Dr. Little’s Techniques
Surgical Techniques for the Mouth
One of the key (but over-looked) markers for facial aging is gradual descent of the mouth, with progressive coverage of the upper teeth (behind a lengthening upper lip) and exposure of the lower teeth (above a dropping lower lip). A slumping of the corners of the mouth with development of negative “bitterness folds” typically accompanies this process. Some surgeons shorten the upper lip with scars across the lip, either under the nose or along the lip margin, but this does nothing to raise the lower lip or corners of the mouth, or hide the narrow, exposed lower teeth, all of which present the more pejorative aspects of the aging mouth. Instead, Dr. Little performs a series of hidden maneuvers through the facelift approach and through small incisions inside the mouth to encourage a natural elevation of the mouth (with both its upper and lower lips) without visible, outside scars…a process he calls “stomapexy” or internal mouth lift. If still further elevation of the lip is desireable, such is added through short scars within the crease under the wings of the nose, as opposed to the conventional scar that stretches across the entire lip. Artistic, tasteful enhancement of the lips is then routinely performed by micro structural fat grafting. Finally, if vertical lip lines are present, these must also be smoothed, but without “whitening” the lip.
Internal Elevation of the Mouth (Stomapexy)
Jowl lift: the vertical re-suspension of the jowl inherent in the basic XJ facelift automatically lifts the tissues to either side of the corner of the mouth, bringing elevation to the region.
Vertical rhytidectomy: the skin movement in the XJ lift, in common with other well-vectored facelifts, is vertical-oblique, lending further support to elevation of the corner of the mouth.
DAO division: Dr. Little divides the DAO (depressor anguli oris) muscle in nearly all of his facelift patients. This muscle underlies the marionette line at the forward margin of the jowl and contributes to formation of the bitterness fold, as it pulls down the angle or corner of the mouth. This helpful trick was not of Dr. Little’s design, but rather that of French plastic surgeon Claude LeLouarn, M.D. Many dermatologists and plastic surgeons routinely paralyze this muscle (temporarily) with Botox™; Dr. Little has found that surgical division at the time of facelift presents the opportunity for a lasting, one-time treatment.
Modiolus hitch: Division of the DAO exposes that key point to either side of the commissure or corner of the mouth where many of the facial muscles come together (modiolus). A fine suture can then elevate this point, bringing further elevation to the corner.
Mentalis hitch: Dr. Little releases and re-suspends the chin pad through a small incision below the teeth (inside the mouth). Not only does this maneuver improve the dropped chin contour (which ranges from the full “witch’s chin” deformity to a more subtle relaxation), but it also elevates the chin muscle (mentalis), helping to support a higher position for the lower lip.
DLI release: during elevation of the chin pad, the release maneuver may be extended to either side to free the origins of the DLI (depressor labii inferioris) muscle from the mandible (jawbone), which further encourages an improved position for the lower lip. This maneuver also was not of Dr. Little’s design, but that of yet another French plastic surgeon, Christian Marinetti, M.D. (Marinetti, C. The lower muscular balance of the face used to lift labial commissures. Plast. Reconstr. Surg. 104:1153, 1999).
Musosal lift: Dr. Little routinely removes a narrow triangle from the wet lining of the lip (mucosa) above the corner of the mouth on the inside. When the triangle is closed, there is further subtle lifting to the corner of the mouth. The small scars end up inside the mouth, near the upper gum…where only the dentist can see them. All the small incisions in the mouth are closed with fine absorbable sutures that typically require no further attention.
Sub-alar hitch: Finally, Dr. Little may add a further, direct elevation to the upper lip with short scars under the wings of the nose, that avoids the conventional scar across the entire lip.
If eight steps seem like a lot of effort for the pursuit of a single goal, meaningful elevation of mouth position is difficult to accomplish during facelift (without visible, often destructive scars). It is not surprising, therefore, that patients with poor mouth position, slumped commissures, and bitterness folds are not often included in facelift websites, publications, and lectures (even though Dr. Little feels such individuals comprise at least a third of all facelift patients). Fortunately, Dr. Little’s eight steps are straightforward and rapid, each adding only minutes to the overall time, and all are accomplished through hidden scars. [view: six of the steps of Stomapexy in diagrammatic form] Dr. Little includes many such patients with an aging focus around the mouth within his website, his publications, and his lectures, where most show significant improvement to their aging mouth posture. Such improvement is best appreciated in superimposed, faded photographic views and in the dynamic (video) format.
Just as we lose significant volume from around our eyes as we age, so do we also from our lips. Micro structural fat grafting has proven highly effective in Dr. Little’s hands for restoring the depleted lip, not only because the volumetric enhancement has proven lasting, but because the micro fat deposits can be placed in subtle artistic patterns that reflect the complex normal anatomy of the natural youthful lip. [view: Artistic Lip Augmentation in diagrammatic form]
Upper lip vermilion: the vermilion or “red” of the upper lip undergoes relatively little loss during aging. Dr. Little, therefore, does not typically add to the vermilion; when he does, he does so with restraint. Augmented upper lips can easily appear unnatural, especially when tubular in shape. As artists understand very well, there are three subtle but distinct volumes in the typical upper lip that reflect the embryologic formation of that structure.
Upper lip white roll: while our upper lip vermilion typically loses little height or thickness during aging, the lip itself flattens as it elongates (best appreciated on the profile view). The concave kick or “flip” at the margin of the lip is almost universally diminished. Dr. Little restores an element of the forward kick of the lip not by thickening the red of the lip, but by enhancing the “white roll” (the subtle undulation in the lip surface just above the join of the red with the white lip) by micro structural fat grafting.
Philtral columns: the vertical thickenings of the upper lip to either side of the central lip dimple (philtrum) are often diminished in aging and may be similarly reinforced by micro structural fat grafting.
Lower lip vermilion: in contrast to the upper lip, the lower lip vermilion typically loses significant volume during aging. On average, the youthful red lower lip at twenty is more than half again as full as the upper; but after aging, lower lip volume is often reduced to that of the upper lip or less. Even when there has been no dramatic reduction in lower lip dimensions, the vermilion often appears empty or flaccid, as with a pillow that has lost filling. Again, a tubular augmentation of the lower lip does not reflect the natural embryologic anatomy of the lower lip, which typically presents a fullness to either side of a subtle midline depression. Here, micro structural fat grafting is particularly well-suited for restoring such artistic subtleties. Dr. Little restores the lower lip in most of his facial rejuvenation patients (moving toward, but not so far as the contour evident in the early patient photographs). When patients are worried about this detail of their overall rejuvenation, the treatment is kept especially conservative (many of these patients will then ask that more volume be added in the office later). Some patients request a particularly full lower lip, perhaps even beyond what they had in youth. Dr. Little will usually accommodate such requests for the lower lip, but not for the upper.
Dr. Little prefers ablative CO² laser resurfacing to diminish the vertical lip lines that develop in some patients. Here, however, energies must be considerably higher than for the thin skin of the eyelids, and there remains a risk of some decoloration or whitening in certain (especially darker) skin tones. In such circumstances, a combination of reduced laser energy with micro structural grafting of the lines (in this case, with a new fat grafting technique using sharp needles) presents a compromise between treatments that brings worthwhile improvement with less risk of decoloration. Each of these compromises is worked out on a patient-by-patient basis.
Illustration: detail from Leonardo da Vinci, “Movement of lips,” Anatomical Manuscipt B, fol. 38v, Royal Library, Windsor.