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Botulinum Toxin Type-A for Lip Augmentation: "Lip Flip"

Article in The Journal of craniofacial surgery · November 2020

DOI: 10.1097/SCS.0000000000007128

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The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021 Brief Clinical Studies

Lateral canthopexy is predominantly used to avoid lower eyelid interest truly exists. Therefore, the authors aim to explore whether
ectropion following lower eyelid blepharoplasty for dermatocha- there is a rising trend regarding ‘‘lip flip’’ and report on clinical
lasia, traumatic approaches to the orbital floor, or after skin cancer results from patients treated in our practice.
treatment. Remarkably, we found no mention of upper eyelid lateral
canthopexy for the adjunctive management of cicatricial upper eyelid
ectropion in the literature. Lateral canthopexy of the upper eyelid Key Words: Botulinum toxin, lip augmentation, lip flip,
offers an elegant adjunctive procedure in managing cicatricial upper orbicularis oris
eyelid ectropion to counteract the cicatricial forces of scar and graft
contracture during scar remodeling. Additionally, once the scar
contracture has resolved, lateral canthopexy is reversible. O ver the last 10 years there has been an explosion in the number
of minimally invasive procedures that patients undertake with
increasing uses of botulinum neurotoxin type A for off label
CONCLUSION indications.1 While botulinum neurotoxin type A was originally
Multiple strategies were employed in this case to reconstruct a approved by the Food and Drug Administration in 2002 for the
traumatic soft tissue defect in the supraorbital and lateral brow treatment of glabellar, forehead, and periorbital rhytids, such off
region, and the sequelae of scar contracture, causing cicatricial label uses have increased as a result of increased predictability of
upper eyelid ectropion. This case serves as a reference of available result and provider comfort.2 One area of expansion over the past
treatment options and ultimately yields an example of the most several years is the ‘‘Lip Flip’’ which involves injection of botu-
effective procedure to counteract cicatricial upper eyelid ectropion: linum neurotoxin type A along the vermillion border to improve lip
upper eyelid lateral canthopexy. contour, eversion and fullness. While techniques and results for
‘‘gummy smile’’ and perioral vertical rhytids have been previously
reported, minimal literature exists on this new trend, including
REFERENCES
whether such increased interest truly exists. Therefore, we aim to
1. Vallabhanath P, Carter SR. Ectropion and entropion. Curr Opin explore whether there is a rising trend regarding ‘‘lip flip’’ and
Ophthalmol 2000;11:345–351 report on clinical results from patients treated in our practice.
2. Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol
2010;25:59–65
3. Leibovitch I, Davis G, Selva D, et al. Non-cicatricial upper eyelid METHODS
ectropion. Br J Ophthalmol 2005;89:1226–1227 Google Trend parameters were set to capture Google Search terms
4. Ozgur OR, Akcay L, Tutas N, et al. Cicatricial upper and lower eyelid from June 1st, 2010 to June 1st, 2020. Search terms focus specifically
ectropion in an ichthyosis patient. Surgical correction. J Dermatol Case on lip flip procedures, and therefore to exclude other lip augmentation
Rep 2011;5:27–29
5. Gracitelli CP, Osaki TH, Valdrighi NY, et al. Cicatricial ectropion procedures, the search terms used in the analysis were ‘‘Lip Flip’’ and
