Comparison of Lip Enhancement Using Autologous Superficial Musculoaponeurotic System Tissue and Postauricular Fascia in Conjunction with Lip Advancement

ORIGINAL ARTICLE Comparison of Lip Enhancement Using Autologous Superficial Musculoaponeurotic System Tissue and Postauricular Fascia in Conjunction With Lip Advancement

William D. Recupero, DO; E. Gaylon McCollough, MD

Objective: To evaluate and compare the short- and long- graphs were evaluated at approximately 6 months and 1 term aesthetic results of surgical lip enhancement using year after the procedure. the superficial musculoaponeurotic system (SMAS) and postauricular fascia graft implantation with and with- Results: Reviewers noted a significant improvement in out vermilion border advancement. aesthetic scoring for each of the methods of lip augmentation examined at 6 months after surgery. This result Methods: A single-blinded cohort study was per- was sustained at 12 months after surgery. Postauricular formed using 39 patients who underwent surgical lip en- fascia graft lip augmentation and combined lip advance- hancement at a private facial plastic surgery practice be- ment and postauricular fascia augmentation recorded the tween 2005 and 2007. The cohort was grouped as follows: highest scores after surgery. The largest mean scoring in- 14 patients underwent lip augmentation using SMAS graft- creases of 1.459 (t=−9.5049; PϽ.001) at 6 months and ing; 10 patients underwent lip augmentation using pos- 1.584 (t=−9.0308; PϽ.001) at 1 year were found in the tauricular fascia grafting; and 15 patients underwent com- lip advancement and SMAS lip augmentation study group. bined lip augmentation and lip advancement (SMAS grafting was used in 8 of the procedures, and postau- Conclusions: Youthful, natural-appearing lips tend to ricular fascial tissue was used in 7). All procedures were enhance an individual’s appearance. Surgical lip aug- performed in a controlled setting by a single surgeon mentation using SMAS or postauricular fascia, with or (E.G.M.). Patients who had undergone previous lip without vermilion border advancement, is a straightfor- augmentation of any kind were excluded from the ward, safe, potentially long-lasting treatment for hypo- study. Preoperative and postoperative photographs plastic lips, with little to no morbidity. were analyzed by 3 blinded physician observers using the Lip Fullness Grading Scale. Postoperative photo- Arch Facial Plast Surg. 2010;12(5):342-348

ULL, WELL-DEFINED LIPS sive and apt to be associated with poten- transcend time and culture tial complications.1,4,7,8 Also, should the re- as a hallmark of youth and moval of nonautologous implants beauty.1 The goal of fuller associated with tissue ingrowth become lips has led to the develop- necessary, extensive filleting techniques mentF of many different techniques and ma- may become necessary as well. More- terials that are available to the facial plas- over, structural fat grafting for lip aug- tic surgeon.1-12 The advent of newer mentation has gained popularity but has synthetic injectable fillers has made lip aug- been associated with mixed results.1,7-9,12,13 mentation popular in medical spas and Along with unpredictable resorption with physician’s offices because of the attrac- grafted fat, multiple procedures are often tiveness of nonsurgical procedures. required to produce a lasting effect.1,9 Though effective, most fillers offer, at best, The ideal lip augmentation material a temporary solution.1,7,8 Surgical op- should be safe, nonreactive, easy to pro- tions for lip augmentation are plentiful and cure and insert, cost-effective, and able to may include the use of synthetic materi- produce predictable, reliable, and lasting als, homografts, autograft implants, and ad- results. More than 35 years of experience vancement procedures.1-6,8-12 Nonautolo- in facial plastic surgery has afforded us gous implant materials, such as expanded more than a passing familiarity with most polytetrafluoroethylene products and per- of the known techniques that are used to Author Affiliations: The manent injectable fillers, offer the ben- provide lip enhancement. Having ob- McCollough Institute for efits of longevity but often create a hard- served and experienced the often disap- Appearance and Health, ened, unnatural feel to the lip. pointing outcomes of other forms of lip en- Orange Beach, Alabama. Furthermore, these materials are expen- hancement, we have found that the

