Systematic review of "filling" procedures for lip augmentation regarding types of material, outcomes and complications

The Use of Facial Fillers in Clinical Practice: The Level of Patient Satisfaction and an Overview of Common Clinical Complications

BACKGROUND

Patient esthetic satisfaction following facial fillers is an essential topic that should be studied as the number of individuals seeking treatment increases. The face is an essential component of the human body that is frequently associated with beauty, youthfulness, and health. Individuals may seek facial augmentation with fillers for a variety of reasons, such as congenital, acquired by means of aging or disease, or current aesthetic trends.

OBJECTIVE

The aim is to assess patient's aesthetic satisfaction and description of common clinical complications in relation to the facial filler injections.

METHOD

A cross sectional survey using a questionnaire derived from the global aesthetic improvement scale and WHO quality of life scale, convenience sampling was used to recruit patients attending cosmetic clinics, descriptive analysis and Chi-square methods were used to analyze the data.

RESULTS

In the study, 500 female participants, with an average age of 28.48 years, were included. Over 90% reported improvement after filler treatment, ranging from improved to very much improved. A statistically significant correlation was observed between patient satisfaction and the number of filler treatments and the anatomical injection site. However, no statistically significant correlation was found when considering age groups. Local side effects, such as swelling and redness at the injection site, were common but generally mild and of short duration.

CONCLUSION

Although the satisfaction level is currently high, practitioners in the field need to pay more attention to this important outcome, since understanding the patient's motivation and expectation before proceeding with the procedure is very important and can contribute significantly in determining patient satisfaction with the result.

The Use of Facial Fillers in Clinical Practice: The Level of Patient Satisfaction and an Overview of Common Clinical Complications

BACKGROUND

Patient esthetic satisfaction following facial fillers is an essential topic that should be studied as the number of individuals seeking treatment increases. The face is an essential component of the human body that is frequently associated with beauty, youthfulness, and health. Individuals may seek facial augmentation with fillers for a variety of reasons, such as congenital, acquired by means of aging or disease, or current aesthetic trends.

OBJECTIVE

The aim is to assess patient's aesthetic satisfaction and description of common clinical complications in relation to the facial filler injections.

METHOD

A cross sectional survey using a questionnaire derived from the global aesthetic improvement scale and WHO quality of life scale, convenience sampling was used to recruit patients attending cosmetic clinics, descriptive analysis and Chi-square methods were used to analyze the data.

RESULTS

In the study, 500 female participants, with an average age of 28.48 years, were included. Over 90% reported improvement after filler treatment, ranging from improved to very much improved. A statistically significant correlation was observed between patient satisfaction and the number of filler treatments and the anatomical injection site. However, no statistically significant correlation was found when considering age groups. Local side effects, such as swelling and redness at the injection site, were common but generally mild and of short duration.

CONCLUSION

Although the satisfaction level is currently high, practitioners in the field need to pay more attention to this important outcome, since understanding the patient's motivation and expectation before proceeding with the procedure is very important and can contribute significantly in determining patient satisfaction with the result.

Computer guided maxillo-malar piezoelectric osteotomies for midface augmentation

PURPOSE

Despite maxillo-malar osteotomies having been discarded in the most recent literature, in the setting of orthognathic surgery they provide several advantages for middle third augmentation. This paper reintroduces maxillo-malar osteotomies as an effective method to increase volume of midfacial region in combination with contemporary technology, including piezosurgery, virtual surgical planning, and navigation.

MATERIAL AND METHODS

Eighteen patients with midface hypoplasia were included in this study and underwent orthognathic surgery with maxillo-malar osteotomies. All patients underwent the same workflow: virtual design of maxillo-malar osteotomies, surgery with navigation-assisted piezoelectric osteotomies, and computerized morphometric analysis.

RESULTS

Simulated maxillo-malar osteotomies were successfully replicated in the operating room, as shown by accuracy evaluation performed using three-dimensional analysis. In long-term follow-up period, no permanent complications were assessed. Superimposition between postoperative and preoperative CBCTs revealed that the soft tissue area influenced by the underlying skeletal movement was comparable for all cases.

