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Tips for Lips

The 17th annual Fall Society of Dermatology Physician Assistants Conference included a pre-conference series on aesthetic procedures. Presenters Ilanit Samuels, PA-C, Jennifer Holman, MD, and Chris Surek, DO, covered the anatomy, techniques, and complications for common aesthetic procedures performed in dermatology practices by physicians, physician assistants, and nurse practitioners.

Ms Samuels presented “Lips: Do’s and Don’ts” as a part of this series, which covered best practices for all providers who perform lip injections. At her practice in Miami, she performs a high volume of lip injections. The number one tip Ms Samuels recommended was knowing when to say no.

Considerations for correct lip proportions include ethnicity, gender, and patient’s desires, she said. For example, black women have full top and bottom lips. Most Asian patients prefer a narrow pout, although this is a generalization and there are exceptions, she added. She emphasized the importance of talking to patients about their expectations and desires prior to performing lip injections. For male patients, for example, they may be in the process of transitioning and want a more feminine look. She noted that she asked key questions during consultation in order to understand what patients’ desired outcomes are prior to the procedure.

When discussing lip injections, Ms Samuels recommended using make up as a way to explain how fillers works, such as lip liner and contouring. She also recommended having photos of different lip options available. Another tip she shared was examining the patient’s mouth because the teeth and any dental procedures to correct them can change the structure of the lips.

According to Ms Samuels, it is much easier to augment then to change the shape of a patient’s lips. She recommended having patients bring in old photos of what they looked like when they were younger in addition to discussing their expectations.

She reviewed the results of a 2017 study published in JAMA Plastic Surgery that found white women perfect lip proportion was 1:2 and women of color was 1:1. The magic ratio, she noted was, 1.16, which differ based on ethnicities. In addition, Ms Samuels discussed the importance of looking at the chin profile and lip projection. The upper lip should project more than the bottom lip, she said, adding that if patients want to go bigger with their lips, she also recommended elongating the chin to make sure everything looked proportional.

For older patients, aging causes peroral lines, flattening of cupids bow and philtrum, downturned oral commissures, ornamental grooves, volume loss, and elongation of the cutaneous portion of the upper lip.

Social media and reality television started trends in overfilling the lips, with patients seeking lips that are bigger than the natural mouth size. While this has declined slightly, Ms Samuels said she still sees patients who have or want overfilled lips. This is a pet peeve of mine, she said, which she calls the “real housewives’ effect.” She encouraged providers to not let patients convince them to overfill their lips; however, she noted that she will sometimes make patient’s lips bigger if she thinks it will work with their face. She recommended not injecting above the lip’s natural fullness.

Ms Samuels also noted that some patients might not want to have tubercles, another trend on social media, but this can make the upper lip look flat.

When performing injections, she inverts the lip for 2 reasons: to see the mucosae and to make sure the filler will not migrate. She recommended injecting fillers slowly to avoid complications and reduce bruising. Prior to injection, she uses ice for patient’s comfort and vasoconstriction, which also helps with bruising. She recommended injecting the lips last, changing gloves and needle, and using antiseptic to clean the lips.

There is no right or wrong way to inject fillers, she said. She usually starts with the vermillion border, followed by the body. because it requires less filler for the lips. She then injects the cupids bow, which is the most painful area to do, and ends with the philtral columns. She suggested providers watch videos of physicians performing injections to learn and figure out the best method for them.

To reduce potential complications, Ms Samuels recommended asking about lidocaine allergies, performing aseptic prep, and talking to patients about disease and immunosuppressive medications. She recommended waiting until patients are healthy if they are sick before performing fillers, especially in the lips. She also recommended Valtrex prophylaxis, especially for patients with a history of herpes simplex virus. In addition, she reviewed arteries of concern and stressed the importance of making sure injections are performed above the muscle.

For preventing bruises, she provides patients with a list of things to avoid a week to 10 days before a procedure, including fish oil and alcohol. She discussed pulse dye light therapy as an option for cutting healing time of post-filler bruising from 3 weeks to about 24 to 48 hours. While topical arnica/bromelain extract does not address bruising, Ms Samuels noted that she has used it to help with redness.

Immediate swelling is usually caused by extrusion force, she said. However, latent swelling, which occurs 2 to 5 months later, is usually caused by an immunologic trigger, such as the flu or a vaccine. This usually resolves in about 6 weeks, she added.

She recommended treating swelling with prednisone, hyaluronidase, doxycycline, and colchicine. For vascular compromise, she recommended hyaluronidase, warm compress, and to follow up with the patient daily. This is the patient a provider should give their cell phone number to, she said.

Ms Samuels stressed the importance of using only hyaluronic acid fillers for the lips, such as Restylane L, Restylane Silk, and Volbella. In addition, she reviewed toxins for lips. Although she prefers fillers, she said she does use them for lip flips and smokers’ lines. In addition, Ms Samuels recommended providers have a management protocol in place for complications from fillers, as well as an EpiPen due to the risk for allergic reactions to toxins.

Patient education is important, Ms Samuels added. She has seen several patients who went to a medical spa for lip injections and do not know what was put in their lips. She educates her patients on what to be aware of and dangers to look out for when going somewhere else for injections, as well as tells her patients to ask what is being injected into their lips and face.

Ms Samuels concluded her presentation some of the more dangerous aspects of social media for both patients and providers. She discussed the medical assistant who was arrested in Texas for performing illegal injections and using non-FDA approved toxins in his practice. The medical assistant had about 200,000 followers on Instagram, she noted. She stressed the importance of discussing with patients that the number of followers does not reflect the skill of the provider.

Skilled providers are posting procedures on Instagram as well, which has opened the door for non-medical individuals to start attempting these procedures at home. Patients can purchase a filler on Amazon and use videos to inject themselves, said Ms Samuels. We need to be careful, she added, saying she never posts videos on Instagram and there is a movement now to start taking them down to prevent people from self-injecting.


Samuels I. Lips. Lips: Do’s and Don’ts. Presented at: 2019 Fall Society of Dermatology Physician Assistants Conference; November 20, 2019; Scottsdale, AZ.

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