Elongated philtrum
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An elongated philtrum is a term used to describe an increased vertical distance between the base of the nose and the upper vermilion border. The infranasal depression, also known as the philtrum (Latin: philtrum), is a central depression bounded by two skin columns converging toward Cupid's bow. Its length depends on the craniofacial structure, sex, age, population background, and the proportions of the nose, maxilla, and lips. It can be a congenital feature or the result of tissue aging in the perioral area. Elongation of the cutaneous part of the upper lip is often accompanied by: a reduction in the visible height of the vermilion, flattening of Cupid's bow, and decreased exposure of the upper incisors. However, there is no single cut-off value that signifies an abnormality or an indication for treatment in every individual.
Elongated philtrum - what is it
In colloquial language, the terms "philtrum" and "cutaneous upper lip" are sometimes used interchangeably, but they are not completely identical. The philtrum is a central anatomical structure, while the cutaneous part of the upper lip extends across the entire width from the base of the nose to the vermilion border.
Morphological assessment takes into account not only the absolute length of the philtrum, but also:
- the ratio of the cutaneous lip length to the height of the vermilion border,
- the contour and symmetry of the philtral columns,
- the shape of Cupid's bow,
- the visibility of the upper incisors at rest and during a smile,
- the position of the nasal base and the nasolabial angle,
- maxillary projection, tooth alignment, and occlusal relationships,
- lip mobility and the activity of the orbicularis oris muscle.
An increased subnasal distance can be a constitutional trait. In some individuals, it results from craniofacial structure, a vertical facial growth pattern, insufficient maxillary projection, or nasal anatomy. It can also occur in developmental defects and certain genetic syndromes; however, a long subnasal segment alone, without other symptoms, does not constitute a basis for diagnosing a disease.
Aesthetic assessment should be based on the proportions of the entire face rather than on a single number. Anthropometric values differ between women and men, as well as between populations. Furthermore, three-dimensional studies confirm that both age and sex influence the length and surface area of the philtrum. For this reason, online "ideal dimensions" have limited diagnostic value.
Elongated philtrum - why it lengthens with age
Aging of the perioral region is a multilayered process. It involves the skin, subcutaneous tissue, muscles, ligaments, vessels, and bone-dental support. Photographic and magnetic resonance imaging studies have shown that in older individuals, the upper lip is, on average, longer, thinner, and less projected forward. In one MRI study, the difference in length between the younger and older group was approximately 18% in men and 19% in women. These data describe average group differences and therefore do not serve to predict changes in a specific individual.
The most important mechanisms include:
- dermal remodeling, including fragmentation of elastin fibers, changes in collagen organization, and reduced tissue elasticity;
- thinning of the skin and soft tissues, causing the lip to lose support and a defined contour;
- atrophy of the orbicularis oris muscle, confirmed in histological studies;
- the effects of gravity and years of facial expressions, leading to a gradual downward displacement of tissues;
- bony changes of the maxilla and pyriform aperture, which weaken the support of the nasal base and lip;
- dental changes, tooth wear, tooth loss, or improper prosthetic support;
- photoaging and smoking, accelerating the degradation of the extracellular matrix.
Along with the lengthening of the cutaneous portion, the vermilion may invert and become less visible. Upper incisor exposure at rest is also reduced. The effect perceived as a "long philtrum" is therefore often the result of several concurrent changes rather than a simple stretching of the skin.
Older MRI studies did not show a clear loss of total lip volume, whereas later analyses on larger groups indicated the coexistence of lengthening, thinning, and volume loss. This discrepancy shows that the anatomy of the aging lip is complex, and the choice of correction should not be based solely on the assumption that every aging lip requires filling.
Elongated philtrum - how to measure it
A standard measurement is performed at rest, with a natural head position, relaxed lips, and unclenched teeth. The vertical distance in the midline between two anthropometric points is measured:
- Subnasale (sn), which is the point located at the junction of the lower border of the nasal septum with the cutaneous upper lip.
- Labrale superius (ls), which is the highest point of the upper vermilion border in the midline, corresponding to the central part of Cupid's bow.
The most accurate direct measurement can be performed using an anthropometric caliper. Standardized photographs or three-dimensional imaging are also used for clinical documentation. Self-measurement with a ruler may be subject to error resulting from head positioning, facial expressions, perspective, and inaccurate landmark identification.
During a professional evaluation, the vermilion height, mouth width, incisor exposure, and proportions of the lower face are also measured. The photograph should be taken:
- with the camera positioned at face level,
- without smiling or tensing the lips,
- without makeup altering the vermilion border,
- without elevating the nasal tip,
- under consistent lighting and at a fixed distance.
