CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY

Dimensional Changes of the Upper Lip

Using Dermis Fat Graft for Lip Augmentation
Reza Tabrizi, DMD,* Ehsan Shafiei, DMD,y and Hossein Danesteh, DMDz
Purpose: Lip augmentation is a facial cosmetic procedure used to augment a thin upper lip or correct a
lip deficiency. The aim of this study was to evaluate dimensional changes 12 months after dermis fat graft-
ing along the centerpiece of the upper lip.
Materials and Methods: In this prospective cohort study, a strip dermis fat graft was harvested from
various sites, namely the presacral, pre-abdominal, and suprapubic regions, and used for augmentation
of the upper lip. Then, it was placed in a pocket prepared in the center of the upper lip near the border
between the wet and dry areas using a cannula. Upper lip vermilion show and lip projection were evalu-
ated before and 12 months after augmentation using preoperative and postoperative photographs and dig-
ital imaging software. Age and gender were variable factors of the study. Changes of vermilion show and lip
projection were considered outcomes of the study. Paired t test was used to compare vermilion show and
lip projection before and 12 months after grafting.
Results: Fifteen patients were studied. No serious complication arose during the study and all patients
were satisfied. The mean change for vermilion show was 1.73  0.74 mm and that for lip projection was
2.33  0.68 mm. Quantitative analysis showed that vermilion show and projection of the upper lip
improved significantly (P < .001).
Conclusion: Augmentation of the lip with dermis fat grafting can be a safe and reliable method to treat
thin lips.
2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:1-8, 2015

Augmentation of facial components, such as the
cheeks, chin, and lips, is an acceptable approach in
facial esthetics. Full lips are associated with an attrac-
tive and youthful appearance. In contrast, thin, tightly
drawn lips convey a flat affect and an aged appear-
ance.1 Many individuals desire more exposure and ful-
ler vermilion show of the lips.2
Upper lip augmentation is used for thin lips or lip de-
ficiencies in patients with cleft lip or senile atrophy.3
Several methods have been suggested for lip enhance-
ment, which include injectable materials such as hyal-
uronic acid derivatives, collagen, silicone, and
autologous grafts.4,5 Compared with autologous
grafts, disadvantages of other materials are infections,
reactions to foreign bodies, and unpleasant
sensation.6,7 For optimal results, providing permanent
changes is important. Permanent fillers have led to a
higher incidence of granulomas and extrusion,
although this has decreased in newer products.8 Autol-
ogous materials include dermis fat, injectable autolo-
gous fat, fascia lata, temporalis fascia, and muscle
from various sites.1,2,9,10
Dermis fat grafting is a reliable, convenient method
with predictable results and provides sufficient vol-
ume for any degree of augmentation. Various donor
sites can be considered for graft harvesting with low
morbidity.9 Integration of the graft leads to an anatom-
ically natural shape and smooth surface by preserving
the continuity and functional activity of the lips. The
resorption is low and vascularization occurs.9

Received from the Department of Oral and Maxillofacial Surgery,
School of Dentistry, Shiraz University of Medical Sciences, Shiraz,
Iran.
*Assistant Professor.
yPostgraduate Student.
zAssistant Professor.
This article was based on a thesis by Dr Shafiei.
This study was supported by the Vice-Chancellor of Shiraz Univer-
sity of Medical Sciences (grant 93-01-03-8299).
Address correspondence and reprint requests to Dr Shafiei: OMFS
Ward, School of Dentistry, Shiraz University of Medical Sciences,
Ghasroldasht, Shiraz, Iran; e-mail: tabmed@hotmail.com
Received January 30 2015
Accepted March 13 2015
2015 American Association of Oral and Maxillofacial Surgeons
0278-2391/15/00332-8
http://dx.doi.org/10.1016/j.joms.2015.03.040

1
2 STABILITY OF DERMIS FAT GRAFT FOR UPPER LIP AUGMENTATION

FIGURE 1. The cannula inserted into the lip.

Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for
Upper Lip Augmentation. J Oral Maxillofac Surg 2015.

