In short
- The subnasal technique is the reference standard. The 2026 systematic review describes it as “the classic subnasal bullhorn approach and its modifications”, and it is the one behind the results of the 1,754 patients reviewed.
- 🔑 The line is bullhorn-shaped because it follows your anatomy: it runs along the lower border of both nasal alae and around the base of the columella. Every stretch falls inside a crease that is already there.
- A strip of skin is removed, of the height calculated for your case, above the muscle.
- 🚨 The technical key that decides the scar: the tension of the lift must fall on the deep plane, not on the skin. If the skin holds the tension, the scar widens.
- And the key that decides the movement: not invading the orbicularis oris muscle, which is what moves the lip.
- The four keys to a good result, according to the standard literature: an incision design that respects the natural anatomy, placing the tension below the dermis, determining the amount of lift appropriate to that particular anatomy, and not violating the orbicularis.
- ⚠️ There is no standardisation. The authors of the systematic review state expressly that the choice of technique and the assessment of outcomes remain unstandardised, and they call for prospective studies.
Explaining the technique properly is the direct answer to the number one fear about this operation. Once you understand where the incision goes and why it goes there, the scar stops being an abstract threat and becomes something you can weigh up.
This page sets out what is done, at a level of detail a patient can understand and use in the consulting room.
✅ This is the technique practised at the Instituto de Cirugía Plástica del Mediterráneo, and also the one the literature recognises as standard. A single incision shape is not used: the line is adapted to each face, according to whether more lift is wanted in the centre or at the sides and according to each person’s proportions. What follows explains what it involves and what separates a careful technique from a hurried one.
Why it is called a “bullhorn”
Because of the shape of the drawing. Trace the line of the incision on a face and the result looks like a pair of bull’s horns: two curves following the lower border of each nasal ala and meeting beneath the columella.
🔑 And that shape is not decorative: it is the entire strategy for the scar.
A straight incision between the two alae would be shorter, quicker and easier to suture. But it would sit on smooth skin, in the middle of the face, with nothing to disguise it. The horn-shaped line is longer in exchange for every one of its stretches falling inside an anatomical groove — the crease of the ala, the crease at the base of the columella — where the natural shadow hides it.
It is the same principle that governs a facelift incision behind the ear or a blepharoplasty incision in the eyelid crease: the scar is hidden in a feature of the contour that was already there.
What is done, step by step
1. The markings. Drawn with the patient standing or sitting, before going in. This matters: lying down, the tissues of the face shift and the reference points stop being valid.
2. How much skin to remove is calculated. It is the most decisive choice of the operation and it depends on your anatomy: the length of your philtrum, how much tooth shows at rest and — critically — what happens when you smile. The literature puts it as “determining the amount of lift appropriate for the patient’s anatomy”, and it is where both the result and the risk of overshooting are settled. It is covered in who is a candidate and who is not.
3. The incision and the excision. The marked strip of skin is removed, above the muscle. No lip or red tissue is taken away: what is taken is skin from the stretch that had lengthened.
4. Closure in layers. Here is the part almost nobody explains and the one that decides how the scar turns out. It is sutured in at least two layers: a deep one, which carries the weight of the lift, and a superficial one, which does no more than bring the skin edges together.
5. The sutures. They come out between day 12 and day 15, or the superficial ones at 7 days and the deep ones at 15 if two layers have been used. It is covered in lip lift recovery.
🚨 Tension: the key that decides the scar
If this page had to be reduced to one paragraph, it would be this one.
When the lip is lifted, there is a force pulling downwards: the weight of the tissue itself. Something has to hold that tension.
- If the deep plane holds it, the skin merely comes together without pulling, and the scar tends to stay fine.
- If the skin holds it, the scar works under traction throughout the whole healing process — and a scar under tension widens.
The standard literature on this operation states it as one of the four keys to a good result: placing the tension of the lift below the dermis, to take it off the skin incision.
🔑 And it matches exactly what the general scar literature says: the most important modifiable factor in preventing an abnormal scar is tension on the wound during the proliferative and remodelling phases, and that tension is determined by the design of the incision and of the closure. It is covered in the lip lift scar.
The muscle that is not touched
The fourth technical key is not invading the orbicularis oris muscle, the ring of muscle around the mouth that moves it: the one that purses, that smiles, that seals the lip when drinking.
A classic subnasal lip lift works above that muscle. Respecting it is what allows the movement to stay yours — so that when you smile and talk the lip behaves as it always did.
⚠️ There are described variants that do act on deeper planes and that pursue other aims. They are covered in the lip lift variants, with the same caveat: they only make sense if whoever operates on you really does practise them.
How it is done here, specifically
So much for the technique. This is what the centre sets down in writing, which is what almost no page publishes:
- ✅ A bullhorn line, and other shapes when the case calls for it. There is no single template. The drawing is decided according to what is wanted — more lift in the central area or more at the sides — and according to the proportions of your face. It is the difference between adapting the incision to an anatomy and adapting the anatomy to an incision.
