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Lip Enhancement by Dr. Klein
Introduction
Throughout history, men and women of all cultures have been attracted to specific features of the human face. Women historically have been attracted to men with strong, heavy eyebrows and a wide, defined jaw, while men have been attracted to specific features of the female face. These classically feminine features consist of a large upper face, a small lower face, large round eyes, a small nose, and, last but not least, large full lips. The lips have been associated with female sexuality throughout time, and women who possess large full lips are thought to be more physically desirable.
As we age, typically in the late 20s to early 30s, we begin to lose dental and structural support in the lower face and experience volume loss in the soft tissues in general and in the lips specifically. As a result, the lips begin to turn downward, fine lines begin to appear along the vermilion border, and the marionette lines and nasolabial folds become more prominent. Sun exposure and/or cigarette smoking significantly accelerate this process.
Minimally Invasive Soft Tissue Augmentation of the Lips
In the early 1980s, the ability of physicians to safely enhance or augment the lips became reality with the use of bovine-derived injectable collagen. While the US Food and Drug Administration (FDA) approved bovine collagen for use in the vermilion border, the frequent off-label practice of injecting collagen into the actual mucosa of the lip became a common occurrence, which allowed physicians to replace volume to the lips that had been lost due to aging. This practice also permitted women not born with naturally full lips to augment their lips with virtually no down time and minimal side effects.
Clinicians and patients soon began to realize that not only the fullness of the lips but also the shape of the lips needed to be enhanced in order to achieve the desired aesthetic look. Indeed, the areas of the Cupid's bow and philtral pillars were not to be altered because any distortions in these areas would draw attention to the lip enhancement and possibly present an artificial or exaggerated appearance, of which we have all seen examples. The use of bovine collagen as a predictable enhancement agent permitted properly trained clinicians to avoid these improper alterations and provide stable, reliable, and reproducible lip enhancement procedures. Additionally, it marked the beginning of a movement toward the use of temporary injectable fillers for 3-dimensional volumetric enhancement in the face instead of simple line elimination.
At this time, there was no information in the dermatology or plastic surgery literature regarding the proper aesthetic proportions and shape of lips. Although beauty magazines consistently show beautiful models with large full lips, there were no guidelines for proper lip augmentation techniques. The unfortunate result was improper lip enhancement through unguided and undefined injection technique, which created an aesthetically unpleasing and often exaggerated result. It became increasingly apparent that the augmentation itself had to be done in a subtle manner that would prevent the results from becoming obvious.
In looking at the shape of lips in young women and through the aging process, one must take note of the importance of the support provided to the lower third of the face by the teeth and bone structure. When augmenting lips and restoring the lower third of the face, the restoration of the ends of the lips must be addressed as well as the building of supportive buttresses at these ends in order to restore lip height to the lower third of the face, correcting the labiomandibular grooves/oral commissures.
Hyaluronic acids (HAs), which were first approved by the FDA for use in soft tissue augmentation in 2004, have proven to be the temporary fillers of choice when used by skilled and properly trained injectors. HA fillers can last 1 year and, in some cases, longer. They are biologically pure with low protein loads. Commonly used nonanimal stabilized HA gel agents include the Juvéderm family (Allergan, Irvine, California) and Restylane and Perlane (Medicis, Scottsdale, Arizona). These agents are approved by the FDA for soft-tissue augmentation, but presently no HA is approved for use in the lips, although this is one of the most common off-label uses of these agents. HAs are both biocompatible and biodegradable, and the lack of animal proteins provides increased purity and eliminates the need for skin testing. When compared with bovine-derived collagen, they offer much greater longevity, and they provide a natural and aesthetically pleasing result with minimal adverse events.
Perhaps the most common side effect of HAs is swelling, which, through application of ice, generally subsides within hours. Lumpiness can also result, especially in the hands of inexperienced or untrained injectors; however, this can be effectively managed with the injection of a very small quantity of hyaluronidase to dissolve the unwanted accumulation of HA.
Permanent Injectable Fillers
In recent years, we have seen an explosion of filling agents available for soft tissue augmentation, including the use of permanent filling agents. However, it is my strong opinion that permanent and so-called semi-permanent fillers can cause permanent problems. As previously noted, no filler is approved by the FDA for use in the lips, and although off-label use is commonplace, some substances should never be used in the lips. The manufacturer of calcium hydroxylapatite (Radiesse, BioForm Medical, San Mateo, California), which is approved by the FDA for the correction of moderate to severe facial wrinkles and folds such as nasolabial folds and the correction of lipoatrophy in people with HIV, specifically warns against the use of this agent in the lips. We have seen disastrous results with this filler when used in the lips and similar adverse events with the use of polymethylmethacrylate (PMMA) and poly-L-lactic acid in the lips, which is currently approved only for use in HIV facial lipoatrophy. In general, when the face changes as the result of aging, certain gravitational changes take place in everyone, and when permanent agents are injected, they do not change or age with the face naturally over time, which can create a very distorted appearance. Furthermore, many of these permanent substances have long-term adverse events; some, such as PMMA, have had foreign body granulomas reported many years after implant. I therefore believe that for purely cosmetic lip augmentation, these agents should be avoided.
Conclusion
Minimally invasive lip augmentation using temporary injectable fillers can dramatically improve aesthetic appearance. When done by a properly trained injector, there are minimal side effects and virtually no down time. Lip augmentation properly done allows patients to look younger, natural, and attractive.
