AH'S FLAGSHIP CLINICAL APPLICATIONS.
Aesthetic facial health and HA
LIP ENHANCEMENT: A NATURAL, SUBTLE APPROACH.
Céline DOLLANGÈRE, MD.
Aesthetic Physician, Roissy en France
"We need to sublimate without transforming!"
Summary
From ancient times to the present day, lips have always been a symbol of sensuality and attractiveness, and the methods used to beautify them have evolved with cosmetic and technological innovations.
Thanks to the artistic and anatomical references that define the beauty of the lips and their proportions in relation to the face, today's aesthetic physicians are able to magnify them using various hyaluronic acid injection techniques.
Key words: Lip enhancement, Hyaluronic acid, Perioral wrinkles, Injection techniques, Russian lips.
INTRODUCTION
In the field of aesthetic medicine, hyaluronic acid injections in the lips have become one of the most popular and sought-after procedures in recent decades.
Statistics show a spectacular increase in lip injection procedures worldwide, underlining a sustained and growing interest in this type of intervention.
This trend reflects a growing quest to improve physical appearance, which can have significant psychosocial implications.
Since ancient times, lips have been a symbol of seduction and femininity in many cultures, and their enhancement can have a profound impact on self-esteem.
However, societal pressure, exacerbated by the omnipresence of social networks, to match beauty ideals can lead to unreasonable and unrealistic demands on the part of patients.
It's up to us doctors to apply our scientific and anatomical knowledge, and our artistic skills, using criteria that govern beauty and harmony, to magnify our patients' lips.
SOCIOLOGY
The gaze and the mouth are the key elements of social interaction between 2 individuals.
Research conducted by Beattie using eye tracking technologies have shown that men tend to look first at the eyes, then at the mouth when they see a photo of a female face.
Lip color also has an impact on visual attraction because on average, red lips hold men's attention for around 7.3 seconds, compared with 6.7 seconds when they're nude [1].
Women with colored lips can therefore be perceived as more attractive and seductive.
This observation ties in with evolutionary theories suggesting that redder lips may signal better health and increased fertility.
The same applies to the size of the lips which can instinctively provide information on health and reproductive capacity, thus influencing social preferences and perceptions.
MORPHOPSYCHOLOGY
Anthropometric and psychological studies have been carried out to explore the correlation between lip size and personality perception.
The 2018 study by Koidis et al. determined that people with fuller lips were often perceived as more outgoing and sociable.
Thin lips were associated with more reserved, introverted personality traits [2].
A study by Little et al in 2011 has analyzed how the shape of the philtrum influences social perceptions.
The results showed that faces with a well-defined philtrum were perceived as more attractive and reliable, and that changes in philtrum shape could alter impressions of youth and vitality [3].
However, all these studies must be interpreted with caution, as they do not always take into account individual variations and cultural and social influences.
EPIDEMIOLOGY
The demand for lip injections in aesthetic medicine has grown considerably over the last few decades and years in particular.
In the survey conducted by International Society of Aesthetic Plastic Surgery, the number of lip injections rose by 29 % between 2022 and 2023 worldwide [4].
In the United States, according to data from the American Society of Plastic Surgeons (ASPS), lip augmentation procedures have seen a significant increase.
In 2022, lip-filling injections were one of the most popular procedures, with almost 1.4 million treatments performed [5].
A survey by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) by 2021 revealed that lip augmentation accounted for around 30 % of facial fillers.
In 2022, the International Society of Aesthetic Plastic Surgery reported around 5.5 million dermal filler procedures worldwide.
30 to 40 % of these injections are estimated to be performed in the lips, giving an estimate of 1.65 to 2.2 million lip injections per year.
In Europe and France in particular, the trend is similar.
A survey by the International Society of Aesthetic Plastic Surgery (ISAPS) has shown that filler injection procedures, including for the lips, are among the most popular in several European countries.
In 2021, over 20 % of aesthetic medicine procedures involved filler injections.
France ranks 7the in the world for the total number of injectable aesthetic procedures, and in 4th place for the number of aesthetic procedures performed.e ranking for Hyaluronic Acid injections, with 234,900 procedures in 2023.
In France, among these injectable procedures, injections of lip fillers are growing rapidly.
According to reports from the French Society of Aesthetic Plastic Surgeons (SOFCEP), requests for lip augmentation have grown steadily.
By 2022, dermal fillers for the lips accounted for around 25 % of aesthetic medicine treatments.
The global dermal filler market was estimated at around 5.8 billion USD in 2020, with growth forecast to reach 9.4 billion USD by 2028. A significant proportion of this growth is attributed to lip augmentation procedures.
