FPSAM - Roundtable 2021 - 4

EXPERT PANEL DISCUSSION
Dr. Fabi: The lips are usually an area that people are
most hesitant about treating, especially when they're
40 years old or older. There is a fear of them looking
unnatural. The facial structure that the lip is housed on
has to match, which adds another layer of complexity.
With that said, I am treating people all over their face,
and if they choose not to treat their lips, and we know
the orbicularis oris that contributes to the roll of the lip
and vermillion border atrophies with age, so I tend to
encourage my patients to consider revolumizing their
lip-not from a place of having their lips walk into the
room before they do, but from a place of having it
match the rest of the face that they have been keeping
so youthful and volumized.
For the lips, I like Restylane Kysse. I tend to use that
in patients who are younger than 50 years of age, as
typically these patients still have the bony structure
and soft tissue volume to support a more voluminous
lip that projects well. For patients who are 50 years old
or older, I sometimes will use Restylane Silk as it
provides a softer look and feel to the lip, and typically
provides a more age-appropriate lip.
Dr. Dayan: Dr. Cotofana, I would like you to comment
on something that Dr. Fabi touched on-the
aging lip. Would you please comment on the
lengthening of the lip as we get older?
Dr. Cotofana: Yes, Dr. Fabi observes a very interesting
point which is exactly how you should start
when you assess the face, and lips in particular. In
terms of the anatomy of the lips-the treatment of the
lips starts outside the lips. As we all know, the lip is
mostly composed of a muscle, the orbicularis oris.
This muscle provides support, but has only a very
small bony attachment. The rest is just free floating
on the underlying teeth. So, when we understand that
everything is free floating, we need to also understand
the interplay between the different muscles.
And, of course, as we get older, the inroll of the orbicularis
oris tends to unroll-similar to the unrolling
of the trump of an elephant. And then of course, the
white portion or cutaneous portion of the upper lip
lengthens, which also inverts the vermilion, which
leads to thinning of the upper red lip portion. If we
understand that this is the case, and that this unrolling
is bound to happen, we know exactly how to treat it
and which product to use, because we know the
processes.
Dr. Dayan: I love your explanation there, and I
want to reiterate and emphasize a bit on that. A few
years ago, I published an article on injecting deep
into the superior cutaneous upper lip and its impact
on the vermilion, where actually it rotated and it
lifted it, and projected it. I think we must recognize
that if you want to treat the lip, it is not just putting
4
in the vermilion, there are other areas, periorally,
that can significantly improve the appearance of
the lip.
Dr. Durairaj, how do you avoid the ''sausage lip''
appearance that we see so much of?
Dr. Durairaj: It is very difficult. I think people come
in grossly undertreated with the rest of their face and
the first thing they want to do is their lips, and that's the
last thing that I want to do.
I'm always a big fan of giving the midface support
first, but I'm avoiding the sausage-y appearance by
respecting the border definition of the lip and doing a
precise outline of the vermilion and avoiding lip filler
migration by staying within the lip. I also like to give
definition of the tubercles and follow the innate embryologic
origin of the lip, so defining the tubercles
gives you those projections of light, which look pretty,
and they don't look flat, sausage-y, or rubbery. I think
that is very important.
The more I grow as an injector, the more I think I
really understand that the asymmetries of the lip are
really based on the dental arch being asymmetric and
on the bones of the lower face. With that said, it's a
challenge to avoid a sausage-y lip these days, and you
have to say ''no'' to patients sometimes. Of course,
many patients want the feeling of sexiness that comes
with lip filler, but the reality is they do not necessarily
need more lips.
Dr. Fabi: An excellent point, Dr. Durairaj. Indeed,
patients want the ''sexiness'' of full lips. As the experts,
we have to also take into consideration and address
that patients might be pursuing a ''feeling'' more
than actual lip injections. Therefore, if we can assess
them appropriately and identify the anatomic changes
that Dr. Durairaj already mentioned, that may be
contributing to the changes they are seeing periorally
and making them feel less ''sexy,'' we can make them
feel what they want to feel without necessarily injecting
their lips.
Dr. Durairaj: I agree, and I lean toward using small
aliquots of filler. Sometimes adding a little ''touch'' to
the lips, but mostly focusing perioral tissues more than
anything else.
Dr. Dayan: Very good points. Dr. Rosengaus, how
important are the formulas we learned coming
through plastic surgery and facial plastic surgery
training, of phi formulas, 1:1.6 and the specific
definitions of what makes an attractive lip?
Dr. Rosengaus: Beauty is not mathematically defined.
One must take into consideration gender, ethnicity,
age, etc. I think that advanced treatment of the lips
requires a refined diagnosis.
ª 2021 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.
FPSAM - Roundtable 2021

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