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Figure 1. Marking the postauricular sulcus for graft harvest. Figure 2. The postauricular fascia graft is harvested in a single or multiple strips. The surgeon must take care to stay superficial to the underlying musculature. combination of autologous superficial musculoaponeurotic system (SMAS) and postauricular fascial tissue has provided consistently predictable results for well over a decade. With SMAS suspension rhytidectomy, the excised preauricular SMAS provides a convenient autologous source of graft material.2,4,14-16 We also frequently use postauricular fascial tissue as grafting material in patients who are not undergoing rhytidectomy or when suit- able SMAS is not available. Each of these autologous graft techniques can be combined with direct lip advancement in patients who require both fuller and larger lips. The focus of this article is a comparative examination of our lip enhancement methods. Furthermore, we present a novel technique for graft placement and positioning that, to our knowledge, has not been previously described. We believe that it offers several advantages over the previously published techniques. Figure 3. Typical postauricular fascia and preauricular superficial METHODS musculoaponeurotic system graft after harvesting. The graft is cut into strips for implantation. DESCRIPTION OF SURGICAL PROCEDURES Placement of autologous grafts for lip augmentation has clas- Our chosen method of harvesting grafting materials during rhyti- sically been described via an incision placed on the mucosal dectomy has been unchanged for more than 3 decades.15 How- surface at each oral commissure.2 As a modification of this tech- ever, we have used excised SMAS tissue for volume replace- nique, an additional small vertical mucosal incision is made in ment in other regions of the face, such as the melolabial grooves, the midline on the mucosa of the upper and/or lower lip. These lips, and deep glabellar creases, only within the past 2 de- 4 separate incisions allow greater ease and accuracy in creat- cades. The use of SMAS for melolabial fold augmentation has ing the submucosal tunnels that are needed for graft place- also been described by others.14 ment (Figure 4). Grafting materials are fashioned so as to add Access to postauricular tissue can also be accomplished only the desired augmentation on either side of the midline. through an incision made in the postauricular sulcus and at or Two separate grafts are used in each lip. Once the grafts are within the occipital hairline, if necessary (Figure 1), at the tailored to the appropriate length and width, an alligator for- time of rhytidectomy or in cases in which rhytidectomy is not ceps is used to pull each graft through its respective tunnel being performed. In either case, once the skin and subcutane- (Figure 5). The central portion of each graft is overlapped for ous tissue are dissected free, the underlying fibrous fascial tis- approximately 3 mm, thereby creating the natural central tu- sue lying superficial to the postauricular musculature and mas- bercle, which is a hallmark of an aesthetically pleasing and youth- toid periosteum is easily dissected with forceps and scissors ful lip. These incisional modifications allow ease in tunnel cre- (Figure 2). Typically, 1 or 2 strips (approximately 5ϫ1cm) ation and graft placement and decrease the potential for twisting of tissue are excised (Figure 3). Care is taken to avoid injury of the graft on insertion. They also help facilitate addressing to the greater auricular nerve or inadvertent inclusion of pos- asymmetries in the lip and ultimately can provide a more aes- tauricular muscle in the graft. In patients who are undergoing thetically pleasing appearance that is not readily achievable with secondary rhytidectomy procedures, the postauricular site pro- the classic single-tunnel technique. vides a bounty of subcutaneous scar tissue. We recommend cau- In cases in which lip augmentation alone is performed—and tion when attempting to obtain materials for lip augmentation once graft placement is satisfactory—all incisions are closed with in the preauricular region in patients who have previously un- 5-0 chromic catgut sutures. Patients are told that their lips ini- dergone face-lifts with SMAS excision. tially will appear overly corrected because of postoperative swell-

