Cosmetic Medicine

Aesthetic Surgery Journal

2015, Vol 35(4) 456–461
T-Shaped Excision of the Orbicularis Oris © Crown copyright 2015
DOI: 10.1093/asj/sju056
Muscle: An Innovative Technique for Upper www.aestheticsurgeryjournal.com

Lip Lift Procedures

Gan-lin Zhang, MD; Hong Meng, MD; Jian-hua Huang, MD;

Xiao-fang Hong, MD; and Hua-sheng Zhang, MD

Abstract
Background: The lips are a prominent part of the face and they age along with the face. Microsurgery for upper lip lifts is becoming popular because
of its association with minimal trauma and rapid recovery.
Objectives: The authors introduced an innovative method of lifting the upper lip.
Methods: From January 2009 to March 2013, a cohort of 30 women underwent an upper lip lift surgical procedure. Patients received local anesthesia
for a regional block of the infraorbital nerve. A T-shaped orbicularis oris and a strip of skin were excised. The superior edge of the orbicularis oris muscle
was sutured to the base of the nose, and the incision was closed with a continuous intradermal suture. Postoperative follow-up time ranged from 1 to
5 years.
Results: At the time of follow-up, the incisional scar was not visible on the patient. The nasolabial angle was 96.20° ± 1.86° before operation and
88.23° ± 2.58° after operation. The difference was statistically significant (P = 0.000 and P < 0.001). The upper lip angle was 65.56° ± 8.60° before opera-
tion and 51.90° ± 3.93° after operation. The difference was statistically significant (P = 0.000) and P < 0.001). After operation, the upper lip appeared to be
clearly thickened.
Conclusions: This innovative surgical technique is a simple and effective way to lift the upper lip.

Level of Evidence: 4

Accepted for publication September 8, 2014. Therapeutic

The face can be divided into thirds from the trichion to the
nasion, the nasion to the subnasale, and the subnasale to
the menton. The distance between the subnasale and the
menton defines the lower one-third of the face. The lips are
approximated through the location of the orbicularis oris.1
The lower one-third of the face significantly influences
facial appearance. The lower face must be adjusted to a
30% upper lip, 70% lower lip-chin proportion.2,3
The aging process induces several changes in the face,
including dyschromia, wrinkles, and folds. Because people
often associate full lips with a youthful appearance, aging
lips are perceived as less attractive. With aging, lips become
long and flat, lose prominence of the philtral columns,
show a reduction in thickness, and lose volume of the
vermilion border.4 As the lips lose volume, they lose their
original shape. As well, the ends of the upper lip tend to
droop, which is the main reason for the increased distance
between the subnasale and the upper lip and the decreased
nasolabial angle.5,6 These characteristics of aging can
appear on the lips of younger people, who then wish to
change their appearance.
Department of Plastic Surgery, HuiZhou Affiliated Hospital,
Sun Yat-sen University, Huizhou, China.
Corresponding Author:
Dr Gan-lin Zhang, E0 ling North Street, #41, Huicheng District
of Huizhou, Guangdong Province, 516000, China.
E-mail: ganlinzhang@163.com
Zhang et al
METHODS
Study Design
Approval for the trial was obtained from the ethics commit-
tee of Huizhou Municipal Central People Hospital. Each
patient was accepted the surgical consent.
From January 2009 to March 2013, 30 female patients
underwent an upper lip lift surgical procedure. Inclusion
criteria for the study included the following: (1) a long dis-
tance between the labiale superius and stomion; (2) a large
upper lip angle (50° to
60°); (3) patients aged younger
than 60 years; and (4) patient preference and request to
undergo the surgical procedure. Exclusion criteria included
the following: (1) higher expectations of the cosmetic
surgery than could be achieved; (2) aging characteristics
of the face that include not only the upper lip; and (3) pa-
tients aged older than 60 years. Patient fulfillment of
criteria was determined by preoperative consultation and
patient preference.
Surgical Technique
The surgeon performed our technique on patients who re-
ceived local anesthesia for a regional block of the infraorbital
nerve. If it were necessary, and dependent on patient prefer-
ence, intravenous sedation could have been administered.
Figure 1. (A) This is a schematic illustrating the region of excision of the orbicularis oris muscle. (B) An intraoperative photograph
of a 32-year-old woman who underwent excision of the orbicularis oris and the upper lip skin. Part of the orbicularis oris was
removed in a T shape. (C,D) Intraoperative photograph of the orbicularis oris sutured together. (E) Removed specimens of the orbi-
cularis oris and skin of the upper lip. (F) Immediate postoperative photograph.
457
The surgeon made a transverse incision at the basal fold
of the nose. The upper lip was dissected carefully between
a layer of skin and the orbicularis oris. The upper lip
was turned down to expose the orbicularis oris, which was
excised in a T shape (Figure 1). The orbicularis oris was re-
sected in a horizontal direction to shorten the height of the
upper lip and in the vertical direction to elevate the sagging
corners of the mouth. Although the effect in patients was
not as obvious as shown in the schematic, the technique
may have provided tension to the upper lip muscle
(Figure 2). A 3- to 5-mm strip of skin of the upper lip was
removed by the surgeon. The amount of skin excised de-
pended on the patient’s preferred thickness of the upper lip
(the distance between the labiale superius and the
stomion); and during the operation, the incisors were
allowed to show slightly. If the patient wanted to obtain
better protrusion of the vermilion border, a larger amount
of the lip skin was removed, and a smaller amount was
removed if the patient wanted less protrusion. The superior
edge of the orbicularis oris muscle after resection was
suspended and sutured to the base of the nose with inter-
rupted absorbable 5-0 Dexon (Covidien, Mansfield, MA)
sutures. The cephalad portion of the muscle was sutured to
complex tissue at the base of nose, including the nasal
spine, the depressor septi nasi, and the deep fascia . The in-
cision was closed with a continuous intradermal suture,
458 Aesthetic Surgery Journal 35(4)

