Your Questions

Q: Dr. Eppley, Can a corner lip lift combined with a subnasal lip lift bring about the same results as a gullwing lip lift if you want to try to do avoid as large of a scar at the vermillion border as possible?

How much can alar retraction be corrected in millimeters? If oyu have an exceptioally severe case is it possible to do two operations the same way if someone wants exceptionally large breast implants they can get implants the first go around and then have the skin stretch, then replace implants later with larger ones? In the case of the nostrils, is it possible that the first time will not fit a large enough graft but this can be replaced later on down the road after the nostrils have adjusted? 

Is there a procedure that can correct  masculine and broad shoulders for a female that wants a more petite upper body? Something like clavicle reduction?

A:  A subnasal liplift combined with an extended corner of the mouth lift is a  way to create a similar effect as that of the lip advancement procedure. (gullwing lip lift) The subnasal lip lift substitutes for placing the excision of skin across the cupid’s bow area. Lateral vermilion advancements brought inward from the mouth corners is still needed but they do not encroach onto the more visible and delicate cupid’s bow area of the upper lip.

Alar retraction is treated by the placement of alar rim cartilage grafts. They will create a several millimeters of correction. More significant alar retaction may need to be treated by the placement of composite skin and cartilage grafts to roll out the inner lining. (which is where the skin portion goes. This it is not like your breast implant analogy at all.

There is no operation to reduce wide shoulders. A bony reduction is not possible because that impinges on the moveable shoulder joints.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr Eppley, After a rhinoplasty I was left with a big space between my nose and lips. My surgery was 6 days ago. Do you think this might still change and I should wait longer until considering a subnasal  lip lift? Thank you so much!

A: It would be entirely premature to judge what effect your rhinoplasty will have on your upper lip length at just six days after surgery. While it is unknown to me as to what type of rhinoplasty you have had, any rhinoplasty surgery that results in tip rotation and/or tip shortening is going to initially create the perception that the upper lip is longer. In reality it be now more exposed with the change (opening) of the nasolabial angle…or it is possible that it may have indeed become lengthened. But until all the swelling from the rhinoplasty surgery has resolved and the tissues have fully settled, any aesthetic judgment on upper lip length can not truly be appreciated. I would not perform an upper lip lift on a rhinoplasty until they are six months out from the procedure, not only because of the uncertainty of the aesthetics, but because of the intervening skin between an open rhinoplasty incision and that of the subnasal lip lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I would like to discuss lip aesthetics. I have noticed that in certain people, their lips in the relaxed, open mouth position, there is a nice exposure of the upper teeth. I would say that this is an attractive trait. 

I would like to posses this feature, but unfortunately, I don’t. When I relax my lips and hang them open slightly, I only feel the my bottom lip hangs and only the bottom row of my teeth show. My upper row teeth do not make an appearance because my upper lip doesn’t move when relaxed. Photos attached,

I have fairly thick lips for a male, so I am looking at getting lip reduction. My question is how to achieve that ‘upper teeth open mouth’ look? Would a lip lift help?

Is there a specific name for this look that I can Google?

A: The procedure yo are seeking does not have a specific name because it is a combination of two well known procedures to try and create the effect you are after. What you need is a combination of a sub nasal lip lift with an upper lip smile line reduction. The lip lift will raise up the central part of the upper lip. (ratio of about 4 :1, meaning for 4mm of skin removed under the nose it will move the smile line level of the upper lip 1mm) Then a horizontal reduction of the vermilion-cutaneous junction of the upper lip of about 4 to 5mms will help raise up the bottom of the upper lip. Together you should be able to develop some natural upper tooth show. The lower lip will, of course, need to be reduced by about 7 to 8mms to match better with the upper lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the following procedures:
1) Lateral commisuroplasty
2) Bullhorn lip lift

My questions are:
1) Is it possible to have the procedures in the same setting?
2) Are the procedures done under local anasthesia or twilight sedation?
3) What are the costs involved with the procedures?

My main concerns with my mouth are as follows:
1) my mouth is too small (horizontally)
2) the gap between the my nose and upper lip is quite long which i also dont like.

The result I am wanting to achieve is a more aesthetically pleasing, youthful looking mouth. I want to create a fuller appearance to this area of my face to create a balance in my face. Thank you for your time.

