Dental Clinical Articles

Posted: 21 December 2010

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How to create heart lips with Restylane and Lidocaine

Author: Dr Bob Khanna

Dr Bob Khanna introduces his new design for lip augmentation using Restylane with lidocaine

Lips are a multi-functional organ. As well as for eating and drinking, we use them to communicate our emotions, both verbally and non-verbally, from a very young age. The rich supply of nerve endings in the lips also enables them to serve as a tactile sensory organ and erogenous zone. The lips also have a strong influence on the aesthetic quality of the face. Along with large eyes, a small nose and delicate features, full lips are traditionally regarded as typically female facial traits and thought to be linked to high levels of oestrogen (Cornwell et al, 2006). Indeed, research shows that higher levels of oestrogen lead to women being regarded as more feminine than their low-oestrogen counterparts (Law Smith, 2006). In an attempt to determine what comprises aesthetically beautiful lips, Bisson and Grobbelaar (2004) found that models have significantly greater upper and lower lip height than non-models, leading to the conclusion that lip fullness is a major contributing factor.

The ageing effect on lips

As with all other areas of the face, the lips are not immune to the effect of ageing. Fine rhytides appear in the upper lip, creating a smudged appearance between the lip edge and the surrounding skin. The philtrum and Cupid’s bow lose definition and the lips become inverted. Options for aesthetic enhancement include augmenting the philtrum, increasing lip height, re-shaping the Cupid’s bow and improving the lip contours, all of which can be achieved with dermal filler (Matarasso et al, 2006). However, dissatisfaction with lip shape or size is not necessarily associated with ageing. In my practice, I increasingly see younger women looking to enhance their appearance with lip augmentation.

One of the biggest problems with lip treatments today is that they have the potential to make lips look unnatural. We’ve all seen the ‘trout pout’ and the over-augmented ‘rubber tyre’ look. A good treatment should always ensure that the lips are in harmony, balance and proportion with the overall size and shape of the face.

Dr Bob Khanna is a cosmetic and reconstructive dental surgeon. He runs clinics in Ascot and Reading, and carries out a full spectrum of treatments from aesthetic dentistry, surgical implantology and bone regeneration procedures to full-mouth rehabilitation.

He is a leading lecturer, trainer and expert in aesthetic medicine, has trained over 7000 doctors, dentists and plastic surgeons in non-surgical facial rejuvenation procedures and has pioneered many techniques.

His state-of-the art, purpose-built training institute attracts delegates from around the world eager to learn his techniques in facial aesthetics. Dr Khanna is also the president and Founder of the International Academy for Advanced Facial Aesthetics (IAAFA).

Heart Lips - a new designer treatment with Restylane

In developing this new design and technique, my inspiration came from looking at women who were naturally very beautiful. I noticed that many of these women had a particular facial feature in common – a discernible cleft in the mid-line of the lower and sometimes even upper lip that results in a twin lobe shape. This means that their lips are naturally heart-shaped. Using Restylane, a hyaluronic acid dermal filler, I have developed a technique that recreates that natural, heartshaped appearance. Heart Lips™ is not an appropriate option for all women; it is particularly suitable for younger women with a tapered oval facial shape and is aimed at women who desire a more voluptuous, more feminine, yet beautifully natural look.

Enhancing the lips

As with all aesthetic treatments, anatomical knowledge of facial structures is an important aspect of ensuring successful treatment. There are four main components to the lips: the skin and subcutaneous tissue, the muscle, the mucosa (inside lining of the lip) and the vermilion (the exposed margin of the upper and lower lip). Lip structures include the philtrum, a vertical groove on the surface of the upper lip, the Cupid’s bow, the double curve of the upper lip, and the oral commisures, where the upper and lower lips naturally meet (Figure 1).

Mammals are the only animals where there is muscular attachment to the lips. It increases lip mobility and allows articulation, expression, the holding of food and its movement into the mouth as well as the ability to drink liquids. The muscles controlling the lips are part of the muscles of facial expression and include the orbicularis oris, a concentric band of muscle which facilitates the sphincter function of the lips. The levator and zygomaticus muscles control lip elevation and the depressors, the risorius and the mentalis, control lip lowering. The superior and inferior labial arteries supply blood to the lips, providing nutrients for lip tissue and the red colouring. The infraorbital and mental nerves (branches of the trigeminal nerve) control sensation in the upper and lower lip respectively, whilst motor control is provided by branches of the facial nerve.

