Introduction

The lips are a defining feature of youth and beauty. While they may represent a small portion of the face based on size, they can have a dramatic effect on a person’s overall appearance. Unfortunately, as we age, lips undergo some of the most dramatic changes of the entire face. Although these changes are a natural part of the aging process, they can be softened or reversed to give a more youthful and rejuvenated appearance.

The aging process on the lips

While this chapter will focus specifically on the rejuvenation of the lips, it is important to consider the lips in the larger context of the perioral region, demarcated by the nasal base, cheeks, and chin. There are a multitude of causes and effects of the aging process in the lower face. In addition to the intrinsic aging process, ultraviolet radiation can cause photoaging of the skin, resulting in mottled dyspigmentation and irregular texture. Additionally, as collagen fibers diminish and elastic tissue is degraded, perioral rhytides become more prominent. Furthermore, there is an overall loss of subcutaneous fat volume and bone. These changes result in an overall drooping of the perioral region, which may call attention to the lips. Therefore, in order to truly rejuvenate the patient’s lips, it may be necessary to rejuvenate the entire perioral region, including the nasolabial folds, melomental creases, and chin. These topics are covered elsewhere in this book, but should be considered in any cosmetic consultation.

The lips specifically are dramatically redefined by an overall loss of lip volume and structure throughout the aging process: the upper lip becomes thin and elongated, while the lower lip becomes thin and rolls inward. This results in a loss of the appearance of the pink vermilion of the lip, and a sagging of the corners of the mouth (which is further accentuated by the activity of the depressor anguli oris muscle). The result is a loss of show of the upper teeth, with an increase in the show of the lower teeth. The overall loss of lip volume leads to a loss of structure of the lip. The Cupid’s bow – the area defined by the two high arched points of the upper lip – becomes effaced and flattened; there is also a loss of definition of the two philtral columns of the upper lip. Over time, the beautiful, defined, arched structure of the upper lip is lost and in its place a thin, poorly defined upper lip develops. In conjunction with the overall loss of lip volume, there is also the chronic effect of activity of the orbicularis oris muscle, which leads to the formation of radiating deep perioral rhytides. Patients often complain that these rhytides cause ‘bleeding lipstick’ lines and are a frequent issue of discussion in cosmetic consultations.

Multiple assessment scales have been developed to quantify these changes. A numeric CKC scale (Table 20.1) was developed to aid in the initial assessment of patients, as well as their response to rejuvenation. Additionally, multiple lip-specific photographic scales have been developed in clinical studies. A recently presented abstract by Werschler et al developed, validated, and utilized a Lip Fullness Scale. Another recently presented abstract by Cohen et al validated the Perioral Lines at Rest (POL), Perioral Lines at Maximum Contraction (POLM), and Oral Commissure Severity (OCS) scales. Previous studies by Carruthers et al and Rossi et al have determined and validated photonumeric grading systems for assessing lip fullness, volume, and thickness (Figs 20.1 and 20.2). These scales may be of benefit in the initial assessment of patients and their clinical improvement following lip augmentation.

Figure 20.1 Photonumeric grading scale for assessing lip volume and thickness.

(Reprinted with permission from Rossi AB et al 2011 Development and validation of a photonumeric grading scale for assessing lip volume and thickness. J Eur Acad Dermatol Venereol 25(5):523-531.)

Figure 20.2 Validated lip fullness grading scale.

Reprinted with permission from Carruthers A, Carruthers J, Hardas B, et al 2008 A validated lip fullness grading scale. Dermatologic Surgery 34(suppl 2):S161-S166.

When done well, lip augmentation and rejuvenation can dramatically address many of these changes associated with aging lips to both replace the volume loss and redefine the lip structure. In a 2009 study by Werschler et al, after treatment with a hyaluronic acid (HA) filler (Juvéderm^® Ultra^®, Allergan Inc., Irvine, CA), multiple features of the lips were improved, including: (1) proportional lip size relative to the face, (2) proportional upper and lower central lip fullness, (3) sharp, well-defined vermilion borders, (4) distinct Cupid’s bow peaks and a well-defined philtrum, and (5) oral commissure fullness to support the lateral aspect of the lip. In the study, the investigators rated these five attributes as ‘adequate’ in only 32–48% of subjects prior to augmentation; after the augmentation was performed, the attributes were scored as ‘adequate’ in 80–90% of subjects.

