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CUPID Lip Lift: Advanced Lip Design Using the Deep
Plane Upper Lip Lift and Simplified Corner Lift
Benjamin Talei, MD, Steven J Pearlman, MD
@

Facial Surgery

Aesthetic Surgery Journal

2022, Vol 42(12) 1357–1373
CUPID Lip Lift: Advanced Lip Design Using © The Author(s) 2022. Published
by Oxford University Press on behalf
the Deep Plane Upper Lip Lift and Simplified of The Aesthetic Society. All rights
reserved. For permissions, please
Corner Lift e-mail: [email protected]

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https://doi.org/10.1093/asj/sjac126
www.aestheticsurgeryjournal.com

Benjamin Talei, MD ; and Steven J. Pearlman, MD

Abstract
Background:  Upper lip lift is achieved with a variety of techniques but many questions remain about the benefits and
drawbacks of each technique. The CUPID deep plane or modified upper lip lift procedure has recently been introduced to
help mitigate risk and optimize outcomes. 
Objectives:  The aims of this study were: (1) to better characterize and simplify the complex and artistic decision-making
process involved in upper lip lift and corner lip lift; (2) to present a mathematical guide to maintain the natural balance of
the upper lip, optimizing muscle function, and to indicate when to add a corner lift; and (3) to elucidate design elements,
aging, and future treatment considerations.
Methods:  A PubMed (United States National Library of Medicine, Bethesda, MD) search was performed in October 2021 for all
journal articles published on upper lip lift and corner lip lifts. The search covered from 1950 to the present day in all languages
and without exclusion criteria. Outcomes and the evolution of deep plane upper lip lift design over the last 6 years were analyzed.
Results:  By following the patterns demonstrated in over 2440 consecutive lip lifts, the authors have been better able to
understand the nuances involved in proper design that will avoid acceleration of aging and exaggeration of appearance,
and reduce the need for revision while maximizing results.
Conclusions:  Upper lip lift design is more complex than most practitioners realize. The mathematical concept described
herein makes it possible to obtain more aesthetically pleasing and consistent outcomes. This novel approach to lip lift
design enables the practitioner to improve lip balance, facial harmony, and tooth show, and obtain adequate exposure of
the lateral vermillion.

Level of Evidence: 4  

Editorial Decision date: May 6, 2022; online publish-ahead-of-print May 18, 2022.

Deep plane upper lip lift performed according to the CUPID technique, the popularity and demand for lip lifting as a
lip lift design described in this paper is a powerful pro- whole has increased substantially over the past 6 years for
cedure that has significant aesthetic impact. This simple both young and older patients.
surgery has the ability to restore youth, sensuality, and bal-
ance to the entire face with natural and reproducible re-
Dr Talei is a facial plastic surgeon in private practice, Beverly
sults, regardless of the patient’s gender, color, skin type, or Hills, CA, USA. Dr Pearlman is an associate clinical professor of
age.1 Upper lip lifting has been described in the literature otolaryngology/head and neck surgery, Columbia University, New
for 4 decades; 2 however, the majority of techniques have York, NY, USA.
a high rate of dissatisfaction. For this reason, the upper
Corresponding Author:
lip lift procedure has classically been reserved for older, Dr Benjamin Talei, 465 N Roxbury Drive, Suite 750, Beverly Hills, CA
lighter, thin-skinned patients with significant skin wrin- 90210, USA.
kles. Coincident with the development of the deep plane E-mail: [email protected]; Instagram: @drbentalei
1358 Aesthetic Surgery Journal 42(12)

Along with the rise in surgical numbers, we have also 3. Easy and proper mouth closure
noticed an increase in complications and revision surgery 4. A gentle slope along the vermillion border from medial
for procedures performed elsewhere. Although a substan- to lateral
tial percentage of secondary cases are performed to fix is- 5. Adequate exposure of the red vermillion along its en-
sues with scarring, a large subset is to treat asymmetry, lip tire length along with sufficient volume
imbalance, poor function, and an unnatural or exaggerated 6. Alleviation of angular depression or buried vermillion
appearance. Detailed descriptions of anatomy and func- at the corner of the mouth
tion with relation to aging and dentition are lacking. There 7. A smooth, continuous internal arc of the lip along the
is also a lack of consistency in nomenclature, adding to wet-dry border.

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confusion about this procedure. This article seeks to eluci- 8. Symmetry at the Cupid’s bow peaks (lateral symmetry
date and quantify the artistic nature of surgical lip design is neither possible nor helpful in many cases)
to help produce more consistent elegant, balanced, and 9. Appropriate anterior projection on lateral view
natural results, while decreasing the likelihood of patients 10. Appropriate vertical slope on lateral view.
requiring revision. Moreover, a more natural and anatom-
ically correct result generally will function more appro-
priately and age better. All too often, patients have been Patient Selection
mismanaged or dismissed due to an inability to appropri-
ately address an elongated upper lip, dental hooding, and A deep plane upper lip lift performed according to the
loss or lack of an elegant Cupid’s bow. Like blepharoptosis, CUPID lift design is a very precise procedure that can
upper labial ptosis may have substantial functional and be performed in a predictable and consistent manner to
aesthetic implications on the face that affect a patient’s ap- shorten the height of the philtrum with or without altering
pearance and function. tooth show to any significant extent. Pre-existing adequate
upper incisor display is not a contraindication, although ex-
cessive display, perioral strain, or vertical maxillary excess
METHODS certainly are. Many of the patients seeking this procedure
simply have an elongated appearance to the midface or
A retrospective review of 2440 consecutive lip lift patients
perioral region. Lack of central incisor show may cause
in the primary author’s (B.T.) practice was performed from
patients to look older and/or lose sensuality. Shortening
November 2014 through September 2021. Follow up on
lip height may improve the balance of the entire face for
patients was performed for a minimum of 3 months. No ex-
appropriate candidates and improve appearance and sen-
clusion criteria were used. Secondary surgeries, those per-
suality.3-6 The surgeon must recognize the necessary bal-
formed initially by other surgeons, constituted 220 of these
ance between the bony skeleton and soft tissue envelope.
cases (11%). Prior to 2019, the primary author infrequently
There are functional and aesthetic ratios that must be re-
performed corner lip lifts as described in a prior publica-
spected.3 Excessive shortening of the upper lip may cause
tion.1 Since that publication and with initiation of the CUPID
strain in the facial musculature and give a predominantly
lip design, unilateral or bilateral corner lip lifts have been
skeletal appearance. The goal is to create a softer appear-
incorporated in roughly 90% of cases. We believe this has
ance with better facial harmony. Exposure of unsightly
resulted in substantially improved outcomes. All research
teeth could also detract from the patient’s physiognomy.
was retrospective and no experimental studies were per-
Elongated upper lips tend to have poorer function with
formed on patients, in accordance with the Declaration of
increased flaccidity at rest as well as increased strain with
Helsinki.
smiling. It is at the discretion of the practitioner to decide
Reviewing failures in the primary author’s patients along
whether the lack of tooth show should be treated with
with the results of other surgeons aided in the evolution
orthognathic, dental, or lip lifting procedures.7 Similar
of this technique and the development a more systematic
to orbicularis oris function, the orbicularis oculi and sur-
approach and design for the upper lip. Although this article
rounding musculature require adequate support from the
delineates some ideal aesthetics, it is important to keep in
eye. Enophthalmos and exophthalmos have profound ef-
mind that our patients’ lips are not all meant to look alike.
fects on eyelid closure and position. A  lip or any portion
We should simply strive to improve upon their already ex-
of the lip that is not supported appropriately by teeth
isting attributes.
cannot function well given the anatomy and dynamic of
The most desirable appearance seemed to come from
the orbicularis oris and perioral musculature. This is quite
a combination of attributes:
evident when dentures are removed from a patient’s
1. Proportionate lip height to width and the surrounding mouth and the lip becomes flaccid with poor movement
structures and entire face and impaired phonation. Conversely, excess prominence
2. Adequate incisor display of dentition may cause labial incompetence and poor
Talei and Pearlman 1359

mouth closure in repose. Be aware that patients with ex- Subnasal upper lip lift should be avoided in patients with
cessive alveolar-dental prominence tend to age more rap- severe angular depression of the mouth, although corner
idly around the mouth. Gummy smiles are more common in lifting may be performed.
these patients although many factors must be considered Surgeons generally question the safety of performing
with regard to diagnosis and treatment.8 The deep plane an upper lip lift at the same time as a rhinoplasty. In most
upper lip lift commonly decreases the gummy smile by cases this is safe, and we advise making a classic subnasal
mitigating strain with smiling. Upon examination, a lower lip lift incision that is distinct and performed simultaneously
lip raising reflex may be noted in some patients when the with the classic midcolumellar rhinoplasty incision.10 Blood
upper lip is raised manually on examination. Over time, supply to all areas should be adequate unless multiple re-