CONCLUSIONS

Virtual surgical planning, navigation, and piezosurgery are today indispensable tools to perform maxillo-malar osteotomies safely and accurately. We suggest incorporating such osteotomies in the surgeon's armamentarium for patients with severe midfacial hypoplasia as they offer an integrated solution to restore functionality and aesthetics.

Clinical outcomes after lip injection procedures-Comparison of two hyaluronic acid gel fillers with different product properties

BACKGROUND

Transient swelling is common after lip injections with hyaluronic acid (HA) based fillers. Swelling and other injection-site reactions may relate to the injection procedure itself, or to gel properties, which differ between fillers due to differences in manufacturing methods.

OBJECTIVES

To evaluate safety and effectiveness of lip injections with two HA fillers manufactured using different gel technologies.

METHODS

In a study sample of 40 subjects, treatment with two soft tissue filler product (HA_RK or HA_JUS ) was randomly assigned. Subjects were injected with 0.5 cc per upper and lower lip using a standardized injection procedure. Early-onset adverse events (AEs) were assessed by evaluation up to Day 14. Aesthetic improvement, subject satisfaction, and AEs post-Day 14 were assessed up to 24 weeks.

RESULTS

In subjects treated with HA_RK , the intensity of early onset swelling, erythema, and pain/tenderness was lower than in subjects treated with HA_JUS . Aesthetic improvement was achieved in both groups, and most subjects were satisfied with the appearance of their lips. Treatment-related AEs post-Day 14 mostly related to the implant site; most were mild-to-moderate, and none were serious.

CONCLUSIONS

The intensity of early-onset swelling, and other injection-site reactions was lower in subjects treated with HA_RK than in subjects treated with HA_JUS . Since both the injection volume and injection procedure were standardized, the difference in local tolerability between the two HA fillers may relate to differences in gel properties. Aesthetic improvement, subject satisfaction, and AE profiles post-Day 14, however, were similar between filler groups.

"Bi-Bi" technique for lip augmentation: A retrospective study on 30 cases

INTRODUCTION

Lip augmentation is achieved mainly by using hyaluronic acid (HA) fillers. The injection procedures are performed either superficially or deeply with a needle or a cannula, and only one type of hyaluronic acid is used. The authors' objective was to evaluate the feasibility, safety, and satisfaction level of a procedure combining two anatomical injection plans, two injection modes (i.e., cannula and needle), and two types of hyaluronic acid fillers.

METHOD

The retrospective study included 30 patients who underwent the following procedure: Intramuscular retro-trace injections of Stylage M (Vivacy® Laboratories) were conducted through a 27-gauge cannula at the level of the upper and lower hemi-lip. Then, intradermal injections of Stylage Lips (Vivacy® Laboratories) using a 33-gauge needle were carried out on the entire lip border as well as the cupid's bow. During a post-injection follow-up, subjects were asked to evaluate satisfaction level and the effect of fillers over time. Elastic (G') and viscosity (G″) moduli of HA fillers were measured with a rheometer (AR2000, TA Instruments) prior to and after extrusion through a 33-gauge needle.

RESULTS

Rheological assessment showed that passage through a 33-gauge needle did not alter the viscoelastic properties of HA fillers. After the clinical procedure, no side effects were observed except for standard post-treatment bruises and edema. No vascular incident occurred. Moreover, overall patient satisfaction was high (2.6/3) and there was a long-lasting perception of the effect of the filler.

CONCLUSION

The current study demonstrated that dissociating the anatomical zones of the lip during the injection procedure by means of different hyaluronic acids in the muscular and dermal planes would efficiently and safely provide both lip projection and fullness for a natural and lasting effect.

An Overview of Maxillofacial Approaches to Smile Design

The oral and maxillofacial surgeon (OMS) has the knowledge and skills to make drastic skeletal changes in favor of a more cosmetic smile. OMS can alter intraoral and extraoral soft tissues to make subtle or significant changes in facial cosmesis. This article provides an overview of the scope of the OMS in smile design. The authors provide a cursory review of pertinent gross and surgical facial anatomy, discuss the role of orthognathic surgery and rhinoplasty in smile cosmesis, and describe the fundamentals of common cosmetic procedures ranging from gingivoplasty to lip lift and lip augmentation and the use of neurotoxins.

