Lip augmentation and rejuvenation using a novel, porcine collagen-derived filler

Journal of Drugs in Dermatology, March, 2008 by Marina Landau

Introduction

There are no universal ideas about the aesthetics of lips, as they vary with cultural beliefs, time, and individual preferences. (1) In an attempt to improve their appearance, many women, prompted by the changes that occur with aging, will seek to augment their lips. Although there is an ever-expanding list of lip-enhancing products on the market, little information on the optimal approach to lip enhancement exists in the dermatological literature. Whenever attempts to improve or restore lips are contemplated, it is important that a number of basic concepts are taken into account.

This article reviews the normal architecture of lips, the changes that occur with aging, and the critical questions that need to be addressed when contemplating lip enhancement. It also provides clinical guidelines for a systematic approach to lip augmentation and rejuvenation, and documents experience with Evolence[R] Breeze[TM], (ColBar LifeScience Ltd, Herzliya, Israel), a novel, porcine collagen-derived dermal filler, developed by Glymatrix[TM] cross-linking technology. (The lip augmentation/enhancement procedure described with Evolence Breeze is currently outside of labeling for the product.) Evolence Breeze differs from the Evolence[R] Classic[TM] formulation currently in use in that it contains collagen fibers of shorter lengths which allow the product to flow through a smaller lumen needle (30G versus 27G with Evolence Classic).

[FIGURE 1 OMITTED]

Normal Lip Architecture and Changes That Occur With Aging

Normal Lip Structure

Externally, the lips consist of skin and mucosa, which is called vermilion; the border between the skin and mucosal layers is known as the vermilion border. Vermilion is red due to the absence of keratin and the close proximity of the underlying rich vascular plexus. It includes both dry (exposed to air) and wet (inner) portions. Deep in the mucosa is an abundant layer of salivary glands and the orbicularis oris muscle.

[FIGURE 2 OMITTED]

The arches of the upper lip vermilion follow the philtral ridges. These arches create the Cupid's bow, which confers a sensual quality to the lip (Figure 1). From an anterior perspective, the lips are located within a line drawn between the pupils of the eyes and the mouth. The upper lip is located 18 to 20 mm from the nose, whereas the lower lip is 36 to 40 mm from the chin. (2) In profile, the nasolabial angle is 80[degrees] to 105[degrees]. It needs to be remembered that distortion of the natural profile of the face may occur if the lip enhancement creates an unnatural fullness of the upper lip (Figure 2). With the head in a postural position, a line (known as Steiner's line) drawn from the mid nostrils to the chin should just barely touch the upper and lower lips. (3)

Evaluation of the upper and lower labial projections should be assessed relative to a line drawn from the subnasal point to the prominence of the chin. The upper lip should extend approximately 3 to 3.5 mm anterior to this line, while the lower lip should extend by only 1.5 to 2 mm. As a result, the upper lip should project approximately 2 mm anterior to the lower lip. However, the lower lip is fuller than the upper lip by a ratio of 1.6:1.

Changes With Aging

Several changes occur to the lips as a result of aging. The lower third of the face loses height because of bone resorption, and the classical proportions of the face are altered. Ptosis of the glabrous skin (non-mucosal part) of the lip occurs due to demineralization of the maxillae, alveolar resorption, and aging of the soft tissue. Skin laxity increases, the mouth commissures droop, and marionette lines and perioral wrinkles develop (Figure 3). Fine wrinkling of the lip surface and solar changes also affect the overall facial look. However, the most obvious change is a loss of fullness and projection of the lips. This is due to a decrease in the volume of dentoalveolar structures, lip musculature, and subcutaneous fat. Smoking and sun exposure significantly affect these degenerative changes of the lips.

Systematic Approach to Lip Augmentation and Rejuvenation

Lip Assessment

Before embarking on augmentation procedures, a thorough lip assessment should be performed. The main questions that need to be answered from this evaluation are: (1) Do the lips need only volume enhancement (augmentation)?; (2) Do they need reshaping?; and (3) Do they need rejuvenation?

Pretreatment Procedures

Before the lip augmentation procedure, patients should be advised to stop, if possible, any use of anticoagulants, aspirin, and nonsteroidal anti-inflammatory drugs. Oral antiviral drugs active against Herpes simplex virus are important for the prevention of herpes labialis and should be started 24 hours prior to the procedure in patients with a history of recurrent herpes labialis.

Before scheduling the procedure, patients should be informed that immediately post-injection, swelling is almost unpreventable. Therefore, the procedure should be scheduled for an "event-free" time, and the patient should be advised that the final appreciation of the results will only be possible 2 to 3 days following the procedure.