History

Throughout history men and woman alike have been attracted to ample, full and pouty lips. Full lips are synonymous with youth and for hundreds of years, people have sought to augment lips. Throughout recent history, many surgical procedures and techniques have evolved which allowed surgeons to do this. Some of these procedures have enjoyed greater popularity than others and some have simply not worked well at all; others have caused disastrous results. Across all cultures, the lips are seen as the aesthetic center of the lower face, and in females they are a landmark of beauty and physical attraction for men. Full and defined lips impart a sense of youth, health and beauty and sexuality to the bearer. Like many facial features, as the lips age, they become less attractive. The hallmark sign of the aging lip is the loss of volume. As the lips lose volume, they become thin and flat and lose their shape. The lines which result from repeated dynamic movement take permanent residence and the corners of the mouth begin to turn inward, which reduces the width of the mouth. Part of the reason behind this is the loss of structural support in the lower face. Throughout our lives, as we grind our teeth, undergo dental work and experience age-related osteoporotic bone loss with a resultant thinning of the mandible, the distance from the lips to the chin is significantly decreased. As we lose dental height and support, the face appears different in that the ends of the lips tend to hang down, contributing to the marionette lines or labio-mandibular grooves. Ultimately, as with all areas of facial cosmetic surgery, the trend towards minimally invasive, office-based procedures, with minimal down time and reduced pain has undergone a vast transformation, and today this concept appears to be the guiding principal in facial cosmetic correction.

In 1984, with the approval of injectable bovine collagen, the goal of simply eradicating dynamic lines and wrinkles caused by aging, sun exposure and smoking moved toward correcting volume loss. No longer did people want a flat, pulled two-dimensional appearance, but rather a full three-dimensional natural appearance. Physicians began to enlarge the cupid’s bow, increase the length of the lower lip and to enhance the projection mass of both the upper and lower lip. The use of bovine collagen as a safe, easy to use, predictable injection agent permitted physicians to provide stable reproducible lip augmentation, which was natural in appearance and provided for a superior cosmetic result. Unfortunately, the dermatologic and plastic surgery literature provided little guidance regarding the proper aesthetic characteristics of lips, and while many women’s magazines presented models with voluptuous, full lips, and many celebrities were admired for their beautiful lips, there were no standard guidelines available to assist physicians with lip augmentation. The unfortunate result of this lack of general information was improper and cosmetically displeasing results. We have all seen frequent examples of women who display lips which have lost their natural proportions, been excessively augmented and appear uneven and unnatural. We believe that techniques which favor subtle correction which prevents the untrained eye from noting the procedure produce a favorable and natural result. In 1984, Arnold W. Klein helped to pioneer lip augmentation that began to focus on increasing volume and on an aesthetically pleasing appearance, rather than simply eradicating lines. This technique has evolved into a better understanding of how lip enhancement should be done. Above all, it must never be detectable to the untrained eye. Lips are about volume, but more importantly, shape, balance and symmetry. Indeed, the areas of the cupid’s bow and philtral pillars could only be slightly altered in that any significant distortions in these areas would draw attention to the lip enhancement and possibly present an unnatural and distorted result.

With the FDA approval of the first hyaluronic acid (HA) preparation for soft tissue augmentation in 2004, this opened the door to a new generation of injectable dermal fillers. The hyaluronic acid products have proved exciting materials which work superbly in soft tissue augmentation. HAs are a naturally occurring polysaccharide found in the dermis and through the cross-linking process, a greater tissue residence time has resulted. As injectors refine their techniques and as manufacturers work on better cross-linking materials and techniques, these agents have proved superior to bovine collagen and in the right hands with the best technique, we routinely obtain lasting results which approach and in some cases exceed one year.

Physical evaluation

Patient selection is not as critical in evaluating patients for lip augmentation due to the fact that as we age, we all will begin to experience the loss of structural support in the lower third of the face and lose volume in the lips. However, there are some important factors to consider when evaluating a patient for lip augmentation:

