Friday, January 25, 2008

Lip Augmentation

Appearance of the lips has always played an important role in the perception and assessment of facial beauty. Since the beginning of the 1990s there has been increasing public demand for changing the outer appearance of the lips. Until recently, plastic surgeons were concerned with techniques of rejuvenation of aging lips, generally in patients at least 40 years of age. Lately, young women have been requesting aesthetic enhancement of the lips.

Lip deficiencies may arise from facial aging, previous ablative procedures or congenital absence of lip volume. The goals of lip augmentation are to increase deficient vermillion volume and elevate the ptotic vermillion border.

There are many techniques available to enhance the lips. The shear number of procedures testifies to the lack of a surefire, non-nonsense method. The volume and shape of the thin upper lip have been enhanced with addition of material (synthetic and autogenous) and by recruitment of local tissue.

TECHNIQUES

The following techniques are used for lip augmentation:

I. AUTOGENOUS FILLERS (the patient's own tissue), such as temporalis fascia, dermal grafts, palmaris longus tendon graft or fat. Some of these procedures can be "invasive".

Autologous fat has become a more popular choice. The distinct advantage of fat as a volume augmenter is that it uses your own tissue. The risk of allergic reactions is avoided since the fat used is the patient's own tissue. As much as 30% of the injected fat can persist after transplantation with appropriate technique, and in some patients almost complete survival of the graft has been reported. Survival of fat graft is decreased in smokers. A disadvantage of using fat injections is that it may be absorbed (note the above mention that often only 30% persists) and repeat treatments are often necessary to obtain/maintain results desired.

Fat Harvest and Transfer

The average volume of purified fat needed for both upper and lower lip augmentation is 6 ml (3 ml each). If no larger volume liposuction is being done at the same time, then the fat can be harvested (technique from the 6th reference below) as follows:

  • 80-cc normal saline and 20 cc of 1% lidocaine with 1:100,000 epinephrine mixed together is injected into the proposed donor site (most commonly the infraumbilical abdomen)
  • Wait 8-10 minutes, then harvest the fat using gentle aspiration with a 10-cc syringe and a short 3-mm cannula (Byron Medical, Tucson, Ariz.). Gentle means "Only 1 cc of negative pressure, as measured by the scale imprinted on the side of the 10-cc syringe, is applied."
  • Wash the harvested fat by rinsing with normal saline over a tea strainer until clear of bloody and oily residue.
  • Dry the fat between a Telfa gauze and manually clear of fibrous remnants
  • Transfer the fat into 3-cc syringes.

To transfer the fat use a Coleman cannula in the standard fashion:

  • Inject the fat evenly as the cannula is withdrawn from a channel.
  • Fat is first placed very superficially along the vermilion border and then into the muscular substance of the lip proper, using many passes along different channels.
  • The relative volume and placement of the fat is a fairly artistic endeavor. More often than not, a total of 6 cc of purified fat will be needed for upper and lower lip augmentation.

Dermis-Fat Graft

If the patient has any previous scars, such as a post-appendectomy (old McBurney's, not laproscopic), this can be used.

  • The graft is obtained from the area adjacent to the scar. In the process, the patient gets a scar revision. In the absence of scars, a good site is the lower abdomen on the border of the pubic hair in women.
  • Dermis shrinks after excision, so the donor area should be marked slightly larger than needed and measured, for both lips, about 8 × 2 cm.
  • It is easier and more precise to remove epidermis in situ, before the graft is excised. After excision, the dermis-fat graft tissue is trimmed with sharp scissors to a final size of about 75 mm (length) × 8 mm (width) × 6 mm (height) for each strip. The bulk of the various parts of the graft can be altered at preparation if there is a desire for greater augmentation of the philtrum area or laterally or if the lip is asymmetric.
  • One 4-mm-long horizontal stab incision is made on inside of each lip commissure, allowing access for graft introduction to both the upper and lower lip. Sharp-pointed, curved Iris scissors are used to create a narrow tunnel 4 to 5 mm deep to the white roll. A specially designed graft passer should be introduced through the proximal end of the tunnel and gently pushed forward, distending the lip and coming out through the incision in the opposite commissure.
  • The dermis-fat graft, protected by gauze soaked in normal saline solution, is introduced. Care should be taken to place the smooth dermis surface of the graft outward and the more irregular subcutaneous fat surface inward. One or two 5-0 Chromic sutures are used to close the incision in the mucosa and to anchor the graft.

II. LOCAL TISSUE REARRANGEMENTS, such as lip border advancement, double V-Y plasty (horizontal and vertical) are more permanent. They are also more invasive and have a longer recovery time.

