AESTHETIC FOCUS

Lip augmentation

BY NESTOR DEMOSTHENOUS

In the second of our two-part special focus on we are delighted to present this comprehensive clinical guide for practitioners undertaking augmentation.

ips and eyes enhance facial beauty. Highlighting these has been dated back to Egyptian Ltimes where primitive forms of make-up were utilised to accentuate these features. Lip augmentation using fillers is increasingly more common and is one of the most sought after filler treatments. With celebrity endorsement and many media fuelled horror stories, it is paramount that aesthetic practitioners develop their skill and knowledge in this procedure.

Lip functions and anatomy Lips are soft, movable, and serve as the opening for food intake, assist in mastication, and in the articulation of sound and speech. Human lips are a tactile sensory organ with densely packed nerve endings, and can be an erogenous zone when used in kissing. The upper and lower lips are referred to as the ‘labium superius oris’ and ‘labium inferius oris’, respectively. The juncture where the lips meet the Before and after photos of a patient treated with 1ml of Juvederm® Volift®. surrounding skin of the mouth area is the vermilion border, and the typically 16 layers. The lip skin contains fewer lateral to the angles of the mouth. The reddish area within the borders is called melanocytes, therefore the blood vessels lower lip lies between the mouth and the the vermilion zone. The vermilion border are visible through the skin of the lips, labiomental groove, which separates the of the upper lip centrally is known as making lips appear red. The skin of lower lip from the chin [1]. The upper and the Cupid’s bow. The vertical groove the lip forms the border between the lower lips are continuous at the angles of extending from the Cupid’s bow to the exterior skin of the face, and the interior the mouth or oral commissures. nasal septum is called the philtrum, with mucous membrane of the inside of the philtral columns on either side. mouth, joining at the wet dry border. The perfect lip It is approximately here that the labial The skin of the lip is very thin (with Lips are the central hallmark of the arteries are found. three to five cellular layers), compared lower face and when they are full and The lip skin is not hairy and does not to typical face skin, which has up to well-defined, they impart youth, health, have sweat glands. Therefore, it does attractiveness and sexuality. Wider, not have the usual protective layer of fuller curved lips with a high vermilion sweat and body oils which keep the skin and a short upper white lip are all signs “With celebrity endorsement smooth, inhibit pathogens and regulate warmth. For these reasons, the lips dry of female attractiveness [2]. One of our and many media fuelled out faster and become chapped more greatest challenges is to achieve natural horror stories, it is paramount easily. The skin of the lips is categorised results after lip augmentation. as stratified squamous epithelium, or To achieve natural results it’s that aesthetic practitioners flattened tissue cells. important to understand our underlying develop their skill and The upper lip lies between the nose anatomy, and just as important to assess and the orifice of the oral cavity. Laterally the lips before us accurately, so as to knowledge in this procedure” the lips are separated from the cheeks by be able to appreciate what is and isn’t the nasolabial grooves that extend from possible. the nose and pass approximately 1cm The rarely achievable ‘perfect lips’

