Lip Augmentation Treatment & Management
- Author: Jorge I de la Torre, MD, FACS; Chief Editor: Deepak Narayan, MD, FRCS more...
Various nonsurgical and temporary applications can plump the lips. These topical applications usually work by causing a mild inflammatory response of the lip mucosa. They usually contain Capsicum annuum or Capsicum frutescens (the fruit of the red pepper plant, used for making cayenne pepper or Tabasco), although some may contain cinnamon oil or caffeine. Newer formulations contain palmitoyl oligopeptide and L-arginine for collagen synthesis.
Surgical lip augmentation can be achieved with injectable fillers, implants, and surgical advancement, roll, or lift.
Significant ease of use, "off-the-shelf" availability, and widespread acceptance by the public make collagen one of the most common fillers used. Lip augmentation with collagen and other fillers can be performed by injecting the material in any or all of the anatomic parts of the lip, allowing for a very controlled and predictable result. Precautions regarding mode of injection and quantity of the substance injected vary widely within this family of products.
Other materials and products that are used commonly overseas include hyaluronic acid preparations such as Restylane or Perlane. Restylane was approved by the US Food and Drug Administration (FDA) for lip augmentation in October 2011.
Hyaluronic acid mixtures containing methylmethacrylate beads (eg, Artecoll) allow for long-term lip augmentation, since the beads remain in the soft tissue permanently after resorption of the hyaluronic acid. Hyaluronic acid mixtures containing hydrogel particles (eg, DermaLive) allow for long-term augmentation (>1 y) after resorption of the hyaluronic acid component because of the permanence in the tissue of the synthetic hydrogel particles. Bioplastique is a filler available in the United States with similar characteristics; it consists of 38% biphasic polymer textured silicone particles suspended in a 62% bioexcretable gel carrier.
Autologous fat recently has become a more popular choice of filler. The distinct advantage of fat as a volume augmenter is that the results obtained are long-lasting (in some cases, permanent), depending on the amount of tissue injected and the location treated. Moreover, the risk of allergic reactions is avoided since the fat used is autologous tissue. Fat is obtained from the patient's donor site under local anesthesia; prepared with saline wash, decantation, or centrifugation; and then injected in the lips. As much as 30% of the injected fat can persist after transplantation with appropriate technique, and, in some patients, almost complete survival of the graft has been reported. Lip augmentation with autologous tissue is a viable alternative to injectables and can produce durable long-term results.
Taking into account the typical pattern of the labial arteries, Tansatit et al reported that superficial filler injection can be safely performed in the vermilion borders of the upper and lower lips, as well as in all parts of the lower lip. Upper lip injection should be to the middle body, according to the investigators, in order to avoid injuring the anastomotic arch of the superior labial arteries.
Synthetic materials such as Gore-Tex/PTFE have been used successfully and allow for a controlled application with ease of use. Expanded tetrafluoroethylene is available in tubes with diameters of 2.4 mm and 3.4 mm. They are applied with a disposable applicator and implanted in the subdermal plane at the vermillion border.
Biologic materials are available commercially in the United States and consist of decellularized dermal matrix products. AlloDerm is a harvested dermis that is prepared through a proprietary process and is available for implantation. Other materials, such as porcine submucosa (Surgisis), provide a nonreactive basis for native tissue integration in the lip. Various reports are available, indicating that the decellularized dermis becomes a scaffolding for neovascular ingrowth, and full integration in the patient's tissues has been verified experimentally. While these materials may have additional costs, they are available off the shelf and avoid both donor site morbidity and the use of prosthetic materials.
Autologous dermis, dermal fat, tendon, and fascia grafts are obtained from the patient, shaped, and implanted. In some patients, the grafts may be obtained from skin resected during local procedures such as lip lift or advancement, de-epithelialized, and then grafted. Once the tissue is harvested and shaped, it is threaded through a tunnel within the lip. A curved tendon passer facilitates this procedure. They provide a natural autologous option for both primary and revisional lip augmentation.
