tip. B, A short graft can roll back and create a cephalic rotation. C, A long
graft with posterior reinforcement adds a lengthening effect to the nose.
A
B
Figure 24-8
A, Cap graft. B, Intraoperative view.

NASAL TIP AUGMENTATION FOR ASIANS
262
A
B
A
B
C
D
Figure 24-9
Preoperative view (A) and postoperative view (B) after placement of cap grafts.
Figure 24-10
A and B, Plumping graft. Preoperative view (C) and postoperative view (D) showing improvement of the nasolabial angle.

MULTIPLE GRAFTS
263
Tip Deprojection
Unlike in Caucasian patients, lowering the tip is rarely
indicated in Asians. In the case of boxy or bulbous noses,
overzealous narrowing of the nasal tip may result in an
overly projected tip (i.e., “Pinocchio nose”). In such cases
the tip should first be deprojected before a radical
narrowing is performed (Figures 24-11 and 24-12).
Resection may be done at the medial crura alone or at both
the medial and lateral crura. Reapproximation is done in
an end-to-end or overlapping fashion. Wedge resection of
the membranous septum may be added. Although it is
somewhat less effective, alar base resection can accomplish
deprojection of the tip.
Multiple Grafts
Nasal tip surgery using a single graft may not be effective
for the Asian nose because of the unfavorable combination
of thick skin and weak cartilages. Tip rhinoplasty in Asians
often requires a sturdier graft to support and thrust the
heavy skin envelope. The author often uses multiple
grafting techniques through an external approach for more
precise application of the grafts.1,3
A
B
C
D
Figure 24-11
Tip deprojection by medial crural resection, overlap, and reapproximation (dotted
line).
Figure 24-12
A and B, Intraoperative views. Preoperative view (C) and postoperative view (D) demonstrate that the nasal tip has been narrowed but its height has been maintained.

NASAL TIP AUGMENTATION FOR ASIANS
264
Strengthening the Lower Lateral Cartilage
Auricular cartilage grafts are used to strengthen the lower
lateral cartilage support (Figure 24-13).
Multilayered Shield Grafts
A columellar strut should also be used in addition to multi-
layered shield grafts (Figure 24-14).
Multilayered Cap Grafts
The choice of the shield graft versus cap graft is based on
the graft’s ability to give better TDPs and the availability
and type of cartilage (Figure 24-15).
Cap and Shield Grafts
The use of cap and shield grafts requires the placement of
a columellar strut (Figure 24-16).
Shield Graft Support
The overly projecting shield graft may bend posteriorly.
Posterior support is necessary to achieve reliable tip
projection (Figure 24-17).
Costal Cartilage Shield and Cap Graft
The costal cartilage shield and cap graft provides strong
support (Figure 24-18).
Figure 24-13
A,The LLCs are reinforced with auricular cartilage before other tip maneuvers are made. B and C, Preoperative views. D and E, Postoperative views.
A
C
B
E
D

POSTOPERATIVE CARE
265
Postoperative Care
Postoperatively, Thermoplast® is applied on the nose. The
sutures are removed on the fifth postoperative day.
Prophylactic antibiotics are given for 3 to 5 days. Appli-
cation of an icepack may reduce the amount of edema and
ecchymosis. Nasal packing is placed for about 6 hours after
septal carilage harvesting. If the septal deviation was
corrected, the packing is left in place for 24 hours. Follow-
up visits are made at the fifth day; 1 week; 1, 3, and 6
months; and annually.
A
C
D
B
E
Figure 24-14
A, Demonstration of the shield graft’s layers. B and C, Preoperative views. D and E, Postoperative views.

NASAL TIP AUGMENTATION FOR ASIANS
266
A
B
C
D
Figure 24-15
A, Intraoperative placement of multilayered cap grafts. B, Intraoperative view. C and D, Preoperative views. E and F, Postoperative views.
E
F

POSTOPERATIVE CARE
267
A
B
C
D
E
F
Figure 24-16
A, Shield graft in combination with cap graft. B, Intraoperative view. C and D, Preoperative views. E and F, Postoperative views.

NASAL TIP AUGMENTATION FOR ASIANS
268
A
B
C
D
E
F
G
Figure 24-17
A, Posterior support of the shield graft. B and C, Intraoperative views. D and E, Preoperative views. F and G, Postoperative views.

POSTOPERATIVE CARE
269
3. Yoon JS, Jung DH, Min YG: Rhinoplasty through the external
approach, Korean J Otolaryngol 40(8):1091-1096, 1997.
References
1. Johnson CM, Toriumi DM: Open structure rhinoplasty,
Philadelphia, 1990, Saunders.
2. Jung DH, Jang TY, Kim YM: Aesthetic nasal tip surgery,
Korean J Otolaryngol 39(10):685-693, 1996.
A
B
C
D
E
F
Figure 24-18
Costal cartilage grafts. A and B, Intraoperative views. C and D, Preoperative views. E and F, Postoperative views.

271
Patients who seek nasal base correction share several
common characteristics. The alar margin may be higher, in
the same plane as, or lower than the columella. While
the higher position is considered aesthetically pleasing, an
alar margin lower than the columella could be perceived as
unattractive as a result of either ptotic ala with a normal
columellar position or a retrusive columella with a normal
position of the alar margin.1 The columella may be too
short, which is often associated with nostrils that are round
or horizontally flat. The columella-labial angle may show
an acute angle with retrusive appearance. The ala may be
unusually large in both height and thickness. This may
result in a ptotic alar and narrow nostril. The ala may flare
out laterally if the nostril is excessively large.
Procedure
Retrusive columella and columella-labial angle are often
corrected by simply inserting the L-shaped dorsocolu-
mellar implant. The columellar portion of the implant
should be long enough to be placed anterior to the anterior
nasal spine. This technique is often more effective than
plumping graft in an elevating retrusive angle. Conserva-
tive lengthening of the vertical height of the columella can
be achieved with the columellar strut or L-shaped implant.
A subtle change in nostril shape is often noticed with the
L-shaped implant. However, overzealous attempt should
be avoided to prevent excessive tension and eventual
extrusion of the implant through the supratip lobule. The
width of the alar base can be corrected with a buried suture
technique using a heavy nonabsorbable suture between the
two alar bases (Figures 25-1 to 25-4). The most significant
Nasal Base Reduction
Jung I. Park
aspect of this technique is the deep bite through the dense
alar tissue. This can be accomplished with a sublabial inci-
sion or an incision on the floor of the nostril. Segmental
resection of the nostril floor may facilitate effective medial-
ization and improve longevity. Segmental resection of the
alar base and the nostril floor and medial advancement of
the alar are effective in both narrowing the nasal base and
projecting the nasal tip (Figures 25-5 to 25-7).2 The alar
base can be resected in conjunction with a wedge resection
of the ala along the long axis of the alar rim (Figures 25-8
to 25-11).3-5 Aggressive resection of both the alar rim and
the deep alar tissue should be done to accomplish even a
modest thinning of the ala. Although such thinning does
not enlarge the size of the nostril, it does give an illusion of
a larger nostril. The patient should be fully alerted to the
possibility of an unsightly scar along the long axis of the
alar margin.
Postoperative Care
The sutures are removed after 1 week. Some degree of
unsightly, “pincushion”-type suture marks is often noticed.
This irregularity resolves relatively quickly. Laser
resurfacing is an option for selected patients who do not
have tendencies toward hyperpigmentation.
Complications
Possible complications include implant malposition,
implant extrusion, asymmetry in both alar thickness and
nostril size and shape, and an unsightly scar.
25

