The Nonsurgical Lip Lift (NLL)

Dr Steven Harris

The lips along with the eyes are arguably the most important
aesthetic features when it comes to judging beauty. Studies involving
eye tracking exercises show that we tend to fixate on the eyes
followed by the mouth (eye-mouth gaze continuum) much more so
than any other area of the face.1 It is no surprise then that lip
procedures involving dermal fillers are the most popular nonsurgical
treatment with increasing interest, especially on social media.
However, the lips are also the most challenging nonsurgical facial
procedure as this subtle, delicate area requires an artistic acumen
with excellent technical skills in order to produce beautiful, natural
looking results.

In the initial phase of treatment, it is useful to address the P’s and S’s
of lip assessment (Figure 1). The patient’s preferences should be
considered a priority in the treatment plan. These may vary with age,
culture and trends; for example, there is a current trend for larger
size lips amongst young women of western culture. If the patient is
making unreasonable demands, or where there is a suspicion of Body
Dysmorphic Disorder (BDD), then further assessment should be
carried out with follow-up and referral as necessary. Patients with
BDD should never have aesthetic procedures as there is invariably
dissatisfaction with outcome and a deterioration of mental state.
Figure 1: The P’s and S’s of lip assessment © Dr Harris

The peripheral outline or ideal facial shape should be assessed

next. The ideal facial shape for both genders is oval, but there can be
considerable variation from a heart shape in women to a more
square shape in men.2 As we age the facial skeleton shrinks with
inward rotation; the unsupported soft tissues weigh in on the lips
which collapse due to loss of their own intrinsic support. Treating the
lips directly without restoring the supportive framework will
invariably lead to an unbalanced and unsatisfactory result. A more
aesthetic result is achieved by a holistic approach to restore the ideal
facial shape (facial reshaping) which leads to indirect beautification
of the lips (figure 2)
Figure 2: Restoring the ideal facial shape (facial reshaping) results in
indirect beautification of the lips; images © Dr Harris

Prior to treating the lips, it is also important to examine the more

immediate structures such as the dentition and position of the
mandible in relation to the maxilla. Conditions such as an overbite or
prognathism will have bearing on the appearance of the lips and
should ideally be addressed first. With respect to perioral lines, these
soften indirectly with use of the Nonsurgical Lip Lift (NLL) described
below, however, very deep lines may require direct treatment with
the placement of small intradermal aliquots of filler.

The proportions of the upper and lower lip in relation to each other
and both in relation to all other areas of the face should be examined.
The current trend for large lips may suit a person with prominent
facial features, but look out of place on a person with more subtle
features. Very youthful looking lips can also look odd on a mature
patient. Therefore, it is important to match the lips to the rest of the
face and ensure they do not look out of place. The ideal ratio of the
upper lip relative to the lower lip is often said to be 1:1.618 (golden
ratio), but the largest survey of its kind shows a preference for a 1:1
ratio.3 In general, anything larger than that (with a larger upper lip)
is considered unaesthetic.

As we age the lips lose position rather than volume per se; the latter
is redistributed towards length so that the mature patient will often
present with a long upper lip. Ideally the centre (opening) of the
mouth should be a third of the way down from the base of the nose
and two thirds up from the inferior border of the chin (in men it
ideally should be one quarter and three quarters respectively). The
lip position should be examined in relation to each other (Burstone B
line) and in relation to the nose and chin (Ricketts E line, figure 3).4

Figure 3: Ricketts E line: A line drawn from the tip of the nose to that
of the chin where the lower lip is 2mm behind the line and the upper
lip 4mm. The E line is an ideal measure for the average Caucasian
face, but there is preferential variation according to culture; images
© Dr Harris

Moving onto the S’s of lip assessment, the ideal shape of the lips may
be restored to varying degrees, but not fundamentally changed to a
different shape. As mentioned above, the process starts with facial
reshaping and indirect beautification so that their shape may be
significantly improved during this process. Newly described
proportions H-lines (Harris planes, H-planes) and H-curves (Harris
curves) help to ideally position the tubercles and optimise the shape
of the lower lip to match that of the chin, respectively5 (Figure 4).

