How Should My Double Lip Be Repaired?

Q: Dr. Eppley, I have a double upper problem but am not sure if a lip reduction of the redundant mucosa would be all that is needed to correct the problem. I am being told the underlying issue is the orbicularis oris muscle, although some surgeons want to just excise the extra tissue that is folding. From my research “double lip is a variant of occult (hidden) cleft lip, which occurs due to mal-alignment of muscles acting on the lip. Correction needs both removal of excess fibro-fatty-vascular tissue as well as restoration of normal lip muscle orientation and frenum lengthening”. The reason I included this is because most surgeons are saying mucosa reduction, or it’s the muscle, but nobody has mentioned in addition to a reduction of the mucosa fold, restoration of normal lip muscle and frenum lengthening would also be needed.

One surgeon has told me that I have a midline diathesis of the distal orbicularis oris muscle resulting in a lack of movement of the central lip relative to the lateral portions. A few surgeons have mentioned that they think the underlying issue is the muscle and that the redundant mucosa may come back down the line after an excision of the redundant mucosa. Some are also cautious with doing a reduction because they think it will thin out my top lip too much relative to my bottom lip. I guess because I keep receiving mixed opinions, I have not moved forward, even though there is the redundant fold.

I know you would probably need to see me for an in person consultation, but any feedback from my notes and photos would be appreciated.

A: You do have a variant of the double lip anomaly although it is not the classic presentation. Most double lips are merely redundant wet mucosa and can be elliptically excised as they lie behind the we-dry vermilion border. They are usually present both at rest and smiling but are accentuated with lip elevation. Double lips have nothing to do with cleft lip deformities and no one knows why they occur.

Your double lip phenomenon, however, has a visible indentation in the dry vermilion anterior to the wet-dry junction. Thus, removal of the ‘overhanging tissue’ would indeed likely thin out your upper lip and, at the very least, give you more visible tooth show at rest and a much thinner upper lip on smile accentuating a mild gummy smile that you have now. (although you may have accentuated that for purposes of showing the tissue roll better)  I do not believe your lip issue is a simple ‘too much tissue’ problem and would not do an elliptical excision. I would be wary that would not improve things and may make them worse.

When it comes to a discussion about the orbicularis muscle component, be aware that this is a theoretical supposition. The orbicularis muscle runs parallel to the lip margins not vertical. There is not a vertical cleft in it, which is what is  referred to as a midline diasthesis, and if there were the overlying skin would reflect that by having a notch or some variant of a cleft. In addition, such a theoretical diasthesis can not really be effectively repaired even if there was one. All that would do would be to make upper lip tighter and more stiff.

I would think more about a lip rearrangement where a  V-Y lengthening of each side of the folds or a running W-plasty along the vermilion indentation is done. Preservation of lip tissue is the objective not removal. It would also be interesting to know what your maxillary frenulum looks like although this would not change how one would approach the double lip problem in any substantative way.

Dr. Barry Eppley

Indianapolis, Indiana