NASAL BASE REDUCTION
272
A
B
Figure 25-1
A, Entries and exits of the needle are through the sublabial incision. A needle or a 2-0 permanent suture is used. The
alar portion of the suture includes thick alar tissue. B, Illustration of A.

COMPLICATIONS
273
Figure 25-2
A, The needle passes through the alar tissue and exits through the alar skin. The
needle then reenters the exit point. This time the needle passes through the alar
tissue as far away from the initial passage as possible to contain a large volume of
the alar tissue within the suture loop. The needle then exits the sublabial incision.
This process is repeated on the opposite alar is repeated. B and C, Illustrations of A.
A
B
C
A
B
Figure 25-3
A, Preoperative view. B, Postoperative view. The alar base has been sutured, but nasal augmentation has not been done.

NASAL BASE REDUCTION
274
A
B
Figure 25-4
A, Preoperative view. B, Postoperative view. Both alar base suturing and nasal
augmentation have been completed.
Figure 25-5
Alar base resection varies in design to either narrow the base or eliminate alar flare.
A
B
Figure 25-6
A, Preoperative view of alar base resection. B. Postoperative oblique view.

COMPLICATIONS
275
A
B
A
B
Figure 25-7
A, Preoperative frontal view. B, Postoperative frontal view.
Figure 25-8
Alar rim resection. A, Design. B, Operative view.

NASAL BASE REDUCTION
276
Figure 25-9
The alar rim and posterior alar base resection.
Figure 25-10
A, Preoperative view. B, Postoperative view.
A
B

COMPLICATIONS
277
A
B
C
D
Figure 25-11
A, Design of the alar rim and posterior alar base excision. B, Design of the alar rim resection. C, Drastic thinning of the ala. D, Postoperative view of
the alar rim resection.
Continued

NASAL BASE REDUCTION
278
References
1. Guyuron B, Behmand RA: Alar base abnormalities, Clin Plast
Surg 23(2):263-270, 1996.
2. Adamson PA, Smith O, Tropper GJ: McGraw analysis of alar
base narrowing, Am J Cosmetic Surg 7:239-243, 1990.
3. Millard DR Jr: Alar margin sculpturing, Plast Reconstr Surg
40:337-342, 1967.
4. Ellenbogen R, Blome DW: Alar rim raising, Plast Reconstr
Surg 90:28-37, 1992.
5. Matarasso A: Alar rim excision: a method of thinning bulky
nostrils, Plast Reconstr Surg 97:828-834, 1996.
E
F
Figure 25-11, cont’d
E, Despite a drastic excision, only modest reduction has been achieved. Alar
thickness was reduced by 27%. F, Bilateral reduction.

279
The distance from the nasion to nasal tip is about one third
of the entire facial height. If the distance is less or the
nasolabial angle is greater than 95 degrees, the nose
appears short, overly rotated, or both.1 Nasal augmentation
in a patient with a short nose may lead to further
shortening and overrotation of the nasal tip. Lengthening
of the nose should be performed (Figure 26-1).
Overrotation of the nasal tip can be developmental or
iatrogenic secondary to previous nasal surgery. Although
the correction of the short, overly rotated nose is relatively
simple in a developmental case, it is complicated in
postsurgical cases because of the presence of cicatrization.2
Graft Choice
Cartilage graft is used. Alloplasts have a high risk of
extrusion. Because of the insufficient supply of septal
Lengthening of the
Short Nose
Dong Hak Jung
cartilage, auricular cartilage is often added. The costal
cartilage provides enough volume to accomplish both
lengthening and augmentation of the nose. The seventh
costal cartilage is preferred for its thickness and length.
Surgical Technique
Lengthening of the nose may be accomplished by lowering
the nasal height, which gives an illusion of a longer nose.
The nasal tip may be lowered by amputating the alar and
columellar support, freeing the lower lateral cartilage from
the upper lateral cartilage, detaching the medial crura from
the nasal septum, or shaving the lower part of the caudal
septum.3 Although cartilage graft can be placed on the
caudal aspect of medial crura, the lengthening effect is
minimal because of the lack of support by the mobile crural
cartilages (Figure 26-2).
26
A
B
Figure 26-1
Augmentation and lengthening of the nose. A, Preoperative frontal view. B, Postoperative frontal view. C, Preoperative lateral view. D, Postoperative
lateral view.
C
D

LENGTHENING OF THE SHORT NOSE
280
The most effective method involves placement of extended
spreader grafts.1,4 The graft can be placed on either side or
both sides of the septum.5 Bilateral spreader grafts achieve
better symmetry and support (Figures 26-3 and 26-4). Rib
cartilage provides excellent strength and reliable support
when used as extended spreader grafts (Figure 26-5). A
unilateral spreader graft has a greater tendency to cause
nostril asymmetry. This can be remedied by wedging the
graft deeper in a cephalic position between the upper
lateral cartilage and the septum to provide stability (Figure
26-6). Layered shield grafts can be placed to increase the
length. The shield grafts are limited to a maximum of two
layers, and the nasal mucosa should be undermined to
allow a tension-free closure. The nasal skin should confirm
to the extended nasal skeleton within 1 to 3 months.
Patients should be informed of this delayed improvement
of the lengthening effect. Placement of composite auricular
cartilage grafts between the upper and lower lateral
cartilages is a viable alternative (Figure 26-7).2,6
Contracted Nose
When contraction develops after implant removal, it
progresses rapidly. Revision is performed 6 months later
A
B
C
D
E
F
Figure 26-2
Cartilage graft to the caudal aspect of the medial crura. A, Only minimal
change is expected. However, the combination of a columellar strut and
shield graft provides a considerable lengthening. B, Intraoperative view
of the strut and shield graft combination. C, Preoperative frontal view.
D, Postoperative frontal view. E, Preoperative lateral view.
F, Postoperative lateral view.

