Lip Augmentation
About Lip Augmentation in New York
So many people have been asking about options for wrinkle correction that Dr. Klapper has launched a new site exploring popular procedures, including Restylane, Radiesse (formerly Radiance), Alloderm, Hylaform, and BOTOX®.
Introduction
Full red lips are one of the hallmarks of youth and beauty in woman. Conversely narrowing and thinning of the lips is a feature of the aging face. The perceived sensuality associated with fuller lips has no doubt been propagated by the appearance of popular sex symbols such as Marilyn Monroe and Brigitte Bardot (Paris lip). Initially the procedures for lip enhancement consisted of lip tattooing for permanent color. Now simply improving the color of the lips and giving the impression of fullness is no longer satisfactory. More commonly, many now desire a more enhanced and physically fuller look to their lips.
Am I a suitable candidate for lip augmenation?
This will be assessed at your consultation. During this time Dr. Klapper will discuss your goals for surgery. Your lips will be examined and evaluated in relation to the rest of your face. After discussion, a treatment option will be based on your goals and concerns as well as your anatomy and lifestyle.
You will also be asked about your medical history, drug allergies, and check for conditions that could cause problems, such as active or dormant skin infections or non-healed sores from injuries. Collagen injections are generally off limits for pregnant women, individuals who are allergic to beef or bovine products, patients who suffer from autoimmune diseases and those who are allergic to local anesthetics.
What are the options?
There are effectively three kinds of lip enhancement procedures:
- Injection (Collagen, Radiance, Restylane, Fat)
- Surgical insertion of implant (Alloderm, Softform, or own tissue such as dermis)
- Surgical advancement of own tissue
1. Injections (NOTE: NOT ALL AVAILABLE IN THE U.S.)
These are probably the simplest to perform. All commercially prepared solutions used for injections (i.e. collagen, restylane, fat) however are usually temporary in nature. There are certainly variations between them in terms of longevity, as well as the likelihood of allergies, and the need for skin pre-testing. This is a list of common used injectables worldwide. Due to FDA regulations not all of the injectables below are available in the United States.
Collagen injections are the simplest of the procedures
and are usually done in the surgery with little inconvenience to the patient.
Collagen is easily injected with a fine needle just under the skin's surface,
without the need of a local anesthetic. It is primarily used to treat the
border of the lips thereby adding definition to this for those who desire
a fuller lip. The results are immediate and in fact one can go to a social
function later that night and look great. Collagen injections however are
not permanent. Because Collagen is similar to the components of you own
skin, it will gradually breakdown and be naturally absorbed by your body
after 3-5 months. This however varies from individual to individual. To
regain the appearance, the Collagen injections must be repeated or topped
up after this period of time. There are also a few people who are allergic
to Collagen itself. It is essential therefore to have a skin test and wait
28 days prior to any treatment session.
Effect: Temporary
Radiance consists of calcium hydroxylapatite suspended
in carboxymethylcellulose gel. It is a new injectable product for lip enlargement
and filling of folds and lines. The advantage of this product over collagen
and other fillers, is the potential for long lasting effects. This new
product has been shown to last up to
Effect: 3 -5 years
Hylaform viscoelastic gel is made from a naturally occurring
material (hyaluronan) that provides support and cushioning with the skin.
Injected in similar fashion to Collagen but does not require a skin test
and therefore can be done immediately. Similar life span to Collagen.
Effect: Temporary
Restylane is a non-animal stabilized hyaluronic acid
(NASHA). It consists of complex sugar chains, which have been stabilized
for longer lasting effect in the skin. The manufacturing process of Restylane
is similar to the production of insulin or antibiotics. When combined with
the body's own hyaluronic acid, it creates volume for the treatment of
lips, as well as other lines or wrinkles. It requires no pre-testing and
is injected in the same way as Collagen. Considered to last longer than
Collagen or Hylaform.
Effect: Temporary
Artecoll is a solution containing polymethylmethacrylate
micro spheres. This is injected beneath the skin and the micro spheres
are encapsulated or trapped by the body's collagen fibres gently lifting
and supporting the skin. It is probably the most promising in terms of
longevity with reports of it lasting up to 3 years. It requires no pre-testing
but may require a local anesthetic.
Effect: Temporary but very long lasting
Side effects of all the injectables include minor lumps, swelling, redness, bruising, itching, and tenderness. These usually disappear within 1-2 days but may last longer. Scarring is extremely rare.
Fat transfer/injection is associated with varying degrees of permanence. However this is generally accepted to be somewhat unpredictable and therefore as a result would probably best be classified overall as having a temporary effect.