Various reference ranges are found in the literature, but there is no universal clinical norm that, regardless of sex, ethnicity, and facial structure, determines a "too long" philtrum. Even a measurement exceeding the population average can remain harmonious. The indication for correction is determined by a comprehensive analysis of proportions, nasal anatomy, the vermilion, teeth, and patient expectations.
Elongated philtrum - how to shorten it
Actual and permanent shortening of the cutaneous upper lip is primarily provided by surgical procedures such as a lip lift. The most commonly performed is the subnasal lip lift in the bullhorn variation, during which a precisely planned strip of skin directly beneath the nasal base is removed, followed by lifting the lip tissues. The procedure can shorten the sn-ls distance, increase vermilion visibility, and enhance the display of the upper incisors.
Systematic reviews indicate an improvement in anthropometric parameters and high patient satisfaction, but the quality of available evidence is mostly moderate or low. There is a lack of large randomized studies and standardized outcome assessment methods. Possible complications include:
- a visible or widened scar under the nose,
- asymmetry and uneven lip elevation,
- changes in the shape of the nostrils or the nasal base,
- undercorrection or excessive shortening,
- sensory disturbances, infection, and prolonged swelling,
- the need for surgical revision.
In a review covering 2,265 patients, the most frequently reported issue was an unsatisfactory aesthetic outcome or an unfavorable scar, with an average frequency of about 7%. Proper qualification requires evaluating the tendency for keloid formation, prior procedures, lip mobility, nasal anatomy, and the amount of incisor show. Overly aggressive resection can lead to unnatural tension and difficult-to-reverse disproportion.
Non-surgical methods do not shorten the philtrum in the anatomical sense, but in selected cases, they can alter its optical proportions:
- Orthodontic, prosthetic treatment, or orthognathic surgery may be appropriate when the unfavorable proportion results primarily from tooth alignment, loss of lip support, or abnormal maxillary structure.
- Lip modeling with hyaluronic acid increases vermilion display and can accentuate Cupid's bow. However, it does not remove excess skin. Excessive product administration can increase lip projection, disrupt the profile, or create an impression of heaviness. Rare but serious complications include vascular occlusion and tissue necrosis.
- Botulinum toxin, used in a procedure known as a lip flip, relaxes the superficial fibers of the orbicularis oris muscle and can slightly evert the vermilion. The effect is temporary and does not reduce the sn-ls distance. Transient difficulties with articulation, drinking through a straw, and maintaining oral competence are possible.
- Ablative fractional laser therapy leads to the controlled removal of microscopic columns of the epidermis and dermis. It triggers the healing process, synthesis of new collagen, and remodeling of the extracellular matrix. It can reduce fine lines above the upper lip, improve skin texture, and partially increase skin tightness. At Ambasada Urody, procedures performed around the mouth area include fractional CO₂ laser resurfacing, iPixel, and the ablative Er 2940 nm laser. These procedures differ in depth of penetration and healing time; therefore, parameters are selected according to phototype, degree of photodamage, and skin thickness.
- Non-ablative fractional laser therapy creates micro-zones of controlled overheating in the dermis without removing the entire epidermal surface. It induces gradual remodeling of collagen fibers, which can improve the firmness and quality of thin skin under the nose. It typically requires a shorter recovery period than ablative procedures, but also yields subtler results. This group of methods used at Ambasada Urody includes ClearLift 4D, also offered as a laser lift for the perioral area and lip vermilion.
- Alma Hybrid laser combines the action of an ablative fractional CO₂ laser with a non-ablative 1570 nm laser. The ablative component is primarily responsible for surface renewal and improving skin texture, whereas non-ablative energy reaches deeper, causing thermal coagulation and collagen remodeling. Ambasada Urody offers a dedicated treatment protocol designed for the mouth area. It may be considered in the presence of coexisting laxity, photodamage, and perioral wrinkles.
- Regenerative and biostimulatory treatments, such as mesotherapy, platelet-rich plasma, and carefully selected tissue stimulators, can support improvements in skin hydration, elasticity, and density. However, they do not remove the excess cutaneous upper lip. Their role primarily concerns tissue quality; therefore, they can be part of a combined therapy rather than a replacement for a surgical lip lift.
The aforementioned procedures can make the subnasal area appear smoother, firmer, and less wrinkled. However, they do not shorten the distance between the subnasale point and the upper vermilion border to the extent that a surgical lip lift does. In the case of actual excess length of the cutaneous upper lip, laser therapy and biostimulation play a complementary role.
The choice of method should be made after a medical examination and determining whether the predominant issue is cutaneous lip length, low vermilion height, volume loss, skin laxity, or insufficient dentoskeletal support.
