- Email: [email protected]
Lip Augmentation
My Practice To Yours
Lip Augmentation
A
youthful perioral region surrounding voluptuous lips is seen as a sign of beauty and sensuality. Unfortunately, the face lift does little to rejuvenate the perioral region, and surprisingly, rejuvenation of the aging mouth area has not received the attention given the cosmetic procedures for other parts of the face.1 Improvement of this area has recently become the focus for new enhancement techniques. The variety of materials used to augment the lips varies in both cosmetic results and permanence, depending on the particular technique and filler material. Autogenous fat has been used since the late 1800s as soft tissue filler.2 However, free fat transplantation has a major shortcoming: the possibility of subsequent and frequently rapid resorption of fat. New harvesting techniques to improve the long-term survival of the transplanted fat cells have been described.2 Another popular autogenous material used for lip augmentation is the dermal fat graft, which, in our experience, has survived longer than injected free fat. Other implant materials that have been used include superficial musculoaponeurotic system material from face lifts,3 latissimus dorsi,4 breast implant capsule,5 and autogenous or banked fascia lata.6
As an alloplastic material, collagen is one of the more popular filler materials.7 Bovine collagen is typically used, but patients can now donate their own fibroblasts to make autologous collagen (Autologen®; Collagenesis Inc., Beverly, MA). Another new product is human collagen derived from cadavers (Dermologen®; Collagenesis Inc., Beverly, MA). Studies with Dermologen® are ongoing. Collagen can be used to plump the lips or to treat the deep rhytids around the lips. The advantage of collagen is the immediate enhancement obtained with little recovery time; the disadvantage is its lack of permanence. In addition, a small percentage of patients will have a bovine collagen allergy. For these reasons we seldom use collagen for perioral rejuvenation. Gore-Tex® (WL Gore, Flagstaff, AZ), initially used in the 1970s as a vascular graft, has been used in more than 4.5
million implants in the body. This material has been frequently cited for its versatility in aesthetic surgery.8-13 It is available as a subcutaneous augmentation material (SAM) that may be implanted in varying thicknesses and sizes that are easily shaped. Additionally, it maintains its size when implanted. The subcutaneous augmentation implant is placed in a submucosal position in the vermilion portion of the lip. Care must be taken to avoid crossing the vermilion border when creating the pocket. The ends of the implant are beveled and are not sewn into the tissues. Because of the greater bulk they provide, we prefer SAM implants rather than GoreTex® sutures.
Richard D. Anderson, MD, Scottsdale, AZ, is a boardcertified plastic surgeon.
Mikel W. Lo, MD, Tucson, AZ, is a fellow in oculoplastic surgery.
A more recent addition to the armamentarium of lip augmentation or soft tissue filling materials is AlloDerm® (LifeCell Corporation, The Woodlands, TX),14 which is supplied in various sizes. We prefer the 3 × 7 cm rectangle. The shape of this implant can be altered before or after soaking in saline solution, but it is easier to cut the material before soaking. When the AlloDerm® implant is prepared for the upper lip, it can be contoured at the corners and near the middle so that more bulk is present at the medial aspects to accentuate the Cupid’s bow area. Alternatively, the entire piece can be rolled and sutured, or it can be cut into several strips of equal size and stacked before implantation. The material is integrated with the tissues. The amount of resorption that occurs is presently unknown. We have used AlloDerm® to augment the upper lip vermilion and have found that it provides good bulk, pliability, and tolerance. Little
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1999
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My Practice To Yours
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B
Figure 1. A, Preoperative view of a 43-year-old woman. B, Postoperative view at 4 months after AlloDerm® augmentation on upper lip and GoreTex® SAM multistrand implant on lower lip. AlloDerm® (3 cm × 7 cm) was rolled lengthwise, and GoreTex® multistrand (1.6 cm × 7.6 cm × 2 mm) was beveled and trimmed 1 cm on the ends. The patient likes the new look and feel but would prefer more definition of the borders. We plan to use SoftForm® implants for the vermilion borders on the upper and lower lips.
