Background:  The mouth is an important aesthetic facial feature of a woman. The main feature of a pleasing mouth area is adequate lip size. Lips that are full and plump are associated with youth and increased sexuality. Some women are born with naturally full lips that last their entire lifetime. Others are born with moderately sized lips that decrease slightly with age. And then there are those women that have always had thin lips than become even more atrophic with age.

The size of the lips is essentially a function of how much vertical vermilion or pink tissue exposure there is. Due to the constant action of the mouth and its muscles, the lips and the surrounding skin are exposed to repetitive motions. This can cause the lips to lose volume from collagen loss. This results in lip deflation and a rolling inward of the vermilion. This creates a smaller or thinner lip, often with the development of vertical wrinkle lines.

When this aging process affects naturally thin lips, the amount of visible vermilion can be quite small with little visible upper lip shape. As the face ages around the mouth and falls forward to it, the corners of the mouth can be pushed downward. This creates a sad or frowning appearance which, when combined with thinning lips, creates an old-looking or aged mouth appearance.  

Case Study: This 62 year-old female presented with an unhappiness about the appearance of her lips. She had always had thin lips but they were getting  even more so as she got older. When combined with the downturning of the corners of the mouth and the vertical lip wrinkles, she really began to dislike her mouth appearance. She tried Juvederm injectable fillers but did not want the recurring expense and the discomfort of the needle injections.  

She opted for a surgical solution that would be permanent for her thin lips, lip advancements. As an office procedure, the design of the lip advancements was marked out like lip liner using a mirror for her approval. The amount of lip advancement was 4mms at the cupid’s bow of the upper lip and along the lower lip. The lower lip tapered down towards the corners of the mouth. The upper lip design did not taper at the commissures so a corner lifting effect could be created. Under local anesthesia, the skin within the marks was removed and the vermilion of the lips advanced outward. A more visible shape of the cupid’s bow of the upper lip was created by the design.  

Her fine lip sutures were removed one week later. She had no restrictions afterwards in regards to eating and oral hygiene. While she did have some slight swelling, there was no bruising. She wore lipstick the next day after having her sutures removed. The change in lip size and shape was immediately apparent and will not change over time. The trade-off for lip advancements is the permanent fine line scar around the lip margins. It is important to not have the advancements go around the mouth corners so that there is not a completely circumferential mouth scar. The other aesthetic trade-off is that lip advancements will cause a flattening in the natural upturning of the white roll. (junction of the skin and the vermilion)

Case Highlights:

1)      Lip advancements can provide a dramatic change in the shape of the aging thin lips. If designed properly, it can also provide a lifting effect of the downturned corners of the mouth.

2)      The effects of a lip advancement are based on the concept of creating more visible vermilion tissue.

3)      Lip advancements have two minor adverse aesthetic effects, a fine line scar and loss of the pout of the white roll.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background:  Lip augmentation is a very common office-based cosmetic procedure that is done by commercially-available injectable fillers. Despite the immediate and dramatic effects of injectable fillers in the lips, their results are not permanent. These lip treatments must be repeated if the results are to be maintained. There are some patients who tire of these repeated treatments or can not get the lip results they want with injections alone.

The lip (vermilion) advancement is a permanent alternative to lip injections. Fuller or larger lips are evident when more of the vertical height of the vermilion (pink portion of the lips) is seen. Injections accomplish this by pushing from the inside out. Lip advancements achieve this by moving the border of the vermilion further out through skin removal.

This is a 40 year-old female who has received injectable fillers into her lips for years. She tired of the discomfort and cost of the repeated injection sessions. While her lips could not be construed as thin to begin with, she sought a very full lip look. She felt that even the injections did not get them large enough. In these before surgery pictures, the lines (mounds) of her existing fillers can be seen around her lips.

At the time of the procedure, the position of the desired new edge of the vermilion was initially lined with a marker. Since the upper lip is usually smaller than the lower lip in most patients, the upper lip line is about 4 to 5mms above the existing vermilion edge and about 3mms below the lower lip vermilion edge. Dental blocks (infraorbital nerve upper and mental nerve lower) were initially performed. This provided anesthesia so that a next set of injections could be done directly along the line of the lip cutouts for absolute comfort and control of any bleeding during the procedure. The previously marked skin was removed along the upper and lower lips as marked. A two-layer closure was then done. For patients that live close, I use very fine 7-0 sutures to be removed a week later. For faraway patients, fine dissolveable 6-0 plain sutures are used. Antibiotic ointment is the only dressing. Some significant lip swelling will initially be seen, accentuated by the previous injection of the local anesthetic.There are no dietary or oral hygiene restrictions. Lipstick may be applied after one week.

