Lip augmentation - how to get a natural look?

Lips are one of the easiest areas to treat with fillers. Understanding what makes lips beautiful is helpful in obtaining great results. However, the "ideal lip" as often described in dermatology literature may not be achievable in all patients, so achieving a nice, natural look should be your goal.

For example, ideally the lips should be divided into 1/3 upper and 2/3 lower; that is, the upper lip is slightly smaller than the lower. However, on some faces this may not look natural at all for their facial shape and contour, so be wary of trying to make everyone fit into a single box.

As with any filler injection, combining the artist's eye behind the syringe as well as the patient's eye for what they desire is the key to achieving successful lip augmentation.

Although we are taught that fillers like Restylane and Juvederm last 6-9 months, I find that Restylane actually lasts 1 year to 16 months; new studies will be published to support these findings. Although you never hear this from inexperienced injectors, it is obvious that when injected correclty, this product lasts longer than reported.

Moreover, last week I removed some improperly-placed fillers from a patient's lip (injected by another physician) that was placed 1.5 years ago and still persisted because  it was placed too superficially. So be aware that individual results do vary!

• Please check physician credentials (are they dermatologists/plastic surgeons/ facial plastic surgeons - skin experts and facial experts)
• Look at photos of real patients injected by your physisican (not the ones the company releases and everyone puts on their websites of the best results the company has ever seen performed by some other injector).

Healthy skepticism and knowledgeable patients will be welcome in any worthy physician's office and will help to ensure successful, great looking filler results!

The fear of "fake" looking lip augmentation

The widespread use of lipstick clearly demonstrates the demand for fullness of the lips. Female patients frequently look at celebrities and socialites whose lips are 'over the top' in terms of augmentation, however, and are fearful that they might end up with huge, 'fake' looking lips if they were to undergo injection augmentation.

The truth is that, similar to breast augmentation, patients can choose the degree to which their lips are enlarged. A reputable, experienced facial plastic surgeon will use injectables such as Restylane, Perlane, Juvederm Ultra, or Juvederm Ultra Plus, in combination with numbing cream and a dental block, to augment the lips to whatever degree, and in any manner that a patient chooses.

As far as choosing an injectable, I find that Juvederm lasts longer for most patients than Restylane. I also strongly recommend against using Radiesse in the lips, as it definitely has the potential to form firm lumps.

Non-invasive lip augmentation

The lips are the only visible sexual organ. Their appearance plays an important role in how we feel about ourselves and how others respond to us.

I invented minimally invasive lip augmentation in 1984. 

Since that time, we have learned much about the best techniques and the proper points of reference for measurement and adding volume to the lips.

One of the most important things that many physicians do not fully understand is that in order to restore the optimal appearance of full and properly shaped lips, you must also use injectable fillers to restore the structural support of the lower face, which is gradually lost as we age.

When this area is addressed and restored, it pulls the mouth forward. Additionally, you must create a buttress, on top of which the lips sit. This helps restore the lips to their intended position; it is only after this has been done that I add volume to the lips.

Many doctors do not understand this concept, and instead they only inject fillers into the lips to add volume. This creates unnaturally appearing lips, which we have all seen!

It is only through treating the lower third of the face and rebuilding the structural support that has been gradually lost due to aging (not unlike what an architect does to a grand building) that I can create the perfect lip!

Lip enhancement is an art. If done correctly, it is one of the more difficult of the non surgical procedures because the shape of the lip is individual and complex. A good lip augmentation has to have the following qualities:

1. The lower lip should be a little bigger than the upper lip and can roll out a bit in a pout.
2. The upper lip should have the shape of the cupid's bow area in the middle preserved. The lip should not go straight across - it looks fake that way.
3. The upper lip should have a smooth and well defined transition from the red of the lip to the skin. It should not have a big ridge - that looks fake too.
4. Both lips should be symmetric from one side to the other and they should be smooth. There's nothing that looks more fake than bumpy lips.

My emphasis in lip augmentation is always on a natural, subtle look. The patient's friends should not immediately notice that she has had her lips augmented. They should just notice that she looks great but they should not be able to put their finger on why.

The difference between a good and bad job with lip enhancement is a matter of a millimiter or less. This is why I really do not think that imprecise techniques like fat injection, surgery or insertion of solid implants like Alloderm or GoreTex are any good.

I use Juvederm exclusively these days - I find that it is less likely to have bumps than Restylane and it seems to last a bit longer (5 to 7 months). Any of the hyaluronic acid fillers do a good job - Restylane, Perlane, or Juvederm - as long as the doctor or nurse injector is very experienced doing lips with that filler.

Another major point with lip augmentation is that it should never hurt. I still have people coming to me who recall their previous lip injections with horror because the injector used topical numbing creams. Lips should always be numbed with a dental block. They are some of the most sensitive tissue in the body and sticking a needle in them hurts like hell. Fortunately, septocaine and other dental injectable numbing preparations do a great job at making the experience completely painless.

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The lips are a very important feature of the face. Whenever we are talking to someone, either consciously or sub-consciously we notice and evaluate their lips. Full lips are a sign of sensuality and youth. There are numerous options today to create soft, natural-appearing lips.