pmfa news | FEBRUARY/MARCH 2017 | VOL 4 NO 3 | www.pmfanews.com AESTHETIC FOCUS should be curved, well-defined, with “I try to explain that a 1ml techniques for lip procedures. It is a crisp Cupid’s bow. The proportions important for the practitioner to develop of Phi (1:1.6) contribute greatly to the syringe of filler will not different techniques and be comfortable perfect lip, where the lower lip should make their lips twice the size using different fillers so as to use an be 1.6 times thicker than the upper lip. appropriate methodology and product, The lower lip should also be longer than of a 0.5ml, but that a 1ml depending on the lips before them. the upper lip. Mouth corners should filler will afford me more The product can be a soft or medium be at least straight and preferentially thickness filler. My maybe slightly elevated. Again drawing opportunity to address size, personal preferences are Juvéderm® from Euclid’s proportions, the distance shape and border, and ask VOLIFT® or ULTRA 3®, and Belotero between the nose and upper lip should them to think of filler as a Balance® or Intense®. represent 1 to the 1.6 of the distance from the lower lip to the chin. tool to achieve better lips” Border definition Lips are of course three dimensional Retrograde linear injections along, or just structures and practitioners must also below, the vermilion border will help give look at the profile of patients when a sharp border and help to slightly evert evaluating them. Steiner line is the line lips. Careful attention and respect must from the mid-nares to the chin [3]. The lip definition. The lower lip will become be given to the Cupid’s bow, as losing this lips should just barely touch it. When shorter than the upper lip, and the will negate the essence of the top lip. they cross this line, the lips have been lower lip and chin area lose height. The Give a 0.05ml retrograde linear over projected. Our aim should be to proportions of Phi are therefore distorted along each column, entering at the apex achieve vertical, not anterior, projection. and a 1:1 ratio of upper to lower is seen. of the Cupid’s bow, with a small bolus An important point to check when deposited just before withdrawing the augmenting the lips is the nasal labial Assessment and technique needle (Note: pinch the column while angle. Armijo et al. found this should doing this). Patients attending for lip fillers have be 93.4 to 98.5 degrees for men and their own specific concerns. Some are 95.5 to 100.1 degrees for women [4]. The Volume worried about a ‘thin top lip’, others concavity of the upper lip should also be Once again linear, retrograde injections purely want their lips bigger. Older assessed. There should be a ‘ski-jump’, so into the vermilion, this time 2-3mm patients may wish to restore the volume a slight elevation at the vermilion border parallel to the border, can help that has been lost. It is vital to take into of the upper lip along the whole length; volumise lips. Another technique is consideration the patient’s wishes, and this point is called the Glogau-Klein bolus injections anterior to the wet dry assess not only their lips, but the entirety point, (point of inflection as the lip turns border, entering percutaneously from of both the peri-oral area and full face. from glabrous skin to mucosa) avoiding above or below the vermilion border At the consultation it is important ‘shelves’, ‘duck-lips’ and other nick names (above for top lip, below for lower lip). to advise what is appropriate and associated with over correction. This is then gently massaged to smooth achievable for the patient’s lips, and Asiatic lips are different from out the product. Aspiration should be what is not. Only when both practitioner Caucasians; they have a relatively fuller incorporated with this technique to and patient are happy to proceed should upper lip, but when thinking about avoid depositing filler intravascularly, treatment be carried out. beauty, the lower lip should be a little as the arterial blood supply runs along When assessing a patient’s lips, I bit thicker. Far fewer male patients the wet dry border. This technique personally sit next to the patient, with attend for lip augmentation, although is very valuable when trying to evert both of us looking into the mirror and it is becoming more common. Males inverted lips laterally. Two to three such explain which features fillers can and actually have thinner lips than females injections from the corner of the mouth, cannot address. Areas discussed include and Caucasian males have the thinnest roughly 5mm apart, will give a mild, but lips. Thin lips are actually considered defining the vermilion border, Cupid’s noticeable result. masculine and males with fuller lips bow and philtral columns, volumising The lower lip should be given the will look a little more feminine. There the lips a little centrally and laterally same attention to detail as the top lip. It are some men attending clinic for lip above and centrally below, as well has protuberances and areas of higher augmentation and practitioners must as everting the corners of the mouth and lower levels. The mid point is our have a specific treatment plan for them superiorly to achieve a fuller lip. In apex and should be everted slightly. as opposed to just performing the same patients with mandibular retrognathia, Percutaneous bolus injections into the procedure as would be done on a female chin augmentation is discussed as this protuberances can help give structure to patient. will impact what and how much can be the lower lip. Through ageing lips become thin and achieved in the lips. A patient’s dentition Lastly the corners of the mouth should lose their curves. The upper lip becomes must also be taken into consideration, be attended to. A small bolus below flat and elongated and actually obscures as over- or under-bite will impact on these of 0.05ml of filler can help to give the maxillary teeth, which is very Steiner’s line. support and turn the corners up or at important for the smile. Radial static lip least make them straight. lines or ‘smoker’s lines’ become evident Techniques and product After the procedure lips are gently as a result of loss of skin elasticity and Once the patient’s lips have been massaged for two reasons: 1. To assess subcutaneous tissue. This is seen less in thoroughly assessed from all angles, the capillary refill throughout; and 2. To men due to thick hair follicles which help practitioner needs to make a treatment ensure there are no lumps of filler keep the skin firm. There is also loss of plan. There are several documented present.

