The Good, the Bad, and the Ugly

One of the most common complaints I hear are about lipstick lines that radiate around the lips. This is usually followed by "and I never even smoked!" The causes of lipstick lines and loss of lip volume are several: loss of soft tissue and bone with chronologic aging, sun damage causing breakdown of elastic and collagen fibers, and repetitive muscle action. And, of course, smoking worsens all of these by both the direct toxin effect on the tissue and the habitual pursing of the lips.

One of the most common complaints I hear are about lipstick lines that radiate around the lips. This is usually followed by “and I never even smoked!” The causes of lipstick lines and loss of lip volume are several: loss of soft tissue and bone with chronologic aging, sun damage causing breakdown of elastic and collagen fibers, and repetitive muscle action. And, of course, smoking worsens all of these by both the direct toxin effect on the tissue and the habitual pursing of the lips.

The deeper the lines are around the mouth and the more the mouth sinks inward, the more aged you look. Additionally the muscle in the chin often becomes hyperactive and pushes the center of the lower lip upward and the corners downward. You see this most prominently in women with dentures but it occurs with most people as they age. Botox treats this very effectively with as little as 5 units per treatment.

Filler treatment of the lips can be very effective, but it is also the area where improperly done treatment has the potential to make you look worse. I used to get “don’t make me look like Goldie Hawn in First Wives Club”, then “don’t make me look like Angelina Jolie”, now “make me look like Angelina Jolie.” News flash—there is not enough filler on the planet to make you (or me) look like Angelina Jolie.

But there are some basic rules that should be followed. Remember these are IMHO, your doctor may feel differently:

  • Lip augmentation should look as natural as possible. You are not a duck or a trout. You are not Angelina Jolie. You want your lips to look like they belong on your face, only a little fuller and with less lipstick lines.
  • The outer corners of the lip should be filled to keep a youthful wide mouth. Don’t just fill the center and the lipstick lines.
  • Turned down outer corners of the lips should be buttressed with filler so that they are either in neutral position or turn up.
  • Most lipstick lines are best treated with filler in the red part of the lips themselves and in the junction of the red and skin, not just treated with filler in the skin above the lips. Sometimes a combination works best.
  • Permanent implants in the lips are a bad idea. There may be some out there that don’t look bizarre but I have never seen them.
  • The best fillers for lips are the hyaluronic acid fillers, Juvederm or Restylane. I usually use Juvederm Ultra XC, as I think it looks and feels more natural and smooth. Thicker and more permanent fillers such as Sculptra, Artefill, Radiesse are not meant for use in the lips and may give lumps and stiffness.
  • Your lips may feel stiff for 3-5 days after treatment with hyaluronic acid. This resolves.
  • The ratio of the vertical dimension of the upper to lower lip should be 1:1.6. Your bottom lip should be more full than the upper lip. I often have requests to treat the upper lip lines and to not treat the lower lip because the patient would prefer to use the rest of the filler on the smile lines or elsewhere. Don’t do it if the upper lip becomes as large as or larger than the lower lip. You will look weird, especially in profile. Spring for another syringe if you need it.
  • I don’t inject fat in lips because I don’t think it is as controllable and it is less predictable in terms of how much will last and how much will reabsorb. If you have fat injected into your lips, be prepared for significant swelling lasting at least 3 weeks, regardless of what you are told. Better to be pleasantly surprised than upset.

The best lip augmentations are those that no one knows you’ve had. It can be done. It does take an experienced physician injector, an aesthetic sensibility and the ability to know when to stop. Do it right or don’t do it at all.

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