CONTRACTED NOSE
281
with an autologous cartilage graft. Contracted skin, when
stretched with a graft, may have a higher risk of infection
because of the lack of reliable blood supply. Adequate time
must be allowed for the skin to relax. The cartilages from
the septum, ear, or rib are used for extended spreader grafts
and shield graft. Extended spreader grafts can be placed
on each side or both sides of the septum (Figures 26-8 and
26-9). Although the columella stretches easily, the ala does
not, which necessitates a staged procedure. Contraction of
the nose results in both shortening and narrowing of the
nostril. Both aspects should be addressed during correc-
tion (Figure 26-10). Asymmetric nostrils are corrected by
reinforcement of the smaller side (Figure 26-11). A septal
flap may be rotated to close the skin in the soft triangle area
without tension (Figure 26-12). Incomplete closure of this
area has a high risk of infection.
A
B
C
D
E
Figure 26-3
If structural support is established with extended spreader grafts, a shield graft (A) can be added to further lengthen the nose. The anticipated skin stretch should be carefully
evaluated. B, Extended spreader grafts from costal cartilage. C, Bilateral spreader grafts from septal cartilage. D and E, Postoperative lateral view demonstrates that the
nasolabial angle has been reduced from 120 degrees to 90 degrees.

LENGTHENING OF THE SHORT NOSE
282
Postoperative Care
Tip-supporting sling tape is avoided to prevent counter-
force against the direction of the extended spreader graft.
Thermoplast® is placed in a manner that assists in
lengthening the nose. Wound dehiscence and subsequent
infection may occur as a result of excessive tension at the
soft triangle region after an excessive lengthening.
Prophylactic antibiotics are used. The nasal skin will
stretch over a period of 1 to 3 months; this postoperative
stretching should be explained to the patient during the
preoperative consultation.
Figure 26-4
Spreader graft on one side only.
A
B
C
D
Figure 26-5
Costal cartilage was used to augment and lengthen the nose. A, Preoperative frontal view. B, Postoperative frontal view. C, Preoperative lateral view.
D, Postoperative lateral view.

POSTOPERATIVE CARE
283
A
B
C
D
E
F
G
H
Figure 26-6
A to D, Intraoperative views of the spreader graft on one side only. E to H, Pre- and postoperative views.

LENGTHENING OF THE SHORT NOSE
284
B
A
Figure 26-7
The use of composite auricular graft between the upper and lower lateral cartilages
is a viable alternative.
Figure 26-8
Lengthening of the nose with bilateral (A) and unilateral (B) extended spreader
grafts. Intraoperative view. Bilateral placement of costal cartilage grafts (C)
extended the length of cartilage graft harvested from the septum (D).
Continued
D
C

POSTOPERATIVE CARE
285
E
F
A
B
C
D
Figure 26-9
A, Contracted nose. B, Extended graft harvested from costal cartilage. C,Two layers
of grafts are fixed between the lower lateral cartilages. D, Additional lengthening is
achieved with onlay grafts. E, Frontal view after revision.
Continued
E
Figure 26-8, cont’d
E,The graft is temporarily fixed to the lower lateral cartilage with a 26-gauge needle until suture approximation is placed to maintain symmetry. F, An additional lengthening
effect is achieved with an onlay graft.

LENGTHENING OF THE SHORT NOSE
286
Figure 26-9, cont’d
F, Preoperative view of revision surgery. G, Postoperative view.
F
G
C
A
B
Figure 26-10
A, Contracted nose. B, Intraoperative view of revision surgery to increase tip width.
C, Postoperative view.

POSTOPERATIVE CARE
287
C
A
B
E
D
Figure 26-11
A, Contraction of the left side only. B, Placement of more graft material on the left lower lateral cartilage for additional support. C, Postoperative frontal view of revision surgery.
D, Preoperative view. E, Postoperative view.

LENGTHENING OF THE SHORT NOSE
288
References
1. Jung DH: Rhinoplasty, Seoul, 2002, Goodmorning Doctor,
pp 246-247.
2. Aiach G: Atlas of rhinoplasty, St Louis, 1996, Quality
Medical.
3. Gunter JP, Rorich RJ: The classification and correction of
alar-columella discrepancies, Plast Reconstr Surg
97(3):643-648, 1996.
4. Gunter JP, Rorich RJ: Lengthening the aesthetic short nose,
Proceedings of the 14th Dallas Rhinoplasty Symposium,
Feb 28-Mar 3, 1997, Dallas, TX, 1997, Southwestern,
pp 155-164.
5. Farrior RT, Farrior EH: Special rhinoplasty techniques. In
Cummings CW, Fredrickson JM, Harker LA, eds:
Otolaryngology head and neck surgery, ed 2, Baltimore, 1992,
Mosby, pp 857-886.
6. Gruber RP: Lengthening the short nose, Plast Reconstr Surg
91(7):1252-1258, 1993.
A
B
C
D
Figure 26-12
A superiorly or inferiorly based septal flap is used for closure of the soft triangle region. The septum heals secondarily
without adverse sequelae in 2 to 3 weeks.

III
289
Although some people hate thick and protruding lips,
others find voluminous lips to be a sexually appealing
feature. In recent years, this trend tended to parallel the
increasing popularity of voluptuous lips among models and
in magazine articles as a symbol of sexual attractiveness.
On the other hand, the upper lip becomes steadily longer
and the lips become thinner as the aging process
progresses. For older people, lip enhancement is a means of
looking younger and increasing confidence at the work
place. Injection, implantation, or free grafts are used to
enhance the lips. Excision of the upper lip and advancement
of the vermilion lip may be necessary in older patients to
regain the upper lip and vermilion lip balance once enjoyed
during youth. Thinning of the lips is not associated with
the ideals of beauty as defined by the media. Rather, desires
for lip reduction are often an individual’s effort to conform
with peers and overcome the perceived oddity of large lips.
Although the techniques of cheiloplasty are no different
from those in the Western hemisphere, this chapter has
been added because of the procedure’s overwhelming
popularity among Asians and different application of the
procedures due to the different skin characteristics and
varied cultural acceptance among the Asian population.
Cosmetic Cheiloplasty
Lip Augmentation
Jung I. Park
Lip Augmentation
Injectable Fillers
Collagen Injection
Both bovine and human collagen
are available for injection into the lips. Although injections
may last only about 4 months, some patients choose
injections instead of surgical procedures because they are
simpler and allow the patient to more quickly return to
work.1 Expense is not an issue for these patients because
repeated injections are more expensive than surgery. Some
patients try injections to see the effect of lip augmentation
without fully committing to the surgery. The patient who
likes the effect may proceed with a more permanent sur-
gical procedure. Older individuals often choose collagen
injections to enhance only the white rolls and soften the
vertical rhitids.
Autologous Collagen
Autologous collagen is a puri-
fied form of liquid collagen derived from the patient’s own
tissue.2,3 It is usually obtained during a surgical procedure
such as a face lift. The patient’s skin is sent to a laboratory
to be processed, and collagen is extracted and then
returned to the surgeon. The processing and shipping time
can be lengthy, and this option is expensive.
27

