Three-Dimensional Computed Tomography Scanning Study of the Superior Labial Artery in Chinese Individuals for Assessing Filler Injection Safety.

BACKGROUND: Lip filler injection is one of the most common minimally invasive cosmetic procedures involving the face; however, vascular complications are not uncommon. The aim of this study was to investigate the anatomy of the superior labial artery (SLA) and provide precise topographic information for dermal filler injection into the lips. METHODS: Computed tomography (CT) scans of 52 cadaveric heads injected with lead oxide were obtained. We then used Mimics software to construct 3D images of the SLA described by a coordinate system based on the bilateral external auditory canal and the left orbit. This study aimed to classify the SLA in the Han Chinese population, measure its diameter at specific points, and determine the thickness of the lip at those points. Ultimately, we utilized a thermal imaging technique to illustrate the course and depth of the SLA within the lip. The objective of this study was to provide safe guidance for clinical injections. RESULTS: In this study, the SLA was successfully identified in all cadavers. The mean overall diameter of the superior labial arteries was 1.36 ± 0.28 mm. The superior labial artery showed a general course from deep to shallow with an average depth of 5.68 ± 1.68 mm from the oral commissure to the midline. CONCLUSIONS: There are anatomical differences in the superior labial arteries among Chinese people. Furthermore, 3D CT images can digitally elucidate the exact positions of the superior labial artery via a coordinate system, improving the safety of upper lip filler injections in clinical settings. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Intraoral nasolabial flap for lower lip augmentation following post-radiation contracture.

The nasolabial flap (NLF) has been reported extensively for reconstruction of various intraoral and extraoral defects resulting from trauma or ablative surgery. However, it has not been described for post-radiation lip augmentation. Herein, we present the case of a 74-year-old female who previously underwent a subtotal glossectomy and free flap reconstruction followed by radiotherapy. While oncologically the patient did well, she developed a significant lower lip contracture which compromised oral intake, denture placement, lip excursion, and psychosocial well-being. The patient underwent release of the scar contracture and a NLF was utilized intraorally to act as a spacer between the gingiva and inner lip mucosa to augment the soft tissue deficit. The patient went on to regain oral intake and placement of her dentures, while reporting significant satisfaction with the post-procedural benefits.

The Ideal Lips: Lessons Learnt from the Literature.

Defining the ideal dimensions and proportions of the human face has been attempted for centuries, popularised in the Renaissance period by artists including Leonardo Da Vinci. The lips are part of the lower third of the face and are central to lower face aesthetics and the overall symmetry of the face. They also place an important part in conveying facial emotions and expressions. Full lips with well-defined Cupid's bow have always been associated with youth and beauty. The approval of hyaluronic acid use for tissue augmentation and the prevalence of social media have caused an exponential increase in lip augmentation procedures (Linkov et al. in Arch Plast Surg 46(3):248-254, 2019), as such researchers and aestheticians have focused on characterising the ideal lips mathematically to help guide clinicians. This narrative review will summarise the available evidence in the literature pertaining to the ideal lips, taking into account age, ethnicity and gender differences. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Impact of Dermal Fillers on Perceived Personality Traits and Attractiveness.

BACKGROUND: Dermal fillers are increasingly popular for facial rejuvenation and enhancement, including effacement of nasolabial folds (NLFs) and marionette lines and lip augmentation. This study aimed to evaluate casual observer perception of physical and interpersonal traits of subjects who receive filler treatment. METHODS: An anonymous survey of 8 before/after treatment photographical sets was administered in Likert scale format (1-7) using online crowdsourcing. Three sets of photographs were before/after NLF/ marionette line treatment, three of lip augmentation, and two internal controls. Respondents were surveyed on personal demographics, as well as perceptions of subject photographs across nine domains (facial symmetry, confidence, likeability, youthfulness, trustworthiness, attractiveness, intelligence, approachability, happiness). RESULTS: In total, 260 respondents completed the survey. The majority were male (63.1%), Caucasian (58.1%), 18-34 years old (58.1%), and college graduates (66.2%). Respondents rated photographs with line filler treatment and lip filler treatment as significantly improved compared to the pre-treatment photographs across all nine trait domains [p < 0.001, for all]. No differences were found between the control photosets [p > 0.05, for all]. Middle-aged respondents (35-55 years) were more likely to perceive treated filler photographs as more youthful than younger respondents (18-34 years) [p < 0.006] Additionally, respondents with lower educational attainment (high-school graduate or less) were more likely to perceive treated patients as less intelligent compared to higher-educated respondents (college/postgraduates) [p < 0.05, for both]. CONCLUSION: The use of dermal fillers for treatment of NLF/marionette lines and lip augmentation have significant associations with the perception of improved attractiveness and several personality traits. Additionally, casual observer demographic subgroups may influence perceptions. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Positional relationship of superior and inferior labial artery by ultrasonography image analysis for safe lip augmentation procedures.

