The shape and size of the lips, particularly in females, is an important feature of the lower third of the face. This is very apparent when one looks at the tremendous popularity aesthetic lip augmentation, primarily done by injectable fillers, has enjoyed over the past two decades. Despite their popularity and the tens of milions of lip augmentation procedures that have been done, the end goal of increased lip size has always been based on patient and/or surgeon preference.
In the February 2017 Online First edition of the JAMA Facial Plastic Surgery Journal, an article was published entitled ‘A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness’. This was a clinical study to evaluate what lip dimensions are the most attractive in Caucasian females. Using synthetic morphed frontal digital images of the faces of twenty young women five varied lip surface areas for each face were created. (amounts of lip augmentation) Those one hundred faces were then assessed for attractiveness. (phase 1) Additional image evaluations were done manipulating upper to lower lip ratios while maintaining the most attractive surface area from phase 1. (phase 2) Lastly the surface area from the most attractive faces was used to determine the total lip surface area relative to the lower facial third.
Their results showed that an increase of just over 50% in the total lip surface area with a linear dimension equal to roughly 10% of the lower face and an upper to lower lip ratio of 1:2 was found to be the most attractive.
While lip dimensions and ratios derived in this study provide some guidelines for lip augmentation efforts, in the end the only aesthetic criteria that matters is in how the patient perceives their own lip size and shape. Probably more important than size is lip symmetry and a well-defined vermillion-cutaneous junction particularly across the cupid’s bow region of the upper lip.
Dr. Barry Eppley
Posted in lip augmentation | Comments Off on Lip Augmentation and Lip Aesthetics
Lip augmentation by injections is one of the most common injectable filler treatments of the face. It has been done since synthetic collagen fillers were introduced way back in 1981. Since then many different injectable filler materials have been used but the ideal lip augmentation material remains as yet undiscovered.
Fat would seem to be an ideal soft tissue injection material given its autologous source and as a natural part of many soft tissue sites. Its main disadvantage is how well it survives the transplantation process which is highly variable. Of all areas of the face into which fat is transplanted the lips are known to have a low rate of success. There are no proven reasons why this is so but it has been conjectured that the high movement and distortion of the lips contributes to injected fat absorption. It could also be that there is little natural fat in the lips and that makes it a poor recipient bed.
The donor source of the fat for lip augmentation may also be a contributing factor. Most fat harvests are taken somewhere on the trunk, usually the abdomen or the inner thighs. Whether this is optimal fat for facial transplantation us unknown. This is ‘body’ fat which may not be ideal for use in the face but it does offer convenience and a relatively large supply. Another option for lip augmentation is the buccal fat pad. It offers more than enough fat for the lip and is easily harvested through an intraoral approach.
Since the buccal fat pad is a solid source of fat rather than obtained by liposuction, its use as an injectable source of fat may be overlooked. But the buccal fat pad can be sectioned into small pieces and placed into a syringe. Between two connected syringes it can be passed back and forth to create a more injectable consistency.
Whether buccal pad survives better in the lips is not known although in my fat injection lip augmentation experience it does. Its only drawback is that there has to be an aesthetic reason to harvest the buccal fat pads so no adverse facial effect is seen.
Background: The size and shape of the lips has taken on great aesthetic significance over the past two decades. Many makeup, injectable and surgical methods have been devised and are available to enhance one’s lips. The usual goals are to make the lips look bigger with increased vermilion show and projection as well as a more defined upper lip cupid’s bow shape.
Cosmetic tattooing of the lips (also known as micropigmentation) is a well established technique to enhance their color and shape. Colored metallic pigments are implanted into the dermis of the skin or mucosa with an extremely fine needle or cluster of needles. Because it is not surgery or temporary fillers, it is extremely popular as it eliminates the daily use of pencils to outline, fill-in, or reshape lip borders. The permanent color that it provides also decreases the need to reapply lipstick or lip gloss.
One technique of lip tattooing is that of a blended lip liner. This is done by placing a liner on the lip border which is then shaded inward so it appears as if the person’s lipstick has faded. Some women find this lip tattooing method more appealing than a plain line lip liner which can appear unnatural and very distinct.