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the mentalis and labial depressors begin to hyperfunction visions have been performed or if nasal base suspension
in order to push the lower lip up towards the upper lip to sutures are placed that may constrict the blood supply.
achieve closure. With age, this may result in “peau du or- Only minor sill-excision alarplasty may be performed at
ange” or pebbling of the chin and a depression or down- the same time. If more substantial alarplasty or nasal base
turn along the oral commissure correlating with depressor narrowing is required, we recommend performing the pro-
anguli oris hypercontracture. cedures at least 3 months apart to avoid effacement of the
This problem has become rampant as some less- nasolabial creases or scarring. We mostly prefer to perform
experienced dental practitioners have become increas- the procedures separately to gain greater predictability in
ingly aggressive in treating patients by applying oversized the final alar sill position and shape.
veneers. To achieve appropriate incisor display, dentists
might overlook soft tissue ptosis of the lip and add veneers
The Effect of Lip Filler
to lengthen and project the upper teeth.9 This may drag
and lengthen the appearance of the midface, ultimately The presence of temporary or permanent fillers must
having a prominent effect on phonation and may even lead be considered and properly planned for. An increas-
to xerostomia. It is of utmost importance for surgeons, den- ingly common reason why patients seek a lip lift is that
tists, and orthognathic surgeons to collaborate to avoid lip fillers have weighed down and expanded the lip.
these issues. Generally, if the patient requires dental pro- Fillers may also cause impairment in muscle function and
jection or lengthening, the lip lift is performed first and is flexion of the orbicularis oris muscle. This is most com-
succeeded by maxillary or dental work 3 or more months monly seen when a hyaluronic acid (HA) filler is injected
later. Conversely, if de-projection or shortening are re- directly along the vermillion border. The filler immediately
quired, it may be easier to have the dental, orthodontic, spreads and crosses the vermillion because the lamina
or orthognathic procedures performed first, and the lip lift propria is a direct extension of the philtral superficial
performed after the soft tissues have settled into their new musculoaponeurotic system (SMAS). The rheology and
position. potential for each filler to migrate differs. The cross-linking
Pre-existing exaggerations in appearance may easily and characteristics of each filler may also change over
become more pronounced during a lip lift. Patients with several years in soft tissues. The most aggressive form of
upturned noses have historically been denied this proce- migration amongst HA fillers likely occurs with Juvéderm
dure, although this is not a contraindication. When per- Ultra or Ultra Plus (Allergan; Irvine, CA). This particular
formed properly, the incision will be barely visible, making product can carry a greater volume of water, may change
patients of all nose types appropriate candidates. The cen- the color of the philtrum or vermillion, and has a greater
tral lip tends to lift to a greater extent than the lateral lip. In migratory potential than other HA products. Moving out
patients with an exaggerated upturn to the central lip or a of an overpressure closed system in the dry vermillion,
short mouth, the practitioner must either take this into ac- the HA migrates with muscular contracture and lymphatic
count during incision design or avoid operating on these drainage patterns. The fillers tend to migrate in a cephalic
patients all together. Asian patients in particular tend to ex- direction above the vermillion border in the plane of the
aggerate centrally very easily. Some Asian patients dem- SMAS. Juvéderm may travel up to 10  mm and last over
onstrate a naturally steep vermillion slope, whereas others 10 years, whereas other HA fillers may move caudally 1 to
may have a narrow nasal base with poor lateral lip support. 2 mm according to our observations. Top-down injection
Caution must also be taken in patients demonstrating an techniques and direct injection of the vermillion and wet-
exaggerated downturn at the lateral mouth and commis- dry border are avoided in most patients. Filler migration
sure. A lip lift can exacerbate the appearance of a down- may be identified on examination as there is typically a
pointing mouth. To improve the results of a lip lift, certain bulge of swelling in the philtrum directly above the vermil-
patients may be treated with a concomitant corner lip lift, lion, which is white or crystalline in nature. Vascular blush,
neurotoxin injections into the depressors, volumization of blotchiness, and hyperemia may also be present along
the triangle inferior to the commissure, or even a facelift. the vermillion border, which can also blunt lip definition.
 
1360 Aesthetic Surgery Journal 42(12)

Misplaced filler can be dissolved with hyaluronidase. If Anatomy and Nomenclature

migrated filler is not identified above the vermillion or in
the philtrum prior to dissolving, incomplete dissolution will In this section we will introduce a novel marking system,
result. Dissolving filler can restore function to the upper CUPID, to aid in the design needed for lip lift surgery. Using
lip by the next day and obviate the need for a lip lift in a proper deep plane release, each radial marking line indi-
some patients. It also decreases postoperative edema vidually gains the ability to control the lip shape in the way
that would have been caused by the presence of hydro- that a puppeteer controls a marionette to raise an elbow
philic fillers. Dissolving is typically performed at least 2 while dropping a hand. This allows the surgeon to enhance
weeks before the lip lift procedure to allow rehydration the shape and slope of the vermillion, while avoiding ex-

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of the SMAS. Once dissolved, some filler may have to be aggeration during lip lifting. Changing the shape, slope,
replaced to plump a collapsed SMAS layer. or curve of the vermillion border can change the char-
Dissolving the filler may also change the soft tissue acter of the patient’s appearance substantially. The classic
character internally, making dissection more difficult as subnasal lip lift inherently lifts the portions of the lip directly
the usually easy dissection plane becomes more adherent under the nose to a substantially greater degree than the
and the thin SMAS becomes more difficult to suture to. lip segments lateral to this. The CUPID deep plane lip lift de-
Dissolving may variably give the upper lip a darkened ap- sign uses a rotational advancement of lip skin towards the
pearance in the skin of the philtrum—the opposite of the nose that is hinged around the apex of the incision at
white glare produced with inappropriate fillers. It may also the lateral ala. Examining the radial markings used to aid
exaggerate indentations in the lip at the end of the lip lift the advancement reveals that the medial markings will ex-
procedure and minor aliquots of HA filler may need to be perience more of an effective vertical lift than the lateral
replenished at this point. If deflation from dissolver occurs radial markings, which have a more diagonal vector. The
in the red vermillion, it may assume a burned, dry, or scaly vector of aging in the upper lip appears to follow the same
appearance until rehydration occurs naturally or with fur- course as the relaxed skin tension lines (RSTLs), drooping
ther HA filler placement. around the upper alveolus. Aging is more exaggerated
The SMAS of the upper lip is the main support mech- laterally in the subfacial lip with a greater degree of re-
anism for the youthful appearance of the skin apart from sistance to ptosis in the midline under the subnasal lip.
the volume contributed by the orbicularis oris muscle it- The appropriate vector of lifting should be performed in
self. The SMAS layer tends to thin with age, worsening the opposite direction to these aging changes to obtain
the appearance of rhytids in the upper lip. This may be a balanced result without redundancies and imbalance.
exaggerated substantially following the dissolution of HA The nasal base and lip may both possess asymmetries, so
fillers. Human leukocyte antigen dissolvers might damage symmetry can be improved by varying the excision design
the naturally occurring human leukocyte antigens in the from side to side. Excessive alterations in design and sym-
SMAS and this layer may lose its fluid-retaining capacity metry may adversely affect the orbicularis muscle function,
temporarily or permanently. The adverse effects from dis- although the limits are difficult to determine.
solver are more notable in SMAS or tissues that have al- For appropriate and thorough lip design, we require
ready been damaged by overexpansion from fillers. The 7 radial markings correlating to 3 different points from
microcystic expansion effect of fillers may have unpredict- nose to lip (Figure 1). Level 1 is the upper limb of the in-
able consequences in the SMAS and soft tissues. The sulci cision; Level 2 is the lower limb of the incision, and Level
laborum, or vertical wrinkles, in the red dry vermillion typi- 3 travels along the vermillion border at correlating points.
cally return following dissolution of fillers. We must remind Guiding lines progress from vertical at the midline point of
patients that this is natural, desirable, and as important as the Cupid’s bow trough, with gradual radial rotation later-
having fingerprints. Occasionally rehydration is required, ally towards the angle of the nasolabial fold, following the
which can be addressed with a gentle refilling of the lip. lip’s natural relaxed tension lines and pores. The RSTLs in
Dissolution with hyaluronidase should be avoided in pa- the perioral region are organized in an increasingly curved
tients with silicone hypertrophy or fat grafting. This will manner as they extend laterally and inferiorly to the man-
shrink and damage the healthy SMAS layer, while leaving dible. Figure 2A,B demonstrates what we refer to as the
the scar, fat, or granulation bed intact. Injection of fat into “RSTL globe.”
the upper lip has a high probability of vertical migration The initial marking line in the middle of the columella
within or deep to the SMAS near the vermillion border. and philtral dimple is designated by the letter “C” for “cen-
This may be addressed during a deep plane lip lift surgery. tral” (Figure 3). The paramedian lines are marked at the
Postoperatively, fillers may have to be replaced to return peak of the subnasal incision just lateral to the columella
to a normally appearing and functioning lip, although ir- at the point where the medial crural footplates diverge into
regularities from dissolvers may persist for several years the nose at the junction with the alar sill. The designation
in some patients. for this point is the letter “P” representing the peak of the
Talei and Pearlman 1361

