Lip Augmentation

Lip Augmentation and enhancement figure prominently in the non –invasive and minimally invasive treatments available. Dr Rupert Gabriel discusses the developments made and the direction the procedures are heading.

Full lips with an accentuated border have often been associated with beauty and youth. The lips occupy both sides of the face and, with the smile, constitute a focal point of overall facial beauty.

The lips and smile are central to the mod-face triangle, increasingly recognised as an important focus of modern aesthetic treatments. As facial aesthetics evolves and as we start to take a more considered approach to the assessment of the face as a whole, it makes sense to broaden our view of the perioral area and lips.

Treatments are now rarely planned in isolation. It is far more common to plan a ‘patient journey’ of a sequence of treatments to provide the most appropriate combination to suit an individual’s needs.

For this reason it is essential to consider lip treatments with other focal treatments, such as muscle-relaxing injections and dermal fillers, as well as consider volume issues and the management of the effects of ageing from sun damage and smoking on the substance, elasticity and general quality of the skin.

The Lips and smile are central to the mid-face triangle, an important focus of modern aesthetic treatments

History

In the 1900’s, surgeons first tried injecting paraffin into the lips for aesthetic embellishment with little success. Years later, in the 1960’s, liquid silicone was used but was abandoned owing to ears about the effects of silicone – both locally and on general health.

Liquid silicone presented similar problems to those experienced with encapsulated liquid silicone breast implants. The liquid silicone, in some cases, could migrate and cause local and distant granulomatous reactions that were difficult to treat in addition to deleterious systemic effects.

In the late 1990’s, with the huge popularity of facial rejuvenation and concomitant increase of cosmetic and plastic surgery procedures worldwide, more substances – along with biocompatible materials common in other medical applications for years – became available to surgeons for augmenting thinning or misshapen lips to render them more plump and attractive.

A popular product was an allogneic material called Alloderm, created from donor tissue taken from cadavers and then denatured, purified and treated to remove viable cells that could pass on disease. Under local anaesthesia, Alloderm was placed into the mucosa or body of the lips in small rolls to make them larger. Alloderm was also placed into the vermillion to provide definition and a sharper border.

Bovine collagen was introduced in the 1980’s and became the standard injectable against which other injectable fillers were measured. But collagen’s popularity has waned as it has limited longevity and requires a test for hypersensitivity before treatment, requiring the patient to wait at least three weeks before the procedure could commence.

Hyaluronic acid fillers, such as Restylane and Juvederm, have captured the attention of potential consumers and aesthetic physicians around the world because of their safety, ease of use and reversibility.

A longer lasting injectable material used in the lip is calcium hydroxylapatite (bone) suspended in a gel. Radiance/Radiesse is a synthetic laboratory-produced solution that has been safely used in medicine for years. Studies have indicated that such products can last longer then hyaluronic products – from three to five years.

However, Radiesse, commonly used in the cheeks and nasolabial areas, is not recommended for the lips, owing to the risk of the formation of modules, which could require surgical intervention.

Methacrylate and collagen in the form of Artecoll has been used to achieve longer-lasting lip augmentation but has fallen from favour because of delayed allergic reaction, nodule formation and over-correction.

Fat transfer can last longer than other injected materials but can cause irregularity or scarring. The length of time a fat transfer may last is determined by how much the area moved and how close it is to a major blood supply. In addition, the donor fat must be harvested from another area of the patient’s body, which leaves another surgical wound.

Gore-Tex, known as ePTFE or expanded polytetrafluoroethylene, previously had many medical uses. For lip augmentation it is known commercially as Advanta, UltraSoft and SoftForm. The ePTFE was provided for use by surgeons in tape form and small diameter tubes.

Early ePTFE implants suffered from some problems with migrating infection, rejection, and hardening of the implant with the passage of time. Due to the porous nature of the surface of the ePTFE tubing, the implant may require significant surgical dissection to remove, causing damage to the lip tissue and a poor cosmetic outcome.

Two examples of permanent implants that offer a long-term solution in lip volume restoration and enhancement that have only recently gained CE marks and FDA approval are Permalip and Fulfil. These implants are placed along the wet mucosal border of the lip, potentially giving a more natural look than attempting a similar volume restoration, with the emphasis on the external vermillion border.

Permalip is made of a sot, solid silicone elastomer, using injection moulding to produce a naturally contoured implant with a smooth, non-porous surface. The implant cannot rupture or deflate and the shape encourages stability, limiting possible migration. The implant may be removed at any time or be replaced with another size.

The Permalip procedure can be performed in a simple office setting under local anaesthesia. The mouth and lips are locally anaesthetised and two small incisions are made in the corners of the mouth. A tunnel is created by blunt dissection through the submucosal plane from each side. The implant is pulled through a tunnel with a tunnelling forceps and centred. This is repeated for the other lip and the incisions are closed using absorbable suture. The entire process can take less than 30 minutes and normal activity may be resumed the following day.

