Introduction

The lips and eyes add to the attractiveness of the face. Full lips are a sign of a youthful, more beautiful lower face, but thinning of the visible red lip is a sign of natural aging.

Full lips that are evenly and naturally plump are a facial feature that many people seek, but not everyone is fortunate with full lips. The good news is that nothing is impossible in today's technologically advanced society.

Photodamage, genetic factors, and smoking all contribute to the decrease of lip volume, perioral rhytides, and mentolabial fold prominence over time. Lips that are genetically thin or have cosmetic asymmetries can be treated in the same way, with soft tissue augmentations utilizing fillers. The use of a sophisticated combination of technologies and injectables is required for perioral rejuvenation to be successful.

Lip augmentation using dermal fillers, such as HA, needs careful administration of an appropriate injection method to optimize the cosmetic effect. Furthermore, attaining cosmetic goals with low risk of adverse effects necessitates a thorough understanding of lip architecture and function, clinical expertise with a variety of injection methods, and a tailored treatment plan.

Anatomy

Lips are divided into two parts: "red" and "white."  The upper lip extends inferiorly from the free edge of the vermilion border to the nasolabial folds and superiorly from the base of the nose to the nasolabial folds. From the superior free vermilion border to the commissures and jaw, the lower lip expands superiorly, laterally, and inferiorly. A small line of pale skin around the circumferential vermilion/skin boundary highlights the color difference between the vermilion and normal skin.

Skin laxity associated with age causes the cutaneous part of the lip to extend, as well as the visible mucosal surface to shorten and the lip to flatten overall. The vermillion inverts, resulting in less pouting of the lips. In comparison to the larger, pouty, young lip, the lips of advanced age have a two-dimensional, flattened look. The three-dimensional structure of youth is reestablished when volume is restored. Because it is less susceptible to shrinking over time, the lower lip is less typically thin in isolation.

However, what exactly is lip augmentation, lip fillers, and plumping? What do these processes involve?

Lip Augmentation

Lip augmentation is a sort of medical cosmetic treatment that aims to modify the look and contour of the lips to a large extent by enhancing their "fullness." It may be done in a variety of methods.

• Lip augmentation is most commonly used to treat hypoplastic lips, which might be age-related or not.
• Lip augmentation is becoming more popular as a result of increased media exposure and consumer demands. Several procedures can be used to provide temporary results, but a new treatment involving the implantation of a lip prosthesis that provides a permanent outcome is gaining popularity. As a result, the implantation of a solid lip prosthesis is a breakthrough in esthetic medicine and surgery. 
• Lip augmentation improves the dimensional connection of the lips to the patient's face by enhancing vermilion height, producing a pout (effacement), smoothing perioral creases and wrinkles, adding volume, and decreasing excess visible teeth.
• Previously, choices were restricted to a few filler substances and a few surgical procedures. Today, new filler solutions are quickly evolving and becoming available to surgeons, and they are frequently directly promoted to patients through multiple media channels. Tissue grafts and autologous fat grafting are also expanding surgeons' choices for lip augmentation, which were previously limited.
• The ideal lip augmentation surgery should provide aesthetically attractive, natural-looking and feeling results, be reversible and/or replaceable, adjustable, and have a low complication rate.

Lip augmentation methods

1. Lip fillers, which include injecting dermal fillers into and around the mouth, are the most popular method of lip augmentation. These fillers include hyaluronic acid, a naturally occurring chemical that aids in the volume development of the lips. Most plastic surgeons currently utilize filler with hyaluronic acid injection as the principal agent for lip augmentation.
2. While lip filling is a temporary procedure, lip implants are a more permanent alternative that involves the use of soft but solid silicone implants shaped like real lips. Then there are fat grafting and tissue grafting procedures to consider. Let's take a closer look at each of these techniques.

Lip Fillers:

The lip fillers are temporary, requiring repeated injections at several month intervals to sustain lasting results. There are numerous different forms of fillers, but the two most common ones are hyaluronic acid (HA) and polyacrylamide (PA). The most common is HA, a naturally occurring chemical in the body that aids in volume gain.