A: A subnasal lip lift (aka bullhorn lip lift) and lateral commisuroplasties (mouth widening procedure) can be done at the same time under local anesthesia. These are common office-based procedures done without the need for general anesthesia or IV sedation. They have minimal recovery in regards to pain, swelling and bruising. The scars do take some time to fade sufficiently but can be covered with make-up in the interim. (four to six months)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wearing braces and the distance between my upper lip and nose is short maybe 1.2 cm now. But I know that if I take off the braces the distance will increase to 1.4 or 1.5cm. I don’t want to do lip augmentation. I want the lip lifting procedure and I want to do it wearing braces. Is that possible?

A: Having orthodontics appliances in place does not impede the ability to do a subnasal lip lift. The question is whether one can tell how much to remove so as not to end up with an overdone result. Subnasal lip lifts that have had too much skin removed have no recoverable strategy…you can’t put back the skin that was removed without a very visible graft under the nose. If your calculations are correct you would do a 3mm skin resection for your subnasal lip lift. If you have do do the lip lift before your braces are removed just make sure it is a conservative amount of skin removed. Removing your braces ma result in the lip lengthenng a few millimeters. But since you have not done that test (remove your braces and measure it), assume that maybe no change in lip length will occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had a subnasal lip lift which I am pleased with the lift in the center of my lips. Now however, it seems to accent the thin corner of my liplips. Aesthetically to balance out the look, I think this is something that should have been done too. Can a corner lip lift be done with local anesthesia?

A: The subnasal lip lift in the right patient is a very effective lip augmentation procedure but it will only affect what lies within the skin excision pattern. By dropping down a vertical line from the sides of the nose to the lip, the lip area improved will only lie within. In essence, it shortens the amount of vertical skin between the base of the nose and the upper lip and only provides accentuation of the cupid’s bow of the upper lip. It would not be rare to a have a lip lift patient turn their focus to the sides of the lip and the mouth corners thereafter.

The key question about changing what was not improved by the lip lift is defining the exact area of outer lip deficiency. This could be either an isolated corner of the mouth lift or an extended corner of the mouth lift that extends further up along the sides of tails of the upper lip. This distinction is critical to understand. An isolated corner of the mouth lift will just change the angle of the corner of the mouth and will not make it thicker. A extended corner of the mouth lift or an outer lip advancement will make the sides of the lip fuller.

I would need to see a picture of your lip to help you decide what is the correct lip augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to explore a lip lift and corner lip lift. I have an unusually long upper lift (distance from bottom of nose to top lip) and would look much more balanced if that distance could be shortened. However, I have an over rotated upturned nose from previous rhinoplasty. This means there is no crease or space in the shadow of a nose that a scar could hide and it would mean that if there was nostril distortion, it would be very visible and unattractive. Given how little room for error my nose allows for this lip lip and corner lip lift, should I consider this surgery or let it go?

A: When it comes to a subnasal lip and corner of the mouth lifts, the most important issues are the potential scars and not overdoing either type of lift. Prominent scars or an overcorrection (which is virtually impossible to correction since you can not add back skin) are aesthetic tradeoffs that one needs to avoid. While I have not seen a picture of you, you may have answered your own question…if there is little to no room for error…why take the chance? I have never seen nostril distortion and have only rarely revised a subnasal lip lift scar but your concerns do have merit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a subnasal lip lift proceure but I must admit that the procedure worries me. There seems to be lots of unhappy results, in which columella has gotten longer, nostrils became wider, and people end up looking like rabbits etc . My local surgeon says that in his experience, after the lip lift,  is that with time the lip always goes back to its original position, due to the weight. Do you use a special kind of suture and/or technique that would prevent the lip from pushing back down?

A: While the subnasal lip lift procedure is relatively simple to do from a surgical standpoint, it is a procedure that has no tolerance for error. From selecting the right patient, to the design of the skin removal area and to the method of closure, all impact what the final result will look like. There are several key points to a successful lip lift result. The first is to recognize that its effects are on the central or cupid’s bow area of the lip and does not extend to the mouth corners. Secondly, the excisional pattern of design should mimic exactly the curvatures of the lip-nasal base junction and should not extend around to the side of the nostrils. Third, the amount of vertical skin excision (as measured at the philtral columns) should never, and I repeat never, exceed 25% in a man and 33% in female. Lastly, no attempt should be made to prevent some after surgery relapse by sewing muscle, removing muscle or otherwise trying to secure the skin down in a tightened fashion.

If you add up all of these points together, one can see that the key to a happy subnasal lip lift result is to not try and over do it. Overcorrection and lack of attention to detail makes for most of unhappy subnasal lip lift results.

