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“What is currently being done for lips.”

 

The lips are second only to the eyes as the most noted facial feature. They play an important role in the perception of facial beauty. Lips are one of our most visible human organs, and perhaps the most emotionally expressive features of our face. They are soft, protruding, pliable, multi-functional providing both verbal and non-verbal communication, a tactile sensory organ, and an erogenous zone.

Young female lips tend to project and are full symbolizing health and fertility, and even become fuller during ovulation. Like many facial features, the definitions of “perfect” or “ideal” lips vary across ethnic, cultural, age, pop-culture, and current fashion trends. Dr. Burroughs will share from his own experience of 13 years of dermal filler injecting as well as what he has learned from others. He is especially grateful to Drs. Jason Emer, Arthur Swift, and Heidi Waldorf for their contributions towards a more comprehensive understanding of facial aesthetics and safe, successful dermal filler injections.

With the advent of dermal fillers starting with collagen about 20 years ago then moving onto hyaluronic acid fillers in the early 2000’s many women and a growing number of men have wanted to know should they have their lips done. Increasing options prompted more awareness that the lips can be done safely and quickly has led to more lip augmentations and even more social and public awareness.

It is widely accepted, however, that shape, size, fullness, symmetry, and certain proportions are important aspects of lip attractiveness and that color and contrast likely also play a role.

With the availability of minimally invasive products for dermal filling and volume creation, lip enhancement and augmentation procedures have become increasingly popular. Candidates for lip enhancement include patients whose lips have flattened or lost volume, show vermilion, become asymmetric, and/or have lost definition as a result of age, photodamage, smoking, or a combination thereof; patients with congenitally thin and/or asymmetrical lips; and patients who desire enhanced lip shape or fullness.

Beautiful lips in terms of shape, volume, and proportion.

Like with many other at-home attempts, there are plenty of ways patients can temporarily try lip enhancement results. These include mixing a little cayenne pepper with Vaseline to using an over-the-counter volumizing products, which create temporary, superficial lip swelling.

In pop culture, the risky “Kylie Jenner Lip Challenge” got started, which was the act of sucking the air out of a glass cylinder to create fuller lips. This was fraught with problems that included: prolonged bruising, blistering, fever-blister outbreak, pain, and others. Because of the risks, Dr. Burroughs does not recommend this or most other over-the-counter attempts to enhance lip size.

With the advent of dermal filler use for the lips, countless patients come in asking to have lips more like Angelina Jolie or like they had when they were younger.

Angelina Jolie and her famous lips.

What make lips beautiful?  Findings of a large study.

Are there gender differences or similarities? Age differences? A large study in Germany found some interesting findings, and appears in the July 2015 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery.

The Results showed:

  1. A significantly higher ratio of upper vermillion height/mouth-nose distance in frontal-view images is considered “attractive” compared with lower ratios in “unattractive” female and male perioral regions. In layman’s terms, a greater upper lip height to nose distance is attractive in females.
  2. The ratio of upper vermillion height/chin-nose distance was significantly higher in attractive vs unattractive female and male lip and chin regions. In layman’s terms, a larger distance between the upper lip height than the chin to nose distance was viewed as more attractive in females.
  3. The nasolabial angle was significantly sharper in attractive compared with unattractive female perioral regions.

  1. Attractive female lip and chin regions were found to have a wider mentolabial (between lower lip and the chin) angle compared with unattractive female lip and chin regions.

Lip Parameters in Men vs Women:

When the researchers compared male and female parameters, they found that attractive female perioral regions showed a higher ratio of lower vermillion height/chin-mouth distance and lower vermillion height/chin-nose distance than attractive male perioral regions.

The authors were able to define certain parameters of the lip and lower third of the face that seem to add to the attractiveness of female and male individuals and prove that there are gender-related differences in form and shape for an attractive lower third of the face.

What is the beauty-phi’d lip?

Drs. Swift and Renton published a great study, “BeautiPHIcation: A Global Approach to Facial Beauty.” They espouse that the stigma of the overinflated, disproportioned lip has permeated the media worldwide.  This great paper is written towards medical professionals, but it interesting to laypersons as well.

The art of beautifying lips revolves around subtle enhancement and not just pure augmentation; treatment goals should include proper proportioning of vertical height and intercommissure width (lip length), as well as recreation of a distinct upper lip white roll. Dr. Burroughs has long felt that you can’t just simply enlarge the lips and have them look good. There are certain proportions and contours that need to be maintained or emphasized.