Anatomy and architecture of the lip

Are there specific considerations that can be established for lip augmentation? In looking at the aging lip, there are two important factors that one should consider. One is the shape of the lips themselves and the other is the importance of the support provided to the lower third of the face by bony structures and the teeth. These are all features dependent upon not only injection of the lips themselves, but also on the volumetric restoration of the lower third of the face. The lips should be full and well-defined. They should be injected without blunting the edge of the vermilion border of the upper lip, which if not done precisely will give a flat simian quality to the upper lip. The injector must also focus on the restoration of the ends of the lips or oral commissures, as well as the building of buttresses at these ends to restore proper height to the lips and lower third of the face; correcting the labio-mandibular grooves/oral commissures. While dermatologic and aesthetic journals deal with substances for implantation, these journals have not, in themselves, held good information dealing with the proper concepts of lip augmentation. Instead, we have found this information in the dental literature where a number of articles have discussed in great detail the proper lip height, size, and location of the lips as produced by dental restoration. The following are some criteria for evaluating the aesthetic lip in the well-proportioned face. The length of the closed, relaxed mouth should equal the distance between the medial aspect of the irises. The ratio of the mucosa show of the upper to lower lips should be 1 : 1.6 (Fig. 72.1).

Fig. 72.1 The length of the closed, relaxed mouth should equal the distance between the medial aspect of the irises.

The inter-pupillary line and commissural line should be parallel when the mouth is relaxed (Fig. 72.2). The distance from the base of the nose to the upper lip should be 18–20 mm and the distance from the lower lip to the point of the chin should be 36–40 mm (Fig. 72.3). These distances change as the face ages and need to be restored. A line from the midpoint of the nose to the chin (Steiner line) should touch the upper lip (Fig. 72.4). The nasolabial angle should range from approximately 84–105 degrees (Fig. 72.5). The most important aspect of lip augmentation involves restoring the ends of the lip and building buttresses at the ends to restore the height loss. This also corrects the labio-mandibular grooves. It is important to inject the lips so as to maintain the ski-jump edge (the Glogau–Klein point) of the upper lip (Fig. 72.6). Oftentimes, using a combination of products can result in an improved aesthetic result. It is important to balance the treatment by refilling lost space in the nasolabial folds, as well as the lower third of the face. Lips must maintain a natural profile. Unnatural fullness above the lip is to be avoided at all costs since it blunts the edge of the lip and gives them a prognathic appearance. With respect to the facial profile, the nasolabial angle should be 85 to 105 degrees (Fig. 72.3). Finally, there is a slight elevation or ski-jump, which is a point of inflection as the lip turns from glabrous skin to mucosa. This site had not been formally noted in the scientific literature previously, therefore, it is referred to as the G-K (Glogau–Klein) point.

Fig. 72.2 The interpupillary line and commissural line should be parallel when the mouth is relaxed.

Fig. 72.3 The distance from the base of the nose to the upper lid should be 18–20 mm and the distance from the lower lip to the point of the chin should be 36–40 mm.

Fig. 72.4 Steiner-mid nares to chin. Ricketts – tip of nose to chin. Burstone – base of nose to chin.

Fig. 72.5 Nasolabial angle should be 85°–105°.

Fig. 72.6 The perfect lip.

Technical steps

Prior to injection, suitable anesthesia should be administered. Dental blocks remain popular among many physicians and patients. However, it is our opinion that dental blocks can prevent normal motion of the lips and mouth during the injection session, and this could compromise the aesthetic result. Furthermore, blocks often allow the physician greater license for quick forceful injections which have been proven to be responsible for increased adverse events, such as bruising, lumpiness of product and distortion of the injected site. Without the use of a dental block, a very gentle injection technique is required. Topical anesthetic such as EMLA and various compounds of lidocaine, betacaine and prilocaine can be employed, if desired, and provide a good anesthetic result. Additionally, even if HA products are to be used, injectable collagen can be used prior to the use of the HA to create a flow track, as well as deliver anesthesia to the site. Our most recent practice, after application of a topical anesthetic agent, is to mix 1.0 mL of 1% lidocaine with epinephrine to the HA product. This is done using a male/female adaptor and gently mixing the HA with the lidocaine. This provides for virtually pain-free injection without the need for dental blocks.

The patient should be seated upright in a chair with strong surgical lighting. Most authorities agree that aspirin, NSAIDs and vitamin E should be avoided for a week prior to the injection procedure. Nevertheless, bruising and a certain degree of swelling with HAs are to be expected. The slower and more gentle the injection, the less associated pain and trauma. To diminish the swelling during injection, intermittent application of ice can be utilized during the procedure and post-injection. A prior history of labial herpes requires prophylactic coverage with appropriate antiviral medication. Finally, an assistant can aid in the assurance of an excellent aesthetic result by being a separate pair of eyes to evaluate the degree of correction and asymmetry from a position in front of the patient while the physician is injecting from their side.