Figure 4: Tubercles, H-lines and H-curves; images © Dr Harris

While facial symmetry is desirable, lip symmetry is essential and
should be a goal of treatment. The size of the lips is related to
proportions (see above); they should match the size of the face and
its features, in particular the eyes. The width of the lips should ideally
fall in between the medial limbus lines and emphasis of volume in the
area between the width of the nose base. The sharpness or definition
of the lips, in particular the vermillion border (VB) and philtrum are
important, but they tend to be overtreated with overprojection and
distortion of the lips; they are best treated indirectly (see below).

The final ‘s’ stands for ‘smile’; it is important to ask the patient to
animate, in particular smile and kiss to assess such changes as a
gummy smile and perioral lines which may be exaggerated on
animation. Asymmetrical smiles are faily common and can be difficult
to treat; priority should be given to the appearance of the lips in their
neutral position.

Once the assessment phase has been completed and the face has
been addressed as a whole, then the practitioner may proceed with
direct treatment. Most current lip injection techniques involve the
VB, either directly inside it, or perpendicular to it as in the ‘tenting’
technique. This practice certainly helps to explain why there are so
few natural looking lip results. It is important to understand that the
VB is not a true divide, but rather a transitional zone between thin
vermillon skin and thick facial skin. As mentioned above, direct
injections here and the philtral columns create an unnatural bulge;
the lips lose their delicate curvy appearance to take on a heavy, bulky
and more rectangular shape.
The Nonsurgical Lip Lift (NLL) was developed as an alternative to
procedures involving direct injections of the VB; it consists of linear
thread, curved thread and bolus injections to work with the natural
anatomy of the lips – their lines, curves and tubercles to restore their
ideal natural shape and rotation. All the injections are performed on
the lip side of the VB to gently press the soft side of the border
against the hard one. As the lips rotate upwards the philtrum is
shortened and the philtral columns are indirectly defined too (figure
5).

Figure 5: Before and after The Nonsurgical Lip Lift (NLL) using 0.3ml
of filler; images © Dr Harris

The NLL technique in classic form involves tens steps with no more
than 0.05ml of filler required per step (Figure 6). The steps vary in
terms of number and order depending on the presenting anatomy. As
the VB is avoided, there is no migration of the filler so that rarely
more than 0.5ml is required for the entire procedure. Any reputable
‘soft’ filler (with medium viscosity and cohesivity) may be used and
injections should ideally involve a needle as apposed to a cannula;
the former allows greater control and precision.

Figure 6: The ten steps of the Nonsurgical Lip Lift involving bolus
injections into the lateral tubercles (steps 1,5,6,10) linear threads
(steps 2,4,7,9) with placement of filler in the central tubercle (steps 4
and 9) and curved threads (steps 3 and 8). The H-planes (white lines)
identify the ideal location of the tubercles while the H-curves (yellow
curves) determine the optimal curvature of the lower lip in relation
to the chin; images © Dr Harris

It is the author’s opinion that in this particularly delicate area of the

face aspiration should not be carried out. It is impossible to
completely stabilise the syringe here so that during aspiration the
needle may be repositioned inside an artery to increase the risk of a
vascular occlusion. In order to maximize safety, the steps involve
only small amounts of product placed very gently, slowly and
superficially (no deeper than 1-2mm below the surface). Common
side effects associated with lip treatments in general such as swelling
and bruising (and the risk of more serious ones involving vascular
compromise) are thus kept to an absolute minimum.

An integral part of the NLL technique involves ‘tubercle shifts’ which

allows the projection or ‘reshaping’ of the lip tubercles in different
planes depending on which aspects they are injected. Thus, injecting
on the medial aspects augments or ‘shifts’ them toward the midline
(narrowing the relevant section of the mouth and increasing their
curvature) whereas placing filler on their lateral sides shifts them
away from the midline (to widen the relevant section). Placing filler
on the anterior or posterior aspects of the tubercles allows forward
or backward movement respectively. In this way the tubercles (one
or more) may be recruited and shifted in multiple planes and
directions towards the ideal natural lip shape.6

