Lip Augmentation Information: Injections and Implants

Lip Augmentation

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costs
initial consultation
pre-op preparation
basic procedures/techniques
recovery
risks/complications
scars
journal article

costs of lip augmentation

LIP AUGMENTATION*
Cost Range: $300-$5,000

Cost per procedure:**
Collagen injection $333
Lip augmentation (surgical) $1,819

Average Total Cost : $2,200
Surgeons fee: $1,800
Facility fee: $400

* Fees generally vary according to region of country and patient needs.
**These fees are averages only. Fees do not include anesthesia, operating room facilities, or other related expenses. Source: http://www.plasticsurgery.org/

initial consultation

At the initial visit, your doctor will likely ask you to describe in detail what you would like improved. Be specific about what you would like done. Bring photos that show what you like and don't like. If your surgeon fully understands your expectations, he'll be able to determine whether your goals are realistic.

Tell your doctor:

if you have any allergies
if you have a history of bad scarring, such as keloids
about any medications you are taking (both prescription and non-prescription)

You are at increased risk for complications if you have diabetes, poor circulation, heart, lung or liver disease, smoke, have a family history of blood clots, etc. You'll want to discuss your medical history thoroughly with your physician before you choose to undergo surgery.

pre-op preparation for lip augmentation

Before Lip Augmentation Surgery:
[ ] Do not take aspirin or anti-inflammatory medications (your doctor can provide you with a list of OTC medications to avoid)
[ ] If you smoke, quit smoking for at least 2 weeks pre-op (and anticipate no smoking for the recovery, smoking greatly increases your risk of complications)
[ ] Obtain a copy of your doctor's protocol
[ ] Make arrangements to have someone drive you to and from the operation
[ ] Fill prescriptions (especially pain medications and antibiotics) before surgery
[ ] Set up home recovery area: lots of pillows, books, magazines, journal, stationery, T.V., remote control, videos, favorite CDs
[ ] Prepare and freeze meals for 2 days
You'll want soft foods that do not require much chewing for the first few days.
Consider: Protein shakes, soup, applesauce, jell-O, frozen dinners, yogurt, oatmeal, cottage cheese, juice (purchase flexible straws for easier drinking)
Be sure to have adequate protein - the body needs it for proper healing
[ ] Prepare Icepacks (can also use packs of frozen veggies or fruit, gel packs, etc/) to reduce post-op swelling
[ ] Laxatives (pain medications are often binding)
[ ] On the day of surgery, wear loose clothing which will be easy to get off and on after operation (a shirt that buttons in front)
[ ] Follow your physician's directions carefully regarding medications, eating & drinking, etc.

basic procedures/techniques

Anesthesia: Local
Location: Office or surgical center
Surgery time: 30 minutes - 2 hours

Lip augmentation procedures increase the size of the lips. The upper or lower lip may be treated alone, or both upper and lower lips may enlarged at the same time.

Lip augmentation can be achieved by injecting or surgically implanting materials into the lips. Some procedures are temporary, others are permanent.

INJECTIONS

Collagen injections
Prepared from the collagen found in cow skin, collagen injections are used to temporarily augment the lips. Although it is purified, this collagen may cause allergic reactions in some people. For that reason, a sensitivity test should be performed before the actual lip augmentation procedure.

Collagen is injected into the lip with small needles. Because the body slowly absorbs the collagen, the results generally last between one and three months. The procedure may be repeated as needed.

Fat injections
Fat can also be injected into the lip. The fat is harvested from another area of the body (often the abdomen or thighs) and is purified before it is injected into the lips. An advantage to this procedure is that there is no possibility of an allergic reaction. As with collagen, results are temporary but usually lasts longer than collagen injections.

Fat injections can cause lumping or scarring.

Artecoll injections
Artecoll is composed mainly of tiny synthetic beads (polymethyl methacrylate) that stay in the lips, and raise them. This technique lasts longer than fat or collagen injections.

Autologen injections
Autologen is collagen extracted from the patient's own skin, often from excess skin removed in a facelift. The results are relatively long lasting, and there is no risk of an allergic reaction.

Dermalogen injections
Dermalogen is extracted from the skin of a cadaver. The donor material is screened and processed to avoid the spread of disease. The effects are temporary, and are similar to the effects of collagen injections.

Fascia injections
Fascia (white connective tissue) extracted from a cadaver can be injected or surgically implanted.

HylaForm injections
Tissue made up of a molecular component of the human body. Extracted from a cadaver.

