Pasadena, Calif. - No one lip architecture is inherently more beautiful than another, and there are many aesthetically pleasing shapes for lips.

With that said, bigger is not necessarily better. Really listen to what patients are asking for—even watch body language to understand expectations. Don’t rush. Don’t do anything out of your comfort level. And make it painless, said Dr. Roberta D. Sengelmann. It’s not so much what you do. but how you do it that counts.

Ask patients to bring in photos or fashion magazines with images of lips that they like, and address their expectations, she suggested.

Fillers for lip augmentation are used off-label, so explaining the risks and getting informed consent from patients are essential. A dozen or more potential adverse outcomes can range from a shorter-than-expected duration of the bulking effect to infection, necrosis, or scaring.

To meet a patient’s desire for more pleasing lips, keep in mind widely accepted characteristics of a “beautiful” face and mouth, she advised.

Lips are symmetrical. The width of the lips is 30%-50% of facial width, and the width between the oral commissures equals the distance between the medial limbi. The upper lip is slightly thinner than the lower one—making the upper lip too big looks unnatural. The commissures should angle up slightly.

With age, the mouth starts to angle down and to look smaller (the lips “cave in”), radial lip lines develop, 3-D volume decreases, and there’s inversion of the lip’s white roll, said Dr. Sengelmann, a dermatologic surgeon in private practice in Santa Barbara, Calif.

Pay attention to anatomy to plan your approach to lip augmentation. The first step is to elevate the oral commissures. If you run out of product or need to stop, the patient still will look better, said Dr. Sengelmann.

If you can do more, define the vermilion border or white roll. Then add volume to the pink part of the lip. If needed, redefine the philtral columns. And, if you have some product left, ablate vertical lip lines. One main caveat applies: The patient’s desires take precedence in deciding which of those steps to address, she said.

Consider antiviral prophylaxis before lip injections, and definitely use it treat anyone who’s had more than six annual outbreaks of herpes simplex virus, she advised. If the patient is on blood-thinning medication, discontinue it a week before lip augmentation. “I don’t treat people on Coumadin, ever,” she said.

Before you start injecting, remove any makeup, and evaluate the patient at rest and in motion. Take photos before and after the first treatment. Mark the philtral columns with an eyeliner pencil, because they can be difficult to see once filled. Review your plans and the patient’s expectations before you begin.

“You can’t rush this technique,” Dr. Sengelmann said. Make it as painless as possible by applying ice, topical anesthesia, or nerve blocks. Consider local anesthesia at the commissures. Vibration seems to work, too, but “I’m not comfortable” using it, she added.

Use only the finest fillers when injecting into dermis, and more viscous fillers for potential space under the skin. Dr. Sengelmann avoids Radiesse for lips because nodules can be a problem, she cautioned. Again, use a slow hand. “Hasty injectors have a much higher complication rate,” Dr. Sengelmann said.

For augmenting the angle of the mouth, she uses Radiesse, Juvéderm Ultra Plus, Perlane, or Restylane. For the vermilion border and philtral columns or to augment the pink lip, she prefers Juvéderm Ultra, Restylane, Juvéderm Ultra Plus, or Perlane. For radial lines, she injects Prevelle Silk, Restylane, or Juvéderm Ultra using a 32-gauge needle.

After treatment, assess lip symmetry before the product is gone—consider saving a little as leftover in case it is needed. Massaging and molding the injected area may help distribution, “but remember, you can’t correct for poor technique,” she said. Apply ice packs after the procedure and have the patient rest for about 6 hours, with no exercise of vigorous activity for the rest of the day.

For a patient whose only complaint is dynamic lip lines (with no vertical lines at rest), botulinum toxin alone may soften those lines, provide some lip eversion, and give the perception of fullness to lips, Dr. Sengelmann suggested.

She advised using caution when considering lip augmentation for a patient with a long upper lip, inverted white roll, coarse radial lip lines, or deep Marionette lines. Other features that should inspire caution include very thin lips, lip incompetence, recessed bone or dentition, lip asymmetry, and unrealistic expectations.

Disclosures: Dr. Sengelmann has been an advisor to Allergan (Juvéderm), BioForm Medical (maker of Radiesse), and MicroAire (formally Coapt Systems), and has received research support from MicroAire.

Listen First, Don’t Rush in Lip Augmentation