MAY-JUN 2018

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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Page 41 of 68 | MAY/JUNE 2018 39 SHAPE CONSIDERATIONS Patients of all ages seek lip augmentation procedures. Younger patients (under 35) who have good lip shape tend to seek volume. In order to provide the luscious looks they desire while maintaining a natural appearance, consider the ratio of lower lip fullness to upper lip fullness, says H.L. Greenberg, MD, of Las Vegas Dermatology in Las Vegas. "The upper lip should be a 1 and the lower lip a 1.3— about 30% larger," he says. "Anyone can fi ll a lip, but you have to understand what will look good on the patient as well as their aesthetic goals," says Michele S. Green, MD, a cosmetic dermatolo- gist in private practice in New York City. "Do they want a mild, subtle look, a Kylie Jenner look, or is the primary concern getting rid of lip lines? Older patients, in particular, don't want a big lip. They want some collagen restored so they don't look as wrinkled." Dr. Green uses a variety of fi llers, including Juvederm Volbella, Juvederm Ultra Plus and Restylane or Restylane Silk. "Don't stick to one fi ller," she says. "Some doctors only use Restylane on the lips. I love Restylane, but you have to think about what you want to accomplish. The same fi ller isn't going to work on everyone. If someone is older, Volbella offers a subtler look. The other products are much too thick." For patients over the age of 35, Sabrina Fabi, MD, a der- matologist with Cosmetic Laser Dermatology in San Diego, California, looks at the frame of the lips before addressing volume loss. "It's not just the actual vermilion of the lip, or what we call the run of the lip, that loses volume," she explains. "It's the entire frame of the lip, which includes the pyriform fossa, or the maxilla, that supports many of the muscles that elevate the lip, as well as the mandible, which supports many of the muscles that pull or depress the lip." In addition, the masseter muscles around the outer edge of the lower face may become larger with age, making the lips appear smaller, she says. "If the lip is dropping because the muscle around the lip is losing support from the level of the maxilla, you can inject a little bit of fi ller along the pyriform fossa," says Dr. Fabi. "This gives those muscles support, and the lip no longer looks like it's falling." By using microfocused ultrasound (Ultherapy) on the upper cutaneous lip, Dr. Fabi can nonsurgically elevate the lip 1 to 2 millimeters. "This is just enough of a change to look natural but to also give the patient nice augmentation without adding volume," she says. If patients have downturned lips, "putting some fi ller in the marionette lines or right in the lateral edge of the lip on either side will help turn that downturned lip up," says Dr. Greenberg. FAT GRAFTS OR FILLER? Fat grafting can be used to add volume to thin lips, though it has lost favor due to the relative safety, reversibility and reliable results of HA fi llers. "You don't want to inject fat accidentally into the blood vessels," cautions Massachu- setts-based plastic surgeon Christine Hamori, MD, who will occasionally use fat grafts for patients already undergo- ing facial surgery. "You can get an infection with either fat or off-the-shelf fi llers, but with fat, the risk is a little bit higher. So know your anatomy, be very careful where you insert your needle and keep it as sterile as possible." A second consideration of fat grafting is the permanence of results. "If we are doing a face lift on the patient, that might be an opportunity for us to inject a little bit of fat into the lips," says Dr. Hamori. "But it is not my go-to product for younger patients because of problems with weight gain and weight loss. If you inject fat into the lips of a 20- to 25-year old, and they gain 10 pounds, their lips also get larger. Many women have weight shifts as they grow older, and it can become a problem because those fat cells respond to caloric intake." One indication for which she does prefer fat is very fi ne lip lines. In these cases, Dr. Hamori performs nanofat grafting not to augment the lips but to rejuvenate the skin. "We harvest the fat from the patient's abdomen, and then pro- cess it by shredding the adipose tissue to get the liquid portion of the fat cells, and we in- ject it into those fi ne lines," she says. "We've had really good success with smoothing the lines while not giving volume to the area." "If you inject fat into the lips of a 20- to -25- year old, and they gain 10 pounds, their lips also get larger."

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