Aspen, Colo. — Appreciating the natural variation among normal lips helps physicians rejuvenate and balance lips of all shapes, sizes and ages, said an expert at The Cosmetic Bootcamp.
"Everybody's lips are unique, and every patient needs a unique approach to giving them the perfect lip for their face," said Ava Shamban, M.D. She is a Beverly Hills, Calif. -based dermatologist.
Dr. Shamban showed many patient photos, with varying lip shapes and sizes, to emphasize the fact that diagrams and dissections do not adequately capture individual lip structure. "Everybody's lips look different, which is one of the beautiful parts of being a human being. I can't change and wouldn’t try to change individual lip shape — I can just make them look younger and better."
Although lips are one of the most commonly treated indications in aesthetic medicine, she added, results overall are not what they could be. "It's important to pay attention to what a normal lip looks like. Look at thousands of lips — young, middle-aged and old — to see what a beautiful natural lip looks like, because if we aren't making people look their best, then what are we doing?"
When we scan someone's face for facial expression, said Dr. Shamban, our eyes move in a triangular pattern — looking first at the person's eyes, then the mouth. "When you're talking, you look at the lips." The lips are also instrumental in sexual attraction. "The lips are the only fully visible sexual organ," she said.
But the uniqueness of each set of lips creates challenges for physicians. "You have to obey that innate shape of the lip, adjusting your technique to that particular lip shape."
Frequently, younger patients request lip enhancement. "They may say, 'I want my lips to look like Angelina Jolie's.' That may not even be possible for their lips." Such lips may not fit the person's face. "And everyone should look like themselves."
Dermatologists can correct the asymmetry that is common in younger lips. However, said Dr. Shamban, this typically requires multiple visits. "I don't know why. But you can't get it to hold that shape with the first treatment. When the lip redrapes over the filler, it takes maybe three times. But it works."
Young people who frequently photograph themselves often notice that their lips look smaller when smiling. Dr. Shamban reassures them that everyone's lips look smaller when performing a big smile. "You must deal with the psychology of the patient as well when you're treating lips."
Mature patients are terrified of having oversized lips, says Dr. Shamban. "People think that everyone in Los Angeles wants big lips, but that's not the case." She reassures prospective patients that her goal is simply to restore age-appropriate volume and shape.
When evaluating older patients, injectors must consider how the lip sits within its cosmetic unit. "It's not just the pink lip or the vermilion. It's also the white or cutaneous lip, because you can't just stick the lips on a stalk like a flower on a stem. The lips have to be a gradual extension of the cutaneous section."
Youthful lips have a natural progression of the white lip into the pink lip. "But in an older face, the cutaneous part may have shrunken down due to loss of fat." This can lead to superficial-to-deep wrinkling around the mouth. And naturally larger lips may be left sitting on what looks like a shrunken base.
"The first approach for an older mouth like that is to address the white lip so that you have a natural extension. Often just addressing the cutaneous lip makes the vermilion look bigger — suddenly, it has something to sit on."
Dr. Shamban typically injects the perioral area with a 27-gauge, 1.5-inch cannula. "With a cannula, you can lay an even sheet of material." This results in smooth contours.
Any filler that is FDA-approved for perioral use can work, she said. But for patients who need more lift here, she prefers products including Restylane Lyft and Defyne (both hyaluronic acid/HA, Galderma). In the lip itself, she typically uses Restylane Silk (HA, Galderma), Juvéderm or Juvéderm Volbella (both HA, Allergan).
To inject the lip in young and old patients, she prefers 0.33 ml insulin syringes (Becton, Dickinson and Company) for their precision. "Ideally, we like a little bit of asymmetry in the face. But lips need to be as close to absolute symmetry from right to left as possible." The precision provided by a small syringe makes replenishing lost volume with exact amounts easier, Dr. Shamban said.
In older patients, she typically outlines the edges of the upper lip first by placing a needle in the white roll and then injecting in a linear retrograde fashion. This technique address the so-called “lipstick lines,” which cross from the white lip into the pink lip — if they are not treated, lipstick will bleed into them. The lip body is then addressed with another linear retrograde injection technique in the wet dry border. “I prefer the precision of the needle in the lip.”
In contrast, the lower lip is treated in a completely different fashion by injecting the tubercles at a 90° angle with a 0.1 cc bolus per tubercle. The sides are injected with a smaller volume injection, giving a pleasing dumbbell appearance to the lower lip, said Dr. Shamban.
"On the lower lip, one thing people do that I find unattractive is to trace the border of the lower lip, starting at the commissure. That looks so unnatural — people are creating sausage lips. Enhancing lips is only going to increase in popularity, and it behooves all practitioners to create a beautiful pout instead of a bizarre, grotesque lip.”
Dr. Shamban is an investigator and receives speaking honoraria from Galderma, Allergan and Merz aesthetics.
Ava Shamban MD. "Creating the Perfect Lip," The Cosmetic Bootcamp. July 23, 2018.