INTRODUCTION

Patients today are increasingly conscious of personal appearance, and much attention has been focused on the smile. Lips represent an integral component of one’s own smile.

Excessively large lips represent an occasional but significant challenge in aesthetic surgery. Excessive large lips are associated with congenital etiologies such as double lip,[1] labial pits, neoplasm, ethnic variations, and acquired causes such as trauma, infections, neoplasms, and syndromes such as Melkersson–Rosenthal syndrome and Ascher syndrome.[2] The excess tissue forms an accessory lip, which is apparent during smiling.

Lip reduction is the surgery to reduce the appearance of larger or fuller than desirable lips. The goals of lip reduction surgery are to achieve a harmonious relationship between the upper and lower lips that is in balance with the entire face as well as to attain normal lip competence. In the past, various techniques have been used for the same, such as bikini lip reduction[3] and Brazilian hang glider cheiloplasty,[4] in which the authors have modified the techniques based on the physical appearance of their respective natives.

The aim of this technique was to minimize the excessive large lips by lip reduction surgery by using a crab claw technique and to give a more native appearance.

CASE SERIES

A total of nine systemically healthy patients aged between 21 and 22 years (mean 20.4 ± 6.5 years) were selected from the outpatient Department of Oral Medicine and Diagnostic Radiology of Swargiya Dadasaheb Kalmegh Smruti (SDKS) Dental College and Hospital, Nagpur, Maharashtra, India, presenting for the smile evaluation and with the complaint of excessive lip fullness. The participants were selected on the basis of the following criteria:

1. Patient with aesthetic concern

2. Excessively large lip interfering with pronunciation and eating

3. Absence of hereditary/congenital abnormalities, cracking of lips, patients with cleft lip, competent lip, and history of surgery in selected area

4. Smokers

Before initiating this case series, the purpose and design of this technique was explained to the patients and informed consent was signed by every patient.

Measurements of lip

The clinical parameters were measured with the help of dental floss and Williams graduated periodontal probe as shown in Figure 1.

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Figure 1

Measurements of upper and lower lip. Upper lip: The measurements recorded were distance from the vermillion border (A) to the lip line at midline (A¹) and 5 mm apart from midline on left (B¹ and C¹) and right side (B and C) and distance between the two peaks (B and B¹) corresponding to the philtral ridges at rest position. Lower lip: The measurements recorded were distance from the vermillion border (D) to the lip line at midline (D¹) and 9 mm apart from midline on left (E¹ and F¹) and right side (E and F) and the distance between the two peaks (E and E¹) corresponding to the philtral ridges at rest position

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Surgical procedure

The surgical protocol emphasized complete asepsis and infection control. Then the area of surgery was dried completely with the help of surgical gauze. The assessment of the excessive mucosa was carried out with the help of adjuvant pinch technique using tissue forceps. Excessive mucosal area was marked by using a marker pencil as shown in Figure 2A, resembling a crab claw. After topical anesthesia (2% lidocaine and epinephrine 1:100,000), infraorbital, mental, and oral commissure block were administered.

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Figure 2

Cheiloplasty in upper lip. (A) Two horizontal marking showing excessive mucosal area resembling crab claw. (B) Incisions given. (C) Excised wedge of tissue. (D) Surgical wound after excision of tissue. (E) Initially suture placed in center. (F) After suture placed

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While squeezing the upper lip between the fingers of the left hand to limit bleeding, a number 15 blade was used to excise the mucosal tissue, making sure the incision was slightly beveled so as to excise a wedge of tissue [Figures 2B, 2C]. Hemostasis was achieved with the help of fine needle tip electrocautery (Servotome, Satelec, Meriganc, France). Excision of the lower lip was conducted in a similar way, followed by careful hemostasis [Figure 3B and 3C]. Both the upper and lower lips were closed with a deep layer of interrupted 4-0 resorbable sutures (Vicryl^®, (Ethicon, Somerville, New Jersey, USA)), followed by a cutaneous layer of interrupted resorbable 4-0 sutures (Vicryl). No dressing was required [Figures 2F and [3F].

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Figure 3

Cheiloplasty in lower lip. (A)Two horizontal marking showing excessive mucosal area. (B) Incisions given. (C) Excised wedge of tissue. (D) Lip mucosa sutured to the alveolar mucosa

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Figure 4

(A) Preoperative view for cheiloplasty in lower lip. (B) 6 months postoperative view for cheiloplasty in lower lip

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Figure 5

(A) Preoperative view for cheiloplasty in upper lip. (B) 6 months postoperative view for cheiloplasty in upper lip

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RESULT

A total of nine subjects (six males and three females) with age range of 20–27 years (mean, 20.4 ± 6.5 years) associated with excessively large lips, were treated by using lip reduction surgery. During the course of study, wound healing was uneventful. A mean reduction of approximately 10 ± 0.70 mm at midline, 10.11 ± 1.05 mm on the right side, and 9.55 ± 0.72 mm on the left side of the lip was obtained in all the nine cases [Table 1]. No postoperative complication was observed in any of the patients, and all the patients were satisfied with the result, which was carried out through a survey completed by all the patients [Table 2].

DISCUSSION

The aim of this technique was to minimize the excessive large lips by lip reduction surgery to restore an aesthetic labial contour. In this case series, mean reduction in the lip of approximately 5–7 mm was obtained in all the nine cases.

Many techniques for lip reduction have been proposed, but they are focused either on the reconstructive side (e.g., cleft palates, hemangiomas, and siliconomas) or solely on the reduction aspect.^[3-9] These techniques rarely emphasize the aesthetic contour of the lip. Pitanguy,[10] since the 1960s, has been one of the pioneer surgeons to approach lip contouring as a cosmetic procedure. His contribution to the importance of Cupid’s bow has guided surgeons over the years in modern cheiloplasty.

In addressing hypertrophic lips, the common approach described in the literature advocates excising a horizontal wedge of soft tissue from both upper and lower lips (Pierce[11]). The present findings were also supported by a study conducted by Fanous et al.,[3] which stated that lip reduction procedure is a more thoughtful approach because it addresses the problem of lip volume while taking into account both the relative proportion of the lips and the aesthetic harmony of the labial unit.

The incisions were modified, which resembles crab claw to make the lip anatomy look more Indian way. The following limitations were found from the previous techniques: (1) normal lip anatomy was not considered, which varies from individual to individual, and (2) the incisions were not extended up to the commissures.

The goals of lip reduction surgery are to achieve a harmonious relationship between the upper and lower lips, balancing with the entire face, and to achieve normal lip competence.

CONCLUSION

This technique restores an attractive labial contour by shifting the shape toward a more “Indian way” and resulting in more aesthetically pleasant lips.