Lip Augmentation and using Fillers

Arnold W. Klein, MD; Bruce W. Ayers, BA, CCRA

From Medscape Dermatology

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.  Request your appointment with A&E Beauty Laser to learn if facial filler injections such as Restylane, Juvederm, or Perlane are right for your anti aging, skin care treatment.

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.

Architecture of the Lip and Proper Injection Technique

Understanding the proper architecture of the face in relation to the lips is critical in obtaining an aesthetically pleasing result. With the patient in the postural head position, the lips should be parallel to a line drawn between the pupils of the eyes. In regard to spatial location, the upper lip should be 18 to 20 mm from the nose, and the lower lip should be 36 to 40 mm from the chin. Finally, in postural head position, a line drawn from the mid-nares to the chin should just barely graze the upper and lower lip (Steiner's line). Lips must maintain a natural profile. Many injectors have had a tendency to inject volume above the lip, which results in an unnatural fullness above the lip and must be avoided; the nasolabial angle should be 85 to 105 degrees. Finally, there is a slight elevation or ski-jump that is a point of inflection as the lip turns from glabrous skin to mucosa. This is now referred to as the Glogau-Klein point (G-K point).

Prior to injection, adequate anesthesia must be administered. Nerve blocks are popular among many patients and clinicians; however, these are not favored by the authors because nerve blocks can cause abnormal motion of the lips during the procedure, which can result in a poor cosmetic result. Furthermore, blocks may permit forceful injection with associated bruising and flow of the material out of the injection tract, which is associated with adverse events.

Without using a nerve block, slow and gentle injection becomes essential. Topical anesthetic creams or ointments such as EMLA or betacaine, tetracaine, or lidocaine compounds are quite effective when applied 15 minutes prior to the procedure. Ice application before, during, and after the procedure is also helpful in keeping the experience comfortable for the patient. Additionally, some practitioners like to use injectable collagen prior to injecting HA to create a flow tract as well as to deliver anesthesia.

The patient should be seated upright in a chair to allow for normal gravity of the facial position. The use of good overhead lighting is important. Patients should avoid using aspirin, nonsteroidal anti-inflammatory drugs, and vitamin E 5 days prior to the procedure to prevent bleeding, which results in bruising. If patients have a history of herpetic outbreaks, antiviral coverage is appropriate. Finally, having an assistant serve as a second pair of eyes can aid in the assurance of an excellent cosmetic result.

The patient should be injected from the right side of the lip to the center and then from the left side of the lip to the center. Preserving the Cupid's bow is critical because it is the defining aesthetic of the upper lip. The lower lip should not be injected as a rounded wheel mass, but instead centrally in the mucosa in order to produce proper rollout of the lip.

As result of aging, the lips in most individuals have started to collapse inside the mouth, and the lips should be stretched laterally. The tip of the needle should be slowly guided into the potential vermilion space at a 45-degree angle on the mucosal side of the lip. The needle is then redirected at a 20-degree angle from the lip and the HA naturally flows into this area. Injection must be slow to assure that the material stays uniform within this tubular potential. It is important to stretch the lip, as mentioned above, because this will provide a firm surface to inject, which increases the natural flow characteristics of the material. Additional care must be taken to assure a good flow, which can be hampered by the high viscosity of the agent. If a point of resistance is experienced, don't force it; instead, move ahead and inject at the next point. This technique is referred to as the Klein Anterior Flow Technique. Once the material is injected past the midline of the lower lip, this section of the lip is complete.

Next, the portion of the lip that connects the lower lip to the upper lip along the side of the mouth is addressed. This single injection is done in the same way as the lower lip. Theoretically, this is done as the material flows past the malleolus. The upper lip is injected in a similar manner as the lower, paying particular attention to retaining the shape of the Cupid's bow. Care again must be taken to keep the material in the proper channel, making sure to avoid a lump above the lip. Once this is complete, buttresses from the jaw to the lip are injected in a sequential manner to support the lips and re-establish the vertical height that has been lost due to bone resorption and any dental changes that may have occurred.

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 the strong opinion of the authors 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. We 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.

This activity is supported by an independent educational grant from Medicis Pharmaceutical Corporation

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