Lips associated with eyes represent one of the most important areas of the face: with mimicity it is possible show a complete and very complex range of feelings, from joy to sadness, from pleasure to disgust, from hilarity to astonishment, and so on for hundreds of expressions, well divided one from each other with little modifications of the lips.

And also when relaxing, lips can provoke attraction and desire while in other cases they can provoke repulsion and disgust.
Also the race remarkably conditions the shape of the lips:some are big and prominent like in black races, some other are thin and almost retracted, as in the northern races.

And also the media that nowadays impose aesthetic standards contribute to modify during the time the representation of the fashionable lip: a full, fresh mouth slightly abundant in the act of sending a kiss, could be the sign of our days.
And so the demand of correction of the lips, both in the target to correct volumetric anatomic faults and give back the correct volumes when these become thin with the time, is always major.
But sometimes, we see exaggerated lips, bad done, clearly faked that, in my opinion, we should refuse to do.
Then, it is worth to waste some minutes in order to consider the aesthetic standard that, from my point of view, should regulate any of our operations of correction.

Anatomy

From an anatomic point of view mouth is distinct in upper and lower lip, the second is the same or slightly shorter than the upper.
The upper lip distinguishes itself in a cutaneous portion of the lip(the so called white lip) that goes from the naso-genian furrows and the nose to the edge of the vermillion determining a marked rising of the Cupid’s Arch in a pretty thin M shape.
The white lip presents a thick cutaneous layer rich of bulb annexes and strongly tight to the muscular layer.

The cutaneous portion of the upper lip presents a depression in the middle, the filter, delimitated at the sides by two risings, the columns of the filter that then degrade towards the sides of the white lip.

The mucous portion of the lip, or red lip, is divided in the vermillion that starts from the cutaneous-mucous junction, the line of the passage of the skin, and continues in the columns of the vermillion that characterize and differentiate it from the mucosa that instead is typically smooth inside the lip, the white lip roll. 

Vermillion or dried lip, without glands and piliferous follicles, arrives to the red lip roll and then continues in the wet, internal lip in continuity with the buccal mucosa with numerous minor salivary glands (sometimes easily visible), laid on a connective loose layer where sensitive vessels and nerves divide it from the muscular layer.
Here internally there are also main arteries of the lip.
Also this line is very important and it has not to be dislocated too externally with exaggerated implants or too internally because it naturally characterizes the fissure of the mouth that must be perfectly located in the middle when the mouth is closed.
The harmony of all this structures is fundamental and the correction has to respect, in my opinion, these standards without changing radically the anatomy, basically with the extreme truthfulness.

Medical techniques of corrections

In order to obtain a sensual and pleasant lip, we have few medical techniques, essentially two: 

• the filling through fillers (needle or cannula)

• the muscular relaxation through botulinum toxin of the buccal orbicularis oris

This is a new technique that if is correctly done, can give results even better than the tested technique of the Paris-lip or Russian lip, or at least it represents a good synergic treatment.

It is a common check that the duration of the correction through fillers, if reabsorbable materials are used, is often very disappointing especially in millennial patients and in my experience, the reduction of the motility of the Cupid’s arch fibres discreetly increases the duration of the correction, without presenting relevant collateral effects.

Technique of injection of BoNT-A

If you decide to use both the techniques almost all the medical protocols presented to the congresses, advise to start with the implant of the toxin executed as a rule in two sessions, to be very cautious, to control the results and eventually make a correction.

Only the most superficial fibres of the orbicular of the mouth have to be relaxed and then absolutely without stinging any important muscles for the smile, mastication or any other important movement. However all the lips’ movements have to remain unchanged.
The patient is seen 15 days after the implants and in this session the result is evaluated. Rarely it is possible a light asymmetry that it is corrected in that case.
It is possible to notice a pleasant extroversion of the Vermillion edge with a clear minimization of the little wrinkles and with an apparent volumetric increment due to the relaxation of the last orbicularis fibers.
I normally prefer Dysport or Azzalure and I inject 1 U Abo in each point of the Cupid’s arch, max 4 points in the upper lip and max 2points in the lower. 

Paris lip, Russian lip, country techniques

In a third and last session I provide the eventual volumetric correction.
The technique is well known and it is based on an injection of filling substances along the Cupid’s arch and the lower Vermillion border (Paris lip) and oblique lines parallel each other from white to red vermilion border (Russian lip).
Personally I prefer use monophasic gels (ART FILLER Lips or Lipssoft) that allow a good volumetric correction but also a long duration in time.
If I have a millennial patient that wants beautification, I prefer Art Filler Lips Soft. For restoration without pumping the lips I prefer Art Filler lips soft, maybe in baby boomers.
I always treat the central V and almost every time I advise my patient to define better the lateral columns of the filter.

In my opinion it is often necessary to treat a little the lateral part of the lower lip, but some times it is better to treat it in the optic of maintaining the right proportions of the mouth, and I always execute an injection in the commissures between the upper and lower lip, to evert the finishing lateral side of the upper lip.
At this point an outcome can be done and evaluate if it is sufficient or not.
In some cases where, beside outline the Vermillion border, you want to give more volume you can do one or more injections for each sides in the submucosa.
The injections of the lips can be done also with a blunt cannula, very safe and less painful. My preferred cannula is called bionutrilift cannula and is 25G x 55 mm, very flexible and safe.
This is the moment when we cannot exaggerate and restrict the correction to the necessary. In my opinion hyper dosage never occurs.
We have to remember to communicate to the patient that the hyaluronic acid can swell but this problem will vanish in 24-48hours like usual.

Conclusions

In my opinion with the methods just described it is possible to correct most of the volumetric faults of the lips and it can also reduce evidently the small “bar code” wrinkles especially the ones of the upper lip, both for conformable problems and aging’s damages.
From my point of view the hypercorrections need to be avoided creating clearly faked lips and maybe a little ridiculous and vulgar.
So, it is fundamental to maintain the whole process within anatomic and aesthetic limits that I reported before.
The use of the botulinum toxin with these dosages and in these injective sites does not present relevant collateral effects but, beside giving in several cases good results itself, surely it lengthens the time between an implant and another.
The advent of monophasic gels associated to the muscular relaxation through botulinum toxin allowed an improvement in the duration.
Evidently further surgery and more aggressive medical techniques, as medium deep peeling and resurfacing laser, can be used or associated, but with a commitment of the patient surely major and not always acceptable and sometimes with a little higher results.

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