Figure 2. A, Preoperative view of a 24-year-old woman. B, Postoperative view at 2 months after AlloDerm® augmentation on upper lip and GoreTex® SAM multistrand implant on lower lip with additional SoftForm® augmentation to the vermilion borders and philtral columns. AlloDerm® (3 cm × 7 cm) was rolled, and GoreTex® multistrand (1.6 cm × 7.6 cm × 2 mm) was beveled and trimmed 1 cm on the ends. SoftForm® (2 cm) was implanted on upper lip from lateral commissures to Cupid’s bow. A 4.5-cm piece was used on the lower lip vermilion border. The patient is extremely pleased with the outcome.
resorption has been apparent after 1 year, and the correction has remained impressive.
Results of Lip Augmentation
Another implant material, SoftForm® (expanded polytetrafluoroethylene) (Collagen Aesthetics Inc., Palo Alto, CA), is currently available as implants shaped like hollow tubes with an outer diameter of 2.4 or 3.2 mm and lengths of 7 cm. Fibrous tissue ingrowth occurs through the center of this tube, providing stabilization of the implant in the tissues. This implant can be precisely placed and comes preloaded in its own trocar placement system. After placement, the ends of the implant are cut in a beveled fashion, checked for patency of the lumen, and inserted into the pocket. We currently use this implant for definition of the vermilion border. We have observed improved definition when using the SoftForm® implant in conjunction with both Gore-Tex® and AlloDerm® lip augmentation.
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Results of our clinical experience over the past 5 years are included in the Table. Generally, patients are pleased with their results (Figures 1 and 2). Few complications have occurred with the use of the described implants. Complications such as scarring, hematomas, or allergic reactions have not been noted, nor has permanent lip numbness occurred. However, patients do notice the implant early in their postoperative course when speaking or eating. No herpes simplex problems occurred after surgery. Free fat graphs were used in more than 100 patients with no problems other than inadequate correction caused by fat resorption. Dermal fat grafts, which have a better survival than free fat, were performed in 20 cases, removed in two lips (two patients), and associated with one infection. Complications with more than 175 Gore-Tex® lip aug-
Volume 19, Number 3
My Practice To Yours
Table. Clinical experience in lip augmentation over 5 years Implant type Free fat graft Dermal fat graft Gore-Tex® AlloDerm® SoftForm® *
Number implanted
Duration of improvement
Number removed
Complications
>100 20 >175 >60 40
Weeks Months to years Years Years (?)* Years
0 2 12 2 3
0 1 infection 2 exposures 1 infection 0
The long-term duration of AlloDerm® is not yet known; no one has had enough experience with it.
mentations (over 100 patients) included two partial extrusions of a Gore-Tex® implant and 12 removals. In spite of our meticulous efforts to create a pocket inferior to the vermilion border in the upper lip, we have noted that the Gore-Tex® implant material tends to migrate or roll superiorly above the vermilion border. When this occurs, patients have been displeased with the results and have occasionally requested removal of the upper lip implants; this has occurred with 10 upper lip Gore-Tex® implants. It should be noted that this problem is confined to the upper lip and has not been observed in lower lip implantation. Two more implants were removed because of exposure. AlloDerm®,
which was placed in more than 60 patients, was removed from two lips (two patients), including one with an infected implant. AlloDerm® remains soft after implantation and does not migrate. However, the degree of resorption that might occur is unknown.
References 1. Austin HW, Weston GW. Rejuvenation of the aging mouth. Clin Plast Surg 1992;19:511-24. 2. Billings Jr E, May Jr JW. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83:368-81. 3. Maloney BP. Cosmetic surgery of the lips. Facial Plast Surg 1996;12:265-78. 4. Isenberg JS. Permanent lip augmentation using autologous breast implant capsule. Ann Plast Surg 1996;37:121-4. 5. Ponzielli G, Campiglio GL, Berlanda M. Lip augmentation using a latissimus dorsi strip graft. Aesthetic Surg J 1997;17:226-9. 6. Burres SA. Lip augmentation with preserved fascia lata. Dermatol Surg 1997;23:459-62. 7. Robertson KM, Dyer WK II. The use of fillers in the aging patient. Facial Plast Surg 1996;12:293-301. 8. Cisneros JL, Singla R. Intradermal augmentation with expanded polytetrafluoroethylene (Gore-Tex) for facial lines and wrinkles. J Dermatol Surg Oncol 1993;19:538-42. 9. Ellis DAF, Trimas SJ. Gore-Tex implants for the correction of thin lips. Laryngoscope 1995;105:207-9.