A study by Tabrizi et al of 15 patients supported the use of dermal fat grafting as an effective treatment for thin lips, finding significant improvements in vermilion show (mean change 1.73 mm) and upper lip projection (mean change 2.33 mm) 12 months after the procedure. No serious complications occurred during the study.
Surgical procedures involving advancement, lift, and roll are designed to enhance various parts of the lip anatomy using the patient's local tissues. Z-plasty, V-Y, and W advancement flaps are intended to project and fill the central and lateral parts of the vermillion.[15, 16, 17] The flaps are designed on the oral-wet vermillion-mucosal aspect of the lip and dissected just superficial to the muscle, containing the mucosa and submucosal elements. Lip lifts can be designed to shorten the distance between the Cupid's bow and the base of the columella by lifting the lip and enhancing the vertical height of the dry vermillion. Reshaping the lower lip also can be performed in this fashion.
Accurate preoperative planning is mandatory since even minor asymmetries are always clearly evident to the patient and observers. In addition, accurate psychological evaluation should focus on identifying patients with unrealistic expectations. Preoperative digital imaging or photo modifications can help in illustrating postoperative outcome and in operative planning.
See the list below:
Inform the patient of the need for a donor site and determine an appropriate site. In general, the periumbilical fat can be accessed quickly with a small incision within the umbilicus, which heals quickly and inconspicuously.
Block the periumbilical fat tissue with an injection of local anesthetic solution of 1% lidocaine with epinephrine 1:100,000.
After performing a small incision, harvest the fat tissue with 1.5-mm cannula and syringe suction. The volume obtained is variable but in general 20 mL of fat fraction results in 8-10 mL of injectable fat after decantation or centrifugation.
Anesthetize the upper and lower lips, preferably by infraorbital and submental nerve block.
Place the access incisions at the corner of the mouth, within the wet vermillion.
Graft the fat in several layers through the vermillion and lip border, using the injection cannula in multiple passes of small volume to allow for better vascularization of the grafted fat. The injection ports may be left to naturally approximate or may be closed with a fine absorbable suture.
Tissue transfer - Superficial musculoaponeurotic system (SMAS)
At the time of the SMAS-ectomy face lift, retain strips of the SMAS removed. For the upper lip, tailor the strip approximately so that it is 4-6 mm in the center portion and tapered at the tip of each end. The length should be approximately 4-7 cm total. The lower lip graft should be 50-75% the size of the upper lip graft.
Block the lip with local anesthetic solution of 1% lidocaine with epinephrine 1:100,000 at least 10 minutes before augmentation and ideally a minimum of 20 minutes. Create a small incision at each lateral margin of the lip near the commissure. Pass a tendon passer from one end to the other.
Place the appropriate graft within the grasp of the tendon grabber and pull through the lip until the central portion is inline with the lip midline. Release the tendon grabber and trim any excess graft.
Massage the graft through the lip vermillion. Suture the access incisions with 5-0 fast absorbing plain gut suture.
See the list below:
In general, implants are used as vermillion augmenters. The most commonly used biomaterial is AlloDerm, which in many cases has replaced synthetic fillers and PTFE.
Prepare AlloDerm according to manufacturer's specifications.
Infiltrate the upper and lower lips with local anesthetic solution and make two small incisions in the corners of the mouth in the wet vermillion. A special passer is available for delivery of the graft or a standard tendon passer can be used to bluntly tunnel from one incision to the other in the submucosa-subcutaneous plane.
Grasp the AlloDerm sheet and carry it through. Massaging the graft smoothes out the material and allows for better placement.
Close the access incisions with fine absorbable sutures.
See the list below:
Preoperative evaluation of the lip anatomy is critical in assessing the position and size of the V-Y incisions. A 2:1 relationship exists between the length of the Y limb and the obtained increase in lip height. Therefore, the appropriate V-shaped incisions must be planned symmetrically on each side of the frenulum.
Infiltrate the lip tissue with a solution of 1% lidocaine and 1:100,000 epinephrine and anesthetize it by local nerve block.