Phi proportions and how they are important to the lips.

The golden ratio has been known since the time of the Greeks, and is a mathematical ratio of 1.618:1, and the number 1.618 is called Phi because it was regularly used by the Greek sculptor Phidias. Elements of beauty throughout nature and man-made objects carry this golden ratio throughout.

Phi is Ideal Phi proportion for lip length maintains red vermilion show to a vertical line drawn down from the medial iris, or medial pupil in patients with prominent masseters and increased lower facial width. Vertical mucosal show in white women is also in the Phi proportion of 1 for the upper lip and 1.618 for the lower lip, which is that the upper lip vertical height should be roughly 62% of the size of the lower lip. Whereas Asian and African American vertical lip to lower lip dimensions may approach 1:1. The ratios of the inter-Cupid’s bow distance compared to Cupid’s bow to the ipsilateral commissure is also 1/1.618. The distance between Cupid’s bows is phi (0.618x) of the distance from columellar base to mid-upper lip vermilion border. The upper lip philtral columns are just inside the Cupid’s bows (rather than aligned with them) in the youthful lip. Spreading and flattening of these columns with loss of upper lip pout is a common feature in the aging lip. Recreation of a lower philtral column just medial to the Cupid’s bow can restore a youthful look to an aging lip. Injections should be performed carefully to deposit very little product superiorly and more inferiorly where the philtral columns meet the vermilion tubercle.

Photo showing a less ideal ratio closer to 1:1 in a Caucasian female.

Beautiful African-American Lips.

The ideal feminine youthful lower lip should be fuller but the upper lip should interestingly project more on profile by 1 to 2 mm.

When enhancing the lips with fillers, the combination use of wrinkle blocking neuromodulators to moderate the accordion contraction of the concentric-shaped lip muscle (orbicularis oris) can increase the longevity of the volume achieved. Dr. Burroughs has found this to be true anywhere that dermal fillers are placed that are under high muscle activity.

Revised Lip Fullness Scale: A better way to evaluate lips.

The lips have become very important to address as part of one’s beauty strategies. For this reason, Allergan sponsored a study to evaluate and improve upon the previously developed lip fullness scale. Since lip-augmentation strategies have become more popular, having a validated measure can help practitioners best identify the lip issues of concern and best address them. The revised Allergan Lip Fullness Scale also was expanded to include multiple races and ethnicities including Caucasians, Hispanics, African-Americans, and Asian women. An online link to this meaningful and clinically relevant study can be found by clicking here.

Assessing Ideal Lip Dimensions: Another Study.

Dr. Brian Wong et al. studied digitally morphed photos of the faces of 20 Caucasian females. The lips were then ranked by internet-based focus groups for attractiveness. They found that the most attractive lip surface area represents a 53.5% increase from baseline, an upper to lower lip ration of 1:2, and a surface area equal to 9.6% of the lower third of the face. This study was published JAMA Facial Plastic Surgery in February 16, 2017.

What Can Happen With Lip Injections:

Common side effects such as bruising, swelling, redness and pain, are most typical of the injection procedure itself rather than the product used. The use of certain medications, supplements, and even alcohol consumption prior to injections can predispose to bleeding. This can include: aspirin, NSAIDs (e.g., Motrin), Fish Oil, Garlic, Glucosamine, Gingko and/or Vitamin E as well as many others. Fortunately, these complications are typically more unsightly and temporary rather than serious, and can be easily managed with cool compresses, camouflage makeup and/or laser treatments (pulsed dye, Excel V) or Intense Pulsed Light (IPL) treatments (e.g., Lumecca).

Rare and more serious complications are more typically due to poor technique, incomplete understanding of the anatomy, lack of experience, or just poor luck. Symptoms to be concerned with after injectable filler treatments are significant pain or change in skin color, redness or bruising from injection. Color changes (e.g., skin pallor, or mottling) distant from the injection site can be an ominous sign of potential vessel blockage and impending skin necrosis. These symptoms have serious implications and should be evaluated immediately if reported after treatment.

