Anatomy & Lip Enhancement
When we look around, we may question some of the outcomes of lip injections.
Is the problem one of shape, balance or movement, i.e. an aesthetic problem? Or is it a problem with the product or the technique?
At Expert 2 Expert, we quickly realised that a book devoted to the lips was becoming essential. We hesitated because the task seemed to be so enormous but the quality of the contributors, who immediately showed their enthusiasm, and the vibrancy of their ideas – based on rigorous, scientific evidence- took the decision out of our hands.
These two years of work have provided insight into certain reasons for failure and complications but, above all, have allowed us to review a great deal of received wisdom to confirm or undermine various therapeutic principles.
Patrick Trevidic, MD
Our 360 degrees approach to lip enhancement
Due to their complexity, the structure and function of the orbicularis oris muscle particularly caught our attention. This unusual circular muscle around the buccal opening, which is not attached to any bone, consists of intertwined fibres that simultaneously act as a dilator and a sphincter. Moreover, the peripheral fibres of this muscle are interlaced with the peribuccal muscles enabling the infinite variations of facial expressiveness. It is essential to understand all of these elements so that they are rigorously safeguarded when undergoing the various type of treatment we can offer.
The second common thread in our book is based on highly practical aspects of the various procedures being proposed. From working environment and preparation of the equipment through well whether anaesthesia is indicated and what operating technique is recommended, the contributors have described their personal technical preferences in a context of consistency in this collective effort. Thus we have addressed lip rejuvenation and augmentation with the same balance.
Although most of the authors routinely use hyaluronic acid in the course of treatment, it seems to us indispensable to pay special attention to techniques based on the grafting of adipose tissue. The use of adipose tissue, which demands mastery of surgical techniques, has shown itself to be efficient and holds yet more potential in many applications because of the way in which this type of tissue develops in situ after fat grafting.
Physicians and surgeons involved in the lip enhancement are working to the same end. We should know all about the sites where we make our injections and to need to analyse with rigour the objective established together with the patient. We all have to take into account the natural balance of the various volumes when remodelling lips to ensure a pretty smile that brings pleasure all around.
In this, as in other areas, modesty and caution are the watchwords.
In writing and publishing this work Expert 2 Expert attempts to build a bridge between the anatomical knowledge essential to our praxis and the routine practice of lip enhancement procedures.
Philippe Garcia, MD
Lips play an essential role in our daily lives and throughout history, they have evolved as a key sensual element of the face.
The achievement of rejuvenation and eternal youth has been sought since the origin of many societies. Examples of the very first quests for medicines believed to restore youthfulness date back to the 4th century B.C. and are exemplified by the likes of the “Elixir of life” and more recently the “Philosopher’s stone” and the “Fountain of Youth”.
Today, aside from simple moisturising and colouring using balms and lipsticks, a large variety of treatment modalities have evolved to cater to an ever-growing demand for lip rejuvenation and augmentation within the non-surgical aesthetics industry.
Nonetheless, it is also crucial to bear in mind the surgical options which often are required, particularly in rejuvenation approaches, to achieve maximum clinical end-points.
Through a thorough understanding of the underlying anatomy, associated challenges and ageing features of the lip and the perioral complex, alongside appropriate selection of treatment modalities based on by Evidence-Based Medicine, and respect for cultural and fashion trends, safe and effective clinical end-points can be met with high patient satisfaction.
Shapely, well defined and full lips with upturned corners and no perioral wrinkling are considered the key elements in achieving successful treatment. But importantly, lips should sit in harmony with the rest of the face when assessed from all angles.
Our treatment approaches should therefore be delivered in an artistic manner and tailored to each individual patient and their needs.
Uliana Gout, MD
The work presented in this book is based on a series of anatomical dissections with and without vascular injection.
Thorough knowledge of the anatomy of the lip is key to understanding the mechanisms underlying their ageing and selecting the most suitable forms of treatment.
According to Poirier and Charpy, the lips are two muscular folds, covered on one side by a mucous membrane and on the other by the skin. There is adipose tissue between the muscle and the skin and a thinner layer between the muscle and the mucosa. There are many minor salivary glands within the submucosa.
Lip’s muscular structure
A distinction is made between the lip’s intrinsic muscular structure composed of the orbicularis oris and the extrinsic muscles converging towards the buccal opening.
Arteries in the lips
Arteries in the lips vary enormously in terms of number and location of the arterial feeders. This explains why different studies of vessels in the lips come to different conclusions.
The anatomy of the lips is a controversial topic, not only with respect to the orbicularis oris but also with regard to the arteries.