Her lip advancement results were very satisfactory to her. She achieved the more extreme lip augmentation result that she had long desired. Her lip scars were very fine and not easily seen even on close inspection.

Case Highlights:

1)      Permanent lip augmentation can only be achieved with a lip or vermilion advancement. The trade-off for this permanency is a fine line scar.

2)      How much vermilion any particular patient wants increased is marked before surgery with their approval. Like drawing lip liner, the exact result can be known before surgery.

3)      Lip advancements should be reserved for those patients who have previously tried injectable fillers or have very thin lips that do not respond well to injections.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis

The mouth area is not spared as the rest of the face ages. Most women focus on changes in the neck and jowls as well as around the eyes. And while there are some well known procedures that make great improvements in these facial areas (facelift, blepharoplasty), how to improve the mouth area is not so standard and well known.

The mouth looks older as a result of  numerous anatomic changes. The upper lip will get longer and thinner. The corners of the mouth start to turn downward. From the downturned corners, grooves extend towards the jaw line creating marionette lines. The nasolabial folds or lip-cheek grooves which ‘parenthesize’ the mouth become more pronounced and deeper. Vertical wrinkles develop on both the upper and lower lip running into the pink (vermilion) of the lip, often resulting in lipstick which bleeds into them.

While wrinkle reduction around the mouth can be done with various laser methods and injectable fillers, improvement in that alone is often not enough to make an overall youthful change. Like the rest of the face, the mouth area can benefit from various ‘nips and tucks.’

There are some small but very effective perioral (mouth) procedures that can create some subtle but significant lifting and upturning of the lips. Youthful changes come from having more exposed vermilion and a more even or horizontal smile line. (mouth corner to corner line) These perioral rejuvenation procedures include lifts of the lip, corner of the mouth, and smile lines.

A long upper lip can be shortened with an upper lip lift, often known as a subnasal or bullhorn lip lift. It is done to primarily shorten the aged long lip, but a small amount of increased upper teeth may result when the lips are slightly open. By using a wavy or bullhorn-shaped ellipse of skin under the nose, the central part of the lip is upturned. The key to this procedure is to remove skin only. If one removes any of the deeper muscle, the upper lip will get tight and look unnatural when smiling. There will be a few millimeters or relapse over the first six months after the lift.

 Rather than done under the nose, lip advancements are done lower at the actual border of the upper lip. It creates a different and more complete upper lip lift because it effects the entire horizontal width of the upper lip. Lip advancement achieves improved exposure of the vermilion and eliminates the bottom end of the vertical lip lines. A small strip of skin abobe the lip line is removed to make the whole upper lip look bigger as well as shortens upper lip length.

The corner of the mouth lift is the ‘cutest’ of the perioral procedures because it removes such a small amount of skin to achieve its effect. Its intent is to elevate the down turned corners of the mouth so that the smile line (lips at rest) becomes more horizontal. This makes one’s mouth appearance more perky. This is done by removing a small triangle or heart-shaped piece of skin above each corner which changes the location and angulation of the sides of the mouth.

Beyond the corners of the mouth, folds of skin may drape downward. This loose skin can be improved somewhat by a facelift but some patients may not want to invest that much effort for improvement. These “parachute” folds of skin can be removed, placing a fine line scar in the lower end of the cheek-lip groove. It also creates a small amount of  lifting of the corners of the mouth as well.

One of the great benefits to these procedures is that they can be done in an office setting under local anesthesia. This keeps the cost down compared to more extensive surgery. They can be combined with injectable procedures such as Botox and fillers as well as laser and light skin treatments. They are a great compliment to be done with a facelift, either before or after.

Nips and tucks of the mouth area will result  in some small scars as a trade-off for their rejuvenating effects. Minor scar revision and touch-ups may occasionally be needed as the margin of error or forgiveness of any scar abnormality is quite small in the very visible mouth area.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Background: Lip augmentation continues to be a very popular non-surgical facial enhancement procedure. It is done in almost every case with some form of injectable filler. But fillers do not work well in very thin lips and some patients do tire of repeated injection sessions as fillers last only8 a limited amoujnt of time..

This is an interesting but different case of a 45 year-old female who had reasonably sized lips with a defined cupid’s bow in the upper lip. She had been having lip augmentation with injectable fillers for the last three years in both the upper and lower lips. But she wanted to have a permanent procedure which would eliminate the expense and pain of periodic lip injections.