HISTORY OF LIP BEAUTY
The history of lip beauty is fascinating and goes back thousands of years, with criteria that vary according to culture and time.
The history of lip beauty reflects social, cultural and technological developments. Lips have played a central role in aesthetics and seduction throughout the ages.
From ancient times to the present day, they have been celebrated as a symbol of beauty, power and desire.
The way lips are represented and perceived continues to evolve, but their role in expressing seduction remains constant.
As far back as ancient Egypt, Women valued colorful, well-defined lips as a symbol of desire and sensuality. They used natural pigments, such as red extracted from cochineal or red ochre, to tint their lips. Cleopatra was a fan of make-up and lipstick in particular, which was made from natural substances mixed with waxes to form balms.
Greek and Roman Antiquity saw a temporary decline in make-up, as a pale complexion was considered a sign of beauty. Women used mixtures of chalk and lead to achieve this pale effect, abandoning lip coloring in the process
In the Middle AgesHowever, lip make-up was often frowned upon, especially by the Church, which considered it immoral. Women seeking to enhance their natural beauty used plant- and fruit-based recipes to give their lips a light color.
RenaissanceLipstick enjoyed a renaissance, especially among aristocrats inspired by classical art. Women used red pigments and oil blends to give their lips a more radiant appearance.
It was a symbol of social status and seduction.
In France, at the court of Versailles, lip make-up became very elaborate and sophisticated, with bright colors and exaggerated shapes. Women, like men, wore lipstick, often in bright red or purple tones.
In the XIXe century, lip make-up is becoming more sober and discreet. Yet lips remain an essential element of feminine beauty, celebrated by romantic writers and artists who continue to depict them as a symbol of love and temptation.
In the 1920s, The era of jazz and flappers saw the rise of dark lips with a well-defined Cupid's bow. Lipstick becomes a symbol of emancipation for women
In the 1940s and 1950sWith icons like Marilyn Monroe representing glamour and femininity, bright red lips became emblematic.
In the 1960s, the influence of pop culture is bringing about changes, with paler shades leading women to use nude or pastel shades.
In the 1980s, we see a return to bright colors and exaggerated lips, in harmony with the bold fashion and pronounced make-up of the time.
Since the 2000s, we're seeing a variety of trends influenced by celebrities and social networks, with lips ranging from nude to bold, bright shades.
EMBRYOLOGY
The beauty of the lips is rooted in complex embryological processes.
Understanding the development of the lips allows us to understand and magnify the different reliefs of this delicate anatomical region in a natural way.
The lips begin to form between the fourth and sixth weeks of gestation, from 5 structures called facial buds.
The fronto-nasal bud contributes to the formation of the philtrum and the central part of the upper lip.
The maxillary buds will form the lateral parts of the upper lip, fusing with the fronto nasal bud to form an upper lip made up of 3 masses.
In the lower stage, only 2 mandibular buds fuse, forming the lower lip, which is composed of 2 masses [6].
A harmonious face is usually defined by horizontal proportions of equal height that satisfy the 3/3 rule:
The upper third from the trichion to the glabella.
The middle third from the glabella to the sub-nasal point.
The lower third from the sub-nasal point to the chin. This last part is itself divided into 2 parts:
-
The upper third, from the sub-nasal point to the stomion (point of contact between the upper and lower lips)
-
and the remaining 2/3 from the stomion to the chin point.
The commissures are located in line with the lowered lines of the inner part of the iris, or at the maximum of the pupil.itle.
The profile view features aesthetic markers that define the optimal lip projection.
Ricketts line The line from the tip of the nose to the chin should be approximately 4 mm in front of the upper lip and 2 mm in front of the lower lip.
Steiner line : the line joining the two lips should not exceed 10 to 15° from a vertical, and should "intersect" the nose at the anterior part of the nostril.
Burstone line: the line between the base of the nose and the chin should be about 2-4 mm behind the upper lip and 1-2 mm behind the lower.
Attractive lips and perioral area must encompass the following anatomical landmarks:
-
The upper cutaneous lip or white lip should be smooth, without fine lines, with a central depression called the philtrum.
-
In profile, the upper cutaneous lip is fairly short and concave.
-
The philtrum is delimited laterally by two diverging lines or ridges called "philtral ridges", by the columella in its upper part, and by the central part of Cupid's bow in its lower part.
-
The vermilion border or mucocutaneous junction line should be a fine but well-defined line.
