Cosmetic

Lip Augmentation with SuperficialMusculoaponeurotic System Grafts: Report of103 CasesNorman Leaf, M.D., and Jimmy S. Firouz, M.D.Beverly Hills, Calif., and Washington, D.C.

Many patients suitable for a lip augmentation are offace lift age, and could benefit from a simultaneous lipenhancement during the rhytidectomy procedure. Thehealthy, live superficial musculoaponeurotic system(SMAS) tissue obtained from the face lift can be recy-cled and grafted with minimal additional operatingtime. From April of 1995 to January of 2000, 103 pa-tients (99 women and four men) underwent a lip aug-mentation procedure by the senior author (N.L.) usingSMAS grafts harvested from a simultaneous rhytidec-tomy. Indications for surgery were purely aesthetic in all103 cases. The surgical technique used for the SMASgraft lip augmentation is as follows: Using a narrowtenotomy scissors, an intramuscular tunnel was createdwith blunt and sharp dissection across the lip. The graft,obtained from the posterior edge of the SMAS dissec-tion, is left as long as possible, and is pulled through thetunnel with a tendon forceps. The lips are thenstretched manually from the central point upward anddownward, respectively. It is important to avoid sutur-ing the ends of the graft into the closure; the graftsshould be allowed to move freely, to avoid postoperativetethering on smiling or mouth opening.

Most patients expressed some initial concern withtheir early appearances caused mainly by the swelling.By 2 weeks, most patients were extremely pleased withthe size and shape, and their main concern was that thelip fullness would shrink even more. By 3 to 4 weeks,shrinkage largely ceased and the correction remainedfor varying periods, some as long as 5 years. A samplingof the results was obtained by means of a questionnairemailed to all patients having undergone the SMAS graftlip augmentation. Fifty-four patients (52 percent) re-turned the questionnaire with their responses. Of thosewho responded to the survey, 42 patients (78 percent)reported fuller lips than before their operation. Signif-icantly, 11 of 14 patients (79 percent) followed up after24 months postoperatively reported fuller lips and ex-cellent or good results. Complications and unsatisfac-tory results were very rare, occurring generally at thebeginning of the learning curve of the series.

SMAS grafts are useful for long-lasting lip augmen-tation, producing a youthful appearance by adding nat-

ural, soft roundness and fullness to lips without theartificial look and feel of synthetic material. (Plast.Reconstr. Surg. 109: 319, 2002.)

The soft, full, rounded lips of youth havebeen a recurring goal in aesthetic surgery, butfew techniques have been reported to give areliable, lasting effect. The growing and, it ishoped, soon-to-be-waning use of synthetic ma-terials has proven to be unacceptable and evendisastrous in a large percentage of patients.These patients, lured by slick advertising andby the momentum of a device-driven market-ing campaign, have suffered a sadly familiarvariety of problems, the commonest and mostbenign being artificially hard, ridged, and im-mobile lips that only under the most desperatecircumstances would pass the “kiss test.”

Various allograft or xenograft productsproduce acceptable but brief improvement.Injectable collagen, either bovine or human,is the mainstay of lip enhancement in theUnited States, but the pain and the need forrepeated injections prove to be limiting. Ca-daver dermis is readily available, but longev-ity of results is disappointing. Autologouslive-tissue grafting is most desirable in thesecircumstances; yet within this category con-flicts abound. Temporalis fascia does nothave the desirable thickness or pliability, anddermal or dermal-fat grafts,1,2 although theymay produce acceptable results with propertechnique, require a donor site, with atten-dant potential problems.

Since many, although certainly not all, pa-

From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles; and George Washington University School ofHealth and Medicine. Received for publication September 21, 2000; revised June 4, 2001.