LIP AUGMENTATION
290
Restylene
Restylene is an injectable gel composed of a
nonanimal stabilized hyaluronic acid (NASHA gel, Q-med,
Sweden), 20 mg/mL, which is prepared through a bacterial
fermenting process. Hyaluronic acid has an enormous
ability to bind water and form hydrated polymers of high
viscosity. It occurs naturally and in an identical form in
the intercellular matrix of dermal layers of the skin of all
species, and it has an extraordinarily high biologic
compatibility.4 Unlike collagen, pretesting is not necessary.
Injection of this material can be painful and may require a
topical anesthetic. The injection may create some palpable
irregularities that improve with time. The results may last
6 months or longer.
Hylaform
Hylaform® (Genzyme Co., Ridgefield, NJ) is
an injectable hyaluronic acid product that is extracted from
rooster combs. It has a higher molecular weight but a lower
concentration of 6 mg/ml.4
Fat Injection
Injected fat tends to disappear faster in
the lips than in other areas. Injection into the muscle may
increase the survival time of the injected fat.5-7 Volume
control and evenness of application are also issues. Any
surviving fat is permanent.
Surgical Lip Augmentation
Use of Implant Materials
Alloderm®
Alloderm dermal graft (LifeCell, The
Woodland, TX) is an acellular dermal matrix derived from
human skin. Cellular components are removed to prevent
rejection. Alloderm retains the maximal structural
integrity of the extracellular material. The acellular matrix
serves as a template for the growth and integration of the
host fibroblasts and endothelial cells into permanent
dermal tissue.3,8
Polytetrafluoroethylene
Among the plethora of per-
manent implant materials, expanded fibrillated polytetra-
fluoroethylene (e-PTFE) has been used as a permanent
implant material for lip augmentation.9,10 The lip/facial
implants are manufactured as SamTM (Gore-Tex®, Gore
and Associates, Flagstaff, AZ), AdvantaTM (Atrium
Medical, Hudson, NH) and UltrasoftTM (Tissue Techno-
logies, San Francisco, CA). Sam facial implants are solid
sheets of Gore-Tex that can be cut into a desired size.
AdvantaTM provides a design with a soft central core and
lightly porous outer surface. A preattached trocar for easy
implantation is available for both implants. Ultrasoft is
a hollow tube that allows tissue growth into the lumen.
The Ultrasoft implant is available with a convenient
preloaded, no-touch delivery system.
Consultation
The patient should be thoroughly educated about the pros
and cons of the various implants and urged to make a wise
choice. The temporary nature of Alloderm and the
potentially palpable nature of alloplastic implants should
be carefully judged.
Procedure
Thorough toothbrushing and mouthwashing with an
alcohol-based solution are done the night before and the
morning of the surgery. A topical anesthetic cream is
applied to the vermilion lip before the injection of local
anesthetics. Intravenous sedation or oral premedication
using 10 to 20 mg of diazepam, 1 tablet of Darvocet-N-
100TM (Mallincrodt Inc., St. Louis, MO), and broad-
spectrum antibiotics are given 1 hour before the surgery. A
regional block
is accomplished by injecting the
infraorbital nerve of the upper lip and the mental nerve of
the lower lip with 2 mL of 0.5% Marcaine with epinephrine
1:100,0000 at each location. The infraorbital foramen can
be palpated 1 cm below the infraorbital rim in its mid-
portion. The injection is made through the upper gingivo-
buccal sulcus using a 1.5-inch, 27-gauge needle. The
mental block is accomplished by injecting the mucosa just
below the canine root. The mental nerve may be seen
under the mucosa when the lower lip is rolled outward and
the mucosa is stretched. The vermilion lip is then injected
with a 30-gauge needle using 1% lidocaine with 1:100,000
epinephrine solution buffered with sodium bicarbonate in
a 1:10 ratio. A total of 5 mL is used for both the upper and
lower lips. Each lip is injected separately approximately
10 minutes before the incision is made. An even injection
of the entire surface is important to maintain an even
contour. Unrecognized unevenness can impair the
surgeon’s judgment of symmetry. The contour irregularity
often appears only after all the swelling has subsided. A
medical marking pen is used to make markings for
the incisions at the four corners of the mouth. Thorough
Phisohex® (Sanofi-Synthelabo Inc., New York, NY) sterile
prepping and draping are applied. The oral vestibule is
packed with sterile 4 × 4 gauze without distorting the
contour of the lips. A #11 Bark-Parker blade is used to
make 0.5- to 1-cm-long incisions approximately 5 mm
medial to the commissure and perpendicular to the
vermilion border across the wet line.