The aim of this study was to use ultrasonography to determine the locations and distributions of the superior labial artery (SLA) and the inferior labial artery (ILA) relative to the vermilion border (VB). Sixty healthy Korean volunteers (35 males, 25 females; age, 21-36 years) were investigated using ultrasonography. The participants had not received any noninvasive treatment or surgical procedure in the facial regions during the previous 6 months. Based on the VB, the overall thicknesses of the upper and lower lips were 9.4 ± 0.4 mm (mean ± SD) and 10.9 ± 0.7 mm, respectively. In most cases, the labial arteries were located in the wet mucosal layer on both the upper (35-57%) and lower lips (28-55%), respectively. In the upper lip, the SLA was in the intramuscular layer in 20-45% of cases, making it the second most common type. At some of the measuring points, the SLA was observed more often in the intramuscular layer than in the wet mucosal layer. In the lower lip, the ILA was also located in the dry mucosa (5-27%). The dry-wet mucosal junction is unclear in the lip area, and the ILA was commonly observed at the dry-wet mucosal junction. The arterial depth was 5.3 ± 0.3 mm in the upper lip and 4.2 ± 0.4 mm in the lower lip. The SLA and ILA are evenly distributed over all parts of the oral mucosa. Injection procedures for lip augmentation should therefore use very superficial approaches. Clin. Anat. 33:158-164, 2020. © 2019 Wiley Periodicals, Inc.

Hyaluronic acid fillers in lip augmentation procedure: a clinical and histological study.

Several approaches have been proposed for soft tissue augmentation using injectable materials for lip and soft-tissue augmentation due to their physical and biological properties. Hyaluronic acid represents a natural component of the connective tissues, related to wound healing and skin regeneration. The aim of this research was to investigate the clinical and histological effectiveness of cross-linked hyaluronic acid for lip augmentation. A total of 8 patients were treated for lip augmentation with a clinical follow up of 60 days. After this period a histological evaluation was performed to evaluate the healing of the treated regions. The healing phase reported no inflammatory response, tissue contractions and no local flogistic evidence in the treated areas, where the filling volume appeared maintained. The 60 days histological evaluation showed evidence of filler resorption with few infiltrated inflammatory cells. The clinical and histological findings suggested that cross-linked hyaluronic acid represents a safe and effective tool for lip augmentation.

Polymethylmethacrylate-induced nodules of the lips: Clinical presentation and management by intralesional neodymium:YAG laser therapy.

The lips are essential part of the beauty and attractiveness of the human face. Lip augmentation has become an increasingly used method to improve appearance. Soft tissue fillers are the most commonly used tools. Permanent fillers, however, have been associated with unwanted side effects after lip augmentation. In the present article the present authors will focus on permanent fillers based on polymethylmethacrylate (PMMA). The present authors provide a short review on PMMA fillers and known associated adverse events. The present authors provide a critical review of treatment options. Illustrated by clinical cases The present authors report our preferred treatment of PMMA nodules on lips by intralesional neodymium:YAG laser and blunt suction cannula with or without minor surgery.

Cadaveric Assessment of Lip Injections: Locating the Serious Threats.