Patient acceptance of SoftForm® has been promising. Forty lips (20 patients) were augmented either with SoftForm® alone or combined with AlloDerm® or GoreTex®. In this group, three upper lip SoftForm® implants were removed, however, because of patient dissatisfaction. Although our long-term experience with SoftForm® is limited, we have observed undesirable fullness and firmness superior to the vermilion in several patients.
10. Conrad K, Gillman G. A 6-year experience with the use of expanded polytetrafluoroethylene in rhinoplasty. Plast Reconstr Surg 1998;101:1675-83.
At the present time, multistrand 2-mm thickness GoreTex® for lower vermilion augmentation and stacked AlloDerm® for upper lip vermilion enhancement are preferred. SoftForm® is occasionally used for vermilion border definition either alone or with the above materials. ■
14. Jones FR, Schwartz BM, Silverstein P. Use of a nonimmunogenic acellular dermal allograft for soft tissue augmentation: a preliminary report. Aesthetic Surg Q 1996;16:196-201.
Lip Augmentation
11. Conrad K, MacDonald MR. Wide polytef (Gore-Tex) implants in lip augmentation and nasolabial groove correction. Arch Otolaryngol Head Neck Surg 1996;122:664-70. 12. Linder RM. Permanent lip augmentation employing polytetrafluoroethylene grafts. Plast Reconstr Surg 1992;90:1083-92. 13. Sherris DA, Larrabee WF. Expanded polytetrafluoroethylene augmentation of the lower face. Laryngoscope 1996;106:658-63.
Reprint orders: Mosby, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/98685
AESTHETIC
SURGERY
JOURNAL
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MAY/JUNE
1999
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Lip Augmentation
A
youthful perioral region surrounding voluptuous lips is seen as a sign of beauty and sensuality. Unfortunately, the face lift does little to rejuvenate the perioral region, and surprisingly, rejuvenation of the aging mouth area has not received the attention given the cosmetic procedures for other parts of the face.1 Improvement of this area has recently become the focus for new enhancement techniques. The variety of materials used to augment the lips varies in both cosmetic results and permanence, depending on the particular technique and filler material. Autogenous fat has been used since the late 1800s as soft tissue filler.2 However, free fat transplantation has a major shortcoming: the possibility of subsequent and frequently rapid resorption of fat. New harvesting techniques to improve the long-term survival of the transplanted fat cells have been described.2 Another popular autogenous material used for lip augmentation is the dermal fat graft, which, in our experience, has survived longer than injected free fat. Other implant materials that have been used include superficial musculoaponeurotic system material from face lifts,3 latissimus dorsi,4 breast implant capsule,5 and autogenous or banked fascia lata.6
As an alloplastic material, collagen is one of the more popular filler materials.7 Bovine collagen is typically used, but patients can now donate their own fibroblasts to make autologous collagen (Autologen®; Collagenesis Inc., Beverly, MA). Another new product is human collagen derived from cadavers (Dermologen®; Collagenesis Inc., Beverly, MA). Studies with Dermologen® are ongoing. Collagen can be used to plump the lips or to treat the deep rhytids around the lips. The advantage of collagen is the immediate enhancement obtained with little recovery time; the disadvantage is its lack of permanence. In addition, a small percentage of patients will have a bovine collagen allergy. For these reasons we seldom use collagen for perioral rejuvenation. Gore-Tex® (WL Gore, Flagstaff, AZ), initially used in the 1970s as a vascular graft, has been used in more than 4.5
million implants in the body. This material has been frequently cited for its versatility in aesthetic surgery.8-13 It is available as a subcutaneous augmentation material (SAM) that may be implanted in varying thicknesses and sizes that are easily shaped. Additionally, it maintains its size when implanted. The subcutaneous augmentation implant is placed in a submucosal position in the vermilion portion of the lip. Care must be taken to avoid crossing the vermilion border when creating the pocket. The ends of the implant are beveled and are not sewn into the tissues. Because of the greater bulk they provide, we prefer SAM implants rather than GoreTex® sutures.
