More permanent options include Alloderm (homograft of skin) [13, 14] and Polytetrafluoroethylene [15], but these have more complications than the injectable materials. Above all, they may need to be removed due to the client being able to feel the implant, for instance, at the time of eating and kissing.

Other rarer complications for implantable materials include seromas, malposition, infection, extrusion, long-term inflammation, and capsule formation.

57.7 Discussion

In the opinion of the author, the best results for lip enlargement are achieved with injectables, and my advice is to use a filler that is absorbable. The filler is injected superficially (under the dermal layer). When approaching the Cupid’s bow or arch, do so from the inferior direction, otherwise it creates inversion of the lip resulting in an unaesthetic appearance. A list of fillers is provided. Most are natural polysaccharides, which are completely biologically degradable. Hyaluronic acid is naturally integrated into the tissues, so nutritive agents pass freely through the implant and cells pass between fragments of gel. Hyaluronic acid exists in the human body and is able to bind water and lubricate movable parts of the body such as muscles. Hyaluronic acid can be extracted from tissues rich in hyaluronan or produced bacterially through fermentation. This can produce hyaluronic acid in unlimited amounts while maintaining high.

Fat transfer techniques have been used to produce aesthetically appealing lips, but there is steep learning curve to this technique. The author prefers the Pearl

technique, which injects small aliquots of fat parcels in multiple layers.

A more permanent material is Alloderm which is a homograft of skin, where the soft form is expanded during the procedure. Polytetraflouroethylene is a permanent material but may occasionally require removal. The patients feel these implants during kissing, eating, and other activities. Other complications include seroma, malposition, infection, extrusion, long-term inflammation, and capsule formation. These complications are fortunately rare. Lip augmentation can be performed alone or in combination with facial surgery. In addition to these injectable and implantable procedures, operative procedures may also be considered. This includes operations which involve advancement, lift, and roll techniques. The complications, however, may be significant and hypertrophic scarring, asymmetry, numbness, and lumpiness may be seen [16–23].

References

1.Segall L, Ellis DA. Therapeutic options for lip augmentation. Facial Plast Surg Clin North Am. 2007;15(4):485–90.

2.Wall SJ, Adamson PA. Augmentation, enhancement, and implantation procedures for the lips. Otolaryngol Clin North Am. 2002;35(1):87–102.

3.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. 2005;55(1):30–5.

4.Sclafani AP. Soft tissue fillers for management of the aging perioral complex. Facial Plast Surg. 2005;21(1):74–8.

5.Godin MS, Majmundar MV, Chrzanowski DS, Dodson KM. Use of radiesse in combination with restylane for facial augmentation. Arch Facial Plast Surg. 2006;8(2):92–7.

6.Bagal A, Dahiya R, Tsai V, Adamson PA. Clinical experience with polymethylmethacrylate microspheres (Artecoll)

for soft-tissue augmentation: a retrospective review. Arch Facial Plast Surg. 2007;9(4):275–80.

7.Ersek RA, Beisang III AA. Bioplastique: a new biphasic polymer for minimally invasive injection implantation. Aesthetic Plast Surg. 1992;16(1):59–65.

8.Sarnoff DS, Saini R, Gotkin RH. Comparison of filling agents for lip augmentation. Aesthetic Surg J. 2008;28(5): 556–63.

9.Ali MJ, Ende K, Maas CS. Perioral rejuvenation and lip augmentation. Facial Plast Surg Clin North Am. 2007;15(4): 491–500.

10.Jordan DR. Soft-tissue fillers for wrinkles, folds and volume augmentation. Can J Ophthalmol. 2003;38(4):285–8.

11.Jacinto SS. Ten-year experience using injectable silicone oil for soft tissue augmentation in the Philippines. Dermatol Surg. 2005;31(11 Pt 2):1550–4.

12.Barnett JG, Barnett CR. Silicone augmentation of the lip. Facial Plast Surg Clin North Am. 2007;15(4):501–12.

13.Gryskiewicz JM. Alloderm lip augmentation. Plast Reconstr Surg. 2000;106(4):953–4.

