COSMETIC

Subnasal Lip Lifting in Aging Upper Lip:

Combined Operation with Nasal Tip
Plasty in Asians
Jae-A Jung, M.D., Ph.D.
Background: The objective of this study was to illustrate a novel technique
Ki-Bum Kim, M.D.
for lifting of the aging upper lip with nasal tip plasty in Asians. With this
Hyun Park, M.D.
procedure, a shortening of the philtrum, an increase of the vermilion, and a
Eun-Sang Dhong, M.D., natural and nicer mouth can be obtained, with increase of the tip of the nose
Ph.D. simultaneously.
Seung-Kyu Han, M.D., Methods: Thirty patients were the subjects of this study. Incisions were made
Ph.D. bilaterally beginning at the alar fold, entering nostrils, and rising medially on
Woo-Kyung Kim, M.D., the skin below the lower margin of the medial crura. Excess skin of the phil-
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVGLGjjqParD6Fts9m7Q60R36/39nQEdieIvS8qFi0QhQ on 03/04/2019

Ph.D. trum was eliminated in two separate pieces and the muscle was suspended to
Seoul, Republic of Korea the base of the nose with interrupted stitches.
Results: All patients expressed a high degree of satisfaction. The average
ratio between the L1 reference line and the height of the upper lip measure-
ment preoperatively was 0.43 ± 0.05. This ratio was improved postoperatively
to an average of 0.32 ± 0.05. The nasolabial angle was 91.31 ± 4.19 degrees
before surgery and 105.62 ± 5.04 degrees after surgery. The angle of the
upper lip was 48.97 ± 2.41 degrees before surgery and 38.21 ± 3.34 degrees
after surgery.
Conclusions: Lip lift is an effective tool for correcting a natural tendency of
the upper lip to cover the upper teeth during aging. There is a dramatic im-
provement in the patient’s facial aesthetic appearance during smiling and at
rest. The authors strongly recommend this technique as part of the surgical
procedure to achieve a youthful face.  (Plast. Reconstr. Surg. 143: 701, 2019.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

