ABSTRACT
In 1984, lip augmentation with injectable bovine collagen changed the goal of filling agents from eradicating lines to subtly increasing facial volume. Lip augmentation would soon become the number one use of agents for tissue augmentation. Soon it became apparent that the lips were the aesthetic focus of the lower face and a critical member of a small group of female facial landmarks that attracted the male species. These attractive female facial features were identical for males of all races and cultures. What were these facial sites that men were hot-wired to? More than simple sites, they were related to size and shape: a large upper face, smooth forehead, small nose, round eyes (bigger, wider apart with prominent eyelashes), a small lower face, and large lips with a plump yet sharp vermillion border (1). When we look at a person’s face, the focus of the upper face is the eyes, and the focus of the lower face is the lips. For years and still to this day, models and actresses have attempted to enhance their lips and correct perioral radial rhytids by using lipsticks and covering agents. This is apparent in early screen stars who were able to create the illusion of any lip they desired through the use of make-up. From the work of Leonardo DaVinci (Mona Lisa) through the present day cinema (First Wife’s Club), the importance of lips is continually emphasized. When full and well defined, lips impart a sense of youth, health, attractiveness, and sexuality to the bearer. Like many features of the face, as the lips age they become far less attractive. Losing volume, they become thin and flat. Also, owing to grinding and wear on the molars and age-related osteoporotic thinning of the mandibule, the distance from the lips to the chin is greatly decreased. As dental height is lost, the face ages such that the ends of the lips hang down, contributing to the marionette lines [labio-mandibular grooves; (2)]; subtle enhancement would be the obvious goal. Some physicians felt compelled to define their personal esthetic for lip enhancement. They directed one to enlarge the
cupid’s bow, increase the relative length of the lower lip, and to augment the projection bulk of both the upper and lower lips. Additionally, it must be remembered that the Collagen Corporation itself attempted to market ‘‘The Paris Lip,’’ which focused on vermilion injection with enhancement of the central portion of the lip and exaggeration of the philtral pillars. A study on lip augmentation was performed by the Collagen Corporation but never published owing to conflicts with the U.S. Food and Drug Administration (FDA) in that mucosal injection was an off-label use (3). The use of bovine collagen as a predictable injection agent allowed physicians to provide stable lip enhancement, which was very natural in appearance (4,5). As stated previously, lip augmentations heralded a movement toward the use of fillers for volumetric enhancement (4-11). Indeed, dermatologic and plastic surgical literature did not contain any information regarding the proper esthetic characteristics of lips. While women’s magazines would present models with voluptuous lips and many celebrities were adored for their lips, no readily apparent guidelines existed to aid physicians in this area of enhancement (10). This resulted in esthetically improper lip enhancement by some physicians through unguided injection procedures. It was this author’s opinion that injections should be performed in a subtle manner that would prevent the augmentation from being readily apparent. While enhancement of the vermilion border was an approved use of injectable bovine collagen, actual mucosal injection was again a frequent, albeit, off-label use of this agent. In 1984, I helped pioneer lip augmentation that began to focus on increasing volume and on an aesthetically pleasing appearance, rather than simply eradicating lines. My technique has evolved into an understanding of how lip enhancement must be done. Above all, it must never be detectable. Lips are about volume, but more importantly, shape and balance. Indeed, the areas of the cupid’s bow and philtral pillars could only be slightly altered in that any distortions in these areas would draw attention to the lip enhancement, and possibly present an artificial appearance and detectable alteration.