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 ing but that approximately 80% of swelling will have subsided It is possible to perform lip and vermilion advancement sur- by 2 weeks and 90% by 2 months, at which time the lips will have gery without the addition of soft-tissue grafting, especially in begun to assume their final size and shape. For patients with thin younger patients; however, when both lip enlargement and vol- lips who require modification of the vermilion borders, a com- ume replacement are desired, the senior author (E.G.M.) rec- bination of lip advancement and autologous SMAS or postau- ommends a combination of lip augmentation and vermilion ad- ricular fascia grafting is recommended. Lip advancement proce- vancement. In his combined lip advancement and augmentation dures have been previously described.5,6,10 However, the method procedure, vermilion advancement incisions are performed first, described herein offers modifications that provide not only en- taking care to incise precisely at the vermilion border and ap- hanced results but also more acceptable postsurgical scars. proximately 2 to 4 mm higher (in the upper lip) or lower (in the lower lip) depending on the amount of vermilion modification desired5 (Figure 6). Meticulous attention during marking must be directed toward preserving and exaggerating the Cu- pid’s bow of the upper lip. If asymmetry exists, markings can be altered to address it. Presurgical markings should be made to allow a slight (1- to 2-mm) overcorrection, taking into account expected postoperative retraction.5 The skin between the 2 incisions is then excised in an immediate subdermal plane, taking care not to remove subcutaneous tissue or muscle, which helps preserve or create the natural ridge at the vermilion border. Undermining the skin or mucosal edges is not recommended. If lip-grafting augmentation is desired, incisions for creating submucosal tunnels are made to receive the autologous tissue grafts (Figure 4). With a combined lip advancement and augmentation procedure, the incisions can be made either within the advancement wound or on the mucosa of the oral commissures, as previously described. The method used to close vermilion advancement wounds is paramount to cre- Figure 4. Creation of a submucosal tunnel for graft placement. ating acceptable scars. To achieve this objective, 6-0 fast- absorbing catgut vertical mattress sutures are placed at, and between, the peaks and trough points of the Cupid’s bow in the upper lip. Vertical mattress closure ensures eversion of wound edges, thereby preserving a natural and symmetrical appearance of the Cupid’s bow. The remaining closure consists of a running 5-0 polypropylene subcuticular suture followed by a simple running 6-0 catgut suture along the length of the incision, but only if additional wound edge approximation and eversion are required (Figure 7).

STUDY DESIGN

To compare the efficacy of these and previously described procedures, we designed a single-blinded cohort study. All procedures in the study were performed by a single surgeon (E.G.M.) at a private facial plastic and reconstructive surgery practice between 2005 and 2007. Patients who were eligible for Figure 5. The tissue graft is pulled through the tunnel with alligator forceps. inclusion in the study underwent primary upper and lower lip Often, the superficial fat will be stripped from the underlying fibrous tissue augmentation with or without lip/vermilion advancement. Pa- as the graft is pulled through. tients who had previously undergone documented surgical or

A B

Figure 6. Preoperative markings (A) for lip advancement and excision of white lip skin. Note the careful preservation of Cupid’s bow (B).

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Figure 7. Appearance after closure of a lip augmentation and advancement (A and B). Five vertical mattress sutures are placed at the key points along Cupid’s bow. A running subcuticular 5-0 polypropylene suture followed by running 6-0 fast-absorbing catgut sutures (if necessary) are used to complete the closure.

nonsurgical lip enhancement procedures were excluded, as were those who did not have appropriate postoperative photo- A B graphic documentation, which was defined as preoperative and postoperative frontal and lateral perioral views (Figure 8 and Figure 9). Postoperative photographs were taken at approximately 6 months and 1 year for inclusion in the study. All procedures were strictly cosmetic in nature. A total of 39 patients met the inclusion criteria for this study. Fourteen patients underwent lip augmentation with preauricular SMAS grafting. Ten patients underwent lip augmentation with postauricular fascia grafting. A total of 15 patients underwent combined aug- C D mentation and lip advancement: SMAS grafting was used in 8 patients, and postauricular fascia was used in 7 patients. A com- prehensive chart review was performed on all patients. Patient demographics, as well as any concomitant procedures at that time and during the follow-up period, were recorded. Short- and long-term complications and the postoperative use of injectable steroids were also recorded. Three physician observers were recruited for photographic scoring; none of them participated in the surgery or care of the pa- E F tient cohort. The evaluators reviewed 3 sets of printed photographs of each patient enrolled in the study. The photographs included preoperative and postoperative results at 6 months and 1 year. Therefore, a total of 117 photograph sets were random- ized and examined by each observer. The observers were also blinded as to which technique was performed as well as to any reference of date and time. Each was instructed to grade the upper and lower lips as a whole using the following Lip Fullness Grad- ing Scale17: 0, very thin; 1, thin; 2, moderately thick; 3, thick; and 4, full. This scale was chosen because of its validation and low in- 17 Figure 8. Photographs taken before (A, C, and E) and 1 year after (B, D, and trarater and interrater variability. The observers were also allowed F) combination postauricular fascia lip augmentation and lip advancement. to refer to a sample set of prescaled photographs to use as a guide for grading.17 They were also asked to note any problems or discrepancies with the photographs at the time of review. ment combination. The average preoperative and postoperative Scoring data from the blinded observers, along with pa- 6-month and 1-year scores were then analyzed for each group tient demographics, were compiled and analyzed in a single da- and between groups for comparison. Statistical analysis was per- tabase. Correlation coefficients between individual graders were formed using a 2-sample t test. calculated to demonstrate interrater reliability. The average scores were calculated for each patient’s preoperative and post- RESULTS operative 6-month and 1-year photographs. For comparative analysis, the cohort of patients was divided into 3 groups: group Patient age demographics and procedure results are sum- 1, preauricular SMAS lip augmentation; group 2, postauricular fascia lip augmentation; and group 3, combined autolo- marized in Table 1. All 39 patients were women (age gous tissue augmentation and lip advancement. Group 3 was range, 18-72 years). The average age in groups 1, 2, and further subdivided into group 3A, representing SMAS augmen- 3A was 56, 62, and 57 years, respectively. However, the tation and lip advancement combination, and group 3B, rep- average age in group 3B was considerably younger, at 38 resenting postauricular fascia augmentation and lip advance- years. Primary SMAS suspension and imbrication rhyti-