Despite its many benefits, lip micropigmentation places pigments that are permanent. Should one later want to remove the lip liner, this can prove difficult to do. The use of a q-switched laser can be used to remove unwanted lip liner. It requires multiple treatments and is not always completely successful.
Case Study: This 24 year-old female had permanent lip liner placed that she ultimately decided she did not like. She did not prefer its color nor the way in which it was placed. (plain line) She wanted the lip liner surgically removed but also wanted her lips bigger at the same time.
Presurgical markings were made for lip advancements that would incorporate the inner border of the lip lines as well as an outer rim of skin for removal. Given that the lip advancements included some vermilion for the lip liner removal, the amount of skin marked to be removed was less than normal.
Under local anesthesia the undesired vermilion lip liner and marked skin were removed. The remaining vermilion was advanced to the outer edge of the excised skin on the upper and lower lips and closed with 6-0 plain sutures.
Lip advancements are a well known surgical method of lip enhancement. It is a powerful technique because it relocates the vermilion-cutaneous border which makes the lips look bigger and more shapely. It does so with the trade-off of a fine line scar at the vermilion-cutaneous border. But in the properly selected patient that aesthetic trade-off may be worthwhile. Removal of permanent lip liner can be one of those patient groups where it has the advantage of an immediate and assured removal of lip pigment as well as that of larger lips.
1) Lip liner is permanent and can not always be completely removed except by surgical excision.
2) A lip advancement can be done to both simultaneously excise the undesired lip liner and increase the size of the lips.
3) The amount of skin that can be removed for a lip advancement when lip liner is being excised will be less than normally done.
Lip augmentation has been done by a seemingly endless numbers of materials and implants. Each one differs in its length of duration and potential side effects. Injectable fillers are by far and way the most popular method but they have only a limited duration of effect.
Permanent lip fillers can be done by implants or autogenous grafts. While successful lip augmentation can be done with synthetic materials, the softness and flexibility of the lips favors a natural soft tissue material. Fat is the most logical candidate and its injection into the lips has been done now for decades. Despite its natural composition fat injections have relatively poor persistence in the lip, perhaps because it does not naturally exist there is any significant amount.
In the Online First issue of the September 2016 JAMA Facial Plastic Surgery Journal, an article entitled ‘Long-term Analysis of Lip Augmentation with Superficial Musculoaponeurotic System (SMAS) Tissue Transfer Following Biplanar Extended SMAS Rhytidectomy’. In a retrospective single-blind study, 423 patients (almost all female) underwent a SMAS lip augmentation using SMAS grafts harvested during the facelift over a six year period. Photographic assessment of the results was done at 3 months, one and five years after surgery. Sixty of the patients were evaluated at five years after surgery.
Both the superior lip and the inferior lip showed statistically significant increases in volume at all evaluated time periods. The greatest volume increase was observed in the upper lip at 3 months while the smallest volume increase was seen in the lower lip at 5 years. The degree of increase in median volume seemed to weaken slightly over time, but remained statistically significant even at 5 years. Two of the five year 60 patients developed complications requiring further surgery. (3%)
The use of SMAS grafts in the lips does require one having a facelift to harvest it. But many women undergoing a facelift have thin lips as part of the aging process so the ‘recycling’ of what would normally be discard is both logical and opportunistic. What differentiates SMAS from fat? It is that it contains more fibrous tissue and the fat that it does contain is less metabolically active. This make account for its longer persistence than other types of lip grafts that contain fat.
Lip augmentation is a popular facial filling procedure that has been done by a wide variety of materials. Synthetic fillers, fat injection and implants have all be done with well known advantages and disadvantages. The perfect lip augmentation material, however, remains elusive
Of all the known injectable fillers, fat has a high appeal but is the most vexing. Fat is a natural material that is unique to each patient and everyone has enough to harvest to do lip augmentation. But even in small volume placements like the lips, its retention and survival is far from assured. In fact, substantial clinical experience has shown that the lips actually have one of the lower rates of fat grafting success on the face. Whether that is due to high motion activity of the lips or their lack of much native fat tissue is unknown.