Her surgical lip options included a non-resorbable lip filler (Advanta), lip advancement, lip lift, and a mucosal roll-out. (i.e., V-Y mucosal advancement) She did not want any foreign material in her lip nor did she want the prolonged swelling and unpredictability of a mucosal-based procedure. This left her with the skin excisional procedures of either an advancement or a lift. The difference between the two is that a lift procedure does not exist for the lower lip and it will only make the central part of the upper lip fuller. (even though it hides the scar along the base of the nose) Because she wanted fuller lips, particularly as they tapered into the corners of the mouth, a lip advancement was her only acceptable surgical option. She was willing to accept fine line scars at the junction of the lip and skin for both lips.

The operation was performed as an office-based procedure under local anesthesia. She did receive oral sedation one hour prior using Valium and Phenergan. Using a mirror, the new lip borders were marked out to her satisfaction. (how much skin to be removed and how much more vermilion would be exposed) Intraoral dental blocks were first done prior to actual anesthetic injections into the lips.

 The skin was then precisely cut out along the marks and the vermilion advanced out and sutured into its new position in multiple layers. The skin sutures were removed one week later.

The lip advancement is a very effective procedure that provides a permanent solution for fuller lips. It does exactly what creates a bigger lip (increased vermilion height or exposure) without making it look unnatural. (sticks out) For very thin lips this is often the only procedure, injection or otherwise, that creates a significant change. Because of the scar, a lip advancement is not a procedure that should not be used recklessly without careful consideration of the permanent scar.

Even though many patients may tire of having their lips injected, the scar may not be a good trade-off for many. If one has some lip fullness already, the use of a lip implant may be a better option than a fine surgical scar.

Case Highlights:

1)   Skin excision is a permanent option for lip augmentation. It creates a very significant amount of lip fullness, particularly when done on both the upper and lower lips.

2)   It is rarely used as a substitute for injectable fillers because of potential scar concerns. It is more commonly used for thin lips that do not respond well to injectable fillers.

3)  When the scar concern is not an issue, it can be done as an office procedure with minimal recovery marked mainly by temporary lip swelling.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Rejuvenation of the upper lip is a commonly requested and performed procedure. There are numerous strategies for treating an aged upper lip and one of the basic approaches is to add volume. Usually through injectable fillers, volume is added to create a more protruding and pouty lip. This is based on the fundamental belief that volume loss is a significant part of lip aging.

The desire for larger lips is commonplace in today’s society. Larger fuller lips (like a strong chin or jaw line in a man) casts an image of desirous femininity. While some ethnic groups have naturally fuller lips, many Caucasian women of northern European and English descent are not so blessed. The upper lip is usually smaller than the lower one which, while not in of itself abnormal, is not the most aesthetically pleasing. Injectable fillers provide an immediate and usually very satisfying result in those so ‘afflicted’, albeit a temporary one.

There is a plastic surgery procedure of the lip that can provide a permanent alternative for lip enhancement. The vermilion advancement procedure is well known and dates back to an era long before any form of injectable fillers ever existed. It is actually more effective than injectable fillers because it directly causes more vermilion lip exposure which is what makes a lip look bigger. However, this procedure has been and should continue to be used very cautiously as it does leave a scar at the junction of the vermilion of the lip where it meets skin. While the scar may be quite fine, it is a scar nonetheless on a visible location. In addition, the white roll of the lip is lost which causes a little bit of flattening of the lip line.

But in the properly selected patient, a lip advancement can be a good procedure despite its drawbacks. In my Indianapolis plastic surgery practice, I have one particular type of lip problem that will consistently yield a very happy patient.

In the very thin upper lip that is so flat, it doesn’t even have much of a defined cupid’s bow, there are no other good alternatives.  While injectable fillers should still be done first as a trial, they are not likely to achieve enough of a difference and may even make the lip look unnatural with so little vermilion to expand. In the older thin lip with vertical wrinkles, a lip advancement achieves several desirable goals… make the lip bigger, accentuate the shape of the cupid’s bow, and getting rid of some of the wrinkles by cutting them out.

Lip advancements are also good for lip asymmetries such as in cleft lip revisions and in cases of lower lip facial paralysis. In these lip surgeries, the vermilion advancement is usually done on just one side for balancing and symmetry purposes.