Any practice or medical spa injecting dermal fillers should have on-site hyaluronidase to be able to potentially and quickly reverse blood vessel compromise from filler injections. Dr. Burroughs has also been trained in safely placing retrobulbar injections behind the eyes, which potentially can be sight saving if a filler has embolized to the central retinal vasculature.   If this unfortunate event happens, blindness can ensue, and high doses of hyaluronidase behind the eye may dissolve the filler and restore blood flow. Prospective patients for filler injections should ask their injector if they have access to hyaluronidase onsite in the event it is ever needed immediately.

Choosing the Optimal Filler

Lip anatomy is complex and unique, and treatment in this area is less forgiving than other areas of the face primarily due to their high/superficial visibility, increased vasculature, variation in shape and dimension, wet and dry borders, as well as frequent, active nearby muscular movements. Pristine technique and proper filler selection is needed to limit complications and give optimal aesthetic improvements. The rheological and hygroscopic principals of the filler chosen determine the likelihood of acute complications such as nodules or swelling as seen in the photo.

Lip nodules and swelling following filler.

Discussion of dermal filler variations and their implications in the lips.

We are fortunate to be in a time that there are many options for facial filling, volumizing, and wrinkle filling. Many fillers that had only recently been available outside of U.S. markets have made their way to America.

Voluma and Restylane Lyft have much higher G prime than the other forms of Juvederm and Restylane, and have the capacity to “lift” the lips significantly, but with an increased risk for nodule formation, irregularities, pain, and more swelling.

Particulate fillers such as Restylane can give more structure to the lip and likely longer lasting results, but may compromise the softness seen with other more homogenous hyaluronic acid fillers such as Juvederm, Belotero, or Restylane Silk. Depending upon the specific needs of a patient, however, dermal fillers can ‘sandwiched” in place with deeper filler placement of the more particulate higher G-prime type fillers and then superficial defining and volumizing of the more superficial portion of the lips and vermillion with softer (lower G prime) fillers like Belotero and Restylane Silk.

The hydrophilic (water attracting) nature of hyaluronic acid fillers requires an appreciation by injectors to avoid over treatment in order to prevent prolonged swelling and unpredictable results leading to patient unhappiness.   The Juvederm family of fillers tend to be more hydrophilic and injected areas can enlarge over many days from immediate post injection sizes significantly and for many months, so Dr. Burroughs does not recommend them for the lower eyelids and he prefers others like Restylane and Belotero for the lips and eyelids because of their improved predictability.

Semi-permanent fillers such as Radiesse, Artefill and/or Sculptra should never be injected into the lips, as the muscular movement can cause clumping of the filler and potentiate nodule formation, leading to potentially permanent irregularity requiring surgical removal.

Dr. Burroughs, however, over the last 13 years, has used with success and safety diluted Radiesse into the skin between the lip and the nose as well as the mental crease, nasolabial, and melolabial areas without problems. Dr. Burroughs has determined it’s all a matter of how it is mixed and placed as Radiesse is even FDA-approved for rejuvenation of the back of the hands where the skin is very thin.

Techniques for Success

Since swelling is immediate in areas of increased vascularity and can cause the local anatomy to quickly alter, optimal aesthetic results of the lip are more difficult to attain if the procedure is not performed swiftly and precisely. Dr. Jason Emer advises a “10-second” rule, where choosing your injection site, performing the injection and deciding if you need to make edits, takes a total of, at most, 10 seconds.  Now the entire lips cannot be completely injected in 10 seconds, but limiting lip injections to timely and specific zonal stages during injection sessions is an idea that Dr. Burroughs agrees with.

Master surgeons and injectors, who have high volume practices, unfortunately know and will admit the only way to avoid complications is to never perform surgery or aesthetic treatments. Having become highly skilled at their techniques, they strive and oftentimes become even better at delivering aesthetic procedures by their extensive understanding of anatomy, the limits of how it can be altered, and how to do so in the safest manner possible.

Along these lines, Dr. Burroughs is a strong advocate for microcannulas as they can limit the amount of swelling and bruising by being blunt rather than sharp, and being more flexible than rigid, compared to needles.

Microcannulas can be used through fewer injection sites to contour and lift areas that would otherwise require a greater number of serial puncture or thread technique injections. The reduced tissue trauma by the blunt nature of the cannulas makes treatments much more comfortable, at times nearly painless and bloodless. Post procedure bruising is also less. With the advent of lidocaine anesthetic to dermal hyaluronic acid and the use of cannulas, Dr. Burroughs no longer performs lip nerve blocks for filler injections, and feels he has gotten better results in a more comfortable manner. See a video of his technique by clicking here.