IMPLANT INSERTION
291
Pocket Dissection
After a pocket is developed or a preloaded trocar is passed
through the lips, the implant is inserted. An assistant
should retract the oral commissure laterally with a single-
prong skin hook. The lip is held tightly and stretched as the
midportion is grabbed and the lip is pulled to the opposite
side for an easy dissection. The pocket is developed by
scissor dissection using a spreading motion. The pocket is
approximately 1.0 cm wide in the deep submucosal plane
immediately above the orbicularis oris muscle and should
follow the wet line. Alloderm grafts require a larger pocket.
However, the non-preloaded e-PTFE implant requires a
smaller pocket depending on the implant thickness. After
the dissection passes the midline, it is repeated from the
opposite oral commissure in a similar manner until the two
tunnels meet in the middle.
Implant Insertion
Alligator-type forceps are inserted through the incision.
The tip of the alligator forceps emerges from the incision
on the opposite end of the lip and grasps the implant. As
the surgeon is holding the lip steadily with the thumb and
fingers, the implant is pulled into the tunnel. The implant
should be designed to be long enough so that both ends
of the implant remain outside the incision site when the
placement is completed. The lip tissue is then spread evenly
over the implant. The redundant portion of the implant is
trimmed. Each end of the implant should be hidden from
the incision. The pocket should be made tightly enough to
prevent the implant from moving. The mucosal incisions
are closed in layers with 5-0 VicrylTM (Ethicon Co.,
Somerville, NJ) and 4-0 chromic catgut sutures in a
horizontal mattress fashion.
Gore-Tex Implant Insertion
Sam Facial Implant is delivered as presterilized packages in
different sizes. It is cut to the desired size on the operating
table. The surgeon’s glove should be washed with sterile
saline to remove the powder. The tunnel dissection and the
insertion method are the same as previously described.
The tunnel is made narrower than that for Alloderm. A
tighter pocket provides stability for the implant. Because
implant extrusion is a concern, the end of the implant is cut
short about 5 mm from the incision site. Sam implant is
also available as a strand with a trocar.11
Advanta Implant Insertion
The Advanta implant is available with or without a trocar.
The method of insertion for the implant without a trocar is
the same as for the Sam facial implant. The preattached
trocar allows for insertion without requiring the previous
creation of a tunnel. The implant can be simply pushed
through the submucosal layer via a small incision at the
oral commissure. The trocar is passed through the sub-
mucosal plane along the wet line and exited near the
opposite oral commissure.
UltraSoft Tubular e-PTFE Implant Insertion
The wet line of the vermilion lip is marked. A #11 Bard-
Parker blade is used to make a 4-mm stab incision
perpendicular to the vermilion border and approximately
5 mm medial to each oral commissure. A small iris scissor
is used to create a 1-cm deep commissure pocket lateral to
the incision site and directed toward the commissure. A
preloaded trocar is introduced into the entry incision site
(Figure 27-1, A). The handle is grasped firmly between the
thumb and fingers as the entry site is gently pinched. The
trocar is advanced through the incision and parallel to the
skin surface in the subcutaneous plane immediately above
the muscle. The trocar then is exited through the opposite
incision site (see Figure 27-1, B). The dominant hand is
used to push the trocar toward the exit incision in a rotary
pushing motion, while the lip tissue is steadily held by
the nondominant hand. The wrinkled lip skin is stretched
evenly over the trocar, and the evenness of depth is
palpated and checked. The locking pin is removed, and
gentle pressure is applied to the plunger of the insertion
tool handle to release the trocar-implant unit. As the
assistant grasps the tip of the insertion tool, the stainless-
steel sleeve is withdrawn through the entry incision (see
Figure 27-1, C). The sleeve is removed with a twisting
motion while the nondominant hand pulls the lip tissue
toward the opposite direction. At this point, the implant is
fully exposed and the trocar is still inside the lumen (see
Figure 27-1, D). Next, the tip of the trocar and the cuff are
disengaged from the implant with a gentle rotating and
pulling motion. The trocar with guide wire is removed
from the lumen of the implant by pulling the tip of the
trocar (see Figure 27-1, E). A short length of the implant
will protrude from the entry and exit sites. The implant
lumen is irrigated with Betadine solution in a 10-mL
syringe with a 20-gauge angiocatheter. Each end of the

LIP AUGMENTATION
292
A
B
Figure 27-1
A,The trocar is introduced through a 5-mm slit entry incision. B,The trocar is
completely passed through a submucosal plane. C, The metal sheath is removed,
exposing UltraSoft implant (Tissue Technologies, San Francisco, CA). D, The inner
cannular is exposed. E, The inner cannular is removed from the lumen of the
implant. F, Excess UltraSoft implant is trimmed. G, The opposite end is also trimmed.
C
D
E
F
G

IMPLANT INSERTION
293
excess implant is then trimmed with scissors (see Figure
27-1, F and G). The end of the implant is buried in the
commissure pocket (see Figure 27-1, H). The incision is
then closed with 5-0 Vicryl sutures for the submucosal
layer and 4-0 chromic sutures in a horizontal mattress
fashion to make a watertight seal (see Figure 27-1, I).12,13
Due to its simplicity, lip augmentation with the use of the
trocar is gaining in popularity (Figures 27-2, A and B, and
27-3, A and B).
Alloderm Graft Preparation and Insertion
The appropriate volume of Alloderm is assessed preopera-
tively. The thickness of the Alloderm is predetermined by
the thickness of the processed dermis, which is 1 to 2 mm
thick. Stacking the material will enable control of the
volume. Precut packages of 2 × 4-cm grafts are ideal for lip
augmentation. The graft is cut or folded to the desired size
and shape. The ideal graft height is approximately 1 cm. If
a longer graft and more volume are required, 3 × 7-cm
prepackaged grafts are available. The graft length is made
to be the same as the length of the lips. The graft is
immersed in a saline solution for at least 10 minutes. A
sheet of paper is peeled from the wet Alloderm. If needed,
the Alloderm pieces are sutured together or rolled before
insertion (figure). A string of heavy 2-0 silk-type suture
material passes through each end of the Alloderm without
tying. The alligator forceps are passed through the tunnel
and grasp the strings. The Alloderm graft is then brought
into the tunnel by pulling the strings. 2-0 silk sutures on
each end of the Alloderm graft are used to move the
implant back and forth to adjust its position. After it is
properly positioned, the strings are pulled from each end of
the implant. The end of the Alloderm is cut short to keep
Figure 27-1, cont’d
H, Lip vermilion is symmetrically and simultaneously stretched. I, The incision is closed.
H
I
A
B
Figure 27-2
A, Preoperative view showing thin and sharp vermilion borders. B, Postoperative view after upper and lower lip augmentation. Smooth, round, voluminous vermilion lips have
been achieved.