The study purpose was to address the stability of

dimensional changes of the dermis fat graft in the upper
lip after 12 months. It was hypothesized that a dermis fat
graft would produce a major dimensional change of the
upper lip with stable results. Therefore, the aim of this
study was to evaluate dimensional changes 12 months
after dermis fat grafting along the centerpiece of the up-
per lip in an open-mouth state as described by Nia-
matu11 in contrast to other studies.9,12,13
Materials and Methods
The authors designed a prospective cohort study
derived from the population of patients who presented
to the Department of Oral and Maxillofacial Surgery at
the Shiraz University of Medical Sciences (Shiraz, Iran)
from September 1, 2012 through October 31, 2013.
The research was approved by the committee of medi-
cal ethics of the Shiraz University of Medical Sciences.
Patients eligible for study inclusion were interested in
upper lip augmentation and had American Society of
FIGURE 3. Vermilion show, with the vertical distance between
points A and B.
Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for
Upper Lip Augmentation. J Oral Maxillofac Surg 2015.
Anesthesiologists physical status I and Class I skeletal
pattern. Patients were excluded if they had previous
lip augmentation. No patient had any history of esthetic
procedures of the nose, jaws, or anterior teeth. All pa-
tients were informed of the dermis fat grafting proce-
dure and technical details.
DERMIS FAT HARVESTING
The graft was harvested from various sites of the
body (except the face and exposed areas). An outline
of the strip graft was measured for proper length along

FIGURE 4. Upper lip projection, with the most horizontal distance

FIGURE 2. The strip dermis fat graft placed in the prepared pocket. between points A and B.
Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for
Upper Lip Augmentation. J Oral Maxillofac Surg 2015. Upper Lip Augmentation. J Oral Maxillofac Surg 2015.
TABRIZI, SHAFIEI, AND DANESTEH 3

Table 1. DESCRIPTIVE DETAILS OF PATIENTS

Vermilion Show (mm) Lip Projection (mm)

Patient Age
Number Gender (yr) Before Operation After Operation Before Operation After Operation

1 female 25 3.4 5.9 0 3.5

2 female 19 3.92 5.62 1.6 3.8
3 female 22 4 5.3 2.3 4.3
4 male 30 4.27 5.27 2.5 4.5
5 female 25 4.5 5 2.8 4.3
6 female 20 4.1 5.4 2.35 4.35
7 male 32 4.1 5.4 2.45 4.45
8 female 48 4 5.3 2.2 4.4
9 female 35 3.92 5.62 1.3 3.5
10 female 28 3.91 5.41 0.8 3.3
11 male 33 3.71 6.21 0 3
12 female 21 3.95 5.35 1.75 3.95
13 male 35 3.8 5.8 0.3 2.8
14 female 27 4 5.4 2 4.2
15 female 31 4.4 5.4 2.5 4.5

Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for Upper Lip Augmentation. J Oral Maxillofac Surg 2015.

the lip when the mouth was open. A strip 6 to 8 mm
wide with an elliptical shape at the ends was cut out.
The authors commonly harvest 5 to 10 mm more
than the measured length of the lip to have enough graft
when necessary. Under local anesthesia (4 to 5 mL of 2%
lidocaine and 1:100,000 epinephrine after preparation
and draping), the outline was incised using a number
20 or 15 scalpel blade. The epidermis was removed
by grasping it from a corner and cutting it toward the
other side (as thinly as possible clinically without perfo-
ration to eliminate retpages and attain white and dense
dermis layers). Harvest sites were closed primarily in 2
layers with 3-0 Vicryl sutures in the deep plane and 5-
0 nylon interrupted single sutures on the skin surface.
LIP PREPARATION
After anesthesia with bilateral infraorbital nerve
blocks (after preparation and draping), 2 3-mm stab
incisions were made across the lip 4 mm medial to
the oral commissures. A cannula (microcannula, flap
type, 1.8 mm, 15 gauge; Altona, Tehran, Iran) was
inserted and gently guided toward the other side.
This was repeated several times with a larger cannula
(microcannula, round tip, 3 mm, 11 gauge; Altona)
in the center of the lip near the border between the
wet and dry areas (Fig 1). This pathway created a
pocket for the strip graft to be placed with a natural
and fully rolled out appearance. Then, the dermis
fat strip was connected to the tip of the cannula
crossed through the lip by 3-0 Vicryl suture thread
(a suture was passed at the end of the graft and was
knotted on the tip hole of the cannula). By withdrawal
of the cannula, the strip graft was brought into the pre-
pared tunnel (Fig 2). After stretching the lip, the tails of
the strip graft were trimmed and tapered to lie just
short of the incision. Stab incisions were closed with

