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Six Steps to the "Perfect" Lip

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Abstract and Figures

Full lips have always been associated with youth and beauty. Because of this, lip enhancement is one of the most frequently requested procedures in a cosmetic practice. For novice injectors, we recommend hyaluronic acid (HA) as the filler of choice. There is no skin test required; it is an easily obtainable, "off-the-shelf" product that is natural feeling when skillfully implanted in the soft tissues. Hyaluronic acid is easily reversible with hyaluronidase and, therefore, has an excellent safety profile. While Restylane® is the only FDA-approved HA filler with a specific indication for lip augmentation, one can use the following HA products off-label: Juvéderm® Ultra, Juvéderm Ultra Plus, Juvéderm Ultra XC, Juvéderm Ultra PLUS XC, Restylane-L®, Perlane®, Perlane-L®, and Belotero®. We present our six steps to achieve aesthetically pleasing augmented lips. While there is no single prescription for a "perfect" lip, nor a "one size fits all" approach for lip augmentation, these 6 steps can be used as a basic template for achieving a natural look. For more comprehensive, global perioral rejuvenation, our 6-step technique can be combined with the injection of neuromodulating agents and fractional laser skin resurfacing during the same treatment session.
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S  1081 
C ©  ORIGINAL ARTICLES 
SPECIAL TOPIC
Six Steps to the “Perfect” Lip
Deborah S. Sarno MD FAAD FACPa and Robert H. Gotkin MD FACSb,c
aRonald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY
b
c
Full lips have always been associated with youth and beauty. Because of this, lip enhancement is one of the most frequently re-
quested procedures in a cosmetic practice. For novice injectors, we recommend hyaluronic acid (HA) as the ller of choice. There is no
skin test required; it is an easily obtainable, “off-the-shelf” product that is natural feeling when skillfully implanted in the soft tissues.
Hyaluronic acid is easily reversible with hyaluronidase and, therefore, has an excellent safety prole. While Restylane® is the only
FDA-approved HA ller with a specic indication for lip augmentation, one can use the following HA products off-label: Juvéderm®
Ultra, Juvéderm Ultra Plus, Juvéderm Ultra XC, Juvéderm Ultra PLUS XC, Restylane-L®, Perlane®, Perlane-L®, and Belotero®. We
present our six steps to achieve aesthetically pleasing augmented lips. While there is no single prescription for a “perfect” lip, nor a
one size ts all” approach for lip augmentation, these 6 steps can be used as a basic template for achieving a natural look. For more
comprehensive, global perioral rejuvenation, our 6-step technique can be combined with the injection of neuromodulating agents and
fractional laser skin resurfacing during the same treatment session. .
J Drugs Dermatol. 2012;11(9):1081-1088.
ABSTRACT
INTRODUCTION
In virtually all women, since the beginning of recorded his-
tory, full lips have been associated with youth, beauty, and
voluptuousness. Robust, pouty lips are considered to be
sexually attractive by both men and women. According to mar-
ket research rm NPD Group, US sales of lip color reached $290
million for 2011, an increase of 13% from 2010, while sales of
lip-gloss were approximately $182 million.1 Even in a period of
economic downturn, women continue to buy products to adorn
their lips. The “lipstick index,” a term coined by Leonard Lauder,
Chairman Emeritus of Estee Lauder, Inc., in 2001, describes the
phenomenon of increased lipstick sales during an economic
downturn.2 Women would rather spend on little luxuries when
purse strings are tighter and the economy is uncertain. Lipstick is
that one affordable luxury that makes women feel pampered and
more condent. Women with beautiful lips feel more beautiful
and are likely to be more optimistic.
In youthful Caucasian lips, the ideal vertical height ratio of the
upper lip to the lower lip is 1:1.6 (Figure 1).3 The fundamental
proportions of the lips change as one ages, however, with length-
ening of the cutaneous portion of the upper lip and volume loss
and thinning of the upper lip vermilion (Figure 2). Genetics, in-
trinsic aging, sun exposure, smoking, and repetitive pursing of
the orbicularis oris muscle produce angular, radial, and vertical
“lipstick bleed lines” (Figure 3). Gravity, osteoporosis, dental
changes, maxillomandibular bony resorption, and further soft
tissue volume loss at the oral commissures cause the commis-
sures to turn downward in a perpetual frown (Figure 4). Midfacial
aging with ligamentous laxity in the cheeks causes the formation
of jowls and vertical geniomandibular (“marionette”) lines that
extend downward from the oral commissures to the mandible.
In addition to this hard and soft tissue volume loss, the lip mar-
gin itself may become blunted with attening of the philtrum
columns and loss of projection of the Cupid’s bow (Figure 5).4-6
Aging also leads to pallor of the vermilion that results in the loss
of sharp vermilion-cutaneous junction demarcation.
While aging Caucasian men and women have similar hard
and soft tissue volume loss with thinning of the vermilion and
cutaneous portions of the lips, men generally do not develop
rhytides of the upper and lower lips. This is because men have
thicker skin with more subcutaneous fat surrounding terminal
hair follicles (as opposed to the ne vellus hairs in women).