Restylane injections
Restylane is a clear gel; the hyaluronic acid in Restylane is similar to that naturally found in the body.

SURGICAL PROCEDURES

AlloDerm
Alloderm is the most popular material for lip augmentation. It is a natural collagen sheet harvested from cadavers and is screened and highly processed. The standards by which it is processed are very strict. The risk of infection is approximately 2%.

Under a local anesthesia, the material is inserted through tiny incisions made in the inside corners of the mouth. Stitches are used to close the incisions. AlloDerm eventually becomes integrated with the natural tissues of the body. The material can be absorbed, so the results are only temporary, lasting from 6 months to a year.

Synthetic Implants
Gore-Tex, SoftForm and soft ePTFE are other synthetic options with permanent results. They do not shrink and are never absorbed into the body. They also remain in place because scar tissue forms on either end.

To insert the implant, a small incision is made in the inside of the lip. The material is then made into the shape of a small tube and it is inserted with a small needle.

Synthetic implants are foreign substances and may become infected or be rejected by the body. If this occurs, the implants can be removed.

Fat grafting
This procedure has permanent results in approximately half of the people who try it. Although it is possible that the body will reabsorb it, many people choose fat grafting because they are most comfortable with using the fat from their own body. The fat is harvested from another area of the body, often the abdomen. It is then prepared and inserted with a needle into the lip from more than one point.

Local flap grafts
Local flaps bring material from inside the mouth outside to enhance the lips. Results are temporary. An incision may be made inside the mouth to push the tissue inside the mouth upward, and outward, into the lip, sometimes in conjunction with grafting. Or, an incision may be along the upper lip line. In this case, skin above the lip is removed, and the lip is then stitched along the line of the incision.

recovery

Pain Level: Mild discomfort. 0-2 days of pain medication
Swelling and Bruising: 3 days-1 week
Work: 1-2 days
Exercise: Wait 2-3 days
Final result: Varies depending upon treatment

For faster recovery:

Keep ice packs applied to your lips for the first 48 hours
Limit talking and chewing should be limited during the first 48 hours
Limit smiling and laughing for the first week
Sleep in a semi-upright position for the first week or so (do not sleep on your stomach)
To avoid unnecessary swelling or bleeding, do not bend over, strain, exercise or do any other activities that could increase pressure to your lips
Avoid strenuous activities for 1-3 days
Keep the lips clean to avoid infection (antibiotics may also be dispensed)

Whether or not an anesthetic is necessary depends on the lip augmentation procedure. Topical anesthesia is generally used before lip injections, so that the procedure is painless. Local anesthesia is normally used during grafts and flaps. The procedure painless during the operation, but may be some discomfort afterward. It takes longer to recover from a surgical procedure than an injection.

Injections: Recovery takes about 1-2 days after an injection. Bruising and swelling may last as long as a week.

Grafts and flaps: Recovery takes about 1-2 weeks after surgical procedures. During this time, you may experience some drooling. Your lips may also feel unnaturally stiff for 2-3 months after the procedure.

risks/complications

List of possible risks & complications:
Allergic reactions to implants
Anesthesia reaction
Asymmetry
Bleeding
Cold sores
Extrusion
Granuloma
Hardening of implant (may require removal)
Hematoma
Infection (risk is less than 2%)
Interference with lip function
Keloid (heavy scar)
Lumpiness
Migration of implant
Nerve Damage
Numbness
Pain
Permanent numbness
Reabsorption of material
Reactions to medications
Skin irregularities
Skin slough
Slow healing
Stiff lips
Swelling
Visible scar

Significant complications from lip augmentation are rare. With any surgical procedure, there is always a possibility of bleeding, infection, reaction to the anesthesia, slow healing or an unexpected result. Other possible complications include asymmetrical lips, cold sores, numbing, scarring, swelling, and permanent stiffness in the lip. Implant material may move to a new location within the lips and it may also protrude unnaturally. Allergic reactions such as itching, redness, swelling may occur. Fat injections can cause lumping or scarring. Any implant that is a foreign substance (such as SoftForm) may become infected or be rejected by the body.

scars

If there are complications that create heavy scarring, your physician may choose excision or steroid injections. Although rare, there are times when it is impossible to improve an unsightly scar.

journal article

Aesthetic Surgery Journal
September/October 2001 • Volume 21 • Number 5

Alloplastic lip enhancement
Richard D. Anderson, MD
10210 N. 92 Street, Suite 307
Scottsdale, AZ
480-860-9333
www.andersonplasticsurgery.com

Abstract

Alloplastic lip augmentation can be safe, effective, and predictable when properly executed. The author describes his surgical technique, which evolved from the performance of more than 432 lip augmentation procedures, and focuses in detail on the materials he uses to achieve the best results. (Aesthetic Surg J 2001;21:445-449.)

