Ideal Lips

Ideal Lips: The upper lip has three segments. The lower lip has two.


Examples: Restylane and Juvéderm

Ideal Lips

Of course, it is important to understand the aesthetics of the lips to know where to inject and how much. Few patients wish to have very full lips. Many patients tell me, “I don’t want to look like Angelina Jolie.” (Men are baffled why not). But I understand their concern. Patients don’t want to be ridiculed. They don’t want to have an unnatural appearance.

At the same time, most of us recognize the advantages of fuller lips. Thin lips look older. Vertical creases are more obvious. The late, great Joan Rivers remarked: “Thin lips on a woman give the wrong impression, of shrewishness and prudishness, and probably other ‘ishnesses’ that are the opposite of alluring and desirable.”

Many women overlap the edge of their lips with lipstick to make them look larger and some even resort to permanent tattooing. But this looks artificial because the red part of the lip normally stops at the “white roll,” which is the anatomic border of the “vermillion” of the lip. If the red color extends over this border, it looks unnatural, even clownish.

Ideally, this white roll itself needs to be elevated, and this can only be done by plumping the upper lip tissue from within. As the lip fills out, the natural border swings out and up, producing an attractive eversion of the upper lip.

Ideally, the lower lip is fuller than the upper lip. This relationship is evident in most models. The lower lip is composed of two lateral segments, whereas the upper lip has three—two laterals and a central, which give the pleasing “Cupid’s bow” contour of the upper lip. It is important to recognize this ideal lip shape and to avoid a “sausage” lip appearance. It is also important to place the filler in the red vermillion part of the lip. If it is injected too high, an unnatural fullness is created just above the lip, creating a simian appearance (if you don’t readily recall what this looks like, just google “ape”), which is unflattering to say the least.

What Are HA Dermal Fillers?

HA fillers are composed of hyaluronic acid, a sugar molecule (“glycosaminoglycan”) that is found naturally in our bodies, a connective tissue component of skin. These commercial fillers are manufactured using recombinant DNA from bacterial sources, as opposed to an animal source for collagen. They have received FDA approval for the treatment of facial wrinkles. Examples of HA fillers include Restylane and Juvéderm.

How Are HA Fillers Different From Collagen?

HA fillers, such as Restylane and Juvéderm, have replaced collagen in my practice and in most doctors’ practices because these fillers last longer. Zyplast, a collagen product, lasts less than 6 months, compared with up to a year for Juvéderm Ultra Plus and longer for Voluma.

Another advantage of hyaluronic acid over collagen is the fact that no allergy test is required, because hyaluronic acid it is a natural component of our tissues and is not derived from an animal source.

The manufacturer added lidocaine to the product, so that it is less painful to inject now. Pretreatment with nerve blocks is unnecessary.

Which Facial Areas Respond Best to Fillers?

Which Facial Areas Respond Best to Fillers?

Nasolabial creases (smile creases). The creases or folds on either side of the nose extending down past the corners of the mouth, resembling parentheses ( ), respond favorably to fillers. The nasolabial creases are a telltale indicator of age and can make your face appear tired.

My experience is that most fillers are effective in the nasolabial creases where there is perhaps more margin for error. The true test of a filler is how it works in other facial areas, particularly the lips, where there is no hiding excessive firmness or nodularity. The filler has to pass the “kiss test.” HA fillers pass the “kiss test.”


Commercial Fillers vs. Fat Injection

Commercial fillers usually have minimal downtime, although there can sometimes be bruising. There is less swelling associated with these fillers than with fat injection, and there is no need to have the fat removed from another part of the body. It is an “off the shelf” treatment that can be done quickly in the office, even during a lunch hour. Treatments are less expensive than fat injection.

On the other hand, the volumes are usually limited to one or two syringes (less than 2 cc). More volume can be injected, but it gets expensive. Also, fat injection offers better longevity. When the cost per volume of filler and duration of effect are considered, fat injection can be more economical.

The temporary nature of commercial fillers is both a positive and a negative. It is a negative because treatments need to be repeated. However, if there are any untoward effects of temporary fillers, such as conspicuous nodules, these resolve in time.

