National report - Contrary to popular belief, all lip augmentation procedures are not created equal.
A subnasal lift and V-Y advancement have significant advantages over other procedures, such as a vermilion advancement or surgical implants, says David A. F. Ellis, M.D., professor in the department of otolaryngology at the Toronto Hospital Corporation, and medical director of the Art of Facial Surgery practice, Toronto.
Dr. Ellis says that to achieve more definition of the lips, the surgeon should concentrate on augmenting the philtral crest or the vermilion rim. To achieve more bulk, the red lip substance should be the target, and the more the central lip is enhanced, the more pouty the look.
"A vermilion advancement will increase the vertical height of the red lip, but there are a number of problems that go along with this procedure, and I strongly oppose this technique.
"Postop, the scar is most visible and achieving symmetry is tricky. With time, there will be either a rounding or a flattening of the vermilion border and loss of the vermilion roll as seen on the side view," Dr. Ellis tells Dermatology Times.
For achieving more lip definition and especially in very thin lips, Dr. Ellis prefers to use a parallel V-Y mucosal advancement.
He says that though the surgeon still must be wary to achieve perfect symmetry, this procedure will increase the vertical height of the lip, and very importantly, has no visible scarring. Here, the incision occurs on the mucosa, meaning that there is no scar to be seen on the outer lip which is the major reason he recommends this procedure over the vermilion advancement.
Dr. Ellis also has had much success with, and advocates, the subnasal lip lift technique when performing a lip augmentation. For optimal cosmetic results, Dr. Ellis advises this procedure be performed only with a long white lip.
He explains that surgical implants can also be used in lip enhancement in the form of expanded polytetrafluroethylene (ePTFE), namely Advanta and Gore-Tex.
Rigid guidelines, technique
Before performing a surgical implant, Dr. Ellis always follows rigid guidelines to ensure a positive aesthetic result in his patients.
"I do a volume test with a local anesthetic or a temporary injectable filler to best assess the position of the implant and volume to be filled. This helps patients' expectations. They can see the theoretical result before the procedure itself. Also, I thoroughly discuss with my patients all of their options for lip augmentation, this way making sure to deliver the best-suited procedure for each patient," Dr. Ellis says.
His technique for a surgical implant is:
He first draws the precise markings on the lips, with the patient in the vertical position. The ePTFE is inserted with a trocar or angio-catheter needle in a threading technique. To be cautious, Dr. Ellis says, he likes to administer preop antibiotics like cefazolin or clindamycin.
"Surgical implants are useful in increasing the vertical height and increasing the red lip bulk. Again, if the surgeon is not careful, symmetry may be a problem. In my opinion though, the implant is not an ideal solution because it can be seen on movement, especially in an unfortunate overly zealous correction of the lip. For permanent lip augmentation and lasting positive aesthetic results, I recommend Artecoll (Artefil, Artes Medical), Bio-Alcamid (Polymekon) or Advanta (Atrium Medical)," Dr. Ellis says.
If a lip reduction needs to be done, Dr. Ellis adds that the surgeon should try to keep the incision lines (and the scar) inside the wet-dry margin. According to Dr. Ellis, variations of the excision seem to be better than performing a straight ellipse.