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Lips enhancement and rejuvenation

Authors: Dr. Ivona

The lips surround the entrance to the oral cavity. They function to provide competence to the oral cavity during mastication and at rest. The lips affect uttered sounds that facilitate spoken language and provide changes of facial expression that facilitate unspoken language.To accomplish the multitude of functions, lips require a complex system of muscles and supporting structures.

When we assess lips we must include the assessment of other oral structures surrounding the lip area,muscels and muscels movements ,chin and its projection and only on that way we can get the complete enhanacment and rejuvanation .We must not forget that lips are not isolated structers that needs rejuvenation or volume augmentation, but part of the face where all the anatomical structures should be in balance . Only this approach is going to lead us to tailor made therapies which are combining chemo-sculpting with Botulin Toxins type A ,Dermal filers and also some of energy based devices like ErYagor NdYag lasers or HiFu.

This approach is artistic approach into aesthetic medicine based on understanding of aging process itself ,anatomy of the face and great know how on injectables , lasers and other medical devices.In aesthetic medicine the medical devices which we use are frequently improving and changing, so update is highly recommended. Aesthetic minimal invasive and anti aging medicine is the most dynamic and most artistic medical branch. The holistic approach ,in assessment and tailor made therapies , is the only approach which is giving us the guarantee of sophisticated aesthetic results.

Superficial anatomy

The upper lip extends from the base of the nose superiorly to the nasolabial folds laterally and to the free edge of the vermilion border inferiorly. The lower lip extends from the superior free vermilion edge superiorly, to the commissures laterally, and to the mandible inferiorly. Around the circumferential vermilion-skin border, a fine line of pale skin accentuates the color difference between the vermilion and normal skin. Along the upper vermilion-skin border, 2 elevations of the vermilion form the Cupid bow. Two raised vertical columns of tissue form a midline depression called the philtrum. The philtrum is located between the Cupid Bowl’s or elevations of the vermilion and the columella above. The labiomental crease passes horizontally in an inverted U-shape across the lower lip, which intraorally corresponds to the depth of the gingivolabial sulcus. Labiomnental crease makes us feel tiered ndunhappy ,everything what we want to erase from our facial expression

From superficial to deep, the layers of the upper and lower lips include the epidermis, subcutaneous tissue, orbicularis oris muscle fibers, and mucosa. The superior and inferior labial arteries course between the orbicularis muscle fibers and the mucosa. The vermilion is composed of non-keratinized squamous epithelium that covers numerous capillaries, which give the vermilion its characteristic color. Numerous minor salivary glands can be observed on a histologic section of the lip. Hair follicles and sebaceous glands are located throughout the lip skin; however, these structures are absent in the vermilion.

Blood supply to both lips starts from the external carotid system.The facial artery ascends from the neck over the midbody of the mandible just anterior to the insertion of the masseter muscle. The facial artery branches into the submental artery that passes under the mandibular body in an anteromedial direction. The facial artery ascends in a plane deep to the platysma, risorius, and zygomaticus major and minor muscles and superficial to the buccinator and levatorangulioris. This artery branches into an inferior and a superior labial artery, which course beneath the orbicularis oris and anastomose with the contralateral vessel.

The sensory innervation to the perioral region is from the maxillary and mandibular branches of the fifth cranial nerve. The motoric innervation of the perioral area is from the seventh cranial nerve. The upper and lower lips are referred to as the "Labium superiusoris" and "Labium inferiusoris", the juncture where the lips meet with the surrounding skin of the mouth area is the Vermillion Border.

The reddish area within the borders is called Vermillion Zone Vermilion border of the middle part of the upper lip where philtrum is descending into the upper lip, creates the center of the Cupid's bow.That fleshy protuberance located in the center of the upper lip is a tubercle known as procheilon or prochilon), the "tuberculumlabiisuperioris", and the "labial tubercle".The vertical groove extending from the procheilon to the nasal septum is called the philtrum. The skin of the lip, is very thin - three to five cellular layers, and has a good blood vassel supply.

The lips are not hairy and donn’t have sweat glands. This is leading us to a conclusion –lips do age ,even faster then the rest of the facial structures, lips are not easy to enhance and rejuvenate , if we want to stay into anatomical borders and make a natural and superb aesthetic result . Technique of injecting is important ,and requires basic knowledge of anatomy of the lipsand sourrounding structures , and adequate medical device.The final aim must be ultimate aesthetic outcome and rejuvenation, which leads to instant refreshed and natural appearance.

Mathematics and Geometry of the
lower facial third

Beautiful lips now days are in a big demand, it has become nearly a fashion trend and a signature treatment of some doctors and clinics in the Western world. Patients are seeking for this procedure more and more... It is always beneficial to improve or enhance lips, but they must be kept within proportion to the rest of the face. There are certain rules which can guide us to get the ideal lips position and projection. In general, the distance between the oral commissures should be equal to the intra pupillary line, and a perfect square should be formed when the ends of these lines are joined.

Line through the oral commissures should transect the lower third of the upper lip in the midline.The well-known golden ratio, or divine proportion (phi), is very relevant to the perioral area too .5Vertical vermilion show in white women is in the phi proportion of 1 for the upper lip and 1.618 for the lower lip. Black and East Asian women may have dimensions approaching 1 to 1. So we see that ethnical background is very important into defining our treatment plan and the way of lip enhancement.

