Lip Enhancement

INTRODUCTION

An individual's smile, anatomy and look of the lips are often referred to as the "locus of our identity". This is an enormously personal and individual indicator of our identity and personality and sexuality. Even small and subtle interventions can have a tremendous impact on our body image and perception. For this reason patients and doctors both need to be extremely cautious and careful with any procedures undertaken in this area.

Lip enhancement also known as lip enlargement or lip augmentation has been practiced by cosmetic surgeons since around the 1960's. It has become much more common recently, mostly due to a tremendous surge in media attention in supermodels, but also because the techniques and materials have been improved tremendously in recent years making this a more safe, predictable and comfortable procedure more easily customized to the patients desires, lifestyle, and budget. This article will go through the spectrum of techniques including the newest advances in lip enlargement.

The spectrum of procedures for enlargement of the lips ranges from simply a 20 minute office procedure with no anesthesia, immediate return to work, and no swelling or discomfort all the way up to a two hour hospital procedure under general anesthesia, significant swelling, 1-2 weeks off work, and some pain. There is a broad range of possibilities in between. For this reason it is easy to understand that no one procedure or technique fits all. It is something that needs to be highly individualized to the patients' desires and expectations, anatomy, lifestyle, and time available to be out of work and social situations.

Both men and women are frequently seeking this procedure. The desire for lip enlargement ranges from slight and modest all the way up to outrageous. Many patients have some unevenness in the size and contour of the upper or lower lip or both, and this needs to be considered when choosing the type of procedure. Small lips usually means the amount of pink tissue visible and how much it "turns up", especially in the upper lip. This is a situation that can be present from birth and not only seen in the aging process where tissue bulk is diminished over time. I have patients aging from their 20s to well into and above 70 years old. Other features which have to be taken into account other than the size and asymmetry of the pink portion of the lips are the length of the upper lips, creases and folds at the corners, and drooping of the corners. The latter features are not corrected with lip enlargement but must be addressed with incisions under the nose or at the corners or the mouth which lift the lips. All these things must be taken into account when considering beautifying and youthifying the lips.

PREOPERATIVE FEATURES AND INDICATIONS

Unlike some other plastic-surgery procedures, nearly anyone can be a candidate for lip augmentation. Especially today, while having fuller, "poutier" lips are in style, more people are considering lip-enhancement procedures, not only to puff up their mouths, but also to correct any asymmetries or crookedness.

Men and women, teen-agers, twentysomethings and octogenarians are all eligible for a lip-augmentation procedure. Up to 40 percent of lip-augmentation patients under 35 choose to have their lips surgically enhanced if they have "underdeveloped" - thin, flat lips. Older folks - who account for about 60 percent of lip-augmentation patients ­ tend to opt for the procedure to reverse a byproduct of the aging process. As we age, muscle tension and tone become more lax; lips begin to hang, lengthen and thin.

Most people seeking lip augmentation simply have small or thin lips. This refers to the pink portion or what we call the mucous membrane. It is usually most obvious in the upper lip and less on the lower lip (since the lower lip has the advantage of gravity and tends to roll out more even when thin). Patients desire a larger and more pouty appearance with more fullness and turning up and out of the lips. Many seek more evenness in the fullness.

In some cases your underlying dental architecture can influence the posture of your lips and cause your lips to droop or hang. Be aware of this if your teeth are very crooked or you have an overbite or underbite. Your plastic surgeon should be aware of this and may first want you to consult an oral surgeon to discuss your options before considering lip augmentation.

The degree of desire for enlargement varies according to the patient from mild to moderate to extreme. The amount of enlargement depends on the anatomy. I use computer imaging in my office which can demonstrate the predicted result or degree of result to the patient to help anticipate ones desires and expectations.

