Lips

1. The amount of red showing (vermilion) in the upper and lower lips should come close to being equal.
2. The lips should have the desired bulk. 
3. No lines or wrinkles around the lips.
4. The amount of upper lip white area (skin) should not be excessively greater than the red area.
5. The lips should not be so large that the inside of the lip shows at rest.

COMMENT:  Big lips are in!  Of course, the desirability of lip size is variable.  There are two separate features to consider.  One is the amount of red showing and second is the bulk of the lip.  Both need to be adequate.  It is important that the lips maintain their natural contour after surgery also. 

1. Pull up the skin along the bottom of your nose to see if this improves the design.
2. Do the upper and lower lips compliment each other?
3. Your doctor may be willing to inject saline into them to give you an idea of how they would look bigger.
4. Are they overly large and distracting?
5. Is there a sharp lip line?  Well developed lip lines, the edge at the border of the red and white area and the creases in the center of the upper lip are termed the "Paris Lip". 

1. Both volume or an increase in the amount of red showing can be achieved.
2. Scarring can be a constraint with lip surgery as with any soft tissue surgery.
3. Wrinkle lines can be smoothed.
4. Lip size can be reduced easily.  Lip reduction is a simple, effective operation.

1. Lip Augmentation

Basically there are two aspects to lips which deserve attention. One is the amount of red that is showing in the lip. This is the area to which lipstick is applied.  Also, I like to look at the width of the red area compared to the total width of the upper lip. 

The second is the thickness of the lip- how much bulk is there?  Lips without much red showing are often deficient in bulk. Sometimes relatively bulky lips may have very little red showing.  In the consultation, we try to address these separate problems, bulk and the amount of red. If a girl's main goal is to put on lipstick, having thick lips won't help her if there is no additional red showing.  Likewise, if more red is created without bulk, the lips may develop a bizarre appearance. 

Another concern may be DEFINITION.  Some lips have very pronounced lip lines and others do not.  People may wish to enhance the definition in the lip to create an effect known as the "Paris Lip" in which the lip edges are all extra distinct. 

The first category of procedures would be those that add volume to the lip by a simple injection. The first material used commonly was silicone, and when used properly, produced excellent results. The present choices include:

1. BOVINE COLLAGEN
2. FAT
3. SCAR
4. FASCIA
5. GORTEX

None of these methods are great, otherwise all the doctors would switch to it. 

COLLAGEN

In place of silicone, a common material used is bovine collagen, produced by the Collagen Corporation. Collagen is the body's natural filler material, the cement that holds the tissues together. It is a very simple protein that tightens like rope.  Collagen is the main material in tendons, ligaments, the dura around the brain, and even the main support substance of skin. 

The Collagen Corporation sells bovine collagen to physicians.  This is an extract of cow skin that is homogenized and sold to physicians in a suspension that has been loaded into syringes. All physicians pay the same price for the materials.  The material is not altered by any physician either, so feel free to shop for the best price for this material. 

FAT INJECTION

Another filler that adds bulk is fat, which can be transferred from other areas of the body.  In this case a region is suctioned, the fat is washed, and then reinjected into the lips.  This may produce a satisfactory improvement, in some cases; however, usually only a small portion of the fat survives.  The fat may be lumpy when it finally heals. 

In our office we consider the results of fat injection too unpredictable, especially in the lip.  Also, there is considerable work involved in harvesting and transferring.  Generally I tell patients that they can expect that in fifty percent of patients the fat is gone between six months to a year, but it is truly hard to be exact. 

SCAR AND FASCIA PLACEMENT

Another method of lip enhancement is dermal grafting, in which a strip of skin or scar tissue is removed from another area of the body and slid into the lip as a whole strip of tissue.  If the patient has a good donor area (place to take the graft from), in particular where there is an excess fold or some other procedure is being done that will make it convenient to harvest tissue, I may recommend this method for them as well. 
Although this procedure may be a good deal of work, this can produce a satisfactory long-term result with natural tissue.  The lip may tend to be stiff for a while and certainly a little numb as well, but this technique may add significant volume. 

Instead of skin or scar, FASCIA has been used, particularly if lip augmentation is desired at the time of a facelift.  Fascia is a thick sheet of natural collagen that holds deep tissues like muscle, in place.  My experience with this is that it tends to reabsorb, without providing the desired volume over a long period of time. 

GORTEX

Gortex is a Teflon sheet material that is FDA approved.  It is introduced in the lip in long strips in a fashion that is similar to the dermal grafting.  The material tends to be thin and I think adds very little real volume to the lip.  This technique may be more appropriate for accenting lip lines.  Even though there is no evidence of problems with Gortex so far, some people are concerned about having a foreign material in their body if there is some other procedure that might work as well. 

Take a look at your lips again and examine the amount of red (vermilion) that is showing.  In many people this is the real issue.  Many women try to compensate for small lips by placing their eyeliner beyond the normal limits of the red or even having permanent make-up placed there. I have seen some horrible results under these situations and the lips can really look like a mess when people try this. 

There are two questions.  First of all, is there an adequate amount of red showing?  Second, is there too much white (upper lip)? 

I like to see the lips come close to matching in the amount of red that shows, or perhaps just a little more in the lower lip.  The upper lip also needs to maintain its natural curvature, and people who operate on the lips need to be careful about preserving
this. 

HOW CAN I INCREASE THE RED?

Besides the techniques we've discussed to increase the volume of the lips,  it may be important to increase the amount of red that shows.  This is because there is no natural barrier between the white area of the lip and the red area of the lip deep in the tissues, so that if fat is injected into the lip, only a small amount may bulge out the red area and the rest may be bulging out the white area of the lip. 

The ultimate goal may be to produce more red so that lipstick can be more effective.  Grafts and injections alone may not be adequate.  In many cases, something must be done to invert more red tissue compared to the white area of the lip, if the larger vision is to be achieved.  Otherwise, any graft or injection placed in the lip may just as readily drift into the upper portion of the lip without inverting more red as desired. 

WHAT PROCEDURES ARE AVAILABLE TO MAKE MORE RED?

I like to evaluate the lips starting at the top and working down.

1. LIP LIFT
2. MARGINAL LIFT
3. LIP ADVANCEMENT