Special Feature: Treating the Lips

By Allie Anderson / 01 Apr 2015

Seldom does a week go by when we’re not subjected to media propaganda about lip enhancement procedures. Whether it’s hype about the latest celebrity to appear with a suddenly-plumper pout, or denigration of the trend when something goes publicly wrong; there is no denying that aesthetic lip procedures have received scrutiny unrivalled by other similar minimally invasive treatments. Allie Anderson talks to practitioners about the different ways to treat this area of the mouth

There has been great public awareness of lip rejuvenation procedures since the infamous Leslie Ash case in 2002, which led to coining of the now-familiar phrase ‘trout pout’. The actress had her top lip injected with permanent filler to make it appear fuller, but an allergic reaction caused permanent swelling and resulted in the product fusing with the muscles between her lips and nose.1 While her story is extreme, she was to be the first of many celebrities whose lips have made it firmly into the spotlight. Media portrayal of lip enhancement has a profound influence on its popularity in clinics, in a number of ways. According to a 2014 survey of 1,000 women, 63% would like fuller lips, yet 78% say they would avoid lip fillers due to fear of ‘trout pout’ and the health risks, as well as the cost of treatment.2 On the other side of the coin, fuller lips are constantly presented as desirable and achievable, and the trend for fuller, more defined lips has translated to an increase in the number of lip procedures being carried out in clinics across the UK. “Lips are incredibly popular [as a treatment area] due to the rise of lip augmentation in the media and ‘celebrity culture’. The most common demographic are the budget-conscious young female patients (18-25), who have £150 to spend and request lip fillers to give them a sexy, glamourous pout,” explains aesthetic practitioner Dr Raj Acquilla. As demand has grown, so has supply, adds Dr Kieren Bong, clinical director of Glasgow’s Essence Medical Cosmetic Clinic. “Unfortunately we’ve seen the general public trivialise medical procedures like this and underestimate the risks and the potential side effects,” he comments. “It’s not helped by the fact there are a lot of practitioners who also underestimate the risk and fail to convey it to the general public. The market is saturated with practitioners from all sorts of backgrounds offering non-surgical procedures, so the availability and accessibility means more people are having the treatment.”

Lip treatment also appears to be particularly popular in certain geographical areas, as Dr Lee Walker, clinical director of Liverpool- based B City Clinics, attests. “It’s probably the second-most requested treatment after botulinum toxin, because it’s a unique demographic in Liverpool,” he says. “There’s an incredibly media- driven image that’s projected with young females in the city; when I speak to colleagues around the country, none of them perform the amount of lip treatments that I do.” Dr Walker explains that around 95% of the lip treatments he carries out are to introduce dermal fillers for a plumper and more defined look.

According to Dr Acquilla, age-related restoration commonly involves the following points:

Image courtesy of Dr Raj Acquilla 

  1. Oral commissure: to correct sad mouths and give positivity to the smile.
  2. Lateral upper lip depression: often associated with previous lip filler but also exacerbated by ageing
  3. Vermillion border: to promote eversion and external rotation of the lip and therefore increase mucosal show.
  4. Peri-oral rhytids: erasing lines and wrinkles associated with ageing of the skin and orbicularis oris.
  5. Glogau Klein points and philtral columns: for definition of the apex of the Cupid's bow and philtral concavity.
  6. Volumetry: precise volumetric augmentation to an upper-to-lower lip ratio of 1:1.618, which is commonly distorted by novice injectors.

While lip shaping and augmentation seems to be particularly popular among the under-35s, a proportion of patients undergoing treatment are seeking to address or reverse the signs of ageing. “The lips are a focal point of the face, and our eyes are drawn to this area when we are talking. They are part of the central triangle and can distinguish our age quite easily,” explains Sharon Bennett, independent nurse prescriber and clinical director of Harrogate Aesthetics. “As we age, and through environmental and extrinsic factors, our lips will become thinner and wrinkly, with downturned corners (oral commissures), and lack the shape and support we once enjoyed. The Cupid’s bow drops down and is no longer upright and defined, and the philtral columns flatten.”