However, in some cases, simply injecting soft tissue fillers into the lips alone may not achieve the best results. Judicious use of low-dose botulinum toxins around the lips may improve perioral rhytides, while botulinum toxin injections into the depressor anguli oris muscles may reduce the downturning of the oral commissures, and enhance the longevity of the fillers. However, while reported in the literature, these are off-label uses of botulinum toxin not approved by regulatory authorities such as the US Food and Drug Administration (FDA), Health Canada, or European regulatory authorities. In severe cases, resurfacing of the perioral skin with lasers or chemical peels may be necessary. Although this chapter will focus on the use of soft tissue fillers, in many cases a multimodality approach may be beneficial for patients to achieve optimal rejuvenation.

An approach to achieving youthful lips

The first issue to address with lip augmentation is to determine the treatment goals of the patient. Does the patient seek enhancement or restoration of the lips? Younger patients typically seek enhancement, whereas older patients typically seek restoration.

If the patient is seeking enhancement of the lips, are they satisfied with their existing lip shape but desiring fuller lips, or is the patient seeking an entirely different shape of his / her lips? It is then important to perform a careful assessment of the appropriateness of that desired look in proportion to the rest of the patient’s face. Lip volume enhancement not only increases the vertical height of the vermilion, but also increases lip volume circumferentially, potentially resulting in the undesirable ‘duck lip’ appearance. We advocate small-volume treatments, especially for first-time treatments, with potential touch-up procedures 1–2 weeks later in order to achieve the best outcome and limit the potential for overcorrection.

For patients seeking lip restoration, it is important to determine their specific concerns. Are the lips asymmetric at baseline? Has the patient lost the overall structure of the lips? Are they having trouble with ‘lipstick bleed’? A single concern may necessitate multiple treatments; fixing ‘lipstick bleed’ may require treatment with dermal fillers in the lips as well as a perioral laser treatment or chemical peel. Conversely, sometimes treating one area, such as the oral commissures, can improve the overall appearance of the face. It is important to determine patients’ restoration goals in order to determine whether a single modality treatment or combination of treatments would best achieve their goals. Treatments do not need to occur in a single session; in fact, it is often better to schedule multiple visits with gradual treatments in order to better assess the effects of previous sessions on the overall restoration goal.

Morphological differences between racial groups, ethnic variations, and individual preferences should also be considered during the cosmetic consultation and are important factors to be considered for optimizing results and achieving patient satisfaction. Many ethnic patients seek lip augmentation based on their cultural and racial background rather than obtaining a more Westernized appearance. For example, individuals of African descent tend to have fuller lips, but as they age volume loss occurs, particularly of the upper lip. Therefore, the goal of lip augmentation would focus more on upper lip enhancement rather than on upper and lower lip restoration.

Filler products

There are numerous filler products available for soft tissue augmentation. A full discussion of all of these products is beyond the scope of this chapter. When performing lip rejuvenation, temporary fillers are the treatment of choice. Historically, collagen was the gold standard product for lip augmentation. At this time, collagen products are no longer commercially available in the USA and HA products have become the most frequently utilized products for lip rejuvenation. These HA products are cross-linked in order to extend their longevity to 6–12 months. The most widely used of these HA products, Juvéderm^® (Allergan Inc., Irvine, CA) and Restylane^® (Medicis Aesthetics Inc., Scottsdale, AZ), are now pre-mixed with lidocaine in order to reduce any discomfort associated with the injections – a particular advantage when treating sensitive areas. In 2007, a multidisciplinary group of experts in aesthetic treatments (the Facial Aesthetics Consensus Group) developed recommendations for lip augmentation and rejuvenation (Carruthers et al). Of the available HA products, the faculty typically utilized Restylane^®, Juvéderm^® Ultra^®, or Juvéderm^® UltraPlus^® for lip and perioral rejuvenation. The majority of the faculty (67%) utilized 1.0 mL of HA while the remainder (33%) utilized 2.0 mL to reshape the vermilion border and rejuvenate the lips.

