Independent nurse prescriber Melanie Recchia details the reasons for treating the cupid’s bow and philtral columns while considering the natural lip shape
Lip augmentation remains one of the most favoured dermal filler treatments in most aesthetic clinics. However, the focus is now more on shape than size.
Popular in all age groups, patients seek lip treatments for several reasons. The ageing patient who is witnessing changes, such as loss of volume and definition at the vermillion border, will want to restore the lip to its more youthful appearance. In contrast, the younger patient may want to obtain a poutier appearance influenced by current trends, social media or celebrity styles.1
However, the industry has progressed from solely volumising the lips – practitioners now focus on the natural features and contours of the lip.
Our lip shapes are determined before birth, with three distinct sections or subunits in the upper lip and two in the lower lip. These develop and join at the midline in the embryo stage, between four and seven weeks of pregnancy.2 No two people’s lips will be alike, even identical twins, who will have similar lip shapes but unique lip print patterns.3
According to a study of 40 sets of twins (23 non-identical, 17 identical), undertaken by Thakur et al., the shaping appears to be inherited from each parent.3 Thakur et al. noted that the centre portion of the lips was similar in both sexes, and the upper lip was generally more hydrated than the lower.3 These lip print patterns tend to change with age, together with the appearance of wrinkles on the adjacent skin, a thinning of the lips and a loss of volume. The lip definition diminishes, with the lip height decreasing and the intercommissural distance increasing.4
The lips are one of the most prominent and individual features of the face. Together with the eyes and nose, the lips create the triangle of beauty – the anatomical areas which draw attention and convey attractiveness by their symmetry and proportion.5 Lip attractiveness is determined by the combination of definition, volume and proportion, with just a few millimetres making a difference. Plastic surgeon Sito et al. discussed the idea that although the lips occupy a relatively small space on the face, they are in fact a focal area of beauty.6
When treating the lips, practitioners need to have a detailed understanding of lip anatomy, as well as the ageing process, highlighting how this affects the appearance of the lips (Figure 1). The vermillion border defines the lips; this is where the red vermillion joins the surrounding skin.7 The centre of the upper lip contains the double curve, known as the cupid’s bow.8
The Glogau-Klein (GK) points are the peaks of the bow which adjoin with the philtral columns. These are raised vertical ridges that connect to the base of the nose at the columellar, with the oral commissures located at the corners of the mouth.7 A fleshy protuberance at the centre of the upper lip is the labial tubercle, sitting between the upper bilateral tubercles – two fleshy tubercles or cushions to the lower lip.7 When treating the lips, we need to be respectful of these different subunits and consider the natural features in order to maintain and enhance these rather than over inflate them and loose the natural shape.7
The most notable change in the lips is with the upper lip becoming thinner, flatter and more inverted. This change tends to show a significant difference between 20-30 and 65-80 years of age.9 Much of this development is due to bony and dentition changes, with a reduction in anterior tooth show, further diminishing the impact of the smile.9
Aesthetic practitioner Dr Lee Walker has noted that approximately 53% of the external appearance in the perioral area is attributed to the internal structures.10 Density in the alveolar ridge is lost with age, with bone resorption accelerated if there are missing teeth or implants, and age-related tooth wear further reducing support to the lips. As a result, the cupid’s bow and philtral columns flatten and widen, becoming less defined.11 Along with the drop of the oral commissures and pull of the depressor anguli oris, the mouth can take on a downward curved, pinched and sad look.12
Whatever the reason for patients seeking lip augmentation, there are numerous methods for creating an improved or augmented lip shape. Most practitioners will follow various rules of proportion, or parameters that are commonly based on the golden ratio or phi.5 The aesthetic lip position can be measured on the E Ricketts, Steiner or Burston lines (Figure 2), as discussed by researchers Ng et al.13
When planning the lip treatment, a full facial assessment and soft tissue analysis should be made of the current features. Good photography is essential, as often patients will not be aware of a specific feature of their natural lip until they examine their lips post-procedure. A discussion should take place with the patient to ascertain their personal expectations, enabling the practitioner to guide the patient on what is achievable. Often, what the patient perceives as big or small may be different from the practitioner’s own ideas, so it’s important to manage expectations accordingly and decline treatment if necessary.
