Lovely Lips

Lovely Lips

Lip augmentation is one of the few aesthetic concerns that bridges all age groups. Young patients often come to practices seeking larger, more lustrous lips; while aging patients are dismayed at loss of definition and the appearance of perioral lines and wrinkles. In order to create the aesthetic outcomes these patients seek, one must gain an understanding of their desired outcomes and step back to examine the entire lower face. “If you are only treating the lip proper, you will not deliver the best result because the lips form part of the environment of the perioral area,” says Vince Bertucci MD, FRCPC, medical director of Bertucci MedSpa in Woodbridge, Ontario, Canada.

Adding Volume

The first step in approaching lip enhancement involves understanding the patient’s goals and pre-existing facial anatomy. “When a patient comes in for a consultation, we always do a full-face assessment,” says Dr. Bertucci. “While they may ask for treatment of the perioral region alone, it’s important that we take into consideration how the different parts of the face fit together. I systematically go from top to bottom to assess the components of the face and the role that they play in perioral rejuvenation and enhancement.”

Because patients seeking perioral treatments vary widely in age, they may require anything from a subtle enhancement to architectural change, says Dr. Bertucci. “If you are treating a woman in her 20s who has never had large lips, then structure and support are important. I would use a product such as Restylane, Emervel Lips, Juvéderm Volift or Juvéderm Ultra,” he says. “At the other extreme of the spectrum we might consider a 50-year-old woman who has always had fuller lips. In that case, I use a refining and defining product such as Juvéderm Volbella or Restylane Silk so as to rehydrate the lip and provide subtle volume.”

Different age groups also have different goals. Younger patients tend to want fuller lips, while older patients are concerned about lip lines. For patients seeking volume, Michelle Yagoda, MD, a facial plastic surgeon in New York City, typically injects Restylane along the vermilion border to add volume, but avoids injecting directly into the pink part of the lip. “The lip is a muscle,” she says. “It is active when kissing, whistling, drinking and talking, and the filler can bunch up.”

Injecting botulinum toxin along the vermilion border can help to create a fuller-looking upper lip without the use of fillers. “This will evert the lip and create a more voluptuous, youthful appearance, because when the orbicularis oris muscle is active it pulls the lip down,” says Tracey Hotta, RN, a plastic surgery nurse and owner of TH Medical Aesthetics in Thornhill, Ontario, Canada, who notes that some patients opt for only toxin injections to enhance the appearance of their lips.

For older patients, Dr. Yagoda uses Restylane Silk to fill perioral lines and may also recommend Restylane Lyft to replace lost volume in the face, which can help improve the appearance of the entire perioral area.

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Dr. Bertucci also looks at facial volume loss when determining the best treatment for perioral lines and wrinkles. “If there is loss of volume and lack of support, then I will add volume in judicious amounts to enhance support in the area,” he says. Once volume has been restored, or if there is not a significant loss in volume, he uses either a linear threading or micro-droplet technique to fill the individual lines.

While fillers may be sufficient for mild perioral lines, they will not address severe wrinkles. For older patients with more pronounced lip lines and wrinkles, Rod Rohrich, MD, professor of plastic surgery at UT Southwestern Medical Center in Dallas, combines fillers with neuromodulators and laser skin resurfacing to relax wrinkles, stimulate collagen production and improve skin quality.

Beyond the Lips

For some patients, lip augmentation will not address their primary perioral concerns, which may include pronounced marionette lines and a frowning appearance, where the edges of the lips point downward.

To treat marionette lines, Dr. Bertucci injects filler using a cannula to “create soft volume and reduce shadows,” he says. Around the oral commissure he prefers a needle syringe and uses a perpendicular injection and towering technique to “give optimal lift and reduce the concavity so frequently seen here,” he says. “Some fillers that can be used in the marionette region and oral commissure include Juvéderm Ultra and Ultra Plus, Restylane and Belotero Balance.” Dr. Yagoda injects filler in an inverted triangle right below the commissure to lift the frown.

Another area where fillers can make a strong impact is the prejowl sulcus. “I use a linear threading technique and sometimes cross-hatching to fill in the prejowl sulcus,” says Patrick Flaharty, MD, medical director of Azul Cosmetic Surgery and Medical Spa in Naples, Florida. “Filling in the prejowl sulcus is important because it improves the jawline, makes the jowl look better, and lifts the corners of the mouth, which takes away the frown. It makes a huge difference in a person’s appearance with just one area of filler. The prejowl sulcus is best treated with a firmer form of hyaluronic acid (HA) filler, like Juvéderm Voluma or Restylane Lyft.”