The patient is injected from right to center and then from left to center (Fig. 72.7). The preservation of the cupid’s bow is critical because it is the defining aesthetic of the upper lip. Furthermore, the lower lip is to be injected not as a rounded wheel mass, but instead to produce central rollout or pout. When the lip is injected, the physician must stretch the lip to assure themselves that they are beginning at the end of the lip that is now part of the labio-mandibular groove (Fig. 72.8). Furthermore, with a firm surface to inject against, the stretched lip provides a better flow surface.

Fig. 72.7 The patient is injected from right to center and then from left to center.

Fig. 72.8 The physician must stretch the lip to assure themselves that they are beginning at the end of the lip that is now part of the labio-mandibular groove.

The tip of the needle should be inserted into the potential vermilion space at a 45-degree angle on the mucosal side. The needle is then redirected at a 20 degree angle from the lip. With the lip stretched, this will allow the material to flow along the potential space. Injection must be slow to ensure that the material stays uniform within this tubular potential. Again, adequate stretch of the lip is critical because a firm surface improves the volume uniformity of flow of the material, which can be hampered by the high viscosity of the agent. The finger can be kept at the G-K point to ensure flow within the channel.

Flow out of or flow above the channel can create an elevated lump, while flow below the channel is also to be avoided. As a point of resistance is met where the material will not flow, the continuation of the injection is moved to the next point. This technique, which was developed by the primary author, is referred to as the Klein anterior flow technique or serial puncture 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 (the Klein space). This will lift the lip and decrease the labio-mandibular groove. One may wonder how this elevates the corner of the mouth. Theoretically, this is accomplished because the material flows around the modeolus and securely elevates the corner of the upper and lower lip. The upper lip is injected in a similar manner, paying particular attention to retaining the shape of the cupid’s bow. Again, care must be taken to keep the material in the proper channel avoiding a lump above the lip. Once this is complete, supportive buttresses from the jaw to the lip are injected in a sequential manner to support the lips and re-establish the vertical height, which has been lost as previously noted to bone resorption and any dental changes that may have occurred (Fig. 72.9). While there are other techniques for lip augmentation, it the belief of the authors (and the literature supports this) that this technique provides for the fewest possible adverse events. It is our hope that this framework will provide the basis for lip augmentation.

Fig. 72.9 Supportive buttresses from the jaw to the lip are injected in a sequential manner to support the lips and re-establish the vertical height.

Postoperative care

Lip augmentation using injectable fillers is a minimally invasive procedure requiring little to no down time. Typically during the procedure the application of ice is initiated and immediately post-procedure continued intermittent ice application is encouraged for 1–2 hours. Some patients report very slight discomfort post-procedure, while others report no discomfort, so pharmacologic pain management is unnecessary. We typically encourage patients to return to normal activities immediately post-procedure. We have found that deliberate, slow, gentle injection provides for the optimal post-procedure experience.

Complications

Complications are rare following lip augmentation using temporary injectable fillers. We advocate only the use of temporary filling agents in the lips and while there have been many reports of significant complications in the literature following lip augmentation with permanent fillers, it is important to note that no filling agent to date has received FDA approval for use in the lips. While it is naïve to expect all physicians will heed the warning of using permanent agents in the lips, and off-label use is commonplace, we strongly discourage the use of permanent filling agents in the lips. When using temporary agents as described in this chapter, we rarely see complications. The most frequent complication is the formation of lumps which can occur with excessive filler placement. The majority of lumps which present immediately post-injection will resolve within a matter of days; however, the placement of a small amount of hyaluronidase works superbly in dissolving lumps caused by excessive material placement when using HAs. On rare occasions, we see angioedema in the lips often associated with the use of certain antihypertensive medications. When encountered, this typically resolves with the use of steroids and antihistamine preparations. Less frequently, tissue necrosis can occur following injection. Again, this is most often due to forceful and rapid injection and/or excessive material placement. The lips are heavily vascular and when injecting too forcefully or rapidly, or by excessive placement of filler material, this can easily put pressure on the underlying vascular structures which may cause vascular occlusion and in turn tissue necrosis. When tissue necrosis occurs, you will often see blanching of the tissue immediately. We have used a small amount of hyaluronidase to remove any excess filler material in cases of hyaluronic acid fillers and have found that a liquid silicone barrier dressing works well if any open skin defect is present. Generally, small necrotic areas will resolve with the passage of time. Granulomas have also occurred and again, aggressive injection technique plays a role in granuloma formation. Granuloma formation is much more common with permanent filler placement and is typically a foreign body reaction. Treatment with intralesional steroids are occasionally successful; however, particularly in cases of foreign body granuloma, surgical excision may be necessary.