Lip lift and corner lift — The three levels, heights by point, and what exposes the incisor

What shortens the lip and what exposes the incisor — not the same thing — the three-level design with its four points, recommended heights, suspension to the piriform ligament and when to add the corner lift.

Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.

Key points

Shortening the lip and exposing the incisor are two different goals, achieved by two different manoeuvres. Confusing them is the commonest planning error.
The first millimetres of resection do not change tooth show. Beyond that, each additional millimetre does.
What really exposes the incisor is muscle plication, not skin resection. And if that exposure is not wanted, the muscle is not suspended.
Lip measurement is not absolute but relative: its height should be around a quarter of the height of the two lower facial thirds.
A rule that prevents the worst aesthetic complication: never invade the nasal subunits — columella, nostril base, alar bases — with the incision.

What ages the upper lip

With age the upper lip lengthens, and that lengthening reduces central incisor show at rest, one of the features the eye reads as ageing. Behind it are three changes worth separating, because each calls for a different answer: skin and SMAS laxity, which produces the excess length and is treated by resection; attenuation of the subnasal cephalic insertion of orbicularis oris, treated by resuspending the muscle; and muscular laxity proper, corrected by plicating the upper portion so function is not lost. There is also a fourth associated phenomenon: with age the depressor anguli oris becomes overactive in order to achieve lip closure, and ends up pulling the commissures down. The lip lift does not correct that; the corner lift does.

The measurements, and how to use them

Upper lip length — from the anterior nasal spine to the start of the vermilion: 15 ± 2 mm in men and 13 ± 2 mm in women.
Measure with callipers, not by eye: these are millimetre differences and the eye cannot resolve them.
But they are not absolute figures: lip height must be proportionate to the face, around a quarter of the height of the two lower thirds.
Target upper incisor show at rest: 0 to 4 mm.

The two manoeuvres that expose the incisor, and which one rules

This is the most misunderstood point. Skin resection below 4 mm does not change incisor show: it shortens the lip and rotates the vermilion, but tooth show is unchanged. Beyond about 5 mm, each additional millimetre of resection does start to expose roughly a millimetre of incisor. The consequence is that chasing tooth show with skin alone ends in a lip that is too short and skeletonised. The way out is the second tool: plication or resuspension of orbicularis, which is what truly exposes. Hence the rule that orders planning: resect 4 to 6 mm of skin and then decide, according to the exposure sought, whether or not to plicate the muscle. And the corollary: if no additional tooth show is wanted, the muscle is not suspended.

The design: three levels and four points

Point	Level 1 — upper incision	Level 3 — white roll
C, central	Centre of the columellar base	Centre of Cupid’s bow
P, peak	Sides of the columellar base	Peaks of Cupid’s bow
I, intermediate	Centre of the nostril base	Intermediate point
D, diagonal	Junction of the nasal alae	Natural diagonal of the tension lines over the white roll

Recommended heights and the 2 mm rule

Point C: 12, 14 or 16 mm. Point P: 12, 14 or 16 mm.
Point I: 14, 16 or 18 mm. Point D: 16, 18 or 20 mm.
Always keep 2 mm of difference between P, I and D. More produces excessive central exposure; less gives an angry-lip look.
Level 2 — the lower incision — determines the height of the central excision, and the rest of the design follows from it.
The lines joining the levels follow the relaxed skin tension lines, radially, and the design is always drawn with the patient seated.

Subnasal lip and facial lip are not the same

This distinction decides whether one technique is needed or two. The subnasal lip is the portion between the D points, and that is what the lip lift modifies. The facial lip is what lies lateral to the D points, and only the corner lift modifies it. A patient with excess central length and dropped commissures needs both; doing only the first leaves the commissures unchanged and sometimes makes them more obvious by contrast. And one prohibition with no exceptions: never make intranasal incisions that invade the nasal subunits — columella, nostril base, alar bases — because of the risk of rhinorrhoea, postoperative alar drop and a skeletonised appearance.