Article

About 15 years ago I became interested in treatments to enhance the lips and the perioral region. Patients who desire lip enhancement generally fall into 2 groups: those who want bigger and fuller lips to correct genetically hypoplastic lips and those seeking correction of thinning lips and perioral wrinkling. Treatments have included autogenous and alloplastic implants to provide more bulk and projection of the lip vermilion(1-23); various surgical techniques to alter the shape and/or projection of the lips(24); midface suspension to decrease the nasolabial folds(25); and the use of chemical, laser, and mechanical abrasion to diminish perioral wrinkles. I have used alloplastic materials to perform more than 432 lip augmentations. Here I present modifications in my technique and second thoughts on choice of materials for lip enhancement.

Materials

The ideal material for lip enhancement should be safe, physiologic, permanent, and easy to use. It also should be easy to remove if the patient desires change. The list of injectable alloplastic filling materials increases almost monthly. Here, I will describe my experience with Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) and AlloDerm (LifeCell Corporation, The Woodlands, TX).

Gore-Tex is an expanded, fibrillated polymer made of polytetrafluorethylene that was developed in the late 1960s and has been used for grafting since the 1970s. More than 6 million implants have been placed in human beings. Gore-Tex is bioinert, noncarcinogenic, nondegradable, permanent, and available in varying thicknesses and sizes. It is also very malleable.

Acellular allogenic dermis (AlloDerm) is a dermal matrix graft harvested from cadaver skin and processed with the epidermis and dermal cells removed. The processed acellular dermal matrix is freeze-dried and remains stable for 2 years under standard refrigeration. AlloDerm is rehydrated after 10-plus minutes in sterile normal saline solution or lactated Ringer's solution. AlloDerm graphs were first clinically used for treatment of full-thickness burns. The first published account of their use for cosmetic augmentation was in 1996.(13)

Technique

A sterile environment is essential when dealing with alloplastic graft placement. I prefer local anesthesia plus intravenous sedation with monitoring and intraoperative antibiotics. The second and third divisions of the trigeminal nerve are blocked with 1% lidocaine containing 1:100,000 epinephrine, followed by lateral and central injection of the vermillion. Small (5-mm) incisions into the vermillion are made bilaterally about 5 mm from the lateral commissure of each lip. Subvermillion tunnels are created with Iris scissors (Fine Science Tools, Foster City, CA). Undermining of the vermillion is performed from side to side at the orbicularis muscle level. Appropriate thickness of the vermillion is an important consideration in preventing ulceration and noticeable irregularity seen with thin vermillion coverage. The tunnels are 1 cm wide and extend from the wet line to the vermillion border.

Lower lip
The lower lip is done first. I prefer to use multistrand Gore-Tex, 1- to 2-mm thick, 1.5-cm wide, and 7.3-cm long. For placement of the graft into its subvermillion tunnel, I prefer 13.5-cm toothed alligator forceps (Figure 1).

Fig. 1. Instrumentation and implants including 13-cm toothed alligator forceps, multistrand Gore-Tex for lower-lip augmentation, 3 contoured AlloDerm strips (before stacking) for the upper-lip augmentation, and Iris scissors for subvermillion tunnel creation. Note that the graft material should not touch the sterile paper drapes.

The forceps are passed through the tunnel, and the implant is grasped securely at one end. The "no-touch" technique is used for this implant. A skin hook, placed in the entrance incision by an assistant, provides counter-traction while the implant is pulled through the tunnel (Figure 2).

Fig. 2. The pull-through procedure for the lower-lip multistrand Gore-Tex graft, with toothed alligator forceps, is demonstrated here.

Lubrication of the implant with sterile KY gel (Johnson & Johnson) during placement is helpful.

After placement of the implant, the lip is stretched from the center laterally while both ends are held with a small hemostat. Uniformity and symmetry are evaluated. The tapered ends of the implant are then tucked laterally into the muscle pocket. No sutures are used to secure the implant; muscle and vermillion prevent exposure. Closure is accomplished with 5-0 Chromic or 6-0 Prolene sutures (Ethicon Inc., Somerville, NJ).