is also prominent medial to the “D” line along the subnasal

lip and peters off past the “D” line where a corner lift can
be performed without scarring or effacement of the vermil-
lion roll. Fillers also have a greater lifting or eversion effect
in the vermillion of the subnasal lip relative to the subfacial
lip, which is very difficult to evert or lift with fillers. Of note,
there is often a muscular indentation present lateral to the
junction of the subnasal and subfacial and the “D” line. This
represents the transition from orbicularis towards the con-

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nections of the buccinator and upper lip levator muscles.
Between the “P” mark and the “D” mark another line is
drawn, called the intermediate line or “I” marking. Note that
the markings from central to lateral spell out “CPID,” giving
our nomenclature for the CUPID lift (Figure 3). Lateral to
the diagonal line, an outer horizontal marking “O” may
Figure 1.  Three horizontal levels drawn on a 38-year-old be placed as a reminder to place the lateral internal mat-
female to determine the excision height and residual or final
tress sutures, which will be explained later and have been
height of the lip. The relaxed skin tension lines guide the
vector of lifting and the final shape of the lip. described previously.1 This line also helps determine the
height of the corner lift. Each side of the lip carries a left
incision and the peak of the Cupid’s bow. “P” also refers to or right designation noted by the letters “L” or “R.” The ex-
the paramedian line and philtral line. Inferiorly, the philtral cised height will be referred to as the “excision height,”
column terminates exactly at the peak of the Cupid’s bow. whereas the remaining height of the philtrum following ex-
Superiorly, the philtral column does not always terminate cision and closure will be referred to as the “final height.”
at the peak of the upper limb incision. It is important to note When performing the CUPID deep plane lip lift tech-
that certain variations of the “bull’s horn” technique place nique, these markings can be used to customize lip de-
the peak inside the middle of the alar sill. This causes an in- sign and improve the character and accent of lips rather
herent deformity at the nasal base and we advise strongly than just lifting them in a uniform, cookie-cutter fashion.
against placement of the incision inside the nose. Invasion This allows for a more balanced lift, improvement in char-
of the nasal subunit with labial skin may cause rhinorrhea, acter, and avoidance of overlifted or overexaggerated lips,
a skeletonized appearance, or more exaggerated ptosis which will yield a more attractive result and will also age
of the nasal base postoperatively. The alar sill and nasal better. This also allows the surgeon to obtain more sym-
base should be kept as an intact anatomic subunit and metry not only in height but in shape and character of each
never crossed or violated. Laterally, a line is drawn from side as well.
the internal angle of the alar recurvature, extending radi- There are 2 slopes to consider when analyzing the lip.
ally down the natural curvature of the lip. This diagonal line The first is the slope of the philtrum seen in lateral or pro-
is designated by the letter “D” and can be placed by fol- file view (Supplemental Figure 1A). This has been detailed
lowing the natural tension lines and radial angulation of the in our previous article, demonstrating the descent of the lip
pores of the upper lip. from the nose on the lateral view, where various curvatures
This diagonal line determines the lateral extent of the lift may be noted. The second is the slope of the vermillion
effect on the upper lip caused by a subnasal upper lip lift. border from the anterior view (Supplemental Figure 1B).
The “D” line also marks the border between the subnasal Analysis of the slope and shape of the vermillion border
lip as it transitions to the subfacial lip (Figure 4A,B). The are novel and important concepts being introduced in this
differentiation between the subnasal and subfacial lip is article. The slope of the vermillion can be observed as the
a novel concept being introduced in this article and will natural vertical descent of the lip from the Cupid’s peak
be of utmost importance to surgeons and injectors when following laterally towards the oral commissure on frontal
learning about aging of the lip and the effect of surgery and view. When designing a lip, great care must be taken to
injectables on various parts of the upper lip. The majority avoid any exaggeration of slope. Although beautiful lips
of patients will experience a greater degree of aging in the with exaggerated slopes occur in nature, we must be cau-
subfacial lip and lateral mouth, which is hanging from the tious never to form one iatrogenically because the face will
anterior cheek and face, relative to the central subnasal lip, not tolerate it. We have found that a pleasant and balanced
which is more densely attached to the pyriform and sup- iatrogenic slope ranges around a final height difference of
ported by the front teeth. The subnasal lip lift inherently 2 mm between points “P,” “I,” and “D” from the anterior view
has more of an effect on the subnasal lip between the bilat- (Figure 3B). Similarly, the trough of the Cupid’s bow typically
eral “D” lines. The white or gray roll of the vermillion border dips roughly 2 mm below the peaks in parallel with the dip
 
1362 Aesthetic Surgery Journal 42(12)

A B

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Figure 2.  The RSTL globe drawn on a 38-year-old female. (A) RSTL globe at rest. (B) RSTL globe with smiling. RSTL, relaxed
skin tension line.

A B

Figure 3.  (A) CPID designation for the RSTL globe: C, center; P, peak; I, intermediate; D, diagonal; O, outer. (B) The residual
CUPID measurements determine the final shape and slope of the vermillion border, shown on a 38-year-old female. A 2-mm
slope between P, I, and D provides a continuous line. Sharp or blunt Cupid’s troughs can be altered by making the C and P
lines equal in height. NLF, nasolabial fold; RSTL, relaxed skin tension line.

A B

Figure 4.  Corner lift markings for Type I and Type II corner lifts on a 52-year-old female. The diagonal line marks the transition
from the subnasal to subfacial lip, which lacks support and is where the vermillion roll tapers off. (A) Type I corner lift utilizing
an elliptical excision to replace philtral skin with red vermillion. (B) Type II corner lift involves an inflection past the commissure
which effects a change to the lower lateral lip angulation and insertion, while lengthening the appearance of the upper lip.
Talei and Pearlman 1363

of the columella from the peak points of the incision; there- existing upward curve, this may result in a “Joker’s smile.”
fore, the heights of “C” and “P” should be roughly equal. A  balanced, beautiful, and appealing commissure design
The excision height of “C” and “P” may be altered when is of utmost importance when maximizing lip lift results
reducing or enhancing the appearance of the Cupid’s bow. and avoiding exaggerated outcomes, while also avoiding
If more control of shape is required, the space between the worsening aging around the oral commissure. The upper
CPID lines may be divided in half and a 1-mm slope may be limb of the corner lift incision is typically drawn as a direct,
used between each marking. Maintenance or formation of straightline extension of the vermillion border beginning
this residual slope aids in maximizing vermillion exposure at the diagonal line. The outer “O” line may be used to de-
laterally and avoiding exaggeration with lip lifting. Lip types termine the height of excision of a Type II lift by keeping

