Many practitioners have faced the notoriously difficult ‘M-shaped’ lips. I myself see this lip shape regularly, however there is limited literature on these types of lips and little guidance on how to treat them successfully. I have found that because of this, some practitioners dread treating ‘M-shaped’ lips, or have been unable to meet the expectations of their patients.
How the ‘M-shaped’ lip presents
Although there are varying degrees of severity, I find this lip type classically presents in the upper lip with a dominant medial tubercle and thin, inverted lateral tubercles. In addition, the difference in vertical height between the upper and lower lip is usually far greater than the ideal 1:1.6 in Caucasian youthful lips.1,2 In my own personal experience, I have found that in the most severe cases, these patients also present with elongated philtral columns, as well as downturned lips.
Treatment
‘M-shaped’ lips are objectively difficult to treat. Given how thin the lateral aspects of the upper lip are, it can be difficult to volumise these to match the medial tubercle’s height. In my experience, practitioners tend to struggle when a simple linear threading approach is used. By dispersing product evenly across the vermillion border and body of the lip, the ‘M shape’ is simply volumised, rather than corrected. I have found that the key to a successful treatment is ensuring absolutely no product is placed in the medial tubercle and that the lips are treated over several visits, over a prolonged period, to gradually expand the lip tissue. Literature supports the concept that results can be enhanced by conducting treatments over a period of time.3
Given the length of time it takes and difficulty in completing an ‘M-shape’ treatment plan, it is paramount at the consultation stage to manage your patient’s expectations.4 Your patient truly needs to trust you as a practitioner and the journey required for this process. In my experience, between two to five treatments spaced at least four to six weeks apart (or ideally longer) are required for correction of the ‘M-shape’ lip. Increasing the interval between appointments allows for the filler to fully integrate into the lip tissue.3 Patients need to be aware of this from the outset to avoid disappointment early in the treatment plan and to budget for full correction.
All lips are subject to high shear forces; hence it is imperative that a soft product able to adapt to these forces is used so the lips can move normally and not look stiff.5 Although practitioners may be tempted to use a more volumising product to achieve results sooner, I would advise a softer product with a slow approach, over multiple sessions, to reduce chances of lump formation or migration of lip filler.6 Although this applies to all lips, in my own experience this is even more important in ‘M-shaped’ lips. As the upper lip is exceptionally thin laterally, for successful treatment, a soft product that can slowly expand the lip will volumise the lateral upper lip, whilst greatly reducing the risk of migration above the lip.
Case Study
Consultation
A 23-year-old female presented to the clinic with concerns about her lips. She felt her upper lip was considerably smaller than her lower lip and that the sides of her upper lip were thin and curled inwards. Upon assessment, it was clear that the patient presented with a classic ‘M-shaped’ lip.
I started the consultation by carrying out a thorough medical history. The patient was fit and well, with no known allergies and had no history of previous aesthetic treatment.
I then gauged the patient’s aesthetic expectations for her lips. The patient described herself as having thin lips and wanted to increase the volume of her upper lip so that it better balances her lower. I made the patient aware of the difficulty in treating this lip type and that for full correction, treatment would require multiple sessions over a prolonged period. I told her that I estimated that for full correction, this patient would require three to four sessions over a course of six to eight months. The patient was happy with this and expected a gradual improvement over time.
Product selection
I chose to use to use STYLAGE Special Lips because, in my experience, at 18.5mg/g concentration, the product ensures a soft looking result comparable to natural lips, yet can still provide enough elasticity and volumisation to correct the deficiencies in the patient’s lips. The addition of the antioxidant mannitol also reduces the post-operative swelling and degradation of the product.7 Alternative low density products such as Juvéderm Volbella, Teosyal RHA 2, Belotero Balance and other comparable products may also have been used.
Treatment
I carried out the treatment over two sessions. Before commencing each one, I cleaned the lips thoroughly with Clinisept+ and applied LMX topically for anaesthesia. I used 1ml of STYLAGE Special Lips during each appointment with the 30 gauge needle supplied with the product. To treat her lips, I used a combination of vertical threads (tenting technique) into the lateral tubercles of the upper lip and linear threads. Placement was superficially into the subcutaneous tissue.
In the first treatment session, in the areas that were deficient in the upper lip, I used several overlapping vertical threads through the vermillion border and tented upwards to both increase the vertical height of the lip and fill the curved border of the inner lip. The vertical threads were stopped short of the dry-wet border to reduce the occurrence of lumps.
The first entry point was through the peak of the Cupid’s bow, however care was taken to make sure the thread was lateral to the medial tubercle and no product was placed medially.
Multiple vertical threads were placed through single entry points in a fanning method, to reduce trauma to the lip. I did not place vertical threads through the entire width of the upper lip, stopping short by about 5-10mm of the oral commissure. Again, this was to ensure the ‘M shape’ was not enhanced and only the deficient areas just lateral to the medial tubercle were volumised.
To complete the upper lip, I placed linear threads along the vermillion border medial to the peaks of the Cupid’s bow and medial to the oral commissure, where no vertical threads were placed. This was to ensure uniform definition along the upper lip.
In the lower lip, no vertical threads were placed as I did not want to alter the height of the already dominant lower lip and nor did I want to widen the lower lip, which is often seen as a less aesthetically pleasing result.8 In the lateral aspects of the lower lip, there was a deficiency in volume. I chose to place linear threads here to gradually increase the volume and maintain the central roundness of her lower lip. To complete the lower lip, I placed small linear threads along the vermillion border to enhance its definition. I changed my needle four times throughout the treatment to reduce pain due to multiple thread placements.
At the end of treatment, I massaged firmly to ensure the lips felt smooth throughout and no lumps could be palpated. I then cleaned the lips with Clinisept+ and applied Derma-Seal to reduce the chances of infection.
The second treatment would normally be scheduled for four to six weeks later; however, due to COVID-19 there was a three month delay. Despite this, I believe it aided in the success of her result as the filler had more time to integrate into her lip and the lip tissue had also expanded and became more amenable to the filler. Although the ‘M shape’ remained, we were already prepared for this and embarked upon the second stage of treatment.
Again, 1ml of STYLAGE Special Lips was used, however I did not place my vertical or linear threads through the vermillion border; instead, I placed them just inferior. This is because the border was already defined from our previous session, and I did not want to run the risk of overfilling a delicate structure and causing migration of the lip filler above.
The result immediately after our second session showed an improvement in volume and height of the upper lip. The ‘M shape’ of the upper lip had mostly been corrected, with an increase in volume in the lateral tubercles. The ratio between the upper and lower lip also improved. A further improvement was in the length of philtral columns, which considerably shortened, producing a more attractive and youthful appearance.8
Although the shape and volume had improved dramatically, there is still room for improvement as there is some lateral deficiency, so we have planned for a further session to correct this area in no sooner than three months. I also warned the patient that her lips were currently swollen and once the inflammation subsides and the filler integrates fully, the ‘M shape’ may remain in part, hence will require follow-up treatment. Despite this, once the swelling had fully subsided three weeks later, the patient expressed her sincere happiness and gratitude for the treatment and was elated with the result, which had far exceeded her expectations.
Conclusion
Lip filler can be used to improve an ‘M-shaped’ lip by adding vertical height to the lateral aspects of the upper lip. I encourage practitioners to take care and use a slow approach with a soft product over multiple sessions to ensure the lip tissue gradually expands, minimising the risk of lump formation and migration of lip filler. If practitioners feel they do not have the skills to treat this lip type, I suggest further practical training in lip augmentation, or refer to more experienced clinicians.
