WHAT IS NORMAL?
The amount of red showing (vermilion) in the upper and lower lips should come close to being equal.
- The lips should have the desired bulk.
- No lines or wrinkles around the lips.
- The amount of upper lip white area (skin) should not be excessively greater than the red area.
- The lips should not be so large that the inside of the lip shows at rest.
COMMENT: Big lips are in! Of course, the desirability of lip size is variable. There are two separate features to consider. One is the amount of red showing and second is the bulk of the lip. Both need to be adequate. It is important that the lips maintain their natural contour after surgery also.
- Pull up the skin along the bottom of your nose to see if this improves the design.
- Do the upper and lower lips compliment each other?
- Your doctor may be willing to inject saline into them to give you an idea of how they would look bigger.
- Are they overly large and distracting?
Is there a sharp lip line? Well developed lip lines, the edge at the border of the red and white area and the creases in the center of the upper lip are termed the "Paris Lip".
HOW MUCH CAN BE IMPROVED?
- Both volume or an increase in the amount of red showing can be achieved.
- Scarring can be a constraint with lip surgery as with any soft tissue surgery.
- Wrinkle lines can be smoothed.
- Lip size can be reduced easily. Lip reduction is a simple, effective operation.
THE OPTIONS: LIPS
INTRODUCTORY REMARKS - THE PROBLEM
The search for alluring is immortal. Recently big lips amongst women have been a fad and we get many inquiries related to this. There are many options for patients.
VOLUME VERSUS RED
Basically there are two aspects to lips which deserve attention. One is the amount of red that is showing in the lip. This is the area to which lipstick is applied. Also, I like to look at the width of the red area compared to the total width of the upper lip.
The second is the thickness of the lip- how much bulk is there? Lips without much red showing are often deficient in bulk. Sometimes relatively bulky lips may have very little red showing. In the consultation, we try to address these separate problems, bulk and the amount of red.
If a girl's main goal is to put on lipstick, having thick lips won't help her if there is no additional red showing. Likewise, if more red is created without bulk, the lips may develop a bizarre appearance.
Another concern may be DEFINITION. Some lips have very pronounced lip lines and others do not. People may wish to enhance the definition in the lip to create an effect known as the "Paris Lip" in which the lip edges are all extra distinct.
ADDING VOLUME - THE CHOICES
The first category of procedures would be those that add volume to the lip by a simple injection. The first material used commonly was silicone, and when used properly, produced excellent results. The present choices include:
- BOVINE COLLAGEN
None of these methods are great, otherwise all the doctors would switch to it.
WHAT IS COLLAGEN?
In place of silicone, a common material used is bovine collagen, produced by the Collagen Corporation.
Collagen is the body's natural filler material, the cement that holds the tissues together. It is a very simple protein that tightens like rope. Collagen is the main material in tendons, ligaments, the dura around the brain, and even the main support substance
The Collagen Corporation sells bovine collagen to physicians. This is an extract of cow skin that is homogenized and sold to physicians in a suspension that has been loaded into syringes. All physicians pay the same price for the materials. The material is not altered by any physician either, so feel free to shop for the best price for this material.
HOW LONG DOES BOVINE COLLAGEN LAST?
The Collagen Corporation claims that the technique of the injection makes a large difference in the result, but most users believe that the great variability in the results has a lot to do with the type of skin that it is injected into.
The question of how long the bovine collagen lasts in human tissue is critical, as it is for all of the materials. First of all, about a third of the collagen solution that doctors buy is water, so already the volume is reduce. Immediately, you can expect that over the next few days that a third of the size of the lips with disappear, for instance.
The next issue has to do with when there is still is a good effect from the material. Some people feel that once the injection starts to wear off, then it is no longer good. To others, the injection has lasted until they can see the slightest change from the way it looked before.
The vast majority of my collagen patients are truly dissatisfied. Partly this is because they want one syringe of collagen to fill every wrinkle in their face.
Frankly, I consider it rare to see a significant affect with liquid collagen after six or eight weeks in most mobile areas of the face. In non-mobile areas, such as the forehead or a scar, the material may last longer.
Since the bovine collagen is a foreign protein coming from cow skin, some patients are allergic to it. About two percent are allergic when tested initially and about another one or two percent can become allergic during the course of treatment. At one time there was a significant concern about the relationship of collagen injections to auto-immune diseases, such as systemic lupus, however at this point, there has not been a proven correlation.
Another filler that adds bulk is fat, which can be transferred from other areas of the body. In this case a region is suctioned, the fat is washed, and then reinjected into the lips. This may produce a satisfactory improvement, in some cases; however, usually only a small portion of the fat survives. The fat may be lumpy when it finally heals.
In our office we consider the results of fat injection too unpredictable, especially in the lip. Also, there is considerable work involved in harvesting and transferring. Generally I tell patients that they can expect that in fifty percent of patients the fat is
gone between six months to a year, but it is truly hard to be exact.
