Lip Enhancement

James J. Romano, MD

INTRODUCTION
An individual’s smile, anatomy, and look of the lips are often referred to as the “locus of our identity.” This is an enormously personal and individual indicator of our identity, personality, and sexuality. Even small and subtle interventions can have a tremendous impact on our body image and perception. For this reason patients and doctors both need to be extremely cautious and careful with any procedures undertaken in this area.

Lip enhancement, also known as lip enlargement or lip augmentation, has been practiced by cosmetic surgeons since around the 1960s. It has become much more common recently, mostly due to a tremendous surge in media attention in supermodels, but also because the techniques and materials have been improved tremendously in recent years, making this a more safe, predictable, and comfortable procedure that is more easily customized to the patients’ desires, lifestyle, and budget. This article will go through the spectrum of techniques including the newest advances in lip enlargement.

The spectrum of procedures for enlargement of the lips ranges from simply a 20-minute office procedure with no anesthesia, immediate return to work, and no swelling or discomfort all the way up to a two-hour hospital procedure under general anesthesia, significant swelling, one to two weeks off work, and some pain. There is a broad range of possibilities in between. For this reason it is easy to understand that no one procedure or technique fits all. It is something that needs to be highly individualized to the patients’ desires and expectations, anatomy, lifestyle, and time available to be out of work and social situations.

Both men and women frequently seek this procedure. The desire for lip enlargement ranges from slight and modest all the way up to outrageous. Many patients have some unevenness in the size and contour of the upper or lower lip, or both, and this needs to be considered when choosing the type of procedure. “Small lips” usually means the amount of pink tissue visible and how much it “turns up,” especially in the upper lip. This is a situation that can be present from birth and is not only seen in the aging process where tissue bulk is diminished over time. I have patients aging from their 20s to well into and above 70 years old. Other features that have to be taken into account, other than the size and asymmetry of the pink portion of the lips, are the length of the upper lips, creases and folds at the corners, and drooping of the corners. The latter features are not corrected with lip enlargement but must be addressed with incisions under the nose or at the corners or the mouth, which lift the lips. All of these things must be taken into account when considering beautifying and youthifying the lips.

PREOPERATIVE FEATURES AND INDICATIONS
Unlike some other plastic-surgery procedures, nearly anyone can be a candidate for lip augmentation. Especially today, while having fuller, “poutier” lips is in style, more people are considering lip-enhancement procedures, not only to puff up their mouths, but also to correct any asymmetries or crookedness.

Men and women, teen-agers, twenty-somethings, and octogenarians are all eligible for a lip-augmentation procedure. Up to 40 percent of lip-augmentation patients under 35 choose to have their lips surgically enhanced if they have “underdeveloped”—thin, flat lips. Older folks—who account for about 60 percent of lip-augmentation patients—tend to opt for the procedure to reverse a byproduct of the aging process. As we age, muscle tension and tone become more lax; lips begin to hang, lengthen and thin.

Most people seeking lip augmentation simply have small or thin lips. This refers to the pink portion or what we call the mucous membrane. It is usually most obvious in the upper lip and less on the lower lip (since the lower lip has the advantage of gravity and tends to roll out more evenly when thin). Patients desire a larger and poutier appearance with more fullness and turning up and out of the lips. Many seek more evenness in the fullness.

In some cases your underlying dental architecture can influence the posture of your lips and cause your lips to droop or hang. Be aware of this if your teeth are very crooked or you have an overbite or underbite. Your plastic surgeon should be aware of this and may first want you to consult an oral surgeon to discuss your options before considering lip augmentation.

The degree of desire for enlargement varies according to the patient from mild to moderate to extreme. The amount of enlargement depends on the anatomy. I use computer imaging in my office, which can demonstrate the predicted result or degree of result to the patient to help anticipate the patient’s desires and expectations.

