eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Lip Implants

Author: Daniel C Daube, MD, Consulting Staff, Department of Otolaryngology, Gulf Coast Facial Plastics and ENT Center
Contributor Information and Disclosures

Updated: Jan 25, 2008

Lip Augmentation Techniques

Overview

Although a plethora of information may be found in the literature regarding lip reconstruction, a relative paucity of information about lip augmentation and aesthetic surgery of the lip has been published, until recently. Aesthetic surgery of the lips has evolved as the field of facial plastic surgery has evolved, from the study of functional repair to aesthetic finesse.

Initial attempts at beautifying the lips probably started with Cleopatra, who colored her lips red. Later, silicone was used to augment the soft tissue of the body and face, including the lips. Other materials were then developed that could be used for lip augmentation. Some of these materials include collagen (bovine), Gore-Tex, calcium hydroxyapatite, hyaluronic acids, and acellular human matrix, to name a few. Recently, many new injectable materials used to augment the lips have become available, and many more are to be approved by the US Food and Drug Administration (FDA). By all appearances, temporary injectable materials will become the most common method of lip augmentation and reshaping for the near future.

The lips are the most malleable and animate of all facial features. Many consider them to be the most pleasing feature of the lower third of the face. These characteristics present the surgeon with a special set of circumstances. Specifically, many of the techniques used on other areas of the face may not work on the lips because of their 3-dimensional animate nature. With this in mind, many methods are used to augment the lips and to change their animate shape, repose shape, or both. The surgeon must always be aware of how static changes to the lip change the animate aesthetics and function of the lip. Patients occasionally refer to this as "kissability."

The lips thin as people age, and the wet line moves caudally in reference to the dentition. In addition, the oral commissures begin to downturn. These thin, flat, and poorly defined lips impart a sense of age. Specific procedures address each of these labial-aging signs. Some of these procedures include augmentation to help restore full, well-defined, and proportional lips that impart a sense of beauty and youth.

Specific features of the lips deserve attention. The vermilion border should be clearly defined, sharp, and slightly raised. The Cupid's bow, the central portion of the upper lip, should be well defined and distinct. Ideally, the lips should have not only horizontal symmetry, but vertical asymmetry, with the lower lip being slightly larger than the upper lip. Lateral portions of the upper lip give an attractive appeal on a female or male lip and also give a very distinctive look. This attribute can also be created on the lower lip with similar results.

All lip procedures may be performed with local anesthetic (eg, field block, nerve block) and this is, in fact, an ideal way to work on the lips. With general anesthesia, the lips become flaccid and adynamic. The ability for the patient to move the lips during surgery is a great advantage. Attempts to limit tissue distortion due to local infiltration of anesthetic agent can be done with specific blocks of V2 and V3.

Balance this admonition, however, against the ability to use local epinephrine to help with hemostasis by direct injection into the lips. Because the lips are so sensitive, buffer injections with sodium bicarbonate and administer them with a slow push. A field block is always performed prior to direct lip injection. Once work begins, the lips quickly swell because the tissue structure of the epidermis in this area does not resist deformation well; thus, the lips are soft. This requires thoughtful and purposeful motion as one operates to maximize results and timeliness.  Postprocedural application of ice to the lips helps to slow the swelling process over the following 24 hours.

The surgeon must have clearly defined goals in mind during consultation with patients who are considering a surgical lip procedure. First, consider whether the patient is a better candidate for temporary or permanent augmentation. For example, temporary injections are better for patients who have had no prior cosmetic surgery and who are unsure if they will do well with larger lips. These patients deserve a trial with bovine collagen or the newer hyaluronic acid products. After this trial, if patients are pleased with their results, a more permanent method may be used. In such cases, surgeons and patients might consider the use of the patient's own fat or dermis, which is thought by most authorities to have a long (but perhaps not permanent) life. One drawback of these materials, however, is inconsistent absorption, which makes the long-term results difficult to predict. 

Temporary Implants

Bovine collagen

Both bovine and human collagen are used for temporary augmentation. As a temporary measure, bovine collagen is an excellent option. This collagen requires skin testing in the forearm prior to injection and is contraindicated in patients with autoimmune diseases. The duration of the implant is a function of the specific type of collagen used (eg, Zyderm 1, Zyderm 2, Zyplast). Zyplast is the best choice if duration of results is the priority. Injection location is also important. The more mobile the area injected, the quicker the resorption time of the collagen implant. Finally, different individuals resorb the implant at different rates. Patients who have had multiple injections in the same spot have longer-lasting results.