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D E F

G H I

Figure 9. Photographs taken before (A-C), 6 months after (D-F), and 1 year after (G-I) postauricular fascia graft lip augmentation.

Table 1. Comparison of Patient Age Demographics and Proceduresa

Primary Secondary Perioral Upper/Lower Full-Face Group Age Range (Average), y Face-lift Face-lift Chemical Peel Blepharoplasty Rhinoplasty Resurfacing Brow-lift 1 (n = 14) 45-72 (56) 13 0 7 10 1 0 0 2 (n = 10) 39-68 (62) 1 5 2 6 3 2 1 3A (n = 8) 35-67 (57) 7 1 2 6 3 0 1 3B (n = 7) 18-66 (38) 1 0 1 1 3 1 2

a Group 1, superficial musculoaponeurotic system (SMAS) augmentation; group 2, postauricular fascia augmentation; group 3A, combined SMAS augmentation and lip advancement; and group 3B, combined postauricular fascia augmentation and lip advancement.

dectomy was performed in 22 patients, 20 of whom un- SMAS augmentation group. The remaining procedures derwent SMAS lip augmentation or combined SMAS aug- were fairly evenly spread among the groups and not con- mentation and lip advancement. Secondary face-lift was sidered to affect perioral appearance. No additional aes- performed in 6 patients, 5 of whom underwent postau- thetic or reconstructive facial procedures, including in- ricular fascia augmentation and 1 of whom underwent jectable fillers, were performed on any of the study patients combined SMAS augmentation and lip advancement. during the 1-year study period. Seven of the 9 patients who also underwent perioral re- Intrarater and interrater statistical analysis was per- surfacing with a Baker-Gordon phenol peel were in the formed using a 2-sample t test. Intergrader reliability was

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6-mo Postoperative 12-mo Group Preoperative Score Score P Value Postoperative Score P Value 1 0.81 1.762 Ͻ.001 1.714 .001 2 1.1 2.367 Ͻ.001 2.267 .001 3A 0.333 1.792 Ͻ.001 1.917 Ͻ.001 3B 1.048 2.524 .001 2.429 .002