Certain ethnic groups, such as Blacks, genetically have greater
volume in their lips. The increased melanin in their skin is pro-
tective throughout their lives. Consequently, their skin is less
prone to solar elastosis. They rarely develop radial rhytides in
the lips and their vermilion tends to retain its volume through-
out their lives.
The volume and, therefore, the vertical height of the vermilion
of the upper and lower lips should t within the framework of
Phi—the Divine Proportion or the Golden Ratio—1:1.618. This
begins with DaVinci’s classic proportions of the lips relative to
the rest of the face. These basic artistic principles from hun-
dreds of years ago still apply today. One can summarize these
proportions as follows:
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D. S. Sarno, R. H. Gotkin
FIGURE 1. In youthful Caucasian lips, the ideal vertical height ratio of
the upper lip to the lower lip is 1:1.6.
FIGURE 2. Lengthening of the cutaneous upper lip, volume loss, and
thinning of the vermilion of both upper and lower lips occurs with age.
FIGURE 3. Angular, radial, and vertical rhytides of the lips are often the
result of both intrinsic and extrinsic aging: genetics, sun exposure,
and smoking. Note the solar elastosis grossly evident in b).
a)
b)
FIGURE 4. Gravity, maxillomandibular bony resorption, and accom-
panying soft tissue volume loss cause the oral commissures to turn
downward in a perpetual frown.
a)
b)
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
D. S. Sarno, R. H. Gotkin
1. The face is divided vertically into thirds: upper third, mid-
dle third and lower third of the face—all equal in vertical
height (Figure 6).
2. The lower third of the face is also divided vertically into
thirds: upper third corresponding to the upper lip and the
lower two thirds corresponding to the lower lip and chin.
In youth, with more correct vertical proportions, the upper/
maxillary teeth show during speech. With aging, it is very
common to observe a lengthening of the cutaneous portion
of the upper lip while the vermilion becomes thinner and
almost completely effaced (Figure 7). It is common to no
longer be able to observe the maxillary teeth during speech
in an older individual. If the upper lip has lengthened so
much, no degree of augmentation will correct this and the
patient should be considered for a lip shortening procedure.
3. On the lateral view, if a straight line is drawn from the sub-
nasion to the pogonion, the upper lip should project 3.5 mm
anterior to the line and the lower lip should project 2.2 mm;
the upper lip should project slightly greater than the lower
lip—again about 1.6:1 (Figure 8). An exaggeration of these
proportions or the wrong ratio can lead to a “duck-like” or
“trout-pout” appearance. Under no circumstances should
the lips enter the room before the individual (Figure 9)!
4. On frontal view, the ideal upper lip: lower lip ratio is 1:1.6. The
vertical height of the upper lip should be less than that of the
lower lip. Women will often present requesting augmenta-
tion of the upper lip alone, without considering the balance
between the upper and lower lips. It is incumbent upon the
physician to educate the patient regarding this ideal ratio.
“Sausage” or “duck” lips (Figure 10) do not merely occur
FIGURE 5. The upper lip margin becomes blunted with flattening of the
philtrum columns and loss of projection of Cupid’s bow.
FIGURE 6. Used with permission: Perkins and Sandel, Anatomic
considerations, analysis, and the aging process of the perioral region.
(Facial Plast Surg Clin N Am. 2007;15:403-407.)
FIGURE 7. Lengthening of the cutaneous upper lip with effacement of
the vermilion is readily evident.
FIGURE 8. Used with permission: Perkins and Sandel, Anatomic
considerations, analysis, and the aging process of the perioral region.
(Facial Plast Surg Clin N Am. 2007;15:403-407.)
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D. S. Sarno, R. H. Gotkin
FIGURE 9. Exaggeration of the correct anterior projection propor-
tions of the upper lip and lower lip relative to underlying craniofacial
landmarks can lead to a “duck-like” appearance.
FIGURE 10. “Sausage” or “duck” lips do not merely occur from
overcorrection, but also from a poor understanding of the delicate
features of lip anatomy.
a)
b)
from overcorrection, but also from a poor understanding of
the delicate contours of normal lip anatomy (Figure 11). Mil-
lard, in the rst of his three volume Cleft Craft,7 described
in great detail the normal surface anatomy of the upper lip.
The subtleties of this surface anatomy must be understood
by the physician attempting to artistically augment the lips.
The objective in treating the upper lip is to artistically create a
form that harmonizes with the patient’s unique facial features
and takes into account the age and ethnic background of the
patient. The goal in treating the lower lip is to create bulk and
greater prominence and artistic projection of the vermilion. The
physician must establish appropriate guidelines and patient ex-
pectations for augmentation relative to normal lip proportions
in order to avoid a bizarre, cartoon-like appearance.