Restylane^® was recently approved for lip enhancement in patients over 21 years of age in the USA. Juvéderm^® is being reviewed by the FDA for this indication. In Europe and many other countries both Restylane^® and Juvéderm^® are approved for the treatment of lips. Semipermanent fillers, such as calcium hydroxylapatite and poly-l-lactic acid, can be utilized to rejuvenate the perioral area including the nasolabial folds, jowls, etc. However, we do not typically inject these products into the lips themselves, as they have an increased risk of adverse effects including nodule formation.

Permanent fillers, such as polymethylmethacrylate and liquid injectable silicone, have been utilized for lip rejuvenation. However, these permanent fillers have an increased risk of granulomas, foreign body reaction, extrusion, recurrent chronic inflammation, and possible permanent scarring when injected into the lips. As a result, these products are not recommended for lip augmentation.

Injection techniques for lip rejuvenation

Most patients feel mild to moderate discomfort during lip injections. Most recently, HA products premixed with lidocaine have been marketed, which can reduce the discomfort. Some patients may still prefer to have either topical anesthesia creams applied or a small nerve block performed. The nerve block should be placed near the infraorbital foramen (mid-pupillary line, lateral to nasal ala) and the mental foramen (angle of jawline, inferior to the corners of the mouth), and can be injected via an infraoral approach or through the skin. Alternatively, a small amount of lidocaine can be placed as a bleb at the junction where the gum and mucosa join. It is important to remember that, if lidocaine is used, the minimal amount of lidocaine should be injected in order to avoid distorting the lip architecture, which would make the aesthetic correction more difficult to assess. In our experience, these blocks are often not necessary.

There are many different techniques for injecting soft tissue fillers including: tunneling, serial puncture, threading, cross-hatching, and fanning. In our experience, the exact location and volume of product injected is most important to the outcome.

In general, injections in the wet–dry junction of the lip and the vermilion border of the lip will augment the volume of the lips, whereas injections in the rolled border of the lip produce definition (Fig. 20.3A, B). Overall, many patients require slightly more volume in the lower lip than in the upper lip, but the exact volume and proportions must be individualized for each patient. For example, African American patients may require greater volume injections into the upper lip than in the lower lip to achieve their ideal outcome.

Figure 20.3 (A) Patient presented complaining of thin lips, a loss of structure and shape on the upper lip, and radiating perioral rhytides. (B) Following lip rejuvenation with 1 mL of hyaluronic acid product, note the defined Cupid’s bow and vermilion border of the lip. There is also enhanced volume and a reduction in the appearance of the radiating perioral rhytides.

Typically, when rejuvenating the upper lip, the first area treated is the vermilion border. The needle is inserted at the lateral edge of the upper lip, and tunneled along the vermilion border to the point of the Cupid ’s bow. A small amount of filler product is placed into the point of the Cupid’s bow to define this point. The remainder of the product is then injected in a retrograde fashion as the needle is withdrawn. Alternatively, the filler can be ‘pushed’ anterograde along the border subdermally. The filler product can also be injected relatively superficially into the dermis. If the patient’s philtral columns are poorly defined, the filler can also be used to redefine these points. A highly cross-linked cohesive filler will be best for the philtral columns. The needle should be inserted at the junction of the Cupid’s bow and philtral column, and then advanced superiorly along the philtral column in a mid-dermal plane. Again, the product is placed with a retrograde injection technique. A small amount of product is sufficient to redefine each column; a slightly greater amount of the product should be placed towards the inferior aspect in order to maintain the natural contour and appearance of the philtral column. If the patient desires volume enhancement of the upper lip, a small amount of filler product can be placed along the junction of the wet–dry portion of the lip. In general, the vermilion border of the lip should be treated first to define the Cupid’s bow and vermilion border prior to augmenting the overall volume of the upper lip. If the patient’s lips are symmetric prior to augmentation, it is important to insure that an equal amount of product is placed into each side of the lip in order to maintain this symmetry. Frequently, patients have asymmetrical lips requiring a slightly different amount to be injected to each side of the lips.