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tients suitable for lip enhancement are offace lift age,3,4 it would be appropriate toconsider using tissue readily available duringthe rhytidectomy procedure. The popularSMAS-based face lift procedure provides anample source of this material for lip augmen-tation. SMAS grafts in lips have been men-tioned briefly in the past, and their usage hasbeen demonstrated for augmentation of thenasal dorsum.5 SMAS is potentially an idealsoft-tissue graft material,6 consisting of fasciaand varying amounts of fat and striatedplatysma muscle. The proportions of thecomponents may vary widely between indi-viduals, and also may vary depending on thelocation of the donor site: in the cheek, fat,and fascia predominate, whereas over themandibular and cervical area there is mainlyplatysma muscle. Secondary rhytidectomies mayalso provide suitable material; often, however, ifthe SMAS has been previously undermined, thetissue is more fibrotic and less muscular. Theobjective of this article is to compare and evalu-ate the patients’ responses as well as to presentthe benefits, longevity, and practicality of SMASgrafts when performing a concurrentrhytidectomy.

MATERIAL AND METHODS

From April of 1995 to January of 2000, 103patients (99 women and four men) under-went a lip augmentation procedure by thesenior author (N.L.) using SMAS grafts har-vested from a simultaneous rhytidectomy.Upper and lower lips were augmented in 98patients; in four patients only the upperlip was done. Results were evaluated byboth patient follow-up visits and a mailedquestionnaire.

Surgical Technique

After moderate subcutaneous undermin-ing, the sub-SMAS layer is entered throughan incision extending from the malar area tothe prelobar area, and extending inferiorlyalong the anterior border of the sternomas-toid muscle into the neck. The scissors dis-section proceeds carefully over the parotidand buccal fat pads (some of which areteased out as needed) anterior to the zygo-maticus muscle. Restraining ligaments arecut as needed for mobilization. The extent ofthe dissection in all cases is determined bythe individual degree of correction required.After dissection is complete, the superior

border of the flap is pulled superiorly andposteriorly and sutured with two rows of 4-0clear nylon to the malar periosteum and thetemporalis fascia overlying the zygomaticarch. At this point, the amount of redundanttissue at the posterior border of the flap canbe easily assessed and excised from the supe-rior edge all the way inferiorly into the neck,the length of the graft being determined bythe extent of the cervical dissection (Fig. 1).Lengths vary from 6 to 10 cm. The grafts arewrapped in antibiotic saline-soaked surgicalgauze and placed on the back table for lateruse. At the conclusion of the rhytidectomyoperation, including any other surgical pro-cedure such as blepharoplasty or forehead/brow lift, the lips are infiltrated with 2 cceach of anesthetic solution containing epi-nephrine. A 7- to 8-mm vertical incision ismade in the vermilion 1 cm medial to thelateral commissure on the upper and lowerlips. Using a narrow tenotomy scissors, a tun-nel is created with mostly blunt dissection

FIG. 1. Harvesting of the posterior edge of the SMAS flap,from the preauricular area into the neck.

FIG. 2. Dissection of intramuscular tunnel with tenotomyscissors.

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completely across the lip, care being taken tostay centered within the bulk of the muscle(Fig. 2). After the tunnel is made and bluntlyenlarged with the scissors, a curved tendonforceps is inserted. The SMAS grafts are thentrimmed of irregular fatty or muscular out-croppings until smooth narrow cylindricshapes are achieved (Fig. 3). It is best to tryto have each component (fascia, muscle, andfat) extend evenly across the length of thegraft. The width of the graft may vary be-tween 5 and 10 mm and the thickness be-tween 3 to 5 mm, depending on the desiredcorrection and the amount of material avail-able. If greater enlargement in the center isdesired, the graft can be appropriatelyshaped, but this must be done cautiouslybecause of the possibility of the graft movingto one side before becoming incorporatedinto the lip; in most cases, a straight cylindricshape is adequate, the desirable contour ofthe lip being created by the existinganatomy.