Any physician performing lip augmentation should recognize
that temporary llers can cause permanent stimulatory effects in
tissues.8 After 2 or 3 sessions of lip augmentation, full correction
may be obtained and persist indenitely. Patients may return
for additional ller merely because a certain amount of time has
elapsed since their last injection, but the physician must evaluate
the proportions of the lips to truly determine if additional ller
is warranted. It is helpful to have a hand mirror for the patient
to observe her lip proportions as the doctor seeks to determine
whether more ller is needed. It is also benecial to show the
patient her lips from the lateral view; digital photography is ex-
tremely useful in this regard.
While there is no single prescription for a “perfect” lip, nor a
one size ts all” approach for lip augmentation, there are some
basic tenets to follow that will help guide the novice injector in
creating attractive, artistic, and aesthetically pleasing results: 1)
Keep in mind the areas that have a natural prominence or protu-
berance (Figure 12): there is a tubercle just lateral to the midline
FIGURE 11. The medial subunit of the upper lip extends from the midline
to the philtrum column; the lateral subunit extends from the philtrum
column to the oral commissure. Cupid’s bow is that central area of the
upper lip vermilion and vermilion-cutaneous junction that traverses
the philtrum columns and dimple. It has the central tubercle flanked
by subtle indentations. From the height of each arch of the bow, the
philtrum columns extend upward to the base of the columella.
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D. S. Sarno, R. H. Gotkin
on each side of the lower lip, a tubercle laterally on each side
of the upper lip, and one tubercle in the midline of the upper
lip. Maintaining these landmarks will help give the often-coveted
“pouty” look. 2) Listen to what the patient wants and make sure
it is reasonable; unrealistic expectations may be a sign of body
dysmorphic disorder. Act ethically and do not be afraid to refuse
treatment. 3) Lips do not swell symmetrically. Treat each side of
the lip in each step before going on to the next step. Keep track
of exactly how much ller is implanted at each location, so you
can inject the same amount to each side. If there is pre-existing
asymmetry, you will have to deviate from this rule in order to
correct for the asymmetry. 4) In most patients, approximately 1
cc to 1.5 cc of HA ller will be adequate to augment the lips and
achieve aesthetically pleasing results. Do not feel compelled to
use the entire syringe if it is not warranted.
MATERIALS AND METHODS
Pre-Treatment Considerations
1. Have the patient sign informed consent.
2. Review the expected downtime with the patient prior
to treatment. Warn the patient that even with the best
technique, there likely will be signicant edema and ec-
chymosis. Point out that the lips are highly vascular; the
trauma from the manipulation of the needles alone causes
swelling and bruising. Furthermore, HAs are hydrophilic
and, therefore, enhance this swelling. The edema may be
asymmetric and the immediate post-treatment results are
not the results she will have in one week.
3. Determine which HA ller will be used for augmentation.9
In 2011, Restylane received FDA approval for lip augmenta-
tion;10 the other HA llers can be used “off-label.
4. Administer antiviral medication in patients with a known
history of HSV I.
5. Take frontal and lateral preoperative photos.
6. Make the patient aware of any pre-existing asymmetries
and explain that you will try to correct for them during
your injections.
7. Have hyaluronidase and nitrol paste available in case of in-
advertent arterial injection or external arterial compression.
8. Be aware of a patient’s medications that may predispose to
ecchymosis or hematoma (aspirin, warfarin, NSAIDs, ste-
roids, Vitamin E, and herbal and other OTC supplements).
In the ideal setting, have the patient stop these medica-
tions prior to treatment. You may want to give prophylactic
arnica montana to minimize bruising.
9. Use a 0.5” 30-gauge needle for implantation of the ller.
Anesthesia
Various topical anesthetics work well for lip augmentation.
They may include combinations of lidocaine, prilocaine, tetra-
caine, and phenylephrine.
Our custom and practice is to apply topical anesthetic ap-
proximately 30 minutes prior to treatment. Infraorbital and
mental nerve blocks, either intraoral or transcutaneous, can
be used as well.
Six Steps for the “Perfect” Lip
In previous years, when the only lling agent available was bo-
vine collagen, the most commonly employed technique for lip
augmentation was injection into the “white roll” of the vermil-
ion-cutaneous junction. The injection of product started at one
oral commissure and continued anterograde to the other. This
created the classic “sausage” or “duck” lip deformity.
Our 6-step technique involves administering approximately 12
injections—about 0.1 cc HA per injection—placed in strategic lo-
cations in the upper and lower lips. Note that some areas of the
lips may not be treated at all; some areas may require slightly
more or less than 0.1 cc. In our opinion, the best position for
the patient is supine with the neck slightly hyperextended. Over
time, even with the introduction of new llers, we have found
this formula to be a template for success in creating aestheti-
cally pleasing lips.
Step 1: Create Philtrum Columns
Sculpted philtrum columns are in style today. As we age, these
well-dened longitudinal pillars are lost, leading to a attened,
ill-dened, unattractive upper lip. If the patient still has discern-
ible philtrum columns, the object is to further enhance them. If
the philtrum columns have been completely effaced, it is im-
perative to re-create them. This is accomplished by supercial
FIGURE 12. The tubercles of the upper and lower lips are natural ar-
eas of prominence that should be enhanced during lip augmentation.