Make the incisions and extend the dissection toward the lip margin in the submucosa plane, just superficial to the muscle, to avoid injury to the small sensory nerve branches in this area.
Once the planned advancement is obtained, carefully approximate the wounds with 4-0 absorbable sutures.
See the list below:
Preoperative markings are critical. Accurately mark the patient prior to injection and ask the patient to review and approve the markings. Even a 0.25-mm difference in vertical height between the peaks of the Cupid's bow can be noticed clearly postoperatively.
Anesthetize the upper lip and perform the planned full-thickness skin resection starting from the vermillion border. To decrease the chances of hypertrophic scarring, do not include the vermillion and skin directly within the philtral columns, corresponding to the prolabium, in the resection.
Close the wound with interrupted half-buried 5-0 Prolene sutures tied on the vermillion side of the wound.
See the list below:
The areas treated with injectable materials require little postoperative care. Coat lips treated by surgical advancement or implantation with antibiotic ointment 3-4 times per day for 1 week postoperatively.
Ice packs are used extensively in the first 24 hours.
Encourage patients to limit talking, smiling, and laughing for 5-7 days postoperatively.
Provide oral analgesics and instruct patients to rinse the mouth with saline solution 4-6 times per day for the first week postoperatively.
Remove nonabsorbable sutures 5-7 days postoperatively.
See the list below:
Significant postoperative swelling is common to all techniques of lip augmentation. The swelling usually resolves within 7-10 days, but it may persist for several weeks. Recommended postoperative care includes ice packs, sun avoidance, liquid diet, perioral care with saline rinses, and rest for 24-48 hours, depending on the extent of surgery. Inform patients of the significant swelling and bruising that may develop with this procedure; usually, they are able to tolerate it well.
One of the most common complaints after surgical advancement is persistent numbness and/or paresthesias around the augmented lips. This problem usually resolves in 4-6 weeks but may become a significant nuisance for patients.
Inform patients of the approximate duration of the significant swelling of the augmented lips; they should plan their social calendar accordingly.
Follow-up care consists of office visits 1, 7, and 30 days postoperatively, at which time shape, symmetry, function, and wound healing are assessed.
Complications of collagen injection include allergic reaction to the compound, possible intravascular injection, skin slough, scarring, granuloma formation, and hematoma. Testing for sensitivity to bovine collagen must be performed prior to injection and observed for 4 weeks.
Complications of fat transfer include donor site hematoma, scarring, infection, lumpiness, asymmetry, infection, hematoma, intravascular injection, and possible skin slough.
Complications of synthetic material implantation include infection, asymmetry, sensitivity to the material, extrusion, need for removal of the implant because of hardening, interference with lip function, and sensation changes.
Complications of surgical advancement, lift, and roll include hypertrophic scarring, asymmetry, numbness, and lumpiness.
Outcome and Prognosis
Outcome is generally good. Adequately informing patients of the expected postoperative course, possible complications, and required postoperative care is essential.
Future and Controversies
All available techniques of lip augmentation have advocates and critics. To date, a single most effective technique has not been identified, partly because of the wide variety of individual cosmetic complaints. Research in long-lasting injectables will likely lead to improved results.
The use of silicone oil injections has long been condemned in the United States because of the high rate of complications and tremendous difficulty in correcting the problems seen in patients who have undergone these procedures. Although this technique is not recommended in the United States, silicone oil injection has been reported as safe and successful outside the United States. The accuracy and long-term outcomes of these studies remain to be seen.[19, 20]
The future of soft tissue augmentation of the lip may be the use of combination therapies. Using the strengths of multiple injection materials could offer off-the-shelf convenience with safe and long-lasting results. For example, using hyaluronic acid (Restylane) in conjunction with calcium hydroxylapatite (Radiesse) minimizes complications seen with the latter when used alone and offers improved outcomes. In any event, any injectable material combination will be measured against the longevity and safety of dermal fat grafts.
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