The graft is left as long as possible, usually

6 to 8 cm, and then pulled through the tun-nel with the tendon forceps (Fig. 4). Someback-and-forth manipulation of the graftwithin the tunnel is performed to ensure thatthe graft slides smoothly, thus minimizingpostoperative lumps. The lips are thenstretched manually from the central pointupward and downward, respectively (Fig. 5).During this manipulation, the protrudingends of the graft will be seen to pull into thetunnel. The ends of the grafts are thentrimmed, leaving about 1 cm excess, which isthen pushed into the tunnel with smoothforceps. The incisions are then closed withthree interrupted sutures of 5-0 chromiceach. It is important to avoid suturing theends of the graft into the closure; the graftsshould be allowed to move freely, to avoidpostoperative constriction on smiling ormouth opening.

In most cases, upper, and lower lips are aug-mented with grafts of approximately equal sizewithin a similar tunnel. A larger or smaller graftmay be placed in one lip or the other dependingon existing lip size and relative balance, patientpreferences, and graft availability.

The patient is kept on a liquid diet for 2days and soft foods for 5 days later. Antibiot-ics are administered intraoperatively and for5 days postoperatively. The mouth is rinsedwith mouthwash after every meal to preventcoagulum on the sutures and subsequentbreakdown of the wound. Lip movement isnot restricted.

RESULTS

Between April of 1995 and January of 2000,103 patients underwent lip augmentationwith concurrent rhytidectomy by the senior

FIG. 3. Trimming SMAS grafts.

FIG. 4. Implantation of SMAS graft through tunnel withtendon forceps.

FIG. 5. Stretching upper lip to pull the ends of the graftinto the tunnel.

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FIG. 6. An early result at 2 months. (Above, left) Preoperative frontal view of 62-year-old woman beforerhytidectomy and lip augmentation of upper and lower lips. (Above, right) Postoperative view at 2 months. Notesome edema still present in augmented lips. (Below, left) Preoperative oblique view. (Below, right) Postoperativeoblique view at 2 months.

FIG. 7. Result at 4 months. (Above, left) Preoperative frontal view of lips in a 55-year-old woman beforerhytidectomy, quadrilateral blepharoplasty, SMAS augmentation to the upper and lower lips, and perioralpeel. (Above, right) Postoperative view at 4 months. (Below, left) Preoperative lateral view. (Below, right)Postoperative lateral view at 4 months.

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author (N.L.). Most patients expressed someinitial concern with their early appearance,mainly because of the swelling. By the end ofthe first week, most patients had begun toaccommodate to the fullness, even as the

swelling subsided. By 2 weeks, most patientswere extremely pleased with the lip size andshape, and their main concern was that theirlips would shrink even more—which theydid. However, at the end of 3 to 4 weeks,

FIG. 8. Result at 18 months. (Above, left) Preoperative lateral view in a 52-year-old womanbefore rhytidectomy, coronal brow lift, lower blepharoplasty, rhinoplasty, and lip augmentationof upper and lower lips. (Above, right) Postoperative lateral view at 18 months. (Below, left)Preoperative close-up frontal view. (Below, right) Postoperative close-up frontal view.

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shrinkage largely ceased and the correctionremained for various lengths of time (Figs. 6through 11). None of the patients in thesephotographs had any injections of collagenor other filler substance during the follow-upperiod.

The duration of the correction is difficult tomeasure precisely, inasmuch as the evaluationis not subject to double-blind studies, measure-ments are at best subjective, and long-termfollow-up of aesthetic surgery patients is noto-riously difficult. However, in postoperativeevaluations ranging from 6 weeks to 5 yearspostoperatively, the majority of patientsshowed natural-appearing, soft enhancement.These findings were based on direct examina-tion by the author and self-evaluation by thepatients.

A wider sampling of the results was obtainedby means of a questionnaire mailed to allSMAS graft lip augmentation patients. Thequestionnaire surveyed the patients’ sense oflip fullness since the operation and their gen-eral evaluation of the postoperative results. Fif-ty-four patients (52 percent) returned thequestionnaire with their responses.

Of those who responded to the survey, 42patients (78 percent) reported having fullerlips at the time they answered the question-

naire than preoperatively (Fig. 12). Signifi-cantly, 11 of 14 patients (79 percent) followedfor at least 24 months postoperatively reportedfuller lips, with 11 of 14 (79 percent) of thesepatients reporting excellent or good results.Dissatisfaction was generally related to loss ofcorrection and unhappiness with immediatepostoperative swelling.