L
ips are major contributors to facial aesthetic
appearance and expression. As facial aging
occurs, aesthetic changes in the senile upper
lip cause concern for many women. During the
aging process, alterations will appear in the upper
lip, including vertical wrinkles, reduction in the
height of the vermilion border accompanied by
lengthening of the dermal area of the upper lip,
and disappearance of the Cupid’s bow.1 In addi-
tion, lips become long and flat. They lose promi-
nence of the philtral columns, showing a reduction
in thickness and losing volume of the vermilion
border. When lips lose volume, they will lose their
original shape. Ends of the upper lip also tend
to droop. This is the main reason for increased
From the Department of Plastic Surgery, Korea University
College of Medicine; and the Park-Hyun Plastic Surgery
Clinic.
Received for publication February 6, 2018; accepted August
29, 2018.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000005315
distance between the subnasale and the upper lip
and decreased nasolabial angle.2,3 These character-
istics of aging can appear on the lips of younger
people, who may wish to change their appearance.
Patients frequently present to plastic surgeons
with questions about facial rejuvenation. Although
they seldom complain about individual compo-
nents of their anatomy, the surgeon must deter-
mine what corrections need to be made to restore
a more youthful appearance.4,5 Thousands of face
lifts, blepharoplasties, forehead lifts, and resurfac-
ing procedures are performed yearly. However, a
few patients will undergo adequate treatment for
the aging upper lip complex.6
The lip-lift procedure was described almost
30 years ago. Dr. Austin began performing the
lip lift in 1980 and presented 83 cases in 1986.4
However, only a limited number of surgeons are
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 701
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 Plastic and Reconstructive Surgery • March 2019
familiar with the technique. The objective of this
study was to introduce a subnasal short-scar upper
lip–lifting technique that could be performed
with nasal tip augmentation without additional
nasal incision. This can induce an improved reju-
venation effect.
PATIENTS AND METHODS
Subnasal lip lifting with nasal tip plasty was
carried out between January of 2013 and Decem-
ber of 2014 for 30 patients (25 women and five
men) with a mean age of 48.7 years (range, 28
to 65 years). All patients underwent primary rhi-
noplasty. Patients who needed correction of dif-
ferent nasal deformities with spreader grafting
techniques, tissue resection, or osteotomy were
excluded. Only tip plasty with tip-suturing tech-
niques and tip grafting were performed.
The minimum postoperative follow-up period
was 12 months. Preoperative and postoperative
patient evaluations, including photographs taken
during regular office visits, were performed. The
study protocol was approved by the Institutional
Review Board of Korea University Guro Hospital
(K2017-6852-002).
Surgical Technique
This lip procedure was carried out under local
anesthesia with a regional block of the infraor-
bital nerve and intravenous sedation depending
on patient request. Regional block (4% articaine
with 1:200,000 epinephrine) can eliminate the
sensitivity of the entire area, and local anesthesia
(0.5% mepivacaine with 1:100,000 epinephrine)
can produce needed vasoconstriction both in the
skin and in the muscular area to be excised.
The incision begins at the alar fold of the
nose, enters the nostril, and rises medially on the
lower margin of the medial crura of the alar car-
tilage. A separate incision begins at the other alar
fold, enters the nostril, and rises medially, similar
to the first incision. A vertical skin bridge is left
intact between the left and right incisions.
The excess skin of the philtrum is eliminated
in two separate pieces as previously marked. The
skin of the columellar area is safe and completely
undermined toward the upper lip as shown in
Figure 1. The amount of skin and/or muscle to
be removed varies depending on whether the
shortening of the philtrum or the extrusion of the
vermilion is preferred. If the goal is to obtain a
better extrusion of the vermilion, a large amount
of skin is removed. The skin of the columella and
philtrum is undermined as far as the Cupid’s bow
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Fig. 1. Illustration depicting incision lines and dissection fields.
Incision lines are made on both sides of the philtrum in two
separate pieces with a safe columellar area. These incisions are
extended into the nostril. Gray deviant crease lines indicate a
range of dissection for upper lip tissue movement and nasal tip
augmentation.
without actually reaching it. A small portion of
the cephalad part of the orbicularis oris muscle is
removed. The superior edge of the orbicular mus-
cle is suspended and sutured to the base of the
nose with interrupted absorbable 5-0 polydioxa-
none stitches (Ethicon, Inc., Somerville, N.J.)
(Fig. 2, below). Finally, an interrupted suture using
nonabsorbable 6-0 Prolene material (Ethicon) is
performed to close the skin.
It is very important to pay utmost attention to
the suture because the labial flap is longer than
the nasal flap (Fig. 2, above, left). Stitches taking
the nasal flap perpendicular to the skin and the
labial flap in parallel have to be placed. In this way,
the length of the labial flap shortens and becomes
as long as the nasal flap, whereas the columellar
skin can be redistributed without cutting this area.
Concerning the undermining of the upper
lip, it has to be performed all over the philtrum,
from the inferior edge of the excised skin straight
through to the Cupid’s arch, plus the columellar
area up to the nasal tip. In men, a large amount
of skin cannot be removed because of the beard.
A range of the amount of skin excision is
determined after measuring each patient’s pre-
maxillary vertical length and philtrum length and
attempting to make ideal proportion. Ideal facial
analysis commonly divides the face into horizon-
tal thirds; the lower one-third of the face consists
of the portion from the subnasale to the menton.
 Volume 143, Number 3 • Subnasal Lip Lift with Nasal Tip-Plasty

Fig. 2. (Above) Excess skin of the philtrum is eliminated in two separate pieces as previously marked. (Center)
The skin of the columellar area is safe and completely undermined toward the upper lip, as is clearly shown.
The incision extends to the alar fold of the nose, enters the nostril, and rises medially on the lower margin
of the medial crura of the alar cartilage. (Below) A small cranial part of the orbicular muscle is removed. The
superior edge of the orbicularis muscle is suspended and sutured to the base of the nose with interrupted
absorbable 5-0 polydioxanone stitches. Because the labial flap is longer than the nasal flap, the skin has to
be redistributed well.

