Creating the perfect pout

Harry Singh explains the treatment process and potential complications for considering non-surgical lip augmentation.

From Hollywood lips to the Essex lip, it seems that a commonly requested procedure from our aesthetic patients is the non-surgical lip augmentation.

Lips have always created attention and there is currently a high public demand for lip enhancement, which many consider to be a sign of attractiveness (Wollina, 2013). 

Full, well-defined lips showcase youth, health, attractiveness and sexuality.

Wider, fuller and curved lips and a short upper white lip are signs of female attractiveness (Verner, 2015) – a feeling only accentuated by the celebrities showcasing their own pout – from Kylie Jenner and Katie Price to most of the Love Island cast.

So why do we see so many distorted results?

In this article, we will look at how you can create that perfect pout. This will involve balancing age-specific treatments with the correct product selection.

Let’s start off with the basic question: who is legally allowed to carry out these procedures?

Shockingly, anyone can – from your local hairdresser to your local beautician. Dermal fillers are not classified as prescription-only medicines (POM), so are freely available to all. Conversely, the enzyme used to reverse dermal fillers – hyalase – is a POM, so can only be administered by a prescriber (or a prescriber must supervise its use).

Understanding anatomy

Figure 1: The anatomy of the lips

Let’s take a look at the most salient features of the perfect pout. Figure 1 shows some common features of the lip anatomy.

In caucasians, the upper lip is narrower, only accounting for 40% of the total volume, with the remaining 60% allocated to the lower lip. Be wary of patients asking for the upper lip to be the same size as the lower lip (a current trend): it will not look natural. However, in Afro-Caribbean patients the split is 50:50.

There are several points to note regarding the ‘ideal’ anatomy of the lips that can be seen in Figure 1:

  • The skin above the vermillion border should generally be smooth, without any visible rhytides
  • There should be sharply-defined philtrum columns
  • There should be a well-defined Cupid’s bow centrally
  • The upper lip should have a prominent medial tubercle with bilateral depressions
  • The lower lip should have a small depression centrally and two lateral protrusions.

In the lateral projection, the upper cutaneous white lip is short with concavity approaching the red lip, and the upper lip should project 2mm further than the lower lip. 

The main arterial blood supply to the lips comes from the superior and inferior labial arteries (branches of the facial artery). The mental artery supplies the chain and lower lip (Radlanksi and Wesker, 2012).

The ageing process

  • Figure 2 and 3: The ageing process

As we age (Figures 2 and 3), there are marked differences in the appearance of our lips, such as:

  • A loss of fullness and projection
  • The development of rhytids
  • A reduction of the vermillion border
  • An inversion of the lower lip
  • A reduction of show of the upper teeth
  • An increased show of the lower teeth
  • A flattening of the Cupid’s bow
  • A flattening of the philtrum columns
  • A lengthening of the cutaneous upper lip
  • A reduction of the nasolabial angle
  • A reduction in the mentolabial angle
  • Reduced vermillion pigmentation.

Note that there is no actual volume loss. Instead, a redistribution of thickness of the lip towards length, a loss of elasticity and resulting ptosis.

At this point we should also make special mention to dental-related changes that also cause ageing of the lips.

Tooth wear affects the smile arc. The maxillary incised edge curvature should be parallel to the curvature of the lower lip. And at rest there should be 2-4mm exposure of upper incisors in relation to upper lip.

Tooth loss causes alveolar ridge resorption, resulting in decreasing facial height. In turn, dentures will affect the position of soft tissues and lips.

Be aware of patients undergoing orthodontic treatment. Generally, you should not treat for non-surgical lip augmentation until you complete and stabilise their treatment.

Filler properties

I would recommend using a hyaluronic acid (HA) filler for the lip augmentation. HAs are safe, occur naturally in the body and are reversible.

There are numerous fillers available on the UK market and several properties that you need to consider. This can be a minefield for the unprepared, as each material’s viscoelastic, elastic modulus, cohesive, HA concentration, and viscosity properties need to be considered.

To simplify, there are three main product characteristics you will analyse:

  1. Particle size – this dictates the amount of volume that is created. A larger particle size will create more volume and hence have a greater longevity
  2. Degree of cross linking – pure HA is very unstable, with a very short half-life. The strands of HA need to be cross linked to give longevity to the filler. The higher the degree of cross linking, the more lifting capacity is given to the filler
  3. G prime – this relates to the resistance to force. A high G prime is like a rubber ball: it maintains its shape and is very resistant to force. It will stay where it is put and not be moulded. A low G prime is more like syrup: it will flow and can be moulded to give a smoother, more natural result.

Be wary: lips are soft, movable, and serve as the opening for food intake and in the articulation of sound and speech. Human lips are a tactile sensory organ, and can be an erogenous zone when used in kissing and other acts of intimacy.

I would advise products with a low G prime. This allows the lips to carry out their natural functions.

