Lip Reduction

 Updated 3/2017 --photos and all links removed as many no longer active and it was easier than checking each one.

Not all of us may want larger, fuller lips. Many people (both men and women) believe that their lips are too big, and want them reduced. Younger patients are often plagued by insecurities brought on by having larger than average lips and the teasing their classmates may do. These younger patients should wait until their late teens to have their lip size reduced due to maturing of the facial features.

Macrocheilia or prominent lips has multiple etiologies affecting one or both lips. Those caused by disease can become a functional issue and not simply cosmetic in nature.

Congenital causes include

• Double lip deformity occurs because of the persistence of the transverse sulcus between the inner lip (pars villosa) and the outer lip (pars glabra), resulting in glandular hypertrophy along with redundant labial mucosa. The excess tissue forms an accessory lip, which is apparent during smiling. The underlying orbicularis oris muscle is not involved.

• Labial "pits" -- usually described as blind epidermal invaginations of lip mucosa with occasional drainage of minor salivary gland secretions

• Ethnic variations demonstrate diffuse thickening of all lip structures and may require resection of muscle.

Acquired causes include

• Trauma -- result in an inflammatory infiltration leading to fibrosis and subsequent lip enlargement
• Infections
• Neoplasms
• Syndromes

1. Melkersson-Rosenthal Syndome -- Miescher granulomatous macrocheilitis is a mono-symptomatic presentation of Melkersson-Rosenthal syndrome that is characterized by granulomatous swelling of the lips. The full syndrome is a condition characterized by the triad of facial paralysis, facial edema, and lingua plicata (furrowed tongue), similarly results in an infiltrative process of the lips.

1. Ascher syndrome is identical to double lip deformity with associated blepharochalasis and endocrine disorders.

• Port-wine (capillary) vascular malformations that enlarge the lips (port-wine macrocheilia) are a different category of lesions that have a different pathophysiology and may require complex reconstruction.

CLINICAL PRESENTATION/ EXAM

The patient will most often present complaining of prominent lips or facial disproportion. The protruding lip or lips often stand out as the most prominent feature of the face, attracting undesirable attention.

Functional difficulties may include labial incompetence, interfere with speech, problems with salivary control (drooling), and problems with mastication (chewing).

The lip and its relationship to other facial structures are evaluated by frontal and profile views. If there is a possibility of underlying dental or facial bone problems to explain the prominent lips, then appropriate x-rays should be done. It is important to assess the lips and the relationship to the nose and chin.

From the face-on-view, evaluate the visible vermilion (vertical height) and the transverse lip excess.

From the profile view, evaluate the upper to lower lip relationship as well as the degree of lip eversion.

Prominent lips are not always the result of lip volume but may be caused by lip ectropion or labial eversion. Furthermore, the orbicularis musculature is assessed for its tone and muscular ring for its competence.

MEDICAL TREATMENT

Medical therapy has limited usefulness in treating prominent lips. It can however help alleviate the underlying cause or associated anomalies. Steroid therapy, antibiotics, salazosulfapyridine, and radiation have shown limited success.

SURGICAL TREATMENT

The goals of lip reduction surgery are to achieve a harmonious upper to lower lip relationship that is in balance with the entire face as well as to attain normal lip competence.

The treatment of macrocheilia is should be individualized to the etiology and patient's needs. Some general principles include the following:

1. Correct underlying dento-osseous (teeth/bone)deformities.
2. Establish a balance between upper and lower lips with the individual patient in mind
3. Do not reduce lips if excessive interlabial distance exists.
4. Optimal frontal aesthetics is more important than profile aesthetics

The basic surgical procedure of lip reduction surgery is a transverse fusiform or elliptical mucosal incision between 1 and 1 cm dorsal to the vermillion border between the lateral commissures (Conway method). W- or Z-plasties may be added to prevent dog ears.

The Mouly method may be added. This method includes the excision of two sagittal triangular wedges at the lateral eminences of the philtrum. This enables the natural protrusion of the eminences and the normal central depression of the upper lip to be preserved. The undermining of the wound edges should be limited to that needed for appropriate tissue apposition. Closure of the resection defects is usually performed in two layers, and sutures are removed 7 to 10 days after surgery.

At other times, a wedge excision may be most appropriate.

Surgical methods. A and B, Conway procedure with transverse sickle-shaped mucosal excision. C and D, Conway procedure in sagittal projection, with excision of mucosal and submucosal tissue. E and F, Central wedge excision. G and H, Z-plasty after wedge resection. I and J, Mouly procedure. (from the second reference article)

Some tips from Drs Dev and Wang's article:

• When designing the incision it is imperative to place the anterior aspect of the incision posterior to the lip seal and wet line (transition from inner mouth mucosa and vermillion).
• Avoid the area of Cupid's bow as well. Cupid's bow should always be preserved during correction of a prominent upper lip since it is an important landmark of the lip.
• The marking should be made prior to the use of local anesthetics, which tend to distort the lip architecture.
• The goal should be removal of hypertrophied labial glands, fibrosis from an infiltrative process, or generalized thickened redundant tissue.
• In the upper lip, macrocheilia usually affect the lip in the vertical dimension. If the dry vermilion is not excessively large, the reduction surgery is designed as a transverse ellipse behind the wet line. However, if the entire vermilion is enlarged, then design of the excision may include the dry vermilion.

COMPLICATIONS
Unfortunately, all surgery has risks and complications.
Infection
Chance of asymmetry
Hypertrophic scarring
Numbness -- usually subsides within the first few weeks, but may be permanent
General dissatisfaction

REFERENCES
Lip Reduction by Vipul R Dev MD and Peter Wang MD--eMedicine Article, June 14, 2006
Surgical Treatment of Persistent Macrocheilia in Patients With Melkersson-Rosenthal Syndrome and Cheilitis Granulomatosa; Arch Dermatol. 2005;141:1085-1091; Birgit Kruse-Lösler, MD, DMD; Dagmar Presser, MD; Dieter Metze, MD; Ulrich Joos, MD, DMD
Macrocheilia due to hyperplasia of the labial salivary glands: operative correction. Surg Gynecol Obstet. 1938;66:1024-1031; Conway H
Correction of hypertrophy of the upper lip; Plast Reconstr Surg. 1970;46:262-264; Mouly R