secondary to psoriatic arthritis. Case Rep Ophthalmol Med ‘‘Botox Lip Flip.’’ The total number of queries were summed for each
2015;2015:1–3 month and subsequently each month’s search terms were then also
6. Astori IP, Muller MJ, Pegg SP. Cicatricial, postburn ectropion and summed for a total aggregate number for each year (Fig. 1).
exposure keratitis. Burns 1998;24:64–67 With respect to injection technique, onabotulinumtoxinA was
7. Worley B, Huang JW, Macdonald J. Approach to treatment of cicatricial reconstituted in preserved saline, 2.5 ml per 100 units, with a final
ectropion: a systematic review and meta-analysis comparing surgical concentration of 4 units per 0.1 ml. Injection sites are shown in
and minimally invasive options. Arch Dermatol Res 2020;312:165–172 Figure 2 and differ from traditional perioral injections in that they
8. Gillies HD, Milliard DR. Principles and Art of Plastic Surgery. 1st ed.
are made very superficial at the vermillion border. Deeper injection
Boston, MA: Little, Brown & Co; 1957
9. Yoon JS, Lew H, Lee SY. Bell’s phenomenon protects the tear film and
or involvement of the peripheral aspect of the orbicularis oris should
ocular surface after frontalis suspension surgery for congenital ptosis. J be avoided which may increase the risk of oral incompetency and
Pediatr Ophthalmol Strabismus 2008;45:350–355 furthermore elongation of the upper lip. Injection of the vermillion
10. Manku K, Leong JK, Ghabrial R. Cicatricial ectropion: repair with border farther laterally closer to the oral commissure should be
myocutaneous flaps and canthopexy. Clin Exp Ophthalmol avoided as it may contribute to increased complications without
2006;34:677–681 appreciable increase in fullness or eversion of the lip. There is no
clear consensus on the specific number of units; however, our
experience recommends that no more than 6 U be used throughout
the vermillion border as greater amounts can result in poor oral
competency. These doses are in line with those used to treat vertical
Botulinum Toxin Type-A for Lip
From the Department of Otolaryngology-Head and Neck Surgery
Augmentation: ‘‘Lip Flip’’ Madigan Army Medical Center, 9040 Jackson Ave, Tacoma; and
yDepartment of Facial Plastic Surgery, Virginia Mason Medical Center,
Jeffrey C. Teixeira, MD, MBA, Jonnae Y. Ostrom, MD,y
1100 Ninth Ave, Seattle, WA.
Marc H. Hohman, MD, and Michael J. Nuara, MDy Received August 2, 2020.
Accepted for publication September 7, 2020.
Abstract: Over the last 10 years there has been an explosion in the Address correspondence and reprint requests to Jeffrey C. Teixeira, MD,
number of minimally invasive procedures that patients undertake MBA, Otolaryngology-Head and Neck Surgery, Madigan Army Medical
with increasing uses of botulinum neurotoxin type A for off label Center, 9040 Jackson Ave, Tacoma, WA 98431;
E-mail: [email protected]
indications. One area of expansion over the past several years is the The views expressed are those of the authors and do not reflect the official
‘‘Lip Flip’’ which involves injection of botulinum neurotoxin type policy of the Department of the Army, the Department of Defense, of the
A along the vermillion border to improve lip contour, eversion and US Government.
fullness. While techniques and results for ‘‘gummy smile’’ and The authors report no conflicts of interest.
Copyright # 2020 by Mutaz B. Habal, MD
perioral vertical rhytids have been previously reported, minimal ISSN: 1049-2275
literature exists on this new trend, including whether such increased DOI: 10.1097/SCS.0000000000007128