In many instances, the lip tubercles may not be readily identifiable

and the practitioner may have difficulty determining their ideal
position. While there are many measures and planes to decide the
ideal size of the lips (horizontal thirds and the golden ratio) and their
position (developed by Steiner, Ricketts, Burstone, Sushner and
Holdway)4, none specifically exist for the lip tubercles. In order to
determine their ideal position, the author has developed H-planes
(Harris planes, or H-lines) to locate the apex of each one on a frontal
view (corresponding to their light reflexes). Lip tubercles are
naturally occurring soft dermal projections largely responsible for
the shape of the lips and their natural light reflexes; there are in total
five - three on the upper lip (upper right, upper left and central) and
two on the lower lip (lower right and lower left). A line drawn from
the top of the right philtral column at the base of the nose through
the right peak of the Cupid’s bow will traverse the peaks of the upper
and lower right tubercles. A line drawn from the top of the left
philtral column at the base of the nose through the left peak of the
Cupid’s bow will traverse the peaks of the upper and lower left
tubercles. Finally, a line drawn down the middle (from the base of the
nose) will traverse the apex of the central tubercle. If the lateral H-
lines are extended to the jawline, than the ideal curvature of the
lower lip will match that of the chin; the author has named these H-
curves or Harris curves (figure 4, figure 6).

In summary, lips are the most popular nonsurgical facial procedure,

but they are also the most challenging technically and artistically. For
natural looking results a holistic approach is necessary involving the
P’s and S’s of lip assessment. The Nonsurgical Lip Lift (NLL) works
with the natural anatomy of the lips to safely and effectively restore
their ideal natural shape. In classic form it consists of ten steps
involving linear thread, curved thread and bolus injections; the
number and order of steps vary according to presentation. The ideal
position of the tubercles and curvature of the lower lip may be
determined using H-planes and H-curves respectively. The tubercles
may be reshaped and repositioned using the process of tubercle
shifts.

Abstract
Lip augmentations involving Hyaluronic Acid dermal fillers are the
most popular nonsurgical facial treatments. However, natural looking
aesthetic results are relatively uncommon because the procedures
require excellent technical skill with an artistic acumen. Most existing
techniques involve an area based approach with direct injections of
the vermillion border (VB) which lead to filler ‘migration’ and
distortion of the natural anatomy. The Nonsurgical Lip Lift (NLL) is a
holistic and artistic approach involving linear thread, curved thread
and bolus injections all on the lips side of the VB to safely and subtly
enhance the natural anatomy of the lips. The initial phase involves
the P’s and S’s of lip assessment such as examining the position of the
tubercles and the shape of the lips; the former may be adjusted with
Tubercle Shifts for optimal placement along H-lines while C-curves
determine the ideal shape of the lower lip in relation to the chin.

References

1. Rogers, S.R., Speelman, C.P., Guidetti, O., Longmuir, M. Using dual

eye tracking to uncover personal gaze patterns during social
interaction. Nature International Journal of Science 8, 1-9. 2018

2. Harris, S. Facial Reshaping. Aesthetic Medicine September, 72-74.

2017

3. Heidekruger, P., Juran, S., Szpalski, C., Larcher, L., Ng, R., Broer, N.
The current preferred female lip ratio. Journal of Cranio-Maxillofacial
Surgery, Feb 45(5). 2017

4. Joshi, M., Wu, L.P., Mahrajan, S., Regmi, MR. Saggital lip positions in
different skeletal malocclusions: a cephalometric analysis. Progress in
Orthodontics, May 16(1). 2015

5. Harris, S. The Nonsurgical Lip Lift (NLL) with tubercle shifts, H-

lines and H-curves. Prime Journal, June, 12-15. 2020

6. Harris, S. The Nonsurgical Lip Lift with Tubercle Shifts. Prime

Journal, July, 24-28. 2019
Biography

Dr Steven Harris MB BCh, MBCAM, MSc completed his medical

studies in Johannesburg in 1997. He has been practicing Aesthetic
Medicine at his clinic in North London since 2004 and has gained an
international reputation for producing entirely natural looking
results. His original approach and techniques include Facial
Reshaping with Myomodulation and the Nonsurgical Lip Lift (NLL).
Dr Harris is also a trainer and educator. His regular educational posts
may be viewed on Instagram @drharrisclinic