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Augmentation of the lips is being done due to the various reasons. Most patients require the aesthetic augmentation of the thin lips volume. Today it is generally accepted that full lips are significantly more sensual, sexy, and they enable significantly easier applying of make-up on the face, all of which contributes to the general impression of beauty of a particular individual. The upper lip is naturally more often less developed or hypoplastic. Two basic anatomical lips terms should be distinguished:

1. volume
2. projection

Volume means the fullness of the lips and rounded shape. Projection is the visibility of the lips from the en-face projection. The ideal aesthetic result augments the volume and projection of the lips at the same time. The lower lip is often of a normal size and projection with most of the individuals and therefore is somewhat rarely treated. Augmenting the lower lip is considerably easier than augmenting the upper lip because of the anatomy and horizontal position on the lower third of the face. Unlike the lower lip, there are big differences in the appearance, thickness and the projection of the upper lip with the different individuals. Sometimes the only developed is the central part of the upper lip, and the lateral parts and the corners of the lips are almost invisible and inverted. These are the most difficult cases in which the optimal aesthetic result is achieved by a combination of injection and surgical techniques. When hearing the opinion of many patients, it seems that many people focus their attention on the lips of the opposite sex first. The pages of advertising magazines, the Internet and electronic media are all covered with full and sensuous lips of various models. We rarely see a person with thin lips in advertisements, no matter what it advertises. We can only conclude that the common opinion is that full and sensuous lips fit the appearance and character of every person.

The method of lip augmentation

There are three main methods of lip augmentation which are being performed in the “Polyclinic Ostojić”, and which are in accordance with the laws of the Republic of Croatia.

1. Augmenting the volume of the lips with its own tissues- (own adipose tissue- lipofilling, dermal transplants)
2. Augmenting the volume of the lips with the injection technique using various implants
3. Augmenting the projection of the lips with the surgical technique of eversion of the lip or using the local flap of the lip mucosa

1. Augmenting the volume of the lips with its own tissue is the safest method to augment the lips with the lowest rate of complications. The most frequently used is the adipose tissue that is usually taken from the abdomen or buttocks liposuction and then injected into the lips. There is no possibility of rejection because it is an own tissue. The disadvantage of the procedure is melting or resorption of the adipose tissue whereby 70% – 80% of the injected adipose tissue melts or resorbs, so the process must be repeated after two or three months. It is usually necessary to make four or five treatments during the year to achieve the desired lip volume. The disadvantages are: yellow-red color of the lips and asymmetric melting process of the adipose tissue which leads to the visible asymmetry in the thickness of the lips. If the free dermal transplants are used (a piece of the subcutaneous connective muscle tissue separated from the skin), first the “tunnel” in which the transplant is inserted has to be made surgically. The disadvantages of the mentioned procedure are the harder lip with the irregular edge and the loss of the volume due to resorption of the transplant.
2. Augmenting the lips with the injection technique is the most common method of the aesthetic augmenting of the lips because it is technically easiest to perform, of shortest duration, and the results are predictable and long-lasting, even to 11 years (Aquamid). There are temporary and permanent implants (fillers).

– Temporary implants are the preparations of hyaluronic acid, which is otherwise normally found in the human organism in the skin, joints and joint envelopes. In Croatia, by now registered and legally available are the Swedish preparations Restylane, Perlane (manufacturer Q-Med) and the Swiss preparations Esthelis and Fortelis (manufacturer Anteis). The aforementioned temporary implants are synthetically produced in the laboratory and are completely identical to the human hyaluronic acid. Fortelis implant consists of the very thick hyaluronic acid and is used for the application in the dermis of the entire face; it was registered in June 2008 in the Republic of Croatia. The augmentation effect usually lasts for 4 to 6 months, depending mostly on the depth of the application, and the effect of Fortelis takes about a year. The shallower the implant is injected, the longer duration of the effect is. It is necessary to emphasize that there are rare individuals with the increased activity of the enzyme hyaluronidase which normally disintegrates the hyaluronic acid. If the preparation of the hyaluronic acid is used to augment the lips, with such patients the duration of the effect will be disappointing (several weeks).