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that have central peaking and lateral drooping are espe- the “O” final height the same as the “D” final height. The
cially at risk of iatrogenic exaggeration. Certain ethnic var- lower limb simply follows the red/white border of the ver-
iations, such as Asian lips, are also predisposed to central million, completely excising the philtral skin and roll abut-
exaggeration and typically require a laterally biased exci- ting the vermillion. The elbow of the inflection in a Type II
sion, removing more laterally than centrally. lift should not violate the horizontal plane of the oral com-
missure. The lateral limb must also end before reaching
the nasolabial fold line of the RSTL globe. If the excision
Corner Lip Design height of the “I” line and “D” line are dramatically different,
Treatment of the lip lateral to the diagonal line may require the corner lift may be initiated medial to the “D” line to
a corner lip lift to expose a buried vermillion or avoid a shorten the final “D” height.
drop off in slope. A primary goal of the lip lift should be to
achieve adequate vermillion exposure throughout the en-
Inferior Vermillion Arc
tire length of the upper lip. A variety of naturally occurring
patterns are noted upon analyzing the relation of the corner The surgeon must also pay careful attention to the shape
of the mouth to the central portion. The most helpful clas- of the vermillion at the wet-dry border. Ideally, the vermil-
sification published is quite similar to what we use in our lion should be exposed for the entire length of the upper
practice and has been described by Jeong et al.11 Similar lip. We believe the amount of exposure directly correlates
to the lateral canthus of the eye, the lower lip should gently to sensuality of the upper lip because the red of the lip is
slope upwards into a canted insertion point at the chelion, recognized by others as a sexual internal structure related
rather than being horizontal, bowed, or down-pointed. The to fertility and youth. Although the Cupid’s bow contains a
connection point of the commissure may lay in the same “M” shape, the inferior vermillion should maintain a smooth
horizontal plane of the aperture of the lips or above this and continuous internal arc. Thin or “M”-shaped lips may
plane. The lateral upper lip should gently sit over the com- portray a thin, villainous character. There are several op-
missural insertion of the lower lip, ideally with exposure of tions for softening this appearance if needed, including
the vermillion extending for the entire lip (Supplemental paramedian VY-plasties12 (Supplemental Figure 3A-D).
Figure 2A,B). A thorough understanding of the oral/dental relation-
The majority of patients undergoing the CUPID lip lift will ship is also important. For the purposes of this article, we
require unilateral or bilateral corner lip lifts. Incorporated will focus mainly on a simplistic explanation of incisor dis-
into the CUPID are two simple corner lip lift markings, des- play of the upper front teeth. In nature we may observe a
ignated Type I and Type II. Type I markings are mostly el- pleasant incisor display of anywhere from 1 mm to 8 mm
liptical or fusiform in nature and end laterally at the oral that looks young and beautiful, although the majority of pa-
commissure (Figure 4A). These are solely used to expose tients under 35 years of age range between 1 and 5 mm.13
and lift the lateral vermillion. Type II markings extend Iatrogenically, we should be more cautious and avoid taking
past the commissure with an upward inflection, similar to a patient to an incisor display over 4 mm. This may cause
the lateral extension limb seen in upper blepharoplasty functional impairment with mouth closure. The orbicularis
(Figure 4B). Type II lifts are used in patients who require muscle naturally constricts against the front teeth, while
lifting of the commissure itself or neutralization of down- the elevator muscles have the ability to pull the upper lip
pointing rhytids extending inferior to the chelion. Type II upwards. The upper lip does not have any inferiorly based
lifts help avoid exaggerations in a down-pointed lateral depressor function to close the mouth. If the upper lip
mouth and make the angular depressions in sad and cannot meet the lower lip in front of the teeth in repose, the
frowning mouths seem more pleasant and neutral. It is im- lower lip and chin must flex and strain to obtain complete
portant to use the Type II corner lift precisely as it raises mouth closure. This may result in acceleration of aging and
the insertion point of the lower lip to the chelion. In the strain around the mouth, causing depressor anguli oris
appropriate candidates this will turn a frown into a happy hyperfunction and mentalis hypercontracture. Physically
or neutral smile, although if performed in someone with an this manifests as a peau d’orange appearance on the chin,
 
1364 Aesthetic Surgery Journal 42(12)

depression and down-pull around the mouth, dimpling in broader extent than a narrow nose overlying a wider lip.
the depressor anguli oris region, rise of the point of the Figure 5A-D shows before-and-after photographs of 2 dif-
soft tissue pogonion, a deepened sulcus mentalis, and an ferent patients following a lip lift without application of a
overall sad or angry appearance. Unfortunately, dentists corner lift. The patient on the left had a larger discrepancy
and surgeons often overlook this dynamic when placing between the width of the nose and the mouth, resulting in
veneers and performing lip lifts, rendering the patient with a failure to expose the lateral lip.
labial incompetence which not only causes the aforemen-
tioned changes in appearance, but functionally may cause Step 3: Intermediate Line
xerostomia and deleterious changes in phonation. Once the “P” line and “D” line are determined, an inter-

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mediate or “I” line is directly between the 2 lines from the
nasal sill, extending to the vermillion border. This line helps
Marking Placement control the slope and shape of the lip. Excessive pull on
Precise incision design is the foundation upon which the this line may cause an angry, scowling, or snarled appear-
deep plane upper lip lift depends. The design, as previ- ance, whereas less relative lift of this line may relieve that
ously described by the primary author,1 outlines a simple appearance.
and effective way to achieve an even and symmetric lift
with proper redistribution of a centrally focused advance- Step 4: Determine Height of Central Excision
ment flap. It is essential to avoid any interruption or efface- The height of excision at the central lip must be determined
ment of the nasal sill as well as excess lateral excision. next (Supplemental Figure 5A). At this point, the surgeon
must negotiate between overall balance, incisor display,
Step 1: Upper Incision Markings and lip height. Patients with longer upper lips sometimes
First, the upper limb of the incisions is marked along display 1 or 2 horizontal creases across the central philtrum
the subnasal, perialar crease (Figure 1). Leaving a ledge where the lip is straining to rise. This has been referred to
around the incision offers no benefit. Laterally, the mark- by the primary author as the “line of declaration” in a pre-
ings must not extend past the natural crease ending in vious publication.1 Above this line is typically considered
any given patient. Going beyond this point will almost cer- lip excess. This line may also become more apparent fol-
tainly cause a visible scar along the lateral alar-facial or lowing rhinoplasty. The lip may drop in height with any
alar-labial crease. The incision should also end where the de-projection technique such as full transfixion without re-
vector of the marking becomes vertical. Further vertical ex- suspension of the columella to the septum. This may also
tension along the crease will not aid in lifting. Centrally, on occur with placement of an excessively long columellar
each side of the midline, there is a peak at the divergence strut that extends in front of the nasal spine, causing lip
of the medial crural footplate and the nasal sill. This may ptosis and impairment in mobility. Binding of the footplates
or may not coincide with the philtral column, also known in front of the spine or septum may also cause this issue
as the paramedian or “P” line depending on the patient’s because the footplates naturally extend around the nasal
anatomy. Avoid the practice of drawing the peaks too far spine laterally. Table 1 provides a general estimate of the
laterally, in the middle of the nasal sill, to hide the incision change to expect in incisor display with relation to excision
intranasally. The incision should hug the border of the nasal height without use of orbicularis suspension. The change
skin to avoid the mixture of nasal and labial skin via exci- produced varies with lip strength, elasticity, and skin quality
sion of nasal skin and transposition of lip skin into the nose. differences between patients of different ethnicities and
Invasion into the nasal sill causes effacement of the natural skin types. Thicker, more elastic skin types will obtain less
subunits as well as skeletonization of the nasal base. This of a lift for any given excision height than a thinner, more
deformity is nearly impossible to repair in revision surgery. deflated skin type.
Incisor display is measured as the difference in height
Step 2: Diagonal/Radial Internal Sill Markings between the border of the 2 central incisors and the lower
Next, the diagonal (“D”) markings are made from the in- vermillion wet-dry border at the stomion. If the lip border
ternal angle of the nostril extending down the natural con- is exactly at the level of the central incisors, we designate
tour and relaxed tension lines of the lip (Supplemental this as “0” incisor display. A  lip that is 2  mm longer than
Figure 4). The vector lines of the upper lip extend out the teeth would have “–2 mm” display, whereas teeth that
radially towards the angle of the nasolabial fold as seen are longer than the upper lip would have “+2 mm” incisor
in the RSTL globe (Figure 2A,B). The “D” line is quite im- display.
portant because it marks the lateral extent of vertical lift Markings must be made with the patient in the upright
effect of subnasal lip lift on the vermillion border. The use position. Just as lying a patient down during upper blepha-
of a subnasal lip lift technique inherently means that in pa- roplasty may result in roughly 2 to 3 mm of lagophthalmos,
tients with a wider nose one can lift a narrower lip to a the supine position may result in a phenomenon we have
Talei and Pearlman 1365

A B

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C D

Figure 5.  The need for corner lifting depends on the amount of subfacial lip lateral to the diagonal line and the discrepancy
between nasal width and labial width. (A) Before and (B) after photographs of a 50-year-old female patient with a narrower
nose and greater amount of buried vermilion lateral to the “D” line, showing an unsuccessful classic subnasal lip lift without
corner lift. (C) Before and (D) after photographs of a 52-year-old female patient with little nasolabial width discrepancy not
requiring a corner lift to obtain lateral vermillion exposure.