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D. S. Sarno, R. H. Gotkin
Step 3: Define The Vermilion-Cutaneous Junction
in the Medial Aspect of the Lateral Subunit of the
Upper Lip
The upper lip is divided transversely into medial and lateral
subunits.12 The medial subunit of the upper lip extends from
the midline to the philtrum column; the lateral subunit extends
from the philtrum column to the oral commissure and nasolabi-
al fold. Inject ~0.1 cc HA laterally from the base of the philtrum
column, along the vermilion-cutaneous junction, about halfway
to the oral commissure. It is important not to augment the ver-
milion-cutaneous junction along the entire lateral subunit, but
only in its medial aspect (Figure 15).
Do not augment the vermilion-cutaneous junction in the medial
subunit as it will obliterate Cupids bow and create the “sausage”
or “duck” lip.
Tip: Pinch the vermilion-cutaneous junction to reduce discom-
fort and to prevent product from splaying from its desired
area of placement. Inject slowly, do not over-ll and watch for
blanching of the lip. This helps to prevent direct injection or ex-
ternal compression of the labial artery, either of which can lead
to ischemia or necrosis.
Step 4: Create Lower Lip “Pillows” or Tubercles on
Each Side of the Midline
Ask the patient to evert the lower lip. Deposit approximately
~0.1 cc of ller as a depot injection into the orbicularis oris
muscle at the vermilion-mucosal junction on each side of the
midline. The depot injection should be about one third of the
distance from the midline to the oral commissure. Gently mas-
sage to prevent supercial lumpiness (Figure 16).
Step 5: Support or Bolster the Oral Commissures
Place ~0.1 cc ller in the most lateral aspect of the cutaneous lower
lip so as to provide upward support to the commissures (Figure 17).
Tip: Injectable neuromodulating agents (botulinum toxin A)
placed into the depressor anguli oris muscles can be used as
vertical injection of ller into each philtrum column. It is im-
portant to realize that the philtrum columns are not parallel to
each other, but rather they form an inverted “V” that narrows
as it approaches the nostril sills and columella of the nose.11
Approximately 0.1 cc of HA ller should be injected into each
philtrum column (Figure 13).
Tip: Pinching the skin with your non-dominant hand during retro-
grade threading of the philtrum columns diminishes discomfort
and keeps the ller in a ridge and prevents it from splaying lat-
erally. Pinching after injection helps to further mold the ller to
dene the philtrum columns. Upon completion of the injections
into the philtrum columns, one notes immediate denition of the
philtrum dimple and enhancement of the Cupid’s bow.
Step 2: Create Cupid’s Bow
The pouty, Cupid’s bow appearance of the central portion of the
upper lip is considered sexy, desirable, and very much in fash-
ion today. Place the tip of the needle at the base of the philtrum
column (at the vermilion-cutaneous junction) and advance to
the vermilion-mucosal junction (“wet line”). Inject a 0.1-cc thin
thread of ller in a retrograde fashion. This thread of ller acts
as an anteroposterior strut to support the projection of the cen-
tral upper lip (Figure 14).
FIGURE 13. Create philtrum columns. FIGURE 14. Create Cupid’s bow.
FIGURE 15. Define the vermilion-cutaneous junction in the medial
aspect of the lateral subunit.
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D. S. Sarno, R. H. Gotkin
an adjunct to further elevate the commissures. This combines
structural support with chemical neuromodulation to shape the
oral commissures.
Step 6: Fill the Nasolabial Creases
Place ~0.1 cc of ller in the upper portion of the nasolabial
crease; this helps to evert the upper lip. One must be cautious
in the region of the piriform aperture so as to not inject or exter-
nally compress the angular artery (Figure 18).13, 14
Tip: Inject just medial to the nasolabial crease to prevent splaying
of the product laterally. Augmentation lateral to the nasolabial
crease only serves to deepen the appearance of the crease.
Post-Injection Care
Cool compresses and ice packs can be used to minimize swell-
ing and bruising. Patients should be advised to avoid ASA,
NSAIDs, and other medications associated with an increased
risk of bleeding. If anti-HSV I medication was prescribed, it
should be continued according to physician recommendation.
Because HAs are hydrophilic, they attract water from the sur-
rounding tissues and further augment the soft tissue volume
beyond that expected from mere implantation. The signicant
swelling of the vermilion in the immediate post-operative peri-
od may be camouaged by applying esh-toned foundation or
concealer to the entire vermilion. Lipstick can then be applied to
a smaller portion of the vermilion than usual so as to not exag-
gerate the swelling that may be present.
DISCUSSION
These six steps will help to augment and evert volume-deplet-
ed lips. For those patients that have pronounced radial “lipstick
bleed lines” in the cutaneous portion of the upper lip, addition-
al treatments may be necessary. Caution must be exercised in
treating these lines not to use a robust, high-G’ ller; the orbicu-
laris oris muscle is a sphincter muscle and its constant “milking”
action may cause clumping of robust llers. This can result in
nodules, lumpiness and migration of product. It is preferable to
“spackle” with a less viscous ller, such as Belotero. This tech-
nique requires very supercial placement of HA ller. A unique
complication resulting from supercial implantation of most HA
llers is a bluish discoloration of the skin known as the Tyndall ef-
fect.15 One advantage of using Belotero in this area is the reported
absence of the Tyndall effect when implanted supercially.16
If the radial lip lines are prominent and dynamic in nature, it
is better to inject botulinum toxin A, off-label, as an adjunct.
