LIP FILLING

punjenje usana

INTRODUCTION

If we say that eyes are the mirrors of soul and that nose is the reflection of character, mouth is for certain the reflection of sensuality. Indeed, when we talk about the face esthetics, there are three main esthetic features that you will initially notice on somebody's face and they "struggle" for domination - mouth, eyes and nose. Certainly, other parts of face are also relevant, such as eyebrows, ears, chin, forehead, teeth, a specific mark or hair. But, mouth, eyes and nose are somehow always in the fore plan.

Herein we shall discuss mouth. It is amazing how many substantially important and different functions mouth has performed and can perform.
Their primary function is speech articulation, speech being a crucial characteristic of human species with all its complexities and diversities. Then we have singing, playing various musical instruments, flute, trombone etc. Then we have nutrition - both food and drink are consumed through mouth. More than 10 twin, exceptionally fine and subtle muscles participate in all diversified movements of lips and their tonus.
Then we have breathing. The air comes into our lungs both through mouth and nose, notably in cases where breathing through nose is difficult or impossible.
A very special place is reserved for their expressive, mimic role - mouth can express a number of different emotions, starting from sorrow, disappointment, pain, anger and rage through to joy, cheerfulness and pleasure. This expressive role, together with speech, is of exceptional importance in communication with other people, as the movements of lips give the impressionistic and emotional component to the words being said.
And then smile and laughter. A renowned colleague once wrote that smile is the cheapest and easiest way of beautification! So true! Other say that 1 minute of cheerful laughter extends life for 10 minutes. This may not be completely true, but there is certainly some truth in it. Mouth is a very sensitive tactile organ - it helps us feel whether something is warm, cold or hot, rough or smooth, soft or firm.
Then there is the sexual role - mouth being one of the most sensitive erogenous zones, kiss, kissing and so forth… Observation of mouth as sexual organ is actually based on their visual attractiveness and on their extremely high sensitivity to touch. That is why kissing is a sensation-linked with pleasure.
And this is all MOUTH! We have not yet mentioned the central topic of this text, namely their purely esthetic role, mouth as a face ornament!

ANATOMY

Mouth is composed of three main segments: skin, mucous membrane and muscle in between. Topographically, they spread from the nose base and nostrils up, on the sides they are limited by nasolabial sulcus (nose-mouth) and oral commisures (angles), and their downward limits are represented by mentolabial sulcus (chin-mouth).
The most prominent part of mouth is Vermilion or red part of the lips. By its unique red colour and specific shape, it is very prominent in the face and it is for many people considered the synonym for mouth. Vermilion is composed of extremely thin skin that is deprived of the so-called corneous skin tissue, so that the red colour of the blood from a dense grid of capillaries underneath is practically transparent and gives the unique scarlet red colour, which is a phenomenon that exists only with humans. This red colour is particularly visible on the Caucasian race, whereas it is only visible in traces with the coloured persons.

Other significant anatomic and esthetic structures of mouth:

  1. Philtrum (vertical groove in the central part of the upper lip, extending downward from the nasal septum and composed of two parallel vertical reefs and a more-less narrow groove between them)
  2. Cupid's bow (structure in the "V" shape at the philtrum's base)
  3. Central Tubercle (central prominent and rounded part of the upper lip Vermilion)
  4. White-Roll (sometimes very visible, actually represents a limit between the Vermilion and skin)
  5. Wet-Dry Line (visible only when mouth is open and represents a limit between Vermilion and mucous membrane)
  6. Commisures (angles where upper and lower lips meet)
  7. Lateral fullness
  8. Medial depression
  9. On the lower lip the structures are oppositely placed than on the upper lip - there is a mild central depression in the middle and two more visible tubercles are on the sides tubercle

Alike fingerprints, the shape and size of the mouth differ from one person to another. This is genetically conditioned, whereas external factors are also very influential, such as ailments, smoking and of course, the ageing process. Overall, it is deemed that fuller and thicker mouth is more attractive, more sensual and a youthful mark. With young women, certain studies demonstrated a direct link between the mouth thickness and high level of estrogen, which can also be linked with fertility. Therefore, the ideal is that both lips are symmetrical, full, fresh and soft in appearance, that lower lip is thicker than the upper, the upper one being mildly lifted with a clear, well-defined, lifted and strong white line, distinctive and well-defined by Cupid's bow in "V" shape, slightly curved and full central tubercle and uplifted angles!

There are 3 basic mouth standard types:

  1. thick,
  2. thin (and flattened),
  3. thin upper and thick lower lip.