Table 1. Guideline for Skin Excision Markings and the Re- and commissure droop to a greater extent than the cen-
sultant Change in Tooth Show tral lip. The central lip is attached to a fixed structure in
Excise 4-5 mm 6 mm 7 mm 8 mm 9 mm 10 mm 11 mm
the midline—the nose—whereas the oral commissure is
attached to and hanging from the remainder of the face.
Show +0 +1 +2 +3 +4 +5 +6 This means that when a patient is supine, the surgeon may
note a greater correction on the lateral lip and mouth than
These numbers reflect the changes noted in medium-density skin types without
the use of muscle suspension. Excess temporary or permanent fillers may is occurring from the lip lift procedure.
change these numbers. This guideline only applies to deep plane lip lifting. In general, a 4- to 5-mm excision would reveal more of
the intraoral anatomy along with improved eversion and
dubbed “lagolabios.” The incisor display may easily in- accent of the upper lip without increasing incisor display
crease 4 to 8  mm or more when lying down and even to any appreciable extent. This is the range of excision
more when injected with anesthetic solution. More im- used in patients with adequate tooth show, pre-existing
portant is the effect of gravity on the commissure and the hypercontracture around the lower mouth, or a predispo-
lateral lip. With the patient sitting upright, the lateral lip sition to exaggerating their appearance with lifting. For
1366 Aesthetic Surgery Journal 42(12)

example, a lip with severe angular depression around the

chelion, drooping of the lateral mouth, and a pronounced
Cupid’s bow tends to exaggerate and worsen with lifting.
For a patient with 0 incisive display, the primary author
would typically begin with a 7-mm or more excision to
provide around +2  mm of tooth show. For a patient with
a tooth show of –1 mm, at least 8 mm of height would be
removed to obtain at least +2 mm of tooth show (or at least
a 3-mm gain). It is important to remember that although a

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natural incisor display ranges from 4 to 8 mm, it would be
unwise to produce this level of tooth show iatrogenically.
Most patients do well with + 2 to + 4 mm of central incisor
display in repose without looking exaggerated or causing
issues with phonation and mouth closure. The central ex-
cision marking is made while holding the lip on gentle
stretch, extending directly down the middle of the philtral Figure 6.  Drawn on a 38-year-old female, Pythagoras’
trough (Supplemental Figure 5A). The residual or final theorem of a2 + b2 = c2 demonstrates that more lateral
height markings must be made without stretching the lip relaxed skin tension line markings will yield less of a vertical
lift than more medial markings. This demonstrates one of the
(Supplemental Figure 5B).
causes of central exaggeration in subnasal lip lifting.
The paramedian/philtral “P” markings are then made
with a caliper while gently stretching the lip. Symmetry
must be considered when determining the excision The surgeon must be sure to leave adequate lip height to
height at each peak. Preoperative photography is essen- avoid impairment in function or a foreshortened appear-
tial in determining the need for an asymmetric excision ance. For most patients, a short residual lip height would
given the many contributions to asymmetry at the midline. be considered 11 mm. Leaving less than 10 mm behind is
Asymmetry at the Cupid’s bow peaks may arise from an not recommended because this may impair function and
asymmetric nasal base, variations in philtral column height, flexion of the orbicularis muscle. Again, we must remember
or neuromuscular differences from right to left. Just as we that although shorter lips may exist in nature, it would be
see with dexterity, the face has a dominant side or domi- unwise to form one iatrogenically.
nant subunits that may sit higher at rest and raise higher A height of 11  mm is a convenient number to keep in
with flexion. If an asymmetry of philtral column height mind for teaching purposes, as it not only refers to the min-
exists, markings may be made by measuring the residual imum residual height of the lip but also refers to the max-
height of the desired side and applying the same marking imum excision height in a single stage. Removing more
to the contralateral side without placing any tension on the than this during a deep plane lip lift may lead to bunching
lip. It is important to note that if an asymmetry exists with and issues with redistribution of skin. A second stage may
residual height measurement but not on the preoperative be performed in the future, typically after 6 months, if indi-
photograph, the photograph should take precedence be- cated on rare patients. We do not believe there to be any
cause it will better reveal nasal base asymmetries contrib- proper lip height or specific range of heights that is better
uting to lip height. If a ptotic nasal base is encountered, the for any particular patient. One must simply analyze the bal-
surgeon must consider any height gains from nasal base ance of the face, improve lip function, and avoid causing
resuspension, which may be asymmetric. If the alar sill is problems with lip lifting.
lower on one side following previous surgery of the nose,
jaws, or lip, this must be restored accordingly with nasal Step 5: Lateral Markings and Slope
base suspension sutures. The remainder of the lower limb excision markings are
Upon analyzing the expected starting point of the lip, it now made, which will determine the excision height along
is also helpful to view the profile view for slope and projec- the entire lip as well as the design, excision bias, and
tion. An attractive lip typically has very little purely vertical slope. When performing a lip lift, the natural inclination of
descent prior to sloping anteriorly like a gentle ski ramp the upper lip is to undergo a more exaggerated rise cen-
(Supplemental Figure 1B). From an anterior view we focus trally than laterally. Several factors in the incision design of
on balancing the size of the upper lip to the nose, the chin, subnasal lip lifts contribute to this observation. The lift of the
and the remainder of the face. Our goals typically are to central portion is purely vertical, whereas the more lateral
decrease philtral height, improve the accent and definition portions lift diagonally. At the “D” marking (Figure 6), the
of the Cupid’s bow and vermillion border, increase tooth surgeon must consider Pythagoras’ theorem, a2 + b2 = c2,
show, and improve the volume show of the red vermillion. meaning a 7-mm diagonal (hypotenuse) measurement with
Talei and Pearlman 1367

a 3-mm gap (horizontal) will result in a 6.3-mm vertical lift controlled differently and may demonstrate the opposite
rather than the 7 mm that would be achieved with a 7-mm dominance. In general, the dominant side of the face will
excision at the “C” line. This means that a 2-mm radial line have a stronger smile, possibly a nasal tip deviation to that
height difference will result in a final slope that is steady side, deeper nasolabial folds, and a higher chelion posi-
with a lift that is gradually diminishing as it approaches the tion. The opposite side tends to exhibit more drooping but
“I” and “D” lines and beyond. less shadowing. These differences are erroneously attrib-
The deep plane upper lip lift is akin to a centrally vec- uted to side preference during sleep. Soft tissue and bony
tored advancement flap. The lateral portions are pulled skeletal discrepancies, such as various forms of dental
superomedially rather than purely in a vertical vector. The malocclusion, open bite, retrognathia, prominent dentition,