A New Approach for Lip Filler Injection Using an Inverted Mercedes Benz Sign

Lip fillers have a great impact on the facial aesthetic industry, where several techniques have been proposed for lip beautification in terms of both the results and delivering a safe injection procedure. The study aimed to report a personal experience with a new lip filler technique, via inserting a microcannula through three entry points, resembling an inverted Mercedes Benz sign. Ten female patients between 22 and 29 years of age had a lip filler treatment with a cross-linked hyaluronic acid injected using a microcannula through two entry points at both Glogau-Klein points of the upper lip and one entry point at the midline of the lower lip. The filler product was deposited in both retrograde and aliquots fashion in the superficial muscular plane. All patients reported a high degree of satisfaction with the results of the procedure, with slight swelling and bruising transiently present in some of the patients. Unlike the conventional cannula technique, this new technique offers artistry in accentuating the cupid’s bow and redrawing the lips.

Lip Reshaping with LOVE Approach: A Prospective Analysis Based on Two Hyaluronic Acid Fillers

Aesthetic improvement of the lips with hyaluronic acid fillers is a popular procedure. A comprehensive, modular, and highly individualizable method has been developed: the Lip Omnicomprehensive Volume Enhancement (LOVE) approach. The present study assessed the safety and effectiveness of LOVE across different patient age groups.

Hyaluronic Acid Is an Effective Dermal Filler for Lip Augmentation: A Meta-Analysis

Introduction: The lips and the mouth play an indispensable role in vocalization, mastication and face aesthetics. Various noxious factors may alter and destruct the original structure, and appearance of the lips and the anatomical area surrounding the mouth. The application of hyaluronic acid (HA) may serve as a safe method for lip regeneration. Although a number of studies exist for HA effectiveness and safety, its beneficial effect is not well-established. Aim: The present meta-analysis and systematic review was performed to investigate the effectiveness of HA on lip augmentation. We also investigated the types and nature of adverse effects (AEs) of HA application. Methods: We reported our meta-analysis in accordance with the PRISMA Statement. PROSPERO protocol registration: CRD42018102899. We performed the systematic literature search in CENTRAL, Embase, and MEDLINE. Randomized controlled trials, cohort studies, case series and case reports were included. The untransformed proportion (random-effects, DerSimonian-Laird method) of responder rate to HA injection was calculated. For treatment related AEs descriptive statistics were used. Results: The systematic literature search yielded 32 eligible records for descriptive statistics and 10 records for quantitative synthesis. The results indicated that the overall estimate of responders (percentage of subjects with increased lip fullness by one point or higher) was 91% (ES = 0.91, 95% CI:0.85-0.96) 2 months after injection. The rate of responders was 74% (ES = 0.74, 95% CI:0.66-0.82) and 46% (ES = 0.46, 95% CI:0.28-0.65) after 6 and 12 months, respectively. We included 1,496 participants for estimating the event rates of AEs. The most frequent treatment-related AEs were tenderness (88.8%), injection site swelling (74.3%) and bruising (39.5%). Rare AEs included foreign body granulomas (0.6%), herpes labialis (0.6%) and angioedema (0.3%). Conclusion: Our meta-analysis revealed that lip augmentation with injectable HA is an efficient method for increasing lip fullness for at least up to 6 months after augmentation. Moreover, we found that most AEs of HA treatment were mild or moderate, but a small number of serious adverse effects were also found. In conclusion, further well-designed RCTs are still needed to make the presently available evidence stronger.