Lip advancements can be done in the office under local anesthesia very comfortably. In local patients, I place very tiny sutures that are moved in a week. For out of town patients, I use small dissolveable sutures which are covered with a tissue glue. Swelling and bruising is largely gone in about a week after surgery.

While some thinner lip patients may be tired of ongoing injectable filler treatments, even though they are successful, I would still hesitate to do a lip advancement. There are other non-scarring lip enhancement options such as fat injections, allogeneic dermal grafts, and even synthetic (Advanta) implants which should be the next step on the treatment algorithm. Lip advancements in these patients should be a last resort when the patient may be more accepting of the fine line lip scars.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The upper and lower lips are one of the five main facial features that makes up and helps define the most recognizeable central third of the face. In today’s society, full lips are viewed as healthy and sensual, thin or wrinkled lips cast the opposite image. While the lips are paired, they are not identical due to their embryological origins. The upper lip is uniquely different than the lower as it has a central cupid’s bow or two-peak wave form which differentiates it from the smooth and continuous lower lip. That is a key aesthetic difference and very important consideration in any form of lip augmentation.

 
While injectable fillers are the most common form of lip augmentation, they are not for everyone and every form of injectable filler is not for lips. Patients who have thin lips can not be injected and end up with full pouty lips. The pink part of the lip will only stretch so much before it begins to look distorted, too full, and unnatural. Results like this are evident everywhere on TV and in the movies. Injections will not make a well-defined cupid’s bow nor make the height of the lip bigger either. While it acceptable to try a small amount of injectable filler in a thin lipped patient, and I frequently do, it is best to not overdo it. Let the patient decide whether the result is worth it. I always place injectable fillers in layers and ask the patient to give me their opinion with each new layer. Enough is when they tell me so. Surprisingly, no injectable filler is formally approved by the FDA for injection into the lip even though it is common practice. Only the hyaluron-based fillers such as JuvaDerm, Restylane or Perlane should be used in the lip as they flow in smoothly and have little risk of a foreign-body reaction….and they are completely reversible with time. The particulated fillers such as Radiesse and ArteFill should not be used in the lip as they do have risks of lumpiness and potential reaction to their particle component. As for silicone oil…be very wary. Not only is it not FDA-approved for any injectable application at this time, its track history from the 1960s and early 70s is not reassuring. (even if this is a newer more purified form)

 
For those thin-lipped patients, some consideration may be given to lip lifts and advancements if careful thought is given to the permanent scar. While these are powerful lip procedures and can do wonders in increasing the size of the pink part and in making a well-defined cupid’s bow, they do produce a fine line scar at the junction of the pink lip and skin. If the patient is certain they can live with that trade-off and has a high lipstick use frequency, this may be the procedure for them. That decision becomes a little easier in the older female where the thinning of the lips and the development of vertical wrinkles on the lip requires more than a simple lip fill with an injectacble can do. If the procedure is done well, it can look fairly natural. If the lip is advanced too much or the peaks of the cupid’s bow made too sharp, it can look very unnatural.

 
Often patients who have had temporary lip injections desire a more permanent fix. Options include fat injections and synthetic implants. Since fat has to be harvested from the patient in a sterile fashion, I always do this procedure in the operating room and is a strong consideration when the patient is going to be there for other plastic surgery procedures anyway. There really is very little to lose by doing it in that setting. While the take of fat grafts is definitely variable, some patients will do well with it. The test is what it looks like at three months after surgery, not in the first few weeks. If fat takes well, it will last longer than any synthetic injectable but it may not last forever as the lip does continue to age. Therefore, further fat inejctions may eventually be necessary. Permanent lip implants (Advanta) have been around for over a decade and in the right ‘qualified’ patient can do well. Qualifying a patient is one who has had lip injections and is really ready to accept a permanent implant over a temporary filler. My experience with Advanta, a soft spongy tube, has been quite good even though all patients will definitely be able to feel it.

 
Two of the most important things in creating natural lip results is that they must not be too big or have treatments which result in them ending up stiff or irregular. We touch the lip area very frequently so we are quite attuned to how it feels And the lips need to be soft and flexible to support easy and painless movement.

 
A good artistic sense in shaping the lips (they enhance the face but should be the focal point), consideration of the many lip treatment options, and preservation of soft flexible lips are needed to get the most natural lip augmentation results.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http:.//www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Improving the size and shape of the lips is a frequent cosmetic request and a very commonly performed aesthetic procedure done in the office. While the vast majority of lip enhancements are done by injectable fillers, and most patients are only aware of this approach, there are other less common but equally effective options.