The density and variability of the arterial vascular network warrants caution. The use of the operating techniques utilising soft-tipped cannulas is strongly recommended.
Thierry Lemaire, MD – Philippe Garcia, MD
Thorough analysis of the youthful lip in its mucosal and cutaneous proportions as well as analysis of the details which compose the natural aesthetic of the lip form the methodological bases for treating lips that have aged.
Henri Rouvière describes the external lip anatomy as two mobile musculomembranous folds which form the anterior wall of the oral cavity and circumscribe the buccal orifice.
Anatomical & histological analyses
Anatomical and histological analyses of a sagittal section through the lip show its different components like as the skin, subcutaneous cellular adipose tissue, the orbicularis oculi muscle, the mucosa and the vessels.
Clinical analysis of the young lip
Clinical analysis of the young lip showed that the upper lip was usually narrower than the lower lip. Commissures were slightly higher than the central point of the buccal opening and the line separating the lips was never perfectly straight.
Clinical analysis of the ageing lip
Ageing is an unavoidable, natural, genetically programmed phenomenon.
Extrinsic factors are also to be considered as contributing to the ageing progress.
Comparative measurements of the cutaneous part of the lip as ageing progresses show a constant elongation between the columella and the vermillion.
Histological analysis of ageing
Young skin histological analysis shows thick epidermis with dense keratinocytes that ensure complete skin turnover in three weeks. Dermis and epidermis are tightly joined. Dermis is thick and rich in collagen and elastin fibres which make young skin firm.
Classification and treatment
Stage 1 corresponds to the appearance of superficial expression wrinkles.
At stage 2, loss of elasticity leads to the appearance of wrinkles at rest.
At stage 3, elongation of the cutaneous part of the lip (white lip) and the diminished projection of the vermillion become obvious.
Thorough analysis of the youthful lip in its mucosal and cutaneous proportions as well as analysis of the details which compose the natural aesthetic of the lip form the methodological bases for treating lips that have aged.
Men seem to be immune to the development of vertical wrinkles. Thick skin is addition to its hair follicles and sebaceous activity provide cutaneous reinforcement.
In contrast, progressive elongation of the cutaneous side and decrease vermillion visibility occur in all lips over the years.
Medical treatment methods are often sufficient to maintain pleasing lips. The loss of a natural look (swollen lip, loss of pigmentation) makes the treatment visible and always results from overcorrection. It is important to know how to avoid the overcorrection in order to ensure a harmonious clinical outcome.
Let us correct the insults of time but warn patients that we cannot, given current surgical and medical knowledge, reproduce the perfection of youth.
Xavier Noel, MD
AGEING OF THE UPPER LIP: PHOTO-MORPHOMETRY, MRI & HISTOLOGY
The performed analyses shed light on the so-far only unsystematically and episodically-described process of upper lip ageing on a histological level
Many different treatments for upper lip rejuvenation have been proposed and described in the literature. As in other medical fields, this suggests that the actual process of upper lip ageing is poorly understood. Although the descriptions are numerous, the scientific evaluation of ageing processes has begun only recently.
Upper lip rejuvenation
Upper lip rejuvenation and beautification procedures are popular and frequently performed. Beautification mainly relies on volume augmentation to achieve fuller, more protruding, “pouting” lips. The same also has become very popular for the rejuvenation of the upper lip complex.
Until recently no scientific data about the ageing process in the upper lip were to be found.
This lack of knowledge encouraged us to perform the analyses presented here.
The often-described upper lip lengthening with decrease of the visible vermilion, as well as lip thinning could be proven, whilst the also often-postulated loss of volume – being the theoretical basis of all volume augmentation procedures – could not be shown.
The presented analyses aim to add another scientific method of investigation to our search for a causal treatment of the older-looking upper lip.
Niklas Iblher, MD – Vincenzo Penna, MD – G. Bjorn Stark, MD
Pain remains the main impediment for patients undergoing filler injections
Hyaluronic acid can be injected to augment the volume of the lips as well as to correct asymmetry in younger patients. It can also be used for rejuvenation, including the filling in of wrinkles on the white lip, eversion of the red lip and restoration of volume lost due to ageing.
Pain remains the main impediment for patients undergoing filler injections, especially in the lips. To ensure satisfied and loyal patients, it is important that practitioners master the local anatomy of the lips and know which products and aesthetic techniques are more suitable.
Types of anaesthesia
Various different types of anaesthesia can be proposed, namely, topical, local or regional. Each of these possibilities should be discussed with the patient. Because of the extreme sensitivity of the lip region, we tend towards regional anaesthesia.