Fulfil is a thin-walled silicone shell containing a small volume of saline coated with a membrane of ePTFE. The thin layer of ePTFE permits only limited ingrowth adequate for tissue anchoring but without the prolific fibrosis that could eventually harden the implant. Limited tissue ingrowth also means that removal of the implant does not require extensive dissection.

The Fulfil procedure is similar to Permalip’s, as a small incision is made at each end of the lip, approximately 1-2mm medial from the commisure. After dissection in the submucosal plane, a sheath is placed in the pocket. The implant is introduced and threaded through the sheath using the attached passing needle.

After removing the sheath and leaving the implant in place, the attached sutures may be used to optimise positioning. Saline is injected through the implant full tube until the desired fill volume is reached. The fill tube is then removed, valve self-sealed and sutures trimmed, leaving the implant in place, and the incisions are closed.

Considerations

The usual list of contraindications apply to all lip procedures and injections, including pregnancy, breast feeding, immune deficiency, bleeding diatheses, and others. Prophylactic cover with anitvirals such as Acyolovir as well as oral antibiotics is judicious for all procedures where the patient has a history of herpes simplex and is essential where a permanent implant is being placed.

Temporary hyaluronic filler carry the usual risks of pain, bruising, swelling and infection, usually short term. In addition, reactions to the material itself can occur, which are usually mild and self-limiting. Rarely, more serious reactions can occur, such as granulomatous reactions and avascular necrosis.

The saving grace of hyaluronic acid as a material is that it is instantly reversible with an injection of hyaluronidase should problems or irregularities occur that cannot be corrected or ameliorated in any other way.

Permanent implants are generally considered only if temporary fillers do not last as long as expected, or if the patient wishes to avoid the repeated pain and downtime associated with such treatments over time. Permanent implants also carry the additional risk of capsular formation, migration and even extrusion, and rejection.

As opposed to the longer-lasting injectable treatments and older implants, the newer permanent implants are easy to remove with a procedure similar to their introduction, which required minimal dissection and, therefore little possibility of adverse sequelae.

Patient selection

Focus on the lip and perioral area has, perhaps, diminished as our appreciation of the value of combination treatment grows and patient assessment and managing patient expectation becomes more sophisticated.

The quality of the skin in the perioral area and in particular, lip lines, need attention. With the advent of fraction ablative laser systems, fast treatments can be offered with minimal downtime.

Surface treatments in combination with volume replacement – either temporary, permanent or a combination of the two – can be offered.

Botox can be used in small doses to improve lip lines and counter ‘mouth frown’ by treating depressor anguli ori in appropriate cases.

There has been less focus on labral (vertical lip) height as it relates to the ageing lip; the approach to successful facial rejuvenation has perhaps neglected this aspect of perioral ageing. Surgeons are increasingly recognising the importance of excessive labral height, either congenital or due to ageing in contributing to the apparent lack of upper lip fullness.

The over-long upper lip allows it to roll in, creating a thin ‘shelf like’ lip. Such patients may achieve an unsatisfactory appearance following temporary or permanent lip augmentation.

A possible perioral lip classification system (PLCS) taking this into account has been suggested by Peter Raphael MD and Scott Harris MD, Tex McFaden, DO (forthcoming publication) who suggest five categories (see table 1)

Table 1: Five categories of labral height for proposed perioral lip classification system

A suggested approach by the originators of this classification is to consider combining lip augmentation with lip-lift surgery having developed a new procedure with high endonasal placement of the anchoring suture which results in an improved scar appearance. Eighty-two such endonasal lip lifts are described that have been performed since August 1998, with a mean follow-up of one year. Complications, including infection and bleeding, have not occurred.

More importantly, there was no case of scar migration, noticeable loss of lift, or unfavourable scarring in contrast with previous types of lip-lift procedures that gained popularity in the 1980’s that were located either inferior to the nasal base or superior to the vermillion border.

Aesthetic practitioners’ and their patients’ options are rapidly expanding for augmentation – both temporary and permanent of the lips, particularly with the newer, safe and easily reversible permanent implant options.

It is perhaps time for a fresh look at our assessment, classification and approach to keep up with and parallel the improvements in our understanding of facial aesthetics in general and the underlying processes we are trying to correct so we can fit the whole jigsaw puzzle together.

When choosing a product, cost is important to patients. With common lip-filler products such as hyaluronic acids lasting approximately six months and costing on average £300 per treatment, a permanent implant might seem an attractive option after three years or so.

As with many new products, manufacturers’ claims tend to be somewhat overstated. A note of caution should be observed on their safety and efficacy, because until long term clinical evidence is gathered, little is known of any potential future complications.

More clinical trials will need to be done over the years to compare the different approaches to lip implants before we have a conclusive view on which materials produce the best results and the fewest complications. Ultimately, the conclusions will point to the products that are safest and offer the best value for money.