Table 2. EVALUATION OF VARIABLES AND Table 3. EVALUATION OF VARIABLES AND LIP

VERMILION SHOW PROJECTION

Change of P Change of Lip P

Variables Vermilion Show (mm) Value Variables Projection (mm) Value

Gender Gender
Men 1.7  0.68 .62* Men 2.37  0.47 .38*
Women 1.74  0.79 Women 2.31  0.76
Age, 28.8  7.55 yr 1.73  0.74 .70y Age, 28.8  7.55 yr 2.33  0.68 .64y
* By independent t test. * By independent t test.
y By Pearson correlation. y By Pearson correlation.
Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for
Upper Lip Augmentation. J Oral Maxillofac Surg 2015. Upper Lip Augmentation. J Oral Maxillofac Surg 2015.
4 STABILITY OF DERMIS FAT GRAFT FOR UPPER LIP AUGMENTATION

Table 4. RESULTS OF QUANTITATIVE ANALYSIS OF UPPER LIP PROJECTION AND VERMILION SHOW

Preoperative Postoperative
Measurement (mm), Measurement (mm), Change (mm), P Value by
Mean  SD Mean  SD Mean  SD Paired t Test

Upper lip projection 1.65  0.95 3.92  0.58 2.33  0.68 .001
Upper lip vermilion show 3.92  0.58 5.49  0.52 1.73  0.74 .001
Abbreviation: SD, standard deviation.
Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for Upper Lip Augmentation. J Oral Maxillofac Surg 2015.

5-0 nylon sutures that were removed after 1 week. All
patients received oral antibiotics 1 hour before the
procedure and then for 3 days (cephalexin 2 g before
the procedure and 500 mg every 6 hours after
the procedure).
ANALYSIS OF DIMENSIONAL CHANGES
All photographs were taken when participants
held their heads naturally and their lips in a rest
position (preoperatively and 12 months after
surgery).
1. Vermilion show was defined as the distance be-
tween the white roll and the lowest point in
the upper lip on the frontal view of a standard
photograph (Fig 3).10
2. Upper lip projection was defined as the maximum
horizontal distance between the subnasal soft tis-
sue pogonion line and the vermilion on the lateral
view of a standard photograph (Fig 4).1
These 2 variables were measured before and
12 months after grafting using Adobe Photoshop 5.0
(Adobe System, Inc, San Jose, CA) and were

FIGURE 5. A 20-year-old woman with a history of cleft lip A, C, before and B, D, 12 months after upper lip augmentation with a dermis fat
graft.
Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for Upper Lip Augmentation. J Oral Maxillofac Surg 2015.
TABRIZI, SHAFIEI, AND DANESTEH
FIGURE 6. A 31-year-old woman A, C, before and B, D, 12 months after upper lip augmentation with a dermis fat graft.
Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for Upper Lip Augmentation. J Oral Maxillofac Surg 2015.
compared by appropriate statistical testing (paired-
sample t test) using SPSS 11.5 (SPSS, Inc, Chicago,
IL). Paired t test was used to compare dimensional
changes before and 12 months after grafting. Inde-
pendent t test was applied to compare vermilion
show and lip projection between men and women.
Pearson correlation was used to determine any corre-
lation between age and vermilion show and lip
projection.
Results
Fifteen adult patients 19 to 48 years of age (11
women and 4 men) participated in this study
(Table 1). The patients mean age was 28.8  7.55 years.
The presacral (10 cases), pre-abdominal (2 cases), and
suprapubic (3 cases) regions were selected for donor
5
sites depending on the patients preference and the op-
erators advice.
Analysis of data did not show any difference be-
tween men and women for changes of vermilion
show and lip projection (P > .05). Patients age did
not show any correlation with lip projection and
vermilion show (P > .05; Tables 2, 3).
The summary of preoperative and postoperative
measured values of vermilion show and lip projection
is presented in Table 1. Vermilion show increased from
0.5 to 3.5 mm (mean, 1.73  0.74 mm) and lip projec-
tion increased from 1.2 to 3.5 mm (mean, 2.33 
0.68 mm); the increase in these 2 values was statisti-
cally significant (P < .001 for the 2 comparisons;
Table 4). No complications, such as hematoma, ecchy-
mosis, infection, neurosensory disturbances, or necro-
sis, were seen in the lip or donor site. Irregularity,
6 STABILITY OF DERMIS FAT GRAFT FOR UPPER LIP AUGMENTATION