The donor site for lip fat injections has been harvested from just about every body donor site imaginable. No one knows if the donor source of fat grafting affects how well the fat graft takes although it is hard to imagine that it does not play some role albeit even if it is a minor one.
One donor source for injectable fat grafting that has not been previously described is that of the buccal fat pad. There is more than enough fat in the buccal fat pads for transfer into the lips. But buccal fat pad harvesting should not be routinuely done due to potential undesired aesthetic tradeoffs of facial hollowing that could occur in many patients. But for those patients with rounder faces that desire facial slimming, a buccal lipectomy can be aesthetically beneficial.
Harvested buccal fat pads can be pass back and forth to create an injectate that can easily be injected through a small blunt-tipped cannula. And for the buccal lipectomy patient who also desires lip augmentation this can be a superb method of fat recycling/redistribution.
Does fat from the buccal fat pads survive better than other donor sites. The fat is clearly different in being encapsulated and with much larger globules. It is tempting to hypothesize that it survives better than subcutaneous fat, and I suspect that it does, but it remains to be scientifically proven.
Lip augmentation is one of the most common and historic procedures for hyaluronic acid-based injectable fillers. It would surprise many then to find out that despite its popularity and common usage, few of these injectable fillers are actually FDA-approved for use in the lips. There are a variety of reasons for this lack of approval but safety and effectiveness are not among them.
On October 1, 2015 the US FDA has approved Juvederm Ultra XC for injection into the lips and perioral (mouth) area for aesthetic augmentation in adults. Juvederm Ultra XC and Juvederm Ultra Plus XC injectable fillers are already FDA-approved for injection for moderate to severe facial wrinkles and folds around the nose and mouth. (nasolabial folds) Juvederm Ultra XC is a well known modified form of hyaluronic acid with prolonged duration (up to a year) that has lidocaine in it to improve the comfort of the treatment.
In FDA trials of Juvederm Ultra XC for lip augmentation, almost 80% of patients had visible improvement in lip fullness three months after injection. A near similar percent, (78%) stated that they had persistent improvement in lip size one year after injection. The most common adverse effects for Juvederm Ultra XC injectable filler are the same as other hyaluronic acid gels such as temporary swelling, redness and lumps and bumps.
What is unique about Juvederm Ultra XC injectable filler is that it offers long-term retention of lip augmentation results. Many hyaluronic acid-based injectable fillers are used for lip augmentation but their results often last six months or less.
Background: Lip augmentation is the historic location for injectable fillers since the early 1980s and remains as one of the top injectable filler sites even today. There are a wide variety of injectable fillers and manufacturers but the use of hyaluronic-acid (HA) based fillers is primarily used in the lips as they have the lowest risk of potential complications. HA injectable fillers flow in the smoothest and the easiest and this makes them ideal for lip augmentation.
While injectable fillers for lip augmentation is highly effective and safe, it is not permanent. (I am excluding the use of silicone oil from this discussion since it is not FDA-approved for this use) This lack of permanency poses a long-term issue in terms of cost. Few women are going to spend $500 to $1,000 per year over their lifetime to maintain a lip augmentation result. It simply is too costly to do so for most women.
The concept of lip implants has been around for a long time and numerous types of lip implants have been tried. While effective in increasing the size of the lips they have posed numerous problems including hardness, irregularities, scar tissue, lip numbness, extrusion and difficulty with removal. This has given lip implants an historic poor reputation.
While no permanent lip implant can be perfect as the lip is a very soft and distensible structure, the problem with past implants is that the materials used were too firm. No matter how it is engineered and designed, polytetrafluroethylene (Gore-tex) is too firm for the lips. A newer lip implant, Permalip, offers an improved material that is of a very soft flexible solid silicone material. Just by feel it seems more like a soft lip structure.
Case Study: This 42 year old female had various HA injectable filler materials placed into her lips for the past six years. While she liked her lip augmentation results, the cost of repeated treatments was becoming prohibitive. She sought a permanent lip augmentation result with implants.
