When to Perform a Lip Lift and When Not To

Let me just get this out of the way: I hate lip lifts. Well not always. I just think they are too often performed creating lips that look unnatural. There are exceptions to this rule but there are very few, which I shall try to elaborate in this blog article. Let’s begin with why do people want lip lifts? The number one reason is a distorted sense of importance imparted to the upper lip for its sign of femininity and youth when in fact the bottom lip can create a much more desirable look without the risk of looking artificial. As I have enumerated in other articles, the upper lip should almost always remain smaller in size relative to the lower lip. When this lip principle is violated, the upper lip can look unnatural. In addition, the upper lip tends to diminish in size as one ages so overlifting the upper lip can look artificial, especially when one is older, which is precisely when someone wants to have a lip lift performed. Again, there is an exception to this rule upon which I shall elaborate.

Donatella Versace looks as if she is a bad victim of unnecessary lip lift surgery

Let’s also clarify what I am defining as a lip lift:  the incision is made underneath the nose along the border of the nose to the face, and tissue is removed so that the lip can be brought upward and rolled out.  This technique is very effective in lifting the lip but sometimes too effective.  When one takes two fingers and gently rolls the lip upward just a little bit the surgical modification is almost always more than what a finger lift demonstrates.  Therefore, caution should truly be exercised when considering a lip lift.  In addition, there will be a scar:  something a prospective patient must know.  Although with a careful plastic surgery 3-layer closure performed with meticulous precision, this incision should be rarely seen, a patient must know that a scar can be visible close up and that makeup may be needed to camouflage it to an ideal level.  In addition, there can be rarely but still possibly slight distortion to the nasal shape due to some pull on the bottom of the nose but again this is unlikely.  What this article is not talking about is a lip advancement in which the incision is made at the border of the lip and white tissue removed to allow for advancing the red lip upward.  In my opinion this procedure is so fraught with complications including an unnatural shaped lip and visible scar not to mention an overinflated look that there is almost no indication to perform a lip advancement.

Now, when would a lip lift be indicated in a patient then?  Let’s first discuss the aging of the upper lip to have you understand that a lip lift is actually the most intuitive surgical maneuver to correct moderate aging of the upper lip but still may not be ideal in many cases.  The white portion of the upper lip begins to lengthen over time and the red lip begins to become thinner.  This causes the upper lip to hang over the front white teeth with and without smiling, which can be a sign of aging.  The lip lift is actually a very targeted procedure that can correct all three problems:  shorten the white lip, increase red lip show, and show teeth better in smiling and in non-smiling positions.  Intuitively attractive right?  Well yes.  But that does not mean in practicality it always looks good, as it seldom does.

Here is who I have found to be the perfect candidate for a lip lift:  an older woman who has absolutely no upper red lip at all, has a very long white lip, has no upper teeth show when she opens her mouth and when she smiles, has bad surface skin that can hide the scar, and does not mind wearing makeup to cover the scar if necessary.  That is the ideal patient for a lip lift.  The least ideal patient is a young 30-something year old man (or woman) with flawless skin, who has a relatively full upper red lip and relatively short white lip, has good or too much teeth showing when smiling and when not smiling but only wants a little bit more red lip to show.  Unfortunately, most people who want lip lifts fall into the latter category or at least towards the latter category and are truly bad candidates for this procedure because of the risk of visible scarring and an unnatural looking upper lip.  Next time you gently pull up on your upper lip and say that is what you want the physician to do, please heed the cautions enumerated above and think twice.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas, specializing in lip augmentation and lip reduction procedures. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ facial plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forums.

Downturned Corners of the Mouth:  How To Fix Them

One of the banes of women’s existence is the downturned corners of the mouth. Whether they are mildly present or severe, almost every woman regardless of age is overly focused on them to their own detriment. I often think that the reason for this is that women look too closely at the mouth when they put on lipstick and then have this weird association where they think minor aging of the lips reminds them of their mother, causing psychological panic that is typically disproportionate to the problem at hand.

I have tried everything for these downturned corners without perfect success. In the past I would perform a corner of the lip lift, a surgical procedure to lift it, but without great success. I have tried facelifting the area but without success. The only thing that I have had success to improve but not to eliminate the fold is with fillers like Restylane (temporary) and Artefill (permanent).