Mucosal Advancement

V-Y plasties evert and direct localized wet oral mucosa to the exterior to become "vermilion". Careful analysis of lips is necessary to plan the position and determine the size of the proposed V-Y-plasties. Placement can be critical in dictating the final shape of the lips. Most often, however, three upper V-Y mucosal advancements and a wide, single, central lower one are designed and carried out. There are nice pictures in the 6th reference below.

  • The designs of the three upper and one lower V-Y-plasties are first applied to the exterior of the lip.
  • The base of each V should lie above the white roll (or below, in the case of the lower lip). The width of each base may vary between 1 and 2 cm, depending on the patient's presentation.
  • 1% lidocaine with 1:100,000 epinephrine mixed with Wydase is injected into the labial mucosa. While awaiting the vasoconstrictive effect of the epinephrine to occur, the lip is everted and a 25-gauge needle is used to transcutaneously translate the external markings (the three points of each V) to the internal labial mucosa. Needle emergence sights are marked with Bovie electrocautery.
  • Before proceeding, verify the final symmetry while the lip is everted by applying even, outward pressure at the oral commissures simultaneously.
  • The incisions are then made and the flaps raised by gentle scissor dissection with care being taken to preserve as many cutaneous nerves as possible. In the upper lip the lateral two mucosal advancements are performed before the central one.
  • In generally, each V-Y is advanced 1 cm. Closure is performed by means of horizontal mattress sutures of 5-0 chromic and facilitated by triangulating the wound with hooks placed at each of the two corner bases of the raised V flap.
  • When all flaps are securely advanced, symmetry should be present. No dog-ears should be visible.

III. HETEROLOGOUS MATERIAL used both as FILLERS and as IMPLANTS, such as silicone, collagen, polytetrafluoroethylene (Gore-Tex), and AlloDerm . You may want to check out my post on Dermal Fillers.

FILLERS

Lip augmentation with the use of injectable fillers allows quick results to be obtained with minimal downtime. Materials used include:

  • Collagen -- They are user friendly, relatively easy to inject, and can be integrated into a simple office visit for the patient requesting dermal augmentation. A skin test must be done. The filling agent is technique dependent for longer lasting results, proportional to the clinician's ability to place the collagen correctly. More often used for the peri-oral wrinkles or to enhance the white roll/outline than to enlarge the lips. This is a temporary solution and the results are not permanent. The three main variation used in the US are:
  1. Zyderm I collagen is a 25% suspension of purified bovine dermis in saline with 0.3% lidocaine. The saline carrier is absorbed and the remaining implant persists for 3-10 months. Zyderm I is used most successfully to treat shallow distensible scars and fine rhytides. Zyderm I has a longevity of 6 weeks to 3 months.
  2. Zyderm II has double the concentration and is a more viscid substance. The longevity of scar correction is increased and it can be used for larger filling defects. Longevity is 4-5 months.
  3. Zyplast is a cross-linked derivative of bovine collagen, which is a heavier filling material and has greater longevity. Zyplast can be used for larger scars that require a greater and deeper filling of volume and lasts longer. It is placed deeper in the dermis and requires 100% correction at the time of implantation, rather than the 150% used for Zyderm I. Expected longevity is 9 months to 1 year, especially in a relatively immobile scar.
  • Cymetra is a micronized form of AlloDerm (see below) that is injectable. This material is rehydrated with lidocaine in the physician's office before injection. Because it is human-derived collagen, no skin test is required by the manufacturer. Clinical trials of 200 patients to date show no evidence of allergic reactions. Results last in the range of 3-6 months.
  • Hyaluronic acid preparations such as Restylane or Perlane . Restylane was approved by the FDA in 2003. Both are free from animal proteins which limits any risk of animal-based disease transmissions or development of allergic reactions to animal proteins. Perlane is a more robust form of Restylane intended for use in the deep dermis and at the dermal-fat junction. The most commonly observed side effects are temporary redness and swelling at the injection site, which typically resolve in less than seven days. Both are made by Medicis.

  • ArteFill is made of permanent, non-resorbable microspheres (20%) of polymethylmethacrylate (PMMA) which become part of the patient’s own tissue, filling in the wrinkle for enduring correction. ArteFill is contraindicated in anyone with a known allergy to bovine collagen or lidocaine. A skin test must be done. If the skin test response is positive, the patient must not be treated with ArteFill. Technique is critical in minimizing these reactions. It is recommended that the linear retrograde tunneling method be used in working with ArteFill. It is a product of Artes Medical. Adverse reactions include granulomas.