THE SPECTRUM OF PROCEDURES
There are three general categories of procedures that enhance the lips. These are injections of materials such as collagen, grafting in substances such as Gore-Tex or fat, and local flaps and incisions that redistribute the tissues from inside the mouth to outside. The results can be temporary or permanent. All of these have different advantages and disadvantages, types of anesthesia, recovery periods, pain, and time off work. Anesthesia ranges from none or very little in an office setting up to general anesthesia in the hospital as an outpatient. The procedure can take from twenty minutes up to two hours. You can usually bathe and shower as usual the next day. There can be minimal swelling and bruising and no numbness with immediate return to work up to tremendous swelling and bruising and numbness that last for days to weeks with one to two weeks off work. There can be no stitches or incisions, or a few at the corners, or many inside the mouth. When present, the stitches are usually removed in seven to ten days. Results can be temporary or permanent depending on the technique. No dressings or drains are used. The procedure can easily be combined with other plastic surgery procedures.

INJECTIONS
This method of lip enhancement refers to placing a semi-liquid substance into your lip. It is an office procedure requiring a little topical anesthetic applied to the surface of the lips only. Injectable substances are nice because they can provide a beautiful “all-over” enhancement, or, by adding more to one side or area than another, they can also be used nicely to adjust asymmetries or unevenness of the lips. The procedure can be repeated over and over with little or no danger, to “adjust up” the size, as the patient likes. Some of the materials are long lasting, and some temporary.

1. Collagen
   Collagen is a purified preparation of bovine (animal) skin available in different concentrations and compositions. It has been used in humans since 1981. For years collagen has been one of the most popular methods of lip augmentation. Though collagen works very well, its effects are always temporary. I like this very much in the first-time patient because it is a real advantage to “try on” the look for a while and even gradually increase it. Remember, this can be a significant body-image change, and it’s hard to predict until you see it on yourself.
2. There is a slight risk of allergic reactions. This usually takes the form of some redness around the treatment sites that lasts for weeks to months. To avoid this occurrence, prior to treatment patients undergo a skin test. For the test, your doctor will inject a small amount of collagen just beneath the surface of your forearm. You look for redness or reaction in the following two weeks. If this is normal, then it will be from two to six weeks from the time of the skin test before the actual administration of the collagen.
3. The procedure is done in the office using a topically applied local anesthesia. Small needles are used to implant the material. It is mostly painless. There is minimal swelling or bruising and patients can return to work or most activities right away. Makeup can be applied in hours. There is minimal risk or side effects.
4. Collagen nicely enhances the look and size of your lips. The substance is quickly absorbed into the body especially in areas—like the lips—where there exists a lot of motion and lots of blood flow. Your lip augmentation with collagen will last between four weeks and three months. More can be added at any time.
5. Artecoll
   Next, I mention this as the newest and latest advance in a filler substance. I am one of only ten doctors in the country approved by the FDA in an investigation to study this material. The basis of Artecoll is a synthetic material called polymethyl methacrylate, and it has been successfully implanted in humans since the 1940s and used frequently even now in dental, neurosurgical, and orthopedic patients. It is composed of microscopic spheres of this material suspended in collagen. As the collagen is degraded by the body, our own natural collagen replaces it and encases the microspheres, providing tissue augmentation that is long lasting. It has been used successfully outside the United States for exactly this purpose in over 100,000 patents since 1989. It is administered exactly like collagen with the same anesthesia, minimal pain and bruising, and quick recovery and return to work.
6. Fat Injection
   This procedure is receiving a lot of publicity. The theory is not new, but the techniques have advanced a lot in the last few years. It involves extracting some of your own fat from somewhere on your body by a tiny needle using local anesthesia. The fat is usually spun in a centrifuge and the excess fluid separated. Special small needles are then used to place tiny “threads” of your own fat into the lips. It is good for an overall enhancement and to correct asymmetries.

Fat cells are tiny and fragile and are removed and moved from one part of the body to another only with great difficulty. The success depends on only one thing: how well the cells survive and how many have a new blood supply grow into the cells so they can survive and persist. The procedure is extremely technique-sensitive and highly individual. I employ a lot of additional resources, such as supplements, vitamins, and even acupuncture to increase the local blood flow with the hope of increasing fat survival.