Treatment with Juvederm Volbella. After image shows patient two weeks post treatment. Images courtesy of Dr Sarah Tonks.

Dr Sarah Tonks, who practices at Omniya clinic in Knightsbridge, says that lip treatments are often carried out as part of – or as a result of – anti-ageing procedures or treatments to the rest of the face. “I do a lot of whole-face rejuvenation in one appointment with my patients, and when you rejuvenate the whole face this can make the lips appear smaller, as the rest of the face has more volume. I warn my patients of this and tell them they will probably need to do the lips too, although they don’t often believe me until they look in the mirror,” she explains. “A lot of people are frightened of looking ‘too done’, and there is an association that if you have your lips done, you will always look fake.”

To counter this, and to manage a patient’s expectations, it’s imperative to conduct a thorough consultation and to consider the anatomy of the perioral area. “The skin, musculature and even the bone structure change as part of the ageing process,” says Dr Bong. “So, first I have to listen to what patients are hoping to achieve, before analysing the anatomy.  Then, I consult with my patients and make them aware of what’s achievable and more importantly, what’s not achievable, as a result of the constraints of the anatomy.” Similarly, to achieve natural and age-appropriate results when using filler, product choice is important. “We don’t use a one-size-fits-all filler; the problem with doing so is that it could be too heavy for some parts of the face, and too light for other parts of the face,” Dr Bong explains. “We only use lip filler that has been exclusively formulated for lip contouring and enhancement. Within this range, there are different grades – there’s no point giving someone a thick grade of filler who doesn’t want too much treatment. Also, if it’s an older patient, we want to emphasise contour rather than volume, so we’d use a different grade again.” 

The clinician’s expertise and skill play a crucial part. Indeed, practitioners have a duty to guide patients on what to expect, and what outcomes can be achieved with different procedures – and there is often a mismatch between the treatment patients initially seek, and those that are recommended. “Of the 100-120 patients I treat per week, more than half request lip fillers and only 20-30% actually need and receive them,” comments Dr Acquilla. For those patients who do, he uses low molecular weight hyaluronic acid fillers “owing to their excellent tissue integration and soft, natural results at rest and on animation of the lips,” he explains. “In addition, I also complement fillers with fractional CO2 laser resurfacing of the perioral skin to remove pigment and fine textural lines,” says Dr Acquilla. Filler containing hyaluronic acid is a popular choice among many practitioners to enhance and plump the lips, alongside peels and botulinum toxins in the perioral region, particularly to address ‘smokers’ lines’. However, the precise formulation and treatment will depend on the patient and their desired result. Dr Bong says that while a large number of his patients are seeking a plumper lip (to varying degrees of fullness), others are increasingly seeking to reinstate hydration, which is often also a casualty of ageing. “We have a range of products that restore hydration and improve the texture of the lips without increasing the volume,” he explains. “We inject a product that has a concoction of ingredients such as vitamins, antioxidants, and hyaluronic acid, which has a very high affinity for water and attracts up to 1,000 times its own molecular weight in hydration.”

While there are manifold topical products available over every high street counter, particularly aimed at rehydrating the lips, Dr Bong suggests that these do not provide the long-term results that injectable treatments do. “With all our technology, it still has not advanced far enough to produce a topical substance with a small enough molecule that will penetrate the deep layers of the skin and provide sustained hydration,” he says. “Hence, a moisturiser will only work when you apply it and won’t result in any cellular changes that will provide sustained improvement.” Similarly, Dr Tonks says of topical, volumising lip treatments: “It’s like replacing missing teeth with a denture.” It is common, however, to use a topical anaesthetic before treating the lip area, such as LMX 4% (lidocaine). “This is effective at taking about 70% of the discomfort away, and makes the procedure manageable for the patient,” says Dr Walker.

