Too often I hear the biggest fear a patient has when it comes to lip filler….”I will look like a duck.” I have also heard statements like, “I don’t want to look like one of those celebrities. I want to look natural.” Or I Iove, “I don’t want my lips to enter the room before me!”
I supposed lip filler could be scary, but my answer is simple. Look at the photo gallery. Why would I want my patients walking around with bad lips? It’s my reputation after all. I have pictures of my patients placed in various locations including a rotation loop on the TV in the lobby as well as walls of the consult and exam rooms in order to ensure patients of my aesthetic style. It should be obvious to everyone that I only allow for a natural-appearing lip. I have even turned patients away if what they are asking for is not within my scope of realistically achievable outcomes, or is not natural in appearance.
The secret is to a natural augmented lip is…respecting the anatomy.
Before I begin, it should be understood there is a wide array of FDA approved fillers for lips. All of them are composed of hyaluronic acid. Go to DrEllenTurner.com to see a complete list of all FDA approved fillers by area.
The lip is composed of the philtrum, the philtrum columns, the red lip and the cutaneous lip. We can break it down even more so to the various parts within the red lip but I am a lumper, not a splitter as my dermatology professor used to say. However, after injecting lips for the past 20 years, with my primary goal to achieve a natural, more filled lip for my patients, I have discovered a simple technique which creates beautiful, consistent results.
Injectors who simply augment the lip without understanding the vital importance of areas such as the philtrum columns (I refer to them as columns to the patient) and addressing volume loss, if present, in the cutaneous lip will find that the lip begins to resemble two sausages stacked upon one another. For the less discerning patient, this might be acceptable, but for most, you will find that patients will not remain in your practice for long.
The columns extend up from the cupid’s bow of the lips. If this critical area of anatomy is neglected when augmenting even the most youthful lip, the upper lip will be stretched flat by the volume of filler placed in the red lip. A sign of fetal alcohol syndrome in newborns is the absence of the columns, or a flattened philtrum. Thus, by simply place a small amount (typically 0.05-0.1cc) of filler in the columns, the injector is able to establish anatomical boundaries and maintain anterior projection of the upper lip and cupids’ bow. In an aging lip, the entire philtrum may be lost and flattened. It must be built up, and in this case, more product must be used—as much as 0.2cc of filler—before proceeding to the red lip and the cutaneous lip.
For augmentation of the actual red lip, I have always followed the wet-dry border and this has worked quite beautifully and appears very natural. Next, if the corners are turning downward, filler can be placed at the angle of the lip corner. Be aware if there is excessive downward turn of the lip corners, the patient may also require a neuromodulator to address the depressor anguli oris muscles. To determine this, ask the patient to show his or her bottom teeth, and the movement of the DAOs will become obvious to the injector. When the DAOS are rested with neuromodulation, this can dramatically improve the appearance of the “upside-down frown” and work in tandem with lip filler.
The cutaneous lip must be addressed in patients with vertical lip lines, or rhytides. Sometimes it has become so severe that even horizontal rhytides have presented as well. There are hyaluronic acid fillers which are specifically designed to address these perioral rhytides, as opposed to simply filling the lips. However, injectors should proceed with caution even when utlitizing the correct product in patients with severe perioral rhytides. Not only must one adequately augment the philtrum columns, red lip and angles of the lip, but adequate product is required for both the cutaneous upper and lower lips. One must take care to avoid lips appearing bulky, and risking the development of the dreaded “HA mustache”. To avoid this, inject vertical lip lines using a 31-gauge needle from the superior aspect of the line to the lip approach, and massage vigorously post injection.
The more aged lip can greatly benefit from multiple treatment modalities such as Skinvive by Juvederm, laser resurfacing devices or other energy-based devices which enhance and stimulate collagen and elastin which have been lost over time due to extrinsic and intrinsic factors.
(Before and immediately after lip filler injection, courtesy of Ellen Turner, M.D.)
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