Treatment protocol

Before treatment

The assessment is the most critical part of this procedure!

During the assessment, I want to discover the patient’s expectations. Are they realistic? Do they suit the patient’s face? Can I deliver these expectations – and most importantly, do I want to?

As more of these procedures become mainstream, you will come across more and more cases of body dysmorphic disorder. This is a mental health condition where a person spends a lot of time worrying about flaws in their appearance. These flaws are often unnoticeable to others.

Once it has been determined that non-surgical lip augmentation is the treatment of choice, we can then assess whether we want to enhance what’s already there or whether we want to rejuvenate/recreate what the patient had previously.

My tip for this is that ‘less is more’.

Medical history

As well as general contraindications such as pregnancy, anticoagulant therapy and Roaccutane usage, we are also looking at specific conditions such as cold sores.

Herpes simplex virus

If it is visible, then postpone the treatment. If the patient is high risk (having experienced a previous outbreak after aesthetic procedures or those that have had three or more outbreaks in the previous 12 months), they should receive prophylaxis. This prophylaxis should start one to two days before the procedure and continue for five to seven days.

Consider 400mg acyclovir twice a day or 500mg valaciclovir once a day.

Bruising

Be aware of medications that predispose to bruising (painkillers, NSAIDs, anticoagulants, and vitamin E).

Consent

You need to obtain consent for the procedure itself. As well as use of photographs for marketing purposes (if you intend to use them for this).

Photographs are essential and mandatory for medicolegal reasons. I also use them for patients requesting restoration of their lips. I ask them to bring an older photo of themselves (ie, when they were younger). This allows me to determine what their lips used to look like.

Anaesthesia

There are a number of anaesthetic options available, such as relying on the lidocaine in the fillers, LMX4 cream or dental infiltrations.

As dental professionals, we have an advantage of providing comfortable infiltrations, which will make the procedure painless.

Disinfection

Disinfecting the perioral area with a suitable disinfectant, such as Clinisept, is self-evidently essential.

During treatment

  • Figure 4: Border injection points
  • Figure 5: Lip body injection points

Should you use a needle or a cannula?

There are pros and cons for each.

In my opinion, needles will give you better control and more precise placement of the filler (and thus the result), but are more traumatic.

Cannulas are less invasive, require fewer injection points, but are harder to control. Cannulas link to less bruising, less swelling and less pain than needles. They are less traumatic, but still invasive.

I personally prefer to use needles for the borders and cannulas for the body.

I recommend starting with the borders (Figure 4). Aspirate first for at least seven seconds. If you are aspirating, it is better not to prime the needle beforehand. If you get a flashback, stop and reposition.

There are many techniques, with new ones coming out every year.

I prefer the retrograde or linear deposit of filler when doing the borders and squeezing the vermillion border with your non-injecting hand.

Then we would fill the body using cannulas (Figure 5). My preferred choice of cannulas are the TSK 25G cannula with 23G needle, 38mm.

By following this protocol you will create natural-looking results that the patients will love (Figures 6 and 7).

  • Figure 6: Patient A before and after
  • Figure 7: Patient B before and after

Postoperative protocol

Once you complete the treatment, discard any unused product. Dermal fillers are for single use only. Give the patient postoperative instructions both verbally and in writing (Figure 8). Take postoperative photographs (depending on the degree of swelling/oedema, you may need to delay your photographs) and book the review appointment.

Figure 8: Postoperative advice

Complications

As with all procedures, there are potential complications. As practitioners we want to minimise or avoid these complications and if they do occur we must know how to manage them.

The soft tissue around the lips is loose, delicate, and easily expandable. The lips have a high muscle activity and rich vascularisation. They are highly sensitive to trauma and prone to swelling and bruising. You must warn the patient of all the above.

Every injection will cause oedema, and this is not necessarily symmetric. Other common post treatment side effects and their treatments include:

  • Swelling – apply cold compress
  • Bruising – arnica cream/tables, pineapple (which contains bromelain, which increases the discharge of metabolic waste)
  • Tenderness – painkillers
  • Redness – reassurance

All the above are transient and mild, and will self-resolve within one week.

Summary

To create the perfect pout, follow the above protocol and you will have very happy patients who are more likely to spread the word. To be safe and get predictable results, follow the four Ps:

  • Patient: am I happy to see this patient?
  • Person: am I the right person to do it?
  • Product: do I have the right product?
  • Place: can I perform this treatment in the right place?

References

Radlanski RJ, Wesker KH (2012). The Face: Pictorial Atlas of Clinical Anatomy. Quintessence Publishing Co, Berlin

Verner I (2015). Lip Augmentation. Body Language 2015. www.bodylanguage.net/lip-augmentation

Wollina U (2013). Perioral rejuvenation: restoration of attractiveness in ageing females by minimally invasive procedures. Clin Interv Aging 8: 1149-55

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