AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Cosmetic lip augmentation consists of the enlargement and reshaping of otherwise normal upper and/or lower lips to improve their dimensional relation with the patient's nose, teeth, and surrounding facial structures. The appearance of the lips is determined by the spatial relation of the lip structures with the teeth in a 3-dimensional space and by their function during animation and speech.

History of the Procedure

Augmentation of the lip has been performed for cosmetic reasons for a long time. Women of all ethnic and social backgrounds have applied cosmetics to their lips to define or alter their appearance since the Stone Age. Tribal ceremonies involving the introduction of various materials in the upper and lower lip to alter their shape, usually with the intent to enlarge them, have been practiced in African tribes for centuries.

Problem

Cosmetic lip augmentation is defined as the procedure designed to augment and change the shape of an otherwise normal lip that is not affected by trauma or congenital deformity.

Etiology

Cosmetic deformities of the lips include both congenital and acquired etiologies. Some patients never develop adequate fullness in the lips; others develop atrophy of the soft tissue of the lips as they age.

Clinical

Cosmetic complaints refer to lip size and shape.

An accurate physical examination determines the specific area of deficiency or desired enhancement. Specifically, evaluate the patient's occlusion, maxillary-mandibular relations, and aging pattern. A general evaluation of the relation between the upper lip and the incisors reveals the appropriate course of action. Dr Bahaman Guyurion summarized the following algorithm approach to physical evaluation prior to lip augmentation:

• Optimal incisor show - Conservative augmentation by fat transfer or dermis fat graft
• Excessive incisor show - Augmentation by fat transfer or dermis fat graft
• Inadequate incisor show, long lip - Lip shortening and lift with incision at nasal base ("buffalo horn") in young patients with acute columella-labial angle or incision at vermillion border in older patients with perioral rhytids
• Inadequate incisor show, normal lip length - Maxillary lengthening with possible lip augmentation

INDICATIONS

Section 3 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Cosmetic indications include patients who desire a fuller or more shapely upper or lower lip and who are otherwise in good health.

RELEVANT ANATOMY

Section 4 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Lip augmentation consists of the reshaping and/or enlargement of the visible portion of the lip, the vermillion. Alteration of the shape of the Cupid's bow and of the relation between the vermillion and the skin underlying the nasal columella also fall within the category of lip augmentation.

Also important is to consider the relationship between lip height and incisor show in the anatomic analysis. Evaluate possible maxillary hypoplasia and protrusion and consider the patient's occlusion status.

CONTRAINDICATIONS

Section 5 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Contraindications for cosmetic lip augmentation include facial nerve disorders, recurrent herpes simplex lesions, diabetes, severe hypertension, history of multiple allergies, and/or autoimmune disorders.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Surgical Therapy

Surgical lip augmentation can be achieved by injectable fillers, implants, and surgical advancement, roll, or lift.

Injectable fillers

Lip augmentation with the use of injectable fillers allows quick results to be obtained with minimal downtime and repeatable applications. The most commonly used materials are collagen and autologous fat. Other materials and products used commonly overseas but not widely available in the United States include hyaluronic acid preparations such as Restylane or Perlane. Hyaluronic acid mixtures containing methylmethacrylate beads, such as Artecoll, allow for long-term lip augmentation, since after resorption of the hyaluronic acid the beads remain in the soft tissue permanently. Hyaluronic acid mixtures containing hydrogel particles, such as the product DermaLive, allow for long-term augmentation (>1 y) after resorption of the hyaluronic acid component due to permanence in the tissue of the synthetic hydrogel particles. Complex mixtures of hyaluronic acid and methylmethacrylate beads are available under the name Artecoll.

Bioplastique is a filler available in the United States with similar characteristics consisting of 38% biphasic polymer textured silicone particles suspended in a 62% bioexcretable gel carrier. Significant ease of use, "off the shelf" availability, and widespread acceptance by the public make collagen one of the most common fillers used. Lip augmentation with collagen and other fillers can be performed by injecting the material in any or all of the anatomic parts of the lip, allowing for a very controlled and predictable result. Precautions regarding mode of injection and quantity of the substance injected vary widely within this family of products.

Autologous fat recently has become a more popular choice. The distinct advantage of fat as a volume augmenter is that the results obtained are long lasting and in some cases permanent, depending on the amount of tissue injected and the location treated. Moreover, the risk of allergic reactions is avoided since the fat used is autologous tissue. Fat is obtained from the patient's donor site under local anesthesia, prepared with saline wash, decantation, or centrifugation, and then injected in the lips. As much as 30% of the injected fat can persist after transplantation with appropriate technique, and in some patients almost complete survival of the graft has been reported.

