Luscious Lips

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, a podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The title of today's episode is Luscious Lips. We've talked about lips before on the podcast. What is our focus today, Dr. Bass, and why are we going there?

Dr. Lawrence Bass (00:30):
Lips are the most popular area for fillers. A beautiful lip is very, very appealing. So this is a big topic. We focused a lot on lip shape in our previous episode and what we do with fillers to promote a youthful, beautiful shape because there's this very complex shape to the lip. And we discussed that in some depth in that earlier episode. Certainly when we're trying to create a fuller lip filler is a mainstay, and it's more about shape than about the magnitude or size per se.

Doreen Wu (01:12):
So what else should we think about with regard to the lip?

Dr. Lawrence Bass (01:16):
Well, I wanted to speak a little bit about how the lip ages and what kinds of issues need to be addressed. And this brings up other kinds of treatments besides injectable fillers, which have a role in addressing the aging lip, but also in enhancing lip appearance in young people.

Doreen Wu (01:36):
Can you lay out some of these issues for our listeners?

Dr. Lawrence Bass (01:39):
Well, let's start by thinking about the skin surface and move to deeper changes after that. So skin of the lip and the vermilion, the pink part, that has issues as we age of texture, smoothness and eventually wrinkles. And there's a whole range of treatments to chase this from makeup to home skincare products, chemical peels, various laser treatments including laser peels and RF microneedling, all for skin smoothing. And more recently, there are superficial fillers that can be used to chase wrinkles on the lips and even to create a smoother vermilion where you get that rough surface to the pink part of the lips and some of the superficial fillers can even help with that.

(02:38):
And these issues were often seen earlier in the skin around the eyes and the mouth, and it probably affects those areas disproportionately at any given age compared with the skin on the remainder of the face. But these were really issues that apply to skin all over the face as well as skin on the neck, décolletage, hands, and on the body as well. So sometimes we're only treating the focused areas around the eyes or mouth, but often we're doing a global facial treatment. Even when we treat the entire face, we're still going to adjust our parameters, how the treatment's done. Fine tuning for the degree of aging in each individual zone of the face.

Doreen Wu (03:29):
What are some other aging changes associated with the lip?

Dr. Lawrence Bass (03:34):
The lip loses volume as we age, becoming on average 41% less in thickness. In one MRI study looking at women's lips, comparing 20 to 30 year olds with people 65 to 80 years old. This study was performed by a plastic surgeon named Patrick Tonnard, who's in Ghent, Belgium. The same study showed that the lip becomes 19% longer in the older group of women. So that lip length or what we call filter length, the lip length right down the center from the bottom of the nose to the top of the pink, that increases and becomes longer. Just like when people get older, they say you're long in the tooth. Well, that's the result of gums recessing and exposing more of our teeth. This is something different. And while lip aging is not extremely well understood, these two changes, loss of thickness or volume, put another way and increase in lip length point to most of the goals of what we're trying to chase and treating aging lips and those techniques are then adapted and applied to enhancing lip shape in younger people.

(05:03):
The volume loss in lengthening results in a roll in of vermilion, the pink part of the lip. This is accompanied by straightening of the shape of the upper lips. So the curviness that we have in youth with bulges and depressions becomes straighter and more uniform. Underlying bony volume loss further contributes to roll in and sagging. And the debate has always been whether it's volume loss or skin sagging. But common sense and a growing body of data suggests that there are multiple factors that add up to contribute to the magnitude of the aging changes that are seen.

Doreen Wu (05:48):
Understanding the causes and these changes is all well and good, Dr. Bass, but I'm most interested in hearing how plastic surgeons are able to address these changes.

Dr. Lawrence Bass (05:58):
Well, for loss of visibility of the vermilion, there are multiple approaches, and it's kind of like the reconstructive ladder in plastic surgery that we've talked about a lot on the podcast. It starts simple and the options become increasingly involved. So the simplest thing is makeup techniques, things like over lining, and if you do a little bit of that to give a little increase to the appearance of the size of the lip, that's okay. If you do that in a overblown way, kind of looks unnatural. So that's good. If you only need a little, as we said at the beginning of this episode, filler is the big one. It's the most popular area to treat at any age in any country. Lip is number one, and unfortunately it's also the least durable area in terms of how long that filler lasts. Nowadays we have lip specific fillers, fillers that have been formulated to have the softness flexibility, but also the fullness specifically to inject in the lip area for enhancement of lip shape.

(07:25):
Another option that people try either alone instead of filler or sometimes in addition to filler is what's called the lip flip. And so this is taking Botox or another neuromodulator and injecting it in the lip, and the idea is to relax the muscle, allowing the lip to roll out further, showing more of the vermilion. Now there's an important fine point here because the muscle around the lips is called the orbicularis oris. This muscle has two layers. The superficial layer is circumferentially oriented, but the deeper layer is more vertically oriented and it's that deeper layer that needs to be injected. For a lip flip, we often inject the superficial portion to the extent that we can separate which one we're injecting, which may or may not be true to try to reduce vertical lip lines. The final option is the lip lift, and this is a surgical procedure that shortens the lip and rolls out the vermilion.