THE SPECTRUM OF PROCEDURES

There are three general categories of procedures that enhance the lips. These are injections of materials such as collagen, grafting in substances such as gortex or fat, and local flaps and incisions that redistribute the tissues from inside the mouth to outside. The results can be temporary or permanent. All of these have advantages and disadvantages, different types of anesthesia, recovery periods, pain and time off work. Anesthesia ranges from none or very little in an office setting, up to general anesthesia in the hospital as an outpatient. The procedure can take from twenty minutes up to two hours. You can usually bathe and shower as usual the next day. There can be minimal swelling and bruising and no numbness with immediate return to work, up to tremendous swelling and bruising and numbness that last for days to weeks with one to two weeks off work. There can be no stitches or incisions, or a few at the corners, or many inside the mouth. When present, the stitches are usually removed in 7-10 days. Results can be temporary or permanent depending on the technique. No dressings or drains are used. The procedure can be easily combined with other plastic surgery procedures.

INJECTIONS

This method of lip enhancement refers to placing a semi-liquid substance into your lip. It is an office procedure requiring a little topical anesthetic applied to the surface of the lips only. Injectable substances are nice because they can provide a beautiful "all-over" enhancement, or, by adding more to one side or area than another, it can also be used nicely to adjust asymmetries or unevenness of the lips. It can be repeated over and over with little or no danger, to "adjust up" the size as the patient likes. Some of the materials are long lasting, and some temporary.

• Collagen

  Collagen is a purified preparation of bovine (animal) skin available in different concentrations and compositions. It has been used in humans since 1981. For years collagen has been one of the most popular methods of lip augmentation. Though collagen works very well, its effects are always temporary. I like this very much in the first time patient where this is a real advantage to "try on" the look for a while and even gradually increase it. Remember, this can be a significant body image change and hard to predict until you see it on yourself.
  There is a slight risk of allergic reactions. This usually takes the form of some redness around the treatment sites that lasts for weeks to months. To avoid this occurrence, prior to treatment patients undergo a skin test. For the test, your doctor will inject a small amount of collagen just beneath the surface of your forearm. You look for redness or reaction in the following two weeks. If this is normal, then it will be from 2-6 weeks from the time of the skin test before the actual administration of the collagen.

   

  The procedure is done in the office using a topically applied local anesthesia. Small needles are used to implant the material. It is mostly painless. There is minimal swelling or bruising and patients can return to work or most activities right away. Make-up can be applied in hours. There is minimal risk or side effects.

   

  Collagen nicely enhances the look and size of your lips. The substance is quickly absorbed into the body especially in areas ­ like the lips ­ where there exists a lot of motion and lots of blood flow. Your lip augmentation with collagen will last between four weeks and three months. More can be added at any time.

• Artecoll

  Next, I mention this as the newest and latest advance in a filler substance. I am one of only ten doctors in the country approved by the FDA in an investigation to study this material. The basis of Artecoll is a synthetic material called polymethyl methacrylate and it has been successfully implanted in humans since the 1940's and used frequently even now in dental, neurosurgical, and orthopedic patients. It is composed of microscopic spheres of this material suspended in collagen. As the collagen is degraded by the body then our own natural collagen replaces it and encases the microspheres, providing tissue augmentation that is long lasting. It has been used successfully outside the United States for exactly this purpose in over 100,000 patents since 1989. It is administered exactly like Collagen with the same anesthesia, minimal pain and bruising, and quick recovery and return to work.

• Fat Injection

  This procedure is receiving a lot of publicity. The theory is not new but the techniques have advanced a lot in the last few years. It involves extracting some of your own fat from somewhere on your body by a tiny needle using local anesthesia. The fat is usually spun in a centrifuge and the excess fluid separated. Special small needles are then used to place tiny "threads" of your own fat into the lips. It is good for an overall enhancement and to correct asymmetries.

Fat cells are tiny and fragile and are removed and moved from one part of the body to another only with great difficulty. The success depends on only one thing, how well the cells survive and how many have a new blood supply grow into the cells so they can survive and persist. The procedure is extremely technique sensitive and highly individual. I employ a lot of additional resources, such as supplements, vitamins and even acupuncture, to increase the local blood flow with the hopes of increasing fat survival.