Richard D. Anderson, MD, Scottsdale, AZ, is a boardcertified plastic surgeon.
Mikel W. Lo, MD, Tucson, AZ, is a fellow in oculoplastic surgery.
A more recent addition to the armamentarium of lip augmentation or soft tissue filling materials is AlloDerm® (LifeCell Corporation, The Woodlands, TX),14 which is supplied in various sizes. We prefer the 3 × 7 cm rectangle. The shape of this implant can be altered before or after soaking in saline solution, but it is easier to cut the material before soaking. When the AlloDerm® implant is prepared for the upper lip, it can be contoured at the corners and near the middle so that more bulk is present at the medial aspects to accentuate the Cupid’s bow area. Alternatively, the entire piece can be rolled and sutured, or it can be cut into several strips of equal size and stacked before implantation. The material is integrated with the tissues. The amount of resorption that occurs is presently unknown. We have used AlloDerm® to augment the upper lip vermilion and have found that it provides good bulk, pliability, and tolerance. Little
AESTHETIC
SURGERY
JOURNAL
~
MAY/JUNE
1999
239
My Practice To Yours
A
A
B
B
Figure 1. A, Preoperative view of a 43-year-old woman. B, Postoperative view at 4 months after AlloDerm® augmentation on upper lip and GoreTex® SAM multistrand implant on lower lip. AlloDerm® (3 cm × 7 cm) was rolled lengthwise, and GoreTex® multistrand (1.6 cm × 7.6 cm × 2 mm) was beveled and trimmed 1 cm on the ends. The patient likes the new look and feel but would prefer more definition of the borders. We plan to use SoftForm® implants for the vermilion borders on the upper and lower lips.
Figure 2. A, Preoperative view of a 24-year-old woman. B, Postoperative view at 2 months after AlloDerm® augmentation on upper lip and GoreTex® SAM multistrand implant on lower lip with additional SoftForm® augmentation to the vermilion borders and philtral columns. AlloDerm® (3 cm × 7 cm) was rolled, and GoreTex® multistrand (1.6 cm × 7.6 cm × 2 mm) was beveled and trimmed 1 cm on the ends. SoftForm® (2 cm) was implanted on upper lip from lateral commissures to Cupid’s bow. A 4.5-cm piece was used on the lower lip vermilion border. The patient is extremely pleased with the outcome.
resorption has been apparent after 1 year, and the correction has remained impressive.
Results of Lip Augmentation
Another implant material, SoftForm® (expanded polytetrafluoroethylene) (Collagen Aesthetics Inc., Palo Alto, CA), is currently available as implants shaped like hollow tubes with an outer diameter of 2.4 or 3.2 mm and lengths of 7 cm. Fibrous tissue ingrowth occurs through the center of this tube, providing stabilization of the implant in the tissues. This implant can be precisely placed and comes preloaded in its own trocar placement system. After placement, the ends of the implant are cut in a beveled fashion, checked for patency of the lumen, and inserted into the pocket. We currently use this implant for definition of the vermilion border. We have observed improved definition when using the SoftForm® implant in conjunction with both Gore-Tex® and AlloDerm® lip augmentation.
240
AESTHETIC
SURGERY
JOURNAL
~
MAY/JUNE
1999
Results of our clinical experience over the past 5 years are included in the Table. Generally, patients are pleased with their results (Figures 1 and 2). Few complications have occurred with the use of the described implants. Complications such as scarring, hematomas, or allergic reactions have not been noted, nor has permanent lip numbness occurred. However, patients do notice the implant early in their postoperative course when speaking or eating. No herpes simplex problems occurred after surgery. Free fat graphs were used in more than 100 patients with no problems other than inadequate correction caused by fat resorption. Dermal fat grafts, which have a better survival than free fat, were performed in 20 cases, removed in two lips (two patients), and associated with one infection. Complications with more than 175 Gore-Tex® lip aug-
Volume 19, Number 3
My Practice To Yours
Table. Clinical experience in lip augmentation over 5 years Implant type Free fat graft Dermal fat graft Gore-Tex® AlloDerm® SoftForm® *
Number implanted
Duration of improvement
Number removed
Complications
>100 20 >175 >60 40
Weeks Months to years Years Years (?)* Years
0 2 12 2 3
0 1 infection 2 exposures 1 infection 0
The long-term duration of AlloDerm® is not yet known; no one has had enough experience with it.