The technique, step by step

AnaesthesiaBilateral infraorbital block and tumescent local anaesthesia. Usual formula: 100 ml saline, 1 mg epinephrine, 10 ml lidocaine and 10 ml bupivacaine
ResectionA strip of skin, subcutaneous tissue and SMAS down to muscle with a cold 15 blade. Start with the lower incision, since blood runs towards the mouth; a vertical midline incision splitting the two sides eases the resection
PocketDissect about 5 mm between the cutaneous-SMAS flap and the underlying muscle with fine scissors, and resect the excess inferior SMAS
Suspend the nasal baseTransnasal mattress sutures at the D points, one per side. This is what prevents narrowing and drop of the nasal base from the caudal traction
Suspend the muscleOnly if more tooth show is wanted. One central suture from the anterior nasal spine to the inferior muscle, and two lateral ones at P and D from the piriform ligament to the inferior muscle
SMAS to SMASSimple sutures joining upper SMAS to lower SMAS, around six, spread across P, I and D. This is the lift proper
ClosureSimple fine monofilament sutures in the skin. Suspending the SMAS to the piriform aperture makes subcutaneous sutures unnecessary

Piriform ligament, not periosteum

A small detail that changes the solidity of the suspension: it is better to suture to the piriform ligament and not to the periosteum, because the periosteum in that area is hard to distinguish and the suture ends up holding little. And a checking trick that saves surprises: pass the suture through the ligament first and pull on it while moving the patient’s head. If the head moves, a firm structure has been caught; if only soft tissue moves, the suture will not hold and must be redone. It takes two seconds and avoids discovering the failure weeks later.

Corner lift: the two types

Type	Design	What it achieves
Type 1, the minority	An ellipse over the white roll, without lateral extension	To expose more vermilion
Type 2, the usual one	A 1 to 5 mm lateral extension at the commissure plus a triangular excision	To raise the commissure and expose more vermilion

The corner lift design

Draw two horizontal lateral lines at the level 2 height and place point O at the commissure.
A diagonal joins level 2 to point O following the tension lines. The lip height at O should be that of D plus 1 mm.
The triangle closes between D, the limit of the lateral extension through O, and the commissural limit.
Never extend the lateral prolongation beyond the nasolabial fold. And beware its length: overcorrection produces a Joker smile.
The technique is simpler than the lip lift: resection of skin, subcutaneous tissue and SMAS down to muscle, a 2 to 3 mm pocket, and resuspension of the lower flap to the upper one.

Who to wait on before operating

There are no formal contraindications, but three situations warrant waiting. Ongoing orthodontics or dental restoration: incisor position will change and with it the exposure target, so wait until it is finished. Rhinoplasty: wait about three months, especially if alar base reduction was performed, because the nasal base is still settling and the lip lift pulls precisely on it. Previous hyaluronic acid filler: over time the product can migrate cephalically because of the oedema it generates; if lumps are palpable in the philtrum or the white roll, dissolve with hyaluronidase two weeks beforehand. A nuance of that last case: dissolving may leave an atrophic SMAS through which the underlying teeth are palpable, and then it will be necessary to rehydrate with hyaluronic acid after surgery, not before.

Adjunctive techniques

Lateral VY plasties in the mucosal vermilion, when still more vermilion show is wanted.
Toxin in depressor anguli oris, around 4 units per muscle, to soften marionette lines and complement the corner lift.
Perioral CO₂ laser for rhytids, which surgery does not correct: it repositions and shortens, but does not change the surface.
And a useful point of nomenclature: the SMAS at the level of the vermilion, submucosal, is known as the lamina propria.

The postoperative course, and what to warn about

First 2 weeksUpper lip swollen and barely mobile. Warn about it by name, because the appearance is alarming: patients describe it as a rabbit mouth
MedicationAntibiotic, corticosteroid and anti-inflammatory, plus an antiviral given the perioral site. Mupirocin ointment twice daily for one week
Day 10Suture removal
2 to 4 weeksThe lip settles and regains mobility. This is when the patient starts to recognise themselves
4 to 6 weeksThe result is established
From 6 weeksIf the scar shows, CO₂ laser under topical anaesthesia. Avoid corticosteroid injection here: risk of skin atrophy and telangiectasia

The three-level design with points C, P, I and D, heights by point, and the corner lift triangle with its lateral extension.

References

Related specialty: Facial Aesthetic Surgery

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