It is important to recognize that in the first six months after surgery there will be some ‘relapse’ of the initial result. This is due to natural skin stretching from lifting any type of tissue upward. (no different than a browlift or facelift) My observations have been that it is about 25% to 33% vertical change in the first six months after the procedure. But trying to overcorrect to factor in this after surgery lengthening is a mistake. It is far better to have a natural looking lip result that a patient wants to secondarily revise (about 10% do) than to have an initial overdone too pulled up look that the patient is waiting months for it to settle down and drop.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a subnasal lip lift. When you perform them, how is the healing of the scar? I know the scar is placed at the base of the nose, but I have seen some horror stories where the incision is just below the nose and thus is very visible. Do you also pull the muscle or just the skin with the lip lift? I have a 21mm gap between the base of my nose and my upper lip. After my rhinoplasty (which I am having first) I am presuming this gap will stretch to approximately 23mm- in any case I am hoping to have a 15mm gap.

A: The key to a good subnasal lip lift scar is two-fold; place it exactly in the nasal-lip crease and it should follow the shape of the nasal base (wavy) and not a straight line. You never manipulate the orbicularis muscle in a subnasal lip lift, that is an assured way of causing tightness and smiling animation deformities. With a 21 to 23mm lip to nose distance and using a 1/3  distance reduction (amount of skin excised), you should be reduced to a 15mm vertical length.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a subnasal lip lift. I have a long upper lip and I think it would make my face more balanced and attractive. I have not read anywhere on how one determines the amount of skin that can be removed between the lip and the cupid’s bow. I want the maximum to be removed but I still want it to look natural and not be overdone. I want to increase the size of my upper to the maximum as it is basically non-existent now. Also, will the subnasal lip lift increase the size of the whole upper lip and not just the cupid’s bow directly underneath the nose? Thank you.

A: In a subnasal lip lift, you do not want to remove more than 1/4 to 1/3 of vertical distance as measured along the philtral columns. Whether that is 6 or 8mms is a judgment between aggressiveness but also wanting to avoid an unnatural and potentially irreversible overdone result. Applying the principle that it is easier to remove more later but you can’t reverse it, I would take no more than 6 to 6.5mms of skin. Also a subnasal lip lift will not change the amount of exposed vermilion out to the mouth corners, it will only change the upper in teh middle third or within or under the nose area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a subnasal lip lift problem. Wish I’d seen your website some months ago. Four weeks ago today, I underwent a sub-nasal upper lip advance (bull horn) by another surgeon. Pre-op I had a lot of distance between my upper lip and my nose and it meant that when I smiled, only my lower teeth showed .(making it appear that I was grimacing). I was advised that I had 21 mm of distance from the top of my lip to the base of my nose, and that I would  benefit from having 6 – 7 mm of tissue removed, in order to show more upper teeth, even when my face was relaxed. Sadly, although visual imaging was available, the visualization was not shown to me. (My mistake for not asking to be shown what I would look like with a lip lift). Although I was told that only 6 mm of tissue was removed, it appears that more than this amount was, in fact, removed. From the base of my nose (columella?) to the top of my cupids bow I have 12 mm of ‘space’ and (for a male) a ‘cupid’s bow’ that is a bit too pronounced. I feel extremely self-conscious, and have been limiting contact with friends and family ever since the surgery. At four weeks post-op, I would imagine that it is doubtful that my upper lip will ‘settle’ any further? Even a ‘gain’ of one or two mm would help things, although 3 mm would be perfect! Although I suspect that this cannot be repaired by replacing tissue, I wonder if surgery to my ‘dangling colummella’  of my nose would allow me to pick up an extra two or three millimeters of space between my nose and upper lip? Of course, not sure if that would ‘relax’ my upper lip so that I did not have such a pronounced ‘cupid’s bow’. Is this something that you have encountered in the patients of other surgeons, and if so, what (if anything) can be done to try to revise this undesired outcome? Incredibly, as you mention in your website, it really is a case of only a few millimeters.