Doreen Wu (08:51):
What is the right choice amongst all these options? How do I know what's right for me?

Dr. Lawrence Bass (08:57):
Well, obviously it depends on the individual filler, what most people use, along with minor makeup enhancement. While there's been a lot of media play about lip flip, I find the effect modest and focus more on Botox and other neuromodulators for some softening of those dynamic vertical wrinkles in the upper lip. Lip lift is surgical, which means there's recovery and you're making a permanent change, but that provides a robust correction. It's a very powerful technique and it has durability at the same time as giving us more vermilion show and making the lip look fuller. We're addressing that increase in lip length that occurs with aging at the same time.

Doreen Wu (09:51):
So is the lip lift for aging lips?

Dr. Lawrence Bass (09:55):
It's good in the aging. It gives a fuller looking lip and a shorter lip, which is a younger looking lip, but it's also for younger people who want to roll out more vermilion, make the lip more prominent or shape the lip. So the use in young people is really to, in a durable way, increase vermilion show and fullness of the lip.

Doreen Wu (10:22):
How is the lip lift performed? Give me a general overview of the steps.

Dr. Lawrence Bass (10:27):
So a wedge of skin is removed at the top of the upper lip just beneath the nostrils. This is then carefully repaired with sutures to hide the incision at the crease between the nose and the lip.

Doreen Wu (10:44):
What does the recovery look like and what are the risks?

Dr. Lawrence Bass (10:48):
So there's always some swelling, typically a little bruising, and that's going to settle basically over two to three weeks. But the incision is still healing. The scar is maturing there. That's going to be red for a lengthy period of time, two to three months for the lip to fully soften. And scar maturity is at least six months. And the risk with a procedure like this is it's permanent. If you don't like the look or shape, you can't put the skin you took out back. It could be revised shape, could be adjusted, but that points up that it's better to remove the skin conservatively because if you really had to, you could come back and take more, but once you take it out, you can't put it back. The big issue with the lip lift is the scar. This usually looks good, but it's based on your individual wound healing.

(11:55):
Everyone worries a lot about facelift scars, the incision that's in front of the ear, but that area of facial skin is much more forgiving than the upper lip. There's a lot of talk about imperceptible lip lift scars, and you can always show an example of a patient who's a good healer, who got a really faint or imperceptible scar, but not everybody heals that way. And again, that's honestly more about your biology than it is about the surgeon. Once you put an incision someplace, you can never 100% remove it. That being said, there are a lot of treatment options today to help take a less than ideal scar and make it much more favorable. We inject anti-inflammatory medicines. We do compression or apply scar gels, and we use fractional lasers on scars. But my general advice about the lip lift is if you can't accept even a minimal scar, don't do it.

Doreen Wu (13:03):
Now, Dr. Bass, you mentioned shaping. What kind of shaping is possible with the lip lift?

Dr. Lawrence Bass (13:09):
As I said, mostly we're rolling the lip out centrally to show more vermillion, but depending on the shape of the excision, which areas from side to side are a little taller, where we're removing more skin and which areas are a little shorter, where we're removing less, that's going to affect which parts of the lip are pulled up and how much, which parts are rolled out and how much there are other steps at deeper levels that facilitate control of these issues. And typically it's mostly central where the effects are. There are some techniques that focus extra, especially centrally to accent the cupid's bow.

(14:06):
Some people have beautiful shape there and others it's a lot flatter and if you're trying to really accent that, there are ways of fashion in your lift to try to amplify that effect. On the other hand, particularly in aging lips, there's sometimes the outer part of the upper lip is hanging or hooded or the corner of the mouth is drooping. This is sort of the smiley face that we have in youth turning into a frowny face. That's another aging change. And by having more excision laterally, sometimes extending around to the side of the nostrils and not just the bottom of the nostrils allows adjustment of those outer portions of the lip.

Doreen Wu (14:58):
Dr. Bass, what should our listeners take away from today's episode?

Dr. Lawrence Bass (15:03):
Nowadays we have multiple options for lip fullness and we always like having options. It gives us different ways to go, what might work better for us individually, but it also makes life more complex because it means we have to make a decision. Lip lift has a big role, especially in the aging lip, but increasingly in younger people who want durability and shape. The big concern with the lip lift is the scar, which may not be imperceptible depending on how you heal, and the lip continues to be a very popular area. Everyone has their own aesthetic, but everyone wants a beautiful lip.

Doreen Wu (15:47):
Very well put. Thank you Dr. Bass for sharing your insight and expertise with us. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.