Everyone wants beautiful lips, even though you may have been wearing a mask during the pandemic. Lips are a central beauty feature on the face. The most popular use of fillers throughout the US and around the world is for lip augmentation. In addition to size boosting, reshaping or other modifications are incredibly common.
Lip augmentation or enlargement is a basic starting place for lip treatments and the most common use for injectable fillers. Even back when we used collagen injections, before the modern era of fillers, this was incredibly common. Surgical implants in lip for enlargement, such as Gortex, silicone, others have been used. Lip augmentation is popular in young adults and older people. Each individual choses their aesthetic goals whether you want a little size enhancement, restoration of volume lost from aging or very obvious bee-stung lips.
How much or how big to go with your lips is partly a product of the projection of the rest of your features and the look you are going for. The beauty of doing this with injectable filler (Restylane, Juvederm) is the tremendous control of exactly where you end up. So size does matter but size really is a secondary consideration to lip shape.
The lips have a complex shape with curves, bulges, dimples and peaks which in proper balance are the major factor in the beauty of the lips, even more so than size. Injectable fillers are excellent at precisely making small shape changes in very specific portions of the lip -something that was never possible with surgical lip implants. Uniform augmentation of the upper or lower lip takes away the natural shape and some of the lipâ€™s beauty. More recently, multiple fillers have been developed and received FDA approval specifically for treating the lip for augmentation or to treat wrinkles (Restylane Kysse, Restylane Silk, Juvederm Vobella).
Natural Lip Shape
The upper lip and lower lip each have a unique shape that is completely different shape from each other. The upper lip is fuller approximately in the mid-portion of each half, tapering towards the side of the upper lip at the corner of the mouth. The upper lip has a small emptier space adjacent to the central pucker of the upper lip â€“the tubercle, which is the fullest or most projecting part of the upper lip. These are all part of the pink lip also known as the vermillion. Above this is a portion of the upper lip with normal skin with a feature called the white roll serving as a thicker roll of skin at the border between the vermillion and skin portion of the lip. Within the white roll is the Cupidâ€™s bow peak on either side of the tubercle. Extending up from each Cupidâ€™s bow peak to the base of the inner portion of each nostril is an additional roll of skin known as the philthral column.
The lower lip shape simpler, classically described as a double pillow with fuller visibility of the vermillion midway across each side tapering toward the corners of the mouth and with less projection in the midline. The upper lip is typically smaller than the lower lip, being two thirds to three quarters the size. Small asymmetries are universal, such as differences in the length, fullness or shape of the two sides of the lip. Filler minimizes but doesnâ€™t eliminate these asymmetries since the filler can only make up for volume differences with limits on changing an asymmetric skin envelope.
The Aging Lip
The lip loses some of itâ€™s beauty and appeal with aging due to loss of volume (thinning) and loss of curviness. There is less vermillion show with the lip rolling in and lengthening of the upper lip (more height to the normal skin part of the upper lip). In addition, aging produces loss of definition of the white roll, including cupids bow peaks and philthral columns. Finally, wrinkles in the skin of the lips and perioral area occur and progressively deepen.
Botox and other neuromodulators (Dysport, Xeomin and Jeuveau) are used to treat dynamic lip wrinkles, those that form with animation. Another use of Botox in the aging lip is to roll out the vermillion providing more pink show, a treatment termed the lip flip. For individuals who pull the lip up too strongly when smiling, showing not only the teeth but also the gums (termed a gummy smile), Botox can be used to soften the smile, converting it into a full tooth smile â€“no gums showing, or relax even more into a Mona Lisa smile.
Injectable fillers can treat wrinkles superficially in the lips. Again, fillers like Restylane Kysse and Juvederm Vobella were specifically designed for and have specific FDA approval for this indication.
Lip surgery is very central to plastic surgery based on techniques plastic surgeons use to treat trauma, to the lips and cleft lip and palate. Cosmetic treatments of the lip are also mainstream. Lip reduction can be performed if the amount of vermillion show is too much. These days, there is much less surgical lip augmentation since this indication is almost always done with fillers.
An increasingly common aging lip treatment is the lip lift which is performed to reduce normal skin lip height, elevate corners of mouth and aid with roll out of vermillion. In this procedure, a wedge of skin is removed just below nostrils. Artistry important in how this wedge is shaped and sized in order to achieve the needed goals and to preserve a natural look. Meticulous closure of the incision is needed to achieve the best possible scar.
Energy based treatments for resurfacing of the lips and peri-oral area are commonly performed to reduce wrinkles using a variety of energy based devices including CO2 laser resurfacing, Erbium:YAG laser resurfacing, Fraxel, Tixel, a variety of radiofrequency devices as well as chemical peeling. These recovery based treatments can be tailored to the severity of the wrinkles and the time availability and willingness of each individual to have recovery time in their schedule.
