Lip Enhancement: Personal Technique

57.1 Introduction

Cosmetic surgery to the lips is one of the most difficult areas in which to achieve success. As well as the psychological implications compared to other types of surgery, there is a paucity in the literature regarding cosmetic augmentation of the lips. The criteria of beauty for the lips include a fuller look, symmetry, contour definition, and a slightly protruding Cupid’s arch. Lips should represent youth, romance, and beauty (Fig. 57.1).

57.2Anatomical Basics of the Human Lip

The lips (Fig. 57.2) are the shape of a soft M for the upper (Labium superius) and a W for the lower lip (Labium inferius). The lower lip is usually somewhat larger. This should be taken into consideration while injecting. The border between the lips and the surrounding skin is referred to as the vermillion border, or simply the vermilion. The vertical groove on the upper lip is known as the philtrum. The skin of the lip, with 3–5 cellular layers, is very thin compared to typical face skin, which has up to 16 layers. With light skin color, the lip skin contains fewer melanocytes (cells which produce melanin pigment, which give skin its color).

Cupids arch (bow)

Because of this, the blood vessels appear through the skin of the lips, which leads to their notable red coloring. With darker skin color this effect is less prominent, as in this case the skin of the lips contains more melanin and thus is visually darker. The skin of the lip forms the border between the exterior skin of the face, and the interior mucous membrane of the inside of the mouth. The lip skin is not hairy, and does not have sweat glands or sebaceous glands. Therefore it does not have the usual protection layer of sweat and body oils which keep the skin smooth, inhibit pathogens, and regulate warmth. For these reasons, the lips dry out faster and become chapped more easily [1, 2].

The basic parts of the mouth and lips are:

1.Upper Lip – (labium superfluous entafada) is the strip of smooth skin that borders the upper edge of the mouth. It is usually thinner than the lower lip and can have pronounced peaks to either side of a groove at the center of the mouth.

2.Lower Lip – (labium inferius) is the strip of smooth skin that borders the lower edge of the mouth. It is usually wider and vertically deeper than the upper lip.

3.Vermilion – is the border of the skin of the lips and the surrounding skin of the face. In some individuals this is more pronounced, while in others the two skin types seem to almost blend.

4.Cupid’s Bow – is the area in the middle of the upper lip which straightens with age. Carefully placed dermal filler can restore the youthful look of the Cupid’s bow.

5.Philtral Columns – is the groove-like indentation often found at the center of the upper lip. It is responsible for the biggest difference in shape between the upper and lower lips and becomes more pronounced when the mouth is puckered.

This is an especially important aspect of the lip that requires attention during treatment.

6.Dry Part – is the part under the lip that separates the dry and wet part and is usually used for fullness.

7.Wet Part – adjacent to the dry part and is important for pouting.

The balanced lip size which is the ratio of the height of the upper lip to that of the lower one is ideally 1.4:1.6.

Clinically, the technique is based on the anatomy:

1.For contouring: inject the vermilion border.

2.For fullness: inject the dry part of the inner lip.

3.For pouting: inject the wet part of the inner lip.

4.For philtrum and ridges: inject directly into the subdermal layer.

5.For oral commissure: requires separate injection.

As a person ages, the following changes occur in the lips:

ss Loss of lip projection

ss Lengthening of white lip ss Flattening of philtrum

ss Flattening of Cupid’s bow

ss Dermal and subcutaneous atrophy ss Atrophy of orbicularis oris

57.3 Injectable Materials

Injectable human-derived collagen comes from a single neonatal human foreskin which was harvested many years ago and which has been shown to be free from known communicable diseases. Examples include CosmoPlast and CosmoDerm. Examples

ofbovine-derived collagen include Zyplast and Zyderm. The mechanism of action is thought to be due to a direct filling effect. With time, injectable collagen, which is similar to dermal matrix collagen, is metabolized leading to loss of filling effect. Collagen has been in use for over 20 years, and now skin testing for possible allergic reaction is no longer required [3, 4].

Injectable hyaluronic acid (HA) fillers are based on a natural part of the extracellular matrix of bone and cartilage. Examples include Restylane and Juvederm, which are both derived from bacterial fermentation. HA fillers absorb water and form a gel which creates volume. Over approximately 9–12 months this is degraded

a

b

[5–10].The author does not recommend the use of nonabsorbable material or Gore-Tex (Fig. 57.3), since longterm complications can occur from these procedures.

57.4 Technique

Emla cream local anesthetic is applied to the lip and skin surrounding the lips approximately 30–60 min before procedure. A complete dental block is performed; this is a vital part of the procedure as lips are very painful and uncomfortable to inject. Good

c

anatomical knowledge of the nerve supply is vital to the success of the local.

1.The infraorbital nerve is a branch of the maxillary trunk. It supplies not only the upper lip, but much of the skin of the face between the upper lip and the lower eyelid, except for the bridge of the nose (Fig. 57.4).

2.The mental nerve is a branch of the mandibular trunk (via the inferior alveolar nerve). It supplies the skin and mucous membrane of the lower lip and labial gingiva (gum) anteriorly.

Betadine antiseptic solution is used to clean the area. Sterile gloves, a magnifying light, and a mirror are used.

An intramuscular injection using a very fine needle on a Luer-lock syringe is performed. In the upper lip, the needle is inserted into the mucosa and pointed upward on either side of philtrum, in order to fill Cupid’s bow and obtain slight eversion. The remaining upper lip is injected through injections at corner of the lips at a 45° angle, progressing slowly toward the midline and philtrum. In the lower lip, the needle is inserted in similar positions to the upper lip. The lip margins are injected superficially to achieve contour definition. This is achieved by injecting parallelly beneath the skin, with slow injection on withdrawal to obtain uniform distribution. Each injection deposits about 0.1 ml of injectable material. This will achieve eversion of the vermilion border, enhance convexity, produce fuller lips, and produce a more youthful appearance due to the improved philtrum and Cupid’s bow. Gentle massage to areas after procedure may be performed.

The patient will be able to see the result immediately, which is an additional benefit to this procedure

(Fig. 57.5). A touch-up may be considered at anytime. Try to remember the arterial supply in order to avoid bruising as the lips have a very rich blood supply. The facial artery is one of the six nonterminal branches of the external carotid artery. It supplies the lips by its superior and inferior labial branches, each of which bifurcate and anastomose with their companion artery from the other side.

57.5 Postoperative Instructions

Sometimes the lips may swell and be red for 1–2 days; however, when this occurs it is minimal and can be camouflaged with make-up. Clients may continue to work and socialize. No antibiotic or antiviral treatment is required. Ice packs for 24 h may be used to reduce swelling and simple pain medication such as paracetamol may be taken if necessary.

57.6 Complications

Very rarely complications may occur. These include infection, allergic reaction, persistent erythema, lumps, and bleeding. For the best results, do not approach Cupid’s bow from superiorly, as this will cause inversion. Fat and collagen do not last long: 3–4 months and 4–6 months respectively, whereas hyaluronic acid lasts 9–12 months. Silicone is no longer available due to possible side effects but may last permanently [11, 12].