The problem and criticisms of fat are that it is temporary. The proponents of fat insist at least some of it survives providing long lasting improvement. Both are true. I simply state this to patients as a situation where we do not know the answer until we give it a try and everybody's "body is different". I evaluate everyone after 6-12 weeks. In general, 5-10% of patients have an excellent first time, one time result. 10-20% have no result. The rest have a partial result. If it works at all then I offer repeat procedures and have had many satisfied and pleased patients. In the latter circumstances I describe this as "building a layer cake".

Unlike Collagen, you can expect a lot of lip swelling and unsightliness for the first few days after the procedure. There is minimal bruising or pain. There are no stitches. You won't know how well it has worked until at least six weeks afterwards. If there is a partial success then I will perform a fat injection up to three times; if after three times you're not satisfied with the results, I suggest an alternative technique to give you the look you desire.

GRAFTS

• Alloderm

  Alloderm essentially is a sheet of human collagen tissue which has been purified and rendered non-immunogenic. It is the relative of Dermalogen which is its injectable form. It is well tolerated and does not cause allergies or need to be pre-tested for allergies. It is inserted as an outpatient procedure performed under a local anesthetic. Incisions are made at the corners of the inside of the lips and Alloderm is rolled up and inserted from one side to the other. A few tiny stitches at the corners in the small incisions are all that is needed. Post-surgery swelling is mild to moderate and disappears mostly within 3-5 days. It is very soft and natural. There is a tendency for this to become reabsorbed and the result seems to diminish or disappear after about 6-12 months.

• Gortex

  This is related to the same material that keeps you dry in a rainstorm. Gortex is desirable because it is a biocompatible material that passes easily through tissue. It comes in sheets or strands. It has been used successfully as a human implant in over 5 million implantations without any allergic reactions. Although commonly used for blood vessel bypasses, it has been approved for tissue augmentation procedures and used in this way since about 1988. There is a slight potential for infection and when this occurs, the material can be easily removed usually with no untoward side effects. It is soft and pliable and the results are permanent. Placement is extremely technique sensitive and if placed less than perfectly, can show or distort especially when smiling broadly. It is much like Alloderm in terms of the incisions and anesthesia. It can be easily surgically "fine-tuned" by adding or removing strands as needed.

• Dermis-fat grafts

  It has been well known and performed from the 1950s that excising fat from the body with a partial thickness of the skin still attached improves the survival of the fat when implanted elsewhere. This dermis-fat graft procedure is popular for lip enhancement. It requires an incision somewhere on your body ­ usually in the groin area ­to take out a wedge of skin with fat still connected to it. The partial serves to bring in the body's own blood supply to ensure the fat graft's survival. The incisions and the stitches and minimal pain are similar to the procedures described above. The swelling is significant so patients need to plan about a week out of work.

   

  Disfavor with this technique centers around the unpredictability of the partial skin attached to the fat. Although the enlargement is good and predictable, the partial skin with its collagen can scar and contract and occasionally distort the mouth and smile. If this happens, your doctor will have to perform a second operation to remove the graft and this can be difficult.

LOCAL FLAPS

• Inside The Mouth

  This last category of lip enhancement has been around since the 1950s and the first technique employed to enlarge the lips. It is still commonly employed today but because it is more invasive, often it is reserved for when other techniques have been unsuccessful. Other times it is used when patients know they want a long lasting result and don't want to "try" the other procedures. This involves making incisions inside the mouth to detach and roll out the pink tissue up and into the lips. It is an outpatient procedure and requires anesthesia. There is a lot of swelling, numbness and some drooling. These symptoms are very prominent for the first three weeks and diminish in the next three weeks. Stitches are removed in 10-14 days. This procedure may be combined with a graft such as Gortex or Alloderm.
  Due to the invasive nature of this procedure, you will experience temporary numbness and severe lip swelling that will last between two weeks and six weeks. Sometimes, this technique is performed in combination with a graft implant.

• Outside The Mouth

  Another procedure is an incision in the upper lip exactly following the lip line (called Cupid's bow). Some skin is removed and the lip is lifted and everted to create a fuller look with more "pout". This incision can be slightly visible but often camouflages well with make-up. It is not that popular only because most plastic surgeons hesitate to make an incision in a completely normal upper lip and risk an unsightly scar. In well-chosen patients the result is excellent. The surgery is an in office procedure with local anesthesia. It takes about one hour and there is minimal pain, quick recovery, and only mild swelling which disappears in 10-14 days.