There are other mathematical aspects that dictate the appearance of beauty in the perioral region. Gingival show on repose should be 1 to 2 mm only. The ideal width of beautiful lips should be 57 to 62 mm.6 On lateral view, the upper lip should project 1 to 2 mm forward from the lower lip and the upper lip should fall 4 mm posterior to the nasomental line while the lower lip should fall 2 mm posterior to the nasomental line (Ricketts line). As we see there are rules how to enhance lips itself and stay intra anatomical borders. Important is to understand the rules of how to implement the enhanced lips into the face and facial features and combine it with aging and aging process which is already present. On that way we don’t risk to create absurd structures as “Ducklinglips” or any other lip dysmorphyia. Which is the typical mistake of a novice injector. There is also a risk to enhance and really get a great result of lips itself, but even more stunning ,”new” lips cannot be well blended into the face.

Symmetry has been suggested to be important in our appreciation and of beauty appeal. When it comes to the lips we must underline that symmetry is extremely beneficial. If we assume that two parts of the face can act like sisters, let left and right lips sides act as identical twins.

Lip assessment
The static aspects of the lips and perioral area should be assessed first. In that checking we observe: lips, corners of the mouth, definition of the vermilion border, Cupid Bow ,Philtrum columns and Cupid Bow ,lateral projection of the red vermilion rising up to a peak at each arch tip off the upper lip(Glogau-Klein point)

In the lateral projection of the upper lip, we do observe red vermilion rising up to a peak at each tip of the arch of the upper lip (the Glogau-Klein point).9 On lateral view, there also are several lines that may be used to estimate lip alignment. Steiner and Ricketts lines indicate the ideal relationship between the nose, upper and lower lips, and chin. The Steiner line is particularly useful and should touch the upper lip, lower lip, chin projection, and base of the columella.

Results in aging patients.

Adequate assessment of the lips involves educating the patient about the perioral region and explaining that the lips and the perioral region change over time. For instance, what looks natural in a 20-year-old patient does not necessarily look natural in a 60-year-old patient, and vice versa. During our explanation to patients we need to mention the nasolabial folds, upper lip atrophy, lip volume, upper lip wrinkles (both at rest and on contraction), marionette lines and pre jowl sulcus, and the jawline.

They must be aware of all the aging signs in perioral region as well. So they can better understand the treatment itself, and what it really consists of. The important steps, after understanding the patients wishes , aging process on his face and stadium of aging patient presents himself/herself ,in our clinic ,are as followed

  • assessment of lips and perioral area –static, no movement
  • assessment of lips and perioral area -in movement
  • assessment of lips –volume
  • 40 assessment of lips- surface
Lower third of the face is perfect for combination therapy with Botulin toxins and dermal fillers and also energy based devices if any need for resurfacing (Bar code zone). It is very important to observe our patient in movement and notice if she/he pursing the chin (m.mentalis), turn the angulusoris downward 9m.depressor angulioris)or has a gummy smile or incompetent lips(m.levatorlabosup. alecquenasi, sometimes even zygomaticusgroup,morezygomaticus major then mirnor) .Also we can consider the expression of Bar code lines(m.orbicularisoris)in movement creating a kiss or also their presence in statics.

Smile assessment is crucial for smile aesthetics , including whether a gummy smile is present; whether the smile subtype is mainly lateral, central, or mixed; whether the smile is asymmetrical or if there is loss of lip show on smiling; or whether there is depression of the nose on smiling. A gummy smile may require injection of the levatorlabiisuperiorisalaequaenasi and orbicularis muscles if the smile subtype is central or the zygomaticus muscles if the subtype is lateral, A loss of lip show on smiling is well-treated with superficial injection of the orbicularis oris muscle, whereas a dipping nose on smiling requires injection of the depressor septi muscle at the base of the columella.

After analyzing and enhancing or stabilizing the movements on the lower facial third we can go into dermal filler therapies and analyze the surface and volume of the structures.(3,4) In my experience, I divide lips and surrounding area into three basic categories 1) overalllip enhancement and augmentation, young patient coming with already well defined vermilion border and enough of volume but wants and needs enhancement-we talk on Underlining Beauty. This category is particularly hard because here we need just an artistic touch to make something that is already nice –stunning and outstanding. This is something usually experience do teach us .We need to decide do we need to enhance the vermillion border, add the volume into the body of the lips or we need just to enhance the Cupid Bow and Philtrum area.

patients with atrophic lips

We need to augment the lips by using a potent and highly cross linked dermal filler which we will inject sub muscular and it is a n deep injection into the body of the lips. It can be done with needle or cannula depends on the preferences of the injector.

patients with atrophic lips ,poorly defined vermilion border and bar code lines

Here we first analyze the rhytides is it static or dynamic. After that we analyze how deep the bar code is and do we need just chemo denervation with toxin in combination with the dermal filler or we need to include laser resurfacing too. Dermal fillers normally used for augmentation are high cross linked (14%)and positioned sub muscular and deep.

The filler which we use for better definition of the vermillion border doesn’t need to be so high cross linked (9%) is enough in most cases. this filler is injected in mid dermis. For getting a better rejuvenation effect I would recommend to add an injection combined with hyaluronic acid and glycerol for overall hydration and brightening effect.


Lips are very important facial feature and now days it is a huge demand on their enhancement. Most important isan overall good assessment of lips and surrounding perioral region . The therapy approach is depending on the injector .Usually it is combined therapy with toxins and fillers .Patients with static rhytidis could benefit from laser resurfacing, as well.The approach must be tailor made for that patient and for his_?hers specific needs. REFERENCES

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