Surgical Lip Remodeling Following Permanent Filler Injection: A Scoping Review

ABSTRACT

Over the years, several techniques have been introduced to obtain permanent lip enhancement, such as the use of silicone lip implants or the off-label use of permanent fillers. Although some reports indicate that permanent lip filler is safe, many others describe early- and late-onset complications. The main issue with permanent lip fillers is the lack of a standard technique to correct undesirable results. The aim of this scoping review was to list and evaluate the surgical pathways described in literature to correct lip deformity resulted from the injection of permanent fillers. The methods and the inclusion criteria of this work were specified in advance and documented in a protocol, according to the PRISMA 2009 checklist. The research was carried out on electronic databases PubMed, Cochrane Library, and Scopus databases identifying articles from March 1991 to December 2020 and conducted up to December 23rd, 2020. Articles language was limited to English. The selection process identified 3 retrospective studies eligible for inclusion. 73 patients and a total of 111 lips (72 upper and 39 lower) were considered. Two early complications were identified, 1 suture dehiscence and 1 total lip mucosa necrosis. Surgical lip remodeling following permanent filler injection seems to be an effective approach although the surgical pathway needs to be customized per each patient. Complication rate seems to be coherent to lip surgery performed with reconstructive purposes. To confirm these data case-control studies with much wider cohorts are needed to reach statistical significance.

MD Codes™: A Methodological Approach to Facial Aesthetic Treatment with Injectable Hyaluronic Acid Fillers

Background

Patients often seek aesthetic correction of facial deficiencies (e.g., lines and folds) that are rarely the underlying cause of dissatisfaction with their appearance. Use of a more holistic approach focused on improving the emotional messages of the face (e.g., looking less sad) may improve patient satisfaction with treatment outcomes. The MD Codes™ system was developed to increase clinician success rates by reducing variability in the technical aspects of hyaluronic acid (HA) filler treatment and focusing on addressing unfavorable emotional attributes of the face.

Methods

The MD Codes, or medical codes, represent specific anatomical subunits for injection of HA fillers. Each MD Code includes information regarding the target depth of injection, the proper delivery tool (needle or cannula) and delivery technique (e.g., aliquot, bolus, fanning), and the minimum product volume recommended to achieve visible, reproducible results (active number). During treatment planning, the appropriate MD Codes are selected using algorithms focused on lessening unfavorable facial attributes (a saggy, tired, sad, or angry look) and enhancing positive attributes (an attractive, younger, more contoured, or feminine [soft] or masculine look).

Results

Three case studies are presented to illustrate how the MD Codes and their algorithms were used to address sagginess, tiredness, and sadness in two women and one man.

Conclusions

MD Codes provide a universal symbolic language for reducing variability in injection technique. The platform provides user-friendly algorithms to help clinicians increase patient satisfaction by going beyond treatment of lines and folds and to focus on reducing unfavorable facial attributes.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Electronic supplementary material

The online version of this article (10.1007/s00266-020-01762-7) contains supplementary material, which is available to authorized users.

Analysis of upper lip appearance after surgical lip augmentation procedure "VY in VY": Progress of results

INTRODUCTION

Many materials and techniques were used for lip augmentation, whereas in the last years all attention is paid for filling material, and long-lasting surgical techniques were ignored.

MATERIALS AND METHODS

This study includes 12 candidate patients for upper lip augmentation; all are females, their age range 21-24 years. Standardized anterior and lateral photographs of each subject were taken at: preoperative, 2, 4, and 12 months later, and were analysed using digital imaging software to quantify postoperative changes. We used t-test of correlated samples to detect any statistical significance and Interclass correlation coefficient test (ICC) for reliability that proved the reliability and reproducibility of our method.

RESULTS

there were statistically significant improvements in al parameters that characterize the fullness of the upper lip. These changes was observed from the 2^nd month (P<0.05) and continued improving until the 4^th month (P<0.05), after that they appeared to be stable (P>0.05). These changes were at the 12^th month postoperative in: upper white lip (-9%), upper red lip (53%), upper red lip area (63%), protrusion (41%) and nasolabial angle (-7%). There was no statistical significance in the change of Cupid's bow curvature (P-value = 0.104 > 0.05).

CONCLUSIONS

VY in VY for upper lip augmentation improves the parameters that define the youthful and fully appearance of the upper lip and the progress of results may be predictable. These improvements appear to be stable from the 4th month. Also, it doesn't change the Cupid's bow curvature.