Botulinum toxin A injections should be administered after ller
injections are completed so as to avoid the resultant uid vol-
ume distention and distortion of the lips.
In patients with severe solar elastosis and photodamage who
desire comprehensive perioral rejuvenation with more lasting
results, fractional laser resurfacing with the CO2 or Erb:YAG laser
can be combined with injectable neuromodulating agents and
our 6-step technique using HA to create the “perfect lip.
CONCLUSION
Lip enhancement is one of the most frequently requested pro-
cedures in a cosmetic practice. We recommend hyaluronic acid
for safe, natural lip augmentation. Our 6-step technique is a
template that can be used to artistically create aesthetically
pleasing “perfect lips.
FIGURE 16. Create lower lip tubercles.
FIGURE 18. Evert the upper lip by filling the upper aspect of the
nasolabial creases.
FIGURE 17. Support the oral commissures.
1088


D. S. Sarno, R. H. Gotkin
DISCLOSURES
Dr. Sarnoff and Dr. Gotkin are both consultants for Merz Aes-
thetics. No nancial support was received for any work leading
to this publication.
REFERENCES
1. Personal communication, Karyn Schoenbart, President and COO, NPD
Group, Port Washington, NY, May, 2012.
2. Cosmetics in the downturn: Lip Reading—Do sales of lipstick really go up
in difcult times? The Economist. January 22, 2009, accessed at http://
www.economist.com/node/12995765.
3. Mandy S. Letter: Art of the Lip. Dermatol Surg. 2007;33:521-522.
4. Klein AW. The Art and Science of Injectable Hyaluronic Acids. Plast Recon-
str Surg. 2006;117:35S-37S.
5. Robertson KM, Dyer WK, Dyer, WK II. The use of llers in the aging patient.
Facial Plast Surg. 1996;12:293-301.
6. Maloney BP. Cosmetic surgery of the lips. Facial Plast Surg. 1996;12:265-278.
7. Millard, Jr. DR. Cleft Craft: The evolution of its surgery—Volume I: the uni-
lateral deformity. Boston: Little, Brown and Company; 1976.
8. Wang F, Garza LA, Kang S, Varani J, Orringer JS, Fisher GJ, Voorhees JJ.
In vivo stimulation of de novo collagen production caused by cross-linked
hyaluronic acid dermal ller injections in photodamaged human skin. Arch
Dermatol. 2007;143(2):155-163.
9. Sarnoff DS, Saini R, Gotkin RH. Comparison of lling agents for lip augmen-
tation. Aesthetic Surg J. 2008;28:556-563.
10. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/de-
viceapprovalsandclearances/recently-approveddevices/ucm276637.htm
11. Klein AW. In search of the perfect lip. Dermatol Surg. 2005; 31:1599-1603.
12. Burget GC, Menick FJ. Aesthetic restoration of one-half the upper lip. Plast
Reconstr Surg. 1986;78(5):583-593.
13. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial emboli-
zation caused by injection of hyaluronic acid (Restylane). Br J Dermatol.
2002; 146:928-929.
14. Lowe NJ. Arterial embolization caused by injection of hyaluronic acid (Re-
stylane). Br J. Dermatol. 2003;148:379.
15. Hirsch RJ, Narurkar V, Carruthers J. Management of injected hyaluronic
acid induced Tyndall effects. Lasers Med Surg. 2006;39:202-204.
16. Personal communication, Brian Pilcher, Ph.D., Vice President, Medical Af-
fairs & Clinical Education, Merz Aesthetics, February, 2012.
ADDRESS FOR CORRESPONDENCE
Deborah S. Sarnoff MD FAAD FACP
625 Park Avenue
New York, NY 10065
Phone:...…...........…….….….…...........................(212) 794-4000
Fax:...…................…….….…................................(212) 794-0231
E-mail:................…….…......…...........sarnoffandgotkin@aol.com
... Lips are considered one of the most important features of facial aesthetics due to their central position in the face and their elemental role in verbal and nonverbal interaction, being able to communicate emotion, even while the face is at rest. [1][2][3][4][5][6][7][8][9][10][11][12][13] Lip shape, contour, fullness and projection play a major part in overall composition of facial aesthetics and outward appearance and are intrinsically linked to selfperception of attractiveness, self-esteem, and social confidence. 5,6 The importance of the lip in overall facial aesthetics has an impact on positive self-image and self-confidence. ...
... [1][2][3][4][5][6][7][8][9][10][11][12][13] Lip shape, contour, fullness and projection play a major part in overall composition of facial aesthetics and outward appearance and are intrinsically linked to selfperception of attractiveness, self-esteem, and social confidence. 5,6 The importance of the lip in overall facial aesthetics has an impact on positive self-image and self-confidence. 6 In virtually all women, since the beginning of recorded history, full lips have been associated with youth and beauty 3,5,7,13 and therefore, lip enhancement is one of the most frequently requested procedures in a cosmetic practice nowadays. ...