The longevity of fillers in the perioral region depends on a combination of factors. “When you inject a filler, it’s expanding the tissue,” says Dr. Flaharty. “The patient’s age and skin tone are key. Younger people have good elasticity, so there is an even, predictable result.” Habits such as smoking, drinking and pursing one’s lips can break down the filler more quickly.

Dermal fat grafts offer better longevity than off-the-shelf fillers, but there are drawbacks. Patients must undergo surgery to remove the fat for the grafts; therefore many physicians, including Dr. Yagoda, reserve fat grafting to the lips for patients already undergoing surgery, such as a facelift or brow lift.

“Fat augmentation is nice because it is living tissue, so there is more longevity,” says Dr. Flaharty. “But with fillers you can fine-tune the result.”

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Avoiding Complications

Although severe complications are rare, filler injections have been associated with skin necrosis and vascular occlusion. The following tips can help prevent complications.
To avoid vascular occlusion, “it’s important to avoid injecting very deeply in the lip,” says Dr. Bertucci. “This minimizes the risk of hitting the labial artery.”

A refresher course in anatomy to re-familiarize yourself with facial vasculature can be useful even for experienced injectors, says Hotta. In addition, she advises injectors using HA fillers to keep hyaluronidase on hand and inject it immediately at the first sign of an adverse event to dissolve the product.

Knowing whether the patient has had previous injections is also essential. “Every time a filler is injected there is a small trauma,” says Dr. Yagoda. “If fillers have been injected in the perioral region in the past, the patient will have scar tissue. I call this ‘scaffolding.’ When the filler dissolves, the scaffolding remains.” The amount of fibrosis varies from one patient to the next, altering the anatomy and influencing the amount of filler needed in subsequent treatments.

To help patients achieve their desired outcome, keep an eye on the natural aesthetics of the area. “If you destroy the normal anatomic borders, like the Cupid’s bow, it’s not attractive in a younger or older patient,” says Dr. Flaharty.

Also, take care to not overfill the lips. “Be conservative and don’t overdo it,” says Dr. Rohrich. “You can always add filler, but you can’t take it out.”

To reduce pain during treatment, Hotta applies a topical anesthetic cream such as lidocaine or Betacaine. While some fillers come with lidocaine in the syringe, using a local anesthetic can minimize discomfort even before the first injection. A regional block may be needed if the patient is more sensitive.

Post-treatment bruising is not uncommon, but there are ways to reduce it. “If someone is prone to bruising, I use a cannula,” says Dr. Flaharty. “It takes longer to work it into the right position to get the filler where you need it. But there is only one small puncture on each side.”

Minor complications, such as post-treatment cold sores, can also occur in some patients. Hotta starts patients with a history of cold sores on an antiviral prior to treatment.

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Patient Satisfaction

Making sure you understand the patient’s unique concerns is key to ensuring patient satisfaction. “It matters what bothers the patient,” says Dr. Yagoda, who notes that there is a significant difference between helping patients achieve a more youthful look and filling every line or wrinkle.

“A patient in her early 70s may not be looking for ‘perfect,’” she says. “Older patients may have thinner, more fragile skin, and it can be challenging to correct every concern in a natural way. But that’s OK, because they aren’t looking for perfect. Physicians can avoid putting themselves in a predicament by listening to their patients’ concerns.”

To ensure that she and her patients are on the same page, Hotta takes pictures from the front and side of the face. “It’s important to look at the patient from all angles,” she says. “They can’t see themselves how others see them. The images help me explain my treatment recommendations.”

If a patient has multiple perioral concerns, it’s crucial to set priorities. “As experts in facial assessment and treatment, it’s critical that we provide guidance to our patients, and this includes informing them of which treatments are most likely to deliver the best aesthetic outcome for their budget,” says Dr. Bertucci.

As patients become more educated on aesthetic treatments, providers must not assume that they are necessarily coming to your office with good information. You must educate patients on the available treatments and risks, and this includes sharing your expertise on creating natural-looking aesthetic outcomes. “With lip augmentation, people sometimes think, ‘A little bit is good, but more is better,’” says Dr. Flaharty. “You have to counsel patients. You want to help people look their best while looking natural.”

Stephanie Kramer is a freelance writer who specializes in healthcare and dermatologic topics.

Photo copyright Getty Images.

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