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 Plastic and Reconstructive Surgery • March 2019
Within this lower third of the face, the lower lip
(lower vermilion border to the menton) is twice
the height of the upper lip complex (subnasale to
upper vermilion border). Therefore, a range of
the amount of skin excision is determined after
measuring each patient’s length.
In addition, making a natural smile after sur-
gery is an important point. An excessive gingival
display or gummy smile is defined in the litera-
ture as a gingival exposure greater than 2 mm
above the dental line when smiling.7,8 Therefore,
a patient with a gingival exposure greater than
2 mm above the dental line was excluded from
the subnasal lip lifting surgery.
After removing the excess skin of the subna-
sal area, dermis is prepared for dermal graft to
increase the height of the nasal tip. It is important
that the skin is removed in a single piece. From
the moment of removal, the skin is kept in saline
solution. The graft is then rolled to obtain an ana-
tomical shape that is adequate to augment the tip
(Fig. 3).
Fig. 3. After removing the excess skin of the subnasal area, der-
mis is prepared for dermal grafting to increase the height of
the nasal tip. It is important that the skin is removed in a single
piece. From the moment of removal, it should be kept in saline
solution. The graft is then rolled to obtain an anatomical shape
that is adequate to augment the tip.
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Protocol for Measuring Distance and Angles
To evaluate outcomes, the distance from the
subnasale to the labiale superius, the nasolabial
angle, the angle of the upper lip, and the nasal
tip projection were analyzed by photography with
an anteroposterior view and a lateral view. Preop-
erative and postoperative photographs were com-
pared. Postoperative photographs taken at least 9
months after the operation were used for analysis.
To obtain objective measurements, we used
Adobe Photoshop Premiere Elements 9 (Adobe
Systems, Inc., San Jose, Calif.). Photographs were
examined at full scale to eliminate systematic
errors from magnification. For objective measure-
ments, anatomical ratios were used, including the
ratio of vertical height from the right alar rim to
the medial canthus (Fig. 4). The alar-medial can-
thus line (L1) served as a reference for calcula-
tion of preoperative and postoperative anatomical
ratios. These ratios were used to eliminate slight
variations in focal distance, head positioning,
and zoom. The distance from the subnasale to
the labiale superius was obtained by using the
Fig. 4. Drawing of the height of the upper lip measurements.
The height of the upper lip was measured by the distance from
the subnasale to the labiale superius. For objective measure-
ments, anatomical ratios were used. These ratios included the
vertical height from the right alar rim to the medial canthus. This
ala–medial canthus line (L1) served as a reference for calculat-
ing preoperative and postoperative anatomical ratios. The dis-
tance from the subnasale to the labiale superius was obtained
by using the subnasale as a starting point, from which a line was
drawn downward through the midphiltrum to the vermilion
border.
 Volume 143, Number 3 • Subnasal Lip Lift with Nasal Tip-Plasty

subnasale as a starting point, from which a line Statistical Analysis

was drawn downward through the midphiltrum to
the vermilion border.
The nasolabial angle was determined by draw-
ing a line from the subnasale to the labiale superius.
The angle between this line and the line from the
subnasale to the most inferior columella was consid-
ered the nasolabial angle. The nasolabial angle and
the angle of the upper lip were also measured using
Adobe Photoshop Premiere Elements 9 (Fig. 5).
The nasal tip projection was measured from
the nasolabial angle to the point of intersection
with a line from the nasion along the dorsum.9,10
The distance between the lateral mouth cor-
ner (commissure) and the upper margin of the
Cupid’s bow (labiale superius) were measured for
the standard. The nasal tip projection ratio was
determined as the nasal tip projection/distance
between the commissure and the labiale superius.
Results are presented as mean ± SD of untrans-
formed data. The paired t test and the Wilcoxon
signed rank test were applied to compare naso-
labial angle, upper lip angle, and height of the
upper lip before and after surgery. All statistical
analyses were performed using IBM SPSS Version
19.0 (IBM Corp., Armonk, N.Y.). Statistical signifi-
cance was considered at p < 0.05.
RESULTS
All 30 patients expressed satisfaction with sur-
gical results achieved. Preoperative and postopera-
tive photographs demonstrated clear improvement
of facial features (Figs. 6 through 8).
Postsurgical swelling and initial lip dysesthesia
resolved in all cases within the first 3 to 6 weeks
without any morphologic or functional sequelae.

Fig. 5. (Left) A 35-year-old woman dissatisfied with her long philtrum and thin upper lip under-
went subnasal lip lifting and tip plasty with 4 mm of subnasal skin removed during the opera-
tion. (Right) Photographs were taken at 12 months after the operation. The upper lip angle was
45 degrees before surgery and 33 degrees postoperatively. The nasolabial angle was 85 degrees
before surgery and 103 degrees postoperatively. Surgical scars were not obviously visible.