# 2021 Mutaz B. Habal, MD e273

Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021

Google Trend Search Terms

100

90

80

70

60
Search Interest

50

40

30

20

10

0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Year

FIGURE 1. United States search terms results for 10 years: aggregate search
terms ‘‘Lip Flip’’ and ‘‘Botox Lip Flip.’’

perioral lines.3 We therefore recommend 0.5 to 1 U per injection

site. Given these small doses, our experience dictates that using a
0.3 ml insulin syringe with a 31-gauge needle allows for precise
dosing. Topical analgesic agent of choice applied before the injec-
tion provides significant patient comfort given the sensitive nature
of the vermillion border. The patient should also be counseled on the
delayed onset of botulinum toxin of 3 to 14 days and it should be
noted that onabotulinumtoxinA is not Food and Drug Adminis-
tration approved for treatment around the perioral area and patients FIGURE 3. A 22-year-old female without previous history of lip augmentation
should be appropriately counseled. who underwent lip flip with 4 U of botulinum neurotoxin type A. (A) day of
procedure before injection (B) 4 weeks post procedure.

RESULTS
Our findings showed an overall increase in interest in those seeking who the end user may be and therefore who is entering the query.
information for lip flip, which is consistent with anecdotal reports of However, Google Trends has been previously determined to be a
increasing trends for this procedure as well as off label botulinum reliable search tool with respect to healthcare trends.4 Our results
toxin type A procedures in general (Fig. 1). While ‘‘botox lip flip’’ did noted a steady interest in search queries until the second half of 2017
not have the level of interest in the early years compared to ‘‘lip flip,’’ with significant increases thereafter. This may be a result of a written
latter years’ correlation between both search terms was consistent. In piece that was published in the influential skincare and beauty
our practice of over 50 patients, satisfaction has been rated as high periodical Allure on the benefits of lip augmentation with Botox
with minor complications consisting of difficulty with whistling or alone.5 Such trends have previously been seen in facial feminization
drinking from a straw lasting several days and no major significant surgery in which celebrity experience with treatment can signifi-
complications. Figure 3 demonstrates a patient who had 1 U of cantly influence interest in such named procedures.6,7 Our analysis
OnabotulinumtoxinA injected at 4 separate points for a total of 4 demonstrates another sharp increase at the end of 2019 which may
U. The photos document the lips preprocedure and 4 weeks after correlate with an article in Harper’s Bazaar and a subsequent
treatment, which demonstrates lasting effects. The patient is noted to decrease in February of 2020 which may correlate with the SARS-
have improved contour of the lip with improvement in the cupid’s Cov 2 outbreak that placed a hold on cosmetic procedures, and likely
bow as well as increase in eversion and fullness of the upper lip. diverted the public’s attention in general.8 While there has been an
increase in patient interest with respect to lip flip procedures, there is a
paucity of literature on technique and results, as most botulinum
DISCUSSION neurotoxin perioral treatments focus on lower face rejuvenation,
There are some limitations with the use of Google Trends given that particularly treatment of the ‘‘gummy smile’’ and perioral rhytids.9
the information is de-identified. As a result, it is difficult to determine Traditionally, such treatments aim to reduce the amount of gingival
show by targeting muscles such as the levator labii superioris and the
orbicularis oris.10 Providers with experience performing these injec-
tions have often noted the added benefit of improved contour, ever-
sion, and lip fullness, which resulted in the development of the peri-
vermilion injection technique. This procedure, known as the ‘‘Lip
Flip,’’ results in relaxation of a portion of the orbicularis oris muscle
called the ‘‘marginal’’ or ‘‘intrinsic portion",’’ which consists of a
single or double band of muscle fibers that starts at the modiolus and
travels to the midline. Along the way, the muscle curls upon itself,
forming the vermillion border; it is the relaxation of these superficial
attachments of the orbicularis oris muscle to the lip mucosa which
causes the upper lip to roll out, resulting in the appearance of a fuller
lip. As a result, the provider must verify that the injection is placed
very superficial to deactivate the ‘‘intrinsic portion’’ of the muscle. It
FIGURE 2. Typical injections sites in the superficial orbicularis oris muscle at the
vermilion border denoted by X. Injection of the vermillion border farther laterally
is important for patients to understand that this procedure does not
closer to the oral commissure should be avoided as it may contribute to increased actually add volume to the lips as hyaluronic acid lip augmentation
complications without appreciable increase in fullness or eversion of the lip. does. However, as demonstrated in our results, the procedure does