Regional anaesthesia is safe and effective, it causes little tissue distortion and it desensitises a large area.
The sensory nerves of the face derive from the trigeminal nerve (fifth cranial or CN V).
The lip region is innervated by the superior maxillary and mandibular nerves, the two lower terminal branches of the trigeminal nerve.
The upper maxillary nerve (V2) supplies sensory nerves to the midface from the lower eyelid down to the upper lip as well as the anterior temporal region.
The infraorbital nerve is the main terminal branch of the upper maxillary nerve.
The third terminal branch, the mandibular nerve (V3), is the largest branch of the trigeminal nerve.
The mental nerve provides a sensory innervation of the lower lip and chin from the commissure as far as the median line.
Nabila Azib, MD
The lips are the central aesthetic hallmark of the lower face. Together with the perioral area the lips actuate facial beauty.
Full, wide, curved, natural-looking lips with high vermillion communicate youth and are signs of female attractiveness.
A natural-looking lip is one of the greatest challenges of lip augmentation and requires a thorough understanding of anatomy and a precise treatment plan.
Prior to choosing the enhancement technique, we should identify which problems require to be corrected, and address our patient’s desires. As most of our patients do not comprehend their own anatomy, it is our responsibility to show and to explain.
We often choose to start by injecting at the edge of the vermillion followed by the white lip and finally into the vermillion itself.
However, every case should be specifically assessed to decide on the injection sequence.
Injection of the lip and the achievement of beautiful, natural-looking lips is one of the most difficult aims in facial enhancement.
To be able to achieve this objective, it is prudent to understand lip anatomy, the desired lip structure and its deviations, thoroughly and carefully examine each component of the lip, and consider whether it should and/or could be corrected.
Explaining the possibilities and impossibilities of correction to the patient will make the patient knowledgeable and thus lead to increased patient satisfaction.
Injecting carefully, using the proper technique and small controlled quantities of filler and evaluating critically your results after each injection, will, in time, lead to increased expertise and mastery of lip injections. Inès Verner, MD
Lip enhancement with injectable products has become one of the frequently requested procedures in the aesthetic medicine field, because for many people the allure and youthfulness of the face are tightly linked with the appearance of the mouth, lips and the smile. Today, cosmetic treatment of the mouth region using various injectable products is sought by patients of all ages.
Prior to embarking on lip enhancement, it is vital to establish a precise treatment plan. The consultation must always start with listening closely to the patient to define the credibility of his or her wishes. Every part of the lips to be corrected should be analysed in detail together with the patient.
Shape and symmetry when smiling are very important features for a harmonious outcome, which have to be assessed both at rest as well as in action.
Practitioners are asked to address many types of cosmetic problems concerning the lips. Whether the problem is related to ageing or congenital abnormality, our therapeutic arsenal is large thanks to constant improvement in the products and equipment available.
In some cases, it is beneficial to work as part of a multidisciplinary team of physicians, surgeons, stomatologists and orthodontists.
Even though our expanding experience is permitting us successfully to treat cases of increasing complexity, still not everything is possible.
In the field of cosmetic medicine and surgery, it is important to discourage unrealistic expectations.
In the interest of our patients, the common objective for specialists is to restore the beauty of the lips and preserve a natural-looking, harmonious, and balanced smile.
Irina Dmitrieva, MD
As the number of lip procedures performed increase, likely so do the complications. Moreover, the variety of products available has widened the treatment options for practitioners, but also means that physicians have a greater of number of products to become familiar with, including learning about their indications and limitations.
All fillers potentially are with both short-term and long-term complications.
Whilst most adverse reactions are mild and transient, more serious adverse events can occur, leaving patients with long lasting or permanent functional and aesthetic deficits.
Understanding the different characteristics, capabilities, risks, and limitations of available fillers is essential for physicians to reduce the risk of complications, improve patient outcomes and care for patients who have experienced adverse events.
Furthermore, proper technique, preparation, and training are essential.
As with all aesthetic procedures, accurate and comprehensive aesthetic analysis is the first step. Any asymmetries, previous injection sites, irregularities and scars should be noted and pointed out to the patient and improved upon if feasible.
Following treatment to the lips, the classic unwanted effects, in particular oedema are common.
Exacerbatory factors are dense vascularisation and high-level of muscular activity.
All injectable fillers are foreign bodies and may elicit a foreign body reaction from the recipient host tissue, the magnitude of which depends on the nature of the foreign body.
In addition to prevention of potential infections, choice of the most suitable filler and injection technique is also essential.
Tatjana Pavicic, MD
A review of anatomy of the lips for botulinum toxin injections
Botulinum toxin has its place among the many forms of lip treatment, be it for rejuvenation or enhancement.