– Long lasting implants – the only registered and available permanent implant in Croatia is Aquamid which consists of hydrogel (97.5%) and polyacrylamide (2.5%). Aquamid persists on the European market for more than 15 years and today is considered to be one of the safest implants. The aesthetic results are superior in comparison to the other methods. The augmentation effect lasts from 7 to even 11 years (recorded). It is expected soon that Aquamid should be registrated in the USA.

The contraindications for the application of the temporary or permanent implants:

Autoimmune diseases (multiple sclerosis, ulcerative colitis, Chron’s disease, rheumatoid arthritis, Hashimoto’s thyroiditis), diabetes, pregnancy, breastfeeding, the presence of any other temporary or permanent implants, the chronic use of corticosteroids or the high dose of nonsteroid antirheumatics.

3. The surgical eversion of the lips is made when we want to augment the projection or visibility of the lips from the front projection. This procedure is indicated with extremely thin lips that are twisted down and toward the oral cavity. Applying its own adipose tissue or implants will not have any result because the lip will anyway be directed down as preoperatively. The aim of the method is to cut a strip of skin around the lips and then connect the edge of the vermilion with the edge of the skin defect, incurred after the skin was cut out. In this way the lip becomes much more apparent when looking from the front and can be additionally augmented with its own tissue or implant. The scar is precisely located on the border between the vermilion and the skin part of the lip, and becomes completely invisible after a few weeks.

The contraindication is a tendency to creating hypertrophic scars or keloids, hemophilia and other similar diseases.

Aquamid in Croatia

Aquamid was registered in Croatia 5 years ago thanks to the initiative of Dr Ostojić who was the first to apply Aquamid in the aesthetic surgery in Croatia. In the past five years more than 400 patients were treated with Aquamid at the “Polyclinic Ostojić”, with the excellent cosmetic results and very satisfied patients, and only one case of lip infection.

Procedure

The first step is preoperative examination where we listen to the wishes of a patient. After that follows a thorough evaluation of the lips. Naturally the lower lip has a bigger volume than the upper lip. The most prominent point of the upper lip lies about two millimeters in front of the most prominent point of the lower lip, and the most prominent point of the lower lip lies 2-4 mm in front of the most prominent point of the chin (normal anatomic relationships). This means that any deviations must be noted on the first examination. Any asymmeteries of the lips must be preoperatively detected and the patient must be warned of their existence. The upper lip is considerably more often aesthetically augmented with Aquamid than the lower lip, because it is anatomically thinner and built more complexly than the lower lip. The upper lips are considerably more varied among the different individuals than the lower lips, which are significantly more similar in  form and volume among the different people. Therefore, the aesthetic augmentation of the upper lip is considerably more demanding and requires greater surgical experience and the feeling for getting the fullness of sensuous lips.

Aesthetic lip augmentation with Aquamid

The first step in a surgical procedure of augmenting the lips is cleansing of the lips and surrounding areas with alcohol disinsept. The face must be thoroughly cleansed, because in this way the risk of the possible infection is significantly reduced.

The picture of the lips before augmenting.

Injecting of the local anesthetic in the area around the lips so that the surgery would be completely painless. It is noticeable that the local anesthetic is not applied directly into the lips, but in the surrounding area so as not to drastically augment the volume of the lips and disable even injection of the implant (Aquamid).

A needle is introduced into the lips parallelly to the edge of the vermilion at the depth of 2 to 3mm, and firstly a tunnel is formed by pulling the needle in and out. Aquamid is applied very easily only when the needle is slowly pulled out. The technique of applying Aquamid is that in one injection Aquamid is injected in several directions in the fan shaped manner, or with as few stitches as possible cover the larger area of the lip (to prevent infection).

Each syringe of Aquamid has a precise scale so that the operator can know exactly how much of an implant he has injected into a particular part of the lip. In this way the possibility for the emergence of the postoperative lip asymmetry is significantly reduced.

Aquamid application in the left half of the upper lip. The same amount that was applied in the right half of the upper lip must be applied to the same places on the left half of the lip. The picture right shows tunneling of the other side of the lip.

After injecting Aquamid it is necessary to check with fingers whether Aquamid is evenly spaced. Given that Aquamid is gel, the lip can be further molded with fingers to achieve the ideal aesthetic result.