- ✅ The markings are made standing or sitting, never lying down alone. 🔑 And this is not a stylistic detail: lying down, the tissues of the face shift backwards and the proportions measured are not the ones you later see. A face is operated on so that it works standing up and talking, so that is where it has to be measured.
- ✅ Closure in two layers: absorbable material in the deep plane and a fine suture in the skin. The deep plane holds the lift; the skin only brings the edges together.
- 🔑 That division is why only one row of stitches has to come out. The deep suture is not removed — it dissolves on its own — and it is what carries the tension during the weeks when the tissue still has no strength. If the skin bore the tension, the scar would widen; that is exactly what this is designed to avoid.
- ✅ Local anaesthetic and around an hour in theatre. Sedation can be added if the patient asks — not because the operation requires it, but because some people would rather not be present.
The four keys, together
They are worth having as a list, because they are four legitimate questions for a consultation:
- An incision design that respects the natural anatomy — the line following your creases, not a template.
- The tension of the lift in the deep plane — so the skin does not work under traction.
- An amount of lift appropriate to your anatomy — neither a standard measurement nor the one you ask for.
- Not violating the orbicularis muscle — so the movement does not change.
🔑 Asking about these four things in the consultation is not distrust: it is the conversation that belongs there. A surgeon who explains them with your face in front of them is doing exactly what they should.
What the evidence still does not settle
So as not to sell more certainty than there is: the 2026 systematic review that brought together the seven available studies concludes that patient selection and outcome assessment remain unstandardised, rates the overall methodological quality as moderate, could not carry out a meta-analysis because of heterogeneity between studies and expressly calls for prospective studies with standardised outcome measures.
⚠️ In other words: the technique works and its results have been measured, but there is no published consensus on which variant suits which anatomy. Anyone presenting their technique as the only correct one is running ahead of the evidence.
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Frequently asked questions
Is it done under general anaesthetic?
No. ✅ It is done under local anaesthetic as a day case, and it takes around an hour. You come in and go home the same day.
And if being awake worries you, sedation can be added at your request. It is not a requirement of the technique: it is an option for those who want it. The detail of the pathway is in the lip lift step by step.
Is the red lip touched?
In the subnasal technique, no. Skin is removed from the stretch between the nose and the lip; the vermilion is not cut. What happens is that it unfurls outwards as the tension that kept it rolled in is released, and that is why more of it shows.
Will my lip feel strange when I talk?
The technical aim is precisely that it should not: hence the literature’s insistence on not invading the orbicularis. What is common and temporary is a feeling of tightness and numbness in the first few weeks. It is covered in the risks of the lip lift.
Why do they mark me standing if I am going to be operated on lying down?
Because lying down the face shifts. The markings capture the real position of the tissues with gravity acting on them, which is the position the result will be seen in.
Is the “deep” technique better?
There is no comparative evidence that allows anyone to say so. There are variants that work in deeper planes and their authors publish good results, but the systematic review notes that there is no standardisation and no comparison between techniques. What is known is that the classic subnasal is the best documented.
Sources
- Komisarek O, Banasiak Ł, Olichwer V, Burduk P. The Bullhorn and Beyond: Evidence-Based Review and Clinical Recommendations for Lip Lift Techniques. Journal of Cosmetic Dermatology, 2026. PMID 41731334. — PRISMA 2020 systematic review with PROSPERO registration covering 7 studies and 1,754 patients published between 2017 and 2025; it assesses the classic subnasal bullhorn approach and its modifications; subnasal techniques reduced philtrum length from 14.0-14.5 mm to 10.8-12.0 mm, increased vermilion height from 5.0-6.0 to 7.0-9.0 mm and incisor show from 1.5-2.0 to 3.5-5.0 mm; patient selection and outcome assessment remain unstandardised; moderate methodological quality, meta-analysis not feasible because of heterogeneity and a call for prospective studies with standardised measures; it recommends an individualised, anatomy-guided choice of technique.
- Sturm A. Lip Lift. Otolaryngologic Clinics of North America, 2022. PMID 35750522. — It lists the keys to a good result: an incision design that respects the natural anatomy, placing the tension of the lift below the dermis to take it off the skin incision, determining the amount of lift appropriate to the patient’s anatomy and not violating the orbicularis oris muscle.
- Son D, Harijan A. Overview of surgical scar prevention and management. Journal of Korean Medical Science, 2014. PMID 24932073. — The most important modifiable factor in preventing an abnormal scar is tension on the wound during the proliferative and remodelling phases, determined by the design of the incision.
Book your consultation
The four keys above are four questions you can ask at any consultation, and the answers say a great deal. At an in-person assessment the line is drawn on your own face and it is explained how much skin would be right in your case and why — which is a different conversation from looking at photographs of other people.
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Last reviewed: 6 September 2026. This content is for information only and does not replace an individual assessment by a healthcare professional.
