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    Mona Lisa's legacy: Technique and patient selection key to mastering the art of the lip


    Dr. Maloney
    It was Aristotle who first defined facial beauty as all parts working as one. But it was Leonardo da Vinci who divided the face into quantitative measurements, so that surgeons would have a system by which to evaluate basic facial proportions.

    The "ideal" face can be divided into thirds: the upper third runs from the hairline to between the eyebrows; the middle section, from between the eyebrows to the base of the nose; and the lower face, from the base of the nose down to the chin.

    "As we look at the lower third, the lips are a dominant feature," says Brian P. Maloney, M.D., facial plastic surgeon, Atlanta, Ga.

    Dr. Maloney, who first gave his cosmetic perspective on the mouth in an article in Facial Plastic Surgery in 1996, says that what fascinates him about the lips is that they are two very different structures.

    "The upper lip, during development, forms from three separate pieces: one piece from the middle and two from the side. And as those three pieces fuse together, that is what gives you the characteristic cupid's bow of the upper lip," he says. "The lower lip, on the other hand, only forms from two separate pieces, which fuse together in the midline, giving us a rather smooth lower lip."

    According to Dr. Maloney, when we are born, our lips tend to be fairly thin. It's only around the time that we reach puberty that the glandular tissues in the lips begin to blossom, filling the lips. Teenagers, he says, tend to be at the height of lip plumpness. As we age, reaching into our 30s and 40s, the lips shrink and decrease, along with declining hormones.

    THE ART OF THE LIP Lips are a romantic and unique facial feature. "We associate full lips with health and youth and all kinds of positive attributes; whereas, we associate thin lips with senility, weakness and frailness," Dr. Maloney says.

    The lure of the lips has spurred great interest especially among women who seek lip augmentation.

    "The most important thing for surgeons when they begin to embark upon lip augmentation is patient selection," Dr. Maloney says. "If you have a patient who was born with a thin lip, the surgeon will never be able to stretch out that lip with fillers to give the patient a full lip. A filler, by nature, is a liquid, and liquids take the shape of their containers." Forcing the issue with a few ccs of filler will only give an otherwise thin-lipped patient an unnatural or odd look, he says.

    "Patients with very thin lips — not much definition of the Cupid's bow and very thin vermilion show — are best suited for a vermilion advancement, meaning we are going to excise some of the skin adjacent to the lip and then recreate a more defined Cupid's by showing more of their vermilion," explains Dr. Maloney.

    The vermilion advancement does not increase the fullness of the lip; as a result, often Dr. Maloney supplements the procedure with a filler, including a short-term filler, such as a hyaluronic acid, or a longer-term lip augmentation, with fat or acellular human dermal matrix (AlloDerm; LifeCell Corp., Branchburg, NJ).

    The advantage of hyaluronic acids, he notes, is that the results can be easily reversed with hyaluronidase. For longer-term results, autologous fat transfer has become a treatment of choice, according to Dr. Maloney, thanks to improved harvesting techniques, low pressure centrifuging and micro-droplet placement of the fat.

    "Fat has the advantage of being autologous and most patients will hold onto the bulk of it. Generally, what I tell patients is whatever volume they have at about three months is generally the volume that they can expect to have," he says. "But throughout our lives, our lips will decrease in size; so, at some point down the road, the patient may decide to have further augmentation."

    CO2 & COLLAGEN What Dr. Maloney wrote about using the CO2 laser for the lip in his paper more than a decade ago he says still holds true today. By using the CO2 laser, Dr. Maloney stimulates new collagen development in the area.

    "If you look at the anatomy of the lip, right around the edge is a white roll that was defined by Gilles. This white roll serves as a reservoir of collagen and skin, which allows the lips to do many things — to purse, pucker...Over time, as we start losing the collagen in the skin, that white roll begins to lose its collagen, tone and support, [and] we begin seeing less of the lip as it turns toward the inside of the mouth," he explains.

    LIP INTEGRITY Functionally, the lips need to be flexible and soft. As a result, surgeons who augment them should not compromise those qualities.

    "Our number one charge should be that we never want to make lips look unnatural," Dr. Maloney emphasizes. "We never want the lips to become a dominant feature on the face or a significant focal point."

    While the products, or fillers, have changed, the fundamental concepts of lip augmentation have not, he says. That is why some fillers simply do not work in the lips, according to Dr. Maloney. One of these includes a material made of calcium hydroxy appetite, which causes a whiteness in the thin mucosal layer over the lip, as well as visible bumps or irregularities. Another material is Gor-Tex, which, he says, often extrudes due to lip movement.

    "I think that it is so important for the doctor to have a good artistic sense of the lips. All we have to do is flip on the television to see horrible examples of monster lips," Dr. Maloney says. "In some cases, bigger is not better."

    Disclosure
    Dr. Maloney is a consultant for Allergan.

    Reference
    Maloney BP. Cosmetic surgery of the lips. Facial Plast Surg. 1996;12:265-278.

    For more information:
    Brian P. Maloney, M.D.
    [email protected]

    Lisette Hilton
    Lisette Hilton is a writer in Boca Raton, Fla., who heads up her company, Words Come Alive.

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