The problem and criticisms of fat are that it is temporary. The proponents of fat insist at least some of it survives, providing long-lasting improvement. Both are true. I simply state this to patients as a situation where we do not know the answer until we give it a try and everybody’s “body is different.” I evaluate everyone after six to twelve weeks. In general, 5 to 10 percent of patients have an excellent first time, one time result. 10 to 20 percent have no result. The rest have a partial result. If it works at all, I then offer repeat procedures, and I have had many satisfied and pleased patients. In the latter circumstances I describe this as “building a layer cake.”

Unlike collagen, you can expect a lot of lip swelling and unsightliness for the first few days after the procedure. There is minimal bruising or pain. There are no stitches. You won’t know how well it has worked until at least six weeks afterwards. If there is a partial success, I will perform a fat injection up to three times; if after three times you’re not satisfied with the results, I suggest an alternative technique to give you the look you desire.

GRAFTS

1. AlloDerm
   AlloDerm is essentially a sheet of human collagen tissue that has been purified and rendered non-immunogenic. It is the relative of Dermalogen, which is its injectable form. It is well tolerated and does not cause allergies or need to be pre-tested for allergies. It is inserted as an outpatient procedure performed under a local anesthetic. Incisions are made at the corners of the inside of the lips and AlloDerm is rolled up and inserted from one side to the other. A few tiny stitches at the corners in the small incisions are all that is needed. Post-surgery swelling is mild to moderate and disappears mostly within three to five days. It is very soft and natural. There is a tendency for this to become reabsorbed, and the result seems to diminish or disappear after about six to twelve months.
2. Gore-Tex
   This is related to the same material that keeps you dry in a rainstorm. Gore-Tex is desirable because it is a biocompatible material that passes easily through tissue. It comes in sheets or strands. It has been used successfully as a human implant in over five million implantations without any allergic reactions. Although commonly used for blood vessels, bypasses, it has been approved for tissue augmentation procedures and used in this way since about 1988. There is a slight potential for infection, and when this occurs, the material can be easily removed usually with no untoward side effects. It is soft and pliable, and the results are permanent. Placement is extremely technique sensitive, and if it is placed less than perfectly, it can show or distort especially when smiling broadly. It is much like AlloDerm in terms of the incisions and anesthesia. It can be easily surgically “fine-tuned” by adding or removing strands as needed.
3. Dermis-Fat Grafts
   It has been well known since the 1950s that excising fat from the body with a partial thickness of the skin still attached improves the survival of the fat when implanted elsewhere. This dermis-fat graft procedure is popular for lip enhancement. It requires an incision somewhere on your body—usually in the groin area—to take out a wedge of skin with fat still connected to it. The partial serves to bring in the body’s own blood supply to ensure the fat graft’s survival. The incisions and the stitches and minimal pain are similar to the procedures described above. The swelling is significant, so patients need to plan about a week out of work.

Disfavor with this technique centers around the unpredictability of the partial skin attached to the fat. Although the enlargement is good and predictable, the partial skin with its collagen can scar and contract and occasionally distort the mouth and smile. If this happens, your doctor will have to perform a second operation to remove the graft, and this can be difficult.

LOCAL FLAPS

1. Inside the Mouth
   This last category of lip enhancement has been around since the 1950s, and was the first technique employed to enlarge the lips. It is still commonly employed today, but because it is more invasive, it is often reserved for when other techniques have been unsuccessful. Other times it is used when patients know they want a long-lasting result and don’t want to “try” the other procedures. This involves making incisions inside the mouth to detach and roll out the pink tissue up and into the lips. It is an outpatient procedure and requires anesthesia. There is a lot of swelling, numbness, and some drooling. These symptoms are very prominent for the first three weeks and diminish in the next three weeks. Stitches are removed in ten to fourteen days. This procedure may be combined with a graft such as Gore-Tex or AlloDerm.
2. Due to the invasive nature of this procedure, you will experience temporary numbness and severe lip swelling that will last between two weeks and six weeks. Sometimes this technique is performed in combination with a graft implant.
3. Outside the Mouth
   Another procedure is an incision in the upper lip exactly following the lip line (called Cupid’s bow). Some skin is removed and the lip is lifted and everted to create a fuller look with more “pout.” This incision can be slightly visible but often camouflages well with make-up. It is not that popular only because most plastic surgeons hesitate to make an incision in a completely normal upper lip and risk an unsightly scar. In well-chosen patients the result is excellent. The surgery is an in office procedure with local anesthesia. It takes about one hour, and there is minimal pain, quick recovery, and only mild swelling, which disappears in ten to fourteen days.

