K.R. Beer, MD
Division of Dermatology, School of Medicine, Duke University, Durham, NC, USA Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, FL, USA Palm Beach Esthetic Center, West Palm Beach, FL, USA
As the range of soft tissue augmentation products proliferates, most will be used (with varying degrees of success) to shape and augment the lip. The range of outcomes for this indication depends on the skill of the injector, the anatomy of the patient and the intrinsic properties of the product. Permutations of these interacting factors are infinite and it is the range of combinations that is responsible for the complexity (and fascination) of lip rejuvenation with injectable products. Based on personal experience, the perfect lip is the one that “wows” the patient and makes them happy with the procedure. Individualizing the injection is of paramount importance and should take priority over a formulaic approach that defines each lip injection as identical. This review will discuss some of the factors that should be considered prior to injecting a lip with soft tissue augmentation products.
Lip rejuvenation, Injectables
The most important aspects of the lip rejuvenation procedure are an understanding of the patient’s goals and an appreciation of her anatomy as it relates to these goals. Prior to any decision regarding which filler may be appropriate, it is worth discussing what the goals are. Providing a mirror and allowing the patient to talk about what she would like to see when she looks in the mirror will facilitate a better understanding of what will be perceived as a successful procedure for that individual. As with any cosmetic procedure, it is important to document the pre-treatment state with photographs and to capture any limitations (such as a constraint on the amount of material used) imposed during the consultation. Initial discussions must also include the range of products available for lip augmentation and the relative risks and benefits of the ones suitable for a particular patient.
- When assessing the lips, I divide patients into three basic categories:
- Group 1 – those that have good shape and definition but who desire augmentation of certain features of their lips
- Group 2 – those that have atrophic lips requiring augmentation
- Group 3 – those that have loss of lip definition and/ or perioral rhytids.
Although each of these categories has a fundamentally different approach, it is not possible to entirely isolate patients into any one category. Consequently, use of these concepts is intended only as a guideline in formulating an approach to treatment. There are other approaches to injecting the lips1,2 and the reader is encouraged to review several articles in order to decide what aspects of each to integrate.
Injections into the lip are painful and prior to injecting the lips with any product, most patients will benefit from anesthesia. The use of dental topical anesthetic and gingival “miniblocks” (small injections of anesthesia made into the gingival sulcus)3 will enable the physician to inject without having to rush and provide a more positive patient experience. One other technique that is helpful for obtaining anesthesia of the lip is to utilize a device known as “The Wand™” (Compudent, Inc.) that delivers a gradual, measured dose of anesthetic. For patients who prefer not to have injectable anesthesia, topical alternatives may be helpful.
Patients with good lip shape (Figure 1a) that want lip enhancement through augmentation (Figure 1b) are technically the most challenging because they already exhibit a nice appearance prior to treatment. These patients tend to be women between 20-45 years of age with a clear idea of their desired outcome; some will bring pictures of what they want to the consultation. For these women, the first consideration from a physical perspective is the choice of filler. Hyaluronic acid fillers are the most versatile products for this indication, e.g., Restylane® (Q-Med), Perlane® (Q-Med), and Juvederm™ (Inamed), although collagen-based fillers such as Evolence™ (ColBar LifeScience), CosmoPlast® (Inamed) and CosmoDerm® (Inamed) may also be utilized. The dermal filler that is selected depends on the patient’s financial constraints, the experience of the injector, and the desired duration of the correction. In general, Perlane® and Restylane® are thicker materials that can add significant volume and structure while Juvederm™ is smoother and less viscous, thus having the ability to flow more consistently. It is important to understand and experience how each product interacts with the lips during injections for different indications and to develop a palette of products depending on the outcome sought.
In order to provide an esthetically pleasing lip augmentation, many physicians begin by injecting into the “wet-dry” junction (the border of the mucous membrane and epithelial layers). This is easily identified in most people as the area where the Fordyce glands end. Eversion of the lip, followed by gentle, gradual injections into this area will inflate the lip. A serial puncture and linear threading technique may be used. Depending on the person’s anatomy and the material, one may notice that filler extravasates into small blebs during the injection process. If this occurs, massage or guidance by the nondominant hand can usually move the product into the correct location. Once the desired augmentation has been approximately achieved, it is important to ensure that the configuration is also as intended. By orienting the needle in a superior manner, injections of small amounts of material into the Cupid’s bow of the lip will help to provide perfect definition of this essential aspect. As with injections of the marionette lines, it is helpful to inject the lateral aspects of the lower lip and to ensure their orientation in a horizontal manner. For the upper lip, small amounts of material are injected laterally to avoid a lip that fades away on the sides.
Once the lips are approximately the correct size and shape, small injections are utilized to finesse the outcome. In general, injections into the rolled border of the lips will provide an added dimension of definition. These adjustments are performed by inserting the needle into the rolled border and gently injecting material. For patients who have not had injections before, there is usually a potential space that can be cannulated. Frequently, a very small amount of pressure can be used to inject material that will flow across the lip for distances of up to half of the mouth. This type of injection will serve to highlight the lip as a distinct anatomic region and tends to produce a highly desired esthetic result.