They key point is: NATURAL. Most people do not want others to know they had their lips enhanced. There are several natural proportions that need to be followed so that the upper lips and lower lips look good together.

• In general, the upper lip should be 1/3 while the lower lip should be 2/3 of the total size of both lips. A curve and "natural pout" can be created to lift and bring out the border of the lips with the skin, known as the "vermillo-cutaneous" border.

Another important point is that lips must FEEL NATURAL. If material is placed that takes the sensation away or makes the lips lumpy or hard, this can be very traumatic for patients.

Here are some effective, yet natural looking and feeling treatment options:

1. Hyaluronic Acid Gels (a substance we all naturally have in our bodies) - Restylane reviews" target="_blank" href="http://www.realself.com/skin_care/skin_treatment/restylane.html">Restylane, Perlane reviews" target="_blank" href="http://www.realself.com/skin_care/skin_treatment/perlane.html">Perlane, Juvederm reviews" target="_blank" href="http://www.realself.com/skin_care/skin_treatment/juvederm.html">Juvederm - These are great and my preferred in office lip enhancers. If a tiny nerve block is used, along with ice, the discomfort is minimal if at all! 
2. Fat Injection - Fat transfer, grafting reviews" target="_blank" href="http://www.realself.com/plastic_surgery/fat_injection.html">Fat transfer is a very natural and great operative technique. When getting a surgical facial rejuvenation (facelift, eyelid lift etc.), this can easily be done at the same time. Fat can cause swelling for a bit longer than hyaluronic acids. In general, about 50-70% of the fat volume lives and becomes a part of your body. 
3. Surgical Lifts - Many times the lips can be lifted directly, either with an incision near the nose, inside the lips, or right on the upper lip border.
4. Alloderm - an engineered skin/soft tissue substite that can be rolled and inserted into the lips. Although, with the above options, the role for this has diminished.

A last point is that aging lips or lack of full lips appear worse when the corners of the mouths form lines and sag, so this area often needs to be corrected also.

Botox and lip augmentation

The second most common cosmetic procedure in the U.S. is the use of hyaluronic acids for lip enhancement and facial shaping (the first being Botox injections). Dr. Lam has excellent feedback when it comes to helping patients understand the need for a balanced and natural look to the mouth. What may look good and appealing on a 20-something year old may not look appropriate on a fifty year old. In our practice, we strive for the same outcomes of educating the patient on how to enhance their mouth in a natural looking way. Not only do hyaluronic acids accomplish this, but we also use small amounts of Botox to the outline of the mouth which then relaxes this muscle. This simple procedure with small amounts of Botox results in a subtle but pretty eversion or rolling out of the lips which then adds a more defined shape and fullness. Another perk to this treatment is that it also helps to soften the fine lines surrounding the mouth. Many of our female patients saw enough improvement with just the Botox that they didn't require fillers (hyaluronic acid) subsequently. Using Botox in this manner has saved patients much money if they were uncertain whether or not they wanted to invest in fillers. On the other hand, using both products together has been ideal as well for those that saw value in the Botox to the perioral area but still wanted more fullness to the lips. Lip shaping is definitely an art and should be tailored to each individual.

The best choices for lip augmentation

I think the best products for lip augmentation are the hyaluronic acid fillers, such as Juvederm, Restylane, and Perlane. They are safe, effective, and have no potential serious complications. Of these, probably Juvederm is the most popular due to its softness. The typical duration of lip augmentation with these fillers is 4-6 months.

Fat injections can also be used in the lips although injected fat does not stay as long in lips as it does in other parts of the face.

Lip implants are also an option for people who want long-term lip augmentation. Gore-Tex lip implants have been used for decades and are proven safe, although hardness can occasionally be a problem. There is a new type of saline-filled lip implant called FulFil, which has great potential for a softer permanent lip implant. One of the advantages of the Fulfil lip implant is that the size can be adjusted at the time of surgery by adding more saline (much like breast implants). The main advantage of lip implants is that they can be removed if necessary.

I think it’s worth mentioning here that use of silicone injections for lips is not recommended due to long-term changes and potential deformities associated with silicone placement into human tissue. Most plastic surgery and dermatology societies consider silicone injections to be unsafe and have recommended against their use by their members. Most insurance companies that insure surgeons do not allow coverage for complications related to silicone injections. Silicone cannot be removed from the lips or other tissue and when there is a deformity from silicone, it must be cut out surgically.

Simple lip augmentation

You can achieve a full, pouty upper lip without putting anything into the lip.

This is done with a sub-nasal lip lift where skin is removed just under the nose, and the inconspicuous scar (similar to that for a nose job) is hidden inside and under the nostril.

The lift pulls up and enlarges the visible red part of the upper lip and creates a pouty look.

This is a simple and effective operation done under local anesthesia with three days of down time, and I just don't understand why it is not done more often.

Plastic Surgeon Dr. Samuel Lam discusses what actually makes the lip look beautiful, the importance of balance between the lips, and how to create a beautifully-shaped lip.