Lip contouring: a course towards naturalness

Author: Maria Shirshakova , Candidate of Medical Sciences, dermatovenerologist, cosmetologist, assistant at the Department of General Medicine at the Russian Medical Academy of Postgraduate Education, scientific consultant at the Expert Research Center (Russia, Moscow)

Source: KOSMETIK international journal, No. 2 (56) / 2014, pp. 24-29

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“Lip fashion”: evolution over time

Beautiful lips largely determine the aesthetics of the face. Looking back, you can be convinced of the existence of “lip fashion”. The ideal of their beauty varied in different eras: from thin, pale, practically absent to extremely full and bright. Women of Ancient Egypt considered moderately full, clearly defined lips to be beautiful, so they were painted dark.

Photo 1. Ancient Egypt: Nefertiti's moderately full, well-defined lips

In medieval Europe, permeated with the spirit of religiosity and puritanism, lips as a sign of sexuality practically disappeared from a woman’s face: small, thin, pale, tightly compressed stripes were welcomed.

Photo 2. The Middle Ages: in an era when carnal relationships were considered “dirty,” lips seemed to be “erased” from the face (Van Eyck. Portrait of Margarita)

Over time, secular laws began to prevail over church laws, spiritual and physical emancipation came, female beauty became a cult, an object of admiration. And fashion began to dictate its own, sometimes bizarre laws. The twenties of the last century were marked by a fashion for neat, thin lips painted along the inner contour. Actresses Ruth Walker and Clara Bow, Louise Brooks and Claudette Colbert - they were the ones who were in the trend of that time. At the same time, the legendary Max Factor introduced into fashion a new lip shape called “rosebud”. Up until the 1940s, lips that were bare at the edges but accentuated in the center with dark lipstick were encouraged. This technique made it possible to achieve two effects at once: highlighting the mouth and reducing its size. Popular shapes were “Cupid's bow” (lips with sharp corners), “vampire lips” (emphasized in a predatory red color) or “bee stung”.

The thirties are Greta Garbo, Katharine Hepburn, Marlene Dietrich, the owners of thin, tense, dark lips. After the war, women again wanted to look spectacular, because there were fewer men, and it was more difficult to win them. The style icons of that time were Marilyn Monroe and Jane Russell, owners of bright and large lips.

Photo 3. Fashion trends: pre- and post-war years

The phenomenon of plump lips among beauties of the early 21st century is associated with the appearance of dark-skinned models on the pages of fashion magazines back in the 1990s. “The 90s came, and the era of supermodels came, among which the sexy African-American star Naomi Campbell stood out,” writes fashion historian Alexander Vasiliev. It took ten years for the consciousness of the inhabitants of Europe to get used to exotic beauty and for European women to decide to try on the image of a black beauty. Many “rich and famous” have undergone lip augmentation procedures in order to achieve sensuality and sexuality. But in most cases, the result was exactly the opposite: owners of “African” (and essentially “silicone”) lips became the subject of ridicule in the tabloids, and not the object of desire.

Photo 4. African American aesthetics and its European transformation

In modern society, a beautiful woman is, first of all, harmonious. Trends in the evolution of lip aesthetics can be described as naturalness and naturalness, and not on a national, but on a planetary scale. According to world sociological research, those with beautiful lips are confident in themselves, and it is easier for them to build personal and social communications. This means that beautiful, natural lips are slightly more opportunities for any woman, regardless of age, race and social status.

The NaturaLips concept is the “fashion” of today

We have developed the NaturaLips concept, based on modern ideas about the aesthetics and health of the lips, their anatomy and ontogenesis and including a technique for correcting the shape, volume and proportions of the lips, increasing brightness, giving them a “young, sensual look” while maintaining the natural appearance as a whole. The procedure for injection contouring and volume modeling of the lips is carried out using fillers based on stabilized hyaluronic acid (HA), including in combination with native HA and antioxidants. The choice of preparations containing native HA is determined by the unique biological properties of this compound, which makes it possible to activate physiological processes in the tissues of the lip area, improve trophism, limit the negative effects of oxidative stress, and prolong the effect of stabilized HA. The technique involves the use of an original injection technique using thin needles 13 and 4 mm long, as well as flexible cannulas.

Among our patients who wish to improve the aesthetics of their lips, four age groups can be distinguished (the data coincide with the statistics of E.I. Gubanova et al. [1]). The majority of patients (more than 40%) are young women aged 18–30 who want to achieve “glossy standards”: give their lips more volume and emphasize their sexuality. But still, many prefer to remain within natural proportions. The ideal for such women are Angelina Jolie and Keira Knightley. Some of the young patients express a desire to correct the shape of their lips, correct asymmetry, and change the position of the corners of the mouth.

