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Lips express emotion, sensuality, and vitality. As far back as 69 to 30BC Cleopatra used crushed beetles and ants along with red clay, henna, iodine and seaweed to create a red ink-like substance to apply to her lips. Nowadays we have lipstick to make the lips look more prominent.
In the commonly accepted youthful attractive female lips there is a distinct bow shape to the outline of the upper lip, prominent columns of skin are present between the nose and edge of the upper lip with a curving slope lip skin surface, in repose the lower few millimeters of the upper incisors are visible, the upper lip has a greater fullness centrally near the midline of the body and near the outer corners which turn up slightly while the lower lip has more fullness just to either side of the midline.
The key components of facial aging are:
-soft-tissue atrophy or volume loss,
-loss of skin tone.
Skin elasticity decreases and the skin also thins so it is more easily abraded. The lips themselves also thin so there is less dry vermillion (pink area where lipstick is applied) showing, the upper lip bow flattens as do the columns, the upper lip's slope flattens and becomes more vertical, the nose to upper lip length increases, the upper and lower lip become equal in appearance and wrinkles appear around the mouth. Typically, the lower lip tends to maintain its volume to a greater degree than the upper lip as one ages. The onset of these changes is earlier and more severe in people who smoke, are exposed to extreme climates, etc.
These photos show the elderly lip on the left and full youthful lip on the right.
For decades plastic surgeons have tried to make aged flat lips fuller and more youthful in appearance. Initially this involved surgical procedures to advance lining inside the mouth outward to create a pout by making a series of V-shaped incisions in the mouth and closing them as Y s. It turned out that lips could be swollen for some months afterward and once the swelling resolved the improvement was minimal. Then some disatisfied surgeons began making these incisions deep into the muscle but scar formation increased and lip motion was adversely affected. Other approaches were removal of skin just under the nose or just above where lipstick is usually worn. These were prone to bad visible scars with abnormal lip shapes.
Then came the 1970s to the 1990s the age of the injectable fillers. This started out as injectable silicone or collagen derived from animals. Although the silicone was permanent it had a tendency to migrate, wrap around nerves and over time become increasingly hard to remove. The problems proved to be so bad that the FDA banned injectable silicone for these uses.
I had a patient who had silicone injected into her lips in Moscow. Following the manipulation of her lips during extensive dental work in Los Angeles the silicone collected into a few unsightly lumps. Luckily under local anesthetic I was able to make a few small incisions inside her mouth and take out almost all of the silicone. In her case she was also lucky that the injection was not too deep.
The animal derived collagens required pre-testing for allergies and only lasted a few months. Even with a negative allergy test patients could eventually become allergic and the allergic response could cause open wounds with loss of skin and eventually bad scarring.
Towards the end of the 1990s human collagen became available and the allergy issue was resolved. However, this collagen also only lasted a few months. Also at this time skin absent of any cells (Alloderm) also became available and theses sheets of tissue could also be placed for fuller lips without any allergy problems. Again the life span of the filler came into question and it is still not clear how much of this survives after 6 months or a year. The survival may vary from patient to patient depending on metabolism, age etc.
This patient had Alloderm placed for lip augmentation in both upper and lower lips. The after photo is taken more than 6 months after surgery.
From the 1990s up to 2009 it seemed a new filler was released every month including the hyaluronates (restylene, juvederm, captique, purogen ...) and then radiesse and sculptra at least doubling the length of time the filler stayed in place. Along the way attempts were also made to use the patient's own tissue (fat, tendon, fascial membranes covering muscles) as a filler. As with all fillers the problem of lumps in the lips after injection was a constant. In fact to date these synthetic fillers are only approved by the FDA for making the margin between where lipstick is worn and the skin more prominent. They are not approved for injection into the lipstick wearing portion of the lip. That is because this area is not skin and lacks the microscopic fingers of the outer skin layers that protrude down into deeper layers. In the absence of these finger like projections the overlying tissue is more easily abraded and injected material can more easily pool into lumps under the surface especially with something as mobile as the lips.
For a short period of time in the early 2000s a soft goretex thread with little memory was popular for lip augmentation. The goretex was very soft and had recovering memory in that when squeezed it would become paper thin. After a brief period of time the goretex would slowly return ot its original shape. These ended up being problematic and so fell out of favor.
The root of the problem with lips is they are very mobile with great differences in shape at extremes of motion. The goal of cosmetic surgery on the lips is supple soft lips with normal contours, no lumps, a greater amount of visible lipstick wearing area, normal movement without restriction in motion, no infection, no extrusion of implanted/injected material, use of a pliable non-reactive filler, long term results that last years instead of months, little or no scarring, a natural look and a short recovery. The filler or implant can't have memory as to what each original shape was. It has to adapt to whatever shape the lips are in with movement.
The ideal treatment for thin, aged lips has yet to be discovered.
Poor technique on the part of the physician, such as uneven injection pressure and superficial injections, is especially likely to lead to lumps on the lips. Although nodules of the inner wet lip are not visible and thus not disfiguring in the eyes of others, they can be equally troublesome to the affected patients: patients may inadvertently bite down on the overlying, protruding mucosa or they may obsessively palpate these annoying nodules with their tongues. Nodules of the lips can be resistant to simple corrective treatments such as steroid injections. In general, steroid injections can be useful for diminishing the inflammatory response and possibly rupturing a nodule so as to express its contents and lead to resolution; at the same time, injudicious placement or inadvertent over treatment with injectable steroids can easily result in an indented, atrophic scar that may be difficult to correct. Most nodules will eventually remit with time. The most conservative management entails gentle at-home massage, reassurance of the patient, and close follow-up. If nodules do not spontaneously resolve over some predetermined time interval (usually, the lifetime of the filler involved), more aggressive corrective action may be needed.
Most Plastic Surgeons believe that the patient's own fat, can be considered the ideal soft-tissue filler because it is abundant, readily available, inexpensive, host compatible, and can be harvested easily and repeatedly. However, one of the main concerns after fat grafting is the potential high rate of absorption over time in the grafted site, which may reach up to 70 percent of the filled volume and the risk of a lumpy/not smooth result.
In 2008 - 2009 a lip implant made of solid silicone became available. This is basically the same material used to make a chin implant only smaller and more flexible. Like the chin implants it has memory in that if you twist it with your fingers and let go it immediately returns to its original shape. Unlike the chin implants which sit on top of stationary bone in the lips these implants are subject to a great deal of motion and deformational forces. The manufacturers were able to clear this through the FDA by basically stating it was the same as the chin implants. However an implant placed on the chin and immobile is quite different than the same type of implant placed in the mobile lips. It is like comparing apples with vegetables. If that was not the case the manufacturer would use the word lip in the supporting documentation, advertising and name of the product but has failed to do so. My initial concern was that the memory of the implant would cause it to push into the surrounding lip tissue and poke out. That problem was confirmed by an associate who had put the implant in a patient and it subsquently poked out.
After first hearing about the implant I put it on the back burner because of the concerns mentioned above. Then I received email about the implant placed into a patient on a doctor television show-live surgery and I viewed the clip. This only confirmed my feeling that these doctor shows are becoming increasingly dangerous for everyone's health. Shortly after that I was informed another colleague in Beverly Hills ordered 10 right away. There are somethings I will not do even for money.
Lip Augmentation with Alloderm
Aaron Stone MD - Plastic Surgeon Los Angeles
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