Lip Augmentation

A heightened cultural emphasis on youth and beauty has resulted in an increase in cosmetic surgery in the Western world. Lip augmentation is one of the most popular cosmetic procedures done because full lips are considered youthful and voluptuous. With reliable and improved techniques, it is possible to change the appearance of the lips utilizing injectable materials and surgical techniques. This article focuses on popular materials and techniques utilized to augment the size and volume of the lips-the most common are dermal fillers. Lip augmentation requires a thorough understanding of anatomy and managing patient expectations, available materials, and techniques.

Hyaluronic Acid Injections to Correct Lips Deformity Following Surgical Removal of Permanent Implant

One of the most attractive areas of the face are the lips, they are crucial for emotion and communication, both during animation and at rest. Throughout the years, several techniques to obtain permanent lip enhancement have been introduced, such as the use of nonresorbable fillers. The main problem related to permanent fillers is that undesirable results could not always be repaired; although lip sequelae can be addressed surgically, some surgeons will not perform this type of procedure due to its complexity and the lack of guidelines.In this paper, the authors present a case of a labial incompetence developed after lips implant removal performed elsewhere; after clinical examination the patient was planned for surgery, although during preoperative instrumental examination (chest X-ray) a solitary pulmonary nodule was noted; further investigation performed with needle biopsy revealed a lung cancer. For this reason, the surgical procedure planned for lip restoration was not performed; however, the patient asked for a minimally invasive procedure, thus to improve, although temporarily, her lips appearance.For the aforementioned reasons, the patient was treated just with hyaluronic acid injections achieving a pleasant result, solving also the labial incompetence at rest.To the best of the author's knowledge, this paper represents the first one describing the use of hyaluronic acid injections to restore lip competence following surgical removal of permanent implant.

Anatomy of the Superior and Inferior Labial Arteries Revised: An Ultrasound Investigation and Implication for Lip Volumization

BACKGROUND

Lips are considered a key element of facial attractiveness due to their central position in the face and their elemental role in verbal and nonverbal communication.

OBJECTIVES

The authors sought to provide clinically relevant information on the 3-dimensional pathway of the superior and inferior labial arteries within the lips to increase safety during labial soft tissue filler injections.

METHODS

The study enrolled 41 healthy volunteers with a mean age of 26.17 ± 9.6 years and a mean body mass index of 23.09 ± 2.3 kg/m2. Ultrasound imaging was performed at 6 different locations. The position of the labial arteries within the lips, depth of the arteries, cranio-caudal location of each artery in relation to the vermilion border, and diameter of the superior/inferior labial arteries were recorded.

RESULTS

The most frequent location of both the superior and inferior labial arteries was the submucosal plane (58.5%) followed by intramuscular (36.2%) and subcutaneous (5.3%) planes. The depth of the superior labial artery in the upper lip was 5.6 ± 0.13 mm, whereas the depth of the inferior labial artery in the lower lip was 5.2 ± 0.14 mm. Both arteries were more frequently located within the red lip: upper lip (83% vs 18.7%) and lower lip (86.2% vs 13.8%). In the midline, the artery coursed within the red lip in all investigated volunteers.

CONCLUSIONS

Clinically, results of this study favor a superficial injection plane for lip volumization procedures. A perpendicular approach to the lip (coming from the cutaneous lip) might increase safety because the artery is located most frequently within the red lip.

Lip Augmentation Using Post-Auricular Fibroareolar Tissue as a New Autogenous Filler

BACKGROUND

Augmentation of facial components is an acceptable approach in facial aesthetics. The best filler material and the optimal technique for facial soft tissue augmentation still remain to be determined. This study has assessed the lip augmentation using post-auricular fibroareolar tissue as a new autogenous filler.

METHODS

This prospective study enrolled patients who were candidate for lip augmentation. Loose fibroareolar tissue was harvested from post-auricular region and was inserted in the prepared lip pocket. Standard digital photography was used for lip analysis in each patient before and 6 months after surgery (the height and projection of the upper lip and lower lip).