FIGURE 7. A 22-year-old woman A, C, before and B, D, 12 months after upper lip augmentation with a dermis fat graft.
Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for Upper Lip Augmentation. J Oral Maxillofac Surg 2015.

extrusion of the graft, and related complications, such
as keratinization, growth of hair, or dermal cyst, were
not observed. Movement of the lip was normal. In
some patients, the only concern was lip edema several
days after grafting; this resolved after 1 to 2 weeks. In
general, after 12 months, 80% of patients were satis-
fied and 3 patients with cleft lip requested further lip
enlargement and were scheduled for a repetition of
the procedure. Clinical examples are shown in
Figures 5, 6, 7, and 8.
Discussion
The fullness and shape of the free border of the upper
lip are esthetically important criteria for a youthful
appearance. The free border of the upper lip consists
of the orbicularis oris muscle and overlying subcutane-
ous tissue, vermilion, and labial mucosa.13 Lip enlarge-
ment can be considered a reconstructive procedure in
patients with congenital deficiencies, such as cleft lip
and hemifacial microsomia, or a cosmetic procedure
to create a better appearance in individuals with thin
lips. Injectable fillers are suitable for short-term augmen-
tation and do not require a secondary surgical site. How-
ever, concerns about infection and reaction to foreign
bodies remain.6,7
Autologous materials have been popular because
they are safe and lead to more permanent and natural
results. Many autologous materials have been used
and dermis fat is one of the best. Injectable autologous
fat is a good option. The main drawback of autogenous
fat augmentation is the high resorption rate. Poor fat
viability produces an inadequate result and thus can
be considered a complication of this procedure.14 It is
commonly suggested to overcorrect the augmentation
sites; however, it is often unacceptable for some pa-
tients.15 Several materials are useful for special surgical
procedures, such as the superficial musculoaponeur-
otic system graft during a facelift, or deep temporalis
fascia for a forehead and brow lift.
Dermal fat grafts have been used in plastic surgery
for reconstructive and esthetic purposes in various
parts of the body.16 A dermis fat graft can be harvested
from various sites and provides abundant material for
the lip or extensive augmentation. Hwang et al17
used the dermal fat graft for nasolabial augmentation.
They had acceptable clinical results using the dermal
fat graft. The authors experience showed that some
TABRIZI, SHAFIEI, AND DANESTEH
FIGURE 8. A 48-year-old woman A, C, before and B, D, 12 months after upper lip augmentation with a dermis fat graft.
Tabrizi, Shafiei, and Danesteh. Stability of Dermis Fat Graft for Upper Lip Augmentation. J Oral Maxillofac Surg 2015.
patients have an emotional fear of an incision in the
temporal zone for harvesting temporalis fascia or inad-
equate volume and length of other autologous graft op-
tions, such as the fascia. Histologic studies on lip
augmentation with dermis fat have reported normal
fatty tissue and vascularized connective tissue without
signs of inflammation and necrosis after 11 months.9,12
Growth of hair and surface keratinization can be
avoided by discarding the epithelial layer to the level
of the deep dermis.18 Donor-site scarring is a downside
of this approach. A previous scar site can be used for
harvesting.9 The presacral region has thick skin with
minimal hair follicles and leaves a minimal scar.12 Dam-
age to the labial artery is avoided by placement of the
graft in the center of the lip in the cross-sectional
plane. According to the method of Niamatu,11 only
lateral portions of the lip are left without augmenta-
tion. Another disadvantage is that dermis fat grafting
is not easily reversible.
Methods applied in the present study yielded results
that were consistent with those of other similar
studies, confirming the efficacy of dermis fat grafting
7
for lip augmentation.9,12,13 However, a larger series
of patients, longer follow-ups, and comparison of
different donor sites are recommended for better eval-
uation. The patients satisfaction is another important
issue, which might need to be evaluated in further
studies. Furthermore, various donor sites were used
in this study. However, the stability of dermis fat grafts
from different sources was not evaluated in this
research because of the small number of patients.
Therefore, the donor site should be considered a vari-
able factor in further studies.
The major increases in upper vermilion show and
lip projection after 12 months showed that dermis
fat grafting can be a useful option for lip enlargement.
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