LIP AUGMENTATION
294
it away from the incision (Figure 29-4, A to C). Despite the
claim of permanency as demonstrated during in-vivo
experiments, the majority of the implant disappears within
6 to 12 months. However, unlike the injectable fillers, a
small amount may remain permanent (Figure 29-5, A to C).
Overcorrection is recommended.
Dermofat/Fascial Graft
Consultation
The procedure can be done as an adjunctive procedure
during a face lift, when a large amount of dermis and fat is
available and the temporalis muscle fascia can be
conveniently harvested. Otherwise the temporal fascia can
be obtained independently through a separate minor
procedure, which uses a well-hidden incision.14,15 Properly
obtained dermal grafts can leave relatively hidden scars in
thick, non–hair bearing skin.16,17 The possible development
of a sebaceous cyst should be explained to the patient. Also,
natural shrinkage of the free graft should be addressed.
Graft Harvesting
Temporalis Muscle Fascia
The patient is asked to
shampoo with antiseptic soap the night before and the
morning of the surgery. Preoperative antibiotic, analgesic,
and sedatives are given orally. The hair is shaved 1 cm wide
B
Figure 27-3
A, Preoperative lateral view. B, Postoperative view. Thickening and a rounding effect
is evident.
Figure 27-4
A, Alloderm implant. B, A submucosal tunnel was created. The implant is ready to
be pulled through the tunnel. C, The implant is in place.
A
B
A
C

DERMOFAT/FASCIAL GRAFT
295
and 5 cm long vertically above the upper attachment of the
auricle. The hair is tied with elastic bands to clearly expose
the shaved area. The patient is placed in the supine posi-
tion with the head turned to the opposite side. A 27-gauge
needle is used to infiltrate the temple area along the
incision site and deep to the area of the temporalis fascia
with a solution of 1% lidocaine with 1:100,000 epinephrine
buffered with sodium bicarbonate. A total of 10 mL is
injected. Next, phisohex prepping is done, and a sterile
head drape is applied. A vertical 4-cm-long incision is
made through the scalp along the direction of the hair tuft.
The subgaleal plane is developed through the loose areolar
tissue with an easy sweeping motion using a Freer-type
elevator. The assistant should expose the temporalis fascia
by lifting the flap with two sharp multiprong retractors.
Additional anesthetic solution is injected into the tempo-
ralis muscle under the exposed fascia. A 1.5 × 5-cm square
incision is made through the fascia. The incision goes
through the superficial layer of the muscle. One end of the
fascia is grasped with toothed forceps and gently raised. A
pair of dissecting scissors is introduced to shave the upper
layer of the muscle with the attached fascia. A 5-cm muscle
fascia strip is then extracted. Hemostasis is obtained. The
fascia does not need to be approximated unless it can be
easily brought together. The galea is sutured with 4-0
Vicryl sutures, and the scalp is closed with 4-0 nylon
sutures in a running fashion. The graft is then cut to match
the length of the lip and the desired thickness of lip
augmentation. The graft needs to be slightly longer than
necessary to anticipate shrinkage. A 2-0 silk suture is
passed through each end of the fascia as described earlier
for Alloderm grafts.
Dermofat Graft
A dermofat graft can be harvested
from any thick, non–hair bearing skin area. Although it
can be harvested independently, it is best done during face
lift procedures. The preauricular area is preferable because
of its thickness. Infragluteal sulcus is another site for the
graft harvesting.16 The graft includes a layer of fatty tissue.
The graft is prepared by removing the epidermis and
midreticular dermis. Only the lower reticular dermis and
fat are used. A 2-0 silk suture is passed in the usual fashion
for traction. The suture needs a deep bite to prevent
tearing during the pull.
Procedure
The tunnel is created in a fashion identical to that
previously described. The graft insertion is also identical in
B
A
C
Figure 27-5
Placement of an Alloderm implant. A, Preoperative view. B, 1-month postoperative
view. C, 7-month postoperative view. Although volume reduction is significant
between 1 and 7 months postoperatively, it has distinctly improved when compared
with the preoperative view. More improvement is noticeable in the lateral lip area.

LIP AUGMENTATION
296
that a temporary suture is placed, alligator-type forceps are
used to pull the graft through the tunnel, and the position
is adjusted by pulling the strings back and forth. The
wound is closed with 4-0 chromic catgut sutures.
Postoperative Care
The patient is advised to apply ice to the lips for 2 days as
much as possible. Strenuous restrictions are applied for
alloplastic lip augmentation. Broad-spectrum antibiotics
are used preoperatively and postoperatively for 1 week. Lip
movement is limited for 1 week. Exaggerated lip movement
such as pursing, whistling, kissing, wide mouth opening, or
wide smiling is to be avoided for 1 month. Eating is not
restricted except for food contact at the incision sites and
wide opening of the mouth.
Recovery
Swelling is dramatic for the first 3 days, and some drooling
is to be expected. Most swelling subsides within 1 week.
Some hardness occurs, regardless of the procedure choice,
and may last as long as 6 months. Numbness is universal
and self-limited. The patient with an e-PTFE implant will
feel lip stiffness for 1 to 2 weeks. The patient may feel the
presence of the implant without discomfort for 3 to 4
months. The patient may not feel the implant at all after
4 months. This is especially true with small UltrasoftTM
implants.
References
1. Matti BA: Clinical use of Zyplast in correction of age- and
disease-related contour deficiencies of the face, Aesth Plast
Surg 14:227, 1990.
2. DeVore DP, Hughes E, Scott JB: Effectiveness of injectable
filler materials for smoothing wrinkle lines and depressed
scars, Med Prog Techol 20:243-250, 1994.
3. Beran SJ, Rohrich RJ: The potential role of autologous
injectable, dermal collagen (Autologen®) and acellular
dermal homograft (Alloderm®) in facial soft tissue
augmentation, Aesth Surg J 17:420, 1998.
4. Duranti F, Salti G, Bovani B, et al: Injectable hyluronic acid
gel for soft tissue augmentation. A clinical and histological
study, Dermatol Surg 24:1317-1325, 1999.
5. Fagrell D, Enestrom S, Berggren A, et al: Fat cylinder
transplantation: an experimental comparative study of three
different kinds of fat transplants, Plast Reconstr Surg
98:90-98, 1996.
6. Churukian MM: Red lip augmentation using fat injection,
Facial Plast Surg Clin North Am 5:61-70, 1997.
7. Colic MM: Lip and perioral enhancement by direct
intramuscular fat autografting, Aesthetic Plast Surg
23:36-40, 1999.
8. Tobin HA, Karas ND: Lipaugmentation using an Alloderm
graft, Oral Maxillofac Surg 56:722-727, 1998.
9. Ellis D, Trimas SJ: Gore-Tex implants for the correction of
thin lips, Laryngoscope 105:207, 1995.
10. Conrad K, MacDonald MR: Wide polytef (Gore-Tex)
implants in lip augmentation and nasolabial groove
correction, Arch Otolaryngol Head Neck Surg 122:664, 1996.
11. Wang J, Fan J, Nordstrom REA: Evaluation of lip
augmentation with Gore-Tex facial implant, Aesth Plast
Surg 21:433-436, 1997.
12. Israelsen LD: Surgical protocol for SoftFormTM and
UltraSoftTM lip implant, San Francisco, Tissue Technologies.
13. Adams WP: Instructional DVD, San Francisco, Tissue
Technologies.
14. Lassus C: Surgical vermillion augmentation: different
possibilities, Aesth Plast Surg 16:123-127, 1992.
15. Maloney BP: Cosmetic surgery of the lips, Facial Plast Surg
12: 265-278, 1996.
16. Kesselring UK: Rejuvenation of the lips, Ann Plast Surg
16:480-486, 1986.
17. Nicolle FV, Chir M, Basim A, et al: Dermal and facial
autografts in facial aesthetic surgery, Aesth Plast Surg
16:219-225, 1992.