Unfortunately, complications can be seen with cannulas also, but Dr. Burroughs believes it is in the best interest of patient safety that injectors employ every means possible to make injections as safe and comfortable as possible. There is definitely a learning curve to using cannulas, but he has felt it was worthwhile to learn.

An exception to microcannula use is ultra-fine-tuning of the lip shape to create eversion, projection, and/or define the vermillion or lip corners, which is more restricted/difficult with cannulas compared to sharp needles. Therefore, Dr. Burroughs will sometimes complete the injection with a few sharp needle injections to assure the best result.

Treatment around the lip/mouth into the vermillion can improve vertical lip lines and give eversion, projection and lift. Treatment of the upper cutaneous lip and pyriform aperture, as well as the lower cutaneous lip and chin fat pads, can give the lip/mouth support that often decreases with age due to fat atrophy and bony resorption beneath.

It’s important to check the inside of the mouth for good dentition, as lack of teeth or periodontal disease can be a cause for poor lip/mouth shape, symmetry, contour, and support.

Dr. Waldorf advises that if a patient really wants to do their lips then they must also do their face or they will look like a skinny and ugly duck. The reason, she emphasized, is that the lips are no different than the rest of the face when it comes to attributing visible signs of aging to a deflated fat pad. It’s all affected. When everything else is sagging on the face, the lips, too, change in appearance — not necessarily because the lips have changed, but because they are visibly altered by falling tissues. Replacing this lost volume can improve the appearance of the lips without oftentimes even needing to fill the lips.

Dr. Burroughs agrees with this priciple for older patients, who likely have significant areas of facial deflation and descent. Younger patients that just have smaller or misshapened lips, however, can be good candidates for lip filler in isolation from other areas.

Dr. Waldorf’s 6 Tips For Lips: “KISSES”

Dr. Waldorf devised the “Kisses” principles for lip injections. These are:

K – Know your anatomy

I – Inject from outside the lip

S – Side view is as important as the front

S – Shape is more important than size

E – Expectations must be realistic

S – Safety first

  1. Know your anatomy

Dr. Waldorf believes that if you know how the face should look normally, the work you do on it will look more natural. For example, if the midface is drooping and deflated and you replace the missing volume, the lips may no longer need much or any injection. Alternatively, if you ignore the fat pat and only inject the lips, the patient may not get the results he or she is truly looking for.

  1. Inject from outside the lip

By using a single injection point from the oral commissure and working from the outside-in, your patients will experience less pain and less bruising. This is especially true with the newer agents that have lidocaine anesthetic mixed in.

  1. Side view is as important as the front

When you’re improving the appearance of the lips, it’s important to carefully evaluate the face from the side, Dr. Waldorf said. The side view reveals deficiencies in facial contours that may need to be addressed as part of the lip enhancement approach. Furthermore, Dr. Burroughs reminds that the upper lip should project 1-2 mm more forward than the lower lip.

  1. Shape and symmetry are more important than size

Think embryology, said Dr. Waldorf: “Accordions and pillows.” Spread out accordion pleats using a tiny thread of filler in the vermillion or white boarder of the lip. Enhance the pillows for a fuller pout. The pillows are where 17 Magazine and Vogue tell readers to put that little bit of gloss to enhance the lip, she offered.  With regard to shape, she also emphasized avoiding creating the overhanging top lip.

“Accordion” lip lines.

  1. Expectations must be realistic

“Be sure the lips fit the face,” Dr. Waldorf said. Ideal proportions for the individual face are key. Sometimes, those ideal proportions may fall short of desired outcomes. One of the responsibilities of an ethical and professional injector is to notify poor candidates that they should not undergo injections, and Dr. Burroughs has had to many times tell patients no more filler if they have gotten out of proportion or excessively volumized in areas of their face or lips.

  1. Safety first

A clean face can’t be underestimated, Dr. Waldorf said. Clean the skin to avoid lumps, bumps, granulomas, potential infections and biofilms. For semi-permanent fillers, although Dr. Burroughs doesn’t place them into the body of the face, he advocates prepping the skin with antiseptic and treating the injections just like a surgical procedure. Using these more sterile techniques, he has never seen a filler or neuromodulator infection. 

Post Lip Injection Instructions

Meticulous technique, cannulas, pressure and icing, and homeopathic treatments, such as arnica, bromelain and vitamin K, can help to limit both minor and serious complications from filler injections.