Upper lip
For the upper lip, I prefer the AlloDerm graft, measuring 3-cm wide and 7-cm long. I use a 0.04- to 0.07-inch (40/70) thickness if significant enhancement is desired. For modest improvement, I have used thinner material. Graft preparation involves soaking for 5 minutes in sterile normal saline solution or lactated Ringer's solution, removing the backing, and soaking for an additional 5 minutes in a second dish. Implant shaping is more easily accomplished before full hydration.

My usual upper-lip AlloDerm graft is a 3-layer stack constructed by cutting a 3-cm-wide graft into 3 strips measuring 1 × 7 cm. The ends are tapered and the graphs are stacked and sutured together with a 4-0 chromic mattress suture approximately 1 cm from each end. The stacked graft is then pulled through the upper lip subvermillion tunnel with special attention to grasping all 3 strips during the pull-through maneuver. These graphs may be customized for lip asymmetry or for less fill at the center (cupid's-bow area) if desired. Each end is then held firmly with forceps while the lip is stretched out for proper symmetric placement. The tapered ends are tucked laterally into the muscle pocket.

Postoperative care includes a multilayer Steri-Strip dressing (Seaway Surgical, Toledo, OH) placed along the vermillion border, cold packs for 24 hours, and avoidance of unnecessary lip motion. Antibiotics and antiherpetic medications are begun a day before surgery.

Discussion

I have found that the multistrand Gore-Tex provides desirable and long-lasting lower-lip enhancement. Complications are unusual, and long-term postoperative complaints about sensation and firmness, made by the patient or the patient's partner are rare. In the short term, there will be some limitation of lip motion and some initial concern about firmness. According to my patients, these concerns usually fade after 3 or 4 weeks. The advantages of Gore-Tex implants over AlloDerm for the lower lip are long-term persistence and somewhat lower cost.

Late in 1996, I first tried AlloDerm for upper-lip augmentation because it was observed that with Gore-Tex, an upward lateral displacement of the implant occurred, resulting in fullness above the vermillion border of the upper lip.(26,27) It is notable that I found the same complication with SoftForm (Collagen Corp., Palo Alto, CA), which I rarely use.(27) I have found Alloderm to be soft; patients and their partners have accepted it, describing it as having a natural feel.

The disadvantages of AlloDerm have been primarily a lack of volume persistence and the cost. Others have reported 80% to 85% persistence at 7 months and a volume diminution of 30% to 40% at 1 year.(22) At 2 years I have found that most of my patients have about 50% of the augmentation they had at 4 months (Figures 3 to 6).

Fig. 3. A, Preoperative view of a 75-year-old woman. B, Postoperative view 5 months after laser resurfacing and upper- and lower-lip augmentation. C, Postoperative view after 27 months. The patient demonstrates about 50% maintenance of upper lip volume and 100% maintenance of lower lip volume.

Fig. 4. A, Preoperative view of a 32-year-old woman. B, Postoperative view 4 months after lip augmentation. C, Postoperative view after 16 months. The patient demonstrates about 50% AlloDerm and 100% Gore-Tex persistence.

Fig. 5. A, Preoperative view of a 52-year-old woman.B, Postoperative view 2 months after facial laser resurfacing and upper- and lower-lip augmentation. C, Postoperative view after 20 months demonstrates 100% lower-lip Gore-Tex persistence and approximately 80% upper-lip AlloDerm graft persistence.

Fig. 6. A, Preoperative view of a 50-year-old woman. B, Postoperative view 4 months after endoscopic facial suspension, full-face laser resurfacing, and upper- and lower-lip augmentation. C, Postoperative view after 12 months with approximately 50% upper-lip AlloDerm maintenance and 100% lower-lip Gore-Tex persistence.

Alloplastic lip augmentation with Gore-Tex and AlloDerm can be safe, effective, and predictable when properly executed. These implant procedures should result in natural-appearing, natural-feeling, attractive, and satisfying results.

References

1. Billings E, May JW. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83:368-381.

2. Maloney BP. Cosmetic surgery of the lips. Facial Plast Surg 1996;12:265-278.

3. Isenberg JS. Permanent lip augmentation using autologous breast implant capsule. Ann Plast Surg 1996;37:121-124.

4. Ponzielli G, Campiglio GL, Berlanda M. Lip augmentation using a latissimus dorsi strip graft. Aesthetic Surg J 1997;17:226-229.

5. Burres SA. Lip augmentation with preserved fascia lata. Dermatol Surg 1997;23:459-462.

6. Robertson KM, Dyer WK II. The use of fillers in the aging patient. Facial Plast Surg 1996;12:293-301.

7. Cisneros JL, Singla R. Intradermal augmentation with expanded polytetrafluoroethylene (Gore-Tex) for facial lines and wrinkles. J Dermatol Surg Oncol 1993;19:538-542.