... 5,6 The importance of the lip in overall facial aesthetics has an impact on positive self-image and self-confidence. 6 In virtually all women, since the beginning of recorded history, full lips have been associated with youth and beauty 3,5,7,13 and therefore, lip enhancement is one of the most frequently requested procedures in a cosmetic practice nowadays. 3,5,6 The injection of dermal fillers is a minimally invasive procedure that has become increasingly popular worldwide and is considered the most popular nonsurgi cal procedure performed to increase the volume and improve the shape of the lips. ...
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Background: The lips and perioral region are a highly dynamic anatomic area of the face and its anatomy and measurements will vary from patient to patient. In many years of clinical practice and as trainers for other injectors we have noticed that the assessment of this region is also very variable regardless of the experience of the injector. Objectives: The goal of this article is to provide a tool for assessment of the lower face and perioral area in other to simplify cosmetic treatments and help injectors identify what needs to be addressed in each patient. Methods: Over the last few years, weanalyzed the most common concerns of every patient presenting for treatment of the lips and perioral area and the most frequent areas addressed in the treatment of the lower face, and organized them into a tool that was able to systematize the different levels of attention needed in each particular area, guiding injectors towards a better final result. As trainers for other injectors, we also analyzed the most difficult aspects of the perioral assessment and simplified them into this tool that can help even novice injectors to do the correct diagnosis and therefore achieve better results while treating the perioral area. Conclusions: We believe that this tool will help both experienced and young injectors in the assessment of the lips and perioral area prior to treatment and in doing so, will provide a better outcome and cosmetic result.
... Many injection models have been proposed. [11][12][13][14][15][16] However, there are few comprehensive approaches that are appropriate for patients of any age and can address all aspects of lip improvement with fillers. ...
... Previously, to restore volume to the lips, practitioners typically had to choose between stiffer products, which were more durable but carried a high risk of lump development, and softer products that reduced this risk but had a faster rate of absorption. 11,25 Newer formulations like VYC-17.5 may provide an improved balance of these properties. ...
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Background:. Aesthetic improvement of the lips with hyaluronic acid fillers is a popular procedure. A comprehensive, modular, and highly individualizable method has been developed: the Lip Omnicomprehensive Volume Enhancement (LOVE) approach. The present study assessed the safety and effectiveness of LOVE across different patient age groups. Methods:. This was a prospective, single-center study of women aged 20–70 years seeking nonsurgical lip enhancement or asymmetry correction. Three equally sized groups were formed based on patient age: 20–34, 35–45, and 46 years or older. Individualized treatment plans were developed taking into account patient preferences expressed in a pre-injection questionnaire. Treatment used one or more of the three modules of LOVE: lip shape [vermilion border, Vycross (VYC)-17.5]; volume (vermilion body, VYC-17.5); and hydration (submucosal area, VYC-12). Follow-up lasted 6 months. Results:. Sixty patients were enrolled (mean age: 41.3 ± 13.3 years; n = 20 per age group), all of whom were White. Most were treated with all three LOVE modules. Mean filler quantities increased with age: 20–34 years, 1.1 ± 0.1 mL; 35–45 years, 1.5 ± 0.1 mL; 46 years or older, 1.6 mL ± 0.2 mL. Mean patient satisfaction at 4 weeks [on a seven-point scale from 0 (extremely dissatisfied) to 6 (extremely satisfied)] was 4.8–4.9 in each age group. Apart from minor and transient edema/bruising, there was only one complication: a case of lumps that resolved with home massage. Conclusion:. The LOVE approach is safe and effective across a range of ages, with high levels of patient satisfaction.
... A proporção do lábio ideal em caucasianos na vista frontal é 1: 1,6, o que se traduz a cerca de 40% do volume do lábio superior e 60% do volume do lábio inferior 15,16,18 . Um exagero ou erro destas proporções pode levar a aparência de "boca de pato" ou "lábios de salsicha" 9,16 . Estas aparências também podem ser decorrentes de aumento do volume labial sem avaliação adequada das estruturas ao redor, tanto a parte esquelética e tecido mole 19 ou, por persistência de pacientes com expectativas irreais ou com anseio de um formato de lábio incomum 8 . ...
... O edema provocado logo após-injeção de ácido hialurônico não ocorre da mesma dimensão em cada lado do lábio e, por isso, recomenda-se tratar um lado de cada vez antes de prosseguir para a próxima etapa. Na maioria dos pacientes, aproximadamente 1 a 1,5 ml de preenchimento com ácido será adequado para aumentar os lábios e alcançar resultados esteticamente agradáveis 9 . Para lidar com as consequências do envelhecimento dos lábios é comum sentir a necessidade de injetar preenchedor no complexo perioral (ritides periorais, oral comissuras labiais e linhas de marionete) 15 . ...