Figure 2. (A) This schematic illustrates a T-shaped excision of the orbicularis oris muscle. (B) This schematic illustrates that a
T-shaped excision can elevate the corners of the mouth.

Figure 3. (A, C) This 35-year-old woman, dissatisfied with her upper lip, underwent excision of the orbicularis oris, and 4 mm of
upper lip skin was removed during the operation. The upper lip angle was 53° before operation and 48° postoperatively. (B, D)
Seventeen months after the operation, the philtrum was visible. The nasolabial angle was acute, but the change of the upper lip
angle was inconspicuous. Surgical scars were not obviously visible. The nasolabial angle was 72° before operation and 68° postop-
eratively. The distance between the labiale superius and the stomion changed from 5.0 mm to 6.2 mm after operation.
Zhang et al 459

Figure 4. (A, C) This 29-year-old woman with a congenitally aging lip underwent excision of the orbicularis oris, and 4 mm of
upper lip skin was excised. (B, D) Twenty-two months after surgery, the upper lip appeared full and the nasolabial and upper lip
angle became acute. Surgical scars were almost invisible.

Table 1. Comparison of Three Values Before and After Operation vermilion. We used Photo Measures (Big Blue Pixel Inc,
Annapolis, MD) software to measure the nasolabial angle
Value Before After t Value P Value
(n = 30) (n = 30) and the angle of the upper lip (Figure 3).

The nasolabial angle, 96.20 ± 1.86 88.23 ± 2.58 13.70 0.000

degrees Statistical Analysis
The upper lip angle, degrees 65.56 ± 8.60 51.90 ± 3.93 7.91 0.000 Statistical analysis was performed using SPSS Version 19.0
Vermilion height of the 5.34 ± 0.60 6.78 ± 0.71 11.22 0.000 (IBM Corp, Armonk, NY). The 2-tailed t test was applied to
upper lip, mm compare nasolabial angle, upper lip angle, and thickness of
the upper lip before and after operation. Statistical signifi-
Data are expressed as mean ± standard deviation.
cance was defined as P = .05.