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 Plastic and Reconstructive Surgery • March 2019

Fig. 6. (Left) Preoperative view of a case with long philtrum in a 43-year-old patient.
(Right) Postoperative view, 2 years after the operation. Note the nicer mouth and
younger appearance on the oblique view. Surgical scars were not obviously visible.

Fig. 7. (Left) Preoperative view of a typical case with long philtrum in a 49-year-old patient.
(Right) Postoperative view at 12 months after shortening of the philtrum and inserting a filler
in the inferior lip. Note the nicer mouth and the better extroversion of the philtrum on the
oblique view.

Upper lip edema was evident during the first 5 to
7 postoperative days. It rapidly resolved afterward,
being minimal by the third week.
In three of 30 patients (10 percent), red-
ness and swelling of the incision occurred 2 to
3 days after the operation. However, dehiscence,
bleeding, or hematoma did not occur in the post-
operative early phase. Most patients had scarring
in the early phase. However, scars became lighter
and disappeared approximately 2 to 3 months
after the operation. In two of these 30 patients
(6.7 percent), incisional scarring was noticeable

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 Volume 143, Number 3 • Subnasal Lip Lift with Nasal Tip-Plasty

from a conversational distance at the time of long-
term follow-up (Fig. 8). These patients underwent
scar revision surgery and received comprehensive
postoperative treatment to prevent additional
scarring. Because of our innovative technique
and the quality of sutures, no other complications
occurred.
DISCUSSION
The aging upper lip is an often-neglected
component of facial rejuvenation.11 Surgical pro-
cedures for upper lip lift have been reported in
Western countries since the 1980s, with the main
aim of modifying the elongation and flattening of
the philtrum caused by aging. The mean age of
patients of Western countries is 40 to 60 years, the
time when the loosening of facial attachments,
soft-tissue atrophy, and bone absorption widely
occur. By contrast, the age range of Asian patients
wishing to undergo this procedure is mostly 20 to
40 years.12 Some of them have a congenitally long
philtrum, whereas others complain that the phil-
trum becomes longer after Le Fort osteotomy or
orthodontics. A short philtrum and an upturned
vermilion might present a lovely, innocent, and
attractive figure to an Asian face. Therefore, in
recent years, an increasing number of young peo-
ple have contemplated this procedure.
Many surgeons have used hyaluronic acid
injection or placement of implant material in
an attempt to improve the lost vermilion volume
and height. Many different types of implant fill-
ers are available.13,14 The ideal filler would be soft,
pliable, permanent, and free of complications.
Unfortunately, a permanent filler that is approved
by the U.S. Food and Drug Administration for use
in the lips does not exist. Autologous fat injection
is also used to increase the fullness of lips.15 How-
ever, many treatments are required and resorp-
tion is unpredictable. In addition, increasing the
volume of lips often fails to provide more vermil-
ion red appearance. In addition, these procedures
do not improve the length of the senile upper lip.
Therefore, surgical reduction is needed to
address the elongated upper lip typically seen in
aging populations. Previous methods for address-
ing a long upper lip are based on direct surgical
excision of the nasal base skin4,16 or a vermilion
advancement.1,17 However, the problem with these
techniques is the visible scar. Although subnasal
skin excision technique is preferred for an older,
thin-skinned patient, this technique usually is not
tolerated by a young, healthy cosmetic patient.
On the basis of the latter finding, many improve-
ments with respect to incision design have been
reported. A few minimally invasive methods have
also been proposed.18–20 However, previous stud-
ies have focused only on skin excision. Enhancing
efficacy by lift of the superficial musculoaponeu-
rotic system in the upper lip is rarely reported.
Moreover, few studies of this procedure for Asian
patients have been reported.12
Our subnasal lip-lifting technique can address
the long upper lip without a visible scar, which may
be of some benefit for younger cosmetic patients.
The merit of this method is that it can enhance
the overall upper lip aesthetics by shortening the
upper lip’s central portion. The relationship of
the upper lip to the surrounding structures can be

Fig. 8. (Left) Preoperative view of a 60-year-old woman who complained of her long philtrum with thin lips. (Right)
Postoperative view 6 months later. Through wide undermining of the skin of the philtrum, shortening of the philtrum,
and inserting a filler in the both lips, we obtained good extroversion of the vermilion. The upper lip angle became
acute. In this patient, the scar at the subnasal area is slightly seen.

