Aesthetic Dermatology

To Achieve Natural Lips, Consider Entire Face


 

When enhancing a patient's lips, consider the patient's aesthetic goals and the natural anatomy of the lip, and remember to think aesthetically about the entire face, said Dr. Kimberly Butterwick.

"Take care to achieve a lip that does not look like it's been done," advised Dr. Butterwick, a cosmetic dermatologist in La Jolla, Calif. "We're not just correcting a defect, but making a patient look prettier, and we have to be mindful how the lips contribute" to the symmetry and proportions of the entire face.

The anatomy of the lip—the vermilion border, the red portion of the lip, the philtral columns, and the balance of the upper and lower lip—and its proportions are the elements that need to be considered to create a lip that is natural looking, "yet enhanced and more beautiful," she said in an interview.

The lip is divided into red and white segments, "at a well-defined and arched vermilion border." Think about the M-shaped cupid's bow of the upper lip, and the lower lip as shaped like a W, with two lateral lobes and a midline groove, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

The relationship to the nose and chin, and facial proportions also should be considered, with the width of the lip falling between a straight line drawn from each inner iris.

A mistake that can be made with the red portion of the lip is to create a fat lip all the way across the upper and lower lip, like a sausage instead of being attentive to the normal contours. There is also a tendency to overstress the upper lip in an attempt to get a pouty look. Ideally, the lower lip should be bigger by 10%-25%, Dr. Butterwick added, noting that often, physicians try to make the upper lip equal to or bigger than the lower lip, which appears unnatural.

Areas of the lips that should be fuller and emphasized to achieve a natural look include the two anatomic mounds of fullness at the highest point of the upper lip, right under the peak of the cupid's bow, as well as the two mounds of volume of the lower lip of the "four pillows." It also often helps to add a little volume to the midline tubercle of the upper lips and the philtral columns.

Hyaluronic acid is the main option used for lip correction and enhancement, "because it is safe, soft, and natural, and it lasts long enough in most cases," Dr. Butterwick said. Currently available hyaluronic acid products are Restylane, Hyalaform, Juvèderm Ultra or Ultra Plus, and Prevelle Silk.

Prevelle Silk is a good option for beginners because it is lightweight, contains anesthetic, and does not last as long as the others. It also can be used first, injected along the vermilion for its anesthetic effects, and can be followed by another hyaluronic acid product that provides for more volume and lasts longer, using the rest of Prevelle Silk for fine lines, she said.

Restylane and Juvèderm are similar, although Juvèderm causes a little less swelling and, therefore, "may be a little softer and more natural in the lips," she said, but a product that is a little thicker may be appropriate for those patients who want more pronounced lips, she added. "That's when you can strike a balance between what the patient wants and still achieve a natural look."

Fat augmentation of the lips provides a natural appearance, but does not last as long as it does in other locations. "I would not go out of my way to put fat in the lips, unless you are already using fat for other indications in the face," she advised.

Semipermanent or permanent injectables that are associated with a high rate of adverse reactions when used in the lips are Radiesse, Sculptra, Evolence, and Artefill, as well as silicone, which should be avoided in lips altogether, she said. Their labels state they should not be used in lips, "yet physicians think that they can get away with it, and wind up every so often having a problem, and it is a big problem."

An important element of lip correction is consideration of the way lips appear in motion: When Dr. Butterwick consults with a patient, she said she observes their lips while they are talking. Some people have vertical lip lines from excessive pursing while they talk, or they pull down the corners of their mouth while talking, which are excess movements that can be "softened" with Botox, she said. Botox also can address a gummy smile.

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