also analyzed. Cohen coefficients of 0.457, 0.642, and tion had run their course in vermilion advancement. The 0.710 confirmed moderate to substantial agreement be- largest improvement was seen in the combined proce- tween graders. A comparison of mean preoperative scores dure group. in the cohort indicated that there were no significant dif- In all conditions, selecting the correct procedure for ferences between groups, with the exception of group 3A the indication is important for obtaining and maintain- (Table 2). The mean preoperative score of 0.333 was ing optimal results. In general, we recommend autolo- significantly less than that of the other groups (P=.03). gous tissue augmentation for patients who require lip bulk The mean score within each procedure group was then and fullness. Often, however, patients desire both fuller examined. The results indicate an overall statistically sig- and larger lips that cannot be created by grafting. Those nificant increase in mean scores at 6 months and 1 year in whom combined augmentation and lip advancement after surgery for each procedure (Table 2). The largest procedures are recommended generally have severe lip score increase was seen in the combined SMAS augmen- hypoplasia, with significant soft-tissue deficit and loss of tation and lip advancement group (group 3A), in which red lip show (Figure 8). Naturally, such patients re- there was an observed preoperative to postoperative dif- quire a more aggressive treatment, with results that are ference of 1.459 (t =−9.5049; P Ͻ .001) and 1.584 achievable only through a combined procedure. In these (t=−9.0308; PϽ.001) at the 6-month and 1-year inter- cases, raising the vermilion border in the upper lip and vals, respectively. lowering it in the lower lip, with or without graft aug- No major short- or long-term complications, includ- mentation, offers a better chance to obtain the desired ing infection, hematoma, and graft extrusion, were re- aesthetic result. However, in patients whose vermilion ported for any of the procedures. Furthermore, none of border positions are acceptable, yet exhibit deep wrin- the study patients required revision procedures. Postop- kling and/or volume deficiency in the red part of the lip, erative steroid injections were used to address localized we recommend autologous tissue grafting alone. delayed swelling and submucosal scarring in 6 of the 15 Our results indicate that combination lip augmenta- patients in the combined augmentation and lip advance- tion and vermilion border advancement can be used with- ment group, with 5 of the 6 requiring multiple injections. out reservation in both congenital and age-induced lip hy- One patient in the postauricular fascia graft augmenta- poplasia. However, it should be noted that we do not tion group required a steroid injection (triamcinalone, recommend lip advancement in male patients, especially 7.5 mg/mL) at the postauricular donor site to soften a ones with heavy beards. Removing the non–hair-bearing scar. Injections were generally spaced 3 weeks to 1 month skin between the vermilion borders and the beard line apart. Insignificant vermilion border asymmetries were around the lips creates an unnatural appearance to the lip. also present in 3 of the 15 patients in the combined aug- In evaluating our study results, it is important to em- mentation and lip advancement group as long as 1 year phasize that we make a concerted effort not to produce after surgery. The graders reported small discrepancies, overly volumized or unnatural-looking lips. We believe including differences in lighting and positioning, in the that this aesthetic paradigm accounts for lower than sus- photographs. pected scores on the postoperative grading scale. How- ever, should more dramatic changes be desired, the COMMENT amount of grafting and/or skin excision can be in- creased to achieve larger and fuller lips. This objective Our experience and data reveal that autologous tissue lip can be achieved with the same surgical techniques that augmentation with or without vermilion and lip advance- are described herein. ment can provide aesthetically pleasing and potentially Our results also suggest that postauricular fascia is a long-lasting rejuvenation to the perioral region of the face. better autologous grafting material than preauricular Results from each procedure category demonstrated an SMAS. We attribute this observation to the paucity of fat average of approximately 1- to 1.5-point improvement in postauricular grafts or scar. Grossly, postauricular fas- on the Lip Fullness Grading Scale at 6 months after sur- cia is a more fibrous graft than preauricular SMAS. There- gery. This score corresponds to at least a 1-grade im- fore, we believe that it is more likely to be longer last- provement aesthetically. More importantly, this improve- ing, resistant to resorption, and more reliable. Other ment was sustained at 12 months, suggesting that the authors have suggested that fat grafts placed within muscle grafts had survived transfer and that swelling and retrac- seem to survive better than those placed in fat or subcu-

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 taneous tissues.11-13 Because all grafting materials used revision of the manuscript for important intellectual con- for lip augmentation are inserted within the orbicularis tent: Recupero and McCollough. Statistical analysis: Re- oris muscle, a more desirable bed is provided for the fatty cupero. Administrative, technical, and material support: portions that are attached to the typical SMAS graft, McCollough. Study supervision: McCollough. thereby potentially having implications regarding graft Financial Disclosure: None reported. longevity. Additional Contributions: Konstantin Tarashansky, MD, Aging patients whose lips are disappearing are ideal Thomas Spalla, MD, and Timothy Goodrich, DO, re- candidates for combination augmentation and lip ad- viewed and scored the photographs for this study. vancement procedures. 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