Complications

Complications and unsatisfactory resultswere rare, occurring mostly at the beginning ofthe learning curve of the series. One patienthad prolonged (9 months) dysesthesia, with adisquieting combination of discomfort andnumbness. A second patient had a prolonged(6 months) fatty bump in the upper lip, thesecondary excision of which gave the opportu-nity to show the presence of transplanted fat(Fig. 13). One patient (Fig. 9) noted a smallswelling near the end of the upper lip graft thatbecame more visible after 3 years, most likelycaused by irregular graft resorption around anonresorbed area. Treatment in this case wasby injection of a small amount of collagenaround the prominence (after the postopera-tive photographs were taken). Two patientsexperienced some irregularity of the lip sur-face on puckering. In all of these early cases,

FIG. 9. Result at 42 months. (Above, left) Preoperative frontal view of a 51-year-old womanbefore rhytidectomy with lip augmentation of upper and lower lips. (Above, right) Preoperativelateral view. (Below, left) Postoperative view at 42 months. Note small swelling near the right endof the upper lip graft. (Below, right) Postoperative lateral view at 42 months.

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attempts had been made to keep the tunnelclose to the overlying vermilion skin ratherthan deep in the muscle. These problems didnot occur once the level of tunneling haddeepened. There were no infections, hemato-mas, paralyses, or permanent anesthesias.

CONCLUSIONS

SMAS grafts harvested during rhytidectomyhave substantial long-term benefits in lip en-

hancement. The procedure gives a long-lasting, natural, soft roundness and fullness tothe lips, without the artificial look and feel ofsynthetic material. SMAS grafts produce pli-ability and longevity that are essential in lipenhancement. Positive feedback expressed inthe patients’ returned questionnaires and ex-cellent results seen in long-term follow-up sup-port the overall effectiveness of this operationin appropriately selected face lift patients.

FIG. 10. Resultat45months.(Above, left)Preoperativeviewofa49-year-oldwomanbeforerhytidectomywith SMAS grafting to upper and lower lips. (Above, right) Preoperative oblique view. (Below, left) Post-operativeviewat45months.(Below, right)Postoperativeobliqueview.Notethemildasymmetryandwhistledeformity present preoperatively, with similar asymmetry postoperatively.

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Norman Leaf, M.D.436 North Bedford DriveBeverly Hills, Calif. 90210norman@pacificnet.net

REFERENCES

1. Niechajev, I., and Sevcuk, O. Long-term results of fattransplantation: Clinical and histological studies.Plast. Reconstr. Surg. 94: 496, 1994.

2. Niechajev, I. Lip enhancement: Surgical alternativesand histologic aspects. Plast. Reconstr. Surg. 105: 1173,2000.

3. Fanous, N. Correction of thin lips: “Lip lift.” Plast. Re-constr. Surg. 74: 33, 1984.

4. Guerrissi, J. O., and Sanchez, L. I. An approach to thesenile upper lip. Plast. Reconstr. Surg. 92: 1187, 1993.

5. Leaf, N. SMAS autografts for the nasal dorsum. Plast.Reconstr. Surg. 97: 1249, 1996.

6. Mitz, V., and Peyronie, M. The superficial musculo-apo-neurotic system (SMAS) in the parotid and cheekarea. Plast. Reconstr. Surg. 58: 80, 1976.

FIG. 11. Result at 54 months. (Left) Preoperative view of a 62-year-old woman before rhytidec-tomy, quadrilateral blepharoplasty, and SMAS graft augmentation of upper lip only. (Right) Post-operative view at 54 months. The fullness in the upper lip is still present and visible.

FIG. 12. Questionnaire results: percentage of respon-dents reporting fuller lips. Postoperative months in 12-monthintervals. N, number of respondents that had the SMAS graftlip augmentation during 12-month period of time.

FIG. 13. Histologic section: lip glands and viable graftedfat cells.

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