I am honored to welcome Dr Lisa Vuich as our first first blogger. Dr Vuich has decades of experience in the art and science of facial aesthetics, and is a foremost leader in her field. She is keeping us all beautiful. Enjoy her post, i know I learned a great deal. Cheers, Pamela.
Nobody Wants to Kiss a Duck- Best Approaches to Natural Looking, Fuller Lips
-Lisa Vuich, MD
One of the most commonly requested procedures at Renew MediSpa is lip filler, and at least here in the Northeast the greatest fear I encounter regarding this area is that the result will look comical, unnatural, and as we say “duck like”. Lips have been getting even more attention in the media in the past few years, fueled in part by celebrities such as Kylie Jenner. It seems there is no end lately to topicals and devices in the cosmetic industry, promising a bigger pout for not a lot of dough. Most recently I was shocked to see an advertisement for a device which applies suction to the lips to get them to engorge- with names like Fullips, Candylipz and JuvaLips (only $129.95!). Juvalips in particular has a lot of negative reviews with reports of lips turning blue, feeling numb and bruising. The results of these suction devices last less than an hour (sometimes only minutes)- all I could think was, “Excuse me, can you order my drink, I need to go to the ladies room and re plump my lips…”
Topical lip plumpers also work by attempting to enhance blood flow as well as hydration, albeit very temporarily. And none of these “solutions” will address the very common associated concern of unwanted lines around the lip. Naturally, those looking for lip enhancement or rejuvenation of the perioral region in general are looking for correction that will last longer than what can be provided by these over the counter fleeting fixes.
The Science of Dermal Fillers
Enter dermal fillers, the most popular choice for lip enhancement in a medical spa setting. Although other more invasive options exist (silicone implants, fat transfer), most clients are not looking to go under the knife for 3 main reasons- cost, risk, and the fear of looking unnatural. The dermal fillers used for lip enhancement are primarily made of hyaluronic acid or “HA” for short. HA is a substance found throughout your body, and in fact it is a naturally occurring sugar. In its pure form it is a powder, and if injected without modification it would dissolve rapidly.
By chemically crosslinking the HA, usually with a substance called BDDE, the HA is stabilized and will have a longer lasting effect wherever it is placed. All of the dermal filler manufacturers use the same HA. What differs is how they then process it, primarily how much they cross link it. The modifications made will affect the physical properties of the filler- how stiff, how elastic, how much it resists deformity for example and to some extent how long it will take to dissolve. Some of the most popular dermal fillers for the lip are Restylane SILK, Restylane Refyne or Defyne, and Juvederm Volbella.
Sculpting the Lip- Techniques of Placement
Dermal filler injection is an art as much as it is a technique. The experienced injector, with an artistic eye, will evaluate the lip proportions and discuss goals with the client- Fuller? Wider? Larger? More pout? Enhance the Cupid’s bow? Correct perioral lines? Turn corners of the mouth up? Many times due to age related changes the upper lip has thinned more so than the lower, and keeping proper proportions intact is an important consideration as well. Sometime we are correcting a natural asymmetry, to better balance the lip volume. After some local numbing has been achieved, the least traumatic placement is with the use of a microcannula. Think of a microcannula as being a very thin, stiff but flexible and blunt tipped hollow probe. It has a hole at the end allowing filler to flow into the region of interest, and the filler syringe attached to the other end.
Microcannulas have enabled us to deliver smoother results with greater safety and less bruising, whereas straight (sharp) needle technique requires multiple punctures which means more lip trauma, more pain, more swelling, more bruising and a greater likelihood of “lumps”.
Here are some of the most common questions I field when consulting with clients about lip injections:
How much filler do I need?
It can be difficult to know, especially if you have never done lip filler before, how much volume you are looking for. Sometimes clients bring in photos of lips they consider to be ideal. In some instances, it will take more than 1 syringe to achieve what is presented in these photos. However, we usually recommend that a client start with a single syringe, let it settle for a few weeks, then decide whether to add more. This allows for a more gradual change which is usually appealing to them. If they opt for a second syringe, we may use all or just some of it in the lip. It really all depends on desired volume and keeping the look natural. If we don’t need all of that second syringe for the lip, we can usually find somewhere else to place it that will further rejuvenate the client’s appearance.
How long will I be swollen?
The amount and duration of swelling is variable and depends on several factors including your own genetics (histamine response), the technique of placement (less swelling with microcannula), and the characteristics of the filler brand (some do cause more temporary swelling than others). In general it is usually not more than a couple of days, and in truth many clients “miss” some of the swelling when it is all gone, which is a good clue that they are looking for more volume!