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other main contributing factor is that the lip is wider than vertical maxillary excess, and other issues, may also lead
the nose in most patients. The larger the discrepancy be- to muscular asymmetries and strain within the face.
tween lip and nose width, the greater difference you will In many patients with pre-existing central exaggeration,
see in central vs lateral lifting. The central portions of the a buried lateral vermillion, angular depression around the
lip directly under the nose will experience a greater extent commissure, low chelion height relative to the stomion, or
of lifting than the lateral portions, which are hanging from a predisposition to exaggeration following a lip lift, a lat-
the face at the oral commissure. The diagonal reference erally biased lip lift must be performed. Revision surgery
marking helps delineate where the effect of lifting on the often requires this as well because the inclination of most
lateral lip will taper off. surgeons is to remove too much centrally. Removing more
To appreciate the ideal slope along the vermillion skin centrally than laterally tends to give the patient an op-
border, the practitioner must first become familiar with the erated and strange appearance that does not age well. If
final incision design of the upper lip lift and all the antici- the lateral portion and corners of the lip are not propor-
pated reference markings as described earlier (Figure 3A). tionately lifted, the down-pointing and sad appearance
There exists a single central marking, 3 pairs of radial around the mouth will become substantially worse as the
markings (paramedian, intermediate, and diagonal), and a remainder of the face attached to the commissures droops
single lateral reminder marking that is used for the lateral with age. There are certain ethnic characteristics that pre-
deep suture. dispose the patient to this as well. For example, patients
The slope serves only as a guideline, but the primary au- with Asian heritage commonly receive a laterally biased
thor has observed that the most pleasant appearance for upper lip lift. A  standard excision design or larger lift in
most lips would result in a height difference along the ver- general may cause excessive exaggeration and volume
million border of 2 mm between each point and the adja- display centrally. With greater levels of lifting and exci-
cent point along the PID line when measuring the residual sion height, control over this potential exaggeration may
vector line height (Figure 3B). For example, a residual “P” be lost. In cases where more tooth show is needed, but
height of 12 mm would correspond to a “I” height of 14 mm greater excision heights would lead to exaggeration, we
and a “D” height of 16 mm. The excision height for the cen- recommend performing orbicularis suspension to achieve
tral markings is placed while the lip is held under gentle the needed changes.
tension. The residual or final height must be performed An excision height disparity of 2 to 4 mm from the “P”
with the lip in repose and not stretched. This will ensure upper excision marking to the “D” point is easily tolerated
the result at rest is as symmetric and aesthetically pleasing by most patients. A  higher skill level is needed to deter-
as possible regardless of the accordion effect seen with mine if a greater fraction would be tolerated by the patient’s
lax skin types or curling of the lip, which may not contribute anatomy because greater differences between central to
to perceived vertical height. This design also helps avoid lateral height excision may cause difficulty with redistribu-
exaggeration or softening of the appearance of bowing tion of the inferior relative to the superior flap. The upper lip
or snarled lips by lifting the “P” and “D” points relatively lift is a centrally vectored rotation-advancement flap with a
higher than the “I” point. Lifting the “I” point excessively longer perimeter along the lower limb of the incision than
relative to the other points may cause an angry, snarled the upper, even when equal amounts are removed. In ad-
appearance. Although it is unwise to make any substantial dition, it is important to restrict any excision that would ex-
changes to the shape or character of the lip, small changes tend laterally or superiorly to the lateral extent of the upper
may be made to avoid exaggeration or to correct changes limb marking apex. This can also cause visible scarring.
caused by fillers over time. Extending vertically past the naturally existing alar facial
The height of the chelion bilaterally may never be sym- crease may result in a deepened scar with pores and pits
metric because the position is guided by facial asymmet- along the alar facial sulcus. Lateral extension may result in
ries and not by subnasal philtrum height. Like the rest of atrophic or hypertrophic scarring from tension, issues with
the body, there exists a neuromuscular dominance on redistribution, alar/nasal widening, and even effacement of
one side of the face. The brow and eye dominance are the upper nasolabial fold in cases where the lip is excised
 
1368 Aesthetic Surgery Journal 42(12)

lateral to the ala and the cheek is attached directly to the final “O” height between the lateral extension line and the
nose. There is a substantial risk of this occurring during re- top limb of the corner lift should be similar to the final “D”
vision surgery where the surgeon may attempt to excise a height (where D = O). The inflection limb should not extend
scar lateral to the ala. This can be avoided by transitioning into or past the nasolabial fold. More than this would be
at the “D2” point to a vertical limb ascending towards the uncommon with this form of corner lift design. The large
end of the alar crease. majority of corner lifts contain some inflection or Type II
extension.
Step 6: Corner Lifting
Direct lip lifts cutting along the central vermillion roll are Step 7: Vermillion Assessment

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avoided because these tend to efface the natural border and Before beginning the surgery, it is important to assess the
definition of the upper lip. Laterally, the white roll tapers off vermillion body for shape, previous scarring, and appro-
around the “D” line, enabling an incision to be made without priate volume. Although the vermillion border and Cupid’s
any notable sequelae. If the incision marking terminates at bow demonstrate somewhat of an M-shape, most aes-
the commissure, we call this a Type I corner lift (Figure 4A). thetically pleasing lips do not parallel this along the wet-
Minor improvements can also be made to improve a down- dry border. Rather, a smooth and continuous internal arc
pointed appearance around the cheilion and angular de- along the inferior line is most appealing and desirable
pression by carefully extending the excision by means of (Supplemental Figure 2A). Embryologically, 3 tubercles
an upward inflection lateral to the commissure (Figure 4B). exist in the upper lip and 2 in the lower.14 Neither fillers
A corner lift with lateral extension is called a Type II corner lift. nor surgery should exaggerate the appearance of the
The inflection elbow is always placed above the horizontal upper lip tubercles. On occasion, paramedian VY-plasties
plane of the cheilion, and the angle of inflection is roughly will help smooth the appearance of an M-shaped vermil-
90° to 120°, following the patient’s natural anatomy. In lips lion (Supplemental Figure 3A-D). The tubercle may also
that will not tolerate lifting of the lower lip insertion into the be trimmed, especially in patients with silicone-induced
commissure, the corner lift should end at the commissure hypertrophy. Postsurgical modulation is often needed
without any lateral extension (Type I). A  1-mm-long inflec- because the tubercle vermillion is sensitive and tends to
tion will give a minor increase in angulation whereas a 2- to thicken and experience hypertrophic scarring.
5-mm-long limb will create increasingly greater amounts of Some patients requiring a lip lift may have an abun-
correction. Overcorrection will cause an unnatural smirk or dance of volume. This occurs naturally in patients of
“Joker’s smile.” On the medial end of the incisions, the mark- African or Asian descent as well as in patients with sili-
ings must taper off and elongate to avoid a notch. cone or other polymers placed previously with subsequent
The decision to perform a corner lift can be guided granulomatous hypertrophy. In these patients, a mucosal
by the relative position of the diagonal radial line “D” by excision or volumetric reduction should be considered to
examining its point of termination along the vermillion and maintain or decrease the size of the vermillion. For patients
whether the lip lateral to this point requires lifting. The goal with excessive amounts of silicone-induced hypertrophy,
is to continue the slope previously depicted from “P” to “I” various forms of reductions may be performed beforehand
to “D” laterally in a straight line towards the commissure. It to avoid postoperative exaggeration. Liposuction should
can be assumed that the deep plane upper lip lift will pro- be avoided because this is much more likely to remove
vide little lifting effect lateral to that line and that a separate soft, healthy native tissue rather than scarred, fibrotic
incision along the vermillion will be needed. As can be seen tissue. Similarly, hyaluronidase would target the healthy
in Figure 5A-D, if a congruence in width exists between the SMAS layer rather than the bulk of scar tissue. The deep
nose and the lip, the lateral lip will receive a strong lifting plane dissection also allows reduction in fat grafting that
effect. In cases where there is more of a disparity, the lat- may have traversed the vermillion into the philtrum. The
eral lip may not receive enough lift as shown on the left fat may be accessed from either the upper lip lift, corner lip
side of the photograph. In this scenario, the patient should lift, or vermillion incisions. In some patients, this may also
have had an asymmetric corner lift, more so on the left side aid in tooth show. Naturally, a fat plane does not exist in the
than the right. The patient was content with the results and upper lip. Only dispersed fat droplets are found within the
refused the addition of a corner lip lift after her recovery. SMAS. Hence, when fat grafting is performed, there is no
The corner lift is typically performed upon finishing the true fat plane for the grafting to incorporate into and it may
upper lip lift to appreciate the resultant curvature of the spread in the submucosal, sub-SMAS plane.15
vermillion. In most cases, a 1- to 4-mm height excision is
needed with 0 to 6 mm of inflection length. The height may
be determined by using the “O” RSTL which extends down
Nasal Base Suspension
from the apex of the incision. A horizontal lateral line ex- When treating a patient with a loose nasal base, a nasal
tension is drawn from the “D2” point horizontally and the base suspension is typically performed. Even with a
Talei and Pearlman 1369

tension-free closure, effects of untoward tension may be weaker. The same phenomenon is also noted with other
noted months later. Laxity of the sill and nasal base may facial mimetic musculature such as the zygomaticus com-
be a congenital or iatrogenic phenomenon. Excess laxity is plex. If the lip is flaccid and excessively ptotic in the set-
very common following rhinoplasty and orthognathic sur- ting of orbicularis hypertrophy, a muscle plication can be
gery. The need for this is more common in rotated noses performed. Orbicularis muscle suspension is performed in
and nasal base types with weaker structure such as is seen roughly 25% of patients in our practices.
in Asian patients. Furthermore, the cephalic orbicularis in- It is important to note that muscle plication inherently
sertion line at the base of the nose tends to disinsert and fibroses and obliterates the function of the plicated por-
rotate out over time in a clockwise fashion on lateral view. tion of muscle and that this procedure should be per-