Improvement in the "puppet line" and downturn of the lip but not full correction, which is oftentimes impossible to achieve

What I typically can accomplish is to make the fold change in shape from 45 degrees downward to near horizontal in non-extreme conditions; but I cannot entirely get rid of it.  This limitation is very important for you to understand before I begin trying to fix the problem.  As a complement to that treatment, injection of the depressor anguli oris (DAO) with Botox can sometimes atrophy the muscle enough that the corner can lift somewhat as well but not with the reliability as I have with fillers.  Combining both techniques can be more effective.  The goal with the Botox injection of the DAO is to atrophy the muscle, i.e., weaken it, so that over time the corner may lift for a longer period of time if not indefinitely.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. Call (972) 312-8188 to schedule a consultation or to ask Dr Lam a question please visit our plastic surgery forum.

Understanding The Importance of Lip Transitions When Creating Natural Looking Lips

I have been thinking about transitions from the red lip to the non-red lip because of two women that I saw in the past few days.  First, there was a woman who came from Oklahoma that had these hanging red lips towards the corners of her mouth that looked like a fish.  She had only those side areas injected with silicone because she wanted to make them look fuller.  But a natural lip should taper gently to nothing as it reaches the corners of the mouth.  Instead, hers bulged as it reached the corner of the mouth.  I performed a lip reduction to correct her problem.  The second lady that I saw insisted on having fillers placed into the sides of her lips because she said she drooled at night.  I explained that functionally I do not think filling those sides would help her not drool but more importantly it would look terribly unnatural.  Remember that I truly understand how lips should naturally look, and I ask you to defer to my better judgment when designing your lips so that they stay natural in appearance to all passersby.

Lips that fail to taper to the corners of the mouth look unnatural, which has been corrected through surgical lip reduction.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon, specializing in lip reduction and lip enhancement procedures . For more info, or to schedule a consultation please call (972) 312-8188. If you would like to ask Dr Lam a question please visit our lip surgery forum.

Concerns After Lip Reduction: Revisited

Since I perform a very large number of lip reductions, I have worked hard to discuss with individuals all of the risks, complications, and recovery issues that I can imagine and that I have experienced over the years.  This blog article will discuss what I have encountered so that hopefully as many of your answers to your questions can be found before having a procedure done with me.

First we will address recovery issues that I think are helpful for a prospective patient to be aware of.  The number one concern that individuals have is how long will they be swollen.  This is a hard one for me to answer because swelling is variable.  I have seen as little as a few days and as great as a few months.  However, in general it is about 1 to 2 weeks of unfavorable swelling with the worst being the first several days.  In fact, the lips can swell after the first few days to be much larger than they were even before the surgery, a fact that can be alarming.  This is normal.  I repeat this is normal.  Most people take only a week off from work for practical reasons but must understand that there can be ongoing swelling into the second week.  For ethnic lip reductions, the worst that I have seen for duration of swelling was 5 weeks but this was in a woman who had a very very large lip reduced and I have yet to encounter that long a time for swelling in another ethnic individual.  For correction of previous bad silicone I have see up to 5 months of mild fluctuating swelling but that one woman had swelling that was already present before I performed her lip reductions so I believe this is an atypical case.

Corrective Lip Reduction for Aquamid

Another concern is how long will the lips have visible sutures.  Typically again this is for 1 to 2 weeks.  It is imperative that the sutures not be trimmed during the first week and only sutures that are hanging loose be trimmed after the first week.  Allowing sutures to dissolve by themselves is the key.  Also the incision for the first several weeks can be hanging outward more until the swelling starts to dissipate.  This is normal.   If the lip has some bleeding in the first week or two, that is normal.  All you have to do is hold pressure.  It will stop.  If a suture becomes unraveled early and even if the wound slightly opens, it should still heal fine.  This happens in a few cases.  The lips can also feel very numb afterward and even stay relatively numb for a few weeks to months, which should not raise alarm.  The lips can also feel tight, especially when opening one’s mouth or smiling and this can last for several weeks and at times even somewhat for several months.