The development of hyaluronic acid fillers tailored to specific areas of the face and emergence of new injection devices and techniques have expanded the opportunities for aesthetic enhancement for men and women of all ages. Restylane (Q-Med, Uppsala, Sweden), launched in 1996, has become an essential component of my aesthetic practice. As a product of NASHA technology it is supported by extensive safety and efficacy data (Friedman et al, 2002; Q-Med Data on File, 2008).

Achieving Heart Lips

Patient counselling
As with all treatments, managing patient expectations with regard to what they can expect both during and after treatment is key to achieving success in facial aesthetics. I discuss all aspects of the procedure and likely outcomes with every patient prior to treatment. I make an accurate and comprehensive assessment of the lips and take high quality photographs of the facial, three quarter and full profile views. These provide an invaluable medicolegal record and diagnostic tool.

Creating Heart Lips
I thoroughly cleanse the lips before commencing treatment and mark the areas to be sculpted. The availability of Restylane with lidocaine means that no local anaesthesia is required apart from topical anaesthetic cream (LMX 4 or Emla). I use approximately 1 ml of product per lip to create the natural heart shape (Figures 2 and 3) while the patient is sitting upright.

Post-treatment recommendations
My recommendations to patients following treatment of the lips are similar to those following any facial aesthetic procedure involving Restylane. I instruct patients to avoid any manipulation of the area. In addition, I usually warn them that they may experience a little post-procedural discomfort, such as a slight stiffness or a tautness in the area, and recommend the use of standard NSAIDs for a couple of days following treatment if required. The highly vascular nature of the lips means that they can be susceptible to bleeding and bruising. I usually find that a small ice pack, placed on the lips for a few minutes, quickly stops any bleeding and can reduce swelling.

Patient review
I usually review patients three weeks after treatment, but it is extremely unlikely for any ‘fine-tuning’ to be needed as I adopt a very careful, systematic approach during all procedures. The Heart Lips™ treatment usually lasts for approximately 9-10 months.

Conclusion

Heart Lips™ is not a treatment for every woman; it is the `finishing touch’ for the woman who really cares about how she looks. Heart Lips™ is inspired by nature and emulates the heart-shaped lips seen in some of the world’s most beautiful women.

Case study one

The first patient is a 27-year-old dentist who attended one of my facial aesthetics training courses (Figure 2). Not only was she intrigued by some of the techniques being taught, but she personally felt that she could benefit from some non-surgical enhancement. She was very happy with her looks but, like most women, just wanted a more feminised and sexy appearance. In the first instance, I treated her masseters with botulinum toxin to achieve a slimming effect on the face (Khanna, 2008). I also used it to lift her brow. I then carried out a cheek augmentation (Khanna, 2009) and then finally, applied the Heart Lips™ technique for the finishing touch (Figure 3).

 

Case Study two

The second patient is a 29-year-old treatment coordinator at a dental clinic (Figure 4). She had already had treatment to the cheeks and brow but was not happy with her lips (Figure 5a). She thought they were too flat, lifeless and they didn’t give her the look she wanted; however, she had not been happy with a previous lip treatment. A Heart Lips™ treatment was suggested as a finishing touch and the final effect is extremely pleasing (Figure 5b).

 

References

Bisson, M, Grobbelaar A. The esthetic properties of lips: a comparison of models and nonmodels. Angle Orthod 2004;74:162-166.

Cornwell RE, Law Smith MJ, Boothroyd LG, et al. Reproductive strategy, sexual development and attraction to facial characteristics. Phil Trans R Soc B 2006;361:2143-2154.

Friedman PM, Mafong EA, Kauvar ANB, Geronemus RG. Safety data of injectable non-animal stabilized hyaluronic acid gel for soft tissue augmentation. Dermatol Surg 2002;28:491-494.

Khanna B. The use of botulinum toxin in bruxers and clenchers for facial contouring. Aesthetic Dentistry Today 2008;2(2):49-54.

Khanna B. Cheeks: Sculpting and volumising with Restylane® SubQ. Aesthetic Dentistry Today 2009;3(5):115-118

Law Smith MJ, et al. Facial appearance is a cue to oestrogen levels in women. Proc R Soc B 2006;273:135-140.

Matarasso SL, Carruthers JD, Jewell ML; Restylane Consensus Group. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast Reconstr Surg 2006;117(3):S1-43.

Q-Med AB. Data on file 2008.