RESULTS

At a mean follow-up period of 6 months, average upper and lower lip height increased from 5.27 to 8.72 mm (p<0.001), and the average upper and lower lip projection increased from 3.97 to 7.75 mm (p<0.001).

CONCLUSION

Our technique was minimally invasive and a safe method, in which post-auricular loose fibroareolar tissue was applied for lip augmentation with minimum donor site morbidity and long-term results. On the follow-up, all patients were satisfied with the results and no patients required any revision operation. Moreover, the complication rate was negligible.

Palatal needle-free anesthesia for upper molars extraction. A randomized clinical trial

BACKGROUND

The aim of this study was to compare the ability of liposomal and non-liposomal lidocaine and prilocaine in hydrogel formulations to promote topical anesthesia in palatal mucosa during upper molar extractions.

METHODS

In this randomized, cross over, triple-blinded clinical trial, a liposomal and a non-liposomal formulation of the eutectic mixture of local anesthetics, 2.5% lidocaine and 2.5% prilocaine, were used to promote palatal anesthesia without the local anesthetic infiltration during bilateral upper molars extractions.

RESULTS

From the total of 40 patients included in this study, the non-liposomal eutectic lidocaine-prilocaine formulation failed in 40% of cases, unlike the liposomal formulation, which was effective for all patients (Fisher's exact test, p < 0.0001). Furthermore, the liposomal formulation (26.75 ± 7,47 min) induced longer anesthesia duration (t-test, p < 0.0001) than the non-liposomal formulation (16.78 ± 4.75 min). No mucosal ulceration or discomfort was reported for both formulations.

CONCLUSION

The liposomal formulation was able to induce adequate anesthesia in palatal mucosa during dental extraction, avoiding the local anesthetic infiltration. For the first time, a topical formulation allowed upper molars surgical removal without injection of any local anesthetic agent into palatal mucosa in adults.

Comprehensive histological investigation of age-related changes in dermal extracellular matrix and muscle fibers in the upper lip vermilion

OBJECTIVE

Few histological studies have directly examined age-related changes within the lips, although non-invasive investigations of such changes are increasing. Therefore, this study aimed to provide histological and molecular data on age-dependent alterations in the vermilion.

METHODS

Upper vermilion specimens from 15 female Caucasian cadavers (age range, 27-78 years) were investigated histologically or immunohistochemically.

RESULTS

Histologically, age-dependent decreases in areas occupied by hyaluronan and collagenous fibres in the dermis of upper vermilion were demonstrated. Elastic fibre content varied widely between individuals. The area occupied by muscle fibres in the orbicularis oris muscle region within the vermilion also correlated negatively with age. Immunohistochemically, signals of four proteins were attenuated in vermilion from older individuals compared with young individuals: procollagen type I, hyaluronan synthase (HAS)1, myosin heavy chain (MYH)2 (a component of fast-twitch oxidative muscle fibres) and MYH7 (a component of slow-twitch muscle fibres). In contrast, signals of cell migration inducing hyaluronidase 1 (CEMIP) were intensified in vermilion from older individuals. No marked differences between young and older individuals were seen in procollagen type III, HAS2, HAS3, hyaluronidase (HYAL)1, HYAL2, MYH1 or MYH4.

CONCLUSION

Age-dependent decreases of hyaluronan in the dermis of vermilion were prominent, possibly due to both the decrease in synthesis (HAS1) and the increase in degradation (CEMIP). Furthermore, age-dependent decreases in collagenous fibres and two types of muscle fibre in the vermilion were also identified histologically. Type I collagen, MYH2 and MYH7 appear to represent the molecules responsible for these respective decrements.

Surgical Lip Remodeling After Injection of Permanent Filler

BACKGROUND

A major concern regarding permanent lip fillers is difficulty with revision should this be required. Currently, the only way to treat lip sequelae is by surgical remodeling.

OBJECTIVES

Based on the senior author's 6-year experience, the authors collectively suggest a surgical method to correct lip deformity in such situations.

METHODS

The records of 38 patients with lip deformity who underwent surgery between 2011 and 2017 after receiving permanent filler injections were analyzed retrospectively. A total of 38 consecutive patients (69 lips) with an average age of 38.8 years (range, 28-52 years) were treated surgically.