Risks of a lip reduction include but are not limited to over or under reduction, scarring, and asymmetry.  I always tell my patients that it is very important for them to trust me on how much lip I can reduce because any more or any less may be a problem for them.  Too much lip reduced and the person could have a gummy smile, lip incompetence, a tight feeling or look unnatural.  Too little lip reduced and no result could be visible.  Given these limitations I always suggest that if one would need a further lip reduction that he or she wait for at least 6 months before contemplating any further reduction (for which I would not charge for the added procedure) because healing may be delayed with too quick another reduction and the risk of overreduction is then possible with all of the attendant problems enumerated above.  I only need to perform a further reduction in less than 5% of those who undergo lip reduction with me.  However, it is fully in my discretion to decline an individual in whom I think the risk is too great to undergo another reduction.

I have had two patients with scarring, and they were both African-Americans.  The scarring was only about 1 mm of thickness at the incision line and was easily handled with 1 to 2 rounds of 5-flourouracil injections.  Unfortunately, I am one of the few people who know how to do this procedure so you may have to fly back for me to do this, which you would be responsible for any incidental and travel expenses but I would not charge you for my services.  Fortunately, I have only had 2 cases of this out of several hundred so the odds are favorable that there will be no scarring.  As a reminder, an actual keloid is near impossible on the face even if you have a history of them on your ears, neck, scalp, or body so I am not concerned about that.  Asymmetry is very unlikely, and I do not remember having a case of this occur but obviously it is always a risk.  More often than not if you see asymmetry it is either something you had before (so please look at your lips carefully before having a procedure with me) or is very slight and should not be noticeable on normal social or professional distances.  I hope this extensive catalog of the risks. limitations, and recovery issues following a lip reduction procedure with me was helpful for you.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon, specializing in lip reduction and lip enhancement procedures . For more info, or to schedule a consultation please call (972) 312-8188. If you would like to ask Dr Lam a question please visit our lip surgery forum.

How I use Permanent Facial Fillers:  Fat Transfer, Silicone, Artefill

In my clinical practice I use both temporary and permanent facial fillers depending on a mixture of budget, desires, and safety. Although permanent fillers carry the risk that they are indeed permanent, I believe that it is important to delineate safety guidelines and also to express how I use them based on those constraints. There are three principal permanent fillers that I use for facial augmentation and enhancement: fat transfer, silicone, and Artefill. In this article I would like to explain how I use each of these products for optimal results.

First, let me summarize the temporary products that I use.  It is only one product, hyaluronic acid, by two manufacturers/companies:  Medicis that distributes Restylane and Perlane, and Allergan that manufactures Juvederm.  I believe that they are both good and are like Coke and Pepsi.  I do not have a strong feeling that one is substantially better but I tend to use more Restylane around the eyes, as I believe it tends to stay put a bit better; and I prefer Juvederm for lips, as it can be a bit softer.  However, for the most part, they are interchangeable; and also reversible using a dissolving product known as hyaluronidase if need be.

Fat Transfer at 1 Year with silicone lip enhancement prior to Artefill “touch up” under the eyes and into the chin area.

I have a thriving practice with permanent fillers too, a large reason is that I feel entirely comfortable and skilled in using permanent fillers, which by their very nature are irreversible and carry risk.  Each permanent product that I use I do for a specific purpose and do not feel they are entirely interchangeable.  By understanding the risks and benefits of each type of permanent filler I am able to use it to optimal advantage.