Images courtesy of Dr Kieren Bong

 Alternatively, a dental block can be used to completely numb the area. The lips, though a focal point of a person’s face, are of course one part of the whole canvas. As such, it’s important that patients are made aware that treating the lips in isolation without attending to the facial and labial skin may well have inadequate results. According to Bennett, addressing the skin of the lips before undertaking a procedure is important. “If there is any evidence of ageing, [tackling the skin] can improve the lip itself greatly and reduce the need for significant work,” she says. “Also, if you only treat the lip, but the surrounding skin is aged, sagging and wrinkly, lacking support and structure, then the lip will probably look somewhat incongruous and very evident. A young- looking plump, hydrated and shapely lip surrounded by a wrinkling face and mouth can look odd. It will not make the patient look particularly younger if the lip is the only area on an ageing face to be treated.”

The lips, though a focal point of a person’s face, are of course one part of the whole canvas 

A holistic approach should be taken to halting or reversing the effects of ageing – and that, according to Dr Bong, ought to incorporate a number of factors. “Emphasis should be on the canvas of the face, which is the skin, because it’s part of looking good that we have radiant, healthy looking skin,” he comments. “Ageing is a multi-faceted, multi-factorial process,
and you need to look at ageing in its entirety. To achieve a natural result, we need to look at everything simultaneously, including hair, teeth and skin.”
As such, patients who seek and undergo procedures on the lips should also be given guidance on the how the area will look against the backdrop of an untreated face, and how treating other areas around and beyond the lips could enhance the overall result. In addition, patients having lip treatments should be encouraged to support good skin health through protecting against sun damage, topical application of antioxidants, retinoids and peptides, and maintaining a good daily skincare regime.

Image courtesy of Dr Kieren Bong

Different cultures and ethnicities have conflicting perceptions of beauty – including what is considered both attractive and undesirable in terms of the lips and mouth. Dr Walker’s mostly white European patients in Liverpool seek a very noticeably enhanced lip. Similarly, practicing in a northern spa town, Bennett treats a high proportion of Caucasian men and women. “The majority of patients are looking at a one third to two thirds [upper-to-lower lip] ratio, which we can measure,” she comments. “Younger women often want to emulate the look of a particular reality TV star or celebrity – Kylie Jenner is very ‘of the moment’ – and they tend to prefer an almost 50/50 ratio. We have few men requesting lip treatments and those who do are not often wishing to have anything noticeable to others.” 

Dr Tonks, on the other hand, has a lot of Arabic patients, and reports that their preferences are quite different, as is their tolerance to more product and the way she approaches lip treatments. “Patients from the gulf have naturally larger lips that can absolutely eat product,” she says. “You can easily use 2ml in a patient in one sitting if they are after something glamorous. They don’t have the problem that Caucasian patients often do, with very thin, almost non-existent upper lips, which are very hard to do that with in one treatment sitting.” Bennett adds that Arabic patients don’t like a wide mouth look, which can be the result of filler injected under the oral commissures to elevate them. People from African Caribbean backgrounds also tend to have fuller lips, and often prefer treatments concentrated on definition at the corners of the lips, says Dr Bong, while in the Asian community, the perception of beauty is more focused on the shape of the face. Religion and culture also have an influence, with some patients reluctant for friends and family to know that they have had treatment due to a negative perception of cosmetic interventions. “Therefore, it’s much more common that they want treatments performed in stages and a result that is much more natural and subtle” he adds.

In order to fulfil each patient’s cultural and personal requirements, a thorough understanding of both is necessary. Dr Acquilla comments, “I travel all around the world teaching injection techniques in different genetic backgrounds. There is definitely a strong link between genetics and aesthetics, such as strong lips in the Middle East and Asia with deficiencies in Caucasian populations. The key to success here lies in accurate assessment and treatment of the whole face in good balance and proportion.” Despite its share of negative press, the case evidently remains that lip treatment is growing in demand. Mass marketing has created the illusion that lip augmentation is a quick and easy way for people to conform to the latest beauty fad with few consequences. This is perpetuated by a concerning trend in such procedures being offered at discounted rates or as prizes. The Keogh Review described such advertising practices as “socially irresponsible” and recommended they be “prohibited by the professional registers’ code of practice”,3 but unless these recommendations are wholly embraced by the aesthetics industry, patients are potentially being put at risk. Practitioners must ensure they market and perform treatments ethically, embracing the Keogh recommendations rather than just paying them lip service. 

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