8. Ellis DAF, Trimas SJ. Gore-Tex implants for the correction of thin lips. Laryngoscope 1995;105:207-209.

9. Conrad K, Gillman G. A 6-year experience with the use of expanded polytetrafluoroethylene in rhinoplasty. Plast Reconstr Surg 1998;101:1675-1683.

10. Conrad K, MacDonald MR. Wide polytef (Gore-Tex) implants in lip augmentation and nasolabial groove correction. Arch Otolaryngol Head Neck Surg 1996;122:664-670.

11. Linder RM. Permanent lip augmentation employing polytetrafluoroethylene grafts. Plast Reconstr Surg 1992;90:1083-1092.

12. Sherris DA, Larrabee WF. Expanded polytetrafluoroethylene augmentation of the lower face. Laryngoscope 1996;106:658-663.

13. Jones FR, Schwartz VM, Silverstein P. Use of a nonimmunogenic acellular dermal allograft for soft tissue augmentation: a preliminary report. Aesthetic Surg Q 1996;16:196-201.

14. Shasan PE, Rahban SR. Presacral donor site for lip augmentation. Aesthetic Plast Surg 2000;24:31-33.

15. Niechajev I. Lip enhancement: surgical alternative and histologic aspects. Plast Reconstr Surg 2000;105:1173-1183.

16. Rohrich RJ, Reagan BJ, Adams WP Jr, Kendel JM, Beran SJ. Early results of vermillion lip augmentation using acellular allogenic dermis; an adjunct in facial rejuvenation. Plast Reconstr Surg 2000;105:409-416.

17. Castor SA, To WC, Papay FA. Lip augmentation with AlloDerm acellular allogenic dermal graft and fat autograft: a comparison with autologous fat injection alone. Aesthetic Plast Surg 1999;23:218-223.

18. Hoffmann C, Schuller-Petrovic S, Soyer HP, Kerl H. Adverse reactions after cosmetic lip augmentation with permanent biologically inert implant materials. J Am Acad Dermatol 1999;40:100-102.

19. Wang J, Fan J, Nordstrom REA. Evaluation of lip augmentation with Gore-Tex facial implant. Aesthetic Plast Surg 1997:21:433-436.

20. Wolf DL. Complications following lip augmentation with Gore-Tex. Plast Reconstr Surg 1995;7:1334-1335.

21. LifeCell Corporation. AlloDerm. Rehydration and application instructions. LifeCell Corporation, Woodlands, TX 77381.

22. Tobin HA, Karas ND. Lip augmentation using an AlloDerm graft. J Oral Maxillofac Surg 1998;56:722-727.

23. Terino EO. AlloDerm acellular dermal graft: applications in aesthetic soft-tissue augmentation. Clin Plast Surg 2001;28:83-99.

24. Austin HW, Weston GW. Rejuvenation of the aging mouth. Clin Plast Surg 1992;19:511-524.

25. Anderson RD, Lo MW. Endoscopic malar/midface suspension procedure. Plast Reconstr Surg 1998;102:2196-2208.

26. Zide BM, Bradley JP, Longaker MT. Lip service for the stiff upper lip with discussion. Plast Reconstr Surg 2000;105:1154-1158.

27. Anderson RD, Lo MW. Lip augmentation. Aesthetic Surg J 1999;19:239-241.

Publishing and Reprint Information

Richard D. Anderson, MD is a board-certified plastic surgeon and an ASAPS member located in Scottsdale, Arizona. To ask Dr. Anderson a question or schedule a consultation, call his office at 480-860-9333 or visit his website at www.andersonplasticsurgery.com.

View Before and After Photos of Lip Augmentation

Information provided is for general education about lip implants, lip augmentation, lip injections and other cosmetic plastic surgery procedures. This information is subject to change. Smart Plastic Surgery.com does not guarantee that it is accurate or complete, and is not responsible for any actions resulting from the use of this information. General information provided in this fashion should not be construed as specific medical advice or recommendation, and is not a substitute for a consultation and physical examination by a physician. Only discussion of your individual needs with a qualified physician will determine the best method of treatment for you. All board certified plastic surgeons listed are board certified by the American Board of Plastic Surgery and/or the Royal College of Physicians and Surgeons of Canada. Board certified plastic surgeons are verified by the American Board of Medical Specialties.