-
The vermilion body or red lip is covered by a stratified squamous epidermis that is continuous with the buccal mucosa, which consists of an epidermoid-type epithelium. This specialized epithelium in the vermilion has slight fractures that must not be erased by lip beautification procedures, as they are the equivalent of our fingerprints.
-
The presence of important sub-units called "tubercles" should not be overlooked. These are natural areas of dermal prominence, known to be embryological remnants, as we saw earlier.
-
There are generally three on the upper lip (one medial: rostrum, two lateral) and two on the lower lip.
-
The red lip should be curved, of reasonable height, full in the center and tapering towards the corners of the mouth.
-
The corners of the mouth should be straight or slightly raised in relation to the central line of the lips, which should be curved to match the shape of the lips.
-
The periorbital frame of the lips should be smooth, without static or expression lines such as bitterness folds [7].
A study published in the Journal of the European Academy of Dermatology and Venereology in 2023 defined the most attractive proportions based on the thickness of the vermilion, the distance between the upper and lower lip in relation to the nose and chin, and the bigonium distance.
Another study, published in JAMA Facial Plastic Surgery in 2017, set out to determine the most attractive lip dimensions in Caucasian women based on the surface area occupied by the lips in the lower third of the face, as well as the upper lip/lower lip ratio.
Using a statistically rigorous process with over 500 participants, it was found that an optimal increase of 53.5 % in lip area compared to the original photo, and a lip area representing 9.6 % of the lower third of the face, are important factors for mouth aesthetics.
In this study, an upper lip:lower lip ratio of 1:2 was considered the most attractive, meeting the ideal dimensions [9].
All these data remain scientific and statistical, because in practice we observe that many patients, especially among the younger generations, are more attracted by the1:1 ratio.(figures C and G).
CLINICAL CASES
We have detailed the optimal anatomical and artistic guidelines concerning the position and dimensions of the mouth in relation to other facial elements, as well as the constituent elements of the mouth such as the philtrum, cupid's bow, white lip, vermilion and commissures. With the help of these guidelines, we'll take a look at a number of clinical cases to illustrate how to magnify or rejuvenate the mouth using hyaluronic acid injections.
Depending on the generation, patient demands and injection techniques will differ.
For baby boomers (born between 1945 and 1960) and Gen-Xers (born between 1960 and 1980), it's all about repairing the ravages of time.
Lhe aging of the lips results in :
-
loss of volume in the vermilion area;
-
a mucocutaneous junction or vermilion border that becomes less defined;
-
elongation of the white lip, with flattening of the philtrum and Cupid's bow; appearance of peribuccal wrinkles.
-
loss of muscle tone around the mouth, leading to sagging and drooping mouth corners.
The causes of this ageing are due to:
-
thinning of the epidermis due to loss of collagen and elastin, and atrophy of the orbicularis oris muscle.
-
In addition, bone resorption contributes to a reduction in the height and width of the mandibular and maxillary bones.
-
Tooth wear and loss can also alter the position and support of the lips, contributing to an older appearance.
In the 2 cases presented, the vermilion was treated to rehydrate it without adding too much volume, in order to maintain a classic ratio consistent with age..
-
The hemline has been redefined on the middle part of the upper lip to avoid the "lipstick that runs" phenomenon.
-
The white lip and perioral fine lines were treated with fluid hyaluronic acid using the "blanching" technique.
-
The labial commissures were treated with a fairly volumizing hyaluronic acid using the "fanning" technique to create a supportive sub-commissural triangle.
For this Generation X patient, the goal was to rejuvenate her mouth..
To achieve this, a moderately cross-linked hyaluronic acid was used to rehydrate the vermilion.
The Cupid's bow has been redefined to give relief and youthfulness to the mouth without increasing lip volume too much.
We notice that the shape of the mouth, which was concave downwards, has regained an upward concavity, giving a rejuvenating, more cheerful effect.
This patient, a former smoker, had wrinkles on her white lip, which were treated with fluid hyaluronic acid using the "blanching" technique.
The next generation, Generation Y also known as "Millenials born between 1980 and 1995 played a significant role in popularizing lip injections.
This generation, often highly connected and influenced by social media like TikTok or Instagram where celebrities and influencers post testimonials about their own procedures, is much more open to aesthetic modifications than previous generations.
This uninhibited generation, which attaches great importance to its physical appearance and that of its lips in particular, had set itself the goal of achieving showy, long-lasting lip volumes, following the example of some famous influencers.
This has led some practitioners to inject large volumes of moderately cross-linked fillers, or to use volumizers that are unsuitable for this delicate area.
