National report - When it comes to lip augmentation, safety should be the cosmetic surgeon's top priority, advises Sydney R. Coleman, M.D. And fat grafting is the best choice, because the substance offers the most safety.
"Fat is your own body tissue. It is far and away the safest," says Dr. Coleman, assistant professor of plastic surgery at New York University, New York.
Not only is fat grafting safe, but it also produces excellent results.
A safer, more permanent solution
Dr. Coleman points out that synthetic fillers such as collagen and Restylane carry with them infrequent risks, including post-operative granulomas or nodules, which can occur after even the smallest of injections.
"With fat, patients cannot have a reaction like they might have to a foreign substance because it is their own body tissue," Dr. Coleman tells Dermatology Times. He says adverse events with synthetic fillers are most likely the result of a patient's immune system reacting to the filler.
Fat grafting also has the benefit of permanency.
However, "Fat grafting requires a certain technique to be permanent, and not everyone practices that technique," he says.
Dr. Coleman explains that there are a variety of fat grafting techniques, and permanent results are possible when fat maintains its viability during transfer.
"If you kill something that is living when you are moving it from one part of the body to another, then it is not going to be permanent," he says.
Understanding lip anatomy
Proper technique is another key aspect of lip augmentation and one that Dr. Coleman says begins with an appreciation and understanding of normal, aesthetically pleasing lip anatomy.
"The cosmetic surgeon has to know what an attractive lip is. Look at lots of lips, young and old ones, and discover differences," he says.
This awareness appears to be lacking in some of today's practicing cosmetic surgeons because surgical residencies typically did not provide comprehensive instruction in three-dimensional lip anatomy until recent years.
"The problem is that people have treated the lip as a sausage and squirted fat or another substance into the lip without paying attention to the shape of lip," he explains. "Lip augmentation should make the lip fuller, but in an anatomically correct fashion so that it has bulges and deficiencies like a normal lip."
Elements that Dr. Coleman notices in younger lips are the big central pout of the lower lip with an area of central deficiency behind that pout, emphasizing a lateral fullness. He points out that the upper lip in a younger person does not follow a straight line across the top but has undulations, and most of the width of the lip comes from lateral upper lip. These are some of the key elements he tries to mimic when performing lip augmentation in an older patient.
Identifying the changes that occur in lips over time as patients age helps the cosmetic surgeon know which lip areas to treat with injections and which to leave alone.
"It is important to place injections in the right level to get eversion and to place them preferentially into areas that should have more in it and less where it should be less," he says. "The idea is to place fullness under the vermilion and mucosa to expand those tissues against the skin" without expanding the skin itself, which can turn a lip inward.
Balancing the size of the upper and lower lips to each other can make the difference between natural and unnatural results. Dr. Coleman says injections to the upper lip should be placed far enough out laterally to maintain the proper lip width (unless the patient desires a more narrow mouth). And the lower lip should have more fullness than the upper lip to avoid a "duck bill" appearance.