e274 # 2021 Mutaz B. Habal, MD

Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021 Brief Clinical Studies

create the illusion of a fuller lip and produces a more natural 24-year-old women with unilateral maxillary sinus hypoplasia who
appearance in patients with previous lip augmentation or those with presented with headache and nasal blockage.
already full lips. Lip flip is well tolerated; however, the marginal
portion of the orbicularis oris, which is being targeted during lip flip
allows for the changing of length and tension of the lip which allows Key Words: Computerized tomography, hypoplasia, maxillary
for consonantal sounds and whistling. As a result, patients may sinus
endorse difficulty with activities that require pursed lips such as
whistling or drinking through a straw, and therefore should be
counseled on this risk prior to injection. In our experience, these
effects resolve within approximately 2 weeks which accounts for the
M axillary sinus hypoplasia (MSH) and maxillary sinus aplasia
are rare encountered conditions1 Frontal and sphenoid
sinuses are rare frequently involved.2 The MSH term describes
small doses of botulinum toxin that are used. an anatomic abnormality spectrum range mild sinus hypoplasia
to cleft-like sinuses. These clinical entities can arise as a result
CONCLUSION of developmental defects, trauma, surgery, systemic disease, or
There is an increasing trend amongst patients seeking off-label neoplasm.2
botulinum neurotoxin applications, and especially increased inter- Maxillary sinus (MS) develops in the third of the intrauterine
est in lip flip procedures. Lip flip can provide natural-appearing, life.3,4 At the age of 10 lower boundaries of MS and the floor of the
fuller lips with minimal downtime and out of pocket cost. nasal cavity are on the same floor.5 Maxillary antrum increases by
2 mm in the vertical and lateral dimensions by 3 mm in the ante-
roposterior dimension yearly until the age of 8. MS size reaches its
REFERENCES maximum volume at about late adolescence ages.
1. Flynn TC. Advances in the use of botulinum neurotoxins in facial Incidence of MSH range 1.5% to 10%. But some studies have
esthetics. J Cosmet Dermatol 2012;11:42–50 reported less than this range.2,6 The majority of patients reported
2. Schlessinger J, Gilbert E, Cohen JL, et al. New uses of were asymptomatic identified only on routine radiological exam-
AbobotulinumtoxinA in aesthetics. Aesthet Surg J 2017;37 ination. Usually, MSH is asymptomatic and it is revealed by X-ray
(suppl_1):S45–S58 studies as an incidental find. This extremely rare abnormality
3. Cohen JL, Dayan SH, Cox SE, et al. OnabotulinumtoxinA dose-ranging
study for hyperdynamic perioral lines. Dermatol Surg 2012;38:1497– should be kept in mind to prevent complications during endoscopic
1505 sinus surgery and misdiagnosis such as sinusitis or tumor.7
4. Tijerina JD, Morrison SD, Nolan IT, et al. Google trends as a tool for A 24-year-old female admitted to the otolaryngology clinic. Her
evaluating public interest in facial cosmetic procedures. Aesthet Surg J complaint was nasal blockage and headache for several years. On
2019;39:908–918 otolaryngological examination revealed septal deviation and hyper-
5. Kinonen S. Why People Are Getting Botox in Their Lips Instead of trophy of inferior concha. The neurological examination was
Actual Lip Fillers. Allure. Available at: https://www.allure.com/story/ natural. Axial and coronal computerized tomography scans of
botox-lip-flip-injectable-trend Accessed June 14, 2020 paranasal sinuses showed hypoplasia of left maxillary sinus, septal
6. Teixeira JC, Morrison SD, Brandstetter KA, et al. Is there an increasing deviation, right hypertrophy of inferior turbinate, and concha
interest in facial feminization surgery? A search trends analysis. J
Craniofac Surg 2020;31:606–607 bullosa of the middle turbinate (Fig. 1). Also, we have noticed
7. Singh M, Singh Chauhan A, Singh G, et al. Did Caitlyn Jenner’s facial mild asymmetry of the infraorbital region in the patient. Under
feminization surgery impact public interest in gender reassignment general anesthesia septoplasty, inferior turbinate reduction through
surgery and facial feminization surgery? Facial Plast Surg Aesthetic radiofrequency and endoscopic concha bullosa resection were
Med 2020;22:117–119 performed. The patient was informed about the sinus condition
8. What is a Botox Lip Flip? Experts Explain. Harper’s BAZAAR. for future symptoms.
Published December 26, 2019. Available at: https://
www.harpersbazaar.com/beauty/health/a28871171/lip-flip-botox/
Accessed June 14, 2020 DISCUSSION
9. Kaplan SE, Sherris DA, Gassner HG, et al. The use of botulinum toxin A Maxillary sinus develops in the 10th week of embryogenic life.
in perioral rejuvenation. Facial Plast Surg Clin N Am 2007;15:415–421 Resorption of surrounding tissue and growth of the maxillary
10. Gart MS, Gutowski KA. Overview of botulinum toxins for aesthetic pouch occur simultaneously. The inferior border of the sinus
uses. Clin Plast Surg 2016;43:459–471 reaches the level of the nasal cavity floor at the age of 10 to 12
years. The growth of the MS lasts until the age of 12 to 20 years.5
Embryogenic developmental anomalies or acquired contributors
such as infection, trauma, and surgery may be causes of MSH.8 The
incidence of MSH has been reported as between 15%, and 10%.9
The majority of the MSH cases are asymptomatic, but in some
cases, MSH causes some symptoms such as headache, facial pain,
A Rare Paranasal Sinus nasal discharge, esthetical deficit, and voice problems.9 Chrcano-
vic et al presented a case of the esthetical deficit caused by
Abnormality: Maxillary
From the Department of Otolaryngology, VM Medicalpark Pendik
Sinus Hypoplasia Hospital, Bahcesehir University Faculty of Medicine, Istanbul, Turkey.
Received August 7, 2020.
Banu Atalay Erdogan, MD Accepted for publication September 7, 2020.
Address correspondence and reprint requests to Banu Atalay Erdogan, MD,
Abstract: Maxillary sinus hypoplasia is a rare condition. The Department of Otolaryngology, VM Medicalpark Pendik Hospital,
majority of patients are asymptomatic but in some cases, Pendik, Istanbul, Turkey; E-mail: [email protected]
they suffer from headaches and facial pain. Awareness of this The authors report no conflicts of interest.
Copyright # 2020 by Mutaz B. Habal, MD
condition is important because of misdiagnosis and possible com- ISSN: 1049-2275
plications during endoscopic sinus surgery. This is a presentation of DOI: 10.1097/SCS.0000000000007129

# 2021 Mutaz B. Habal, MD e275

Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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