Women aged 31–40 years make up about 15% of those who seek lip correction. For them, this is, first of all, a step towards changing their inner world, maintaining (not gaining!) self-confidence. The aesthetic dominant shifts from bright sensuality and sexuality to restrained correctness of forms, prevention of age-related changes, restoration of volume lost with age and giving lips freshness, that is, obtaining a natural and natural effect.

Patients over 40 years of age, as a rule, already need correction of age-related changes in the lips and skin of the perioral area. Their key wishes are to correct “purse-string” wrinkles, correct the position of the corners of the mouth, restore the contour of the lips, and improve their color. As for the volume, its increase, especially in patients over 55 years of age, does not always lead to the desired result due to the low efficiency of correction, short retention time of the result and a number of other reasons.

Despite the use of modern methods of aesthetic lip correction, taking into account their morphological features, our analysis of clinical observations conducted in 2010–2013 shows that about 20% of patients are to one degree or another disappointed with the procedure. According to V.V. Atamanov [2], dissatisfaction is associated precisely with the results of contour and volumetric lip surgery.

In this regard, I would like to discuss one very important point: patients, when formulating their wishes, often focus on a certain ideal and try on the facial features of another person. Moreover, it is the lips that are “pulled out” from the general context, and all other features of the “ideal face” are simply not taken into account. In this case, it is necessary, without sparing time and words, to explain that eyes, nose, lips, eyebrows, the oval of the face - all these elements are perceived precisely as a whole, forming individuality and irresistibility. By making any aggressive changes to the balanced picture of the face, you can get imbalance and disproportion, that is, exactly the result that the patient will not like, although lip correction will be carried out strictly in accordance with the expressed wishes. This is where you need to decide for yourself the question of whether it is worth following the lead of patients with dubious requests.

One more nuance: a significant increase in lip volume is not always possible due to the characteristics of the individual lip architecture and the maximum capacity of the tissues. The lips today are considered as a separate anatomical zone, the correction of which must be carried out with great care, specifically in terms of introducing large volumes of filler [3]. Before the procedure, it is necessary to carefully discuss with the patient all the details of the upcoming intervention and explain why it is impossible to make very plump and voluminous lips from anatomically thin lips.

We tried to answer many questions by developing a strategy for aesthetic lip correction NaturaLips. When creating it, we took into account the wishes of patients of the main age group (up to 40 years), objective aspects relating to the ontogenesis and anatomy of the lips, as well as the negative experience of carrying out similar procedures - both our own and our colleagues.

Lip ontogeny: why should we remember it?

At the 4th week of development in the human embryo, on the sides of the frontal protrusion on the frontal surface of the head, two symmetrical thickenings of the ectoderm appear - olfactory pits (nasal placodes). The pits deepen as they invaginate and due to the rapid proliferation of mesenchymal cells of the bottom.

The two ends of the resulting nasal eminences are called the “middle and lateral nasal processes.” The middle nasal processes, as a result of fusion along the sagittal plane, form the apex, dorsum and septum of the nose, as well as the central part of the upper lip, its philtrum. The lateral nasal processes turn into the wings of the nose. The paired maxillary processes also grow in the medial direction towards each other and finally approach the middle nasal process of the corresponding side. As a result of the fusion of the two middle nasal processes with each other (along the midline) and with the maxillary processes (laterally), the maxillary arch and upper lip are formed.

The lower jaw and lower lip are formed from the rudiments of the first visceral (mandibular) arch. These rudiments have the appearance of paired thickenings, which quickly grow as a result of proliferation of mesenchymal tissue and merge along the midline, while the arch of the lower jaw becomes solid.

Note that seemingly single anatomical units - the upper and lower lips - are formed by the fusion of two paired elements. The border of the two halves is marked by a “proboscis” on the upper lip and a hollow on the lower lip. We tried to take this fact into account when performing lip correction, injecting the filler separately as a bolus into the right and left halves of the lips, while in the upper lip during modeling we sought to combine two portions, and in the lower lip we intentionally left them separated. The resulting result is striking in its harmony!

Materials and methods in the NaturaLips strategy

When performing lip correction, we mainly use monophasic filler Glytone 3 (Pierre Fabre, France), containing stabilized HA at a concentration of 22.5 mg/ml, high molecular weight native HA at a concentration of 4 mg/ml, as well as mannitol at a concentration of 41 mg/ml and phosphate buffer to maintain pH 7.1. The rationale for choosing this drug is its high efficiency and safety when performing contouring procedures, which has been proven in a number of scientific and clinical studies [4, 5].

Glytone 3 filler is designed to correct deep wrinkles/folds on the face and to fill volume deficits. Due to its monophasic structure, fairly high elasticity and cohesiveness, this filler is distributed evenly in tissues (including lip tissues), is well modeled after injection, and subsequently retains its shape under dynamic loads. The latter property is extremely important when carrying out correction in such a moving area as the lips.