pmfa news | FEBRUARY/MARCH 2017 | VOL 4 NO 3 | www.pmfanews.com AESTHETIC FOCUS

Outcomes and risks post details of the product used, and contact Further reading information. They are urged to get in 1. Dayan SH, Bassichis BA. Facial dermal fillers: selection treatment of appropriate products and techniques. Aesthet Surg J During the consultation, aside from touch if there are any concerns at all. A 2008;28(3):335-47. discussing the aims of treatment, and as two-week follow-up appointment is made 2. Vedamurthy M, Vedamurthy A. Dermal fillers: tips to for every patient. achieve successful outcomes. J Cutan Aesthet Surg part of the consent process, practitioners 2008;1(2):64-7. need to discuss the associated risks to 3. Luthra A. Shaping lips with fillers. J Cutan Aesthet Surg treatment. These include swelling, either Conclusion 2015;8(3):139-42. transient (less than 24 hours) or more With an ever growing demand for lip sustained (three to five days), bruising, fillers the modern practitioner must and necrosis. Should there be a learn to assess, diagnose and formulate concern of necrosis during the procedure, a treatment plan specific to each set the measures that would be taken should of lips. They must hone and develop be explained and patients are consented different skills to treat a plethora of for the use of hyaluronidase. lip imperfections, striving to make lips Furthermore, it is vital to have a better, in a very natural way. There should discussion of what is realistically be little hesitance in saying ‘no’ when achievable with the amount of filler patients wish to have. I explain that unrealistic and unnatural results are a 0.5ml syringe of filler will help with requested of them. With an abundance shape but do little for the size. I try to of fillers on the market, the appropriate explain that a 1ml syringe of filler will not filler should be used, depending on the make their lips twice the size of a 0.5ml, treatment aim: to volumise, to rejuvenate, but that a 1ml filler will afford me more to hydrate, etc. The correct products opportunity to address size, shape and are the ones that work best in each border, and ask them to think of filler as a practitioner’s hands. tool to achieve better lips. Nestor Demosthenous, Post treatment instructions include References 1. Moore KL, Dalley AF. Clinically Oriented Anatomy. Cosmetic Doctor, Edinburgh, UK. applying only petroleum jelly to lips 4th Edition. Philadelphia, USA; Lippincott Williams & Associate Member of the British and to avoid lip balms and make-up. I Wilkins: 1999. College of Aesthetic Medicine and instruct patients to avoid massaging 2. Verner I. Lip Augmentation. Body Language 2015. Member of the Association of www.bodylanguage.net/lip-augmentation Scottish Aesthetic Practitioners. their lips in the first week as any lumps 3. Su YY, Wang CL, Liu DX, et al. Influence of chin E: [email protected] are likely to be a result of underlying prominence on anteriorposterior lip positions of facial swelling. Furthermore, I give them strict profile.Shanghai Kou Qiang Yi Xue 2008;17(6):598-602. 4. Armijo BS, Brown M, Guyuron B. Defining the ideal Declaration of competing interests: None declared. instructions to avoid intensities of heat nasolabial angle. Plast Reconstr Surg 2012;129(3):759- or cold for a week. Patients are always 64. given written post treatment instructions,

pmfa news | FEBRUARY/MARCH 2017 | VOL 4 NO 3 | www.pmfanews.com