The lips and the eyes enhance facial beauty, and they have been highlighted since time began, rejuvenating the lips with fillers most commonly hyaluronic acid (HA), is no recognised as a widely requested procedure but requires expertise & a keen eye.
Lips that are augmentated well are deemed aesthetically pleasing to the eye and can maximises the attractiveness of this facial feature.
As patients age, they lose volume in the lip, which may result in a reduction in the definition of the upper lip and a once well-shaped Cupid’s Bow can become flattened. Treating these issues can be very straightforward and all that is needed for an immediate recreation of what was once there. You can create volume by injecting filler just within the vermillion of the lip below the skin vermillion border. If you stay superficial to muscle then that will rotate the Cupid’s bow upwards and you will get a nice natural rotation of the lip, which will improve the profile. Then you can continue to volumise in order to restore what previously existed.
Surface anatomy of the Lips
If you understand the anatomy and where the vessels lie, then the risk of vascular events are significantly minimised.
The lips are found at the entrance to the oral cavity and have multiple functions; they collect sensory data and are used for verbal and non-verbal communication. Lips have an intricate system of muscles to aid chewing, facial expressions and the formation of sounds for language.
The upper lip extends from the base of the nose superiorly to the nasolabial folds laterally and to the free edge of the vermilion border inferiorly.
The lower lip extends from the superior free vermilion edge superiorly, to the commissures laterally, and to the mandible inferiorly.
Around the circumferential vermilion-skin border, a fine line of pale skin accentuates the colour difference between the vermilion and normal skin.
Along the upper vermilion-skin border, 2 paramedian elevations of the vermilion form the philtrum.
Two raised vertical columns of tissue form a midline depression called the philtrum. The philtrum is located between the paramedian elevations of the vermilion and the columella above.
The labiomental crease passes horizontally in an inverted U-shape across the lower lip, which intra orally corresponds to the depth of the gingivolabial sulcus.
In the upper lip, the superior labial artery lies deep to the muscle, just below the mucosa on the inner aspect of the lip. There will normally be two branches of the columellar artery, which run almost parallel and lie in the middle of the lip. They run up to the nose and these vessels are also lying deep to the muscle
Beginning your treatment
The clinical outcomes for lip augmentation are defined by the patient’s unique anatomy, injection technique and the type and amount of filler used.
There will always be a need to assess for asymmetry of the upper and lower lips and document accordingly. If this is not pointed out to the patient before the treatment, he or she may point it out afterward and blame the injector for the asymmetry. Enhancing the lips with dermal filler can often temporarily highlight imperfections.
Understanding the vascular pathway of the facial vessels is crucial when providing aesthetic injection treatments. As previously demonstrated within the complication section, Injection into or occlusion of a blood vessel can be a serious complication resulting from the use of dermal fillers. Understanding the vascular structure of the face can help decrease the risk of such complications.
The facial artery should be considered for embolization following injections of the cheek, nasolabial folds, and lips. Being able to visualize the path of the facial artery will help determine the needle depth and placement – we will cover this is greater depth during your practical training,
The facial artery crosses the mandibular border, approximately one fingerbreadth anterior to the masseter muscle. It then passes forward and upward across the cheek to the angle of the mouth, where it gives rise to the inferior labial artery (lower lip) and the superior labial artery (upper lip), This can be roughly measured by placing a thumbnail beside the corner of the mouth. The superior and inferior labial arteries form a circular vascular network around the mouth, with several small blood vessels branching out radially with the vermilion border of the lip.
Naturally, Injection treatments bring with them a risk of bruising and swelling.
This will need to be communicated to you client prior to treatment, so they can be planned at least 1–2 weeks before a special event to allow the product to settle and any bruising to fade.
Lip enhancement into the vermilion border, or the red of the lip, is a commonly sought-after injection procedure. The injection technique may be done with a needle or cannula, depending on the aesthetic provider’s experience and comfort level.
You will learn delivery method via needle during your foundation learning
Product selection /suggestion
When performing a lip enhancement, reversible hyaluronic acid fillers pre-filled with lidocaine are the product of choice for most practitioners. Some of the brands of fillers available and suitable for lip augmentation.
Juvéderm Volbella- Juvéderm Volbella is a soft product, designed for subtle lip enhancement. It incorporates short and long chain hyaluronic acid to enhance the crosslinking without increasing stiffness. This makes it a good filler choice for those patients seeking a subtle look with a softer feel. The manufacturer claims that results last 12 months.
Belotero Intense – Belotero Intense is a thicker yet elastic product that can still be injected through a small gauge needle. Great for clients requesting fuller’ more voluptuous lips. The manufacturer claims that results last six to nine months.
Emervel Lips – Emervel Lips is formulated to enhance, define or augment the lip body and border. The product is designed to be altered via a combination of factors, including the levels of cross-linking and particle sizes, which aim to have a maximum effect in the different layers of tissue into which they are injected. In my experience, this can be suitable for those patients who want a ‘fuller’ appearance without looking too big. The manufacturer claims that results last six to nine months.
Teosyal RHA – Resilient hyaluronic acid (RHA) is a dynamic gel with high strength and stretch capacity. Teosyal RHA comes in 1,2,3 and 4 according to its simplicity, but for lips, we recommend using RHA 2 and RHA 3. According to the manufacturer, RHA 2 should be used in patients wanting a ‘natural’ appearance as it has less viscosity and firmness than RHA 3, whilst those demanding ‘fuller’ or ‘pouty’ lips are better treated with RHA 3. The manufacturer claims that results last approximately 12 months.