The lower lip is similarly treated. We recommend inserting the needle at the lateral edge of the lower lip, and then either pushing the filler in an anterograde fashion in the subdermal space or tunneling the needle along the vermilion border to the mid-point of the lower lip and injecting in a linear retrograde fashion. If augmentation is also desired, product can be injected along the junction of the wet–dry border of the lower lip. Again, if the lips are symmetric at baseline, we recommend injecting similar volumes into both sides of the lips in order to maintain this symmetry. It should be noted that sometimes a small amount of filler (0.1–0.3 mL) can make an enormous difference in the appearance of the lips. In addition to rejuvenating the lips themselves, it is often necessary to buttress the corners of the mouth in order to prevent or reverse downturned corners of the lips. This can be easily accomplished by injecting filler product underneath the lateral corners of the mouth, providing a scaffolding to support the remainder of the lips. This effect can be further enhanced by injecting botulinum toxin into the depressor anguli oris muscles to help turn the corners of the mouth up, thereby rejuvenating the lips and mouth.

Finally, the patient may desire treatment of perioral rhytides. These lines can be improved with soft tissue augmentation. The needle should be placed at one end of the rhytides, and then tunneled along the depression. Very small amounts of filler product are needed for treating these lines, and we advocate injecting small microdroplets of the filler in a relatively superficial plane. Injecting diluted HA filler (1 : 1 mixture of HA with 1% lidocaine, injected superficially with either a 30- or 32-gauge needle) in the perioral fine lines can be quite effective. Botulinum toxin can also be administered to relax the orbicularis oris muscle and help prevent or reduce these rhytides. In severe cases, a chemical peel or laser resurfacing may be necessary to provide better improvement.

Case Study 1

A patient presented for lip rejuvenation (Fig. 20.3A). On examination, there is loss of the shape and structure of the upper lip. Overall, the upper lip is flat, with a loss of the Cupid’s bow. The philtral columns are also not well defined. There are multiple perioral radiating rhytides. The lower lip is also small and lacks definition.

The patient underwent lip rejuvenation with 1 mL of hyaluronic acid product (Fig. 20.3B). Following the augmentation, note the reshaped and defined Cupid’s bow; there is also greater definition of the inferior aspects of the philtral columns. The overall volume of the upper and lower lips is increased slightly as well. Finally, there is a reduction in the appearance of the radiating perioral rhytides.

Potential side effects

Bruising and swelling are the most common side effects following lip augmentation. These are typically mild and self resolve within a few days. Small-volume injections reduce these side effects and also reduce the likelihood of overcorrection and asymmetry; potential touch-up procedures 1–2 weeks after the initial treatments can be performed as needed. In addition, there is no evidence of the risk of post-inflammatory pigment alterations, hypertrophic scarring, or keloid formation in ethnic patients following treatment. Finally, the use of semipermanent and permanent fillers should be avoided when possible to decrease the risk of granuloma and nodule formation.

Case Study 2

A 40-year-old female patient presents for lip augmentation. The upper lip is augmented with 0.3 mL of hyaluronic acid (HA) to define the rolled border. The lower lip is augmented with 0.5 mL of HA, with injections along the rolled border and into the wet–dry junction of the lip. At the conclusion of the procedure, the lips are slightly swollen, but appear symmetric. Two days later, the patient calls the office upset that her lips are ‘huge and overcorrected’. She requests treatment with the reversing agent to undo the augmentation. What should the treating physician do next?

The patient should be reassured and instructed to return to the office. Swelling following the augmentation is very common and may require several days to resolve. Hyaluronidase will remove the product, but will not improve bruising or swelling associated with the injections themselves. Patients often benefit from massage of the area to smooth down any nodules or lumpiness. Patients should then be instructed to ice the areas and wait for any swelling associated with the procedure to resolve before judging the final result. The patient in this case study returned to the office, had a good response to massage, and 1 week later was thrilled with the appearance of her augmentation.

Conclusion

The lips are a dramatic and defining feature of the face. Unfortunately, the aging process denies patients of the beautiful structure and volume of the lips. Lip rejuvenation and augmentation is a safe, simple, and effective procedure to reverse these changes. HA fillers are the treatment of choice to both redefine and restore volume to the lips. In more advanced cases, a multimodality approach may be necessary to complete the rejuvenation of the perioral area.