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Lip Service

Top doctors share lip enhancement strategies.

By all accounts, 2016 is set to be the year of the plumped-out pucker. Early data suggest that lip enhancement procedures are on the rise. A survey by RealSelf found that 30 percent of dermatologists and 43 percent of plastic surgeons said they got more requests about lips in 2015 than in 2014.

The availability of soft tissue fillers specifically approved for lip augmentation has done much to erase collective memories of the “duck face” and “trout pout” that were seen with overly generous collagen injections and the non-judicious use of lip implants.

For sure, Kylie Jenner, the youngest daughter of Caitlyn Jenner (formerly Bruce) and Kris Jenner, has helped propel lips into the spotlight—first with a viral but ill-advised lip challenge (Find shot glass, insert lips, and suck.), followed by a new and quickly sold-out lip kit and the eventual disclosure that she has used fillers to add volume to her envy-of-many lips.

There’s more to it, though, explains Modern Aesthetics® co-chief medical editor Steven Dayan, MD, FACS, a Chicago facial plastic surgeon and author of “Subliminally Exposed: Shocking truths about your hidden desires in mating, dating and communicating.” “There is a lot of evidence that full lips do correlate with fertility and libido,” he says. “They can be a subliminal clue that catches an unknowing eye and suggests that a female is fertile and available,” he says. “In the Ethiopian Suri tribe, lip plates are a sign of beauty, and the larger the lip plate, the more cows the girl’s father can demand in dowry when his daughter is married.”

“I am confident that most aesthetic procedures have a biological reason and if we dig deep enough and far enough back we can find it,” Dr. Dayan says. As for lip augmentation, “this is not a fad. It’s here to stay and will only get more popular,” he predicts.

Modern Aesthetics® spoke to top cosmetic doctors top find out how they approach this increasingly common procedure and learned that there is certainly no one-size-fits-all approach to lip enhancement. Ahead, see what our experts had to say.

The most important part of lip treatment is proper diagnosis. Does the patient need volume, outline, commissures, lipstick lines, or philtral definition? Younger patients only need a little air in the tire while older patients require multifocal treatment. I tend to treat younger patients with flexible cannulas and older patients with needles. The reversibility of hyaluronic acid fillers is a great insurance policy. I also use silicone for select patients for whom I have first performed reversible treatment. Silicone is the most natural feeling filler.

Joe Niamtu III, DMD | Cosmetic facial surgeon | Midlothian, VA

When performing surgical lip augmentation, I always assess each case individually to choose the best approach. Often times, a lip lift is the best method to create naturally beautiful lips that do not look like a ‘trout pout.’ The lip lift procedure targets only the upper lip and can be executed to elevate different sections of the lip along the central Cupid’s bow, resulting in the creation of a Golden Ratio between the Cupid’s bow apexes not present in a flat lip.

Andrew Jacono, MD | Facial plastic surgeon | New York City and Great Neck, NY

This is the year of really targeted and strategic enhancement to the lips. We are addressing wrinkles around the mouth with Restylane® Silk and volume loss in the lips with Restylane® or Juvederm®. Microfocused ultrasound therapy is another great tool to help tighten the skin above the upper lip. This is what I call a stackable approach to lip enhancement. I can do Ultherapy® and in the same setting or day, I can do filler around the mouth and add volume to lips. The results last longer when you combine agents.

Julius Few, MD | Plastic surgeon | Chicago

The important thing to realize for natural-looking lip augmentation - especially for patients beyond their early 30s or so who’ve lost some facial volume due to aging is that it’s at least as much about restoring lip support as injecting the lips themselves. Often the lip support is the important part, because loss of this support is the cause of thinning lips, and injecting instead into the lips themselves can produce that notorious, unnatural-looking “duck lip” effect due to addressing the effects of what is seen rather than the cause.

In my teaching, I define immediate and peripheral perioral frames to which volume should be restored for most effective lip rejuvenation. The peripheral perioral frame extends as far out as the skin just in front of the ears, and down to the base of the chin. For lip injection, the aim is for the lips to be soft and the filler completely undetectable. I like Belotero Balance® for its scientific properties (low elasticity or G’ and low viscosity) that make it soft and easily spreadable. It doesn’t tend to swell too much after injection. For immediate lip support just below, above, and around the lips, I like Belotero Balance® or Restylane® Silk injected as a superficial thin sheet parallel to the red border of the lips, just below the skin. This is good also for the “bar code” also known as the vertical lip lines that are sometimes called “smoker’s lines.” For surrounding lip support, I like Juvederm® Ultra Plus, Restylane® or Restylan® Lyft, Radiesse® or Juvederm® Voluma, injected deeply into the fat layer below the skin. The choice of filler depends on the quality of the patient’s skin and on the desired amount of ‘lift’ or tissue re-volumization. I avoid very firm products in thinner skin as they may cause lumps and bumps.