The second category of patients, those with atrophic lips (Figure 2), may have small lips due to aging or genetics. These individuals tend to need some additional counseling during the initial consultation so that they understand the limitations of the proposed procedure. Material selection for these patients requires a similar analysis as the former category of patients (Group 1). In general, the hyalurons or collagen-based fillers are the most suitable choices. Injections for treatment of lip atrophy begin with injections into the wet-dry junction, adding the desired amount of volume to both the upper and lower lips. Additional injections are then made into the Cupid’s bow and the two medial protuberances of the lower lip, which will provide visual focal points for observers and photography.
In general, atrophic lips tend not to have the anatomic distinctions and inflection points seen in patients presenting for augmentation of normal sized lips. This means that injections into the body of the lip, which provide volume and structure to a previously anatomically bland feature of the face, will inevitably be perceived as an improvement. To maximize the extent of this improvement, it is important to observe each patient and to highlight certain aspects. Injections to evert the lips can produce an appearance of fuller lips, and these may be achieved by injecting the lips as they are rolled outwards and by placing the needle at the wet-dry junction oriented towards the rolled borders.
Lip rejuvenation primarily for the treatment of perioral rhytids (Figure 3) is a procedure commonly requested by patients who are typically older than 50 years of age, and who smoke, or are former smokers. This treatment requires more attention to material selection than other procedures. For patients with thin skin and etched-in perioral rhytids, the use of a thin product, such as Restylane® Fine Lines, Evolence® Breeze, Cosmoderm® II, or Juvederm™ 24 is appropriate.
Whereas other injections of the lip may be accomplished with 30G needles, perioral rhytid rejuvenation may be best accomplished with a 32G needle in some patients. In addition to the use of fillers for rejuvenation, this indication frequently requires adjunctive treatments. These may include traditional resurfacing with a CO2 laser, fractional resurfacing, or the use of botulinum toxins (BOTOX®, Allergan). Used judiciously, this latter addition may produce the most synergistic results in this area. When injecting botulinum toxins, it is helpful to begin by injecting small amounts of material injected into the orbicularis oris in strategic locations, each of which is identified by the prominence of the dynamic component of the perioral rhtyids. When using BOTOX®, approximately 2 units are injected into each of four locations.4 Other toxins may also be utilized for this indication.
Two types of injections are useful when treating perioral rhytids: those that fill the lines and those that define the lip. In order to fill each line, the needle should be inserted at the junction of the rhytid and the lip, oriented along the course of the rhytid. Using the thumb and second finger of the non-dominant hand to guide the product into place, gentle pressure should be used to inject the product. Following the injection, firm pressure should be applied to smooth out the filler and ensure that it fills but does not overcorrect the rhytid. One common mistake that occurs when injecting perioral rhytids for lip rejuvenation is to overcorrect thereby trading a series of bumps for the rhytids.
Once the individual rhytids are filled, attention should shift to the rolled border of the lips. Since the chief complaint of most female patients with perioral rhytids is lipstick “bleeding” into the lines around their mouth, providing a border for the vermillion will help to confine lipstick to the vermillion and limit its extension into the adjacent areas. To provide this junction, the needle should be inserted into the rolled border and a small amount of material injected. Careful observation of the injection site is essential in order to prevent lip augmentation when definition is the goal. In most patients with perioral rhytids, there is a degeneration of the collagen and elastic fibers around the mouth that facilitates the injection into the border and a small amount of material can flow a long distance from the point of insertion.
Injecting the lips with soft tissue augmentation products can be technically challenging, but can also be extremely rewarding for both the patient and physician. A thorough understanding of the anatomy of the areas involved, as well as of the physical properties of the products utilized is critical if one is to obtain consistently good outcomes. Injecting into the body of the lip will tend to produce volume, while injections into the rolled border will tend to produce definition. Despite a proliferation of the number of products available, the fundamental principles of lip augmentation have not changed. Understanding the patient’s goals, observing their anatomy, and individualizing each treatment are essential to successful outcomes when augmenting lips with injectables.
- 1. Klein A. In search of the perfect lip: 2005. Dermatol Surg 31(11 Pt 2):1599-1603 (2005 Nov).
- 2. Carruthers J, Narukar VA. Management of the lips and mouth corners. In: Carruthers J, Carruthers A, editors. Procedures in cosmetic dermatology series: soft tissue augmentation. Philadelphia: Saunders (2005).
- 3. Rohrer T. Soft tissue augmentation. Presented at: the American Society for Dermatologic Surgery Annual Meeting, San Diego, California (2004).
- 4. Semchyshyn N, Sengelmann R. Botulinum toxin A treatment of perioral rhytids. Dermatol Surg 29(5):490-5 (2003 May).