Implants

Lip augmentation can be obtained by the implantation of various synthetic materials, including polytetrafluoroethylene (PTFE; SoftForm), as well as biomaterials such as fascia, dermis, and decellularized donor dermis (AlloDerm).

Synthetic materials such as Gore-Tex/PTFE have been used successfully and allow for a controlled application with ease of use. Expanded tetrafluoroethylene is available in tubes of 2.4-mm and 3.4-mm diameter. They are provided with a disposable applicator and implanted in the subdermal plane at the vermillion border.

AlloDerm is available commercially in the United States and consists of decellularized donor dermis. Through a proprietary process, this material is produced in precut sizes and is available for implantation. Various reports are available, indicating that the decellularized dermis becomes a scaffolding for neovascular ingrowth, and full integration in the patient's tissues has been verified experimentally.

Autologous dermis, dermal-fat, and fascia grafts are obtained from the patient, shaped, and implanted. In some patients, the grafts may be obtained from skin resected during local procedures such as lip lift or advancement, de-epithelialized, and then grafted.

Surgical procedures

Surgical procedures involving advancement, lift, and roll are designed to enhance various parts of the lip anatomy using the patient's local tissues. Z-plasty, V-Y, and W advancement flaps are intended to project and fill the central and lateral parts of the vermillion. The flaps are designed on the oral-wet vermillion-mucosal aspect of the lip and dissected just superficial to the muscle, containing the mucosa and submucosal elements. Lip lifts can be designed to shorten the distance between the Cupid's bow and the base of the columella, "lifting" the lip and enhancing the vertical height of the dry vermillion. Reshaping the lower lip also can be performed in this fashion.

Preoperative Details

Accurate preoperative planning is mandatory since even minor asymmetries are always clearly evident to the patient and observers. In addition, accurate psychological evaluation should focus on identifying patients with unrealistic expectations. Preoperative digital imaging or photo modifications can help in illustrating postoperative outcome and in operative planning.

Intraoperative Details

Fat transfer

• Inform the patient of the need for a donor site and determine an appropriate site. In general, the periumbilical fat can be accessed quickly with a small incision within the umbilicus, which heals quickly and inconspicuously.
• Block the periumbilical fat tissue with an injection of local anesthetic solution of 1% lidocaine with epinephrine 1:100,000.
• After performing a small incision, harvest the fat tissue with 1.5-mm cannula and syringe suction. The volume obtained is variable but in general 20 mL of fat fraction results in 8-10 mL of injectable fat after decantation or centrifugation.
• Anesthetize the upper and lower lips, preferably by infraorbital and submental nerve block.
• Place the access incisions at the corner of the mouth, within the wet vermillion.
• Graft the fat in several layers through the vermillion and lip border, using the injection cannula in multiple passes of small volume to allow for better vascularization of the grafted fat. The injection ports may be left to naturally approximate or may be closed with a fine absorbable suture.

Implants

• In general, implants are used as vermillion augmenters. The most commonly used biomaterial is AlloDerm, which in many cases has replaced synthetic fillers and PTFE.
• Prepare AlloDerm according to manufacturer's specifications.
• Infiltrate the upper and lower lips with local anesthetic solution and make two small incisions in the corners of the mouth in the wet vermillion. A special passer is available for delivery of the graft or a standard tendon passer can be used to bluntly tunnel from one incision to the other in the submucosa-subcutaneous plane.
• Grasp the AlloDerm sheet and carry it through. Massaging the graft smoothes out the material and allows for better placement.
• Close the access incisions with fine absorbable sutures.

Surgical advancement

• Preoperative evaluation of the lip anatomy is critical in assessing the position and size of the V-Y incisions. A 2:1 relationship exists between the length of the Y limb and the obtained increase in lip height. Therefore, the appropriate V-shaped incisions must be planned symmetrically on each side of the frenulum.
• Infiltrate the lip tissue with a solution of 1% lidocaine and 1:100,000 epinephrine and anesthetize it by local nerve block.
• Make the incisions and extend the dissection toward the lip margin in the submucosa plane, just superficial to the muscle, to avoid injury to the small sensory nerve branches in this area.
• Once the planned advancement is obtained, carefully approximate the wounds with 4-0 absorbable sutures.

Lip lift

• Preoperative markings are critical. Accurately mark the patient prior to injection and ask the patient to review and approve the markings. Even a 0.25-mm difference in vertical height between the peaks of the Cupid's bow can be noticed clearly postoperatively.
• Anesthetize the upper lip and perform the planned full-thickness skin resection starting from the vermillion border. To decrease the chances of hypertrophic scarring, do not include the vermillion and skin directly within the philtral columns, corresponding to the prolabium, in the resection.
• Close the wound with interrupted half-buried 5-0 Prolene sutures tied on the vermillion side of the wound.