297
Consultation
Unlike the lip augmentation described in the previous
chapter, the lip advancement procedure may leave a visible
scar. Although most scars are faint and barely visible,
a good candidate for this procedure is a person who
normally applies lipstick and is willing to accept a visible
scar. The popular lip tattooing procedure may help mask
the visible scar. Although lip advancement shortens the lip
height, eliminates some vertical wrinkles, and widens the
vermilion lip, it does not enhance lip volume. The
vermilion lip may look wider, but it is unnaturally flat.1-3
Although the nasal base–lifting procedure achieves the
same result and is favored by Caucasians,4,5 the scar at the
base of the nose is more visible and poorly accepted by
Asians. The perioral peel is also used to evert the vermilion
border in the Caucasian patient3 but is not used in the
Asian patient because of hyperpigmentation problems.
Various lip-mucosal V-Y flaps are available, but their use is
limited in Asian patients because of the extensiveness,
limited improvement, and potential need for revision
surgery.6
Preoperative Care
The patient is advised not to use lipstick on the day of
surgery and to use an alcohol-based mouthwash for 15
minutes the night before and the morning of surgery.
Premedication
The patient should take Xanax (Alprazolam; Purepac
Pharmaceuticals, Elizabeth, NJ) (1.5 to 2.0 mg), Darvocet
(Propoxyphene naphsylate/acetaminophen, Mallincrodt,
Inc., St. Louis, MO) N-100 (1 tablet), and broad-spectrum
oral antibiotics before the procedure.
Lip Advancement
Jung I. Park
Marking
The first marking is made along the white roll of the
vermilion border. The line should be within the vermilion
lip. The second line is made parallel to the first line at a
predetermined distance (3 to 5 mm) based on the degree of
desired lip advancement. The two lines join at each end of
the oral commissure. The area of skin excision should be
larger than the anticipated lip advancement. Because of
gravity and scar contracture, the newly formed vermilion
border tends to retract toward the mucosal side, resulting
in less advancement. Retraction seems to be somewhat
more pronounced near the oral commissure. In the upper
lip, the cupid’s bow tends to become flat as a result of
cicatrical contraction. A somewhat exaggerated design is
necessary to maintain the desired curves and angles.1 This
dynamic seems to be more applicable to the older patient
with an atrophic orbicularis muscle. Younger patients do
better, possibly because they have better underlying soft
tissue support.
Anesthesia
Regional and local anesthesia is administered as described
in Chapter 27, “Lip Augmentation.” Sterile preparation may
not require such stringent discipline as used in alloplastic
implant surgery.
Dissection
Lip advancement may be achieved by two methods. After
resection of a strip of lip skin, the vermilion lip may be
advanced by development of a vermilion mucosal flap. The
vermilion flap is elevated from the orbicularis oris muscle.
The submucosal minor salivary glands are included in
28

LIP ADVANCEMENT
298
the flap to ensure an adequate thickness of the flap. The
vermilion mucosal flap is undermined well into the oral
mucous membrane (Figure 28-1, A). The upper incision is
undermined 2 mm from the edge to allow passage of
dermal sutures and create eversion of the suture line. The
closure is done in two layers with 5-0 VicrylTM (Ethicon,
Inc., Somerville, NJ) suture in an interrupted fashion and
6-0 black nylon suture in a subcuticular continuous fashion
(see Figure 28-1, B). Healing is quick, and lipstick can be
applied in 10 days (see Figure 28-1, C). This technique is
suitable for the younger patient with the presence of
adequate fullness of the lip and orbicularis oculi muscle
bulk (Figure 28-2, A and B).
In the second method, the vermilion lip is allowed to roll
over the recipient lip defect and is sutured to the skin part
of the lip in two layers. This method is more suitable for the
older patient with atrophic dermis and orbicularis oris
muscle. The incision is made along the markings (Figure
28-3, A and B). The skin island of white lip is excised and
Figure 28-1
A, Vermilion mucosal flap. B, 5-day postoperative view of vermilion flap
advancement. C, Lipstick may be applied 10 days after surgery.
Figure 28-2
Vermilion lip flap advancement. A, Preoperative view. The lower lip is thin, and the
vermilion edge is sharp. B, Postoperative view. The lower lip became full and soft.
The scar is quite acceptable.
A
B
A
B
C

DISSECTION
299
A
B
C
D
E
F
Figure 28-3
A, Marking on the white lip. B, The incision is only made through the dermis. C, The
skin is only excised deep to the dermis. The subcutaneous tissue is preserved as much
as possible to enhance volume. D, Gaping wound. E, The vermilion skin is rolled out
and sutured to the white lip. F, Additional subcuticular interrupted sutures with
tissue eversion are made. G, View of a subcuticular running suture made with 6-0
nylon.
G

LIP ADVANCEMENT
300
discarded (see Figure 28-3, C and D). A short vermilion
flap is developed at the interface between the submucosal
glands and the orbicularis oris muscle. The dissection only
extends approximately 2 mm from the vermilion incision.
The width of the flap should be equal throughout the
length of the lip. Next, a short flap is developed for the lip
skin. The lip skin is undermined about 1 to 2 mm from
the incision. These short flaps are designed to cause
an exaggerated eversion of the wound closure.2 The skin
island is then excised, leaving a deep dermis as a founda-
tion for the white roll that will be built by the flaps. After
meticulous hemostasis has been achieved, the flaps are
advanced. Deep dermal sutures are placed at the dermis
muscle junction, and the skin edges are brought together
with an exaggerated eversion (see Figure 28-3, E). 5-0
Vicryl dermal sutures are placed at even distances across
the lip (see Figure 28-3, F). The skin is closed with 6-0 black
nylon suture in a subcuticular running fashion (see Figure
28-3, G). The vermilion edge has a tendency to become less
distinctive after lip advancement (Figures 28-4, and 28-5)
and become more distinctive after lip reduction.
Postoperative Care
Antibiotic ointment is applied to the incision site. An ice
pack is applied to the lip for 2 days. Lip movement is
restricted for 1 week. The patient eats with a spoon with-
out touching the lips. Sucking with the lips is not allowed.
A straw may be used with the tongue and palatal sucking.
A liquid or soft diet is used for 1 week. Oral antibiotics are
administered for 1 week.
A
B
Figure 28-4
A, Preoperative view. B, Postoperative view. Despite the augmented philtral advancement, the phitrum appears blunt.
Figure 28-5
A, Preoperative view. B, Postoperative view. The lip is fuller.
A
B