QUICK REFERENCE AND SUMMARY

• Pain

  Expect minimal discomfort in the hours and days following most lip-augmentation procedures, however, do be prepared for some pain if you opt for either any of the grafts or local flaps techniques.
  If you choose one of the injection procedures, your doctor will most likely use a topical anesthetic that's swabbed on the lips and this makes it a painless procedure.

   

  In any of the graft procedures, your lips will be completely numbed with tiny needles and a novacaine solution. After this takes effect the enhancement is performed. You will not feel anything. Afterwards you can expect to experience mild to moderate discomfort up to three days afterwards.

   

  If you undergo an inside the mouth local flap procedure, expect moderate to severe pain for up to five days following the surgery. There is moderate discomfort, swelling, numbness and even drooling that may persist for 3-6 weeks.

• Recovery

  When can you expect to return to your normal daily routine? Fortunately, lip augmentation generally is not a very invasive procedure, but recovery time varies depending on the procedure you choose.

   

  With the exception of the local flaps procedure, you can expect to return to work either the same day or two to three days afterwards. Bruising and swelling following most procedures can last three days to seven days. If you opt for the local flaps technique, you are advised to be prepared for 1-2 weeks of unsightliness.

   

  In all cases, refrain from strenuous activity or exercise for at least several days.

   

  If stitches are present, they can be removed in 1 to 2 weeks.

   

  Bruising ranges from almost nothing with the injections to very severe with the local flaps. It usually diminishes quickly and there are things that can help speed up this process.

   

  Swelling is much like the bruising and is minimal with injections, moderate with fat grafting and flaps, and very severe with inside the mouth local flaps.

   

  Incisions heal imperceptibly and are almost never noticeable.

   

  Ice packs will help reduce swelling and soothe incisions.

   

  Follow up visits are frequent initially, then once a week and then as needed. If at any time following surgery you experience fever, bleeding, or other symptoms of infection, immediately inform your doctor.

• Risks

  Though lip augmentation is considered a very safe procedure, as with any surgery, it has its risks. These are not common, but could occur:

  • Numbness
  • Swelling
  • Ulceration
  • Scarring
  • Unnatural movement when smiling or talking
  • Kinking if an implant is used
  • Permanence of a large or uneven lip
  • Hardness, unnatural to the touch
  • Scarring
• Costs

  The costs of a lip-enhancement procedure can vary from doctor to doctor and from region to region, but the procedures ranges from $400 to $6000. You usually can pay with a credit card or finance the procedure. The following are average costs you can expect to pay for the technique you choose. Lip augmentation is considered elective or "cosmetic," which means you'll have to pay for it yourself.

  • Collagen: $400 per tube of 1cc.
  • Dermalogen: $400 per tube of 1cc.
  • Artecoll: $400.00 per tube of 1cc.
  • Autologen: $1500 ­ 2000 for the entire process.
  • Fat injection: Costs vary: $500 per area, or $1000 ­ $1500 per session
  • Alloderm: $2500 for one lip; $4000 for both.
  • Gortex: $2500 for one lip; $4000 for both.
  • Dermis-fat graft: $4000-5000 for both lips.
  • Local flaps: $4000-7000.00

  These prices generally reflect all costs including anesthesia and hospital fees where necessary.

• Other Options

  Some people opt for a procedure other than a lip augmentation to enhance the fullness of their lips. One option is to have your skin pigmented by a tattoo artist to make the skin around the lips look pink and full.

WHAT'S NEXT

Lip augmentation, like any surgical procedure, requires that you be in good health. Talk over any health concerns or problems that you may have with your doctor. Review what things are done and used to help prepare you for surgery and speed your recovery. For instance, I employ numerous supplements and dietary recommendations.

If you believe that lip augmentation is for you, make sure the doctor you select is a board-certified plastic surgeon and be aware of how to select a plastic surgeon. Discuss the procedure, its risks and benefits with the physician you choose and be certain you are comfortable with him.