Fat is usually harvested from elsewhere on the body,
usually the hip or abdomen, by micro liposuction using a syringe. First
the area that the fat will be taken from (donor area) is anesthetized and
then, using a specialized instrument called cannulae, fat is gently hand
suction out then washed and filtered. The small amount of fat extracted
does not noticeably change the donor area. The filtered fat is then injected
under the skin of the lips to build up a fuller lip. Although theoretically
live fat cells should be able to "take" well in the injected
area, there are several factors that influence this. An important factor
is movement. The less movement the treated area gets, the more fat cells
survive. Therefore in highly mobile areas like the mouth and surrounding
tissues, "take" after one injection is probably only about 15-20%.
Multiple injections are therefore necessary. Injection intervals for the
fat transfers are recommended at 8 weeks. Since one's own fat is used,
there is no risk of an allergic reaction to the fat. After the injection
there is some temporary swelling, soreness, and bruising. Patients can
usually resume normal activity the day of surgery, although strenuous activity
should be delayed for a week.
Effect: permanent to varying degrees
2. Surgically Inserted Implants
On the contrary the advantage of Surgically inserted implants is that these tend to be either permanent or very long lasting.
i. Alloderm: This is one of the newer types of implants. Alloderm is a material made from human skin. It is obtained through tissue banks in the United States which surgically remove a thin layer of skin from dead donors using sterile operating room techniques. The skin is placed into an antibiotic solution and then sent for processing. This involves removing the epidermis (top layer of skin cells) and all of the cells in the dermis (deepest layer). The remaining material is a collagen framework, which provides strength to the skin. There are thus no components left to cause the rejection or inflammation that can result with unprocessed tissue transplants. Therefore, when transplanted to a patient, the Alloderm graft gradually incorporates or binds to become a natural part of the patient's own tissues and performs like normal healthy tissue thereafter.
Are Alloderm grafts safe? Before any processing of the skin takes place the tissue donors undergo rigorous screening by the Tissue Bank. The donor's medical and social history and cause of death are carefully reviewed and documented. The Tissue banks or a certified laboratory using FDA-licensed tests extensively tests Blood samples. The donor must be found negative for Hepatitis B and C, HIV types 1 and 2 antibodies (screening for AIDS) and syphilis. Its important to understand that human pathogenic viruses, including HIV, require certain types of human cells to be present and alive in order for the viruses to live and grow themselves. These viruses essentially are "parasites" of cells and cannot reproduce without them. The alloderm process removes all cells, thereby removing the components necessary for the survival and transmission of these viruses. Additionally, after cell removal the Alloderm grafts are freeze-dried. As an extra safeguard, Alloderm grafts undergo microscopic and other analytical testing, both before and after processing, to rule out pathogenic contamination and promote uniform quality.
How long has Alloderm been used? Use of Alloderm began in 1992 for burn patients and in 1994 for periodontal and plastic surgery. Currently more than 50,000 patients have received Alloderm grafts.
What are the advantages of Alloderm? Alloderm is the only available product capable of regenerating normal soft tissue. Since it is human tissue it does not incite an inflammatory or allergic reaction, and the pre-treatment skin testing required with animal collagen is not needed. Also the graft does not have the feeling of hardness that is reported with many synthetic material. When Alloderm is used as an implant, it thus completely eliminates any need to take donor fat or dermis from one part of the body to transplant to another area and thereby eliminating further scars.
What are the disadvantages of Alloderm? Despite the thorough processing which Alloderm undergoes, rendering the implant devoid of most cellular components, some people may still be averse to the thought of having "someone else's skin" inserted into theirs. Although Alloderm appears to be long lasting, with initial studies confirming up to 2-year survival rates of the graft, longer term and larger studies are needed to determine whether or not Alloderm is indeed permanent. There have been reports of a small number of patients completely absorbing the volume of Alloderm within 6 months of surgery. Alloderm lip enhancement is irreversible after a period of 7-8 weeks. This is due to the incorporation of Alloderm to your own tissues, and therefore any attempt at removal of the Alloderm is extremely difficult or in fact impossible after this period of time.
The Procedure: Surgery is usually performed as a day case under local anesthetic with the aid of some sedation or "twilight anesthesia. The Alloderm graft, which comes freeze-dried, is re-hydrated in a sterile solution. This makes it very soft and pliable and in fact feels just like your own tissue. The graft is then rolled into a tube, to a thickness depending on how much fuller the patient wants to be. Tiny incisions are then made inside each corner of the mouth. A tunnel is then created under the skin of the lips and the Alloderm is then threaded through. A single suture is then used to close the incisions and an antibiotic ointment is applied over these for the next few days until the incisions are healed. You will also be prescribed a short course of antibiotics to minimise infection risk.
Postoperatively: Following surgery you should expect to have a "bee stung" appearance due to the swelling. There may also be some bruising. Cold compresses to the lips in the first few day's helps to lessen this. Although much of the swelling will be gone with a few days, the healing process will continue. This may take up to 2 months. During this period the graft sometimes feels slightly firm. Firmness may persist longer if you develop a postoperative infection, react to the suture material or if you had other materials previously implanted or injected into the same area. As the graft heals and becomes a part of your own tissue, it softens and in several months should feel no different that the surrounding skin. It is important to bear in mind that Alloderm becomes incorporated into your own natural tissue. This process will be significantly advanced by about 2 months. Therefore should you wish to have the implant removed for whatever reason, then this must be done by 5-6 weeks postoperatively or complications may arise if this is undertaken at a later stage.