SCAR AND FASCIA PLACEMENT
Another method of lip enhancement is dermal grafting, in which a strip of skin or scar tissue is removed from another area of the body and slid into the lip as a whole strip of tissue. If the patient has a good donor area (place to take the graft from), in particular where there is an excess fold or some other procedure is being done that will make it convenient to harvest tissue, I may recommend this method for them as well.
Although this procedure may be a good deal of work, this can produce a satisfactory long-term result with natural tissue. The lip may tend to be stiff for a while and certainly a little numb as well, but this technique may add significant volume.
Instead of skin or scar, FASCIA has been used, particularly if lip augmentation is desired at the time of a facelift. Fascia is a thick sheet of natural collagen that holds deep tissues like muscle, in place. My experience with this is that it tends to reabsorb,
without providing the desired volume over a long period of time.
Gortex is a Teflon sheet material that is FDA approved. It is introduced in the lip in long strips in a fashion that is similar to the dermal grafting. The material tends to be thin and I think adds very little real volume to the lip. This technique may be more appropriate for accenting lip lines. Even though there is no evidence of problems with Gortex so far, some people are concerned about having a foreign material in their body if there is some other procedure that might work as well.
INCREASING THE RED
Take a look at your lips again and examine the amount of red (vermilion) that is showing. In many people this is the real issue. Many women try to compensate for small lips by placing their eyeliner beyond the normal limits of the red or even having permanent make-up placed there. I have seen some horrible results under these situations and the lips can really look like a mess when people try this.
There are two questions. First of all, is there an adequate amount of red showing? Second, is there too much white (upper lip)?
I like to see the lips come close to matching in the amount of red that shows, or perhaps just a little more in the lower lip. The upper lip also needs to maintain its natural curvature, and people who operate on the lips need to be careful about preserving
HOW CAN I INCREASE THE RED?
Besides the techniques we've discussed to increase the volume of the lips, it may be important to increase the amount of red that shows. This is because there is no natural barrier between the white area of the lip and the red area of the lip deep in the tissues, so that if fat is injected into the lip, only a small amount may bulge out the red area and the rest may be bulging out the white area of the lip.
The ultimate goal may be to produce more red so that lipstick can be more effective. Grafts and injections alone may not be adequate. In many cases, something must be done to invert more red tissue compared to the white area of the lip, if the larger vision is to be achieved. Otherwise, any graft or injection placed in the lip may just as readily drift into the upper portion of the lip without inverting more red as desired.
WHAT PROCEDURES ARE AVAILABLE TO MAKE MORE RED?
I like to evaluate the lips starting at the top and working down.
- LIP LIFT
- MARGINAL LIFT
- LIP ADVANCEMENT
The first procedure that comes to mind would be the lip lift. In this instance, an incision is made along the base of the nose and the lip skin is pulled up as it would be in a face lift. The excess skin is trimmed off and the incision is sewn down along the base of the nose. Usually the scarring from this is minor and the incision heals well.
The ideal candidate for this procedure has a large amount of upper lip with a very small amount of red lip. The only real limitation in this procedure is that the area of lift can only extend as far as the width of the nostrils. Very often that is more than enough.
I have found this to be a very satisfactory procedure and occasionally enhance it by adding bulk of some kind of graft material.
The second type of lip lift that can be done is directly at the edge between the white and the red. For some surgeons this operation can be performed well with good results, but I find that very often there is blunting and scarring at the margin of the red and the white that can produce a very unnatural curvature. This can be difficult to repair if it does occur.
In this operation, approximately 4 or 5 millimeters of the white portion of the skin is removed just above the edge of the red. This can be a helpful procedure in older patients in which there is severe wrinkling of upper lip skin that does not respond to any other therapy. In this case, the benefits of both removing the wrinkled skin and generating more red lip may be worth the blunting of the margin line.
The second category of procedures would be those that push the lip out further from the inside. The principle is that by increasing the red on the inside of the lip, it will tend to evert the lip. The most common procedure is the V-Y advancement in which small areas of tissues inside the lip are pulled together so that the outer lip is pushed further forward.
INJECTIONS VERSUS SURGERY
I think patients who don't have a lot of red showing should give these procedures more consideration since it would save them a lot of money from repeat injections. A push out procedure can give the effect of more bulk visually. These may last a long period of time, and usually they are little more than an inconvenience.
HOW ABOUT THE LOWER LIP?
All of the same remedies apply to the lower lip as the upper lip although often the lower lip is large enough.
WHAT IF MY LIPS ARE TOO BIG?
A LIP REDUCTION is an excellent surgery that we have done regularly with good results. It is a simple surgical procedure in which an incision is made far inside of the lip in a zigzag fashion that pulls the lip inward by removing a small sliver of tissue.
Usually this procedure is reserved for males.
Often this can balance out the lips, especially an overly enlarged lower lips.