Lip augmentation, a procedure designed to change the size and appearance of the lips is a fairly frequent desire, which falls under cosmetic surgery as well as aesthetic medicine. In our Caribbean clients lips tend to be fuller as a base line ethnic characteristic compared with Europeans or North Americans. Thin lips thus stand out even more as being afar from a prevailing ideal of beauty than in geographic regions with a predominantly Caucasian population. Clients for lip augmentation in the Caribbean fall thus into one of two groups: those with constitutionally thin lips (a minority) and those with relatively full lips, but not full enough to give a “pouting” look.
Although the overwhelming majority of lip augmentations is performed with injectable fillers, there are other, less well known methods, which may be equally or more effective. Clients may not be aware of them and unless properly counseled by a plastic surgeon experienced in all of them their choice of treatment options may be very restricted indeed.
If lip augmentation with fillers is considered, hyaluronic acid based materials (the best known being brands such as Juvederm or Restylane) represent the standard of care, period. Anything else but a hyaluronic acid based filler is not even worth considering due to the potential for intractable complications. Hyaluronic acid is the predominant constituent of the so called extracellular matrix of the body wherein the body’s cells are embedded like raisins in a pudding. It is thus a natural substance, which is produced and degraded constantly by the cells in the body. Those molecules degrading hyaluronic acid of the extracellular matrix also degrade injected hyaluronic acid. Thus injected hyaluronic acid fillers disappear over time. Although various manufactures claim varying longevity of their products, it is our experience that after six to eight months any lip augmentation performed with such is fillers is not any longer visible.
There are longer lasting materials such as Radiesse or Artefill, which are not based on hyaluronic acid. They contain particles similar to ceramics or plastic, which cannot be (ever !) degraded by the body itself. They have the potential to result in foreign body reactions and irregularities when injected for lip augmentation. These complications cannot in any meaningful way be resolved without surgery and scars. No permanent filler should ever be injected into the lips (or anywhere else for that matter).
When viewed from the perspective of potential complications, the six to eight months effect of hyaluronic acid based fillers appears in a whole new light. Not only does the effect of lip augemntation disappear, but also potential complications and irregularities do. Being a natural substance the body also produces the molecules necessary to degrade it. The enzyme hyaluronidase happens to be available as a commercial, off the shelf antidote to hyaluronic acid fillers and hastens the resolution of potential problems if injected into previously treated areas.
In the past there were attempts to use strips of connective tissue recovered either from the client’s own body e. g. during a facelift or harvested from cadavers and subjected to chemical processing to avoid rejection for lip augmentation. The surgical insertion of these strips is much more traumatic than the injection of fillers and the effect did not turn out to be that much more durable. So there really is not much of a point to this method, given its considerably higher cost.
Another alternative to fillers for lip augmentation is autologous fat transfer. Only a few milliliters are necessary, which can be harvested relatively expeditiously with appropriate technology under local anesthesia. As long as sterility during harvest, processing and reinjection can be maintained, lip augmentation with fat grafting is an office based procedure. The effect of fat injection is permanent lip augmentation, so all involved parties should be pretty sure what they want as the procedure cannot be undone completely.
The body’s own fat is of course one hundred percent biocompatible – no rejections, no foreign body reactions, no problems. In principle it would be the ideal filler material were it not for the unpredictable survival of transplanted fat cells. We know with relative certainty – if certainty exists at all in plastic surgery – that a fraction of the transplanted cells does not survive the transfer. How large this fraction actually is and if there are any adjunctive treatments able to reproducibly decrease that fraction is open to argument, conjecture, superstition and research. Seventy percent survival rate, thirty percent loss is an accepted rule of thumb for autologous fat transfer. The odds may be better in case of lip augmentation or injection into the face in general but are, well – unpredictable. It follows that overcorrection should probably be avoided as unpredictability may come back to haunt client and surgeon with an occasional close to hundred percent survival resulting in overcorrection. The latter is by far more difficult to treat with attempts at removing injected excess fat than undercorrection which just requires injection of a usually small amount of additional fat. We thus prepare clients mentally for two or three sessions of fat grafting until the desired lip augmentation effect is achieved and remains stable.
A further possibility to achieve permanent lip augmentation is the insertion of PTFE (polytetrafluorethylene, also known as GoreTex) implants. Mounted on an introducer resembling a knitting needle they are threaded across the lip from one angle of the mouth to the other under local anesthesia. The implants are not resorbed and permanently add volume to the lips. Although relatively soft, they can be felt through the lip even if placed correctly, although this to date has not been a noticeable source of client dissatisfaction. We use those implants in clients who have previously had lip augmentation with hyaluronic acid fillers and liked the result enough to desire permanent augmentation while accepting the downsides of this method (implants can be felt in lips, foreign body reactions, potential for infections) as well as its permanency e. g. lips implants can only be removed surgically with considerable difficulty and with likely permanent deformity. The combination of popularity of other methods and disadvantages of permanent implants in the lips results in fewer and fewer cases performed with this method each year in our practice.
Other surgical options for lip augmentation are so called vermilion advancement and subnasal lip lifts. Both are very effective methods to alter the shape and increase the size of lips. Their disadvantage lies in the fine, but permanent external scars, which have to be accepted by the client. They are not usually a problem in older, fair skinned patients. In clients with dark skin tones in the Caribbean we restrict the use of these surgical methods to men who wear moustaches or are willing to do so after the procedure. Vermilion advancement and subnasal lip liftings are best used in light skinned, older patients with constitutionally thin lips further shrunk by aging or long upper lips appearing ‘saggy’ as well as in those clients with thin lips desiring a more permanent solution after having tried a hyaluronic acid filler.
Thus there is more than one solution for the problem of lip augmentation. There is no one ‘best’ method applicable to all clinical scenarios and clients. The key to client satisfaction in lip augmentation is (like everywhere in plastic surgery) individualization – adapt the solution to the problem, not the other way round.
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