BACKGROUND: Lip augmentation could be a possible cause of blindness following filler injections. This study evaluated the risk by simulating clinical scenarios of marginal injections to the upper and lower lips and then evaluated the risk of vascular injuries. METHODS: A 22G cannula was inserted bilaterally along the wet-dry junction of the upper and lower lip margins in fifteen cadavers, and then both lips were dissected to verify possible injuries to the superior and inferior labial arteries. The position of the labial arteries in the vermilion zone was documented to determine the appropriate injection technique. RESULTS: In the marginal injections to the lips, arterial injuries occurred at the medial segment of the vermilion zone of both the upper and lower lips, at the terminal part of the labial arteries or a distal branch. Considering arterial anatomy, the upper lip has a higher chance of arterial injury than the lower lip. The cannula should not be inserted in the submucosa as it is recommended to evert the vermilion because both the superior and inferior labial arteries are located in the submucosa of the medial and middle segments of the vermilion in all specimens. CONCLUSION: Awareness of the possibility of vascular injury is necessary during injections of the medial segments of the vermilion of the lips. Vermilion border and marginal injections are recommended for safe and effective lip augmentation. Deep injection around the oral commissure and submucosal injection of the medial and middle segments of the vermilion zone are prohibited because of the high risk of arterial injury. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Effective prevention of recurrent dislocation following primary cemented Endo-MarkIII/SP2 total hip arthroplasty using a posterior lip augmentation device.

PURPOSE: This retrospective study was performed to determine the effectiveness of preventing recurrent dislocation following primary cemented Endo-MarkIII/SP2 total hip replacement using a posterior lip augmentation device (PLAD). METHODS: Between January 2003 and Dezember 2006, 27 PLADs were used in the treatment of recurrent hip dislocation in 27 patients who had received a cemented primary total hip arthroplasty using Endo-MarkIII/SP2 (Waldemar LINK, Hamburg, Germany) components. The mean number of dislocations prior to stabilization with this specific device was 2.6 (range 2-4, SD ± 0.4) with a mean time to revision surgery of 10 months (IQR 13). The mean age of the patients at time of revision surgery was 81.5 years (range 70-94, SD ± 6.9). The control group evaluating the clinical outcome using the Harris Hip Score (HHS) also received a cemented primary total hip arthroplasty using the same implants. A retrospective clinical and radiological review was carried out at a mean follow-up of 68.5 months (range 30-103, SD ± 17.7). RESULTS: Of the 27 patients, 6 had died at the time of the latest review, with the posterior lip augmentation device still in situ and without reported further dislocation after PLAD application. In 2 of the remaining 21 patients recurrent dislocation occurred, thus a subsequent revision of respective implants had to be performed to achieve persistent joint stability. At latest follow-up no deep infection or implant loosening occurred. CONCLUSION: Surgical treatment of recurrent dislocation following primary cemented Endo-MarkIII/SP2 total hip replacement using a posterior lip augmentation device is a safe and effective procedure which can lead to a secondary stabilization of the total hip arthroplasty in about 90 % of the patients.

Complications of injected vitamin E as a filler for lip augmentation: case series and therapeutic approach.

The strive for proficient cosmetic facial appearance is growing in the past decades. Fillers for tissue augmentation are gaining wide popularity. Uncertified products based on oleic solutions are applied by untrained staff, thus growing the risk for certain complications such as infections, allergic and irritant contact dermatitis, and lipogranuloma formation. We present a series of three cases lipogranuloma after liquid vitamin E injection for lip augmentation. In all cases, painful edema at the injected area followed the procedure. The patients were presented with erythema, firm indurations of the lips and the perioral skin, and tenderness. Histological examination of skin biopsies showed round-ovoid cavities of varying sizes, resulting in a Swiss cheese-like appearance, consistent with a lipogranuloma. In this paper, we propose a protocol for treatment of this specific complication with systemic corticosteroids and a broad spectrum antibiotics.

The effects of VY closure on lip morphology after Le Fort I maxillary advancement: A systematic review.