Under local anesthesia in the office using infraorbital and mental nerve blocks with direct infiltration into the lips, Permalip implants were placed. A 4mm implant was placed in the upper lip and a 3mm implant placed in the lower lip through small incisions placed just inside the corner of the mouth.
Permalip implants offer the only permanent method of lip augmentation. Of all lip implants ever manufactured, their soft silicone composition is the best material and design offered to date. They are easy to place and, just as importantly, easy to remove should that be necessary. Because they have a smooth surface it is very important that the chosen length of the implant is at least as long as a measurement taken across the lip from one mouth corner to the other. If the implant is short of this distance it will become displaced with asymmetry of the implant between the two lip halfs.
Currently the largest Permalip implant is 5mms in size. This produces a very noticeable lip augmentation change but will not create dramatically large lips. The use of larger lip implants, even if they were available, would not be advised. When the ratio of the implant size to that of the natural lip exceeds more than 50% the rate of complications is bound to exponentially increase.
While lip implants offer a permanent method of lip augmentation, it is important that patients realize that they have the potential for complications like implants placed anywhere else in the body. The most common complications are palpability and implant asymmetry being at different tissue levels between the two lip halfs.
1) The only permanent FDA-approved method for lip augmentation are silicone implants. (Permalip)
2) Permalip implant are generally used in qualified patients who have tried other injectable methods and now seek a permanent lip augmentation solution.
3) It is important to remember that Permalip implants are implants that are placed in a flexible and sensitive body part with exposes them to certain risks.
Augmentation of the upper lip is one of the most commonly done non-surgical facial enhancement procedures. This can usually be successfully done through the use of a variety of different hyaluronic acid-based injectable fillers. Despite their popularity and frequency of use, however, injectable fillers can not solve all aesthetic upper lip concerns. A thin upper lip with little vermilion height often does not respond well to volume addition alone and is prone to result in the dreaded ‘duck lip’ look where most of the filler volume comes horizontally forward rather than increasing vertical vermilion height.
Surgical lip augmentation offers a better result in the thin upper lip because it can alter the location of the vermilion-cutaneous junction…the one anatomic feature by which lip size and shape is mainly judged. This can be done by an ‘upper’ lip procedure known as a subnasal lip lift or a ‘lower’ upper lip procedure known as a vermilion advancement. While very close by location the effects of these two surgical lip procedures can be dramatically different.
One way that they differ is in the effects on the cupid’s bow area. An aesthetically important feature of the upper lip, the cupid’s bow or tubercle, is a double curve of the lip which resembles a bow laid on its side. The peaks of the bow coincide with the vertical philtral columns coming down from the nose giving a prominent bow appearance to the upper lip. While a subnasal lip lift will pull up on the central cupid’s bow area it will really reshape or ‘sharpen up‘ its shape. Only a vermilion advancement can create that change since it changes it directly by skin excision.
A cupid’s bow lift can be created as an isolated procedure (in an upper lip with adequate volume) or can be combined with other lip enhancement procedures such as injectable fillers or a subnasal lip lift. Removing a few millimeters of skin can really change the cupid’s bow appearance even if it is just limited to the peaks of the cupid’s bow alone.
While cupid’s bow augmentation does create a fine line scar at the new vermilion-cutaneous junction it typically heals very well as it is not under undue tension due to the limited resection area.
Background: Lip augmentation is one of the most popular non-surgical cosmetic facial procedures and is one of the most common sites for the placement of injectable fillers. But injectable fillers only add volume and in the vermilion deficient lip may create a very pouty lip or ‘fish’ lips. Without adequate vermilion height the filler merely pushes the lip forward and not up as well.
For the vermilion deficient upper lip, there are several surgical procedures to change the location of the vermilion-cutaneous junction. Such change is instrumental in getting a good and natural lip augmentation effect. These two well known procedures are the lip lift and the vermilion advancement. The subnasal lip lift is, literally, a lifting procedure of the lip by removing a segment of skin from right under the nose. It achieves two important effects, shortening the lip-nose distance and creating more of a central lip pout. In some patients and with enough tissue removed more tooth show may also result. (but the risk of excessive tissue removal and a ‘chipmunk look’ can be created with too much of a lip lift) It is equally important to appreciate that it is does not create a corner to corner lip change and only augments the portion of the nose that lies between vertical lines drawn from the sides of the nostrils.