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Table 1.  Parameters Measured before and after the
Procedure
Parameter Before After
No. 30 30
Distance from the sub-
nasale to the labiale
superius 0.43 ± 0.05 0.32 ± 0.05
Nasolabial angle,
degrees 91.31 ± 4.19 105.62 ± 5.04
Angle of the upper lip,
degrees 48.97 ± 2.41 38.21 ± 3.34
Nasal tip projection ratio 0.84 ± 0.08 1.06 ± 0.09
appreciated on the sagittal view, showing the naso-
labial angle and upper lip projection. On a perpen-
dicular line drawn from the Frankfort horizontal,
the upper lip should be 2 mm anterior to the lower
lip and 4 mm anterior to the chin. By making an
incision in the subnasal area, the central lip land-
marks are not violated or significantly distorted.
From undermining the philtrum area and
suspension suture, we discovered that by limiting
the dissection to half the vertical height of the lip
and placing the suture at the end of this dissection
plane, tethering of the lip and interruption of oral
competence did not occur. This method allows
elevation of the lip. It retains oral competence,
and the shape of the upper lip in the lateral view
is changed from a convex or straight appearance
to a more youthful concave appearance. This sen-
sual appearance does not affect the lip’s dynamic
function. Moreover, a significant change is seen in
the lateral view of each patient, namely, a change
in the lip contour from a straight line or convex-
ity to a concavity, thus creating the appearance of
fullness and pout. Most of all, every patient who
underwent the lip-lifting procedure was satisfied
with the result.
Many Asian patients are dissatisfied with their
low nasal tip projection. They might need a for-
mal nasal tip rhinoplasty to modify and increase
the tip projection. Using discarded dermal tissue
from lip lifting, all patients underwent primary tip
augmentation rhinoplasty simultaneously. Patients
who needed to correct different nasal deformities
with spreader grafting techniques, tissue resec-
tion, or osteotomy were excluded from this study.
Only tip plasty with tip-suturing techniques and
tip graft were performed. In our opinion, this
additional rhinoplasty technique can maximize
the effect of lip lifting at lateral view contour with-
out tissue distortion or visible external scars.
No patient experienced any major intraop-
erative or postoperative complication. Postop-
erative dysesthesia of the upper lip area resolved
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • March 2019
shortly. In three of the 30 patients (10 percent),
redness and swelling of the incision occurred 2
p
to 3 days after the operation. However, dehis-
cence, bleeding, or hematoma did not occur in
the postoperative early phase. Most patients had
scarring in the early phase. However, these scars
0.000 became lighter and disappeared approximately
0.000 2 to 3 months after the operation. In two of the
30 patients (6.7 percent), incisional scarring
0.000 was noticeable from a conversational distance at
0.000
the time of long-term follow-up. These patients
underwent scar revision surgery and received
comprehensive postoperative treatment to pre-
vent additional scarring. In addition, no patient
had complication after autologous dermal tissue
graft tip augmentation.
The lip lift is meant to provide an additional
option to upper lip rejuvenation. It is not intended
to replace lip fillers. Some patients require addi-
tional volume augmentation for better lip contour.
However, with a lip-lifting procedure, the patient
may require less volume replacement to achieve
an aesthetic improvement. With a combination of
lip-lifting and tip augmentation procedure, slight
change in the sagittal projection or vertical height
can drastically change the overall cosmetic out-
come. Such changes might seem subtle. However,
these changes are what most patients desire and
consider aesthetically pleasing.
CONCLUSIONS
The lip-lift procedure is a simple and effec-
tive procedure that could be used as an adjunct
to other rejuvenation procedures. There is a dra-
matic improvement in the patient’s facial aesthetic
appearance by increasing the tip projection and
nasolabial angle resulting from skin redraping.
We strongly recommend this technique as part of
the surgical procedure to achieve a youthful face.
Eun-Sang Dhong, M.D., Ph.D.
Department of Plastic Surgery
Korea University Guro Hospital
148 Guro-Dong, Guro-Ku
Seoul 152-703, Republic of Korea
prsdhong@kumc.or.kr
PATIENT CONSENT
Patients provided written consent for the use of their
images.
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