A: In performing subnasal lip lifts, my general rule is to never remove more than 1/3 of the philtral length in females and only 1/4 of that length in men. In judging the amount of upper lip skin removal, it is always better to be conservative as one can always do more. If too much is removed, some skin relaxation will eventually occur (even up to six months after surgery) but there is no method to add more skin. This skin can not be recruited from the columella…hanging or not. You should keep working on stretching the upper lip with your fingers and tongue as you should be able to gain a millimeter or two over time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am trying to decide between a lip lift and a lip advancement. I am aware of some of the differences between the subnasal lip lift and the vermilion  lip advancement. I have read through the information concerning these two procedures on your website. As I understand it, both procedures will reduce the distance between the lower portion of the nose and the upper lip. However,  the vermilion lip advancement will result in an increase in vermilion show throughout the entire upper lip, while the subnasal will only lift the central portion of the lip. In addition, the lip advancement  requires an incision along the entire upper lip which will result in a scar that will most likely be longer and more noticeable than the scar underneath the nose from a bullhorn lift. I would like to know any other advantages/disadvantages concerning both procedures that I may not be aware of. Based on the photos that you have before you, I would like to know what your recommendation would be in my particular case.

A: You seem to have a good grasp on the differences between a lip lift and a lip advancement. The decision then for any patient is balancing the concern about the scar vs. the degree of improvement they desire. Unless one has an absolute pencil thin lip (in which only the vermilion advancement will be effective), many patients opt for the subnasal lip lift due to less scar concerns even though only the central part of the upper lip is affected. Doing a subnasal lip lift first does not exclude the option of proceeding later to a vermilion advancement if one finds they want a more significant result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some lip augmentation procedures. My lips are getting thin with lines above them and the sides of lips are turning downward. So I would also want to have lip enhancement like implants which are permanent. And a treatment to reduce the lines above my lips.  Can I have these procedures on the same day? I have attached some pictures of my lips close-up.

A: Your lip augmentation will require a composite of procedures to get the best overall result. You actually do have some reasonable vermilion height although the upper lip is thinner than the lower. Your upper lip is also very long. Putting these lip issues together the best approach for your upper lip is a subnasal lip lift (to shorten the length of the upper lip), lip implant (for permanent volume), extended corner of mouth lifts (to lift up the corners and to make the tail ends of the upper lip thicker) and laser resurfacing of the upper lip. (to reduce the depth and number of vertical lip lines) These combined lip procedures can be combined with a lower facelift which is commonly done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21 years old. In March I have planned some maxillofacial surgeries. Currently I have a chin implant large anatomical. I have a problem in my maxillary prognathism which is vertically long. A maxillofacial doctor also diagnosed me with micrognathia. I have no problems with my bite. My upper jaw is too long like my upper lip. Then I realized I needed an upper lip lift and a Lefort 1 osteotomy. The only plastic surgeon I have seen thinks I need a upper lip lift (remove 6-7 mm) but the problem is that I have a gummy smile. My question is what is best to do first? And how long should I wait to do them?

A:  With a vertically long maxilla and an overlying long upper lip, it is an interesting question as to which one should be done first. If I make the assumption that you really need both bone and soft tissue shortenings, whichever one is done first will leave you with an increased aesthetic deformity before the second stage correction. In these situations, it is always best to do the underlying foundational change first. Because the bone surgery is more involved and may change what is eventually done in the amount of upper lip lifting, the LeFort impaction procedure should be done first. Once the bone level is set then the upper lip lift can be done based on the position of the lip to the maxillary anterior teeth. Also dependent upon how long your upper lip is and how much vertical maxillary shortening is needed, it is also possible to both together…but using only a conservative upper lip reduction as more can be done later if needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe you are a real specialist in the matter of lips aesthetics and procedures and will greatly appreciate your advice if I should undergo a lip lift or fat transplant. Temporary fillers don’t work for me. I have attached some pictures from different angles for you to see the shape of my lips.

A: Thanks for sending your photos. I think they illustrate well your longer upper lip and you have always illustrated to some degree the effects of a subnasal lip lift. I think you are a good candidate for the procedure. I think with your vertical upper lip length that you are much better off  with a lift rather than fat injections. Also the result from a lift will be more predictable than with fat injections. Fat injections also will not shorten your upper lip length nor will they create a more prominent cupid’s bow. This can be done under local anesthesia in the office as I do many isolated lip lifts that way. The biggest issue is the fine line scar along the base of the nose but if well placed it fades very nicely and quickly. (a few months)

Q: Dr. Eppley, I had a rhinoplasty revision a year ago which has ultimately resulted in a much longer appearance of my upper lip. Since you’re an OMFS and a plastic surgeon, I’d really be interested in consulting with you about a lip lift +/- autologous fat grafting. I’m definitely interested in the subnasal approach, and since I talk to people all day long and occasionally engaging in public speaking, I’m also looking to leave the orbircularis oris alone as well. I would greatly appreciate your expertise and evaluation.