14.Fagien S, Elson ML. Facial soft-tissue augmentation with allogeneic human tissue collagen matrix (Dermalogen and Dermaplant). Clin Plast Surg. 2001;28(1):63–81.

15.Singh S, Baker Jr JL. Use of expanded polytetrafluoroethylene in aesthetic surgery of the face. Clin Plast Surg. 2000; 27(4):579–93.

16.Seymour PE, Leventhal DD, Pribitkin EA. Lip augmentation with porcine small intestinal submucosa. Arch Facial Plast Surg. 2008;10(1):30–3.

17.Trussler AP, Kawamoto HK, Wasson KL, Dickinson BP, Jackson E, Keagle JN, et al. Upper lip augmentation: palmaris longus tendon as an autologous filler. Plast Reconstr Surg. 2008;121(3):1024–32.

18.de Benito J, Fernandez-Sanza I. Galea and subgalea graft for lip augmentation revision. Aesthetic Plast Surg. 1996;20(3): 243–8.

19.Niechajev I. Lip enhancement: surgical alternatives and histologic aspects. Plast Reconstr Surg. 2000;105(3):1173–83; discussion 1184–7.

20.Mutaf M. V-Y in V-Y procedure: new technique for augmentation and protrusion of the upper lip. Ann Plast Surg. 2006;56(6):605–8.

21.Wilkinson TS. Lip enhancement. In: Practical procedures in aesthetic plastic surgery: tips and traps. New York: Springer; 1994, pp. 117–144.

22.Guerrissi JO. Surgical treatment of the senile upper lip. Plast Reconstr Surg. 2000;106(4):938–40.

23.Burres SA. Lip augmentation with preserved fascia lata. Dermatol Surg. 1997;23(6):459–62.

Liposuction of the neck is the removal of unwanted adipose tissue using a tumescent technique, which can restore the jaw line and cervicomental angle. Liposuction of the neck has become a common cosmetic procedure, either on its own or in conjunction with facelifting or other facial procedures. It has many advantages over older techniques. In the author’s practice it has improved the results of facial rejuvenation manyfold. The practitioner must be aware of all the pitfalls associated with this procedure. In my opinion most facelifting and facial rejuvenation procedures today require some form of liposculpturing to achieve the best results. Liposuction of the neck achieves excellent results in patients with excess fat along the jowl and in the neck, good skin elasticity, and minimal platysmal banding (Figs. 58.1 and 58.2).

Liposuction of the neck is performed using local anesthesia in the form of a tumescent solution [3, 4]. Fat is aspirated using small cannulas that have been introduced through small incisions below the earlobes and in the submental crease. I use the manual syringe technique to aspirate the fat. Negative pressure formed in the syringe allows adipose tissue to enter the hollow cannula. Back and forth motion of the cannula disrupts fat and creates a series of interlacing tunnels within the fat. Once completed, the patient will wear a compression garment which compresses the tissues and aids in skin contraction. Good knowledge of the anatomy of the neck and musculature of the face is important prior to performing this procedure [5, 6].

58.2 Advantages

1.Inexpensive.

2.Less traumatic than open procedures.

3.Safe.

4.Small scars.

5.Simple technique.

6.Fat aspirated may be used for lipotransfer [1, 2].

A. Erian

Pear Tree Cottage, Cambridge Road,

Wimpole 43, SG8 5QD Cambridge, United Kingdom e-mail: plasticsurgeon@anthonyerian.com

58.4 The Tumescent Technique

The tumescent technique was introduced by Klein in 1987 and was the milestone that allowed liposuction to be performed with local anesthesia [7]. Various tumescent solutions have been described, but the author prefers the following:

1.250 ml of saline

2.Adrenaline 1:1,000

3.Lignocaine 1% 20 ml

This is injected with a 19 gauge needle. The technique of injecting is superficial and in a linear fashion. The nondominant hand, often called the “smart” hand, must be used as a guide for the depth at all times. The linear threading method is the least traumatic.