Lip enhancement (Lip enlargement)

To have full, pouting lips appears to be one of the characteristics for beauty. Inborn thin, narrow lips give a "peaky" appearance and ageing changes the structure of the lips. The subcutaneous tissues and the muscle loose their elasticity due to hormonal changes making the skin thinner and the upper lip longer. The border between the white and red skin of the lip, vermilion or lip roll is in the younger lip well defined and elevated. This structure diminishes with ageing. The described visual changes are not so evident on the lower lip. There are some different treatments according to the demanded correction.

	Broadening of the red of the lip: A broadening of the part of the lip is only possible with an operation. These procedures are done under conscious sedation and local anaesthetic.
	Shortening of the skin at the base of the nose (upper lip): This operation is only effective on senile lips. A gullwing shaped piece of skin is excised at the base of the nose, which pulls the lip upwards.
	Shortening of the skin at the lip roll (upper and lower lip): A very effective method but the scars remain visible and the lip roll disappears. This method is not recommended.
	Forward transposition of mucous membranes (upper and lower lip): With multiple V-shaped incisions in the mucous membrane on the inner side of the lip, the membrane can be pushed forward and broaden the visible red lip. This gives no augmentation and the long-time effect is doubtful. If bloodsupply is restricted during healing, indentations in the lip can occur.
	Transposition of mucous membranes from the cheeks (upper and lower lip): From each cheek a strip of mucous membrane is excised and rotated on a stalk into an incision on the inner side of the lip. The red lip is broadened, the fullness is augmented and the effect is permanent. The bloodsupply through the stalks is vulnerable and if hampered, parts of or the whole flap can necrotize. This heals with scarring and indentations.

Enhancement of fullness: All these procedures can be done under local anaesthetic.

Operations:

	Transposition of mucous membranes from the cheeks ( upper and lower lip ): See above.
	Fat-dermis implantation: A transplant that is as long as the lip is wide is taken from a suitable region (groins or around an already present scar) and introduced through small incisions on the inner side of the lip at the commissures. Advantages: Small, quick operation. Own biologic material. Disadvantages: Scars at donorsites if not already present. Transplant can be resorbed.
	Implant of muscular membrane: A strip of muscular membrane is taken in the hairbearing scalp. This leaves an inconspicuous scar that is as long as the lip is wide. This is introduced like a fat-dermisimplant. Advantages: Small, quick operation. Own biologic material. Disadvantages: Transplant can be resorbed.
	Gore-Tex implantation: A 2-mm or 3 mm thick tube of Gore-Tex is introduced in the same manner as for fat-dermis transplantation. Gore-Tex is a biocompatible material used for f.i. vascular prostheses. Advantages: Small, quick operation. Permanent enlargement. Disadvantages: Foreign body.
	ALLODERM implantation: Prepared commercially available dermis implants from Corp is introduced in the same manner as earlier described. Advantages: Small, quick operation. Disadvantages: Implant can be resorbed.Expensive.

Injections:

	Collagen (f. i. Zyderm®) Short time filling effect
	Hyaluronic acid (f. i. Restylane®) Short time filling effect
	Silicone Not offered
	Glass fibre pearls (f. i. Artecoll®) Permanent filling Not offered
	Fat Short time filling effect Fat is aspirated into a syringe and is reinjected after preparation.
	Aquamid® Permanent filling

What happens afterwards?

	All manipulations of the lips cause a transient, heavy swelling from someday to a week. A certain pain can occur in all procedures.
	After mucosal plasties the lips are swollen for at least one week.
	Liquid food should be eaten the first 3 days.
	If blood supply is constricted, parts of or the whole flap can fall of (necrosis). This will heal with scarring and cause deformities.
	If infections occur, the implants must be removed.
	All implanted material can be felt as an induration in the lips between the fingers on palpation. Foreign bodies or semiliquid material (Gore-Tex, Silicone, and pearls of glass fibres) is more easily palpated and injected material can aggregate.
	Foreign bodies can dislocate. The mouth is from the surgical point of view contaminated and in spite of prophylactic antibiotics infections can occur.

AQUAMID

Recently a new filler for permanent tissue augmentation by injection was introduced in Europe, Aquamid® . The information about this material is put in front of our normal information on lip augmentation, which of course still should be read by anyone seeking information about this type of operation. The clinic expects the treatment with Aquamid® to replace some of the suggested operations.

As general tissue augmentation like breasts, lips, malars, chins and calf for a long time have been and still are demanded corrections, the industry has been seeking a suitable substance for this indication. Through years injectables with time restricted durability like collagen and hyaluronic acids have been used. Due to resorbtion the injections had to be repeated. Allergic reactions have been reported.

Other injectable substances with more or less permanent durability have also been used. These are silicone and polymethylmethacrylate, which can aggregate and cause lumps or disappear depending on the molecular size. Again other materials as a permanent filler is the Gortex® tube. Autologous tissues with a variety of long term results have been used. Fat injections do mostly have a transient filling effect and are no alternatives for permanent augmentation. Fat-dermis or fascia implants do commonly have a permanent filling effect, although they can be absorbed. Acellular implants from corps does also exist for this purpose. Biologic auto transplants need vascular ingrowth to survive and if this does not occur, the material is partially or totally absorbed.

Bigger augmentations like breasts, muscle, buttocks etc. can only be achieved by implants today.

Aquamid® is a neutral hydrogel consisting of a stable chain of polyacrylamide in 90% of water. Polyacrylamide should not be confused with the poisonous acryl amide. The gel can be directly injected into the subcutis where it integrates with the tissues. If injected gel is to be removed, it can at least partially be aspirated or pressed out during the fist 8 months after injection. After this time there is an ingrowth of fibrous tissues into the gel which makes a surgical removal necessary to ablate it. Polyacrylamide gel has been used successfully for over 10 years in Ucraine, mostly for breast augmentation and facial corrections. The cosmetic results have been excellent with a very low frequency of side effects/complications of about 0,02%.

This information is related to facial corrections as the only officially cleared indication.

Method: With a very thin needle, the gel can be introduced into areas to be filled or enlarged.

Typical areas:
Malar region, chin, cheeks, lips and nose.

There will be a short swelling and erythema that will disappear within 12 hours.

There will be no pain.

The injected gel stays soft or hard depending of the injection technique and it does not migrate.

The treatment is done under local or general block anaesthetic. The anaesthesia makes the face feel hard and big, but have no fear, it is invisible! The analgesia disappears within a couple of hours.

No after treatment is needed.

Side effects:

	No reports of any complications so far.
	Irregularities can occur. This can be corrected by massaging or secondary injections. It is important that the physician should be able to see and to manage these side effects.
	Sometimes it is difficult to decide what volume is aesthetically needed. If one is in doubt, it is better to give a secondary treatment later than to inject to much. · Injected Aquamid® can be firm for a month. It softens gradually with time.

This text is edited and controlled by Dr. Per Gunnar Opitz, Opitz plastikkirurgiska klinik i Malmö Sweden