The article entitled “Upper Lip Augmentation: Palmaris Longus Tendon as an Autogenous Filler” by Trussler et al.,1 published in the March 2008 issue, was interesting. It is another addition to the problem of upper lip augmentation.2 The authors have used the palmaris longus tendon, when present, from the nondominant hand, cut it into pieces, and stacked the pieces if required before placing them in the submucosal tissues of the upper lip. Their anatomical achievements are well described. Their cases had a follow-up of 1 year, which seems more or less adequate and allowed enough time for the tissues to settle and for absorption to take place. In the case shown in Figure 5, the preoperative appearance appears to be better than the postoperative one.
The tendon graft is not supple, and I guess the feel of the lip is likely to be different, though the lip might have tissue mobility. The tendon acts more like a stent to enhance the upper lip, exposing more of the vermilion.
I can compare it to breast implants, in which the feel is different. The external appearance may be gratifying, but in intimate relationships, the feel also matters. One can appreciate this difference by palpating the upper lip in middle-aged and older persons,3 in whom the hardness of the underlying teeth can be felt.
A fascia lata graft, with its underlying fat and areolar tissue, can be another tissue filler that is “softer,” is always abundant, and can be removed with a stripper and folded or stacked to provide the needed bulk. Gracilis muscle fibers along with their facial sheath can be another tissue source without significant morbidity. Problems arise when we try to find a single solution to all sets of problems. The authors have not been able to get out of this compulsion. The answer to the individual problem has to be tailor-made.
G. N. Malaviya, M.S.
Plastic and Reconstructive Surgery Unit
National Jalma Institute for Leprosy and Other Mycobacterial Diseases
Tajganj, Agra 282 001, India
1. Trussler AP, Kawamoto HK, Wasson KL, et al. Upper lip augmentation: Palmaris longus tendon as an autogenous filler. Plast Reconstr Surg.
2. Niechajev I. Lip enhancement: Surgical alternatives and histologic aspects. Plast Reconstr Surg.
3. Guerrissi JO. Surgical treatment of senile upper lip. Plast Reconstr Surg.
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