Lip augmentation procedures with hyaluronic acid dermal fillers have become increasingly popular worldwide because full lips are often considered beautiful and youthful. The goal of a lip augmentation procedure is to create smooth lips with adequate volume and a natural appearance. Various techniques for lip augmentation have been utilized and described. Deborah S. Sarnoff MD & Robert H. Gotkin MD shared their 6 Steps to the "Perfect" Lip in Journal of Drugs in Dermatology back in 2012. Let's revisit the classic again.
The 6-step technique involves administering approximately 12 injections—about 0.1 cc HA per injection—placed in strategic locations in the upper and lower lips. Note that some areas of the lips may not be treated at all; some areas may require slightly more or less than 0.1 cc. The best position for the patient is supine with the neck slightly hyperextended. Over time, even with the introduction of new fillers, the author has found this formula to be a template for success in creating aesthetically pleasing lips.
Step 1: Create Philtrum Columns
The injector may recreate the Philtrum Columns by superficial vertical injection of filler into each philtrum column. It is important to realize that the philtrum columns are not parallel to each other, but rather they form an inverted “V” that narrows as it approaches the nostril sills and columella of the nose. Approximately 0.1 cc of HA filler should be injected into each philtrum column. Tip: Pinching the skin with your non-dominant hand during retrograde threading of the philtrum columns diminishes discomfort and keeps the filler in a ridge and prevents it from splaying laterally. Pinching after injection helps to further mold the filler to define the philtrum columns. Upon completion of the injections into the philtrum columns, one notes immediate definition of the philtrum dimple and enhancement of the Cupid’s bow.
Step 2: Create Cupid's Bow
Place the tip of the needle at the base of the philtrum column (at the vermilion-cutaneous junction) and advance to the vermilion-mucosal junction (“wet line”). Inject a 0.1-cc thin thread of filler in a retrograde fashion. This thread of filler acts as an anteroposterior strut to support the projection of the central upper lip.
Step 3: Define The Vermilion-Cutaneous Junction in the Medial Aspect of the Lateral Subunit of the Upper Lip
The upper lip is divided transversely into medial and lateral subunits.The medial subunit of the upper lip extends from the midline to the philtrum column; the lateral subunit extends from the philtrum column to the oral commissure and nasolabial fold. Inject ~0.1 cc HA laterally from the base of the philtrum column, along the vermilion-cutaneous junction, about halfway to the oral commissure. It is important not to augment the vermilion-cutaneous junction along the entire lateral subunit, but only in its medial aspect Do not augment the vermilion-cutaneous junction in the medial subunit as it will obliterate Cupids bow and create the “sausage” or “duck” lip.
Tip: Pinch the vermilion-cutaneous junction to reduce discomfort and to prevent product from splaying from its desired area of placement. Inject slowly, do not over-fill and watch for blanching of the lip. This helps to prevent direct injection or external compression of the labial artery, either of which can lead to ischemia or necrosis.
Step 4: Create Lower Lip “Pillows” or Tubercles on Each Side of the Midline
Deposit approximately ~0.1 cc of filler as a depot injection into the orbicularis oris muscle at the vermilion-mucosal junction on each side of the midline. The depot injection should be about one third of the distance from the midline to the oral commissure. Gently massage to prevent superficial lumpiness
Step 5: Support or Bolster the Oral Commissures
Place ~0.1 cc filler in the most lateral aspect of the cutaneous lower lip so as to provide upward support to the commissures. Tip: Injectable neuromodulating agents (botulinum toxin A) placed into the depressor anguli oris muscles can be used as an adjunct to further elevate the commissures. This combines structural support with chemical neuromodulation to shape the oral commissures.
Step 6: Fill the Nasolabial Creases Place
~0.1 cc of filler in the upper portion of the nasolabial crease; this helps to evert the upper lip. One must be cautious in the region of the piriform aperture so as to not inject or externally compress the angular artery. Tip: Inject just medial to the nasolabial crease to prevent splaying of the product laterally. Augmentation lateral to the nasolabial crease only serves to deepen the appearance of the crease.
These six steps will help to augment and evert volume-depleted lips. For those patients that have pronounced radial “lipstick bleed lines” in the cutaneous portion of the upper lip, additional treatments may be necessary. Caution must be exercised in treating these lines not to use a robust, high-G’ filler; the orbicularis oris muscle is a sphincter muscle and its constant “milking” action may cause clumping of robust fillers. This can result in nodules, lumpiness and migration of product. This technique requires very superficial placement of HA filler.
Lip enhancement is one of the most frequently requested procedures in a cosmetic practice. The classical 6-step technique is a template that can be used to artistically create aesthetically pleasing “perfect lips.”
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