Evolution in Techniques: Lip Augmentation

"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.

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.

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

Development and validation of a photographic scale for assessment of lip fullness

BACKGROUND

As lip augmentation becomes more popular, validated measures of lip fullness for quantification of outcomes are needed.

OBJECTIVE

Develop a scale for rating lip fullness and establish its reliability and sensitivity for assessing clinically meaningful differences.

METHODS

The initial Allergan Lip Fullness Scale (iLFS; a four-point photographic scale with verbal descriptions) was validated by eight physicians rating 55 live subjects during two rounds, conducted on one day. In addition, subjects performed self-evaluations. The revised Allergan Lip Fullness Scale (LFS), a five-point scale with a broader range of lip presentations, was validated by 21 clinicians in two online image rating sessions, ≥14 days apart, in which they used the LFS to rate overall, upper, and lower lip fullness of 144 3-dimensional (3D) images. Physician inter- and intra-rater agreement, subject intra-rater agreement (iLFS), and subject-physician agreement (iLFS) were evaluated. Additionally, during online rating session 1, raters ranked 38 pairs of 3D images, taken before and after lip augmentation, as "clinically different" or "not clinically different." The median LFS score difference for clinically different pairs was calculated to determine the clinically meaningful difference.

RESULTS

Clinician inter- and intra-rater agreement for the iLFS and LFS was substantial to almost perfect. Subject self-assessments (iLFS) had substantial intra-rater reliability and a high level of agreement with physician assessments. Median LFS score differences for overall, upper, and lower lip fullness were 1 (mean: 0.63-0.69) for "clinically different" and 0 (mean: 0.28-0.36) for "not clinically different" image pairs; thus, clinical significance of a 1-point difference in LFS score was established.

CONCLUSIONS

The LFS is a reliable instrument for physician classification of lip fullness. A 1-point score difference can detect clinically meaningful differences in lip fullness.

Global 3-dimensional approach to natural rejuvenation: recommendations for perioral, nose, and ear rejuvenation

BACKGROUND

There is a move toward a global, 3-dimensional approach to facial rejuvenation that has been prompted by advances in techniques and available products. However, little published literature exists on the procedures involved in this global approach, and currently, no validated recommendations exist.

OBJECTIVES

To provide a detailed, practical guide to rejuvenation of the perioral area, nose, and ears based on expert consensus recommendations.

METHODS

The aim of this approach was to take into account both volumetric and dynamic aspects of treatment, as well as the benefits of treatment combinations, for example, combining botulinum toxins with hyaluronic acid (HA) fillers and volumizers. Each set of recommendations was documented, comprising a clinical definition of the aging severity scale, together with recommendations of appropriate products, doses, site, depth, and injection techniques, as well as indication-specific rules to be respected.

RESULTS

HA fillers are ideal for replenishing volume loss in the lips, while rhytides around the lips can be treated with small doses of botulinum toxin. Botulinum toxin can also be used to raise the tip of the nose, to reshape nostrils, and to narrow nasal flare, with HA fillers also be used to correct small defects. HA fillers can also be used to rejuvenate sagging, atrophic or irregular ear lobes, repair torn earlobes, or erase vertical rhytides.

CONCLUSIONS

By providing practical guidance on rejuvenation of the perioral area, nose, and ears, esthetic facial physicians can achieve optimum patient outcomes.

Imaging of cosmetic facial implants and grafts

SUMMARY

A wide variety of implants and grafts have been used for cosmetic facial surgery, including forehead, nose, cheek, lip, and chin augmentation. Some of the implant materials include silicone, expanded polytetrafluoroethylene (Gore-Tex), hydroxylapatite, and porous polyethylene (Medpor). Grafts include bone and cartilage, which can be prepared as "Turkish Delight" for rhinoplasty. Imaged facial implants and grafts can be encountered incidentally or purposely to evaluate complications. Many of these materials have distinct radiologic imaging features and should not be misinterpreted as pathology. Conversely, implant complications should be appropriately recognized by using a focused imaging approach. The purpose of this article was to review the different types of cosmetic facial implants and grafts with an emphasis on their expected and complicated radiologic imaging appearances.

An index for quantitative assessment of lip augmentation

BACKGROUND

Lip dimensions and their relation to the whole face have been discussed mainly in the dental literature. There have been few attempts to scientifically measure the degree of lip augmentation, regardless of method.

OBJECTIVES

The authors describe a Lip Index that will allow reliable, quantitative analysis of the human lip complex, which is necessary to assess the efficacy and duration of attempts at lip augmentation.

METHODS

The authors developed a Lip Index as the basis for objective measurements of the effect and duration of lip augmentation with dermal fillers. Measurements may be taken directly from the patient, from standardized photos, or from the computer screen. Using a metric ruler, the height of the vermilion in the middle of the Cupid's bow is first measured (in mm) on the frontal view. The point of maximum protrusion of the vermilion is then measured (in mm) on a standardized side view perpendicular to a vertical line connecting the base of the columella to the fold demarcating lower lip and chin. Vermilion height multiplied by horizontal protrusion directly correlates with the central volume of the lips, upper and lower.

RESULTS

The easily applied ruler provided consistent measures before and after the injection of dermal fillers or soft implants. Adding upper and lower lip indices resulted in the Overall Lip Index for each patient, which was found to be approximately 50 in average females of Caucasian descent, about 100 in females of Asian descent, and nearly 200 in females of African descent.

CONCLUSIONS

The Lip Index allows for the practical evaluation of the clinical effects and duration of dermal filler injectables or implants. Quantitative assessments of results over time are easy to calculate, without the need for complex measurements or sophisticated analyses.

Reconstruction of the lower lip in Van der Woude syndrome

Van der Woude syndrome (VWS) is a congenital disease characterized by labial cysts, accessory salivary glands, congenital lower lip pits, fistula, and paramedian sinuses, and is often accompanied by cleft lip and palate. VWS is an autosomal dominant craniofacial syndrome, which represents only lower lip pits due to variable gene expression. The principles of VWS surgery include excision of lower lip pits and accessory glands, reconstruction of the lip and nose, and correction of accompanying anomalies. In this article, we present a technique with dermal allograft reconstruction to prevent deformities after excision of the accessory gland in the lower lip pit.