- My lips are swollen, lumpy, and a little uneven, when will they get better? This is the most commonly asked question on Realself.com. The lips take about 7-10 days to settle down after getting filled. Restylane Silk will swell the most of all the fillers. Juvederm, and Restylane are the most commonly used fillers and the swelling and lumps will all even out gradually over the first week. Sometimes there is asymmetrical swelling, and that usually evens out too. Elevating the head of bed will help lessen the swelling. Unless there is bruising, ice will not change the swelling, nor will antihistamines. The swelling is most often related to the HA filler absorbing water from the surrounding tissues. On an extremely rare occasion, the lips and surround tissues swell abnormally, and this is called angioedema. This most often occurs in people that take a blood pressure medicine that is in the “ACE inhibitor” family. If this occurs, immediate attention is needed by your doctor or the emergency room.
- I’m very bruised, when will it go away? Bruising is related to technique, not the filler itself. Bruising can take up to 10 days to go away. Early bruising can be treated with a laser (VBeam or Excel V) to decrease the duration to 2 or 3 days. It is best to stop all supplements, anti inflammatories, fish oils, vitamin E, or all other medications that can thin the blood a few days before injections if possible. Aspirin takes 12 days to get out of the system. Cannulas help minimize bruising as does careful technique, but bruising isn’t always avoidable. Arnica will help bruising too.
- My upper lip is very full, is this normal, I look like a fish or duck? There is an art to filling the lips. The upper lip should be smaller than the lower lip by the golden ratio of phi, 1:1.6. If the doctor does not abide by normal anatomic ratios, the lips look done and abnormal. It does not happen to most people and is unrelated to the product injected. It is poor technique by the injector. In ethnic people, sometimes a 1:1 ratio does look normal, but never when the upper lip is larger. Click here to learn about perfect lip anatomy.
- Can the corners of mouth be turned up, I always look sad? The corners of the mouth can be lifted with properly placed filler. Also, an injection with a neuromodulator such as Botox or Dysport can be injected into the depressor angularis oris, DAO, to relax the muscle pulling the corners down. Often, support is also needed in the above the upper lip in the triangle of volume loss near the corner. Also, injection into the corner (commisure) is needed.
- I’m not happy with my lips after injection, what can I do? First thing is to discuss with your injector. After waiting the 10 days, lips that still have bumps, look odd, or are uneven, can be dissolved with hyaluronidase. This is not a precise procedure, so fine tuning is not possible. Most often, one treatment is needed but sometimes 2 are needed. Sometimes a little filler can be added to make things more symmetric. Asymmetries are very frequently noticed after injections by patients, but after careful review of photos, were present before the procedure too.
- I have severe pain, days after the injection. Pain should not be present after about a day or 2 from the procedure. This needs to be discussed with your injector. Concerns would be possible injection, or herpetic outbreak. Severe overfilling can cause this too.
- What can be done for my upper lip lines, “smokers lines”? Upper lip lines, “smokers lines”, are some of the hardest wrinkles to treat. This occurs even in non smokers and is mostly a volume related problem. Best treatments include filler placed horizontally in the white lip or ergotrid (with cannulas), a fine bead of filler along the vermilion border, and a small amount in the lip body. Adding Botox in small amount help too. Don’t expect elimination, just improvement. Longer term solutions are laser resurfacing with ablative lasers, Infini, or dermabrasion.
Enhancing lips has become a very popular cosmetic procedure. Most of the press has been negative because of the abundance of poorly performed injections, particularly on celebrities. Instead of improving ones looks, and sensuality, they become a turn off, negatively affecting one’s attractiveness if not done properly. A slew of new terms for these lips has arisen: “Fish Lips”, “Sausage Lips”, “Trout Mouth”. Patients go into the doctors office with aspirations of “Angelina Jolie” lips and leave with “Lisa Rinna’s” lips. Unfortunately, the bad outcomes of these celebrities and close friends, scares off a number of interested women, fearing they too will end up like Goldie Hahn from the “First Wife’s Club.”
Fortunately, with an experienced injector, and the newly approved filler Restylane Silk, cosmetically attractive lips are well within reach for most clients. Restylane Silk’s advantage lies with it small particle size. This enables the injector to more precisely place the filler, for better contouring, and with less chance of leaving lumps or bumps. Also, because it is superficially placed, there is less bruising and less discomfort during injections. It’s not just the filler though, it takes the skilled eye, technique, and knowledge of an experienced injector to get the lips just right.
Knowing the esthetically correct dimensions and landmarks of the face goes back to Leonardo Da Vinci, in the 1400’s. He recognized the golden ratio, phi, that equals 1.618. Throughout the face, he saw that relationships between spacing and dimensions of the face, and all were related to the pi ratio. In the lips, the golden ratio is found between the upper and lower lip, with the upper to lower lip ratio being 1:1.618. In African Americans, this can be close to 1:1 and Asians are somewhere in between. Several other aesthetically appealing features of the perfect lips are:
- Prominent tubercles in the middle of the upper lip, and either side of the midline on the lower lip
- A strong cupid’s bow and philtrum
- Corners of mouth that are neutral or turn up slightly
- Very little red lip visible on the lateral 1/3rd of the upper and lower lip
- The length between the columella and space between the lips should be about 1/2 of the length from the space to the chin
- The peak of the cupid’s bow is continuous with the philtrum
- The upper lip should project more than the lower lip when visualize on a lateral view
- A “Paris Curl”, lips curling up at their vermillion borders
- Phi ratio: length between cupids peaks: length between corner of mouth and cupids peak
What goes wrong with lips that look obviously done or unattractive? The simple answer is that ratios and landmarks are ignored. Several common errors are: upper lips that are bigger than lower lips, lower lips that project more than the upper lip, tubercles (or other landmarks) that are obliterated, and no attention to the cupids bow. Also, enhancing lips to the “age appropriate size” is part of the art of an experienced injector. Selecting the appropriate filler is important too. Fillers other than Restylane Silk, are too thick to be added superficially in the lips without the risk of being noticeable or palpable. Silk can be injected just beneath the surface of the lip and not be perceptible. Fine tuning is much easier with this technique rather than the deeper injections that have more associated bleeding, bruising, and swelling.
