Dimitrije E. Panfilov
Only the human race has exposed lip redness to imitate visible mucous membrane. This phenomenon does not exist in primates as they use direct sexual signals opposite from humans, who communicate and mostly copulate frontally owing to an erect gait. Only carps and humans have such a small mouth compared with their face size.
There is a plastic surgery phenomenon: I have done many lip enlargements but only in female patients -
none in male patients. I have done some lip reductions but only in male patients - none in female patients (the exception being Mongoloid girls with macrochei-ly of the lower lips).
When we reduce the lower lip we resect a longitudinal wedge of mucous membrane deep inside the lower lip, so that the consecutive scar stays invisible from outside.
For lip enlargements there are numerous fillers (see Chap. 73 by Gottfried Lemperle), which provide a simple and inexpensive method. We prefer, however, autologous material because resorbable fillers disappear sooner or later and there is no nonresorbable filler that would be completely free of negative side effects. Nowadays we have the very reliable method of autolipografting which gives stable results for years without allergic or foreign-body reactions.
Sometimes complex facial lipostructuring has been requested.
It is interesting that different nations have different ideas of the beauty of female lips. German and Slavic plastic surgeons prefer the upper lip with its Cupid's bow as important for attractiveness, whereas French and British plastic surgeons prefer the lower lip. Brazilians and Mexicans balance both lips.
If we perform superficial musculo-aponeurotic system (SMAS)-ectomy during facelift surgery, we can take a strip of SMAS, model it, and insert it into the upper or lower lip or into both.
from one to the other incision grasping the SMAS graft. SMAS graft c pulled out through the first incision and d adjusted into the upper lip
For lip enlargement we can take also temporal fas- mentation or reduction at the same time. In our hands cia, muscle strips from upper eyelids if we perform muscle take is less than 50% and fat stays stable in upper blepharoplasty at the same time, or from the 60-80% of cases. edge of the pectoralis muscle if we make breast aug-
The "bull's-horn" method is a very nice method to harmonize the upper lip which has been popularized by Ulrich Hinderer (Chap. 41). Sometimes the white area of the upper lip is quite large and the upper lip too narrow. Both can be corrected if we excise skin
with underlying solid connecting tissue in the shape of a bull's horn. We deepithelize this strip of tissue, remove the epidermis, and insert a dermis-subder-mis graft into a prepared tunnel of the upper lip.
If the opposite happens such that the upper lip looks too short, it produces "teeth-show". Mostly, the reason for this is a too short frenulum. We can prolongate this by simple or multiple Z-plasty.
Around the lips and around eyes there are the only facial muscles which have no attachments to the deep structures or the periosteum, but which have only cutaneous attachments. In these areas small vertical wrinkles on the upper lips are especially noticeable and are called by some patients "lemon wrinkles", recalling the contracted orbicularis oris muscle when tasting something which is sour like lemon.
There are many wrinkle fillers which can give quick help, like collagen, but these wrinkles could be treated with longer-lasting results by peeling, mechanical peeling (dermabrasion), chemical peeling, laser peeling(see Chap. 70 by Ashok Gupta), or, the method we prefer, peeling with radiowaves.
The suture should be pulled from the lip to the ipsolateral vestibular incision. With the needle we pass columella and knot the suture under slight tension. In this way we have elevated the vermilion border by 1-2 mm. e Dermographic markings. f Result 3 months postoperatively
I remember times when we excised 2-3-mm-wide strips of upper-lip and sometimes lower-lip skin to pull out and extend the red surface of the lip, enlarging the lips in this way. Scars after this procedure were not completely invisible. Now I prefer filtropexy, which was introduced by Onur Erol. This is a simple and effective method.
Another suspension we have developed and which we presented at the 37th American Aesthetic Meeting in Vancouver 2004 is "optimistic sutures". Many
(mouth) or solid subcutaneous bridge of connecting tissue below the nostril. d The hollow probe drives below the nasola-bial fold from the medial end of the mouth angle incision to the medial end of the alar base incision pulling a 4-0 nylon colourless nonresorbable suture through. (Fig. 57.12 e-h see next page)
methods have been suggested to elevate descendent lip commissures. This produces sad, pessimistic facial expressions, which is of disadvantage in social life.
angle incision, where we tie a knot. g No overcorrection in this procedure! h We should elevate the lip commissure up to the horizontal line, not further
Our "optimistic sutures" can optimize the outcome of the facelift.
Many patients can benefit from this simple proce- This procedure takes 5 min, we need only two indure. struments, one suture, and the outcome of the facelift can be optimized.
"Optimistic sutures" can be combined with any other facial surgery, just being one of some small but important mosaic stones of facial expression.
We face from time to time patients whose upper-lip insertion is too high. The result of this anatomic variation is an "unpleasant smile" with "gingiva-show". Some patients call it the "horse smile of Mr. Ed".
Simple vestibulectomy and suturing the supralabial mucous membrane to the gingiva was unsuccessful. These sutures had no stable support and were pulled out after only a few days.
All the suspension sutures we know in the face elevate anatomic structures upwards. In this case we need something which will immobilize the nostrils with strong perilabial and nasal musculature not allowing the sutures to be pulled out.
After having done the upper preoral vestibulecto-my, we bore with K-wires a horizontal channel in the processus alveolaris maxillae over the second incisor. Through this we pull the 4-0 colourless nylon suture.
We prepare the tissue till we feel firm insertion of the nostril to the periosteum, drive with a Dechemp hook around it, and go down to the other end of the nylon thread and suture it. In this way we have immobilized the nostril and our vestibular suture is not in danger anymore of being pulled out.
Please see the general bibliography at the end of this book.
Fig. 57.19. Aesthetic principles have to be respected in reconstructive and constructive surgeries too: a Bilateral, complete cheilognathopalatoschisis. b Lip closure (Tennison), palate closure (Kriens) and pharigeal flap at the age of 6 months. c She is now 14 years of age; tip of the nose constructed with two helix-tail grafts, proximaly sutured - tip suture still to be done. d Three-level procedure: columella advancement from filtrum; upper lip formation of M-shaped Abbe-lip-flap rotated from the lower lip (for 10 days); donor site of lower lip closed with M-Y-plasty. e Her profile before last surgery. f Six weeks after profiloplasty; note proper fullness of both lips. g Nose and lip correction planed with dermographic markings. h Her look 6 weeks after last surgery.
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