A: The long upper lip implies too much vertical skin between the base of the nose and the upper lip, a small or diminished vermilion show at the cupid’s bow area, lack of adequate upper tooth show or any combination of these three effects. For most patients, the subnasal lip lift is almost always preferred because of the less visible location of the resultant scar in a natural skin groove. There never is any reason to manipulate the orbicularis muscle in a subnasal lip lift as that only causes animation problems and accomplishes no positive effect. Injectable fat grafting can be done in a lip lift if an enhanced cupid’s bow or the lateral vermilion down to the corners of the mouth is desired to be enhanced. Micrografting of fat in 0.1cc aliquots is the best method of injection in an area where fat retention is notoriously difficult.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Can you please tell me the cost of a subnasal lip lift? I am not interested in having surgery on the muscle. I only want the lip lift where the skin is removed.

A: A subnasal lip lift should never have the muscle manipulated in any way. That leads to problems such as tightness, columellar base retrusion and an unnatural upper lip movement and smile appearance. In my hands, it is always a skin only procedure. While this may be associated with a 1 to 2 mm relapse in some cases over the first six months after the procedure, it does not in any way affect how the upper lip moves or alters one’ smile.

A subnasal lip lift for most patients is done as an outpatient procedure in an office setting under local anesthesia. The typical cost would be in the $2,200 range.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, Hi. I have a few queries about possible procedures which may enhance my smile and lip shape. First of all, I have quite a small mouth, as in the horizontal distance from corner to corner of my lips is quite short, and therefore my mouth at rest is small and my smile does not show many teeth. Is there any procedure, such as lip lengthening, which can make my mouth opening wider- hence make the horizontal distance of my mouth at rest longer, and to make my smile wider? My next issue- which I think is related, is that my top lip covers quite alot of my top teeth when smiling, and also I would like my top lip to be more outturned or ‘pouty’. Is there a surgery which can reduce the distance between the nose and the lip to reveal more vertical distance of the teeth when smiling, and to achieve a more “pouty” shape? I’m not sure if it would help to send photos, but I can if that is needed. Thank you in advance!

A: What you are seeking is a horizontal widening of the corners of the mouth and a vertical shortening of the upper lip. There are surgical procedures for each of those changes. The upper lip can be vertically shortened, the upper lip become more pouty and more upper teeth can be shown through either a subnasal lip lift or an upper lip vermilion advancement. Which one is better for you would depend on seeing a picture of your lower face for my assessment and what location of scar would be preferable. (under the nose or along the vermilion-cutaneous border) The corners of the mouth can be widened through a commissuroplasty procedure where a v-shaped segment of skin is removed (about 5 to 7mms per side) and the corner vermilion advanced outward on each side. Whether that fine line scar around the corners of the mouth is acceptable would be the concern.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am serious about getting a bullhorn lip lift. I am a model and, although I am considered very attractive, I do not feel my mouth area looks the best. My lips are reasonably full but my upper lip is too long and I don’t show any teeth even when I smile. That is why I think a lip lift would enhance my appearance. I have attached some modeling photos for you to see what I mean. What do you think?

A: Thank you for sending your excellent photos. While you do have a very nice shape to your upper lip, I can see your concerns that it is vertically too long between the base of the nose and the upper lip vermilion. I think you would be a good candidate for the subnasal lip lift as it would decrease this vertical skin distance, give more pout to the central cupid’s bow portion of the upper lip, and has a chance of increasing some tooth exposure between the canines.

This is an office procedure done under local anesthesia. (infraorbital nerve blocks and direct infiltration into the base of the nose) The key is to have a wavy excisional pattern for the lift so the scar blends in along the base of the nose. As an out of town patient, I would use tiny dissolveable sutures for the final skin closure so no postoperative visit is necessary. There is always about a 20% to 30% relapse of the lip lift over the first six months after the procedure so it is a little ‘over-corrected’ in the beginning to compensate for that event. However, it is very important to never remove too much lip skin as there is no way to reverse that problem. You can always take more if needed so undercorrection is always better than overcorrection.

Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in a subnasal lip lift. I have had other minor plastic surgery procedures which were done with very good results, little scarring and very little down time. My upper lip is my greatest area of facial concern due to the length of my upper lip. It actually seems to be getting longer as I get older. It was always a little long even when I was younger but time is not making it shorter! I can send you pictures if you like. I live out of the states so please let me know if  this procedure is something that could be accomplished with an out of town surgery visit. Thanks so much!

A: Thank you for your inquiry. A subnasal lip lift is a relatively simple procedure that can be performed in an office setting under local anesthesia. It is a delicate and precise lip procedure but the process to do it and the recovery is the simple part. It is a common procedure that patients from far away come into Indianapolis for me to perform. There is no physical recovery required with minimal swelling and virtually no bruising. One could have it done and leave for home whenever they want. There is no reason to stay here afterwards. I always use tiny dissolveable for the skin closure so the patient has no need to return for their removal. Please send me a picture of your lips for my assessment to determine if a subnasal lip lift procedure is for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in getting a subnasal lip lift as my upper lip is way too long and is getting worse as I age. I have several concerns about the procedure, hwoever, and wonder what could be done if undesired results happen. I had a previous rhinoplasty dne through an open rhinoplasty several years ago that I am quite happy with. Since the subnasal lip lift puts an incision at the base of the columella could that stretch or distort the space between my nose and lips and make it appear freakishly short? I know initially it may look a little short and that it does relax and stretch out somewhat later, but what if it doesn’t. Can any secondary correction be done if things didn’t resolve on their own? Thanks for your opinion.

A:  Your concerns about overcorrection in a subnasal lip lift, also known as the bullhorn lip lift, are very valid and it is something I think about every time I do this procedure. This is because of it is overcorrected, too much lip skin removed, there is no recovery from it. There is no aesthetic method of putting skin back once too much is removed. It is for this reason that it is always better to be more conservative than aggressive with this procedure. My rule of thumb on subnasal lip lifts is too never remove more than 1/3 of the vertical distance of skin as measured from the based on the columella down to the height of the cupid’s bow along the philtral column. Sometimes I may only remove 1/4 of that distance. Yes it is too true that it may relax and be undercorrected in some cases later. But it is always easy to repeat the procedure, it is impossible to reverse it if too much is removed.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am interested in getting my nose fixed and have my upper lip shortened at the same time. I have been some research on lip lifts and it seems wonderful and the results are exactly what I want. But you have written that a rhinoplasty can not be done at the same time. That bothers me because I did not want to recover twice. But I have been doing some searching and som,e doctors do both at the same time but some don’t. Is there a possible reason/ I really want to have my surgery with you because you have the best before and after pictures I’ve ever seen for noses that are similar to mine.

A: The reason that I don’t combine an open rhinoplasty and a subnasal lip lift is because of the potential risk of skin necrosis. When done together, there will remain a small area of columellar skin between the two incisions, that of the open rhinoplasty and about 6 to 8mms below that of the subnasal lip lift. The survival of that skin depends on having an adequate blood supply coming into it. Part, and may be most, of the blood supply to that skin is cut off by making those two incisions at the same time. While it is likely that it would be fine with some blood supply coming from the septal mucosa, there is some risk that it might not be and that skin would then die. That would be a cosmetic disaster and my concern is more then theroetical…I have taken care of a patient who had that exactly happen when those two procedures were done together by another surgeon. Given that the lip lift can be done as a simple office procedure later under local anesthesia with very little recovery, I don’t think the risk is worth it for an elective cosmetic operation.

If one was doing a closed rhinoplasty, in which a columellar incision is not used, then a subnasal lip lift could be done at the same time. It is likely that is the type of rhinoplasty the doctors who say they do it at the same time are performing.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to know what you recommend to make my nose smaller and my upper lip bigger. I have attached some pictures of myself for you to see and do computer imaging as well as some pictures of my goals. I understand the results are not going to be identical. The pictures are just an “inspiration” of what i want to achieve. I’am very excited to see the computer imaging!

A:  Thank you for sending your pictures. I have done somecomputer imaging on your nose and lips. The side view is not a good quality image but I did the best I could. The refinement in your nasal tip will be somewhat limited by the thickness of your nasal skin which is always the limiting factor in tip definition from a rhinoplasty. But the tip area can definitely be improved. I also did some cartilage buildup of the dorsal line and bridge area. This will help make the rest of the nose higher and slimmer which will also help the appearance of the tip.