RESULTS

All patients experienced postoperative swelling (average duration, 15 days), and no infections were recorded. In 3 cases, a 1-cm dehiscence was documented, which healed by secondary intention. In 1 case, a hematoma noted several days after surgery resolved spontaneously within 3 weeks. In 2 upper lips, a minor touchup procedure (with the patient under local anesthesia) was performed 9 months after the initial surgery. Overall, patients noted that it took at least 6 to 9 months to achieve natural lip movement. The average time until softening of the lip tissue was 4 months.

CONCLUSIONS

This study emphasizes the importance of informing patients that complete removal of permanent filler is not always possible. However, most of the authors' patients were pleased with the results. This study also highlights the importance of paying strict attention when approaching the area adjacent to the oral commissures in order to avoid potential reductions in mouth opening that can occur from postoperative scarring.

LEVEL OF EVIDENCE: 4

Serious complication as a result of lip augmentation with vitamin E

Nowadays lip augmentation with FDA-approved fillers is becoming popular. However, because of financial concerns many patients seek for unregistered materials. Here, we report two cases who use vitamin E for lip augmentation. They experience severe infiltration and discharge less than one month after injection. Biopsy revealed lipogranuloma formation. They were treated with incision and drainage, antibiotic, and corticosteroids. Although these complications are usually difficult to treat, the patients had good clinical response and no recurrence in 5-month follow-up.

A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness

Importance

Aesthetic proportions of the lips and their effect on facial attractiveness are poorly defined. Established guidelines would aid practitioners in achieving optimal aesthetic outcomes during cosmetic augmentation.

Objective

To assess the most attractive lip dimensions of white women based on attractiveness ranking of surface area, ratio of upper to lower lip, and dimensions of the lip surface area relative to the lower third of the face.

Design, Setting, and Participants

In phase 1 of this study, synthetic morph frontal digital images of the faces of 20 white women ages 18 to 25 years old were used to generate 5 varied lip surface areas for each face. These 100 faces were cardinally ranked by attractiveness through our developed conventional and internet-based focus groups by 150 participants. A summed ranking score of each face was plotted to quantify the most attractive surface area. In phase 2 of the study, 4 variants for each face were created with 15 of the most attractive images manipulating upper to lower lip ratios while maintaining the most attractive surface area from phase 1. A total of 60 faces were created, and each ratio was ranked by attractiveness by 428 participants (internet-based focus groups). In phase 3, the surface area from the most attractive faces was used to determine the total lip surface area relative to the lower facial third. Data were collected from March 1 to November 31, 2010, and analyzed from June 1 to October 31, 2016.

Main Outcomes and Measures

Most attractive lip surface area, ratio of upper to lower lip, and dimension of the lips relative to the lower facial third.

Results

In phase 1, all 100 faces were cardinally ranked by 150 individuals (internet-based focus groups [n = 130] and raters from conventional focus groups [conventional raters] [n = 20]). In phase 2, all 60 faces were cardinally ranked by 428 participants (internet-based focus groups [n = 408] and conventional raters [n = 20]). The surface area that corresponded to the range of 2.0 to 2.5 × 104 pixels represented the highest summed rank, generating a pool of 14 images. This surface area was determined to be the most attractive and corresponded to a 53.5% increase in surface area from the original image. With the highest mean and highest proportions of most attractive rankings, the 1:2 ratio was deemed most attractive. Conversely, the ratio of 2:1 was deemed least attractive, having the lowest mean at 1.61 and the highest proportion of ranks within 1 with 310 votes (72.3%).

Conclusions and Relevance

Using a robust sample size, this study found that the most attractive lip surface area represents a 53.5% increase from baseline, an upper to lower lip ratio of 1:2, and a surface area equal to 9.6% of the lower third of the face. Lip dimensions and ratios derived in this study may provide guidelines in improving overall facial aesthetics and have clinical relevance to the field of facial plastic surgery.

Level of Evidence

NA.