There are several criticisms/concerns about the subnasal lip lift. Some feel that if only skin is removed there will be significant relapse.(recurrent lengthening) This has led to lip lift techniques that remove or tighten the orbicularis muscle which can lead to its own set of problems. (lip tightness, smile deformity) There is always the concern about the appearance of the scar right under the nose and whether it will deform the nostrils or the base of the columella.
Case Study: This 26 year-old female wanted a lip lift to shorten her lip to nose junction and provide some some additional central lip pout. She already had reasonably good vermilion fullness and did not need/want any direct vermilion augmentation. Given her greater skin pigment there was good presurgical discussion about the resultant scar.
Under local anesthesia, a subnasal lip lift was performed removing 25% of the distance of the philtral column. (4mms) Only skin was removed without any muscle manipulations. Only small resorbable sutures were used on the skin as she lived far out of town.
When seen one year later, the subnasal scar was barely detectable and there was no nostril/nose deformity. Comparing her immediate and one year pictures, the subnasal lip lift result has remained stable. (no change in the lip-nose distance or the amount of central lip pout)
The subnasal lip lift can be an effective procedure that has minimal risks if it is not overdone or involves muscle manipulation. It must be meticulously measured and executed to be both symmetric with a good scar outcome.
1) The subnasal lip lift is a surgical procedure for enhancing the central part of the upper lip and shortening the nose-lip distance.
2) The amount of relapse or recurrent skin stretching is 10% or less and is not that noticeable.
3) A skin excision (muscle sparing) subnasal lip lift is both safe and effective and has a very low risk profile.
Background: Lip augmentations are very popular and are most commonly done with the use of injectable fillers. But not every smaller lip can be satisfactorily augmented by fillers alone and, even when a satisfactory result is achieved, women may eventually tire of the need for repeated injection sessions and their cost.
A lip advancement is one of the three surgical lip augmentation options which include lip lifts, lip advancements and lip implants. The lip or vermilion advancement procedure is the most effective lip augmentation procedure because it does what ultimately makes lips permanently bigger…it changes the vermilion or pink part of the lip to have more vertical exposure. And it does so from one mouth corner to the other which is what differentiates it from the lip lift which only changes the central part of the upper lift. The lip advancement can be done equally well on the lower lip as well as the upper lip.
The one disadvantage to the lip advancement is that it creates its powerful effect at the expense of a fine line scar at the vermilion-cutaneous border. These lip advancement scars can be very minute and acceptable in most cases. But there is very little tolerance for even the smallest asymmetries in the shape of the lip particularly in the cupid’s bow area.
Case Study: This 40 year-old female has a prior upper and lower lip advancement from another surgeon that turned out to have significant lip asymmetries. The cupid’s bow was oriented to the left of the midline and the height of the lower lip vermilion was very different between the two sides. This gave the lips a very unnatural and twisted appearance.
Under local anesthesia in the office, new lip vermilion edges were marked to realign the lips shape. New skin areas were cut out and the vermilion edges realigned. Her postoperative result showed substantial improvement but healed with some minor scar hypertrophy at the peak of the left cupid’s bow and along the outer thirds of the right lower lip.
A second stage lip revision was done under local anesthesia six months later. The left cupid’s bow was repositioned and the right lower lip hypertrophic scar excised.
After two revisions, a satisfactory lip advancement revision result was obtained.
While the concept of lip advancements is simple, its execution requires careful preoperative markings, precise skin cutouts and a meticulous closure. The very visible presence of the lips on the face make any amount of asymmetry or hypertrophic scarring very apparent. Revisions of lip advancement problems usually led to a much improved and more symmetric outcome.
1) Lip advancements are technically precise procedures that must be measured before surgery and technically executed carefully.
2) Revisional surgery can salvage asymmetric lip advancement results.
3) It may take more than one revision to optimize lip shape and scar outcomes from adverse lip advancement problems.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.