Focusing purely on the clinical analysis of the upper lip, we recognise two parts. The white lip is covered with skin, while the red lip corresponds to the dry visible part of the buccal mucosa (as opposed to the wet red lip inside the mouth).
Injecting botulinum toxin in the lip region can reverse the signs of ageing in this part of the face as well as improving unsightly muscle movements and correcting dynamic asymmetry.
The toxin is particularly useful for facial rejuvenation strategies in which it provides an ideal complement to filling. It affords excellent outcomes as long as the practitioner is expert on local anatomy, and the recommended technique is closely adhered to.
The disadvantage is the temporary nature of the toxin’s effect.
Perioral rhytides, marionette lines, orange peel skin on the chin, gummy smile
Complications are rare as long as the technique is respected and care is taken. Extensive, in-depth
familiarity with facial anatomy is essential.
Autologous fat grafting can be easily combined with laser dermabrasion and hyaluronic acid fillers.
The modern era of autologous fat grafting
The modern era of autologous fat grafting was launched by Illouz and Fournier in France and systematised by Coleman (Lipostructure ™) at the end of the 1990s.
Various changes have since made the procedure safer and more predictable, recovery quicker with less discomfort, and –in experienced hands – complications rare and minor.
An advantage of autologous fat grafting is that it uses sufficient appropriately-placed quantities of autologous tissue to deliver long-lasting results.
However, it is a surgical method which requires identification of donor sites, accurate technique and hence a significant learning curve for the practitioner.
The current technique – now in use for some years – will be described in detail, and long-term outcomes will be shown.
Autologous fat grafting has its place in the therapeutic array of lip treatments.
Like any technique, it has its own specific indications and limitations of which one should be aware, and should take into account to ensure satisfactory outcomes, whether autologous fat grafting is carried out on its own or combined with other techniques.
Yves Surlemont, MD
Over time the upper white lip lengthens, thins, draws back, atrophies, acquires wrinkles and tends to hide the upper incisors when the lips are slightly parted.
Today there are many possible treatments for enhancing the appearance of the lips.
Outcomes are often satisfactory as long as balance is maintained between the various volumes.
This means avoiding injecting too much filler into the wrong place in a lip that is already too long.
After an in depth examination of the face and, if possible, inspection of photographs of the subject when young, the aim of surgery is to reduce the height of the upper cutaneous lip to restore harmonious proportions. In most cases, intervention is confined go purely cutaneous part of the lip which is demarcated by the edge of the nostril superiorly and the Cupid’s bow inferiorly.
The technique involves excising a predetermined section of the skin under the base of the nose which is flush with the nostrils and the columella.
Establishing precise indications for surgery is important but the technique is simple, well codified, and relatively free of complications.
This intervention is often simultaneously combined with another surgical facial rejuvenation procedure.
Bernard Cornette de Saint Cyr, MD
BONE SUPPORT OF THE LIPS : HOW ADULT ORTHOGNATHIC SURGERY CAN ENHANCE THE SMILE
Orthognathic surgery is a distinct surgical specialty in itself.
Satisfactory execution of orthodonticosurgical protocols depends on collaboration between different members of a multidisciplinary team.
The team’s efficiency will depend on collaboration and mutual understanding, steadily built up by virtue of our common practice.
Patient’s cosmetic demands are strong.
The whole team should be capable of coordinating the approach in an objective whose cosmetic dimension tends to outweigh functional and occlusal considerations.
The purpose of orthognathic surgery on the maxilla and mandible is to correct the position of the supporting bones and malocclusion, which is a common secondary effect.
The objective of this multidisciplinary approach is both to improve function (with restoration of static and dynamic occlusion) and to enhance the cosmetic appearance: definitive restoration of facial balance, mouth closure at rest and osseous lip support all tend to enhance attractiveness.
We will review the therapeutic objectives of orthodonticosurgical protocols, the key elements of preoperative work-up and finally various different indications depending on the position of the teeth when smiling.
This type of surgery necessitates a highly individualised approach based on an in-depth clinical and aesthetic analysis of the patient.
Jean-Baptiste Charrier, MD
Clear guidelines on men’s lips enhancement
Although objectives are different, the treatment programme in men is comparable to that in women.
During the courses of treatment, it is vital to maintain an essentially masculine character.
The chin and mandibular angles need to be reinforced.
It is important to harmonise the smile line by bringing out the commissures and filling in the bitterness and the nasolabial folds.
Thick skin and deep folds mean using cohesive, bulking forms of hyaluronic acid.
Hervé Padey, MD