VY closure of the Le Fort 1 incision may commonly be indicated to mitigate the lip shortening effects of maxillary advancement. The objective of this systematic review was to investigate if VY closure prevents lip shortening when compared with conventional continuous closure (CS) methods, in patients who underwent le fort 1 maxillary advancement. PubMed, Embase, and Cochrane Library databases were accessed. Hand searching was also performed. Observational studies, non-randomised and randomized controlled trials were included if Le Fort 1 maxillary advancement was performed to correct a dentofacial deformity. Comparisons were made between VY and CS, and morphological changes to the upper lip were evaluated. The demographic data, study methodology, magnitude of maxillary movements and outcomes related to the lip morphology (length, vermillion exposure, thickness and angulation) were extracted. The search yielded 487 articles. Six studies were included after the application of the selection criteria. A total of 100 and 94 patients received CS and VY respectively. VY was not found to reliably prevent lip shortening. VY was more likely to mitigate lip shortening when there is a large maxillary advancement. It was consistent for a protrusive or "rolled-out" lip morphology to occur after a VY closure. This was demonstrated by the increase in lip vermillion exposure, thickness, and angulation. VY closure was a useful adjunctive technique in patients undergoing large maxillary advancements to mitigate the lip shortening effect from the procedure. Surgeons who employ this technique must also be aware of the consequence of a more protrusive lip with increased vermillion exposure and assess if this would be aesthetically desirable for the individual patient.

Enhancing the vermilion in adult secondary cleft lip repair with a continuous V plasty without closure of the donor defect-a case series.

The aim of this paper was to describe a modification to an old method to enhance the vermillion in adult cleft patients. We present ten consecutive patients who requested enhancement of the upper lip vermillion. The technique involves a continuous V plasty within the non-visible mucosa to elevate the vermillion. Each V incision is of a different size to match the defect. Then the V flaps are sutured to one another but the donor defect is left open to epithelialise. Adjunctive procedures are possible at the same time. There were no major complications but one patient was over corrected and needed reduction of mucosa. The technique offers a permanent enhancement of the vermillion and is a safe alternative to other methods of lip augmentation including fillers.

Real-World Outcomes of Lip Augmentation Using a Hyaluronic Acid-Based Filler With Low 1,4-Butanediol Diglycidyl Ether Content: A Prospective, Open-Label, Multicenter, Post-marketing Study.

Background 1,4-butanediol diglycidyl ether (BDDE) is the most common cross-linker used to produce hyaluronic acid (HA)-based dermal fillers. However, BDDE may have cytotoxic and potentially mutagenic effects, raising safety concerns. Consequently, manufacturers are developing new HA filler formulations with reduced BDDE levels to mitigate potential biological risks. Here, we sought to evaluate the clinical outcomes of lip augmentation performed using an HA-based filler with a reduced BDDE content (Agex Fill Volume®; Biodue SpA, Barberino Tavarnelle, Italy) in a real-world clinical setting. Methods This was a prospective, open-label, multicenter, post-marketing study conducted over six months. Thirty adult subjects (29 women and one man) who desired a ≥1-point improvement on the validated Lip Fullness Scale 2 (LFS2) were enrolled. The primary efficacy endpoint was the post-procedural increase in the investigator-reported LFS2 compared to baseline. Other endpoints included self-perceived happiness assessed using the Happiness Measure Scale (HMS) and safety. Results Of the study participants, 73% (22/30) demonstrated an improvement of at least one point in their LFS2 scores immediately after treatment compared to baseline, thus qualifying as responders. Six months later, the responder rate, based on LFS2 scores, remained steady at 66.7% (20/30). Importantly, these aesthetic improvements were consistently associated with a positive impact on subject-reported HMS, with a significant difference (p < 0.001) between post-treatment and baseline scores. All adverse events (AEs) reported after treatment were mild. Conclusions Agex Fill Volume®, a HA filler with low BDDE content, provides a safe and effective option for enhancing lip volume in real-world aesthetic settings.

Delayed Granulomas as a Complication Secondary to Lip Augmentation with Dermal Fillers: A Systematic Review.