mentations (over 100 patients) included two partial extrusions of a Gore-Tex® implant and 12 removals. In spite of our meticulous efforts to create a pocket inferior to the vermilion border in the upper lip, we have noted that the Gore-Tex® implant material tends to migrate or roll superiorly above the vermilion border. When this occurs, patients have been displeased with the results and have occasionally requested removal of the upper lip implants; this has occurred with 10 upper lip Gore-Tex® implants. It should be noted that this problem is confined to the upper lip and has not been observed in lower lip implantation. Two more implants were removed because of exposure. AlloDerm®,
which was placed in more than 60 patients, was removed from two lips (two patients), including one with an infected implant. AlloDerm® remains soft after implantation and does not migrate. However, the degree of resorption that might occur is unknown.
References 1. Austin HW, Weston GW. Rejuvenation of the aging mouth. Clin Plast Surg 1992;19:511-24. 2. Billings Jr E, May Jr JW. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83:368-81. 3. Maloney BP. Cosmetic surgery of the lips. Facial Plast Surg 1996;12:265-78. 4. Isenberg JS. Permanent lip augmentation using autologous breast implant capsule. Ann Plast Surg 1996;37:121-4. 5. Ponzielli G, Campiglio GL, Berlanda M. Lip augmentation using a latissimus dorsi strip graft. Aesthetic Surg J 1997;17:226-9. 6. Burres SA. Lip augmentation with preserved fascia lata. Dermatol Surg 1997;23:459-62. 7. Robertson KM, Dyer WK II. The use of fillers in the aging patient. Facial Plast Surg 1996;12:293-301. 8. Cisneros JL, Singla R. Intradermal augmentation with expanded polytetrafluoroethylene (Gore-Tex) for facial lines and wrinkles. J Dermatol Surg Oncol 1993;19:538-42. 9. Ellis DAF, Trimas SJ. Gore-Tex implants for the correction of thin lips. Laryngoscope 1995;105:207-9.
Patient acceptance of SoftForm® has been promising. Forty lips (20 patients) were augmented either with SoftForm® alone or combined with AlloDerm® or GoreTex®. In this group, three upper lip SoftForm® implants were removed, however, because of patient dissatisfaction. Although our long-term experience with SoftForm® is limited, we have observed undesirable fullness and firmness superior to the vermilion in several patients.
10. Conrad K, Gillman G. A 6-year experience with the use of expanded polytetrafluoroethylene in rhinoplasty. Plast Reconstr Surg 1998;101:1675-83.
At the present time, multistrand 2-mm thickness GoreTex® for lower vermilion augmentation and stacked AlloDerm® for upper lip vermilion enhancement are preferred. SoftForm® is occasionally used for vermilion border definition either alone or with the above materials. ■
14. Jones FR, Schwartz BM, Silverstein P. Use of a nonimmunogenic acellular dermal allograft for soft tissue augmentation: a preliminary report. Aesthetic Surg Q 1996;16:196-201.
Lip Augmentation
11. Conrad K, MacDonald MR. Wide polytef (Gore-Tex) implants in lip augmentation and nasolabial groove correction. Arch Otolaryngol Head Neck Surg 1996;122:664-70. 12. Linder RM. Permanent lip augmentation employing polytetrafluoroethylene grafts. Plast Reconstr Surg 1992;90:1083-92. 13. Sherris DA, Larrabee WF. Expanded polytetrafluoroethylene augmentation of the lower face. Laryngoscope 1996;106:658-63.
Reprint orders: Mosby, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/98685
AESTHETIC
SURGERY
JOURNAL
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MAY/JUNE
1999
241