Permanent Fillers Can Cause Permanent Complications

Permanent synthetic fillers have been tried with mixed results. Over 100 fillers have been marketed. However, all permanent fillers share the same complications—infection, the formation of granulomas (nodules), unnatural consistency, and migration (movement of the filler material to an unintended area). After experiencing such complications in even a small number of patients, doctors quickly lose enthusiasm. For most operators in the U.S., these disadvantages outweigh the single advantage of longevity. A general principle is that permanent implants should be removable. A breast implant is an example. A permanent foreign body that is difficult or impossible to remove is bound to cause problems. Examples: Gore-Tex, silicone injections, and Artecoll (or Artefill).

Fat Injection Is the Gold Standard

Hyaluronic acid is the most commonly used filler in the U.S. However, fat injection remains the gold standard. In experienced hands, fat injection offers the highest degree of safety, effectiveness, consistency, and longevity. Because fat is harvested from the patient, the filler does not need to be purchased and larger quantities are both practical and affordable. Most patients are happy to have fat removed from their tummy or other areas simultaneously, and it is common for me to perform fat injection of the face or buttocks at the time of liposuction.

Temporary fillers are often used in women in their 30s and 40s to treat nasolabial creases and lips. Commercial fillers can fill in creases that have not yet become very deep. But their usefulness is limited in women over 50, who usually have loss of skin tone making these creases worse and causing jowls. A facelift and fat injection are more effective.

Compatibility of Fillers

T.A., Age 51
Procedure: Juvéderm injection of perioral lines (lines around the mouth) and Botox injection of forehead and crow’s feet.

Before, immediately after, and 1 week after


C.M., Age 51
Procedure: Restylane injection of nasolabial (smile) creases.

Before, 6 weeks after


C.P., Age 52
Procedure: Restylane injection of smile creases and upper lip (1 cc).

Before and immediately after

After injection, there is some redness that resolves in a few hours. Swelling is normal and can last up to a few days. There may be a small amount of bruising at an injection site. Although no bruising is obviously preferred, there is an element of luck in avoiding any superficial blood vessels when the filler is injected. One reason I try to minimize needlesticks is to reduce the risk of inadvertently pricking one of these small blood vessels that can cause bruising. Immediate pressure is helpful in limiting any bruising. There may be some asymmetry, particularly in the lips, which can usually be evened out by gentle lip massage.


Irregularity usually responds to massaging. If irregularity persists, a touch-up injection may be recommended.


It is not unusual to have existing asymmetry. One side of the lip may be fuller than the other to start with. In this situation, more filler is used on the deficient side. However, sometimes the smaller portion of the lip is less distensible, which can limit its ability to expand during injection.


This can happen if the filler migrates from the intended recipient site. Sometimes, creases are resistant to our efforts to fill them and the filler may accumulate on either side, particularly if the creases are “stuck down.”

Bluish Color

Sometimes the HA product can impart a bluish hue to the skin, especially when injected superficially in the tear troughs. This can usually be concealed with makeup and eventually tends to wear off.


Infection is rare. Antibiotics would be prescribed.

Skin Necrosis

If the filler enters the arterial circulation it may block off blood supply to an area of skin, causing skin necrosis, or even loss of vision if a vessel to the eye is affected. This is extremely unlikely.

Allergic Reaction or Reaction to Local Anesthetic

Such reactions would require prompt medical treatment, but are unlikely.

Pregnancy and Nursing

Studies have not been performed, so it is not recommended that pregnant women or nursing mothers receive hyaluronic acid filler treatments.

Unsatisfactory Result

As in all cosmetic treatments, there is no guarantee that you will be satisfied with the result. There is always an element of unpredictability.

Q: How long does the filler last?

A: Juvéderm Ultra Plus lasts up to a year. Voluma lasts 1–2 years.

Q: Is it painful?

A: Yes, but the lidocaine helps, along with reducing the number of needlesticks. It takes only about 5 minutes to do and is usually less painful than Botox treatment of the forehead and glabella.

Q: What if I find my lips too big afterward?

A: This is unlikely. However, an advantage of temporary fillers is that the filler is absorbed over time.

Q: What is the downtime?

A: This can be a lunchtime procedure. There is minimal swelling. However, there may be a little bruising. Immediate pressure can help minimize bruising.