Introduction Lip augmentation with dermal filler is rising in popularity. There are generally minimal side effects that are mild and transient. However, long-term complications may occur and include lumps, bumps, nodules, or granulomas. To better understand this uncommon but challenging outcome, we aim to perform a thorough systematic review of the published literature related to nodule or granuloma formation after cosmetic soft tissue augmentation of the lips. Methods A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in April 2021 and included PubMed, ScienceDirect, Embase, Google Scholar, and Cochrane databases. The Medical Subject Headings (MeSH) terms used included the following terms: "lip filler," "hyaluronic acid," "lip injection," "lip augmentation," "silicone," "poly-L-lactic acid," "calcium hydroxyapatite," "polymethylmethacrylate," "complications," "reaction," "granuloma," and "nodule." All studies were reviewed by two independent reviewers. Any discrepancies were resolved by a third reviewer. Results The initial search for filler-related nodules or granulomas yielded 2,954 articles and 28 were included in the final analysis containing 66 individual cases of lip nodules. All but one patient was female. The mean age was 50 years. Nodules presented on average 35.2 months or 2.9 years after initial treatment. Thirty-seven nodules underwent histological analysis, the majority of which identified the presence of a foreign-body granuloma. Silicone was the most reported filler used followed by hyaluronic acid. Most cases resolved following multiple treatments including oral antibiotics or steroids followed by surgical excision. Conclusion Understanding the sequelae of lip augmentation with filler products allows clinicians to provide safe and effective treatment. Nodules that present months to years following dermal treatment may represent a foreign-body granuloma. A combination of oral antibiotics, intralesional or oral steroids, and surgical excision successfully treated the majority of cases in our study.

A minimalistic approach for effective lip augmentation-A case report.

BACKGROUND: Lip augmentation using dermal fillers is a widely performed procedure, which gives immediate and gratifying results. However, the cost associated with it is a major concern and reservation for a lot of patients. An innovative minimalistic technique can be used to enhance the lips using minimal amount of filler to provide maximum results, especially in aging lips. Though a simple and effective method, this technique has not yet gained popularity worldwide. AIM: To present a case demonstrating a new and innovative technique for lip augmentation as a part of lower face rejuvenation. METHOD: A 55-year-old female patient underwent augmentation of lips using the described technique. Since she had a limited budget, treatment was planned to rejuvenate her face in just 1 ml of filler. Areas on the face which would give maximum impact with minimal amount of filler were treated. Treatment was done using Juvederm Ultra Plus XC (JUVX+ ; 24 mg/ml) dermal filler. RESULTS: Using this technique, we were able to demonstrate that a small quantity of filler when used suitably with an understanding of the areas of concern could provide an impact on the overall rejuvenation. CONCLUSION: The described technique is an effective method of lip enhancement with minimal cost, especially in aging patients. Skillful application of a suitable injection technique is required to achieve a desired esthetic outcome.

Lip Lift.

The perioral area can be an important feature to convey femininity, particularly when speaking and smiling. A feminine lip has a shorter distance between the nasal sill and the vermillion border, fullness of the vermillion, and a few millimeters of tooth show with the mouth slightly open. The keys to a good outcome are incision design that respects the natural anatomy, placing the tension of the lift deep to the dermis to take tension off of the skin incision, determining the appropriate amount of lift for the patient's anatomy, and not violating the orbicularis oris.

Superior labial artery and vein anastomosis configuration to be considered in lip augmentation.

The treatment of cleft lip and palate is performed over a long period, starting immediately after birth. However, esthetic problems remain after lip augmentation. Endothelial cells of new capillaries are important for wound healing. Thus, the reconstruction of vascular networks is key to postoperative wound healing during lip augmentation. However, studies describing the superior labial artery (SLA) and superior labial vein (SLV) are rare, and their mutual positional relationship thus remains unclear. We procured 29 adult cadavers and ten fetuses. Macroscopic and histological examinations were performed on adult cadavers. We extracted soft tissues and blood vessels after micro-computed tomography (CT) and 3D tissue reconstruction. We performed histological investigations of vascular networks within the cleft lip in fetal samples. In adults, the SLV was distributed throughout the cutaneous side of the orbicularis oris muscle and the SLA, throughout the mucosal side. The SLV and SLA were separated by this muscle. Micro-CT images revealed that the SLA on the mucosal side transversed the orbicularis oris muscle to the SLV (55％). Histological analysis of fetuses revealed that the SLA was on the mucosal side, similar to that in adults, and traversed the orbicularis oris muscle in continuity with the SLV of the cutaneous side (100%). In lip augmentation, the reconstruction of the vascular structure, which involves the anastomosis of SLA and SLV passing through the orbicularis oris muscle, is an important factor when considering esthetic repair.