The take home messages are that achieving desirable, sensuous lips requires a skilled injector with a keen awareness of natural ratios and landmarks. Using the newly approved FDA filler for lips, Restylane Silk, allows for greater control and results that can’t be achieved with the other, more viscous, hyaluronic acid fillers.
(In the older patient: It is very hard to restore lips to their youthful state when there is severe volume loss, multiple upper lip lines, and loss of the normal curvature of the lips. The lip muscle in a young lip forms a “J”, creating a natural curl in the lip. In some patients, this elongates into an “I” shape, making it difficult to create the natural shape with a filler injection without it appearing abnormal. In these patients, the author gradually enhances over several months and this seems to lead to better outcomes.)
Lip augmentation has received a lot of press over the past couple years and its been mostly bad. That’s because most physicians either overfill the lips or don’t understand what makes lips attractive and natural appearing. In addition, most patients equate lip augmentation to severe pain and several days of downtime with bruising and swelling. I would like to try to convince the public that you don’t have to fear the process of plumping up your lips and don’t have to have days of downtime where you either are hiding in you house or explaining to people that your significant other didn’t beat you.
Blunt cannulas have changed the game for lip augmentation. Through one entry port (which requires a small needle poke) on each side, you can have both upper and lower lips filled with little or no bruising. After applying topical numbing creams to the lips for about 10 minutes, the procedure is very well tolerated. The other advantage is that the swelling is minimized because the lips are minimally traumatized. Many patients go straight out to lunch or drinks or back to work without being self-conscious of people looking at them. On the contrary, traditional lip augmentation using needles requires 4-5 penetrations (each time causing discomfort and risking bruising) per quadrant (so you have to multiply by 4). The blunt cannulas push vessels out of the way with their rounded tips so bruising is minimized. Also, most of the pain is in the surface penetration and once under the surface, the blunt cannulas give less discomfort.
Dental blocks are performed by many of my colleagues. I’m critical of this technique because:
- Dental blocks are not comfortable
- Often times the block is incomplete so there is still discomfort during the lip injection.
- You often stay numb of a prolonged period of time with the associated drooling, etc.
- The lip anatomy can be distorted with the block making precise lip enhancement difficult.
Some doctors are critical of using cannulas for the lips because they say the control of placement of the filler is less than when using the needle. Admittedly, there is less precision for the novice, but over time, I’ve become very efficient at using cannulas and there is little difference as far as results. Sometimes, after filling the lips with the cannulas, I will go back into the already numb lip and place minute amounts of filler along the vermilion border or in the tubercles with the needle technique. This usually does not cause significant bruising or swelling.
A natural set of lips is about 33-40% upper lip and 60-66% lower lip. Often doctors will make the lips the same size or the upper lip bigger and this looks very abnormal. Sometimes when the doctor is trying to improve the upper lip lines, this problem occurs by accident. The best way to correct the upper lips lines is to place filler in the area between the lips and nasal area with the cannulas in a horizontal fashion. This usually doesn’t affect the ratio described above. There is loss of bone in the upper jaw as well as loss of fat, and this injection technique replaces those tissue losses and improves the lines. (For more the most severe lines, I will use Belotero into these lines but this is with a needle and does lead to bruising in most cases.) Also, the lip is not supposed to go all the way to the corners. It should gradually taper off on the sides. Those people who get there lips injected evenly all the way across end up with “sausage lips”. Another error is placing too much filler in someones lips. Small lips can only be enhanced to a certain degree before they appear awkward and you look like a “trout mouth”. People with extraordinarily small lips are gradually made larger in my office. Over successive fills, they are slightly larger than their previous treatment. That way you avoid the lips which get through the doorway before the body.
Procedures which should be avoided at all costs, in my opinion are: permanent filler/ implants in the lips or the Valentine lip lift. These lead to abnormal lip appearance, unnatural mobility/movement, long-term complications (firmness, bumps) and unhappy patients. Some patients are trying to avoid repeated injections due to discomfort and resort to these solutions. Don’t do it!! Cannulas offer a more comfortable injection, and overtime, there is collagen stimulation which lengthens the times between treatments. My long-term lip augmentation patients get filled every 9-12 months.
In summary, lip augmentation doesn’t have to prolonged downtime, be considered intensely painful, and look unnatural. Blunt cannulas in the right hands can make for a much more pleasant experience. It’s important to seek out a physician who knows the anatomy of aesthetically pleasing lips and what is needed to achieve those results. Although bruising can occur with cannulas, it usually is minimal or nonexistent, and you can continue your active social schedule after the procedure.
Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.