Morphologic variations of the philtrum and their effect in the upper lip lift.

Abstract

Sir: Lip rejuvenation and enhancement is a rather common patient demand that increases over time. With aging, the upper lip length augments and loses its thickness, and the vermilion flattens and loses the “pout” projection.1 Upper lip lift and vermilion volume enhancement have been proposed to address these situations, and several techniques have been proposed to reduce the height of the white lip, or philtrum. These techniques may consist of simple subnasal skin excision, subnostril skin excision, or even vermilion advancement.2 The philtrum is a unique entity and the only distinct landmark of the upper lip. Its anatomical description is not very clear. Anatomical and histologic studies show that it is a dynamic effect of superficial orbicularis oris skin insertions.3 What is interesting, though, is that the philtrum may have different forms. Mori et al. analyzed 109 children and found three different philtrum types.4 When taking into consideration these variations, the authors believe that the standard bullhorn or seagull subnasal skin excision5 of one-third of the lips may lead to philtral column displacement to a more lateral position from their original nearly midline insertion. The authors wanted to verify this hypothesis by analyzing the photographs of 50 healthy female volunteers. The clinic’s photographer took standardized photographs of their lips in a neutral closed-mouth position. The main objective of the study was to calculate the percentage of patients that will hypothetically present a significant lateral displacement after an upper lip lift. The authors defined as significant a displacement that was greater than or equal to two-thirds of the philtral column width. A vertical line was drawn from the base of the columella to the tip of the Cupid’s bow that defined the lip’s midline. The distance between this line and the philtral crest insertion was calculated and named a. Then, a horizontal line was drawn at one-third of the philtral height where the authors decided to place hypothetically the end of the subnasal skin excision. The distance between the intersection of this line with the middle of the philtral column and the midline was calculated and named b (Fig. 1). This defined the new philtral column insertion. After this, the authors calculated the lateral displacement of the philtral column as a proportion of the a distance with the following formula (b − a)/a. This gave the proportion of the lateral displacement of the new philtral crest insertion as a relation to the initial a distance.Fig. 1: Measures taken for this study. The red line represents the initial philtral insertion. The blue line represents the theoretical upper lip level after a theoretical upper lip lift and thus the new philtral crest insertion. In this patient, the upper lip lift at this level would have displaced more than 1.72 times the initial value, which means more than three-fourths of the philtrum width (yellow line).The mean age of the patients was 42 years (range, 21 to 62 years). The lateral displacement after a theoretical upper lip lift had a mean value of 0.39, which means that it will be 39 percent more lateral than its initial position. We found that for three patients (6 percent), an upper lip lift could displace significantly the insertion of the philtral column with a mean value of 0.79, meaning almost 80 percent more laterally than the initial insertion. When we analyze these patients, we may deduce that this “at-risk” patients are the individuals that had a small a value and proportionally large b value. These are the patients that have an extremely central insertion of the philtral crests that are situated almost under the columela and philtral columns that descend the upper lip in a nonparallel way (as in type I of the philtrum described by Mori). When an upper lip lift is performed we may see that the new insertion of the philtral column is more distant from the midline than it was before. In these rare cases, there is a morphologic modification of the upper lip that may give the impression of an amputated upper lip. Thus, the surgeon should proceed with caution to address this issue and redistribute the skin to reinsert the philtral columns in a more central position. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Charalambos A. Georgiou, M.D. Marc Benatar, M.D. St. Roch University Hospital of Nice Nice, France Jacques Bardot, Ph.D. La Conception University Hospital of Marseille Marseille, France José Santini, Ph.D. Face and Neck institute of Nice Nice, France Bérengère Chignon Sicard, M.D. St. Roch University Hospital of Nice Nice, France