Postoperative Details

• The areas treated with injectable materials require little postoperative care. Coat lips treated by surgical advancement or implantation with antibiotic ointment 3-4 times per day for 1 week postoperatively.
• Ice packs are used extensively in the first 24 hours.
• Encourage patients to limit talking, smiling, and laughing for 5-7 days postoperatively.
• Provide oral analgesics and instruct patients to rinse the mouth with saline solution 4-6 times per day for the first week postoperatively.
• Remove nonabsorbable sutures 5-7 days postoperatively.

Follow-up

• Significant postoperative swelling is common to all techniques of lip augmentation. The swelling usually resolves within 7-10 days, but it may persist for several weeks. Recommended postoperative care includes ice packs, sun avoidance, liquid diet, perioral care with saline rinses, and rest for 24-48 hours, depending on the extent of surgery. Inform patients of the significant swelling and bruising that may develop with this procedure; usually, they are able to tolerate it well.
• One of the most common complaints after surgical advancement is persistent numbness and/or paresthesias around the augmented lips. This problem usually resolves in 4-6 weeks but may become a significant nuisance for patients.
• Inform patients of the approximate duration of the significant swelling of the augmented lips; they should plan their social calendar accordingly.
• Follow-up care consists of office visits 1, 7, and 30 days postoperatively, at which time shape, symmetry, function, and wound healing are assessed.

COMPLICATIONS

Section 7 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Complications of collagen injection include allergic reaction to the compound, possible intravascular injection, skin slough, scarring, granuloma formation, and hematoma. Testing for sensitivity to bovine collagen must be performed prior to injection and observed for 4 weeks.

Complications of fat transfer include donor site hematoma, scarring, infection, lumpiness, asymmetry, infection, hematoma, intravascular injection, and possible skin slough.

Complications of synthetic material implantation include infection, asymmetry, sensitivity to the material, extrusion, need for removal of the implant because of hardening, interference with lip function, and sensation changes.

Complications of surgical advancement, lift, and roll include hypertrophic scarring, asymmetry, numbness, and lumpiness.

OUTCOME AND PROGNOSIS

Section 8 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Outcome is generally good. Adequately informing patients of the expected postoperative course, possible complications, and required postoperative care is essential.

FUTURE AND CONTROVERSIES

Section 9 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

All available techniques of lip augmentation have advocates and critics. To date, a single most effective technique has not been identified, partly because of the wide variety of individual cosmetic complaints. Research in long-lasting injectables will likely lead to improved results.

The use of silicone oil injections has long been condemned in the United States because of the high rate of complications and tremendous difficulty in correcting the problems seen in patients who had undergone these procedures. Although this technique is not recommended in this country, silicone oil injection has been reported as safe and successful outside the United States. The accuracy and long-term outcomes of these studies remain to be seen.

The future of soft tissue augmentation of the lip may be the use of combination therapies. Utilizing the strengths of multiple injection materials could offer off the shelf convenience with safe and long-lasting results. For example, using hyaluronic acid (Restylane) in conjunction with calcium hydroxylapatite (Radiesse) minimizes complications seen with the latter when used alone and offers improved outcomes. In any event, any injectable material combination will be measured against the longevity and safety of dermal fat grafts.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

• Ersek RA, Beisang AA 3rd. Bioplastique: a new biphasic polymer for minimally invasive injection implantation. Aesthetic Plast Surg. Winter 1992;16(1):59-65. [Medline].
• Godin MS, Majmundar MV, Chrzanowski DS. Use of radiesse in combination with restylane for facial augmentation. Arch Facial Plast Surg. Mar-Apr 2006;8(2):92-7. [Medline].
• Guyurion B. Discussion. Plast Reconstr Surg. 2000;105:1184-87.
• Jacinto SS. Ten-year experience using injectable silicone oil for soft tissue augmentation in the Philippines. Dermatol Surg. Nov 2005;31(11 Pt 2):1550-4; discussion 1554. [Medline].
• Kanchwala SK, Holloway L, Bucky LP. Reliable soft tissue augmentation: a clinical comparison of injectable soft-tissue fillers for facial-volume augmentation. Ann Plast Surg. Jul 2005;55(1):30-5; discussion 35. [Medline].
• Niechajev I. Lip enhancement: surgical alternatives and histologic aspects. Plast Reconstr Surg. Mar 2000;105(3):1173-83; discussion 1184-7. [Medline].
• Sclafani AP. Soft tissue fillers for management of the aging perioral complex. Facial Plast Surg. Feb 2005;21(1):74-8. [Medline].
• Wilkinson TS. Lip enhancement. In: Practical Procedures in Aesthetic Plastic Surgery: Tips and Traps. 1994. 117-44.

Article Last Updated: Jun 12, 2006