# Modified Lip Repositioning Surgery in the Treatment of
## 3 Discussion
The complications of LipStat reported in the literature include discomfort, bruising, post-operative edema, some rare cases of mucocele, paresthesia, and transient paralysis [3; 16; 18; 23; 27]. Additionally, the risk of recurrence should be thoroughly discussed. Previous reports have shown a higher likelihood of recurrence, especially in cases with limited indications for this technique [21; 22; 33; 34; 35]. A study conducted in 2021 subjected four patients with EGD of 6 to 8 mm to modified lip repositioning surgery, using internal horizontal mattress sutures to immobilize the upper lip elevator muscle. None of the patients experienced complications, and healing occurred without incident. All patients demonstrated favorable results with stability over an average follow-up period of 3.5 years [12]. Accurate case selection is crucial for reducing the risk of recurrence in lip repositioning surgery, and if followed correctly, the results will be sustainable for months [13; 36]. The stability of the lip in its new position is crucial for the overall success of the procedure. Therefore, it is recommended to use appropriate suturing techniques for an adequate period to limit the action of the lip elevator muscles for an extended time [37; 38; 39]. The stability of the sutures in the post-operative period is crucial. After closing the surgical edges, in cases where orthodontic brackets are present, they can be used as anchorage for suspensory sutures in the sulcus, further limiting the mobility of the upper lip during the post-operative period [35]. The risk of an asymmetric smile can also occur when the surgeon does not pay attention to different levels of gingival exposure in patients who already have a pre-existing asymmetric smile [27]. The use of botulinum toxin can be an alternative in the treatment of gummy smile [6; 17; 19; 23; 24; 27; 39]. A systematic review conducted in 2018 investigated cases of excessive gingival display (EGD) treated with upper lip repositioning (LipStat). On average, they observed a reduction of 3.4 mm in gingival exposure, suggesting that the technique could be successfully used to treat EGD [1]. This reduction in gingival exposure was also observed in the present case (average of 3.5 mm). Another method used for surgical lip repositioning is the use of a diode laser due to its beneficial characteristics, such as efficient tissue ablation capacity, reduced wound contraction, minimal scar formation, and decreased pain after surgery. Thus, the use of lasers in lip repositioning surgeries aims to minimize pain, bruising, swelling, and discomfort, providing long-term aesthetic benefits [40]. Patients often report that the most challenging aspects are discomfort, pain, hematoma, swelling, and limited lip movement during the initial recovery period. However, laser surgery has proven to be more effective than conventional scalpel surgery, as it can mitigate these effects [41]. Several reports showed improved outcomes, with reduced recurrence, when the surgical lip repositioning technique is combined with myotomy of the levator labii superioris alaeque nasi muscle [18; 19; 20; 42]. Despite promising results, there are still inconsistencies in the existing evidence. Conducting further structured clinical trials is essential to determine the effectiveness of myotomy compared to the traditional method [42]. In 2021, a study evaluated the long-term clinical results of a modified lip repositioning technique that utilized periosteal sutures in a population of 12 twins with hypermobility of the upper lip. The patients were divided into two groups: the control group received treatment with the original LipStat technique, while the test group was treated with the addition of periosteal sutures. In the control group, there was a slight increase in gingival exposure over 3 years. On the other hand, in the test group, higher satisfaction and more stable results were observed over a 3.5-year follow-up [43].