Filler and Botox Pitfalls
Getting natural results requires an experienced injector with good technical and artistic skills who will listen carefully to your aesthetic concerns and craft a plan in partnership with you. There are a number of causes of an unnatural look with lip filler. This is not surprising given the large number of treatments in this area by a wide range of providers with variable skills and experience.
- Enlarging the lip without maintaining the natural curves and shapes, producing a sausage-like look.
- Filling onlythe corners of the upper lip so the natural taper from full midportion to the corner is lost â€“an intrinsically unnatural look. Some patients ask for that look because it is so commonly seen â€“even in fashion magazines. Also, it is a quick, easy injection for beginning lip injectors but not natural.
- Too much injection in the white roll creating a duck-billed look. This is obviously unnatural and most people would like to avoid this look. Alot of lip injecting was done in the white roll with collagen which was softer than most modern fillers. The stiffer modern fillers can be injected in the white roll, especially to accent the cupidâ€™s bow peak but this must be done conservatively or excessive prominence will result â€“the duck-billed look.
- Pushing a good Botox result too hard. Completely relaxed muscles is aesthetically desireable with no adverse functional consequences in some parts of the face, especially in upper facial areas but this is never okay in the lower face/perioral areas. To avoid an unnatural look and even functional problems, the dose of Botox or other neuromodulators must be tightly limited. A little is good but more is not better. We can get some nice effects with neuromodulators but have to accept that we canâ€™t get more result by overdoing it.
Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. This is your cohost Doreen Wu. I’m joined by Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. This episode title is kiss and tell revealing all the ways plastic surgeons can beautify your lips. I’m excited to jump into today’s episode to really understand what makes a beautiful lip and how plastic surgeons can make lips more beautiful.
Dr. Lawrence Bass (00:34):
This is really an episode for everyone of every age, male or female. Lips are a central beauty feature on the face and very popular for a little boosting reshaping or other modification. If we look at the makeup industry, lipstick is the single most inflation and recession proof product for good reason. This is a little less true right now since we’re all wearing masks in the pandemic. But we all still want to look good both to ourselves. And when we get on those zoom meetings and on FaceTime,
Doreen Wu (01:15):
Everyone always thinks about lip augmentation and have this image in their head of big, full bee stung lips. Dr. Bass, when it comes to lips, is it true that size matters?
Dr. Lawrence Bass (01:27):
Well size is a big part of it. Enlargement or augmentation of the lip, this was a big starting place in the aesthetic treatment of the lip. Even before we had modern injectable fillers, various things were implanted or injected into the lip to build a bigger size, uh, in modern plastic surgery. Things like Goretex was slipped into the lip to build the size. Silicone was injected in the lip, many, many other things historically in plastic surgery. So this is definitely something that is captivated interest over many decades back in the 1990s, when, uh, in the early nineties, when collagen injections were the available filler, one of the principle and most popular uses was for lip augmentation in the era of modern fillers like Restylane and Juvederm. This became longer lasting and even more popular. It’s a treatment that’s popular in young adults and in a number of decades of older adults going, going forward from there. The question always is how big is too big? Should the lips look obviously bulging the bee stung look or just imbalance with other features? That’s a question of personal taste, more than anything like everything in plastic surgery. I personally think finesse in some understatement works best, but how much or how big is definitely partly a product of the projection of the rest of your features and the look you’re going for
Doreen Wu (03:16):
So bigger is better at least up to a certain point. Is that the end of the story for lip injections and fillers?
Dr. Lawrence Bass (03:24):
Not really. In fact, it’s, it’s just the beginning, actually in my view, it’s a secondary issue. Size is part of it, but the most important feature of a beautiful lip is shape. The lip has curves, bulges, dimples, and peaks. The beauty of injectable fillers is the incredible shape control that we have using them, which far exceeds that, which we see in surgery on the lip, based on the amount and exact location of placement, we can really control the shape, the size and the gestalt that the lip projects.
Doreen Wu (04:07):
Can you talk about some of the shapes and styles? In other words, what makes a beautiful lip?
Dr. Lawrence Bass (04:14):
So again, it’s not an across the board, big size or uniform size. The lip is always curving and contouring as you transition from one part to another. And those shape differences need to be maintained for the lip to look natural and for the lip to look attractive. The upper lip and the lower lip have completely different shapes. And so again, just uniformly augmenting the upper or the lower takes away. Some of that distinction and looks unnatural. Natural. The upper lip is a tapers towards the side, fills towards about two thirds in from the side, and then has a little bit of an empty space before the central pucker or tubercle. That’s the central part of the upper lip. Now here, I’m talking about the pink part of the lip, what we call the Vermilion in medical terms. That’s not the only part of the lip though. We have white lips skin of our lip, and we have the white roll, which is the transition zone, that little, that little zone of thicker skin in between the pink portion of the lip and the white portion of the lip. In the white roll, we have something called cupids bow peaks.