Patients should be aware and instructed on proper at-home care of the treated areas to limit the more serious consequences such as necrosis and infection, as well as migration and asymmetries. Manipulation of the treatment areas with massage should be avoided for at least two days after treatment as it can cause asymmetry and premature loss of the filler benefit. Most fillers only rarely migrate, but it has been reported at distant sites and in different planes (superficially) from injection. This may be a result of the technique used, the filler used, but also the result of at-home management.

Inflammatory reactions, product migration, excessive swelling, premature loss of effect, and extensive bruising can result from hot yoga, saunas, massage table or CPAP mask pressure, scuba/snorkeling/swim goggles, and trauma to treatment areas in the early post-treatment phase. If significant post-procedural swelling or potential angioedema develops then oral antihistamines (e.g., Benadryl or Allegra), corticosteroids (methylprednisone or prednisone), and/or diuretics (furosemide, hydrochlorothiazide) can be helpful.

Long-term use of hyaluronic boosting topical cosmeceuticals can be helpful to prolong the effect. HA Intensifier by SkinCeuticals has become very popular in Dr. Burroughs’ practice at Springs Aesthetics.

Remind patients that simultaneous and interval use of wrinkle blocking neuromodulators can both potentiate and prolong the effects and results of dermal fillers. Dr. Burroughs also has found that the neuromodulators are good to relax the lateral lip depressor muscles to give a nice and pleasing upturn to the outer corners of the mouth. Neuromodulators are also helpful to address chin dimpling and the gummy smile.

Fixing Lips After Suboptimal Injections

Prevention trumps having to address poorly treated or displeasing lip outcomes. This is best achieved by using meticulously great technique, low volumes, expeditious injection technique, strategic placement, having a thorough understanding of individual product characteristics, the anatomic variances between individuals and lip anatomy, finding out what a patient desires, explaining what can and/or should be done for ideal lips, and having proper patient education for post injection care.

  1. Suggest avoidance of manipulation or trauma to treated areas for 48 hours after treatment. Dr. Burroughs advises patients to come in for an evaluation first before trying to improve a situation on their own.
  1. Avoid intense exercise, extreme temperatures and applying chemicals or irritants to treated areas for a few days.
  1. Avoid pressure to the treated areas with masks of any sort.
  1. Be sure patients know how to reach the office after hours if they have an urgent concern, which can include severe pain, concerning skin color changes, or any vision-related issues.

Treating Filler Adverse Events:

  1. Extensive swelling, asymmetries, or nodules may be reversed and effectively treated with hyaluronidase injections. Dr. Burroughs has developed treatment protocols for these issues and has become a local referral source for hyaluronidase enzyme injections to improve dermal filler outcomes and patient satisfaction.
  1. For extensive bruising, consider laser or IPL treatments in the first 24 to 48 hours after treatment to speed resolution.
  1. If a patient reports extensive pain, blanching, mottling, or duskiness, and/or mucosal change/sloughing, consider impending tissue necrosis and established guideline protocols for treatment must be followed.

In summary, the lips are the second most notable feature of our faces. Their appearance is of utmost importance especially to the aesthetic female patient. They are much more modifiable, as compared to the eyes, without any surgery. Although optimal outcomes for filler lip augmentation require an aesthetic eye, understanding of anatomic beauty ideals, proper injection technique, proper filler selection, and delivering results in a comfortable yet safe manner they are a very sought after procedure and aesthetic providers should study and master their technique and understanding. Besides the lips, it is important that the “framing” around the lips to include the folds (nasolabial, melolabial) be addressed with dermal fillers when necessary.

Shown below is one of Dr. Burroughs’ long-standing patients that is an over 50 African American female that wanted restoration of her former lip volume, projection, and lip symmetry. Her right upper lip (left side on photo) was narrower horizontally than the other side of her lip. She was very pleased with the improved symmetry and that her lips looked like they did when she was younger. She was very pleased that the lip lines were greatly improved as well.

Here is another patient of Dr. John Burroughs that has been coming to Dr. Burroughs for over 10 years. She had never felt her lips had much volume, and was thrilled to have lips before her wedding.

This is another patient that felt her lips were asymmetric and too small and not full enough for her face.

Interested in getting your lips augmented, made more symmetric, or more beautiful? Then give us a call at 719-473-8801. Dr. Burroughs or one of his trained staff will be happy to provide information and your available options.