The drug provides a predictable and long-lasting result in restoring both the shape and volume of the lips: according to our observations, the effect lasts for eight months or more. The drug is easily administered through a 27 and 30 G needle and cannula. After administration in an adequate volume (taking into account the natural and individual “capacity” of tissues), it does not migrate. The result of the correction looks natural, the drug is not palpable, and the sensation of a foreign body in the lips, which usually worries patients, is almost invisible.

Due to the presence of native HA, the effect of prolonged hydration of the lips is ensured: their color improves, peeling disappears [6].

When carrying out correction, we are guided by the following parameters and indicators that determine the harmony of the lips in the context of the entire face:

Photo 5. Aesthetic parameters of “ideal lips” (explanations below)

• The width of the mouth - the distance between the commissures - averages 50.9 mm. This parameter cannot be changed; minor correction is carried out using dermopigmentation;
• clearly defined structures - columns of the philtrum, "Cupid's arch", curves of the upper and lower lips - emphasize the beauty of the lips and ensure a harmonious perception of the lower third of the face;
• the area of the red border and the volume of the lower lip exceed the area and volume of the upper (their ratio is approximately 1.6:1, that is, corresponds to the proportion of the golden ratio);
• the most protruding point of the upper lip (“proboscis”) in profile is slightly moved forward compared to a similar point of the lower lip;
• the profile of the upper lip from the subnasal point to the most prominent point of the upper lip should not be strictly vertical. The ideal profile option is a slightly concave curve (points 2 and 3); A series of soft curls runs from the point at the tip of the nose to the chin (points 1–7). There is only one clearly visible angle - between the upper and lower lips (points 3–5);
• Ricketts' aesthetic line (Riccets E-line) - a straight line connecting the tip of the nose with the protruding point of the chin - runs at a distance of about 4 mm from the upper lip and 2 mm from the lower lip (points 3 and 5).

Lip contour correction

Since they are highly sensitive to pain, topical anesthesia is performed before the procedure. In particular, we use Emla cream, which we apply to both the dry and wet mucous membranes of the lips for 30 minutes. under the film. In some cases, for the purpose of additional pain relief, it is possible to spray a spray with lidocaine 10% onto the area of moist mucosa. After the end of the anesthetic exposure time, the correction area is thoroughly disinfected with an aqueous antiseptic solution.

To correct the lip contour, Glytone 3 is injected to a depth of 2 mm using a linear-retrograde technique using a 27 G needle. The needle is inserted to its full length along the border of the white ridge, while it is contoured, and its cut is directed towards the inner border of the lip. Correction of the contour of the upper lip is carried out from the commissures to the columns of the philtrum. For ease of insertion of the gel, the lip is fixed between the thumb and index fingers of the free hand. Particular attention is paid to the detailed study of the “Cupid’s arch” and the columns of the philtrum, to emphasize which the drug is injected using a microbolus technique into the middle part of the red border with a 4 mm long needle, as well as using a linear-retrograde technique into the skin of the upper lip - from the red border to the nose. The amount of drug per administration is 0.03–0.05 ml. A total of 0.3–0.5 ml is injected along the contour of the upper lip and philtrum; along the contour of the lower lip - 0.2–0.3 ml. This method of lip contour correction allows you to correct the shape, delay the appearance of “purse-string” wrinkles, lift the corners of the mouth and provide some lifting to the middle part of the lip.

Increased lip volume

To increase lip volume, bolus and multipuncture injection techniques are used. Preliminary marking involves identifying four sections of the upper lip (two central and two lateral) and two sections of the lower lip. In the central part of the upper lip, injections are performed from a point located at the border of the dry and wet mucosa, towards the curve of the “Cupid's arch”, using a 27 G needle with a length of 4 mm. From 0.2 to 0.3 ml of filler is injected into each point with the formation of a microbolus in the submucosal (!) layer and subsequent active massage to evenly distribute the drug in the center of the upper lip, which ensures accentuation and some inversion of the lip in the central segment. The volume of the drug injected into symmetrical areas should be the same.

Correction of the lateral areas of the upper lip is carried out using a 4 mm long needle using a multipuncture technique. The needle is again inserted at the border of the dry and wet mucosa, and the injection is carried out into the submucosal layer in a total volume of 0.3–0.5 ml on each side. The volume of the drug depends on the wishes of the patient and the anatomical features of the structure of the lips. After the filler is injected, an active massage of the injection area is performed.

For patients with negative experience with lip correction, filler can be injected using a 25 G cannula to minimize the risk of hemorrhage. The cannula entry hole is created using a 23 G needle. The blunt-tipped cannula is inserted very slowly, creating a tunnel at the border of dry and wet mucosa. In the lateral parts of the upper and lower lips, a total of 0.3 ml of the drug is first injected linearly-anterogradely and then retrogradely. Injecting a small volume of a viscous solution minimizes trauma and does not stretch the skin, providing the most natural result.