Treatment of the cupid’s bow, the double curve at the centre of the upper lip and the philtral columns can either result in a beautiful and natural lip or can appear false and overinflated if overtreated. If treated incorrectly, it may even affect the seal of the lips and speech.
Proper training and anatomical understanding are crucial for minimising risks due to the high vascularity in the perioral area.
The blood supply to the lips is provided by the inferior and superior labial arteries, which branch from the facial artery. These vessels run at varying depths through the body of the lips.13,14 Cadaver and ultrasound studies also show a considerable variation in the path of these vessels.14,15 Some showed the facial artery bifurcating into the lateral nasal artery and superior labial artery at the angle of the mouth, and other variations were noted. In one study for example, the facial artery became an angular artery after branching off into the superior labia artery, and the lateral nasal artery then branched off from the superior labial artery.14
However, anastomosis between branches was seen in the upper lip, columella base and nasal tip in another paper.13 Several variations of the columellar arteries have also been noted including evidence of a single artery, a forked artery or double arteries, which run directly up the philtral columns at varying depths.16
Based on my experience, a needle is more precise than a cannula for sharp, defined results in treating this area. In my technique, I insert the needle at the GK area, pinch the skin into a tunnel shape, and place a linear retrograde filler thread. A small amount of filler at each peak lifts the GK points, enhancing the cupid’s bow.
The ideal shaping of the cupid’s bow for many patients would be the ‘rose bud’ lip, seen on babies and young children. In youth, the fullness develops from the centre of the lips.8 The distinct philtral ridges/columns from the GK point up to the columellar, and the depression between is known as the philtral dimple.8
To define the bow more, I inject a short linear thread one needle length from the peak. The needle is then inserted into the vermillion border to reach the peak, with a small bolus delivered before linear threading laterally. The double curve at the centre of the bow (the philtral dimple) is treated to further define the bow. This is approached from the centre of the bow with the needle advanced up and towards the GK point to one side. A small bolus is delivered before running the linear thread back to the centre point, which is repeated into the other side. By treating the area in this direction, the peaks are further enhanced. Some practitioners choose not to treat the cupid’s bow or the philtral columns as some suggest that creating a philtral column can risk an unnatural look.
A neuromodulator can also be used in this area to create the ‘lip flip’.18 From my experience, this works well in a lip that has a slight eversion, as relaxing the orbicularis oris muscle with toxin can enhance the everted direction of the upper lip. For a lip that it is thinner and flatter, it appears to have little effect, and could exacerbate the heavy lip by creating a flaccid upper lip.
The patient must be warned of the potential for affecting the function of the lip. For example, the lips may not seal efficiently with some sounds and pronunciation being affected.17 My personal technique is to place the toxin in two points either side of the philtral columns but not further lateral than a line from the alar triangle. The needle is introduced directly into the vermillion border to a depth of 2mm, and one unit is deposited. The lip lift can further be enhanced by injecting the depressor septi nasi to elevate the tip of the nose slightly. A quantity of two to six units is usually all that is required.
Treating this area has the potential for significant side effects and complications. Not just the cupid’s bow and philtral columns, but the entire perioral area. Bruising is the most common side effect, and I advise my patients to avoid having filler treatment within two weeks of special occasions.18 Herpes simplex outbreak can be triggered by having lip fillers in those with a history.18 Bacterial infection is rare, but is always possible any time the skin is broken with a needle. Therefore, scrupulous hygiene must be adhered to.18 A vascular occlusion (VO) is another potential complication which may arise due to the vascularity in this area.19
The practitioner must be aware of the signs and symptoms of various complications and can deal with any adverse event or side effect, from hand holding and advising the patients about bruising, to being able to treat a possible VO. A referral pathway should be implemented if you need additional help from another practitioner.
Providing lip augmentation can be a satisfying procedure for both the practitioner and patient. It takes skill and artistry to create a natural but aesthetically pleasing lip shape. Nevertheless, practitioners must not forget that this is an area of high risk in terms of adverse incidents. The injector should be aware that if the patient has never had a defined philtrum, one created through an injectable procedure may look out of place and advise the patient appropriately.
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