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Nasal base suspension simultaneously aids in strength- formed judiciously. If the orbicularis appears to roll onto
ening of the nasal base and sill, while reinserting the origin itself as the lip flap is lifted to the nose, muscle plication
of a ptotic orbicularis internally and superiorly. If scarring would also be of benefit. If 5 mm of muscle folds over an-
exists from any type of previous surgery, the scar at the other 5 mm of muscle, this obliterates or restricts the mo-
alar-labial junction should be excised and a subnasal ra- tion of 10 mm of muscle. Rather, a 3- to 5-mm plication can
vine may be formed to deepen the nasolabial angle. be performed which would solely result in the upper 3 to
It is important to mark the orbicularis suspension height, 5 mm of muscle becoming fibrosed and obliterated. This
discussed in the next section, before passing this suture. leaves the remainder of the orbicularis oris to function in
To perform the suspension, a 4-0 polydioxanone suture is a more normal fashion. This problem is commonly seen in
passed from inside the pyriform aperture out through the skin-only excision techniques without release because all
nasal and labial muscle junction at the “D” line, then back the muscle in the excised area bunches onto itself upon
in as a mattress, passing through the periosteum with a closure. Bunching of the orbicularis oris muscle may have
knot tied on the internal nasal rim. Typically, 2 sutures are substantial effects on lip mobility and function. The mis-
placed on each side unless more are required. Great care take many practitioners make during muscle plication is
must be taken to avoid asymmetric nasal base suspension suturing the muscle to muscle or muscle to the subdermal
or a snarled appearance by lifting the mid-sill excessively. region of the nose rather than to the periosteum or pyri-
If a patient possesses hyperlaxity at the “I” line, the dermis form ligament.1 Rather than lift the lip, this tends to drag the
may be incorporated on the second pass as the suture is nasal sill downwards.
reversed and passed back internally. This will provide a sill A more advanced maneuver is to use minor muscle pli-
pexy at the most sensitive point of dermal ptosis seen in cation to strengthen a weak nasal base and avoid exagger-
patients with laxity. Nasal base suspension sutures should ation in patients with more prominent, steep slopes such
be avoided in cases where simultaneous rhinoplasty is per- as with patients of Asian descent. Typically, a 3- to 4-mm
formed to avoid strangulation of the basal columellar skin. marking is placed paralleling the nasal base and upper lip
incision. Five buried 5-0 polydioxanone sutures are used
to perform the muscle plication, attaching to the pyriform
Muscle Suspension ligament or periosteum in a mattress fashion at the “C,” “P,”
Once hemostasis is obtained, the central lip flap is elevated and “D” points only. Suture placement must alternate back
to the nose to evaluate if there will be appropriate flexion and forth from left to right to avoid twisting the insertion of
and contracture of the orbicularis oris muscle underneath the pars peripheralis. An added benefit is the formation of
the advanced lip flap. A  major benefit of deep plane re- a scroll of tissue at the nasal base which may strengthen
lease is that the orbicularis muscle will have even redistri- it and decrease the chance of ptosis following healing. If
bution under the skin as opposed to other techniques that the lip excision height determined is appropriate for ex-
bunch the muscle in the excision area up towards the nasal ternal balance but inadequate for tooth show, a muscle pli-
base in an uncontrolled fashion, which may adversely af- cation may also be performed to increase incisor display
fect orbicularis strength and function. The orbicularis oris without increasing the height of skin excision. In these situ-
muscle appears to function best in a mid-range of stretch ations, we compare the lip excision height to the volume
or flexion. Longer lips seem to strain more when flexing, of a speaker, while the muscle plication is the gain or the
whereas excessively short lips have no further room to fine tuning. When plicating or imbricating, we knowingly
flex. Hence the length and function of the orbicularis oris sacrifice the function of the upper portion of muscle for the
muscle must be considered, looking at the overall length greater function of the remainder of the muscle.
as well as the length compared with the remaining skin. In patients with a tendency for hypertrophic scar-
Hydration and cushioning also play an important role. ring, such as those with Asian, African, or Indian skin
A mimetic muscle that is desiccated or denuded typically types, neurotoxins may be injected into the skin edges.
displays hyperfunction, whereas a mimetic muscle bogged We are undecided regarding the efficacy of neuro-
down by an edematous or granulated SMAS becomes toxin injection into the incision because the results have
 
1370 Aesthetic Surgery Journal 42(12)

been equivocal. Typically, 5 units of Dysport (Galderma; patients are given valacyclovir, a skin flora oral antibi-
Lausanne, Switzerland) diluted with saline is injected into otic, and a steroid pack for recovery. Oral antibiotics are
the dermal-epidermal junction of the upper and lower flaps, not used. Antibiotic ointment is switched to Aquaphor
avoiding any intramuscular injection. This may mitigate (Beiersdorf Inc.; Hamburg, Germany) ointment after 3 days
the need for any postoperative modulation with CO2 or to avoid the rash formation seen with antibiotic oint-
5-fluorouracil (5-FU), which is rarely needed in the incision. ments. Patients return at Days 3 and 5 for suture removal.
Prolonged presence of sutures may result in hypopig-
mentation, striations, and delayed formation of epithelial
Intraoperative Adjuncts and bridges between upper and lower suture points.

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Postoperative Maintenance Patients may then return at 6 and 12 weeks
postoperation for an off-label injection of 5-FU deep into
The surgical technique for the modified or deep plane
bumps that may be present laterally in the muscle bed as
upper lip lift has been detailed previously by the primary
well as low-energy CO2 laser treatment of the incisions.
author.1 The procedure is typically performed under local
Injections of triamcinolone are avoided because this is a
anesthesia after administering 10 mg of oral valium to the
high-risk area for tissue atrophy, telangiectasia formation,
patient. Anxiety should be avoided because bleeding may
and discoloration. In rare cases where incisional hyper-
increase dramatically if not controlled. This may be due to
trophy is present, 5-FU may be injected into the hyper-
diminished ability to clot16 as well as increased blood pres-
trophic scar. Microneedling may also be performed. 5-FU
sure and heart rate. Patients are advised preoperatively to
and lasering cannot be performed on the same area at the
stop all blood thinners, oral supplements, and some food
same time because of the risk of skin breakdown. Rarely,
additives, including turmeric and curcumin, which have
hyperpigmentation of the philtrum may occur in darker
been used increasingly over the past several years and
skin types. This will typically resolve without intervention,
tend to increase bleeding.17 Patients without any contra-
although the primary author has used microneedling of
indications are given low-dose oral tranexamic acid the
tranexamic acid into the pigmented areas to speed up
day before and on the day of surgery.
the process. Confluent lasering may be performed on hy-
Perioral rhytids will be temporarily exaggerated during
pertrophic strands. Incisional lasering may be performed
healing. The lip lift does not routinely improve these wrin-
on all skin types, although low power is used to avoid
kles. For this reason, if rhytids exist a fractionated perioral
hypopigmentation.
CO2 laser resurfacing is performed at the end of the pro-
The deep plane technique commits the patient to a
cedure. The lip is resilient to laser damage and performing
much longer recovery time with much more postoperative
a laser resurfacing on appropriate skin types is low risk.
swelling than other techniques. Theoretically, the post-
Patients undergoing more substantial lip lifts also may ex-
operative edema may aid in incisional healing because it
perience dryness and peeling of the vermillion skin. This
decreases dynamic movement of the lip. Botulinum toxin
likely occurs as the wet-dry border is lifted and a new wet-
placed intraoperatively should never be injected into the
dry junction forms over the area of the wet vermillion mu-
muscle—only into the dermis itself. Patients may look pre-
cosa. Squamous metaplasia may continue over the next
sentable at 3 weeks, but most require 3  months to look
several months as the new mucocutaneous line forms.
event-ready. We advise patients that the lip may have a stiff,
Indentations along with “D” line may occur infrequently
awkward, and asymmetric appearance for up to 3 months
in patients who have a deflated SMAS either from age or
with some temporary widening of the nose. The feeling of
from prior dissolving of fillers. In these patients a small
stiffness may persist for over a year although displayed
amount of HA filler should be placed into the subdermis/
motion and smiling is visibly natural and easier in postop-
SMAS. Only a tiny amount is needed because the filler will
erative photographs at the 3-month mark. The healing time
partially hydrate after injection. Juvéderm and thicker fillers
must not be underemphasized to the patient. Patients with
should always be avoided in the philtrum. If this philtrum
HA fillers, silicone, or other polymers may have even more
appears darker from aging and deflation of the SMAS in
prolonged healing. Postoperative photographs are taken
the preoperative photographs, the volume and supple na-
at a minimum of 3 months. Any cosmetic dental work is typ-
ture of the SMAS may be improved using nanofat/platelet-
ically performed after 3 to 4 months once the lip position
rich plasma injections. The patient shown in Supplemental
has settled. Male patients can hide the healing more easily
Figure 6A-D was treated with nanofat/platelet-rich plasma
given their ability to grow facial hair.
injections to the SMAS layer and CO2 laser along with bi-
lateral Type II corner lip lifts.
Mupirocin 2% nasal ointment may be given to use RESULTS
twice daily to diminish the risk of methicillin-resistant
Staphylococcus aureus colonization and infection, al- A retrospective review of 2240 consecutive lip lift pa-
though infection is exceedingly rare. Postoperatively, tients in the primary author’s practice was performed from
Talei and Pearlman 1371