From an upper lip standpoint, you have nice contours and definition but just need some more volume. I would recommend concentrated fat/stem cell injections into the upper lip. That could be done at the same time as the rhinoplasty. An alternative is a subnasal (bullhorn) lip lift but this can not be done at the same time as an open rhinoplasty. Therefore, I would do the fat injections at the time of the rhinoplasty and see how that turns out. The subnasal lip lift can always be done later as an office procedure under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 38 years old and I need some changes to my face. It is a very round face without much definition or highlights. From a side view, I think my profile would be much improved with chin augmentation and fat removed from under my chin.. I do not know if my chin augmentation would benefit more from an implant or osteotomy. From a frontal view, I would like the distance between my upper lip and nose shortened. It is too long and I have a thin upper lip as well. I am attaching some picture for you to image to show me what could be done with plastic surgery.

A:  Thank you for sending your photos. I have done some computer imaging based on your desired changes.  I think you are correct in predicting that chin augmentation (implant not an osteotomy) with submental liposuction would make a nice change. The combination of the two can completely change the profile of your lower face. From a lip standpoint, your upper lip is very long and a subnasal lip lift would help shorten that distance. I have also added a buccal lipectomy to help slim your cheeks which would provide a good thinning complement to the proposed fat reduction in your neck.

 The combination of all four of these changes would help make your face more proportioned and balanced. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have some questions about the lip lift. I know that this procedure is quite controversial in cosmetic medicine. The plastic surgeons in my area will not perform it. However, after doing some research I have found that there are ways for it to be done successfully without cutting the orbicularis  muscle. What is your opinion and experience with this procedure?

A:  When you say lip lift, I will assume you are referring to the subnasal lip lift. (aka bullhorn lip lift) This is where skin is removed from under the nose to lift up the central third of the upper lip and shorten the long upper lip. Despite a lot of hesitancy from plastic surgeons to perform this lip enhancement procedure, I have found it to be very straightforward and uncomplicated. There is no reason whatsoever to remove any orbicularis muscle when shortening the upper lip. This is fraught with problems if done including a tight upper lip and an abnormal smile. While muscle resection probably does prevent any vertical relapse, it causes irreversible lip problems. Relapse is a much more easily treatable ‘problem’ so only skin should be removed. As a general rule, no more than one-third the vertical distance along the length of the philtral columns should be removed. One can expect 1 to 2mms of relapse in the first few months after the procedure.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hi there, I was interested in your lip lift procedure and wondering if you did fat transfer to the face for reshaping/volumizing, and a butt lift using fat transfer.  I’ve been researching for several months and I’m ready to have it done, but I’m wanting to find the right surgeon for me.

A:I do a lot of fat injection surgery, most commonly to the face for volumetric enhancement and to the buttock for augmentation, otherwise known as the Brazilian Butt Lift.  Fat transplantation by injection is a really exciting approach for numerous face and body contour problems even if its ultimate survival is not always assured. The exact technique for fat preparation varies by surgeon and there is no absolute agreement as to how it should be done.  I use a fat concentration technique and then mix it with PRP and Acell Particles to enhance survival and volume retention. These are by far the most common recipient locations. The key is whether one has enough fat to harvest which is an issue for the buttocks and not the face.

Lip ‘lifts’ can be done as either a subnasal lip lift or a vermilion advancement depending upon the shape of the upper lip and the patient’s scar tolerance. Please send me some photos of your lip for my assessment. Both approaches can be very successful when properly done. Vermilion advancements produce the most dramatic change in lip size and shape. True subnasal lip lifts are more limited in how they change the shape of the upper lip.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi, I live in the UK and am interested in a gull wing lip lift. I have a few questions. How bad can the scar be? Do you have any photos of ‘worst case scenario’ ? Also can there be tightness or loss of feeling afterwards? Why do so few plastic surgeons do this operation? If I have a lower lip increase as well as upper would I have increase bottom tooth show? (which I don’t want). Lastly, how soon after can I fly back to the UK?  I could get a surgeon here to remove stitches if necessary.

A: Thank you for your inquiry. Having done a lot of subnasal lip lifts, I have never seen a bad scar and not a single patient has ever complained about any scar issue. While there may be some temporary upper lip tightness, it passes quickly and no patient has ever told me that it is a long-term problem. Patients do say that they have some upper lip numbness for a period of time which has always surprised me but it is a consistent finding. No sutures are placed that need to be removed as they are all dissolveable. One can return home the very next day. There are no restrictions after surgery.

While you will have some increase upper tooth show (1 to 3 mms), which is desired, there is no increase in lower tooth show. That is controlled by the lower lip position not the upper lip.