Various temporary and permanent fillers have been used to shape the lips, with positive outcomes. Granulomas have been documented with both temporary and permanent fillers, with the latter being more common.

The effectiveness and safety of HA fillers are well demonstrated by their widespread use and published reports. They're an important part of any successful combination therapy for the aging face and lips.

Lip filler augmentation is an in-office surgery that takes approximately 15-30 minutes and allows you to return home the same day. It's also a short-term treatment, lasting only six to eight months.

What to treat?

The most prevalent complaint is deflated vermilion (the red part), followed by drooping angle of the lips. Together, they complete the sorry face image. Lips with a lot of volume can be defined and injected into the white edges to make them look bigger (the vermilion border)

The upper lip is usually treated more frequently than the lower. The optimal technique to lip augmentation is determined on the defect's type and the subject's cosmetic goals. Structured augmentation with a deeper-placed filler followed by volume correction with a surface filler is excellent for genetically thin lips.

Female lips are somewhat fuller than male lips on average. They protrude forward somewhat more than male lips, making them slightly more "pouty." When viewed from the front, female lips are not significantly larger, but they do protrude forward more when viewed from the side. When treating male and female lips, we must keep this in mind. Overvolumization of the male lip might result in the region becoming feminized.

It's also crucial to examine the anatomical link between lip height and incisor, as well as potential maxillary hypoplasia and protrusion, as well as the patient's occlusion status.

Treatment Techniques

It's crucial to avoid distorting the lips' form. The injection discomfort is reduced by using premixed HA with lidocaine as an add-on. Some patients may be concerned about the degree of swelling and bruising, and may require cold baths, nonsteroidal anti-inflammatory medications, or even prednisolone to relieve their discomfort.

Hyaluronic Acid Filler Benefits

Hyaluronic acid fillers have several advantages:

• Hyaluronic acid fillers stimulate new collagen, give volume and soften fine lines.
• Hyaluronic acid represents a natural component of the connective tissues, related to wound healing and skin regeneration.
• The clinical and histological findings suggested that cross-linked hyaluronic acid represents a safe and effective tool for lip augmentation.
• The doctor can control the volume of substance injected, and thus control the lip volume.
• Injections can be staggered till desired results achieved.
• Lumps created by lip movement can be dissolved easily.
• Bruising is less compared to other dermal fillers.
• Reasonably lasting results, though not permanent.
• An allergic reaction is unlikely as hyaluronic acid fillers are made from substances similar to those found in the body. But the doctor should be told if you are allergic to lidocaine.

Patient selection and outcomes

A comprehensive consultation explaining the advantages, limits, and adverse events of lip reshaping goes a long way toward achieving the desired outcomes. Because many patients are secretive about their operations and do not want to disclose any therapy received, discussing the immediate aftermath of a lip augmentation, that is, swelling and bruising, is an important part of counseling.

Downtime, which can last anywhere from two days to two weeks, must be addressed; the recent use of cannulae rather than needles has helped to decrease it. What the patient wants might not be really possible, therefore it's important to set expectations for them.

The doctor will evaluate the symmetry and contour of your lips, as well as your overall facial balance, throughout the lip filler augmentation procedure. It is then determined which regions of the lips need to be plumper and fuller. Fillers are then injected into the upper or lower lips, or both. The filler's gel supports and shapes the tissues of the lips.

Lip Implants

Implants, a more permanent alternative, are placed beneath the lip fat and above the lip muscles in a narrow tunnel created by the surgeon to fit the implant. Typically, surgeons make incisions at the corners of the mouth, but depending on the method, they may pick another location on the lips.

A lip implant aims to restore a more youthful and aesthetically pleasing look to the perioral region

The most common forms of lip implants are GORE-TEX, SoftForm, and AlloDerm. This in-office treatment takes around 30 minutes to perform, and you are then sent home the same day.

Areas of the lip/peri-oral region addressed with lip implantation :

• Decreased vermilion height
• Decreased pout (lack of effacement)
• Perioral lines and wrinkles
• Decreased volume (fat and muscle atrophy)
• Excess visible dentition

Though various implant materials have been utilized, there are now several types of implants that can be used safely, depending on the surgeon's and/or the patient's preferences.

