Lip Augmentation

Lip Teh
January 2006
Lip Augmentation
o assess: length of the upper cutaneous lip, the presence of philtral columns,
upper incisor show, lower incisor show, upper vermilion width-to-lower
vermilion width ratio, oral commissural position, and vertical rhytides
need to be assessed
o With the lips in repose, a minimum of 3 mm of the upper incisors should
be visible in the female patient, and 1 to 2 mm is sufficient in the male
o lower incisor show should be absent, with the lower lip eclipsing them by
sufficient superior positioning
o upper lip width should be one-third to one-half the corresponding width of
the lower lip as measured in the midline.
o corners of the mouth should evoke a slight superior cant
o upper cutaneous lip should be short and exert a concave curvature
emanating from the base of the columella and ending with the provocative
pout of the vermilion border
o lower lip should likewise exhibit a rather steep concavity from the sharp
vermilion border to the labiomental groove.
o upper lip should protrude beyond the lower lip by approximately 1 to 2
The ideal perioral anteroposterior appearance. (Left) The lateral appearance of the
aging lips. (Right) The ideal lateral appearance of the lips. Note the provocative
concavity bordering the upper and lower vermilion and the 2-mm upper lip protrusion
beyond the lower.
The aging lip
Lip Teh
January 2006
1. vertical wrinkles – exacerbated by smoking and sun damage
2. a reduction in the height of the vermilion border with lengthening of the skin
3. disappearance of Cupids bow
4. convexity and elongation of the upper lip – covering the incisors
5. thinning of the lips
6. lip inversion - bone resorption and teeth retrusion may contribute to lip
inversion by lessening their internal suppor
7. oral commissures may sag, as may the lower lip in general, resulting in
exposure of the lower anterior incisors when the lips are parted in repose
Methods that deal with
1) volume
2) shape (lip lifts/reduction)
 temporary injections are better for patients who have had no prior cosmetic
surgery and who are unsure if they will do well with larger lips.
 Try a trial with hyarulonic acid (first choice for most), bovine collagen or the
newer cadaveric collagen.
 After this trial, if patients are pleased with results, a more permanent method may
be used – Alloderm probably the best compromise
Volumetric Lip Augmentation
1) Alloplast
2) Allograft
3) Xenograft
4) Autologous tissue
1) Temporary
2) permanent fillers
Alloplast options
Silicone oil and Radiese(calcium hydroxyapatite) not recommended on lips - high risk
of subcutaneous nodules
1. Non-toxic
2. biologically inert
3. nonallergenic
4. noncarcinogenic
5. it should not promote inflammation
6. does not migrate
Lip Teh
January 2006
7. feel soft, smooth (most alloplasts aren’t soft)
8. long lasting
9. should be adaptable for any cosmetic defect
10. result has to be predictable and permanent
11. sterilisable
Commonly used:
Temporary fillers
1) Poly-l-lactic acid (NewFill/Sculpta)
2) Restylane/Perlane
3) Reviderm Intra
Permanent fillers
1) Bioplastique
2) Artecoll
3) Gore-Tex (PTFE threads)
4) Polyacrylamide hydrogel (Aquamid)
1) Injectable bovine collagen(Zyderm I/II, Zyplast)
Additional Requirements
1. no risk of transmitted diseases
1) Acellular human cadaveric dermis (Alloderm/Cymetra)
2) Human bioengineered collagen( CosmoDerm/CosmoPlast and Dermalogen)
Autologous options
Additional Requirements
1. mimimal donor site morbidity
Injectable autologous dermal collagen(Autologen)
 available through the processing of patient skin that otherwise would be discarded
 benefits: does not require skin testing and that it lasts longer than bovine collagen
 no long-term results
 drawbacks include small quantity and high expense.
 requires careful timing of the procedure since it must be used within several hours
of delivery
Injectable autologous fibroblasts (Isolagen)
 3-mm punch biopsy obtained from the patient
Lip Teh
January 2006
Processing usually takes 6 week, test dose administered in the meantime
needs to be injected into multiple levels of the dermis for best results
must be given within 24 hours after delivery
Autologous fat injection
 Average amount of fat required for both lips - 6mls
 Should be regarded as a nonpermanent autologous filler
 Compared to other nonpermanent fillers, the longevity is equal but results are not
as easily predictable (4 weeks to 7 years)
 Expect 20-90% loss in volume
 Often need to overcorrect
 significant swelling and discomfort common post op
 Histologic sampling at 7-36 months revealed fat cells in an organized structure.
Longer-lived specimens demonstrated more pronounced fibrosis and organized
connective tissue.
Dermal fat grafts
 Conveniently harvested as part of another procedure done concurrently (ie
 Method of choice in most cases
 5mm incision 5mm medial to commissures
 6-10 cm strips 3-5mm thick
Temporalis fasica grafts
 does not have the desirable thickness or pliability
SMAS Grafts (Leaf PRS 2002)
 harvested during facelift
 potential to provide long-term augmentation
 potential for creating a high incidence of surface irregularities
Autologous breast capsule (Ann Plast Surg 1996)
 Possibly more resistant to resorption (PRS Apr 2005) – “The low rate of
resorption in capsule grafts was attributed to the environmental conditions that
triggered the potential cause of resorption, such as inflammation in the
localization conditions when it is was carried from the region where it was
Mucosal advancement
 first described by Lassus 1981
 gain an outward protrusion with more vermilion show
 Problem – no volume gained, transfers wet mucosa to dry, lengthy recovery
period requiring
 Often combined with augmentation – ie fat transfers dermal-fat, hyaluronic acid
Lip Teh
January 2006
3 V-Y plasties (Haworth PRS 2004)
Lip Lifts
1) perivermilion excisions (lip advancements)
2) paranasal lip lifting
Lip Advancements
Z Plasty
 Modest results
 The incisions must be relatively long for each arm of the plasty.
 Generally, only 3-4 lengths can be created on each side of the central lip only.
These lengths should extend from the wet line to within 1 cm of the labial alveolar
Lip Advancement  Dermal flap (Guerrissi PRS 2000)
 Ideal where there is lengthening of the upper cutaneous lip
 Can cause some eversion of the red vermillion
 May be combined with volumetric lip augmentation using dermal-fat grafts,
Goretex or Alloderm
 Advantage: ability to directly and precisely position the Cupid’s bow.
 Disadvantage:
a. Doesn’t address fine wrinkles well
b. possible obliteration of the natural “white line”.
c. Scar visible and may need camouflage with lipstick - poor choice for
males in almost all cases.
Lip Teh
January 2006
Lip Lift - Paranasal excision
 buffalo horn excision at the base of the nose. May need to add a vertical
 Overcorrection required
 Better scar than lip advancement but much less eversion of the red vermillion
Lip Teh
January 2006
Lip Reductions
 longitudinal wedge excision on the internal surface of the lip
Perioral rhytides
Lip Teh
January 2006
addressed with
o laser
o dermabrasion
o chemical peel