Lip Lifting Efficacy of Hyaluronic Acid Filler Injections: A Quantitative Assessment Using 3-Dimensional Photography.

The study aimed to compare the volume enhancement and the lifting capacity of two different hyaluronic acid gels for lip injection. Thirty-six Korean female patients were randomized into two groups according to the cross-linking degree of the hyaluronic acid filler injected. Using a fixed injection protocol, patients were injected with 1 mL of hyaluronic acid filler in the lips and followed up at four and 12 weeks after injection. Lip volume, lip projection, and columella-labial angle were measured using a 3-dimensional imaging system at each time point. Follow-up values were compared with baseline. Compared with pre-treatment values, there was a statistically significant increase in mean lip volume and lip projection at four and 12 weeks after injection, with no significant differences between the two groups. Lips injected with hyaluronic acid filler of intermediate cross-link density resulted in more acute angles than lips injected with lightly cross-linked hyaluronic acid. The difference was statistically significant at each follow-up time point. No serious complications were observed throughout the study period. Our results imply that in patients who want a prominent upper lip lift, lip injections using hyaluronic acid fillers with intermediate cross-linking density can be a good option due to their lift capacity. The degree of cross-linking may not be a significant determinant of simple lip volume augmentation when other variables are constant.

Evaluating safety in hyaluronic acid lip injections.

INTRODUCTION: Soft tissue filler augmentation has become increasingly popular due to its perceived ease and impressive results. Unfortunately, although the results are impressive, so are the reported complications. This article describes complications specific to peri-oral soft tissue filler injection and then discusses evidence-based, anatomic prevention and treatment guidelines. AREAS COVERED: The authors aimed at providing an overview of the complications associated with peri-oral soft tissue filler. Hyaluronic Acid (H.A) fillers may have devastating complications which are oft undisclosed or published. This narrative review aims to describe the various complications and provide preventative strategies. EXPERT OPINION: Given the paucity of prospective, randomized clinical trials on the subject and in light of complication underreporting, the authors believe that efficacy and safety literature on the subject is lacking. Injectors must rely on the one strength which exists in the lip literature to date, that is anatomy. The basis of all successful injections is a mandatory understanding of normal as well as variations of vital structures in an area, combined with meticulous injection techniques, deposition of small aliquots of product and the ability to recognize unwanted adverse events early enough to act on them.

The use of botulinum toxin A in upper lip augmentation.

BACKGROUND: Full lips are beauty standards. Botulinum toxin A (BTA) paralyzes the orbicularis oris muscle to achieve the eversion of the lip, and thus makes the lip look plump. AIMS: This study presents three cases of BTA injection to the lip and evaluates the possible changes in the labial morphology and the lip surface area. METHODS: Three patients received a total of 4U BTA injection at the vermilion border of the upper lip. Vectra® H1 3D imaging system was used to capture 3D photographs of the lips before injection and two weeks after injection. Eight linear distances and the upper lip surface area were measured. Anthropometric measurements before and after injection were compared. RESULTS: Patients displayed a larger upper vermillion height (P = .038) and a smaller cutaneous upper lip height (P = .024). There was a trend for a larger upper lip surface area, but not statistically significant (P = .109). Symptoms of slight perioral muscular palsy and mouth incompetence lasted about one month in three patients. CONCLUSION: BTA helps to enlarge the upper lip and shorten the philtrum. The BTA injection can be an option for lip enhancement with caution.