A Beautiful Lip
Everyone wants beautiful lips, even though you may have been wearing a mask during the pandemic. Lips are a central beauty feature on the face. The most popular use of fillers throughout the US and around the world is for lip augmentation. In addition to size boosting, reshaping or other modifications are incredibly common.
Lip augmentation or enlargement is a basic starting place for lip treatments and the most common use for injectable fillers. Even back when we used collagen injections, before the modern era of fillers, this was incredibly common. Surgical implants in lip for enlargement, such as Gortex, silicone, others have been used. Lip augmentation is popular in young adults and older people. Each individual choses their aesthetic goals whether you want a little size enhancement, restoration of volume lost from aging or very obvious bee-stung lips.
How much or how big to go with your lips is partly a product of the projection of the rest of your features and the look you are going for. The beauty of doing this with injectable filler (Restylane, Juvederm) is the tremendous control of exactly where you end up. So size does matter but size really is a secondary consideration to lip shape.
The lips have a complex shape with curves, bulges, dimples and peaks which in proper balance are the major factor in the beauty of the lips, even more so than size. Injectable fillers are excellent at precisely making small shape changes in very specific portions of the lip -something that was never possible with surgical lip implants. Uniform augmentation of the upper or lower lip takes away the natural shape and some of the lip’s beauty. More recently, multiple fillers have been developed and received FDA approval specifically for treating the lip for augmentation or to treat wrinkles (Restylane Kysse, Restylane Silk, Juvederm Vobella).
Natural Lip Shape
The upper lip and lower lip each have a unique shape that is completely different shape from each other. The upper lip is fuller approximately in the mid-portion of each half, tapering towards the side of the upper lip at the corner of the mouth. The upper lip has a small emptier space adjacent to the central pucker of the upper lip –the tubercle, which is the fullest or most projecting part of the upper lip. These are all part of the pink lip also known as the vermillion. Above this is a portion of the upper lip with normal skin with a feature called the white roll serving as a thicker roll of skin at the border between the vermillion and skin portion of the lip. Within the white roll is the Cupid’s bow peak on either side of the tubercle. Extending up from each Cupid’s bow peak to the base of the inner portion of each nostril is an additional roll of skin known as the philthral column.
The lower lip shape simpler, classically described as a double pillow with fuller visibility of the vermillion midway across each side tapering toward the corners of the mouth and with less projection in the midline. The upper lip is typically smaller than the lower lip, being two thirds to three quarters the size. Small asymmetries are universal, such as differences in the length, fullness or shape of the two sides of the lip. Filler minimizes but doesn’t eliminate these asymmetries since the filler can only make up for volume differences with limits on changing an asymmetric skin envelope.
The Aging Lip
The lip loses some of it’s beauty and appeal with aging due to loss of volume (thinning) and loss of curviness. There is less vermillion show with the lip rolling in and lengthening of the upper lip (more height to the normal skin part of the upper lip). In addition, aging produces loss of definition of the white roll, including cupids bow peaks and philthral columns. Finally, wrinkles in the skin of the lips and perioral area occur and progressively deepen.
Botox and other neuromodulators (Dysport, Xeomin and Jeuveau) are used to treat dynamic lip wrinkles, those that form with animation. Another use of Botox in the aging lip is to roll out the vermillion providing more pink show, a treatment termed the lip flip. For individuals who pull the lip up too strongly when smiling, showing not only the teeth but also the gums (termed a gummy smile), Botox can be used to soften the smile, converting it into a full tooth smile –no gums showing, or relax even more into a Mona Lisa smile.
Injectable fillers can treat wrinkles superficially in the lips. Again, fillers like Restylane Kysse and Juvederm Vobella were specifically designed for and have specific FDA approval for this indication.
Lip surgery is very central to plastic surgery based on techniques plastic surgeons use to treat trauma, to the lips and cleft lip and palate. Cosmetic treatments of the lip are also mainstream. Lip reduction can be performed if the amount of vermillion show is too much. These days, there is much less surgical lip augmentation since this indication is almost always done with fillers.
An increasingly common aging lip treatment is the lip lift which is performed to reduce normal skin lip height, elevate corners of mouth and aid with roll out of vermillion. In this procedure, a wedge of skin is removed just below nostrils. Artistry important in how this wedge is shaped and sized in order to achieve the needed goals and to preserve a natural look. Meticulous closure of the incision is needed to achieve the best possible scar.
Energy based treatments for resurfacing of the lips and peri-oral area are commonly performed to reduce wrinkles using a variety of energy based devices including CO2 laser resurfacing, Erbium:YAG laser resurfacing, Fraxel, Tixel, a variety of radiofrequency devices as well as chemical peeling. These recovery based treatments can be tailored to the severity of the wrinkles and the time availability and willingness of each individual to have recovery time in their schedule.
Filler and Botox Pitfalls
Getting natural results requires an experienced injector with good technical and artistic skills who will listen carefully to your aesthetic concerns and craft a plan in partnership with you. There are a number of causes of an unnatural look with lip filler. This is not surprising given the large number of treatments in this area by a wide range of providers with variable skills and experience.
- Enlarging the lip without maintaining the natural curves and shapes, producing a sausage-like look.
- Filling onlythe corners of the upper lip so the natural taper from full midportion to the corner is lost –an intrinsically unnatural look. Some patients ask for that look because it is so commonly seen –even in fashion magazines. Also, it is a quick, easy injection for beginning lip injectors but not natural.
- Too much injection in the white roll creating a duck-billed look. This is obviously unnatural and most people would like to avoid this look. Alot of lip injecting was done in the white roll with collagen which was softer than most modern fillers. The stiffer modern fillers can be injected in the white roll, especially to accent the cupid’s bow peak but this must be done conservatively or excessive prominence will result –the duck-billed look.
- Pushing a good Botox result too hard. Completely relaxed muscles is aesthetically desireable with no adverse functional consequences in some parts of the face, especially in upper facial areas but this is never okay in the lower face/perioral areas. To avoid an unnatural look and even functional problems, the dose of Botox or other neuromodulators must be tightly limited. A little is good but more is not better. We can get some nice effects with neuromodulators but have to accept that we can’t get more result by overdoing it.