using 5-0 absorbable material. It was essential for the RESULTS

surgeon to pay attention while suturing to reduce scarring.
Protocol for Measuring Distance
and Angles
We used a vernier caliper to measure the distance from
the labiale superius to the stomion, which is located on the
All 30 patients were women. The mean age was 33.2 ± 4.7
years (range, 29-54 years).
Postoperative follow-up time ranged from 1 to 5 years
(mean 1.7 ± 0.4 years). The nasolabial angle, the upper lip
angle, and the vermilion border height of patients are pre-
sented in Table 1. The nasolabial angle was 96.20 ± 1.86°
before operation and 88.23 ± 2.58° after operation. The
460
difference was statistically significant (P = 0.000, <0.001).
The upper lip angle was 65.56 ± 8.60° before operation
and 51.90 ± 3.93° after operation, and the difference was
statistically significant (P = 0.000, <0.001). The upper lip
was clearly thickened after operation (Figure 4).
In 3 of the 30 patients (10%), redness and swelling of
the incision occurred 2 to 3 days after the operation; but
dehiscence, bleeding, and hematoma did not occur in the
postoperative early phase. Most patients had scarring in the
early phase, but the scars became lighter and disappeared
around 2 to 3 months after the operation. In 2 of the 30 pa-
tients (6.7%), incisional scarring was noticeable from a
conversational distance at the time of long-term follow-up.
These patients underwent scar revision surgery and re-
ceived comprehensive postoperative treatment to prevent
additional scarring. Because of our innovative technique
and the quality of the sutures, no other complications
occurred.
DISCUSSION
The philtrum and the vermilion contour of the upper lip are
prominent and striking features of the face and make it dis-
tinct. In an Asian face, the philtrum and the bow of the
upper lip are prominent, the prolabium is short, the
angulus oris appears slightly elevated, and the lips are gen-
erally plump; these characteristics are regarded as attrac-
tive.7 Aging, however, causes the orbicularis oris to
become darker and sunken. As aging increases the distance
between the base of the columella and the Cupid’s bow,
the lips simultaneously decrease in volume and vertical
wrinkles appear. Additionally, the antigravitational support
of the orbicularis oris and facial ligament becomes weak,
which results in prolapsed ends of the upper lip.8
For treatment of an aging upper lip in patients, surgeons
traditionally have applied different techniques, including
lip augmentations using fat injections, acellular dermis
grafts, suspension sutures, and alloderm implants.9,10
Through these surgical procedures, surgeons aimed to
shorten the distance between the base of the columella and
the Cupid’s bow, augment the lip, and elevate the angulus
oris. The trend in facial rejuvenation during the past decade
has been toward the suspension suture technique. This is
suitable for a face aging in its entirety11 but unsuitable for
treating local deformities of the upper lip in a younger face.
In Weston et al’s report of their experience with lip lift
procedures, they excised the skin in the shape of a wavy
ellipse around the mouth, following the contour of the
aging skin in older patients.12 In contrast, we removed the
skin below the nasal sill and excised the orbicularis oris in
a T shape during the operation. The theoretical basis for
our T-shaped excision was based on the wide belief that
wrinkles are caused by sagging muscles.11,13 Peter et al
made a battlement-shaped skin excision under the nasal
Aesthetic Surgery Journal 35(4)
base to hide the incision inside the nasal cavity,14 and they
folded the orbicularis oris under the incision rather than
removing it. In a procedure done by Santanche et al, they
excised the excess skin of the upper lip in 2 separate pieces
and did not cut the nasal sill, which guaranteed the integri-
ty of the columellar area.7 Santanche et al also undermined
the skin from the columella and prolabium as far as the
Cupid’s bow and removed the cranial part of the orbicularis
oris muscle. We found this method to be similar to ours.
Through our experience and follow-up results, we found
that the undermining technique was not detrimental to the
skin and did not flatten the philtral columns.
Our innovative technique hides the scar under the fold
of the nasal base and strengthens the force of the orbicula-
ris oris. A transverse resection of the muscle elevates the 2
ends of the upper lip and decreases the upper lip angle.
Removal of the lip skin and muscle shortens the longitudi-
nal distance between the base of the columella and the
Cupid’s bow. Excising the muscle vertically and not excis-
ing the surface skin projects the philtrum, causing the
philtral groove to become visible. Although elevating the
corners of the mouth with this method is limited, it decreases
the upper lip angle through shortening the height of the
upper lip. A slight protrusion of the upper vermilion border
causes the lip to appear plump and therefore attractive.
In our experience, the limitation of our surgical procedure
was its unsuitability for older patients. Our technique must
be combined with other techniques if used for older patients.
Additionally, during the early phase after operation, the sur-
gical scar appeared more obvious in some patients.
CONCLUSIONS
Our T-shaped excision of the orbicularis oris muscle was
characteristically different from the other reported
methods. By excising the muscle vertically and not excising
the surface skin, we projected the philtrum, causing the
philtral groove to become visible. Though our ability to
elevate the corners of the mouth was limited, decreasing
the upper angle diminished the effect of aging. Because of
our innovative technique and the quality of the sutures, no
serious complications occurred.
Disclosures
The authors declared no conflicts of interest with respect to the
research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
Zhang et al 461

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