Recently, the authors have been using more of the hyaluronic injectables (see Hyaluronic acid), as these do not require testing. Patients who desire softer lips still enjoy the results of these products; however, collagen is still the softest of all of the approved injectables in use. The hyaluronic acid products last longer but have a firmer feel in the lips. Injectables are great for augmenting the vermilion border and do well for mucosa and diffuse enlargement.

If lip tattooing is contemplated in the near future, collagen use is not recommended. Instead, inject after tattooing has been performed. In addition, the duration is a linear change and not a here-today-gone-tomorrow phenomenon, which accounts for some of the variation in patient self-reports.

AlloDerm sheets

AlloDerm sheets, which come from a single source at present (LifeCell Corporation), last much longer than collagen and may also offer some permanent results. AlloDerm sheets are softer and easily augment in a more diffuse manner than Gore-Tex. At present, the disadvantage of augmentation with AlloDerm sheets appears to be its duration of only 1-2 years on gross inspection. The sheets are relatively easy to implant, although a touch-free method should be used. In addition, AlloDerm sheets may become lumpy during healing, although this is almost always temporary. Because these products are impregnated with an antibiotic solution, confirm allergies prior to implantation. Obtaining graft material free of antibiotic or impregnated with a different antibiotic may be possible if the supplier is contacted with enough prior notice.

A number of products now on the market have varying concentrations and sources of hyaluronic acid. Hyaluronic acid is a natural substance that already exists in the human body and is used to provide volume and fullness to the skin. The hyaluronic acid in these products is a crystal-clear gel that is biodegradable and completely biocompatible. No testing is required for its use, and it lasts longer than collagen but is a bit firmer.

Some of these products are synthesized in a laboratory and some come from process animal products.

Radiesse

Radiesse is a synthetic injectable implant composed of smooth calcium hydroxylapatite (CaHA) microspheres. Radiesse is intended to fill or augment oral or maxillofacial defects. Radiesse functions as an osteoconductive scaffold for bone filtration. In a long-term animal safety study, explanted tissue at the 12-month interval reveals a well-defined bleb at the implant injection site. It remains soft, pliable, and noncalcified. This was placed into the lip by the author and many others, but on long-term follow-up appears to create some irregularities and does resorb after a prolonged period of time.   The author no longer recommends its use in the lip.

Other temporary implants

Many reports describe the use of a patients' own harvested fat, fascia, or dermis. However, human collagen and autologous implants of dermis, fat, or fascia are prone to resorption, and they often require an additional incision from the donor site. Augmentation with fat occasionally requires multiple procedures; however, newer techniques are making this a much more popular procedure for lips, as well as the entire face.

Permanent Implants

Gore-Tex

Gore-Tex (W.L. Gore & Associates) makes both solid implantable threads in different sizes and SoftForm, which is hollow down the length. Both are excellent for procedures that involve the vermilion border; however, because large lips are in style, and the hollow implants are larger in diameter, the authors use SoftForm exclusively. Exercise caution during the placement of these materials; precise placement and uniform depth are crucial. Technically, placement of all these products is easy; however, because SoftForm comes in its own delivery device, it is a bit easier to place than the other forms.

A touch-free technique must be used with all of the implants; the importance of this point cannot be overemphasized. The author prefers to put implantable threads in the barrel of a 10-mL syringe filled with antibiotic solution and to place the implant under negative pressure to saturate it with antibiotic. Ensure that the patient has no allergy to the antibiotic used. If implants are placed too superficially, they extrude or create a white firm lump. The disadvantage of nonautologous implants is the risk of infection. Migration, allergic reaction, and formation of a foreign body granuloma are always risks. Although rarely reactive, migration has been reported with Gore-Tex.

In addition, these implants almost universally shorten over the first year following implantation. Therefore, put in a bit of extra length. The upper lip implant should be split in the midline, and the lower implant (because the lower lip moves much less than the upper) can be a single implant. This is also a great choice for reconstruction of the cleft lip to create a philtrum.