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... A aplicação dele como preenchedor, consiste na técnica em que se aplica com uma seringa o produto nos lábios, possibilitando aumento de volume e contornos mais definidos. Assim, criando um aspecto agradável e de "lábios perfeitos" (Sarnoff & Gotkin, 2012). ...
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Recentemente tem-se observado, com o advento da Harmonização orofacial, uma grande demanda de pessoas, principalmente mulheres, exibindo em suas redes sociais, ou em mídias de uma forma geral, os tratamentos estéticos e rejuvenescedores realizados. Dentre as regiões mais escolhidas, a dos lábios parece ser uma das mais procuradas. Assim, esta revisão integrativa tem por objetivo pesquisar as principais complicações relativas ao preenchimento dos lábios com Ácido Hialurônico (AH), com finalidade estética, e como foram tratadas. Foram selecionados artigos dos 10 últimos anos, utilizando-se das bases de dados da Biblioteca Virtual em Saúde - BVS e PubMed obtendo uma amostra de 107 publicações de casos clínicos que após aplicação dos critérios de inclusão e exclusão resultou em 08 artigos que foram incluídos nesta revisão integrativa. Após análise dos artigos incluídos na revisão os resultados dos estudos apontaram que dentre as principais complicações estão os nódulos ou granulomas, entendidos como corpos estranhos. Nestes casos a biópsia, na maioria das vezes excisional, foi apresentado como procedimento de tratamento.
... 34 In addition to lip contouring, enhancement of lip volume is one of the most frequently demanded aesthetic indications, particularly in younger patients. 35 Other popular indications in this age group include lip hydration and lip projection. Most patients prefer a natural aesthetic improvement, but some may request a more visible lip augmentation. ...
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Background: As the treatment indications for the Cohesive Polydensified Matrix® hyaluronic acid (CPM-HA) portfolio continue to expand and diversify, injectors new to the range or those who are expanding the treatments they offer may be unsure of the optimal product and injection technique for specific facial areas. Each product in the CPM-HA portfolio has been intentionally designed to provide the best physical properties for a specific indication and target tissue. This document has been developed to provide a comprehensive, one-stop reference for clinicians using the portfolio. Methods: An international panel of experts in the field of aesthetic medicine convened to develop guidelines on effective and safe injection technique when performing treatments with the CPM-HA range of soft-tissue fillers. Results: Consensus members considered treatment indications in the upper, middle and lower face. Landmark deficiencies and anatomical considerations are described for each indication and consensus recommendations provided on the optimal product, injection depth and treatment technique. This is supplemented by the experts advice on avoidance of complications. Throughout, an evidence-based approach to selection of products and injection techniques is provided. The result is a fully tailored approach to a range of indications covering the full portfolio of CPM-HA products, including the newest addition for skin revitalization. Conclusion: The recommendations in this consensus document are provided to assist clinicians in the selection of CPM-HA products, administration techniques and depths of injection with the aim of providing seamless and natural treatment results, enhanced safety and patient satisfaction.
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To perform aesthetic medical treatments, knowledge of the latest surgical and minimally invasive treatment methods is a natural prerequisite. In order to be able to apply these successfully, a detailed analysis and surgical or therapeutic planning should be carried out first. An aesthetic appearance of the face is multifaceted: on the one hand, it can be described objectively by mathematically approximated equations and formulas for describing a “universal attractiveness”, but on the other hand, there are also subjective aspects that depend on cultural and individual influences. This review discusses important connections between behavioural psychology, evolutionary biology, and the specific functions that the components of a face should ideally serve. Understanding these relationships facilitates diagnosis and effective establishment of the right treatment plan.
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Introduction: Lip augmentation is achieved mainly by using hyaluronic acid (HA) fillers. The injection procedures are performed either superficially or deeply with a needle or a cannula, and only one type of hyaluronic acid is used. The authors' objective was to evaluate the feasibility, safety and satisfaction level of a procedure combining two anatomical injection plans, two injection modes (i.e. cannula and needle) and two types of hyaluronic acid fillers. Method: The retrospective study included 30 patients who underwent the following procedure : Intramuscular retro-trace injections of Stylage M (Vivacy® Laboratories) were conducted through a 27-gauge cannula at the level of the upper and lower hemi-lip. Then, intradermal injections of Stylage Lips (Vivacy® Laboratories) using a 33-gauge needle were carried out on the entire lip border as well as the cupid's bow. During a post-injection follow-up, subjects were asked to evaluate satisfaction level and the effect of fillers over time. Elastic (G') and viscosity (G") moduli of HA fillers were measured with a rheometer (AR2000, TA Instruments) prior to and after extrusion through a 33-gauge needle. Results: Rheological assessment showed that passage through a 33-gauge needle did not alter the viscoelastic properties of HA fillers. After the clinical procedure, no side effects were observed except for standard post-treatment bruises and edema. No vascular incident occurred. Moreover, overall patient satisfaction was high (2.6/3) and there was a long-lasting perception of the effect of the filler. Conclusion: The current study demonstrated that dissociating the anatomical zones of the lip during the injection procedure by means of different hyaluronic acids in the muscular and dermal planes would efficiently and safely provide both lip projection and fullness for a natural and lasting effect.