REVOLAX™ Deep with Lidocaine is biodegradable, non-animal based, crystal clear Crosslinked Dermal Filler which has high viscoelasticity.
Revolax™ Deep with Lidocaine is a thicker and longer lasting gel to treat deep sized wrinkles and nasolabial folds or augmentation of (cheeks, chin, forehead, lips, nose) – suitable for clients wanting fuller lips this product can last between 6 – 12 months.
Filler suitability When selecting a suitable filler for the lips, the following factors must be taken into consideration:
Cannula or needle?
The decision to use a cannula or a needle depends on the part of the lip that is being treated and of course your skill set As needles are thinner, they are best used to define the vermillion border, recreate the philtral columns, lift the oral commissure, volumise the lip in the sub vermillion area, efface oral rhytids and create lateral protrusions in the lower lip.
Cannulas are best used in patients with thin lips where product needs to be placed behind the muscle; the rationale behind this decision is based on the position of the labial arteries, which usually reside behind the muscle. The use of a 25g cannula will help to reduce the risk of intravascular accident in this highly perfused area.
There is no single technique that fits every lip, and each practitioner should be equipped with various techniques to deliver the best outcome. Below are the factors of which we follow when it comes to lip augmentation:
Visually assess the lip in 3D: i.e. the lateral and frontal view. This will give an idea of projection required. For an attractive lip, the upper lip should project around 1.6 – 2 mm further than the lower lip.
Assess the smile: if the patient has a ‘gummy’ smile and the lip disappears upon smiling then often botulinum toxin injection can be used with more to success to soften the action of the lip elevators.
Determine the amount of filler: agree with the patient the amount of filler that will be used. It is important to not over or underfill the lip (amount is case dependent). For example, overfilling certain aspects of the upper lip can create a protrusion or duck lip appearance, which is usually not regarded as aesthetically appealing.
It is generally regarded as good practice to use no more than 1ml per visit to prevent over correction and reduce the risk of vascular compression.
Enhancement or restoration: it is essential to understand wether your client is seeking an enhancement or restoration – this can depends on the patient’s age / demographic
The Golden Ratio and Your Lips
As previously discussed there are proportion to the anatomy of the lips that are deemed to be the most attractive.
Known as ‘the golden ratio’ & also known as the “golden mean” or “divine proportion” is a mathematical concept that asserts that the most aesthetically pleasing proportion between two objects is 1:1.618. More accurately, 1.618 is written as the Greek letter phi (Φ). This concept has been traced back as far as Greek mathematician Euclid, and it was perhaps most famously highlighted in Leonardo da Vinci’s illustration of Divine Proportion, written by Italian mathematician Luca Pacioli.
In nature, this ratio is very prominent. It can be seen in the pattern on snail shells, leaves, flower petals, and human anatomy. It also applies to human lips, where the bottom lip should ideally be 1.618 larger than the top lip. Similarly, the top lip should protrude outward 1.618 more than the bottom lip when viewing from the side, and the lips should be 1.618 times wider than the width of the nose.
With this proportion in mind, an artistic injector can enhance a person’s natural beauty by adding just enough filler to come as close to the golden ratio as possible. However, exaggerating this ratio or incorrect placement of product can result in “duck lips” or a fake appearance.
However, today’s practitioners will need to consider the fact that these ideals do change with trends. For example, the balance between the top and bottom lip in terms of the aesthetic ideal has been altered and more recent evidence suggests that the ideal has now become 1:1, with the upper lip having much more volume than previously recommended.
Of course, we believe it’s more appropriate to treat every individual lip in a bespoke way and assess how it appears on a unique face, rather than strive for these ratios exactly.
Topping up other practitioners work: it is essential to gain a detailed history of previous enhancements, including the date the procedure was carried out, what product was used and the amount that was injected. Ask your client if they were happy with the results, and if they feel there are any existing lumps bumps or irregularities
Choose your clients wisely. Always go with your “gut feeling” -If clients come to openly or inappropriately complaining about past procedures done by other practitioners, assess wether you can genuinely make a difference. In most instances it is wise to offer this type of client a cooling off period or alternatives if appropriate
Make sure you conduct full explanatory consultation and cover every single aspect of the procedure including side effects and possible complications. Make sure your clients consents, by signing both forms (medical and consent). Look for signs from clients who present psychological conditions such as depression, anxiety and, especially, body dysmorphia syndrome. These patients can be hard to please as they are often looking for undrealistic out comes or chasing the initial high that ‘treatments’ can produce for them.
Look out for contraindications such as medication they are currently taking through to allergies and medical conditions. Ask them to sign your consent form at the end of the treatment and agree they are happy with their results you. Recorded notes are very important. Most importantly note any findings of previous injection procedures such as lumps and bumps. Record capillary refill test prior and post treatment. As with any of your clients If you are not sure that you can make a positive difference – do not treat.
A full understanding how the underlining hard tissue, skeletal support and dentition affects the appearance of the face will also impact treatment outcome. Always assess and understand these supportive structures in relation to lip support. Some patients, even relatively young patients, may have a denture, which can impact the appearance of the lip and therefore your treatment