The upper lip after augmenting with Aquamid. The swelling of the upper lip that will disappear after one to two days is noticeable. Also, the lack of haematoma immediately after the procedure is evident.

Antibiotic ointment (mupirocin) is coated over the lips and surrounding parts of the face in order to prevent infection. The “Polyclinic Ostojić” prescribes antibiotic ciprofloxacin in the next five days to minimize the possibility for the emergence of infection.

Postoperative period

Swelling and/or bruises last very shortly (1-3 days). It is necessary to avoid the sauna and solarium for the next ten days, and the local cold packs are not recommended either. The patient must put antibiotic ointment with clean hands. Applying make-up is not recommended until at least 48 hours after the application of Aquamid. Patients should not take large doses of nonsteroid antirheumatics (especially Ibuprofen) in the next few weeks. In addition, patients should not take corticosteroids for at least 6 months after the application of Aquamid, and after this period of time, there are no restrictions in getting all kinds of therapy. It is considered that the result achieved with Aquamid is final after 2 weeks, and that the effect lasts for about ten years, sometimes even longer.

Complications

So far only one complication of Aquamid application has been described, and that is a very rare infection. In fifteen years as Aquamid persists on the European Union market, one hundred of cases of infection have been described. In the “Polyclinic Ostojić” we had only one case of lips infection in the last 5 years, compared to over 400 patients which had Aquamid applied. The infection is not life threatening and it does not cause lasting deformities. It is considered that the infection occurs with the transmission of the skin saprophyte (acne propioni bacteria which are the causative agents of acne), located deep in the hair follicle into the deeper layers through the syringe needle, which is used to apply Aquamid. The infection can be successfully treated with the antibiotics, incisions and drainage.

APPENDIX

Surgical eversion of the lips

The surgical eversion of the lips is performed when we want to augment the projection or visibility of the lips from the front projection. This procedure does not augment the volume of the lip. The surgery is indicated if it is the case of extremely thin lips which are facing the oral cavity (in this case, augmenting the lip with Aquamid can not augment the projection of the lip). Patients who do not wish to take the implant because of the various reasons are also candidates for the surgical method of lip eversion.

Surgical procedure

The preoperative marking of the part of the upper lip skin which will be removed. The natural line of the upper lip must be accurately followed.

The application of the local anesthetic so the surgery would be painless.

The completion of the initial incision, which extends along the entire upper lip.

The upper incision is almost parallel with the lower and extends along the skin of the upper lip. The incision is about 1 mm deep.

Cutting out of the skin strip of the upper lip between the two incisions. Only the skin underlying the operating field is cut out, where the muscular fibers of the orbicular lip muscle can be seen.

The strip of skin is completely cut out, and it is visible that the operation is relatively bloodless. The image on the right shows the cut out strip of skin.

Placing the 6-0 interrupted resorbable sutures so that the contours of the new Cupid’s bow of the upper lip would be formed symmetrically (Cupid’s bow has the shape of the letter M).

The right part of the incision is being sewn with the intradermal 5-0 suture. The edges of the vermilion and the skin of the upper lip perfectly stick to one another.

The completion of sewing the incision of the left half of the upper lip.

The projection or visibility of the lips is now significantly higher than before the surgery. The incision between the upper edge of the vermilion and the lower edge of the skin of the lip is symmetrical, with the preserved anatomy of the upper lip. The distance between the incision and the lower part of the nose is naturally long. The scar will be almost indistinguishable in a few weeks, and it will look as a bright rim (halo) around the lip, which is the natural characteristic of the lips in younger people.

On the pictures above the upper lip, which was subjected to the given procedure, is displayed. The upper image shows the upper lip before the specified procedures, and the lower image shows the upper lip after the specified procedures. The upper lip in the picture below was taken a month after the procedure, so it can be expected that the final result will be even better. We see that the lip maintained the natural shape, and the vermilion is drastically increased. Thus the hypoplastic or poorly developed upper lip can be successfully corrected only with the mentioned procedure, because, for example, by applying Aquamid the lips augment, but still remain twisted and turned toward the oral cavity. These lips can be possibly treated further with an injection of Aquamid to get even more beautiful and rounded shape that contributes to the sensuousness of the lips.