QUICK REFERENCE AND SUMMARY

1. Pain
   Expect minimal discomfort in the hours and days following most lip-augmentation procedures; however, do be prepared for some pain if you opt for either any of the grafts or local flaps techniques.
2. If you choose one of the injection procedures, your doctor will most likely use a topical anesthetic that’s swabbed on the lips, and this makes it a painless procedure.
3. In any of the graft procedures, your lips will be completely numbed with tiny needles and a novocaine solution. After this takes effect the enhancement is performed. You will not feel anything. You can expect to experience mild to moderate discomfort for up to three days afterwards.
4. If you undergo an inside-the-mouth local flap procedure, expect moderate to severe pain for up to five days following the surgery. There is moderate discomfort, swelling, numbness, and even drooling that may persist for three to six weeks.
5. Recovery
   When can you expect to return to your normal daily routine? Fortunately, lip augmentation is generally not a very invasive procedure, but recovery time varies depending on the procedure you choose.
6. With the exception of the local flaps procedure, you can expect to return to work either the same day or two to three days afterwards. Bruising and swelling following most procedures can last three days to seven days. If you opt for the local flaps technique, you are advised to be prepared for one to two weeks of unsightliness.
7. In all cases, refrain from strenuous activity or exercise for at least several days.
8. If stitches are present, they can be removed in one to two weeks.
9. Bruising ranges from almost nothing with the injections to very severe with the local flaps. It usually diminishes quickly, and there are things that can help speed up this process.
10. Swelling is much like the bruising and is minimal with injections, moderate with fat grafting and flaps, and very severe with inside-the-mouth local flaps.
11. Incisions heal imperceptibly and are almost never noticeable.
12. Ice packs will help reduce swelling and soothe incisions.
13. Follow-up visits are frequent initially, and then once a week, and then as needed. If at any time following surgery you experience fever, bleeding, or other symptoms of infection, immediately inform your doctor.
14. Risks
    Though lip augmentation is considered a very safe procedure, as with any surgery, it has its risks. These are not common, but could occur:
1. Numbness
2. Swelling
3. Ulceration
4. Scarring
5. Unnatural movement when smiling or talking
6. Kinking if an implant is used
7. Permanence of a large or uneven lip
8. Hardness, unnatural to the touch
9. Scarring
10. Costs
    The costs of a lip-enhancement procedure can vary from doctor to doctor and from region to region, but the procedures ranges from $400 to $6,000. You can usually pay with a credit card or finance the procedure. The following are average costs you can expect to pay for the technique you choose. Lip augmentation is considered elective or “cosmetic,” which means you’ll have to pay for it yourself.
11. Collagen: $400 per tube of 1cc.
12. Dermalogen: $400 per tube of 1cc.
13. Artecoll: $400 per tube of 1cc.
14. Autologen: $1,500–2,000 for the entire process.
15. Fat injection: Costs vary: $500 per area, or $1,000–1,500 per session.
16. AlloDerm: $2,500 for one lip; $4,000 for both.
17. Gore-Tex: $2,500 for one lip; $4,000 for both.
18. Dermis-fat graft: $4,000–5,000 for both lips.
19. Local flaps: $4,000–7,000.
20. These prices generally reflect all costs including anesthesia and hospital fees where necessary.
21. Other Options
    Some people opt for a procedure other than a lip augmentation to enhance the fullness of their lips. One option is to have your skin pigmented by a tattoo artist to make the skin around the lips look pink and full.

WHAT’S NEXT
Lip augmentation, like any surgical procedure, requires that you be in good health. Talk over with your doctor any health concerns or problems that you may have. Review what things are done and used to help prepare you for surgery and speed your recovery. For instance, I employ numerous supplements and dietary recommendations.

If you believe that lip augmentation is for you, make sure the doctor you select is a board-certified plastic surgeon and be aware of how to select a plastic surgeon. Discuss the procedure, its risks, and benefits with the physician you choose and be certain you are comfortable with your doctor.