 A. Autogenous Implants

• Fat - Commonly collected concurrently with face, neck, or body liposuction, the fat is typically placed through injection or cannula method, similar to filler augmentation.

NOTE: Because of its unpredictable absorption/survival rate, fat augmentation may cause persistent swelling, asymmetry, or a nodular appearance ,especially in mobile areas such as the lips.

• Superficial musculoaponeurotic system (SMAS) – harvested during a concomitant facelift
• Postauricular fascia – temporalis muscle fascia
• Scar tissue (previous facelift/neck lift scars)

B. Alloplastic Implants

Lip augmentation using alloplastic implants is a cost-effective, long-lasting, and aesthetically attractive lip augmentation procedure with little side effects when compared to repeated injectable filler treatments.

• Extended polytetrafluoroethylene
• Silicone – commercially available in three diameters (3, 4, and 5 mm) and three lengths (55, 60, and 65 mm). The 4-mm-wide prosthesis is the most often utilized standard size in practice.

To optimize cosmetic outcomes and reduce problems, the surgeon must be cautious in selecting the appropriate implant size. To begin, measure the distance between the commissures of the wet-dry lip with the lips slightly parted using a conformable ruler (e.g., a paper ruler).

NOTE: Do not measure the patient's lips when the patient's mouth is open. The ideal prosthesis length is few millimeters shorter than the commissure-commissure distance. It is fairly unusual for upper and lower lip implant sizes to differ due to the curved curvature of the top lip compared to the bottom lip.

Implant Benefits

The main advantage of permanent lip augmentation is that it is permanent. This technique has a longer duration of action than temporary fillers, which are eventually eliminated by the body. Apart from offering permanent lip augmentation, the effects are more polished than dermal lip fillers, making them an excellent choice for people with thin lips.

Contraindications of Lip implants

First, lip implants will not fix pre-existing lip asymmetry, which is best addressed with fillers such as hyaluronic acid.

Second, “razor-thin” lips, where inadequate tissue or vermilion show may prohibit even the smallest (3 mm) alloplastic implant from fitting, are a relative contraindication to lip implants.

In patients with thin lips, the implant may become apparent due to severe mucosal distension, or they may be at higher risk of extrusion or infection with typical postoperative lip movements. If a patient wants lip augmentation with alloplastic implants but has an abnormally long white lip and thin red lips, the surgeon should first conduct a lip lift and/or mucosal advancement surgery 3 to 6 months before lip implantation.

Preparation for Lip implants

• Medications

As with other cosmetic treatments, patients are instructed to abstain from smoking and using any blood-thinning medications for 1 to 2 weeks prior to the operation. Some surgeons will prescribe antiviral medicine one day before surgery and for ten days thereafter to avoid posttraumatic herpetic lesions, especially in patients with a history of zoster/shingles.

• Marking

To begin, the surgeon must measure the lip to ensure proper implant size; the measurement is taken from the oral commissure to the oral commissure along the wet-dry junction of the red lip. Too-short implants will have visible tapered ends just shy of the commissure. The red lip's wet-dry junction should be marked to ensure a consistent dissection pocket.

While lip implantation may be done under general anesthesia, most surgeons prefer to do it under local anaesthetic.

Complications of Lip implants

Lip implants are a long-lasting, low-risk alternative for lip augmentation with high satisfaction rates; nevertheless, patients who have lip implantation should be informed of the possible hazards, which include:

• Malposition (7 to 10%):

Malposition is the most prevalent consequence of lip implantation, which is most likely caused by uneven tunneling in the submucosal plane or asymmetry in insertion.

• Extrusion (less than 1%):

If there is significant asymmetry and wound collapse, an implant may extrude. This extrusion can be avoided by utilizing the correct size implant, keeping good dissection planes, preserving a small/narrow submucosal pocket, and closing the commissure incisions with excellent suture technique.

Note: For the first several days following implantation, instructing the patient to avoid excessive manipulation of the implanted region (e.g., chatting, chewing, massaging) may also assist prevent malposition/extrusion.