Will it look natural?
Today’s dermal fillers have a wide variety of properties which help us enhance volume without creating a stiff, unnatural looking “sausage lip” as I call them. We have fillers such as Restylane Refyne and Restylane Defyne, two of my favorites for this region, which are very flexible and move naturally.
How often will I need to repeat the injection?
Most clients will have lip filler done once or twice a year- perhaps every 6 to 8 months. It really depends on the rate at which it dissolves (it lasts longer for some than others) and what is your tolerance for losing all or part of the “correction”. At 6 months there is often still some filler effect, but a client is starting to miss the lost volume so they will touch it up. Over time, with repeat injections, I see clients going about 8 months in between injections.
Once the filler goes away, will my lips be “stretched out”?
The answer is no. Our body tissues accommodate subtle changes in volume up and down thanks to tissue elasticity. I have never seen a lip look “deflated” after the filler is gone. If anything there is some improved volume due to the small amount of collagen stimulation produced by the filler while it is present in the region.
Which filler is “Best”?
There is no “best” filler. There are options, but there is no best. My word of advice to clients and potential clients is this: Worry less about what is in the syringe, and more about who is holding the syringe. Chose an injector the way you would chose an artist, expect to see before and after images of work they have personally done, and be sure your questions have been answered to your satisfaction.
What is the cost of dermal filler lip enhancement?
Most spas will charge “per syringe” with prices ranging from $525 to $750 on average, for a 1 ml syringe. That may seem like a wide spread in pricing, but there are as with anything regional differences in pricing of cosmetic services, and some of the difference can be accounted for by differences in overhead costs, injector acquisition cost for the product (what the syringe costs the injector to purchase). If you see a practice advertising a much lower price, it is time to ask some pointed questions as to how much volume you are receiving, where is the product coming from, and what is the skill level and experience of the injector. It is illegal to import dermal fillers from other countries (at a markedly reduced cost compared to what we pay here in the U.S.) because the FDA is not in control of how facilities outside of it’s domain are storing and safeguarding the integrity of the materials. Nevertheless, some practices will violate this law which is a risk of their medical license, not to mention their client’s safety. There is no telling how a product has been handled or mishandled when it is being transported long distances. Practices in the United States must receive their product direct from the US manufacturer to comply with federal laws.
I don’t smoke so why do I have “smoker’s lines”?!
Think about how much movement occurs about the mouth on a daily basis and it is easy to imagine why collagen breaks down sooner here than many other places. Of course genetics and muscle habits play a role. I am often suggesting that clients stop chewing gum and sipping on straws. Sun damage will also lead to premature collagen loss. These lines can be addressed nicely with dermal filler, and more and more often now I am combining the dermal filler with platelet rich plasma (PRP) to further enhance the collagen stimulation achieved with the procedure, and sometimes also with collagens stimulating “smoothing threads” which can also be placed in regions where you want smoothing but not necessarily more volume. PRP is a portion of your own blood, obtained at the time of injection, which contains your growth factors and is injected using the same technique we use to inject dermal filler. Although it does not provide immediate volume the way dermal filler does, some clients opt to do this instead if they are looking for “the very most natural approach, without injection of any chemical substance”. Smoothing threads are available that can be placed with a needle technique and will provide some ongoing collagen stimulation in the region in which they are placed. They are often made of PDO, which is a suture material that has been used in medicine for many decades. And of course, we have many other procedures for collagen building such as laser and medical microneedling which can be used for surface smoothing. All of these options, which are beyond the scope of this discussion, can be used to combat age and sun damage related changes in the perioral region. The benefits and expectations from each option can be reviewed with you by your experienced injector, so that you make an informed decision about how you would like to proceed.
Lip injection and perioral rejuvenation are some of the most common procedures performed in any medical spa. We have literally decades of experience with dermal filler and they are among the safest of cosmetic medical procedures performed worldwide. Literally millions of these injections are performed every year throughout the United States and abroad. Injector experience and artistic eye are of paramount importance in ensuring a desirable and aesthetically pleasing outcome. There are some non-filler options which can also be considered and are offered at more advanced spas. Your aesthetic service provider is your best resource, helping you navigate the many options available today and ensuring that you are making informed choices. Collagen loss is inevitable, but we can still “grow old gracefully” by softening the effects with the many tools now available to us in the non- surgical aesthetic realm.