RECOVERY
301
Recovery
Swelling is significant for the first 3 days. The vermilion
lip may remain somewhat ecchymotic for 10 days despite
meticulous hemostasis. The lip remains numb for several
weeks.
References
1. Fanous N: Correction of thin lips: “lip lift”, Plast Reconstr
Surg 74:33-41, 1984.
2. Kesselring UK: Rejuvenation of the lips, Ann Plast Surg
16:480-486, 1986.
3. Maloney BP: Cosmetic surgery of the lips, Facial Plast Surg
12:265-278, 1996.
4. Rozner L, Isaacs GW: Lip lifting, Br J Plast Surg 34:481-484,
1981.
5. Austin HW: The lip lift, Plast Reconst Surg 77:990-994, 1986.
6. Lassus C: Thickening the thin lips, Plast Reconstr Surg
68:959, 1981.

303
Consultation
Lip reduction is the least complicated lip procedure.
Asymmetry may occur. The fine contouring of the cupid’s
bow and lip tubercle, if present, may change in shape.
Preoperative Care
The usual oral hygiene and mouthwash with an alcohol-
based solution are recommended. Xanax (1.5 mg),
Darvocet N-100, and broad-spectrum antibiotics are
administered.
Anesthesia
A regional block of the infraorbital nerve, mental nerve,
or both is carried out using 1% lidocaine with 1:100,000
epinephrine solution. Approximately 2 mL are injected at
each site. A 30-gauge needle is used to infiltrate 5 mL
of local anesthetic into each lip. The surgeon should be
careful to make even injections to prevent an asymmetric
excision caused by distortion.
Dissection
The line of excision is marked with a medical marking pen.
Usually, the patients with thick lips has a large vermilion
border. An elliptical excision is marked with the wet line
in the center. The width of the ellipse varies with the
thickness of the lip. Usually a 1-cm excision is sufficient.
The excision is made in a wedge-shaped fashion and
includes a layer of the orbicularis oris muscle (Figure 29-1,
Lip Reduction
Jung I. Park
A and B). Both oral commissures are retracted as the
assistant applies tension with skin hooks. The center of the
lip is marked vertically for future reference during wound
closure. Hemostasis is obtained with bipolar cautery. The
center of the defect is sutured first, taking a big bite with
a 3-0 chromic catgut suture. While the lip is stretched
between the midline suture and the commissure suture,
two submucosal sutures are placed at even distances. The
rest of the closure is made with a 3-0 chromic continuous
running suture (see Figure 29-1, C).
Postoperative Care
A cold compress is applied for 3 days. Analgesics and
broad-spectrum oral antibiotics are prescribed. The
patient should use a spoon while eating. Chewing is
prohibited for 7 days. Gentle toothbrushing is allowed after
the third postoperative day.
Recovery
Other than significant lip swelling during the first 3 days,
the postoperative course is unremarkable.
Wound dehiscence may occur if excessive lip movement is
allowed.
Case Study
See Figures 29-2 to 29-5.
29

LIP REDUCTION
304
Figure 29-1
A, Wedge resection of the upper lip. B, The lip segment includes a wedge of the
muscle. C, A simple running suture of 4-0 chromic catgut.
Figure 29-2
Upper lip reduction. A, Preoperative view. B, Postoperative view. The upper lip to lower lip vermilion thickness ratio has changed from 93% to 50%. The vermilion edge has
become more distinctive.
A
B
C
A
B

CASE STUDY
305
A
B
A
B
Figure 29-3
Lip reduction. A, Preoperative lateral view. B, Postoperative view. The upper lip vermilion thickness to philtrum length ratio has changed from 110% to 83%.
Figure 29-4
Lip reduction. A, Preoperative frontal view. B, Postoperative view. The vermilion edge has become more distinctive.

LIP REDUCTION
306
References
1. Stucker FJ Jr: Non-Caucasian rhinoplasty and adjunctive
reduction cheiloplasty, Orolaryngol Clin North Am
20:877-894, 1987.
2. Pierce HE: Cheiloplasty for redundant lips, JNMA
68:211-212, 1976.
A
B
Figure 29-5
Lip reduction. A, Preoperative lateral view. B, Postoperative view.

IV
307
Traditionally, Asian women have favored an egg-shaped
face. Although many enjoy these features, some suffer from
an unwelcome harshness of the face as a result of either
excessive development or deficiency of the facial skeletal
structure. A prominent malar bone, wide zygomatic arch,
protruding
premaxillary
component,
hypertrophic
masseter muscle, and an outwardly flared mandibular
angle are the features that differentiate a harsh-looking face
from a typical, soft, conservative-looking Asian face. A
somewhat retrusive perinasal midface and weak chin
accentuates the skeletal prominences. When these features
are combined with brachycephalic Asian skeletal
characteristics, the departure from the ideal becomes
an obsession. Surgical creation of a narrower face with
modification of the zygomaticomalar prominence and
mandibular angle reduction will produce a more oval-
Aesthetic Facial
Skeletal Surgery
Introduction to Aesthetic
Facial Skeletal Surgery
Jung I. Park
shaped face. Enhancement of the perinasal deficiency and
reduction of the premaxillary prominence will soften the
harshness. Extensive skeletal surgery, alloplastic implant
augmentation, or biologic bone grafting may correct
midface deficiency. A relatively large number of Asians
have a chin that is not only receding but also has poor
definition. Chin augmentation converts a round face with a
weak lower half to a face with an ideal profile. Despite
significant potential improvement with chin surgery,
patients pay relatively little attention to their chins. The
recent introduction of Botulinum toxin type A (Allergan,
Inc., Irvine, CA) to the field of cosmetic surgery opened a
new avenue to achievement of the same result with a
simpler nonsurgical injection of the masseter muscle to
reduce the width of the lower face.
30