As regards the width and angle position, mouth can be:

  1. wide,
  2. narrow (small) or
  3. curved (angles uplifted).

With the ageing process, lips are more or less thinning (upper lip more progressive than the lower one), they lose their volume and protrusion, upper lip is curving down and the upper lip takes the inverted position compared to the previously everted one, so that eventually the upper and lower lip become almost equal by thickness i.e. they both become thin. In addition, tiny and radial lines start to appear on the lips.

PHYSICAL EXAMINATION

There is a vast number of parameters to be observed during lip examination and many of them can be corrected:

    1. Thickness-fullness (thick, thin)
    2. Contour (sinusoidal or flat)
    3. Eversion (lifted upwards or downwards)
    4. Colour
    5. Texture (lumpy, smooth)
    6. Angle position (ascedent-uplifted, horizontal, downward-oriented)
    7. Width (from angle to angle) (wide, narrow)
    8. Central part (shape and size of tubercle and Cupid's bow, as well as philtrum)
    9. Relation to the tip of the nose (distance from the nose base, short lip, long lip, stiff lip)
    10. Muscle activity (hyperfunction, hypotony, status without and with movement)
    11. Lip wrinkles (with and without movement)
    12. Asymmetry (physiological, pathological)
    13. Position of teeth and jaw bone structures
    14. Lip scars
    15. Traces of previously injected substances

INTERESTING FIGURES

LIP CORRECTION

There are several techniques for increasing-enhancing-lifting-reshaping of lips, and they can be classified as follows:

  1. NON-SURGICAL TECHNIQUES
    a) where the increase is achieved by application of different injectible substances, whether temporary or permanent
  2. SURGICAL TECHNIQUES
    a) where the increase is achieved by transplantation of own tissue (fat, dermis, fascia, tendon) or by use of synthetic implants (Goretex, Softform, Ultrasoft)
    b) surgeries such as lip-lifting, multiple VY-plasty, philtropexy etc.

SUBSTANCES USED FOR LIP THICKENING

There is a number of substances used for lip thickening. They belong to the group of so-called Soft tissue fillers (to fill - fill up, refill) and they are used for filling, enhancing and increasing the soft tissues, primarily of skin and subcutaneous tissue, but also for others than the mouth, such as correction of wrinkles and lines, different skin irregularities, defects etc. These are the substances that are either in form of thick fluid with high viscosity, or suspensions of macro particles - micro spheres. There are currently more than 70 substances of this kind in the world market!
Unfortunately, a perfect and ideal soft tissue filler has not been produced yet. And indeed, such substance would have to meet a large number of criteria:
It would have to be safe, non-toxic, non-cancerogenous nor teratogenous, it must not result in allergic reactions, it would have to be long-lasting yet reversible (to be easily removed if necessary), not to migrate, to be soft, not to be pulpitable, to adequately follow the process of tissue ageing, to be easily applicable, to give predictable reactions and results, to have minimum trauma and reconvalescent period and not to be expensive.
Having in mind that there is a vast number of this kind of substances, the question of their classification naturally comes about. Depending on the criteria applied, they can be classified in several ways:

    1. AUTOLOGOUS/HOMOLOGOUS/HETEROLOGOUS
    2. ORGANIC-BIOLOGIC/NON-ORGANIC-SYNTHETIC
    3. TEMPORARY/SEMI-PERMANENT/PERMANENT
    4. BIODEGRADABLE/NON-BIODEGRADABLE
    5. COMBINED

One of the most approved classifications is according to whether they can/cannot be decomposed in the tissue i.e. whether they are biodegradable or not.

PREPARATION, TECHNIQUE, RECONVALESCENT PERIOD

Lip enhancement has definitely become one of the most frequent so-called "ambulance" esthetic surgeries. People of different age are interested in this type of intervention, mostly female but also increasingly male population. The intervention is done under a local anesthesia (topic, infiltrative) or regional block anesthesia, sometimes even general anesthesia when performed within a substantial surgery (face-lifting, nose etc.). In case of injectable fillers, the intervention is rather short (15-30min), whereas in case of tissue transplantation (fat, fascia etc.) or a surgery (lip-lift, VY-plasty etc.) it takes a bit more time, sometimes even in two or three sessions.
Interview and examination are mandatory prior to any intervention. Doctor should introduce the patient to basic facts of different substances and different surgical possibilities, on variety of impacts, effects and possible complications. Based on the current state of the lips (thickness, width, edge shape, angle position, state of skin and subcutaneous tissue, muscles, possible existence of wrinkles, prior interventions etc.) and taking into account specific desires of individual patients, the doctor establishes the required quantity of substance in millimeters (ml) or cubic centimeters (ccm).
Following the intervention, there are swellings that are rather mild with some patients, whereas they are more intense with others. Major swelling shall withdraw after 2-4 days and it would fully disappear after 7-10 days. Bruises are also frequent and they usually disappear after 5-10 days. The lip is often hard and tense, with possible temporary itching. The patient obtains necessary instructions for behaviour in the post-operation period, in terms of possible use of cold compress, massage, use of antiedematous and analgetic therapy, as well as substances for bruise treatment. The examination is usually scheduled after 15 days. Possible minor re-fillings, correction of irregularities and asymmetry is done after one month or earlier when necessary.
Significant notes for the patient in post-op period are as follows:

  1. avoid solarium, sauna and generally exposure to sun and heat /-15 days/
  2. avoid very low temperatures as well
  3. avoid heavy physical activity (fitness, gym, jogging etc.)
  4. refrain from expressive mimics (laughing, chewing, kissing)
  5. avoid aggressive cosmetics treatments
  6. do not consume alcoholic drinks
  7. stop smoking!?
  8. avoid medicaments with acetylsalicylic acid (Aspirin)
  9. face and teeth washing with gentle movements

COMPLICATIONS

  1. EARLY /FIRST 3 DAYS/
    - rash, swelling, bruises, hardness and tenseness, itching
  2. LATE
    - infection, discoloration, reactivation of herpes, persistent local symptoms (rash, swelling, hardness, itching), teleangiectasis, dislocation of preparations, asymmetry, nodulus, granuloma, ulcerations

What is most annoying both for patients and doctors is certainly the occurrence of the so-called "lumps", which are bothering the patients even when the lumps are not visible. Naturally, if visible, these lumps impair the natural and attractive effect of the lips and they may even cause the deformities.
We are herein discussing the two completely different phenomena which are both appearing as bigger or smaller, individual or multiple, soft or hard - "lumps".
These are nodulus and granuloma:

  1. Nodulus appears during the first 2 months, it is usually individual and the size of lentil bean or a smaller pea. It is clearly distinct. Sometimes it can be eliminated by massage, and if not, the only solution is to await the spontaneous resorption (if the material is resorptive) or to undertake a surgical excision.
    The cause of nodulus is most often the inadequate injection technique.
  2. Granuloma appears later, after 6 months, one or more years, almost always in multiple numbers and its size is bigger than the nodulus, sometimes it even spreads to the surrounding tissues. The recommended treatment is application of corticosteroids, locally and systematically, which is fairly successful. Such mutations even disappear spontaneously over time, but this could last for years.
    The cause of granuloma is sill unknown.

Unfortunately, at this moment it is impossible to foresee a patient's reaction to different substances.
Two issues have appeared to be particularly unpredictable (and being at the same time most important for the patients!):

  1. the duration of the effect achieved and  
  2. the possibility for granuloma generation.

The so-called temporary substances usually last for 4-6-10 months, but they could be resorbed even faster, which is naturally not soon enough. As regards the permanent substances, we talk about multi-annual effects, and indeed some of them may last for years (5-10, even longer), but the problem is that the complications can also last for years!
The possibility of granuloma generation is fortunately very low, and according to statistics it ranges from 0.01 - 1.0%. This complication, alike the others, may occur regardless of the substance used - permanent or temporary, but the definite conclusions are as follows:

  1. frequency of complication increases by the use of permanent relative to temporary substances,
  2. frequency of complication increases by application of inadequate injection technique (often inadequate layer, too deep, too superficially),
  3. frequency of complication increases by the increase of the substance quantity injected (mostly permanent).

As regards the production, sale and use of different injectable substances (soft tissue fillers), legal regulation significantly differs from state to stat - hence fully incompliant. Even the two leading world's institutions in this area - the US FDA (Food and Drug Administration) and European CE (Conformité Européene) apply different criteria and positions. In some countries, the application of permanent substances is completely prohibited by their national associations for plastic surgery. In other countries, the use of such substances is neither prohibited nor approved i.e. there is no CE-mark or FDA approval. We hence conclude that, by now, clinical studies published by the producers have been insufficient, notably as regards the forecasted frequency of the delayed complications, whereas the clinical studies published by the doctors in professional literature are mostly retrospective and also insufficient. At the moment, it is deemed as necessary to have as many serious and detailed prospective scientific researches and clinical analyses, particularly regarding permanent materials, in order to ensure maximum safety of the patients.
Dr V. Ribnikar