Lip Fillers – What Product to Use

Lips form a focal component of facial aesthetics enabling individuals to communicate and express personal emotions and sentiment. Full lips with defined borders are a hallmark of youth and attractiveness. As we age, our lips can become thin, flaccid and wrinkled with loss of volume and elasticity. Sun damage, smoking, genetics, loss of teeth and bony structure all contribute to a weary and worn appearance with perioral lines, downturned corners of the mouth, lip thinning and ill defined border.

Lip fillers are frequently used to enhance fullness, shape, contour and minimise perioral/smoker’s lines. Individually tailored filler injection techniques, sometimes in combination with other procedures, can provide a marked improvement in appearance.

There are numerous dermal fillers available that are suitable for lip enhancement with the most commonly used based on hyaluronic acid, sometimes called ‘hyaluronic acid (HA) fillers’. Although other products are available such as semi-permanent fillers, fat injections and implants, HA fillers remain popular due to their safety, duration and ‘natural’ results. Permanent fillers can cause problems over time and pose the risk of potential lumps, unevenness and granulomas which may require surgical excision.

Reasons against Permanent Fillers

• Lips change with age and this permanency may not look harmonious in the context of an aging lip.
• The lips are dynamic and constantly move. This may alter the pattern of the lip fillers in the future.
• There is no reversal of permanent injectable fillers.

Hyaluronic Acid

Hyaluronic acid (HA) exists naturally in all living organisms and is an important component of connective tissues, including the skin. In fact, 50% of the total body HA is found in the skin where it helps to provide structural support, nutrients, add volume and fullness. HA fillers vary in their source, concentration, particle size, cross-linking, viscosity, gel/particle form, volume and inclusion of anaesthetic.

Benefits of Choosing Hyaluronic Acid Fillers for Lips

• Aesthetic results: Hyaluronic acid is hydrophilic, hydrating and volumising. It helps to support lip structure and achieve a natural lip shape.
• Gradual volume: The volume injected is controlled and tailored to individual’s needs.
• Lumps can be dissolved: It is possible to quickly break down any product lumps.
• Duration: HA fillers tend to last 6-12 months. Additional filler can be added during that time.
• Allergy is rare: As the fillers contain hyaluronic acid that is similar to that found in the body, they are unlikely to cause an allergic reaction. Bacteria sourced HA has become the filler of choice due to its high purity, viscosity and non-animal base making allergy rare. If there is a known allergy to lidocaine, the practitioner should be informed.
• Further treatments possible: A gradual enhancement can be made over time at different appointments adding additional filler.

Disadvantages of Dermal Fillers

• Temporary swelling and bruising may occur after treatment
• Repeat treatments required to maintain results

Hyaluronic Acid Fillers for Lips

The lips are one of the most requested areas for tissue augmentation in both young and old clients. HA fillers are ideal in replenishing the volume lost and re-establishing aesthetically pleasing well proportioned, contoured, fuller lips. There are several HA fillers on the market with some of the more popular ones specific for lips being:

Restylane Lip Volume^®
Q-Med, Galderma

Juvéderm^® VOLBELLA^®
Allergan

Teosyal Kiss^®
Teoxane

All the above are colourless, contain lidocaine and results last up to 12 months. Every practitioner tends to develop a personal preference for a particular HA filler which may vary depending on the area of concern. However, in the right, experienced hands, excellent results can be obtained from all listed above.

Choosing A Filler

There is no universal filler that is ‘advisable’ for every procedure or for every patient. The physical properties of HA fillers are important and influence the clinical outcomes, such as HA concentration, modulus, swelling, particle size, cross-linking and extrusion force.

Modification and Crosslinking

In its natural state, HA is biocompatible and has a high affinity for water but it is also rapidly broken down. In order to improve its durability HA may be modified (usually at the carboxylic acid or hydroxyl groups) and cross-linked. The degree of modification will greatly affect how the filler behaves. With increased cross-linking, the distance between cross-linked segments becomes shorter, increasing the network strength and the ‘stiffness’ of a gel.

Concentration

HA concentration is expressed in mg/mL and the total HA concentration consists of insoluble HA gel and soluble-free HA (incorporated to facilitate ease of filler extrusion). Only the cross-linked HA will resist degradation and extend durability.

Elastic Modulus

Fillers with a lower G’ are best used where volume and softness & mobility are important, such as in lips where we recommend first time patients using the more standard fillers like teosyal global, restylane, juvderm 2 or equivalent.  Usually the filler by most companies dedicated for lips provide more volume, longer lasting results but a little stiffer lip due to increased G’.

Swelling

HA has a high water binding capacity. The longer the HA molecule, the more water molecules are bound per unit. Fully hydrated gels will cause little swelling when injected, whilst those that are not (nonequilibrium gels) tend to swell post injection.

Particle Size

The particle size must be appropriate to be able to pass through a fine-bore needle with ease. Larger HA particles tend to last longer and may be more suitable for deeper defects and injections. Biphasic dermal fillers consist of particles of various size depending on their indication. Monophasic HA fillers are cohesive gels rather than just HA particles.

Available fillers have a wide variety of properties that will affect clinical outcome. These should be taken into account when deciding on an appropriate filler for a particular application and patient. The results will vary depending on the experience of a practitioner and the response of the patient to the filler. There is no single parameter that defines the use and effectiveness of a HA filler.

Procedure Overview

All HA filler lip enhancement can usually be performed within a 30 appointment. Advise will be given prior to treatment on particular medications and supplements to avoid before the procedure. Alcohol should not be consumed 2 days before and prophylactic antiviral medication may be required for those that suffer from cold sores.

Contraindications

Side Effects and Complications

Common Side Effects

• Swelling – the majority of individuals will experience swelling which may last from a couple of days up to 2 weeks
• Bruising
• Redness and tenderness

Possible Complications

• Asymmetry – this can usually be amended by added additional filler product where needed.
• Lumps and bumps – most irregularities can be massaged smooth immediately after the procedure. Lumps that persist or appear later may need to be broken down with Hyaluronidase or, rarely, steroid injection.
• Infection
• Tissue necrosis – tissue loss following injection into a blood vessel.
• Scarring
• Allergy

In Summary

In experienced hands, HA fillers can give highly satisfactory results for perioral rejuvenation. Appropriate patient selection is critical to ensure a satisfying aesthetic outcome with realistic expectations. Often it may be beneficial to combine dermal filler treatments with other procedures such as botulinum toxin injections, chemical peels or laser resurfacing.

The major benefits of HA fillers include their known safety profile, temporary duration and ability to be broken down with Hyaluronidase. Serious complications are rare and clients can opt to continue with further enhancement procedures as required.