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Just as priceless procedure of art and science needs the visual frame to bring out the subtle proportion to your face and bring out the best frame for the smile. Lip augmentation procedures with hyaluronic acid dermal fillers have become increasingly popular worldwide because full lips are often considered beautiful and youthful. The objective of a lip augmentation procedure is to create smooth lips with adequate volume and a natural appearance and not to be over corrected. Various techniques for lip augmentation have been used and described.
Chapter
Targeted facial volume restoration and recontouring form an essential part of modern aesthetic rejuvenation procedures. This chapter provides a comprehensive overview of each stage of the patient consultation from evaluation of baseline anatomy, injection procedures, and techniques, with valuable tips and tricks to avoidance of adverse events. Three commonly used nonsurgical treatments for facial aging are discussed: dermal fillers, botulinum neurotoxins, and fat transfer. These procedures all have roles in facial rejuvenation and contour enhancement, whether alone, in combination, or to complement surgical options. Neurotoxins eliminate or reduce dynamic wrinkles, but by altering the balance of muscular action, a variety of other conditions can also be treated, from poor brow shape to a gummy smile. Dermal fillers are available for a wide range of facial indications, tissues, and injection depths, from restructuring facial architecture to smoothing fine lines. Finally, fat transfer is a biocompatible option that can be particularly valuable in areas where volume loss is most pronounced, and which may also have regenerative properties. The use of these procedures to individualize treatments for patients will allow physicians to achieve optimal aesthetic outcomes.
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An abstract is unavailable. This article is available as HTML full text and PDF.
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Background and Objectives Soft tissue augmentation represents a cosmetic procedure performed with increasing frequency.Study Design/Materials and Methods Correct utilization permits precise correction of facial rhytids and scars. Novice injectors occasionally inject too superficially in tissue with the resultant appearance of discoloration secondary to the Tyndall effect.Results and Conclusion In this article, we will review the Tyndall effect in the skin and management options for this growing problem in aesthetic dermatology. Lasers Surg. Med. 38:202–204, 2006. © 2006 Wiley-Liss, Inc.
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The authors discuss various filling agents currently available that can be used to augment the lips, correct perioral rhytides, and enhance overall lip appearance. Fillers are compared and information provided about choosing the appropriate agent based on the needs of each patient to achieve the much coveted "pouty" look while avoiding hypercorrection. The authors posit that the goal for the upper lip is to create a form that harmonizes with the patient's unique features, taking into account age and ethnicity; the goal for the lower lip is to create bulk, greater prominence, and projection of the vermillion.
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Aesthetic units of the face have been previously described. The lip itself may be divided into smaller topographic subunits. The lateral subunit is bordered by philtrum column, nostril sill, alar base, and nasolabial crease, while the medial topographic subunit is one-half the philtrum. When a large part of a subunit has been lost, replacing the entire subunit rather than simply patching the defect often gives a superior result. The only tissue suitable for the aesthetic restoration of moderate-sized defects of the upper lip is lower lip. An exact pattern is outlined and an Abbé flap is taken from the midline of the lower lip and transferred in two stages. Like tissue is replaced in kind, border scars are positioned aesthetically, and the orbicularis sphincter is reconstituted with an intact symmetrical commissure, muscular modiolus, and upper and lower lip symmetry. Spontaneous reinnervation by appropriate segmental facial branches occurs within 1 year. Four patients are presented.
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To keep pace with advancements made in facial plastic and reconstructive surgery, surgeons continue to search for the ideal soft-tissue filler. A review of the literature reveals the advantages, disadvantages, and indications for the use of injectable collagen, Fibrel, autologous fat, and fascia. Recent studies on the new synthetic injectables methylmethylpolysiloxane (Bioplastique) and polymethylmethacrylate (Artecoll) also illustrate guarded results. Expanded polytetrafluoroethylene (Gore-Tex) has been shown to be biocompatible and clinically effective in a variety of head and neck applications. In 246 consecutive soft-tissue augmentations of nasolabial creases, we found Gore-Tex to efface the depth of crease significantly. In two patients, elective repositioning was performed because of superficial placement; however, there were no instances of extrusion or infection. Preoperative grading of crease severity reveals that an increased number of procedures are required to augment moderately severe or severe nasolabial folds.
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Lips are the central feature in the lower third of the face. When they are full and well defined, they impart a sense of youth, health, and attractiveness to the bearer. Thin, flat lips, on the other hand, imply fragility and senility. The characteristics of the lips responsible for these qualities are the shape of Cupid's bow, the relative length of the upper lip, and the projection or bulk of the lips. Esthetic guidelines are presented for each of these characteristics, which when understood help the surgeon formulate an operative plan. Lip augmentation techniques using autogenous and alloplastic materials are presented. For patients with a long upper lip, vermilion advancement and nasal base resection are discussed in detail. With a look to the future, a discussion of preliminary experience with carbon dioxide laser lip advancement concludes the article.