We then saw the emergence of a large number of young girls with outrageous and disproportionate lip volumes, with mouths defined as "grouper mouths", "duck beaks" or other "sausage lips".
These disparaged and often mocked results, unfortunately not always performed by doctors, have contributed to a poor image of aesthetic medicine.
To avoid these unsightly results, the "Russian Lips" technique was introduced in 2019/2020.
This technique is particularly popular with Generation Z born between 1995 and 2012driven by selfies, the race for likes and self-improvement.
This generation with a strong propensity for narcissism and selfishness is flocking to aesthetic medicine practices for preventive and beautifying aesthetic procedures.
Paradoxically, however, there is a renewed interest in naturalness and authenticity, a phenomenon echoed by the many female influencers and reality TV starlets who are having their hyaluronic acid injections removed.
The "Russian Lips" technique has revolutionized the approach to lip augmentation, offering a precise and delicate injection method for naturally full, well-defined lips.
This technique is characterized by a particular accentuation of the Cupid's bow and philtrum, giving the lips a sharper contour and uniform volume, with a marked vertical projection without too much horizontal stretching.
Injection of the philtral ridges should be deeper, retrograde from the columella (without injecting there) to the hemline. Don't inject under the ridges, but inside them, otherwise you'll end up with too great a gap.
But beware: philtral ridges are not suitable for all mouths. The thinner the lip, the less philtrum. Attempting to reconstitute a philtrum that never existed would render the result unnatural and therefore unsightly.
The aim of this technique is to create voluptuous shapes with an appearance that is less swollen laterally and more lifted in the center. The technique involves injections of moderately cross-linked hyaluronic acid with a 30G needle at the sub-mucosal level.
The product is injected retractively from the hemline towards Klein's line (the junction between the dry red lip and the wet red lip), at a rate of 4 to 6 vertical lines in the center to oblique lines laterally per hemiliped.
Injections can be adjusted to suit the unique characteristics of each patient, enabling a high level of personalization.
In addition to its natural, aesthetic result, this technique has the advantage of reducing vascular risks, as the injections remain superficial.
In fact, in 60 to 80 % of cases, the superior and inferior labial coronary arteries, branches of the facial artery, are located in the deep layers of the lips on the endobuccal, supramuscular side.
However, caution is always called for in medicine, as anatomical variants of arterial structures can be found intramuscularly in 18 to 38 % of cases, and subcutaneously in 2 to 5 % of cases.
CONCLUSION
Thanks to their scientific and anatomical knowledge, aesthetic doctors work on beautifying and rejuvenating physical appearance, and the lips in particular. But this approach requires him to train his eye in the sense of beauty, to develop his artistic skills.
To improve the perception of aesthetic medicine, it is essential that practitioners adopt ethical practices, prioritize natural results and educate patients on realistic expectations.
A patient-centred approach, with objective advice and appropriate management of patient expectations, is crucial to maintaining the reputation of our profession.
The medical aesthetic care provided must make you more beautiful, more youthful, more rested, while remaining undetectable.
We must sublimate without transforming!
BIBLIOGRAPHY
-
Beattie G. et al. Effect of Lip Color on men's Attention to the Mouth: The Role of Cosmetic's in the Perception of Facial Attractiveness. The QuarterlyJournal of Experimental Psychology, 2010.
-
Koidis P. et al. Lip Dimensions and Personality Perception. Journal of Facial Studies 2018.
-
Little A.C. et al (2011) The Role of the Philtrum in Perceptions of facial Attractiveness. Evolution and Human Behaviour.
-
International Survey on aesthetic /cosmetic procedures performed in 2023.
-
2022 ASPS Procedural Statistics Release.
-
Khonsari R.H.,Catala M. Development of the Face. EMC-Oto-rhino-laryngology 2018 ;13 (2) :1-10 (20-264-A-10).
-
Vania Hiratsuka Dalmedo Lips and the perioral area: anatomical considerations for safer and natural results. The PMFA Journal, 2 August 2023.
-
Kempa J., Alfertshofer M., Swift A., Green J.B., Antoszewski B., Timler W., et al. The perception of lip aesthetics in the context of facial proportions-An eye-tracking-based analysis. Eur. J. Acad. Dermatol. Venereol. 2023 ; 00 : 1-12. https:// doi. org/10.1111/jdv.19727
-
Popenko N.A., Tripathi P.B., Devcic Z., Karimi K., Osann K., Wong B.J.F. A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness. JAMA Facial Plast Surg 2017 Jul 1; 19(4): 261-7. doi: 10.1001/jamafacial.2016.2049.
