Cosmetic Medicine

Aesthetic Surgery Journal Open Forum

Introduction of the Lip Classification of 2023, 1–5

© The Author(s) 2023. Published by
Oxford University Press on behalf of the
Tubercles: A Novel Approach to Minimally Aesthetic Society.
This is an Open Access article

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Invasive Aesthetic Lip Treatments distributed under the terms of the
Creative Commons Attribution-
NonCommercial License (https://
creativecommons.org/licenses/by-nc/4.
0/), which permits non-commercial re-
use, distribution, and reproduction in any
Steven Harris, MBBCh, MSc; Michael Alfertshofer, MD ; Rory Allen, PhD; medium, provided the original work is
Fabrizio Castellari, BDS; Don Othoro, MBChB; Greg Bran, MD, PhD; properly cited. For commercial re-use,
please contact
and Sebastian Cotofana, MD, PhD journals.permissions@oup.com
https://doi.org/10.1093/asjof/ojad007
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Abstract
Background: Lip enhancement procedures involving dermal fillers are one of the most sought after nonsurgical aesthetic
treatments. However, current trends are associated with unnatural results and involve increased risks of complications and
compromise to normal function. It appears that lips may be classified according to the presentation of their tubercles and
this may be used to guide minimally invasive techniques which aim to preserve individual lip shapes and normal function.
Objectives: To test the reliability of a classification system based on lip tubercle morphology, named the Lip Classification
of Tubercles (LCT).
Methods: To test the reliability of the LCT, a total of 214 high-definition photographs of patients’ lips with no previous his­
tories of lip treatments were classified independently by 4 experienced aesthetic practitioners on 2 separate occasions
3 months apart; the second followed a more detailed explanation of the classification.
Results: When inter-rater reliability was calculated for the first attempt, the results were 36% and 43% for upper and lower
lips, respectively. The second attempt following an education process resulted in 79% for both lips. When 1 practitioner was
considered the standard, the average score for the remaining 3 showed some individual variation but improved signifi­
cantly from 58% to 85%.
Conclusions: The LCT is a reliable way to classify lip types based on the morphology of tubercles.

Level of Evidence: 3

Editorial Decision date: January 18, 2023; online publish-ahead-of-print March 15, 2023. Diagnostic

