PHOENIX, ARIZ. -- The lip that is enhanced with filler should meet definable proportions and yet retain its individuality, Arnold W. Klein, M.D., said at a clinical dermatology conference sponsored by Medicis.
"Lips are about volume but more importantly shape. Any enhancement must be undetectable," said Dr. Klein, who holds a dermatology chair in his name at the University of California, Los Angeles' David Geffen School of Medicine.
Lip augmentation requires fillers to increase facial volume in a subtle and aesthetically pleasing manner, he said. It is not about "simply eradicating lines."
The lower third of the aging face, including the lip, is the area least amenable to plastic surgery. Along with the thinning of both lips, he cited prominent labial mandibular grooves, the ends of the upper lips hanging down, loss of bone support from dentition and from the mandible, and decreased vertical support, he said.
According to Dr. Klein's formulation of the aesthetic lip: "The length of the closed, relaxed mouth should equal the distance between the medial aspect of the irises in the well-proportioned face." In addition, the ratio of the upper lip to the lower lip should be 1:1.6.
When the head is photographed in a postural position with a relaxed mouth, an interpupillary line drawn horizontally across the eyes should be parallel to a horizontal commissural line drawn where the lips meet.
Dr. Klein cited other characteristic facial landmarks including curvature of the dorsum and angulation of the nose. He said the base of the nose should be 18-20 mm above the upper lip, whereas the recommended distance between the lower lip and the chin is 36 mm.
Looking at the postural head position in profile, the physician should make sure both lips touch the "Steiner line," he said.
When seen in profile, the nasolabial angle should be about 84-105 degrees, he continued: "You want a good nasolabial angle."
To illustrate this, he showed a photograph in which one extended line connected the base of the nose to the tip of the nose. A second line from the base of the nose touched the "Glogau-Klein point" at the center edge of the upper lip. The angle is formed where the two lines intersect.
The G-K point describes the "ski slope" shape of the lip in profile as you move from the skin above the lip down onto the pink vermillion. There is always a little upturn, a point of reflection, which becomes lost as one ages, Richard G. Glogau, M.D., told SKIN & ALLERGY NEWS.
The cosmetic implication is that you have to recreate this shape with fillers used in the border of the lip to make the lip young and attractive. Also, if you use too much Botox on the upper lip, the orbicularis muscle flattens and makes an older looking lip. Therefore, it is generally a good idea to combine fillers with the Botox if you are trying to reestablish a youthful looking upper lip, said Dr. Glogau, who is a consultant to Allergan Inc., Medicis, and Inamed Aesthetics.
Dr. Klein cited a study of 100 women which showed that aging lips lose height (Dermatology 2004;208:307-13). He said the most important aspect of lip augmentation involves building buttresses to restore the lost height and the ends of the lips.
"You want flying buttresses to hold up the lips because of the loss of dentition," he said. "You want to restore the ends and build buttresses to support the lip. That's really important."
The choice of filling agent is less important than the physician's skill in using it, according to Dr. Klein, who disclosed ties as a consultant and/or investigator for Allergan Inc., Genzyme, Inamed Aesthetics, Anika Inc., Medicis, SkinMedica, and OrthoNeutrogena.
"It is not what you use. It is how you use it," he said, recommending physicians become really skilled in one or two products rather than plow through what he described as a delicatessen menu of filling agents on the market.
Except for correction of scars, Dr. Klein opposes the use of permanent fillers. He warned that these agents could become increasingly visible or create an unnatural appearance as facial contours change over time. "For aesthetic indications I believe permanent fillers are a formula for disaster," he said.
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