Hema Sundaram, MD | Dermatologist | Fairfax, VA and Rockville, MD

The ideal lip aesthetic has been frequently described in the literature. The most commonly noted components are an upper lip with a defined and shapely Cupid’s bow, approximate symmetry in terms of fullness to the upper and lower lip, a degree of upper incisor show as well as a well defined philtrum and philtral columns. 

As these traits diminish with age, lips lose their anatomic demarcation. Lips thin out, they start to sag and relax, and there is a reduction in the show of upper teeth during a relaxed smile. Furthermore, the corners of the lips begin to turn down, which creates a sad or cross expression when resting.

To create a desirable improvement, I adapted a lip lift procedure to extend the lip borders, even out asymmetries, shorten the distance between the upper lip and the nose, and correct drooping corners. After a thorough evaluation of the patient’s anatomical defects and goals, I utilize two basic types of techniques; the direct lip lift and the indirect lip lift. The direct lip lift is effective for increasing the prominence of the vermilion of the lips, by removing tissue as needed, either directly from or from above the vermillion border. By removing a select amount of tissue through carefully placed incisions, this technique can be used to improve the shape of the upper lip. It will advance the vermilion from both peaks of the Cupid’s bow outwards to the commissures. Incisions may also be placed below the lower lip to increase the projection of the vermilion, if desired.

Indirect lip lift techniques may involve several variations or a combination of methods to achieve the best result. I most frequently perform the sub-nasal lip lift, also referred to as the bull-horn lip lift, which involves the removal of an ellipse of tissue from under the nose. The skin is elevated and sutured to lift the lip and reveal more upper-lip vermilion. This technique may also include a lift to address drooping commissures.

The advantage of a lip lift procedure is that if it is performed well, you can achieve very natural results and patient acceptance is high.

Many times lip lifts achieve a lift which can not be achieved with fillers alone. Fillers alone in the upper lip can create the “duck-face” appearance. I also complement upper lip lifts with fillers in lower lip because the lower lip needs to be one third larger than upper lip.

Sam Rizk, MD, FACS | Facial plastic surgeon | New York City

The No. 1 way to make lips look better is to stay away from lips. Start instead by improving the structure of the surrounding areas of the face that support the lips. For example, replenishing volume in the cheeks and chin will improve visibility of the corners of the lips. Lifting the nose can shorten a long upper cutaneous lip and lift the Cupid’s bow.   

My patient population is very wary of getting obviously filled lips and primarily complain of perioral lip lines. I explain that hyaluronic acid fillers can be used to improve the lines and the lips’ ability to hold onto moisture, something that is lost with age.  I superficially flood the entire upper cutaneous lip with Belotero Balance® softened with lidocaine to fill the lines and add substance to the dermis and subdermis. Patients who strongly purse their lips while talking also need a few units of neurotoxin along the vermillion. I inject Restylane® Lyft or Juvederm® Ultra XC also softened with lidocaine to define the vermillion border and replenish the lips themselves. The goal isn’t size, but natural and more youthful appearing lips.”

Heidi Waldorf, MD | Co-Chief, Medical Editor, Modern Aesthetics® | Dermatologist | New York City and Nanuet, NY

The most important factor when creating inviting lips is to maintain facial harmony by tailoring each procedure to the patient’s facial aesthetic, age, and ethnic background.  When I evaluate a patient’s lips, I start at the corners and work my way in. The corners of youthful lips should be horizontal to the face or ever so slightly turned upward.  Down-sloping corners are a sign of aging and subconsciously denote dissatisfaction. Although fillers can help improve the orientation of the corners, sometimes I use neuromodulators such as Xeomin® to relax the depressors of the lip corners.  Next, I examine overall lip fullness. With age, lips tend to thin out and curl inwards. Strategic placement of fillers such as Juvederm® or Restylane® Silk not only restore the volume, but rotate the lips outward showing more mucosa. Women try to accentuate this mucosa by applying glossier and thicker lipstick, but a well-placed filler can create this look naturally. I make sure to inject in varying depths to avoid the creation of rolls or duck lips. Then I turn my attention to Cupid’s bow, the seagull shaped white border of the central portion of the upper lip. Minimal filler here can help accentuate the bow and create a more sultry look. To smooth out the fine lines and wrinkles surrounding the mouth I use a combination of lasers and super-fine fillers such as Belotero Balance®. The goal is to create a natural look and feel that is imperceptible yet appealing. n

Ulysses Scarpidis, MD | Plastic surgeon | New York City

Editor’s note: “It’s really incumbent on doctors to be extra cautious with filler in the lips because too much can look unnatural. Some people have very thin lips and regardless of how much filler you use, you aren’t going to get a good result. “ – Steve Dayan, MD

WATCH IT NOW

“Perioral rejuvenation is really a central point in our aesthetic practices. And many patients come in thinking one particular modality or particular device is going to give them great results. In reality, I think we really need to think about combination therapy,” said Joel L. Cohen, MD, Director of AboutSkin Dermatology and DermSurgery in Englewood and Lone Tree, CO, at the Cosmetic Surgery Forum 2015 in Las Vegas. Watch more on ModernAesthetics.tv Search key: perioral rejuvenation