  • Radiesse is composed of microspheres of calcium-hydroxylapatite suspended in an aqueous gel carrier. The biodegradable microspheres serve as a lattice upon which the body forms scaffolding for tissue infiltration. The spheres slowly degrade. The improvement is effective for 9-18 months. Radiesse is biocompatible and does not require pre-testing. Side effects may include swelling, bruising, pain, itching, and tenderness at the injection site. These conditions typically resolved on their own within one to two days. It is a product of BioForm Medical.
  • Bioplastique is a filler available in the United States with similar characteristics consisting of 38% biphasic polymer textured silicone particles suspended in a 62% bioexcretable gel carrier.

Significant ease of use, “off the shelf” availability, and widespread acceptance by the public make collagen one of the most common fillers used. Precautions regarding mode of injection and quantity of the substance injected vary widely within this family of products.

IMPLANTS

Lip augmentation can be obtained by the implantation of various synthetic materials, including polytetrafluoroethylene (PTFE; SoftForm--no longer available as of November 2006; Fulfil by Evera--approved spring 2007), as well as biomaterials such as fascia, dermis, and decellularized donor dermis (AlloDerm). Insertion of these implants require the use of local anesthesia by nerve block, local infiltration, or both.

SoftForm

  • An local block using 1% lidocaine with 1 part per 100,000 parts epinephrine and 0.5% Marcaine in a 50/50 mixture is used for anesthesia. The skin is cleansed with Betadine solution. The entry and exit sites are approximately 2 mm medial to the commissure in the lower lip. To introduce the implant beneath the dermis, a Keith needle is used.
  • The current recommendations for SoftForm use are one implant for the upper lip and one implant for the lower lip. These should be at least 9.0 cm long and 3.2 mm thick (11.0 cm long and 4.8 mm thick for greater augmentation).
  • Implant placement in the lip varies depending on the type of implant used. If the strands are used, gently stretch the tissue of the lip. Do not stretch the lip tissue if using SoftForm. Lip implants are placed to enhance the vermillion border and augment the lip's fullness. If using SoftForm, the larger diameter implant accomplishes these goals. If strands are used, the number and exact placement can be varied to not only enhance the contour but also enhance the degree of augmentation.
  • Push the needle to the desired exit spot and make an incision of similar size to the entry wound. Externalize the needle and cut the polymer to size so that the distal end is not protruding from the entry wounds. Skin is closed with 6-0 white nylon, and Steri-Strips are applied to the skin. Sutures are removed after 5-7 days.

AlloDerm is an acellular human dermal graft processed from tissue bank–derived skin. It has been used since 1992 on more than several thousand patients; initially, it was used for burn victims and, later, in oral surgery and soft tissue augmentation. It is available in sheets 1-2 mm thick and is not injected but implanted surgically. After rehydrating the graft in normal saline, the dermal sheet is rolled and trimmed to the appropriate length of the defect. A tunnel is then created under the scar or contour deformity and an instrument is used to pass the tissue to the opposite side, where it may be sutured into place. Results from AlloDerm last for approximately 6-12 months, but persistence of grafts can reach several years. AlloDerm appears to have greater longevity than collagen fillers, though no controlled studies have been performed.

IV. A COMBINATION of TECHNIQUES, such as fat transfer and simultaneous mucosal advancement (FATMA)

POSTPROCEDURE AFTERCARE
  • Discomfort is most apparent in the first 48 hours postoperatively but rapidly subsides thereafter, usually treated with judicious amounts of nonsteroidal antiinflammatory medication.
  • The areas treated with injectable materials require little postoperative care. Coat lips treated by surgical advancement or implantation with antibiotic ointment 3-4 times per day for 1 week postoperatively. Then follow with use of Aquafor or petroleum jelly to prevent dryness.
  • Ice packs are used extensively in the first 24 hours.
  • Encourage patients to limit talking, smiling, and laughing for 5-7 days postoperatively.

Follow-up care:

  • Significant postoperative swelling is common to all techniques of lip augmentation. With the surgical procedures, the swelling may be significant enough to interfere with your social routine for 2 weeks or more. It may take 8-10 weeks to completely resolve.
  • Recommended postoperative care includes ice packs, sun avoidance, liquid diet, perioral care with saline rinses, and rest for 24-48 hours, depending on the extent of surgery. Use of a sippy cup rather than a straw will help, as it is difficult to use a straw or purse one's lips when swollen.
  • One of the most common complaints after surgical advancement is persistent numbness and/or paresthesias around the augmented lips. This problem usually resolves in 4-6 weeks but may become a significant nuisance for patients.
  • Follow-up care consists of office visits 1, 7, and 30 days postoperatively, at which time shape, symmetry, function, and wound healing are assessed.