When correcting the volume of the lower lip, dental floss is used, which is placed between the central incisors of the lower jaw, dividing the lip into two symmetrical segments. On each side, in the area of the red border, 0.2 ml of the drug is injected using a 27 G needle or 25 G cannula. In this way, boluses are created from one point in half of each lip. The drug is administered very slowly to avoid pain. After removing the dental floss, a light massage is performed, but even after this, an accent remains in the form of a hollow in the center of the lower lip, which gives it additional expressiveness and piquancy. In rare cases, or at the request of the patient, additional correction of the lateral areas of the lower lip is performed using a multipuncture technique: filler is injected at the border of the dry and wet mucosa. After completing the injections, a massage is performed to evenly distribute the drug in the tissues. In order to relieve swelling and reduce the severity of bruises, cold packs are briefly applied to the affected area.

Clinical study of the effectiveness of the technique

After finalizing the protocol for the NaturaLips procedure, we conducted a limited observational clinical study at one of the Moscow aesthetic medicine clinics.

The study involved 20 women, average age 35 years.

Criteria for inclusion in the study: somatic and mental health, desire to change the volume and shape of the lips. All participants signed a voluntary informed consent protocol for participation in the clinical study.

Exclusion criteria: standard contraindications to injection lip surgery, any aesthetic manipulations within the last three months, individual hypersensitivity to the drug used.

For photographic documentation, a digital camera was used; filming was carried out in standard projections under normal lighting. The patients were photographed before the procedure, immediately after it, one month and 6 months after the correction.

Before injections, standard anesthesia was performed using Emla cream 5% under film for 30 minutes.

During the procedure using the technique described above, all patients were injected with 1 ml of the drug Glytone 3. After the procedure and during 6 months of observation, the patients themselves and the doctor assessed the moisture, elasticity, volume and clarity of the lip contour on a 10-point integral scale (0–2 points - unsatisfactory result, 3-4 points - satisfactory, 5-6 points - good, 7 points or more - excellent result). Possible adverse events were monitored throughout the entire period.

Of the 20 patients, 18 participants completed the study (two patients dropped out for various reasons). Two patients asked for filler to be reinjected for additional lip volume 14 and 21 days after the initial procedure. After completing the observation period (6 months), the majority of patients did not need a repeat procedure: in their opinion, the correction effect was maintained.

The results of the study showed a high degree of satisfaction with lip correction using the NaturaLips method.

Photo 6. Results of contouring and volumetric lip surgery using Glytone 3 using the NaturaLips method . Left - before, right - after

Thus, according to the assessments of the doctor who performed the injections, the correction effect immediately after the procedure corresponded to 6 points and higher. Over time, the indicator increased and after a month reached a level of 8 points. The patients' assessments reflect not only the nature of objective indicators, but also changes in the psycho-emotional background and features of self-perception. After the procedure, the treatment result was rated as good by the majority of patients - 5.4 points. At this stage, the score could be reduced due to the presence of predictable adverse events such as bruising, swelling and, as a result, some lip asymmetry. However, over time, satisfaction with the results of the procedure increased and after a month reached almost the upper threshold - 9.7 points. After six months, the study participants assessed the result as satisfactory and good (an average of 4.5 points). In a separate line, it should be emphasized that both doctors and patients noted positive changes in lip parameters such as color and moisture.

It is also necessary to pay attention to the good tolerance of the procedure. Adverse effects include redness of the skin at the injection site, swelling, pain on palpation, and hemorrhages. These phenomena were temporary and resolved within a week without any therapy. There were no cases of overcorrection and migration of the drug; uneven distribution of the material was observed in three out of 20 patients (15%) and was eliminated by performing a modeling massage.

Conclusion

An analysis of patients’ requests for cosmetic lip correction indicates that our contemporaries’ ideas about beauty are associated, firstly, with naturalness, harmony and health. Flashy sexuality has given way to calm pragmatism, and cosmetologists must take this trend into account.

The growing popularity of injection procedures for modeling the shape and volume of the lips dictates the need to use drugs whose biological and mechanical properties correspond to the characteristics of this delicate area. Our experience in using combined fillers based on stabilized and native HA in combination with antioxidants allows us to talk about the possibility of achieving different effects, both aesthetic and health-improving. The NaturaLips correction technique allows you to obtain a predictable aesthetic result, taking into account the anatomical and age-related characteristics of the lips.

Literature

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2. Atamanov V.V. Possible complications of injection lip surgery Injection methods in cosmetology. – 2010; 1:72–76.
3. Sandoval SE, Cox JA, Koshy JC, Hatef DA, Hollier LH Facial fat compartments: a guide to filler placement // Semin Plast Surg. – 2009; 23, 4: 283–287.
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