A B

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C D

Figure 7.  (A) Laterally biased revision in a 30-year-old male patient using the CUPID design to balance a laterally deficient
lip status post deep plane lip lift that was performed with classic design and uniform height of excision. (B) Laterally biased
revision on a 31-year-old female patient. The patient felt imbalanced status post classic design deep plane lip lift. The CUPID
design was used to gain more uniform exposure along the entire lip. The results are shown in Figure 8. (C) Revision lip lift
following subnasal lip lift by another surgeon on a 35-year-old female. The CUPID design was used with a lateral bias and
asymmetric excision to gain increased exposure, balance, and symmetry with minimal change in tooth show. (D) Revision lip lift
on a 35-year-old female patient for improved symmetry using the CUPID design on 1 side only. The original lift had removed
more from the left according to the patient, but failed to gain symmetry. A 2-mm slope was not obtained to minimize down-turn
of a bilateral revision.

November 2014 through September 2021. Patients were disproportion, and inadequate lifting. Several patients from
followed for a minimum of 3 months. No exclusion criteria other practices had their lips shifted off midline upon clo-
were used. Patients were primarily female (98%) and aged sure. Nasal base widening and ptosis was also common.
from 20 to 85 years old. Secondary surgeries, those per- Twenty-two patients had impaired lip mobility from pre-
formed initially by other surgeons, constituted 141 of these vious lip lifts that improved after performing a deep plane
cases (6%). In the primary author’s practice there were 23 release.
revisions of primary cases (1999 primary patients) contrib- Of the primary author’s own cases, only 2 were revised
uting to a 1% revision rate. Herpetic vesicular outbreak oc- to improve hypertrophic scarring on 1 side of the nose.
curred in 1 patient, hyperpigmentation in 2 patients, and The remainder of the primary author’s revision cases (21
dissatisfaction in 2 patients, both of whom were already cases) were performed to achieve a greater amount of
suffering from silicone hypertrophy and expected the lip lifting, better symmetry, or involved a corner lift to improve
volume to decrease. a lateral vermillion that had previously been inadequately
Revision patients from other practices were mostly treated before the addition of corner lifting and the CUPID
treated for scarring, asymmetry, exaggeration and lift design in the primary author’s practice. Patients who
 
1372 Aesthetic Surgery Journal 42(12)

A B C

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D E F

Figure 8.  Revision CUPID lift on the 31-year-old female patient shown in Figure 7. (A, D) Before photographs showing filler
excess. (B, E) After a classically designed, uniform excision deep plane lip lift. (C, F) After applying the CUPID lift design to
revise the classic lip lift performed by the primary author.

follow up regularly are routinely treated with CO2 laser Suspension of the SMAS to the pyriform ligament en-
over 2 appointments at 6 weeks and 12 weeks. Roughly sures a more stable lift with less risk of causing nasal sill or
5% of patients require more intervention with 5-FU or fur- alar base ptosis. We have also introduced novel portions
ther lasering. of the procedure to help prevent nasal base ptosis in sus-
The addition of the final slope calculations to the deep ceptible patients and to perform nasal base resuspension.
plane design along with incorporation of corner lifting Incorporation of the subnasal ravine and nasal base sus-
in most patients have led to substantially more impres- pension suture is a valuable and easily performed adjunct
sive and predictable results in primary and revision cases during lip lifting surgery. Deep plane lip lift and SMAS sus-
(Figure 7A-D). This article provides several examples of pension avoids the use of dermal sutures which may split
appropriate lip design resulting in comprehensive im- and cause hypertrophic or atrophic reactions along the in-
provement throughout the upper lip (Supplemental cision. Although the primary author has an international pa-
Figures 7-10). tient base, follow up was performed with nearly all patients
The deep plane upper lip lift addresses issues seen either in person or virtually with videoconferencing for a
with scarring, nasal base effacement, disproportion, and minimum of 3 months. The main limitation of this study is
overall failure of previous lip lift or bull’s horn techniques. the duration of follow up. The primary author has only been
The orbicularis muscle is separated from the SMAS-skin in practice 7 years and the design has evolved during this
flap and allowed to contract or redistribute evenly under time. With an international patient base, several patients
the flap advancement. Alternatively, the muscle may be were not followed past a 3-month virtual follow up.
shortened for further gain in dental show without substan- The CUPID lip design allows more uniform improve-
tial sacrifice. The deep plane dissection also allows the ments along the length of the entire lip, treating the
surgeon to address issues such as permanent injections subfacial as well as the subnasal lip. This technique also
and fillers. aids in the design of revision lip lift markings. The CUPID
Talei and Pearlman 1373

lift technique offers clear advantages over the prior deep and Reconstructive Surgery. Butterworth-Heinemann;
plane design1 and alternative lip lift techniques involving 1971: 1127–1129.
endonasal incisions18 which may not have the ability to 3. Penna  V, Fricke  A, Iblher  N, Eisenhardt  SU, Stark  GB.
shape the upper lip and control the slope, curvature, and The attractive lip: a photomorphometric analysis. J Plast
shape of the vermillion border. The benefits of the CUPID Reconstr Aesthet Surg. 2015;68(7):920-929. doi: 10.1016/j.
bjps.2015.03.013
lift design are clearly demonstrated in a photograph of a
4. Kar  M, Muluk  NB, Bafaqeeh  SA, Cingi  C. Is it possible
patient who initially received a deep plane upper lip lift to define the ideal lips? Acta Otorhinolaryngol Ital.
followed 2  years later by a revision with the CUPID lift 2018;38(1):67-72. doi: 10.14639/0392-100X-1511
design (Figures 7B, 8A-F). The aim is to create a central 5. Ramaut L, Tonnard P, Verpaele A, Verstraete K, Blondeel P.

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CONCLUSIONS Aging of the upper lip: part II. Evidence-based rejuven-
ation of the upper lip—a review of 500 consecutive cases.
This article is intended to serve as a reference to better
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Disclosures 10.1097/00006534-199301000-00028
Dr Talei reports honoraria for filler training sessions with 13. Khan F, Abbas M. The mean visible labial length of maxil-
Prollenium/Revanesse (Raleigh, NC) and Galderma (Lausanne, lary and mandibular anterior teeth at rest. J Coll Physicians
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IJPS_214_17
Funding 15. Mulliken JB, Pensler JM, Kozakewich HP. The anatomy of
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The authors received no financial support for the research,
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