I don’t know why so few plastic surgeons do lip lift or advancement procedures. In the right patient they are extremely successful with no significant problems.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in shortening my upper lip. It is way too long. It is big enough that you could land a plane in that part of my face! I have read about the subnasal or bullhorn upper lip lift and that seems like a good solution to my problem. However, I am Hispanic and am concerned about the car under my nose. I have read about the Italian upper lip lift which does not create the scar under the middle part of the nose. Do you think this is a good option for me?

A: The only way to really shorten an upper lip is to remove a strip of skin, either across the subnasal base (under the nose) or across the top of the cupid’s bow. in the ‘Italian’ version, the select removal of skin from just under the nostrils will not significantly shorten the upper lip. That published article, which I have read and reviewed in the past, is quite frankly flawed. All of the patient results shown have the after photos with the head tilted upward which makes it look like the lip is shorter. (or the before photos have the head tilted slightly downward to make the lip appear longer than the afters) While I don’t think the authors deliberately meant to deceive the readers, the results do not support that it actually works. While having less scar under the nose is certainly appealing, the upper lip is not going to get shorter if the central part under the columella is not removed. That is the cornerstone of upper lip lifting. With your ethnicity and skin pigment, a scar anywhere is always a concern more of a concern than it would be in a Caucasian patient. It may be for that very concern that the Italian upper lip lift was devised.

Dr. Barry Eppley

Indianapolis Indiana

Q: I read with interest your article about upper lip lifting in the case of a retracted columella.  I’m a 35 year old trangendered male who’s already undergone a feminizing forehead procedure elsewhere.  My upper lip is VERY long and unattractive, but I’ve been told that, because of my nose, to shorted it I’d have to have grafts taken from elsewhere or even have my upper jaw moved, which needless to say I’m not crazy about.  I have a short, upturned nose that I really rather like, but the long upper lip is a big issue and I’m curious if anything can be done without rib grafts or the like.

A: A subnasal lip lift can be done whether you have a retracted columella or not. The ability to do that fairly simple lip lifting procedure is not restricted by a retracted columella or decreased nasolabial angle. It may be aesthetically better to deal with the retracted columella at the same time however. That could be done in a variety of ways, all of which involve the insertion of some supporting graft behind the nasolabial angle. Instead of a rib graft, I would consider a dermal graft which does not need to be harvested from the patient. That could be inserted directly down to the columellar base from the a small opening after the bullhorn lip skin is removed and before final lip closure. But whether you even need that is unclear to me at this point. I would need to see see some lip photos to answer that question.

Dr. Barry Eppley

Indianapolis Indiana

Q : Hi, I found you in reading an article you wrote. This situation applies to me as I very recently had a subnasal lip lift done and I am still in recovery. I can see that my upper lip is crooked and way over corrected so much that my upper lip may be unfunctional. The worse part is however I had no idea I would not be able to smile, and appear deformed should I try to smile!!! I was told to expect some tightness but this is beyond tightness. What are my options? Can I get my smile back?

A: In the subnasal lip lift procedure, a wavy amount of skin (thicker in the middle) is taken directly beneath the nose with advancement of the lower edge of the incision to the area directly beneath the nose. The final closure is tucked in along the base of the nose from one side of the nostril to the other. This procedure shortens the distance between the top  of the upper lip vermilion and the base of the nose allowing for more upper tooth show when the lips are slightly parted. It also everts more of the upper lip vermilion, therefore creating an increased amount of a central pout of the upper lip. It is always slightly overcorrected as there will be some relaxation (mild re-lengthening) of the upper lip afterwards.

While this is a fairly simple procedure, I have seen and read of some problems associated with it. One complication appears to be from manipulating the underlying orbicularis oris muscle besides the skin while doing the upper lip lift. In theory, sewing the orbicularis oris muscle to the periosteum underneath the nose may make for a more stable long-term result. However,such a maneuver creates an unnatural stiffness and deformity of the upper lip when can be evident during smiling. This is not a good trade-off for the theoretical benefits of this manuever.  It is far better to run the inconsequential risk of doing a secondary tuck-up the procedure if there has been some relapse. Correction of this stiff lip problem can be done with re-opening the incision and releasing the abnormal attachments, with the possible insertion of a dermal or dermal-fat graft to prevent recurrence. The sooner this is done the better.

Dr. Barry Eppley

Indianapolis, Indiana