UK. Dr Cotofana is an associate professor of anatomy, Department of

Drs Harris and Othoro are physicians in private practice in London, UK.
Dr Alfertshofer is a physician, Division of Hand, Plastic and Aesthetic
Surgery, Ludwig-Maximilians-University Munich, Germany. Dr Allen is
an associate lecturer, Department of Psychology, Goldsmiths,
University of London, UK. Dr Castellari is a dentist in private practice in
London, UK. Dr Bran is a plastic surgeon in private practice in London,
Clinical Anatomy, Mayo Clinic College of Medicine and Science,
Rochester, MN, USA.
Corresponding Author:
Dr Steven Harris, 48 Crouch Hall Road, London N8 8HJ, UK.
E-mail: steveharris001@icloud.com; Instagram: drharrisclinic
2 Aesthetic Surgery Journal Open Forum
Lips are a central feature of facial aesthetics as they play an
essential role in facial expression, phonation, sensation,
mastication, physical attraction, and intimacy.1 Since early
recorded history full lips in females have been associated
with youth, beauty, and voluptuousness.2 It is no surprise
then that lip enhancement is one of the most frequently re­
quested nonsurgical procedures.3 A number of studies
have evaluated lip positions and shape based on cephalo­
metric analysis and facial dimensions.4-7 However, the mor­
phological features of lips vary greatly between individuals
according to age, sex, and ethnicity.8-11 A significant aspect
of lip morphology is the lip tubercles—embryological rem­
nants of development which appear as dermal projections
in both the upper and lower lips.
To help identify different lip types based on shape (tuber­
cle morphology), a classification system was developed,
the embryological Lip Classification of Tubercles (LCT).
The LCT describes a pattern of 4 tubercle presentations
based on their number, size, and position in the mid-third
of the upper and lower lips, denoted the Letters A-D and
E-H, respectively, for a total of 16 different morphological
types (Figure 1). While the LCT has been used to classify
and guide lip enhancements by one of the authors, this
has never been formally tested for reliability.
METHODS
A total of n = 214 subjects were randomly selected from a
patient population of an aesthetic clinic in North London,
England. Written consent was provided, by which the pa­
tients agreed to the use and analysis of their data. This
study was performed in adherence to the Declaration of
Helsinki (1996), and in accordance with regional laws and
good clinical practice for studies in human subjects.
Participants were excluded if they had any previous aes­
thetic treatment (surgical and/or nonsurgical) which could
affect the shape of their lips; these would include proce­
dures such as a face lift or previous lower face (including
lips) minimally invasive procedures (including Botulinum
Toxin Type A injections in the last 6 months or if they
ever had dermal fillers). Patient photographs were taken
close up—30 cm in front of the patient with focus on the
lips using a wide lens 28 mm (aperture f1.80 of an iPhone
8 HD camera). The patient’s photographs (frontal view of
the face at rest) were used to only identify their lower third
from pronasale to menton. All 214 photos were distributed
to each of the panel of experts for classification of the pre­
senting lips using the LCT chart (Figure 1). A 10-min descrip­
tion of the classification was first introduced to each panel
member. The didactic explanation included lip embryology
—how tubercles form in both the upper and lower lips and
the different tubercle patterns in the LCT chart including
how to identify and classify them by focusing on the mid-
third of the (upper and lower) lips. Each panel member
was then asked to classify each of the lips in the photo­
graphs using the LCT chart. The same task was repeated
after 3 months, but this involved a longer 20-min explana­
tion which included testing using 20 specific examples in a
more socratic approach.
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RESULTS
The n = 214 subjects consisted of 173 females and 41 males
(female/male ratio = 4.2:1) with an average age of 39 ±
10.4 years (range: 18-68 years). The majority of patients
were Caucasian (n = 151), followed by Indian (n = 26), Black
(n = 25), and Asian Chinese (n = 12).
The average follow-up time between the 2 expert mea­
surement sets was 94 days (range: 91-100 days). The data
were analyzed separately for the 2-task completion at­
tempts, and reliability scores were calculated for each at­
tempt. This analysis would show whether the initial 10-min
presentation was sufficient to ensure accuracy, or whether
the more extended 20-min presentation led to a significant
and desirable improvement in performance on the part of
the experts. In each case, separate measures were calculat­
ed for upper and lower lips to check consistency.
Two measures were taken of reliability in the judgments
of lip type. It was assumed that since one of the panel of ex­
perts was the person responsible for the classification de­
sign, his decision could be taken in all cases as the
“correct” assignment. The measures therefore calibrated
the degree to which the other 3 experts agreed with his
decisions.
The first measure calculated the percentage of subjects
for which the 3 experts all obtained the same, correct as­
signment. A high score on this measure would suggest
that the method had good reliability, with the effect of indi­
vidual differences between expert judgments being negli­
gible. Since there is a possibility for judgments to be
correct purely by chance, a correction was applied
(Cohen’s kappa) to allow for this. It should be noted that
the same calculation would be carried out without the as­
sumption that 1 expert was “correct,” giving the identical re­
sult, but in this case, the result can be conventionally
interpreted as a measure of inter-rater reliability.
Analysis of First Data Set
Analysis of the data from the first task completion trial gave
figures of 36.4% for the upper lip and 43.0% for the lower lip
evaluations. Since these figures were well below accept­
able levels, a second set of reliability measures was calcu­
lated comparing each of the 3 experts with the “correct”
judgment. This time, again applying Cohen’s kappa, the re­
sults were 52%, 47.7%, and 59.5% for the upper lip, and
Harris et al 3

A B C D

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E F G H

Figure 1. The Embryological Classification of Tubercles (LCT). Panels A-D show the upper lip pattern and E-H show the lower lip
pattern. With respect to the upper lip, (A) Type 1, shown in a 26-year-old female, represents a single large middle tubercle
occupying the full mid-third; (B) Type 2, shown in a 35-year-old female, represents a small middle tubercle occupying less than the
mid-third; (C) Type 3, shown in a 27-year-old female, has an inverted tubercle; and (D) Type 4, shown in a 53-year-old female, is flat.
With respect to the lower lip, (E) Type A, shown in a 33-year-old female, is represented by a central indentation. (F) Type B, shown
in a 31-year-old female, has no central indentation and is full but level. (G) Type C, shown in a 30-year-old female, has no central
indentation and curves upward with more fullness and Type B. (H) Type D, shown in a 49-year-old female, is flat.

