Using medical terminology, the three central bumps of the upper lip are called tubercles. The lower lip bumps are also called tubercles; note, there's three in the upper lip and two in the lower lip. In most patients, the midline tubercle of the upper lip is not as prominent as the two on either side of it. The border between the red lips and the surrounding upper and lower white lips is referred to as the Vermilion border. In youthful lips, this is a slightly prominent ridge that serves to frame the lips. The corners of the lips are referred to as the ‘oral commissures’. With age and volume loss, the commissures can start to spread out and become wider. The small depression that runs from the midline upper lip to the base of the nose is referred to as the philtrum - this comes from the ancient Greek phrase for love potion because the Greeks found the philtrum to be a sexually attractive region of the face. The curved border of the upper lip centrally is referred to as Cupid's bow.

In addition to the anatomical subunits, there are also certain proportions that one must keep in mind when analysing lips and planning for either an augmentation with filler or a volume restoration with filler. The ratio in vertical height of the upper lip to the lower lip in a Caucasian female is thought to be ideally 1 - 1.6. This ratio of 1 - 1.6 is known as ‘Phi’. This ratio has been found throughout nature and is also applicable in analysing facial beauty. Phi is also referred to as the golden ratio and it's very interesting to study it. It should be noted that in women of colour, the ratio approaching one to one is also considered attractive. So, a patient's ethnicity and overall facial structure must be taken into account when planning the ideal height of the upper lip in relative proportion to the lower lip. This diagram also highlights that the width of the nose, ideally, should be the same distance as the width between the corners of the eye. This is also the width of the central two-thirds of the lower lip, which are the largest relative to the lateral one-third of the lower lip. When evaluated in profile, what's considered more ideal is if the upper lip projects more anterior than the lower lip. In this different patient, you can see that her lower lip actually projects more interior than her upper lip and it's not quite as pleasing to the eye.

With age, lips lose volume shape and definition. In addition, the commissures start to thin out and widen and the commissures also start to turn down. The skin of the upper lip also shows age. The dermis becomes thinner, losing collagen and elastin, this leads to the vertical lines that develop above the upper lip. Factors such as sun exposure and smoking accelerate the loss of collagen, loss of elastin and the development of these fine lines. Men have less of a problem with vertical lines on their upper lip with age because of the whiskers that we have that help support the skin.

As is true for many things in life, an ounce of prevention is worth a pound of cure. It's much simpler to maintain the quality of the skin and prevent the formation of the lines than it is to try and treat the lines once they formed. Skin care products that boost the production of collagen and elastin and thicken the dermis. Daily use of sunscreen and avoidance of drinking from straws when started in the late 30s and 40s, can really delay the onset of these upper lines that typically develop in patients during their 50s and 60s. Once significant vertical lines develop in the upper white lip, trying to correct them with filler can run the risk of the upper lip becoming more convex in appearance which can lead to more of an ape-like appearance and is not attractive.

Another change that occurs with aging is the skin of the red lips themselves loses elasticity. When this happens, there's a limit to how much expansion can occur when filler is injected to re-inflate or volumize the lips. Regular use of Giannini Siesta lips in combination with clinicians’ complex lip enhancer can restore collagen and elastin to the skin of the red lips, thus increasing their elasticity. When filler is injected, the lips can actually expand and become more volumized eyes with more of a youthful shape. When planning an injection of the lips, there are multiple products that can be used. They all have slightly different properties and the choice of which filler to use is based upon the patient's anatomy and the specific aesthetic desires for that patient. But what is more important than the choice of a specific filler is the skill and experience of the injector. Many patients don't realize that lip augmentation or restoration of lost volume is challenging and requires experience, knowledge of the anatomy and a good visual eye. A great property of all of these fillers is that they’re hyaluronic acid and can be dissolved if necessary.

The woman in this photograph had received filler to her lips elsewhere. One can see that the misplaced filler led to a flattening of her Cupid's bow, there's also an asymmetry to the upper lip as well. This is another photo of a woman who'd received filler elsewhere and specifically, came to us to try and improve the appearance. One can see that the specific subunits of the upper and lower lip were not fully respected and the lip is a bit too wide laterally with almost a sausage type appearance. This is an example where vid trays can be used effectively to melt a portion of the filler to try and reduce the areas that are too full to improve the natural appearance of her lips.

As is the case with all the other facial features, there's a tremendous variability from one patient to another in the anatomy of their lips. In this example, you can see a patient on the left with very thin lips and the patient on the right has very large full lips. It's a common myth that you can go from the patient on the left to the patient on the right with simply applying enough filler in the right locations - this is not true. There are definite limits to what can be achieved with filler and going from a naturally very thin small lip to a very full luscious lip is not achievable. We can certainly improve the contour and overall shape of the lips on the left and give them more volume, but we can never volumize them to the size of the lips on the right, while retaining a natural shape and appearance.

This next patient is a woman in her 30s who has a nice shape and proportion to her lips but has always desired slightly larger lips. Filler was used to augment the size of her lips while retaining a natural and attractive shape and contour. This is a photo of a woman in her 50s who has typical age-related changes to her lips; the lips have lost volume and their shape has changed from when she was more youthful. In addition, she has thinning of the white skin of her upper lip with the beginnings of some vertical lines. After filler injection, her age-related lost lip volume has been restored and the contour and shape of her lips has been improved, while still remaining natural in proportion.

So, whether we're injecting layers to enhance naturally small lips or to restore lost volume in aging lips, it's essential that the end result is a natural attractive lip that's in harmony with the rest of the face. And for those of you interested in maintaining youthful appearance of your lips as we age, it's really essential to maintain the quality of the skin specifically to boost the collagen and elastin content of both white and the red with. A couple products we have do a great job at this, the Siesta lips, as well as the clinicians complex lip enhancer. And Dr. Bomer has an excellent video discussing the use of these products. It's much easier, again, to prevent than to try and correct down the road.