Cadaveric Assessment of Lip Injections: Locating the Serious Threats

BACKGROUND

Lip augmentation could be a possible cause of blindness following filler injections. This study evaluated the risk by simulating clinical scenarios of marginal injections to the upper and lower lips and then evaluated the risk of vascular injuries.

METHODS

A 22G cannula was inserted bilaterally along the wet-dry junction of the upper and lower lip margins in fifteen cadavers, and then both lips were dissected to verify possible injuries to the superior and inferior labial arteries. The position of the labial arteries in the vermilion zone was documented to determine the appropriate injection technique.

RESULTS

In the marginal injections to the lips, arterial injuries occurred at the medial segment of the vermilion zone of both the upper and lower lips, at the terminal part of the labial arteries or a distal branch. Considering arterial anatomy, the upper lip has a higher chance of arterial injury than the lower lip. The cannula should not be inserted in the submucosa as it is recommended to evert the vermilion because both the superior and inferior labial arteries are located in the submucosa of the medial and middle segments of the vermilion in all specimens.

CONCLUSION

Awareness of the possibility of vascular injury is necessary during injections of the medial segments of the vermilion of the lips. Vermilion border and marginal injections are recommended for safe and effective lip augmentation. Deep injection around the oral commissure and submucosal injection of the medial and middle segments of the vermilion zone are prohibited because of the high risk of arterial injury.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Permanent implants for lip augmentation: Results from a retrospective study and presentation of tips and tricks

BACKGROUND

Requests for lip augmentation are increasing because of expanding media exposure and consumer needs. Temporary effects can be obtained by several techniques, but a recent procedure consisting of lip prosthesis implantation, offering a permanent result, is emerging. Accordingly, the implantation of solid lip prosthesis represents an innovation in the field of esthetic medicine and surgery.

METHODS

A total of 100 women with atrophic or hypoplastic lips were treated with lip implants. The treatment was performed in a single session, and controls were scheduled at fixed time intervals. A standard digital photo was used for measurement and analysis. Data concerning patient satisfaction and complications of the technique were collected and analyzed. Variations to the original technique were also discussed.

RESULTS

Patient evaluation revealed that a permanent and natural result without discomfort for the patient and/or the partner was reached with the implantation of silicone prosthesis in the upper and/or lower lip. Swelling, bruising, and malpositions were the most frequent adverse events. A case of severe edema was reported. Practical tricks acquired through experience were discussed to prevent complications.

CONCLUSIONS

One of the most widespreading methods for lip remodeling is hyaluronic acid injections. Nevertheless, hyaluronic acid has a variable duration, and it is not always the first choice. This context allowed for the development of other techniques such as the implantation of silicone prosthesis. The advantages of this prosthesis are as follows: safety, definitive result, and reversibility considering the possibility to remove the implanted prosthesis in the case of a request.

Age-Related Changes of the Orolabial Region in Caucasian Women: An Anthropometric Analysis

PURPOSE

Anthropometric data can provide valuable support for the attending physician in planning surgical and nonsurgical esthetic procedures with regard to a patient's age. The purpose of the present study was to identify age-related orolabial changes in younger and older Caucasian women.

MATERIALS AND METHODS

In the present cross-sectional study, anthropometric landmarks were identified using indirect anthropometry (2-dimensional photometry) in younger (≤35 yr) and older (≥50 yr) Caucasian women to analyze age-related parameters and proportions of the orolabial region, especially of the lower and upper lip vermilion areas. The Mann-Whitney U test was applied to compare the results between the younger and older populations.

RESULTS

The study population consisted of 45 women. The cohort was divided into a younger population (24 participants; mean age, 27.4 yr) and an older population (21 participants; mean age, 58 yr) to evaluate age-related differences. Increases of upper lip height, cutaneous height of the upper lip, and cutaneous height of the lower lip were observed in older women. In contrast, the vermilion height of the lower lip decreased significantly with increasing age.

CONCLUSION

These results show changes of the orolabial region occur in Caucasian women with increasing age. The statistically relevant decrease of the vermilion height of the lower lip should be given particular attention for (age-appropriate) diagnostic, esthetic, and prosthetic treatment planning.