Let’s first discuss fat grafting, which is a surgical procedure, requiring that fat be harvested from one’s belly and/or thighs to be placed into the face.  The real benefit of fat grafting is for an individual who is at least late 30s with enough aging that would justify having this procedure.  Every decade that goes by after that, fat grafting becomes actually the most financially beneficial procedure because I always say “fat is free”.  In other words, I do not have to take an expensive single syringe off the shelf of filler product and place it into the face.  Instead I can harvest whatever I want and place it wherever I want.  Oftentimes individuals feel then that I will overfill their faces, which this is simply not the case.  Actually, when you put a little bit of fat in many small areas of aging, the entire face actually can look less fat and also significantly more balanced and rejuvenated.  However, fat grafting has its limitations and risks.  The limitation is that fat grafting cannot correct little tiny areas of the face with as much precision as a filler targeting that same area.  For example, the smile lines are an area that I truly believe fat is too soft a product to get reliably consistent results.  However, there is nothing like fat grafting to provide a uniform, global rejuvenation, which would be cost prohibitive with fillers in someone with enough aging to justify a fat transfer.  In general, I think the risk of fat grafting occurs in someone that is too young (let’s say late 20s or early 30s) before they have had children yet and in which I cannot determine whether they will gain significant weight later in life.  In short, I think the risk of a fat transfer is in someone who gains 20 to 30 pounds afterward because the fat unlike other fillers is a bioactive material so it is not good looking if you gain weight.  Fortunately, if you lose the weight, the face that I built is restored to its former glory.  But that risk of significant weight gain is very important to understand.  Interestingly, I have found that weight loss of even 10 to 15 pounds does not seem to take my fat graft results away.  That is why I recommend if someone is going to have a fat transfer to do so before some moderate weight loss rather than afterward.

Silicone injections have carried with it a lot of misinformation and confusion.  For example, I am well known for my lip reduction procedures to correct very badly injected silicone lips.  Fortunately, I do not have to correct the lips that I have created but I had had to do that for the lips created by my overzealous colleagues instead.  If silicone is placed with very small droplets spaced out by at least one month between treatments, the silicone will not migrate. The reason is that microdroplets of silicone are held in place by the surrounding collagen when only a little is placed at a time.  I also believe silicone is very good for the lips because the product is very soft, especially when someone kisses you.  I also use silicone to manage acne scarring and have had life-changing results for my many patients who have failed all other methods of treatments.  However, because only small amounts of silicone can be placed at any given time, I do not believe that it is safe or even reasonable to build up an entire face with silicone.  That is why I use it only in the lips, for acne scarring, and other very small areas of facial correction.  One more word on the lips:  when I use silicone in the lips I am always worried that it will not age well for someone for two reasons.  First, very full lips can look natural in a young face but not in an older face because it will not match.  Second, too much applied to the upper lip can also start to hang further, covering the teeth more as one ages thereby aging someone.  Accordingly, I tend to prefer to use only conservative amounts in someone in her 30s but could be persuaded to be more liberal as one ages so long as the result stays natural.  Fortunately, when I inject the lips I tend to be very conservative in the upper lip, which when overinflated can first of all look unnatural and second age poorly as one matures.  Therefore, I believe that I keep people pretty safe even at a young age if they have silicone in their lips using my technique.

Artefill has become a workhorse for me to augment various areas of the face.  My favorite area to use Artefill is in the smile lines.  The reason for this is twofold.  First, I find that temporary fillers like Restylane do not tend to last a long time in this area so one can reach injection burnout relatively quickly.  Since Artefill is twice the price of other fillers I try to be as judicious as I can when I fill the face since it is so expensive.  Since it is a permanent filler, I also do not tend to start using it until one’s thirties and even then only in the folds.  Every progressive decade I use more of it more liberally.  I can use it just like Restylane or fat now that I have cannulas (blunt instruments) that allow me to safely and accurately place the product around the eyes and into the temples, which I could not do in the past.  I also love to use Artefill in individuals who have had a fat transfer and have a result that is near perfect but would like a little “touch up” in an area that I know further fat would risk overfilling or be too imprecise to correct.  For example, a little bit more in the tear trough or filling the smile lines are two great areas to transform a very good fat-graft result into an amazingly excellent one.  Artefill however is not safe in the lips as it becomes lumpy so I only use Juvederm/Restylane or silicone there.  If I forgot to state it, I also do not like fat in the lips because I think the recovery is too long, the absorption rate is too high, and the results are inferior to silicone and fillers.  I know that this summary of all the risks, benefits, and limitations of each of these permanent products may be a bit overwhelming but I believe I can personally guide you when I see you in person regarding all of the above products in your goal for overall facial enhancement.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon. To learn more about Dr Lam’s facial rejuvenation procedures in Dallas, Texas please call (972) 312-8188 to schedule a consultation. If you would like to ask Dr Lam a question about face rejuvenation please visit our face rejuvenation forum.