Dr. Lawrence Bass (05:52):
And in the white lip, we have philtral columns. We have similar roll of skin to the white roll that go down from the nostrils to the Cupid bow’s peaks. So all of those shapes should be visible and they need to be in balance. Lower lip shape is a little simpler. The classic description of the lower lip shape is a double pillow look so fullest again, about two thirds of the way in, from the side with a little less fullness, right in the center, a simpler shape, but still a very important shape for the lip to look natural. There are also considerations of the size of the upper and lower lip relative to each other. The lower lip typically looks bigger than the upper lip. The upper lip will be two thirds to three quarters, the size of the lower lips. So it’s a little bit smaller, not half the size, but two thirds to three quarters.
Dr. Lawrence Bass (06:59):
The final consideration in lip shape is symmetry improvement. A lot of people have small asymmetries on the face. Almost all of us have very small asymmetries. All of us do, but many people have moderate asymmetries on the face that manifest in the lip as a difference in length, a difference in fullness. And these symmetry differences can be minimized using injected fillers. However, we can’t eliminate them because there are many things that are responsible for that asymmetry. And just for starters, the skin envelope is different on the two sides, and that limits the ability to completely remove the asymmetry.
Doreen Wu (07:46):
This is likely a question that many people have. What happens to the lip during the aging process?
Dr. Lawrence Bass (07:53):
That’s a really important question. And like almost every other part of our body, as we age our lip loses some of its its real power, beauty and appeal, and it loses it for several different reasons. We lose some of the curviness, uh, the lip thins or become smaller. And again, this applies to both upper and lower lip. We see less of that Vermilior pink portion of the lip. This is caused by multiple factors that cause the Vermilion to roll in and less of it be rolled out where it can be seen, uh, bone loss as we age lengthening of the upper lip and intrinsic volume loss in the lip, all contribute to loss of Vermilion show. We also lose definition of the white roll, including cupids bow peaks and philtral columns. And we start to develop fixed and dynamic wrinkles. And what I mean by that fixed wrinkles or wrinkles you see when the lip is in repose. And when you animate you talk, you smile, you eat, dynamic wrinkles are the wrinkles that form when the muscle is buckling the skin because it’s in action.
Doreen Wu (09:11):
What role can Botox and fillers do to combat that?
Dr. Lawrence Bass (09:15):
So there are a number of treatments for these aging changes that Botox and other neuromodulators and fillers help us with. Um, we do treatments to restore the volume, to restore the shapes that are lost using injectable fillers. We can put injectable fillers into the wrinkles superficially in the skin. That helps us to an extent, it blunts the appearance of the fixed wrinkles. And it also stiffens the skin a little bit, which blunts the dynamic wrinkling. The main treatment for dynamic wrinkling is Botox, which can soften the amount of buckling, the upper lip skin undergoes. When we talk smile or animated, uh, there are a couple of other things that Botox, Dysport, Xeomin in Jeuveau are being used for. One is the gummy smile. That’s not really an aging change, but people who show not only their full teeth, but some of their gums when they smile, that’s sometimes seen as an unattractive smile, again, not really an aging change, but you can relax the muscle a little.
Dr. Lawrence Bass (10:33):
So it doesn’t pull up quite as hard and get more of a full tooth smile. Uh, or you can even relax things further and come to just that trace of a smile. The Mona Lisa smile. Another treatment using Botox and neuromodulators that’s really popular and really useful is what’s called the lip flip by relaxing certain portions of the upper lip muscles. You can promote rolling out of the Vermilion. Remember I said the Vermilion or pink part of the lip rolls in and we see less of it as we age, but by relaxing certain parts of the muscle, we can get that lip to roll back out, showing us a little more of the Vermilion.
Doreen Wu (11:29):
We’ve been talking about non-surgical options so far. What can plastic surgeons do in the operating room to help the lip
Dr. Lawrence Bass (11:37):
Operating on the lip is something that’s very central to plastic surgery. Uh, this comes from the reconstructive legacy of plastic surgery, treating trauma to the lip and treating things like cleft lip and cleft palette, cosmetic treatments of the lip though using plastic surgery are also a mainstream item. One of the treatments for cosmetic treatment of the lip, if the lip is overly large, rather than too small is lip reduction. There’s less surgical lip augmentation these days than there used to be because the risks of implanted materials in the lip, Goretex silicone implants and other types of, of lip augmentation in the long run end up being riskier and also having distinctly less precision and shape control than injected fillers have. So lip augmentation using surgery is, is not as common as it was 20 or 30 years ago. The mainstream treatment for surgery of the lip, which is really an aging lip treatment is the lip lift and the other main treatment being done on lips.