• Need for revision/size adjustment (1 to 10%)
• Capsular Contracture (1%):

Expanded polytetrafluoroethylene implants, in particular, have been found to shrink and contract with time, resulting in an uneven and frequently asymmetric shape. As a result, their use has mostly fallen out of favor.

• Infection (less than 1%):

Infection is uncommon, but it can occur with any type of implant; it is generally treated with systemic antibiotics, but it may necessitate implant removal if the infection is severe.

• Dissatisfaction (1%)
• Prolonged edema and ecchymosis (majority resolves between 1 to 2 weeks)

Fat, Tissue Grafting

• A third approach, known as autologous lip augmentation, involves utilizing your own fat and tissues to give volume to your lips. This treatment, like the prior two, is performed in the doctor's office. Fat grafting includes the harvesting of fat from your abdomen. The operation, which is done under local anesthetic, lasts around 60-90 minutes. Lips enhanced with fat retain their plumpness for at least five years.
• Tissue grafting includes the use of dermis or a deeper layer of skin, often from the abdominal wall or scalp; however, the tissue is sometimes taken as a byproduct of another procedure (abdominal reduction, breast reduction, and face-lift). This takes around an hour as well, with benefits lasting up to five years.
• A simple approach for lip augmentation using autologous fat is demonstrated. Local anesthetic is administered into the regions used for fat harvesting as well as the perioral locations that will receive the grafts. The fat is extracted using a large needle and syringe, washed on mesh gauze, put in the syringe, and injected into the lip tissue.
• The strained fat is deposited in horizontal tunnels within the lips via multiple passes with a small needle. Subsequent injections are given every 3 months at the very least. Lip swelling is temporary, and permanent lip augmentation develops after two to three grafting treatments.

Lip fillers are the least expensive choice, while fat and tissue grafting treatments are the most expensive. In all situations, a change is immediately noticeable.

Although the lips should feel natural after healing, it is best to avoid using lipstick or similar cosmetics following the surgery. One of the primary advantages of these two operations is that because the fat or tissue is removed from your own body, you are unlikely to develop an allergic response or reject the tissue.

Choosing Your Doctor

Choosing the proper surgeon is a crucial factor when considering lip augmentation. You must locate a competent doctor who is particularly skilled at delivering injections. This is due to the fact that it reduces the chance of disfiguring your lips and face.

Lip augmentation can be performed by a variety of professionals, including plastic surgeons, dermatologists, and cosmetic face surgeons. How do you choose who to visit?

When it comes to selecting the appropriate surgeon, the doctor's training and education, the number of surgeries they have done, and if they are a certified member of the specialty's medical association all play a role.

The Prerequisites:

While the doctor can advise you on the best lip augmentation choices, you must be honest with them. As previously said, if you are allergic to lidocaine, tell the doctor before to the surgery. The same is true for any other known allergies, current medicines, including prescription and over-the-counter pharmaceuticals and vitamins, and any previous cases of oral herpes.

In the case of current infections, the operation is not recommended if you have oral herpes, diabetes, lupus, or blood-clotting problems. To undergo lip augmentation, you must also be in good physical condition and a nonsmoker.

Post procedure outcomes

Edema, bruising, and ecchymosis are all possible side effects of lip augmentation surgery. Nodules and lumps can be massaged in or eliminated with hyaluronidase injections, although these are exceedingly unusual complications. Although intravascular injections might cause rapid blanching, the lips' collateral circulation is forgiving. Warm compresses, hyaluronidase, and topical nitroglycerin are effective treatments. Oral antivirals are effective in preventing herpes reactivation (acyclovir, famciclovir or valaciclovir)

If the product is injected too deeply, it can cause beading, but if it is injected too aggressively, it can cause irregularity or lumpiness.

Conclusion

Lip augmentation is a cosmetic procedure that may make your lips fuller and plumper. Lip augmentation using an injectable dermal filler is now the most used procedure. Lip augmentation with injectable fillers produces rapid results with little downtime. Lip augmentation with fillers can be accomplished by injecting the material into any or all of the anatomic sections of the lip, resulting in a fairly regulated and predictable outcome. One of the most widely utilized fillers is HA.