Lip Revision: Timing, Techniques, and Reconstruction Principles
Primary Recommendation
Lip revision surgery should be delayed until growth has definitively ceased—typically at 3 to 5 years of age—to minimize surgical interventions, reduce anesthetic risks, and achieve superior cosmetic outcomes, with reconstruction focusing on restoring normal lip anatomy including the orbicularis oris muscle, vermilion border, and proper lip contour. 1, 2
Optimal Timing for Lip Revision
General Timing Principles
Wait until 3 to 5 years of age for most lip revision procedures because: (1) the lesion may resolve significantly without intervention, (2) the operation is easier with smaller tissue volume, (3) the tissue is primarily adipose rather than highly vascular, making surgery safer, and (4) this timing minimizes stigma while avoiding unnecessary delay since most deformities don't improve significantly after age 3-4 years 1
Reconstruction of scarred and disfigured lips is best performed only after growth has definitively ceased, as premature intervention may require multiple subsequent procedures 1, 2
Early surgical intervention (before 3-5 years) corrects residual deformities before the child's self-esteem develops, which can be psychosocially beneficial 1
Exceptions Requiring Earlier Intervention
Early surgery may be indicated when: (1) the lesion has failed local wound care and/or pharmacotherapy, (2) the lesion is well-localized and early surgery will simplify later reconstruction, or (3) there is ulceration, obstruction, or deformation of vital structures 1
Small ulcers in cosmetically favorable areas may warrant early surgical resection, though this is the exception rather than the rule 1
Surgical Reconstruction Principles
Anatomic Goals
The primary objectives include: establishing normal lip anatomy, reconstructing the orbicularis oris muscle, creating normal lip contour, establishing proper vermilion border, and placing scars along natural boundaries such as the vermilion border or philtral columns 2, 3
Technical Approaches Based on Lesion Location
Lesions exclusively on the vermilion: Remove using a transverse mucosal incision to hide the scar at the junction of the vermilion and vestibular mucosa 3
Lesions traversing both vermilion and cutaneous tissues: May require a vertical incision 3
Bulkier lesions causing lip lengthening or crossing the vermilion-cutaneous border: Best addressed using wedge excision 3
Scar revision using a subunit approach: Place scars along aesthetic borders and perform subunit reconstruction to camouflage scars, which is the preferred method for treating perioral scarring 4
Specific Technical Challenges
Setting the "white roll" (ridge at the vermilion-cutaneous border) and restoring normal sublabial concavity are particularly challenging aspects of lip reconstruction 3
Debulking lip lesions while preserving vermilion is exceedingly difficult due to the challenge of separating tissue from orbicularis oris muscle 3
Eversion of the lower lip may require excision of a mucosal strip, while correction of inversion may require a dermal implant or graft 3
Advanced Revision Techniques
For Severe Deformities
Complete labial revision with secondary cheiloplasty combined with a submucosal inferiorly based flap in the central tubercle can address severe whistle deformity in bilateral cleft lip, solving both orbicularis oris function and normal labial anatomy in a single operation 5
Converting previous repairs to anatomic subunit repair: Previous Millard or straight-line cleft lip repairs can be converted to Fisher anatomic subunit repair, placing favorable scars along the philtrum 6
Surgical Technique Options
Available surgical techniques include: direct excision, scar reorientation, local flap rearrangement, pedicled flaps, and regional or free flaps, with selection based on defect characteristics 4
Non-Surgical Alternatives for Minor Enhancement
Hyaluronic Acid Fillers
HA fillers provide volumizing effects lasting 6-18 months for minor lip enhancement without surgery, representing the primary non-surgical option 2, 7
Technical administration: Use small gauge needles (27-30 gauge) or cannula (22-25 gauge), inject above the orbicularis oris muscle to avoid vascular complications, use 0.2-0.5 mL per quadrant, and inject in retrograde fashion 7
Autologous Platelet Concentrates
APCs provide rejuvenation effects rather than significant volumizing, with benefits including improvement in lip color, moisture, dermal structure, and texture through biostimulation of natural collagen production 2, 7
The 3D volumizing effect does not last beyond 3 months with platelet concentrates, though rejuvenation effects persist longer 7
Critical Safety Considerations
Surgical Risks
Risk of surgical complications and general anesthesia must be weighed against benefits, particularly in younger children where anesthetic risks are greater 1
During proliferative phases, the tumor is highly vascular, posing higher risk of blood loss and iatrogenic injury 1
Non-Surgical Risks
Warn all patients about bruising, swelling, and tenderness as the most frequent treatment-related effects with fillers, though most adverse events are mild to moderate and self-limited 7
Avoid treating the perioral area too superficially—maintain injection depth above the orbicularis oris muscle to prevent vascular injury 7
Post-Procedure Care
Lubricate lips with lip balm or cream to promote healing 3
Maintain good oral hygiene with a soft toothbrush and mild fluoride-containing toothpaste 3
Avoid irritants including spicy foods, hot foods and drinks, and citrus fruits that may delay healing 3
Common Pitfalls to Avoid
Do not operate during infancy except in specific circumstances (ulceration, obstruction, or deformation of vital structures), as anesthetic risks are higher and the tumor is more vascular 1
Avoid using APCs when significant volumization is the goal, as the 3D effect does not persist beyond 3 months 7
Do not dismiss patient concerns about bruising—set realistic expectations preoperatively about common adverse events 7
Avoid waiting longer than 3-5 years unnecessarily, as the previously accepted adage about continued improvement through age 9 has proven incorrect 1