COMPLICATIONS

All this improvement may not come without a price. The cost in some patients is lip tightness, resulting in a restricted smile and an adynamic central upper lip. With all the procedures, there is the possibility of disappointment in the final results (both too big or too small) -- reported in up to 10% of patients. In doing this post, I came across these photos of Meg Ryan. I personally like her lips before she had any augmentation work done. I wonder how she feels.

Complications of collagen injection include allergic reaction to the compound, possible intravascular injection, skin slough, scarring, granuloma formation, and hematoma. Testing for sensitivity to bovine collagen must be performed prior to injection and observed for 4 weeks.

Complications of fat transfer include donor site hematoma, scarring, infection, lumpiness, asymmetry, infection, hematoma, intravascular injection, and possible skin slough.

Complications of synthetic material implantation include infection, asymmetry, sensitivity to the material, extrusion, need for removal of the implant because of hardening, interference with lip function, and sensation changes.

Complications of surgical advancement, lift, and roll include hypertrophic scarring, asymmetry, numbness, and lumpiness.

REFERENCES

Lip Augmentation by Jorge de la Torre, MD and Mario Diana MD-- eMedicine Article, June 12, 2006

Lip Implants by Daniel C Daube MD --eMedicine Article, April 4, 2006

Autologous Lip Augmentation: A Comparative Analysis; Plastic & Reconstructive Surgery. Abstract Supplement. 118(4), Supplement:49-50, September 15, 2006; Trussler, Andrew P. MD; Dickinson, Brian P. MD; Keagle, Jennifer J. MD; Bradley, James P. MD; Kawamoto, Henry K. MD, DDS

Correction of thin lips: a 1 7-year follow-up of the original technique; Plast Reconstr Surg, 11 2(2):670-5, 2003; Yoskovitch A, Fanous N.

Lip Enhancement: Surgical Alternatives and Histologic Aspects; Plast Reconstr Surg. 105(3):11 73-83, 2000; Niechajev I

Customizing Perioral Enhancement to Obtain Ideal Lip Aesthetics: Combining Both Lip Voluming and Reshaping Procedures by Means of an Algorithmic Approach; Plast Reconstr Surg. 11 3(7):2182-93, 2004; Haworth R.D.

Lip Service for the Stiff Upper Lip; Plastic & Reconstructive Surgery. 105(3):1154-1158, March 2000; Zide, Barry M. M.D.; Bradley, James P. M.D.; Longaker, Michael T. M.D.

Narsete, T. A. V-Y advancement flap in upper-lip reconstruction. Plast. Reconstr. Surg. 105: 2464, 2000

Collagen Injections by Thomas J Gampper MD -- eMedicine Article, May 3, 2007

Implants, Soft Tissue, Gore-Tex by Michael Mercandetti MD -- eMedicine Article, Jan 8, 2008

9 comments:

Dreaming again said...

So my keloids aren't worthless? *grin*

Dr. Smak said...

Your before and after photos are impressive.

But as to the description of the fat harvest, ewww.

rlbates said...

Not mine--some I found on the internet as good examples. I agree they are impressive. Not all turn out so well.

Femail doc said...

So do you do this? The ArteFill lady looks grand--but how creepy to have some non-resorbable goo in your lips, especially if you have a reaction. And Meg Ryan looks awful--she shoulda' left well enough alone--her before picture is gorgeous.

rlbates said...

Femail Doc, I try to talk them out of it. These days I usually refer them to someone else. I have done several of the fat injections, but they seem to only look good for the first six months (at least in my hands). I too have problems with artifical "stuff" in the lips. I hope Meg likes her lips better than you and I do.

Anonymous said...

Is there any way to make the lips look bigger, side-wise in other words what can be done to increase the length of the mouth opening.

rlbates said...

Anon (Feb 21, 09), not anything simple. See your local plastic or ENT surgeon for a consultation if that is a big issue.

Anonymous said...

Lovely upper and lower lip V-to-Y flap augmentation, evidenced in this p/t's before and after photos.

So natural looking and lush.

Thanks for posting; it's the first I've come across this technique.

Dr Rob said...

Late to the party but I ALWAYS inject the patient FREE OF CHARGE with saline. Only if they like the result, do we see them back for fillers. Bottom line is: you can't make an ugly lip into a pretty lip. It just becomes a bigger ugly lip.