Dr. Lawrence Bass (13:09):
And in fact, in the entire perioral area of the upper and lower lip are a variety of wrinkle treatments using energy based devices like laser peels, non ablative, laser radio frequency, microneedling, and chemical peels to peel down the wrinkles and even up the skin. So that it’s smoother flatter. So this is a treatment not for dynamic wrinkling, which is again, Botox, but a treatment for fixed wrinkling, which many people have in their lips, the, the so-called smokers lines or lipstick bleed lines, which mostly in actuality are from sun damage. The lip lift surgery takes out a wedge of skin located just under the nostrils. That’s where the incision tries to hide. And lip lift surgery involves a lot of differences in technique, depending on what each individual needs, and it can accomplish several different things. The lip lift can roll out the Vermilion. It can help elevate and sharpen the corner of the mouth.
Dr. Lawrence Bass (14:25):
As we age our typical youthful upturned corners start to sag down. And that takes us from the smiley face to the frownie face. So lip lift can help us boost that back in position and the length of the white lip, the height from the nostrils to the Vermilion increases as we age, a long lip is an old looking lip and a shorter lip is a younger looking lip. So by taking that wedge of skin out, you can shorten the height of the white lip, creating a more youthful appearance. The main pitfall of the lip lift is the scar. Or if it’s not artistically done, you can create an exaggerated or unnatural look, a lip that’s too upturned or upturned in an unnatural portion or direction. Lip lift is something that’s done everywhere in the United States, particularly popular on the west coast of the United States, but common and popular in the Northeast and everywhere else at this stage of the game as well.
Doreen Wu (15:41):
Speaking of pitfalls, what are the pitfalls with fillers? How can they be avoided?
Dr. Lawrence Bass (15:47):
So there are a number of pitfalls with fillers, but the good news is they’re relatively easy to avoid. If you’re working with an experienced injector who has good technical and artistic skills. And, um, so it’s something we don’t need to be afraid of. We always see the unnatural examples and we don’t see all the beautiful work that just walks past us looking good, but has definitely been treated with plastic surgery and injectable fillers. So one of the biggest pitfalls is enlarging the lip without maintaining the curves and shape that are natural to the lip. Either pumping up the lip across the entire length, creating sort of a sausage like look or just pumping up the corners of the lip, which is a very fast and dirty injection technique. You put the needle in once at each corner of the upper lip and scored in a bunch of filler that creates a, an intrinsically unnatural look.
Dr. Lawrence Bass (16:56):
Now, there are so many folks who have that look and it’s in so many of the fashion magazines that I’ve actually had patients come into the office and ask for that. And if you like that look for some reason, that’s okay. Uh, but it’s important to recognize that is an intrinsically unnatural look that that humans who have not been treated don’t possess, um, the outer portion of the upper lip should be tapering towards the corner. It should not be fullest at the corner, uh, in times past and particularly with collagen, which was a much softer injectable and the current injectables, most of the injecting in the lip was on the white rolls, that transition zone between the pink and white lip. And that’s, what’s responsible for giving people a duck billed look, there are portions of the white roll that can be injected and look good. But if that’s overdone or it’s done all the way across the lip, you end up with a duck billed look, which again is unnatural. And most people are trying to avoid.
Doreen Wu (18:06):
What about when it comes to Botox? What are some of the pitfalls there?
Dr. Lawrence Bass (18:11):
Yeah, so Botox in certain areas of the face, we’re trying to get target muscles completely asleep because that’s aesthetically desirable and there’s no functional consequence in the area around the mouth and the lip, a little is good, but more is not better. We need to maintain a good level of function so you can speak swallow, drink, seal the lip, uh, and overdoing it in this area will make unnatural motion and eventually, uh, the inability to function adequately. So we have to accept that we can get some nice effects with Botox in the oral area. It’s an advanced injection area, not for beginning injectors, but it’s really an excellent, excellent treatment for many features in, in the lip and perioral area. But we have to accept the limitations and not overdo it.
Doreen Wu (19:14):
I never realized all of the complexity surrounding the lip. It was really interesting to hear the different ways in which plastic surgery can help people achieve beautiful lips. This episode has definitely given me a lot to think about if you think of other trends in plastic surgery that you would like us to explore in upcoming episodes, feel free to reach out, see you next time. This is Doreen Wu, thanking you for joining Dr. Bass and me for this discussion of beautiful lips and plastic surgery. Be sure to join us next time for our episode, discussing new FDA regulations for breast implants that went into effect October 2021. Stream the episode to find out about new consent processes and the new black box warning on breast implants in the United States.
Speaker 3 (20:03):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.