Lip lift

A lip lift is a relatively simple and pleasing procedure used in the patient with a vertically long philtrum. This type of lip lift is performed via the excision of subnasal skin to show greater maxillary incisors and to roll the lip out to create a greater vertical red lip height relative to the upper subnasal lip. More maxillary dentition shows after this procedure. Thus, if the lowest horizontal third of the face is too long and shows the mandibular dentition, include a lip lift as part of the treatment regimen. This is a great procedure for the upper lip that is too long vertically. The incision is caudal to the nasal sill and is barely visible to observers. Make sure the incision is not straight, but follows the lines of the nasal sill.

Lip advancement

Lip advancement, by means of excising the skin just above the upper lip vermilion border with advancement of the vermilion border itself, yields poor definition of the white roll. Accordingly, this procedure is a poor choice unless the female patient is willing to outline her lips, either daily or permanently. Lip advancement is a poor choice for males in almost all cases. An exception to this is a poorly defined vermilion border, an already flat vermilion border, or lip tattooing that has gone awry. Marking is critical; follow the Cupid's bow and extend only about 3-5 mm. Extend the markings all the way to the commissure before tapering, and excise only skin with no undermining.

VY plasty

V-Y plasty of the upper lip, lower lip, or both lips is an outstanding choice with or without an implant, although the results are modest. The incisions must be relatively long for each arm of the plasty. Generally, only 3-4 lengths can be created on each side of the central lip only. These lengths should extend from the wet line to within 1 cm of the labial alveolar sulcus. If an implant is also used, it may be placed later in a staged procedure or simultaneously if it is placed anterior to the V-Y plasty and anterior to the wet line. If the latter approach is chosen, undermining of the lip is limited at the time of surgery. Other materials used for implantation include galea, the patient's own dermis, breast capsule, and deepithelialized flaps.^1,2 These have been used with variable success and have been described in the medical literature.

Corner lift

If the lateral commissures require a small lift, excise a small pie shape above the commissure and lift the corner. The apex of the wedge is at the tip of the commissure, and the circumference of this excision is above this apex point. This is a nice finishing touch to any of the above techniques.

Permanent Cosmetics

Some patients are truly poor candidates for lip augmentation by any of the methods discussed. Camouflage may be a better option for these patients. Long-lasting options include tattooing the vermilion border of the lip with a darker color or even extending the pigment beyond the natural borders to give the appearance of larger and fuller lips. These techniques can be outstanding options for most patients who are poor candidates for lip augmentation, and they may be used with other techniques. Laser surgery or chemical peels are best for patients who request only a smoothing of wrinkles, without a change in the shape or volume of the lips. These techniques can also be combined with other procedures.

Many incisions may be used to implant materials in the upper and lower lips. In addition, the surgeon must decide how much of the lip is to be augmented horizontally and vertically. Often, lip projection is difficult to control, and lip protection always occurs with augmentation. In other words, the surgeon must determine if only the vermilion border should be augmented or if the wet line should also be enhanced.

General principles

Observe the following general principles regardless of the material being implanted. Never use a single thread of material to stretch across the entire upper lip. This results in an abnormal showing of the upper gingiva when the patient smiles. For this reason, the surgeon usually must place 3 incisions, 1 centrally and 1 at each commissure. The lower lip requires only 2 incisions; however, the surgeon may not want to go from commissure to commissure but instead may want to augment only the central region to create a pout. The surgeon should never place implants directly under the incision.

In addition, the lips are extremely sensate. This attribute, to some degree, is altered by any invasive manipulation. Changes are usually temporary but may be quite disconcerting to the patient. Changes may rarely be severe enough to affect function (eg, speech competence, oral competence).

If the implant becomes infected, treat with antibiotics first. Trim implanted materials that extrude under sterile conditions and close the exit site, or extrusion may persist. The closure should allow for drainage. Inform the patient that optimal healing occurs when the patient's lips move as little as possible. Bactroban ointment also aids in healing. Remove the implant if the infection does not resolve.

Risks

In many ways, results can still improve with increasing safety; increasingly consistent, lasting, safe, and predictable volume gains; and increasingly predictable changes in shape.

Multimedia

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Media file 1: SoftForm lip implantation.

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Media file 2: Fat injection, 1 year after surgery.

Keywords

lip implants, lip augmentation, cheiloplasty, collagen injection, lip injection, lip lift, aesthetic surgery of the lips, collagen, lip re-shaping, lip reshaping, permanent cosmetics, temporary lip implants, permanent lip implants, lip advancement, bovine collagen, V-Y plasty, corner lift

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