What are the risks? As with any operation, risks such as bleeding and infection can occur. People who are prone to developing cold sores may develop an exacerbation following this type of surgery. If this were to happen then you would be given tablets and ointments to treat the cold sores which should not alter the overall result. There may also be slight asymmetries of the lips, scarring, firmness of the graft, and changes in sensation (temporary).
ii. Softform: The Softform implant is a soft, hollow, tubular ePTFE(expanded polytetrafluorethylene-a Goretex derivative) implant that offers a permanent, yet reversible, lip enhancement. Its hollow configuration was designed to promote your own tissue ingrowth into the central lumen of the implant to provide stability. It is currently available in two outer dimensions-2.4mms and 3.2 mms, with an approximate length of 7 cms. Depending on the size chosen it is excellent for either defining or highlighting the upper edge of the lip vermilion (where the red colour of the lip meets the normal pigmented skin) or to add more bulk overall to the lip.
How long has Softform been used, and is it safe? Softform was only developed about 2 years ago. The material however which it is made of i.e.PTFE has been used in vascular grafting for more than 20 years, and in more than 3.5 million people. It has also been used for hernia repair, abdominal wall reinforcement, and facial applications, showing high chemical stability and low infection and extrusion rates. So far there have never been any reported allergic reactions to ePTFE.
What are the advantages? As Softform is chemically stable and not metabolized by the body its effect is considered permanent. Additionally, should the Softform not be desired after any given length of time, then this could be removed. As Softform is a synthetic material it is commercially available and therefore eliminates the need to take donor fat or dermis from another part of your body, thereby eliminating the need for further scarring.
What are the disadvantages? Although there is a softening of the treated area over time, patients will likely be able to feel the implant or even a ridge after insertion. Occasionally a "bow stringing" appearance in the skin overlying the implant may be seen in extremes of smiling. Due to the synthetic nature of the Softform implant, there have been rare reports of extrusion of the implant over time.
The Procedure: Softform is usually inserted as a day-case/outpatient basis under local anesthesia. A small incision is made in each corner of the mouth and the Softform is threaded under the skin of the lips by means of its own closed delivery system. Following insertion a small suture is used to close the incision and some antibiotic ointment is applied over this until the incisions are healed. A short course of antibiotics is then prescribed.
Postoperatively: Treatment results are visible immediately, although there will be some associated swelling and bruising. Some patients may experience a sensation of tightness at the implantation site. The swelling and bruising will have subsided by day 7-10. Although you may always be able to feel the implant under your skin, softening of the implant is anticipated over time.
What are the risks? As with any operation, risks such as bleeding and infection can occur. People who are prone to developing cold sores may develop an exacerbation following this type of surgery. If this were to happen then you would be given tablets and ointments to treat the cold sores which should not alter the overall result.
There may also be slight asymmetries of the lips, scarring, firmness of the graft, and changes in sensation (temporary).
iii. Autologous Dermis/Fat (own tissue): Dermal grafting uses a piece of the dermis, which is the tissue just under your skin, taken from a different part of your body. Because it is your own tissue, the new material is completely compatible. It is therefore likely to take in your lip in a predictable way. You will get a conservative amount of lip filling from a dermal graft. The disadvantages are that you will be left with a scar from the site where the dermis is taken and that sometimes the body may reabsorb all or part of the graft. In addition, lumpiness and firmness can arise in this type of implant although over time this does tend to settle.
This is probably the first surgical type of lip enhancement developed. This procedure is commonly used for reconstruction following an accident that scars or destroys parts of the mouth or lips. In this procedure a flap of your own lip tissue from inside your mouth is borrowed or advanced forward to give your lips a fuller look. This procedure involves much more surgical trauma to your lips than insertion of implants does and as such has fallen out of favor with most surgeons. In addition there is always a lengthy scar on the border of the lip where it meets the normal pigment of the skin, and the amount of enhancement can also be limited by the amount of available tissue present.
Lip Augmentation Summary
Lip enhancement is very individualized. The duration and effect of any lip enhancement very much depends on the treatment chosen. Different treatments suit different individual's needs and therefore its important to discuss your hopes and expectations as clear as you can at the initial consultation. Providing the right treatment is chosen, chances are that you will be very pleased with the look of your new lips.
With Great Respect and Appreciation for Mr. Karidis
(London, England) for Permission to borrow his Excellent Text
www.nipntuck.co.uk
You must also be aware that these notes make no recommendations for surgery
and in no way should it be considered promotional material for any organization.