62%, 49.5%, and 78.2% for the lower lip, across the 3 ex­
perts. These showed some apparent difference between
lips, but the profile of scores across the 3 experts was
similar.
Averaging across upper and lower lips gave scores
of 57%, 48.6%, and 68.8%. Since the standard devia­
tion for the difference between 2 percentage scores
in this case is around 3.3% (normal approximation to
the binomial distribution for 428 trials), the 3 experts
differed substantially in the accuracy of their judg­
ments. The average corrected score over the 3 ex­
perts was 58.2%.
Analysis of Second Data Set
The second analysis was performed for the task that was
completed after the second training session. The data
showed that all 3 experts agreed with one another and
with the correct classification on 78.6% of occasions, the
scores for upper and lower lips being identical. When the
performance of individual experts was analyzed, averaged
across upper and lower lips, the scores were 79.4%, 84.7%,
and 90.3% respectively, with an average of 84.8%. The raw
scores in the absence of a guessing correction averaged
88.9%. Although the scoring profiles of the experts showed
some variation across the 3, the differences did not achieve
statistical significance. The improvement from 58.2% to
84.8% between the first and second trials (26.6%) was high­
ly statistically significant.
DISCUSSION
The LCT was developed by the first author of this study
5 years ago after recognizing that lip morphology may be
characterized by the presentation of tubercles. The minimally
invasive technique he invented termed the Nonsurgical Lip
Tubercle Technique (NLTT) focuses on the enhancement of
tubercles to preserve individual lip shapes along with normal
lip function (Figure 2). In addition to playing a central role in lip
morphology, it is likely that tubercles facilitate complex move­
ments of the mouth by gathering extra surface area in much
the same way as the philtral columns.12-15
The LCT was developed earlier on to classify the mor­
phology of lip types based on an understanding of embryol­
ogy. Lip development begins at gestational week 4 with the
appearance of the frontonasal prominence and the maxil­
lary and mandibular prominences. A series of steps involv­
ing extension and fusion of the prominences leads to
formation of the external face, including the lips. While the
4 Aesthetic Surgery Journal Open Forum
A B
C D
Figure 2. The lips of a 28-year-old female patient shown (A, C)
before and (B, D) after lips using the Nonsurgical Lip Tubercle
Technique (NLTT). A total of 0.3 mL hyaluronic acid (HA) filler
was used for this patient’s lips (Type 1A).
basic steps are common to all humans, the degree and ex­
tent of fusion of the prominences determine the appear­
ance of the tubercles and their different presentations
represented in the LCT. For the upper lip, a median tubercle
is absent in a cleft lip when the medial nasal prominence and
maxillary prominence fail to fuse. As part of normal develop­
ment varying degrees of fusion may appear as partial (an in­
verted median tubercle in the mid-third), more complete (a
small upper tubercle in the mid-third), or complete (a large
central tubercle occupying the mid-third). In the lower lip, fu­
sion of the mandibular processes may be partial with a cen­
tral indentation, more fused with no central indentation, or
completely fused with a mid-third central prominence.
With age and thinning of all the anatomical layers of the lips,
the tubercles themselves may appear flattened in the upper
lip and/or the lower lip. When the lips are flattened, the goal
of lip enhancement may be for a greater dry vermillion expo­
sure which may be achieved most safely and effectively with
the use of a cannula; the aim of treatment would not be to cre­
ate tubercles where there are none, but to work with an un­
derstanding and respect of the presenting anatomy. When
the patient does present with tubercles (the majority of cases),
the LCT helps to classify the lip type and can act as a guide to
enhance the presenting shape in keeping with the individu­
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al’s lip type while maintaining normal lip function.
To our knowledge, the LCT is the first lip classification of
its kind based solely on the morphological presentation of
tubercles. It provides an easy to learn classification system
which is both reliable and practical for aesthetic practitioners
who want to adopt procedures to enhance lips by focusing
on the lip tubercles in order to maintain individual lip types
and normal lip function. The results based on a large sample
of 214 provided good statistical power; the testing involving
4 examiners on 2 separate occasions spaced 3 months
apart showed a highly significant improvement in reliability
on the second test following a 20-min training session.
Therefore, it is imperative that the practitioner undergoes
the appropriate training before adopting the LCT. While
our test sample was large and included a wide range of
ages, different ethnicities and genders, most of the partici­
pants were young Caucasian females. Greater representa­
tions for age, ethnicity, and gender would have been
desirable to improve reliability. A larger number of examin­
ers with more training and testing could have further opti­
mized the inter- and intrarater scores. Other limitations are
that the scale itself does not take into account the different
presentations of philtrums (such as length) which are an in­
tegral part of the upper lip, or indeed the actual vermillion
border which has variable presentations. While the authors
agree upon the natural aesthetic outcome of the NLTT, fu­
ture studies utilizing the LCT classification in treating pa­
tients with the NLTT will be evaluated.
CONCLUSIONS
Not withstanding these limitations, the LCT provides a sim­
ple, reliable, and practical way for aesthetic practitioners to
assess vermillion lip shapes and can act as a guide to en­
hance them in keeping with normal anatomy and
physiology.
Disclosures
The authors declared no potential conflicts of interest with re­
spect 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, including payment
of the article processing charge.
Harris et al
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