Injectable fillers are the most common lip enhancement method and the hyalurons such as Restylane and Juvaderm are usually used. The longevity of hyaluron fillers, while touted differently amongst manufacturers, is in the range of 4 to 6 months. While longer-lasting injectable fillers exist, such as Radiesse and Aretfill, these contain particles which may be prone to lumpiness and foreign-body reactions. Because of their predictability and safety, with very few complications, hyaluron lip enhancement is the current gold standard.

There other other types of non-injectable lip fillers. Over the years, many collagen-based implants have been tried, such as Alloderm and Fascian. Unfortunately, while conceptually appealing, their longevity has not been shown to be any greater than the hyaluron fillers. But they are more expensive and cause much more lip trauma to place. As a result, they have fallen into disuse.

Despite the frequent touting of your own fat as an injectable filler, and reports of great longevity and possible permanency, most plastic surgeons have not had that experience. Fat in the lip is simply unpredictable. I will still use it…..when I am performing other procedures in the operating room where the use of fat is ‘easier’ than in the office and there is little to lose by doing so. I suspect that repeat fat injections over time do consistently work but that is fairly traumatic for a patient to go through.

Permanent lip augmentation can be done by synthetic implants known as Advanta. These very soft implants are threaded into the lips, corner to corner, by a metal trocar under local anesthesia. They are non-resorbable, fairly soft, and the volume added is permanent. They can definitely be felt in the lips but I have not had a patient yet who has reported that as a problem. I use Advanta when the patient is ‘qualified’, meaning they have tried injectable fillers first and want to move on to something permanent.

More surgical lip enhancement is known as vermilion advancements or subnasal lip lifts. While these are highly effective are making the lip bigger, they have a trade-off of permanent scars. A patient must be very willing to make this trade-off and accepting of fine-line scars. I use these in patients that have very thin lips and a very flat cupid’s bow and have ‘failed’ lip enhancement by fillers. (meaning it does not look good or do what the patient expected. Lip lifts are often most effective in the older patient whose lips (which were not big to start with) have shrunken with age.

As you can see, lip enhancement has lots of options. All work well at achieving larger lips….but not every enhancement procedure is for every patient.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Lip Enhancement by Lifts and Advancements in Indianapolis

By far, the most popular form of lip enhancement or rejuvenation is by injecting any of the commercially-available forms of hyaluronic acid gels (e.g., Restylane or JuvaDerm) By injecting into the body of the lip or along the white roll, good results can be consistently obtained in the vast majority of patients. However, there are some patients with very thin lips in which injecion treatments do not produce a good result. And by good result, I am referring to a natural lip that is both bigger and aesthetically pleasing. When the amount of vermilion (pink) show is small, injections may make the lip bigger primarily by making it stick out. This is not very aesthetically pleasing and usually makes the patient standout as ’someone who has had their lips injected’. A look that not a one of my patients would ever want.

 In these atypical cases, it is usually an older woman who has lost much of her upper lip with age (because she had a small one to begin with) or, rarely, a younger patient who simply has very little upper lip and a poorly-defined (flat) cupid’s bow. The surgical procedures of vermilion advancement or subnsasal lip lift are better for these thin lip patients. With the vermilion advancement, a strip of skin along the white roll is removed and the vermilion ‘advanced’ upward and sutured into place. This is a powerful procedure that can make an upper lip fuller….forever. But at the price of a fine line scar along the border of the vermilion and the upper lip skin. The cupid’s bow can be highlighted and better defined with this procedure as well. For those patients who cannot accept an upper lip scar and, only want the cupid’s bow area enhanced, then the subnasal lip lift is an option. Skin is cutout along the base of the nose and the entire middle-third of the upper lip is lifted as it is sewn into place. It is important to remember that the subnasal lip lift will do nothing for the sides of the upper lip which lie beyond the nostrils which is the tail of the cutout. This results in a more lip scar in a better location but the effect is not as great as the vermilion advancement procedure.

In either case, It is extremely important to use these procedures as a ‘last measure’ for a thin lip problem. I always have the patient go through a trial of lip injections first, even if I think it will not work well. They may very well make the patient happy….and that is the ultimate goal. If not, then they have qualified themselves to be willing to make the trade-off of a lip scar for a significant change in their lip appearance.

Lastly, remember the vermilion advancement procedure can be used on the lower lip as well. When both lips are done together, the effect can be quite dramatic.

 Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis