Lip Filler, Lip Lifts, and the Overfilled Era

Lip filler has been responsible for some of the biggest aesthetic failures in cosmetic medicine. That is the bold claim that kicks off this episode, and both hosts agree it is true.

Board-certified plastic surgeons Dr. Sam Jejurikar (Dallas) and Dr. Sal Pacella (San Diego) dive into the most visible topic in plastic surgery: the lips. They trace the evolution of lip aesthetics from the thin lips of old Hollywood through the J.Lo gloss era to the overfilled Kylie Jenner years, and explain why the pendulum has finally swung back toward natural results.

Along the way they cover the permanent scarring that years of filler can leave behind, the silicone lip implant disaster that should have never happened, who is (and is not) a good candidate for a lip lift or corner lift, why fat grafting to the lips so often disappoints, and Dr. Pacella's preferred technique of using the patient's own SMAS tissue during a deep plane facelift for longer-lasting augmentation.

For anyone considering their first syringe of filler, the advice is simple: less is more. And for patients with years of built-up, scarred filler, the hosts walk through the "lip rehab" approach of dissolving old product over multiple sessions before starting fresh.

Plus, a cautionary tale about Botox around the mouth that involves one of the hosts, a missing front tooth, and nine months of talking funny.

New episodes every other Tuesday.

Transcript

SPEAKER_02 0:00

Lips are oftentimes a gateway procedure that they've been thinking about for years prior to them coming in for this comprehensive facial rejuvenation. I mean, if you think about a patient coming in in their late 40s, early 50s for baselift, necklift, all the other stuff. Well, they've been coming in to get their lips done for probably 15 or 20 years before that.

SPEAKER_01 0:21

All right. Everyone, thank you so much again for tuning in to our latest podcast, the Beauty and the Beast podcast. I'm, of course, Dr. Sal Pachella in San Diego, California. I'm joined by my good friend and fantastic aesthetic surgeon, Dr. Sam Jajurikar from Dallas. Welcome once again. So happy to be here. Now, are you ready to talk about one of the most visible topics that I think we ever see in plastic surgery? And that's lips. Okay. What if I say no? Can we move on? Then we're done. I'm so ready. Let's do it. So lips, part of the center of the face. And I'm going to say something very controversial here. Okay. Lip fillers have been probably responsible for some of the greatest aesthetic failures that have ever occurred in aesthetic medicine. Would you agree with that statement?

SPEAKER_02 1:14

Yeah. I mean, I think that's a that's a bold statement, but I think it's a true statement. If you look at where we have gone in terms of the evolution of lip aesthetics, we had a period of time not that long ago where we were seeing people getting three, four, five CCs of filler in their lips at a given time. And it is some of the most unnatural, strange aesthetics that we have seen.

SPEAKER_01 1:43

It really has been fascinating over the last 20 years, hasn't it? I mean, when you look at, you know, some of the history and the evolution of lips in the world, right? In the 70s, 60s, there was no such concept of lip fillers, right? So if you look at some of the Hollywood actresses, their lips are very thin. As we get into the 90s, we're talking a bit more plump, right? A little bit more of a central appearance of fullness. You get into the late 90s, early 2000s, you have people like Jennifer Lopez, okay? It was about volume but shininess of the lips. And then, of course, as we get into the mid-2000s, we have, you know, the Kylie Jenners, where it's all about thickness and fullness of the lips. And I think that aesthetic has changed dramatically and is continuing to change.

SPEAKER_02 2:31

Yeah, I mean, we've only had fillers around for what, 20, 25 years that they've been commonly used in the US. So prior to that period of time, when we would think about how we could enhance the appearance of the lip, we had two basic ways to do it. I mean, women could use uh makeup, you know, used to try to make their lips look more plump, or we would do operations like lip lifts and and and variations thereof, which have come back into vogue to try to try to create the aesthetic. And so you couldn't really veer that far from the natural aesthetics. When hyaluronic acid fillers first came on the market, we still stuck with that. You know, I remember when we were first training on fillers when they were relatively new or when they were completely new. I mean, someone would come in and we would put in one syringe filler and you would carefully balance it between the upper and the lower lip, and you'd obsess over the amount of time you spent, you know, putting it into this area, and you would create a very natural aesthetic. And there was always this fear from the patient in the beginning that, oh my God, with the swelling that's there, is this going to look too big? Then there's the era that you talked about, which we, you know, there was that whole you know phenomenon with Kylie Jenner in the shot glass where she was, you know, she was trying to make her, you remember that? Where she's pulling the lips out and and you know, just claiming that it was non, that it was non-procedural that was creating that change. And then all of a sudden the aesthetic started changing for a while. And it was, and it was uh not only a strange aesthetic, but then we started seeing problems. Um, you know, what problems uh have you seen in patients who have, you know, have regret over the over sort of some of their aesthetic choices they've made? Are you just seeing that the filler goes away easily or creates any changes to the lips?

SPEAKER_01 4:13

Or I think no filler doesn't have some permanent component in cane. It's not necessarily a function of the filler, but it's the scar tissue related to the filler that that your body creates afterwards. So invariably I see patients who have had their lips injected for many, many, many years, and they may say, Well, I haven't had filler for three years now, but my lips still look scarred and they look distorted. And that's somebody that, you know, has had some permanent damage from filler, right? I think the biggest one of the patients who suffer the biggest regret from lip augmentation was when I was a fellow, um, there was a popular technique of adding a little silicone worm, a little silicone strip to the lips. And this was like tunneled right underneath the lips, both upper and lower. And I remember doing this in my fellowship, and I just thought to myself, this is the craziest idea I've ever seen. Because, you know, you're gonna be feeling these things constantly. Okay. And sure enough, as I went through my practice, a good fair share of the of these patients, which I never operated on other than fellowship, I would see the see some of these patients coming into the office with erosion or distortion. And it it is just a technique, I think, that just needed to go away over time, you know.

SPEAKER_02 5:23

Yes, I agree that these permanent lip implants, the long-term destruction is intense because not only um does it cost stretching out of the soft tissue, it can erode through the soft tissue and it creates significant scarring. It's hard to fix those deformities.

SPEAKER_01 5:39

Now, let me ask you a question here. So you're um when you have a patient come in, and maybe it's a patient that reg uh that says, you know, Dr. J, I want to do everything I can in my face. Okay. And you talk to them about brow, quadble, full facelift, deep plane, et cetera. How often is is your thought to do a lip procedure on them? How often does that come up?

SPEAKER_02 6:03

You know, it comes up a lot as part of comprehensive facial rejuvenation for sure. Um I like lip lifts in certain patients. Um, so if you see a patient who's got a relatively thin upper lip, um, what we refer to a long cutaneous or the white part of the lip is long, they might be a very good candidate. And what a lip lift is, a traditional lip lift is an incision that you hide in the very base of the nose, and you can get some elevation. It's a predictable operation. I will say that I tend to reserve it for patients. We have a grading system for skin types, which is one through six. I tend to only do it in patients that are one through four. Uh, patients that with darker pigmentation can sometimes have scars that don't look that don't look great.

SPEAKER_01 6:48

But let me ask you, let me stop here there for a second. So going back to when I asked about you you mentioned a lip procedure for them. Are your patients in general um resistant to the idea of doing anything on their lips? Or they say, oh yeah, that makes a lot of sense, or are they asking for it? How what what do you what do you think?

SPEAKER_02 7:06

They're not resistant to it. They're oftentimes asking for a lip lift for sure. I'll oftentimes see that on the request. And and you know, lips are take to take a step back, lips are oftentimes a gateway procedure that they've been thinking about for years prior to them coming in for this comprehensive facial rejuvenation. I mean, if you think about a patient coming in in their late 40s, early 50s for baselift, necklift, all the other stuff. Well, they've been coming in to get their lips done for probably 15 or 20 years before that. So there's not a lot of resistance to that. A question that I will commonly get from the patients, though, is what about some fat grafting to the lips? Um, fat grafting to the lips in my hands, I am remarkably talented and not making it look great. I find that the fat grafts to the lips just don't stick around. But I know you have a technique that you like during facial surgery to augment the lips using patients on tissue. Tell the viewers what you like to do.

SPEAKER_01 7:57

Sure, absolutely. So I think um in general, a lot of times when I'm doing a deep plane facelift, I'm doing something related to the lips, either an augmentation, a central lip, a corner lift, et cetera, which we'll get into in a few minutes. Um, so I have for many years taken free fat, like we would inject into the temple or the eyelids and use that for augmentation. And like you, I I haven't been super impressed with it. I do the procedure, I tend to overfill it a bit, knowing that it's going to recede a bit. And in general, it it always looks a little bit smaller than what I anticipated in the operating room, despite the fact that when these patients wake up, they look like, you know, they can float on their lips, right? These are huge, huge uh appearance afterwards. That fat acts like uh a sponge, it just sucks in a ton of fluid. So what I started using um uh a few years ago is any of the pieces of what we call the SMAS, the submuscular apeneurotic system of the face. That's the the actual deep lane, deep lane that we're supporting. I'll I'll take that piece of tissue, it's oftentimes a strip of about five centimeters by a centimeter, and I'll thread that into the upper lip and the lower lip. And in general, I've found much more longevity. And the thing, the reason I think this works much better than just free fat is you're adding fat to that, but you're also adding some collagen and some structure. And I think the body incorporates this really well as a graft. Um, I think that collagen avoids scarring because it's we're we're transplanting like tissue to like tissue. And overall, I've been very, very happy with the appearance of that.

SPEAKER_02 9:37

Yeah, I mean, I think it's great with the aesthetics that we're currently um going after, which is a natural augmentation. I think everything you're saying makes sense that because it is the patient's own tissue, um, they're much less likely to have a foreign body response or profound scoring. Now, I will say though, that I have used that technique in the past, and I don't tend to find it to be all that reliable. I find that the results are subtle. Um, and I think that at least when I see the patient six months afterwards, I oftentimes can't tell that I did much. Um, I um think it's great and it lasts longer than fat. I'm still not that big of a proponent. Now, you did mention corner lifts and other forms of direct lip lifts. Clearly, if you thought SMAS augmentation was enough by itself, you wouldn't be going to these other procedures. Tell me when you start doing other forms of lifts for patients. Right.

SPEAKER_01 10:32

So, so great question. So let's first talk about the uh the aesthetics of the lip in general. Okay, and I think this is a key point. If you look at the aging lower face, you see that the lips actually take an inverted smile. They the lips sort of on the corners go downwards, right? And so now when we've looked at the center of the face, like in your patient that I just described, and you say, okay, well, I'm gonna do a central lip lift, the traditional bullhorn lift lip lip lift, okay. And that's because the distance from the base of the nose to the lip is long, elongated. But what happens when you do that? You're raising the center of the lip, you're not really raising the sides of the lip. Okay. So I think if we're not careful, we can create a sense where that inverted smile looks a lot worse as time goes on, because the center of the lip is raised, but the corners are not. And invariably, when I do this with a facelift or a D-plane facelift, I'm going to get some elevation of the corner of the mouth. It's not dramatic, but we will get a little bit of elevation. So I usually reserve a corner lift after the fact, after I've done a facelift or a or a lip lift.

SPEAKER_02 11:45

Tell the viewers where the incision goes for a corner lift.

SPEAKER_01 11:48

Yeah. So the center lip lift, that bullhorn lip lift, goes underneath the lips or underneath the nose. The corner lips go off to the side here. So it is a slightly more visible scar than you than you're used to in the upper lip lift. Um, but if done the right way, I think it can be done subtly in the right position. And like you, patients who are Fitzpatrick one through four tend to do a bit better than patients who have a lot of pigmentation in their skin. I think it's a it's a technique that works really well in the right patient, and it can look really odd in the wrong patient.

SPEAKER_02 12:20

Yeah, and that's the key. And you need someone experienced like Dr. Pachella telling you as the patient, you are a good candidate for this or you're not a good candidate for this, because I'm sure you're in the same situation that I am where you've seen patients that have gotten them done that were not great candidates for it, and then they have prominent scars that they're very unhappy with. And so, you know, the right skin type, a corner lift and a liplift is a beautiful result with an incredibly subtle scar that's really well camouflaged. But in the wrong patient, it can be a little bit of a nightmare.

SPEAKER_01 12:53

And I've seen a couple nightmare scenarios. I think if you if you attempt to be aggressive and you do the triumvirate, okay, the facelift, the center lip lift, and the corner lift, you can easily overcorrect this and it can look very odd. So I I oftentimes tend to stage this a little a bit.

unknown 13:10

Yeah.

SPEAKER_02 13:10

And I I tend not to be as big of a proponent of corner lifts. Instead, what I'll do is I'll take that central lift and I will curve it more around the base of the nose to try to get some more indirect pulling, particularly if we're doing it in combination with a facelift. And typically I find that that can help me avoid the need for doing a corner lift. Um, I want to go back to the topic of fillers just a little bit more, just because if you look at the overall aesthetic market that's out there, the number of patients in the US that have had lip filler in the past is many, many millions. The number that have had lip lifts and corner lifts are a few thousand. So, you know, my first question is because I know when we've had conversations before about our relative enthusiasm for filler, you always revert to fat. You're always of the mindset, oh, fat's the best filler, let's talk about fat. But I imagine in your practice, you have patients that come in that want injectable fillers. How do you counsel a patient, one, who's never had filler before and is trying to get, you know, some sort of filler in their mouth, what types of fillers do you sterum towards? And two, how do you handle a patient who's had a lot of filler in the past and is scarred up, um, you know, wants more filler or wants to have more natural appearance? How do you handle these scenarios?

SPEAKER_01 14:26

So let's first take the first one. So the newbie, if you will. Okay. Um, I tend to use a lot of the lesser-acting, low molecular weight fillers like Restilin that have small molecules, right? And I'm a firm believer in if you've never had any filler before, you got to take it easy on the first couple, right? Because the last thing you want to do is overcorrect and look odd. You don't want people at work saying, hey, did you do a 50-yard dash in a 40-yard gym? That's what I want to avoid. So we'll usually, you know, I'll I'll use one syringe, maybe 0.5 cc's in the upper, 0.5 cc's in the lower, augment a little bit around in uh the the lip line and where patients tend to have a lot of those deep, deeper set wrinkles, you know, and that little bit of that little bit of lip flip that you see is really can do, I think, wonders. So I'm not averse to to to these fillers, but I just think that they're not they're not the best for longevity, right? And if you think about it, you know, these fillers cost anywhere from you know 400 to $1,000 a syringe. Okay. Uh after you've done that four or five, six times, you've already paid for a lip procedure, right? And so I think the fat to me is a good value. A lip lift is a good value comparatively to getting fillers every six months to a year. Um, for the patients that are um experienced and scarred in in lip augmentation from fillers, I think those are very tough conversations I have with patients because um a lot of times they come in, they have some visible deformities. And the interesting thing about filler is it's going to go to the path of least resistance, right? If I have an indentation from scar tissue and I try to inject, and many patients say, well, can't you just inject a little filler in there and that'll fill it in? Well, I think that doesn't necessarily deal with the physiology of scarring, right? What happens is you inject it into that divot and it just goes everywhere else besides the divot, right? And so I think that that is a huge challenge. And those patients sometimes are better served without anything.

SPEAKER_02 16:33

Yeah. And, you know, I am a typical surgeon in the sense that I prefer surgery over doing injectable treatments. But I'm very fortunate in my practice to work with a master injector, Erica Goff, who um it really has a wide breadth of experience. And for both of those patients, you know, she's really developed protocols that I that I like. I think what what you've said about the newbie patient, I could not agree with more. Less is more if you've never had filler before. So um we she used does something which which we call a lip pop, which is a half syringe filler. We take use relatively short acting, short half-life hyaluronic acid fillers that we are feeling more comfortable are going to go away.

SPEAKER_01 17:18

Um which ones use?

SPEAKER_02 17:21

Um, I think she uses Versa. That's her sort of her preferred one that she goes to right now, but she uses a lot of different, a lot of different products depending on the you know the anatomy of the patient. But um, you know, you had mentioned, yeah, there's a cost involved to doing that. It's not, it's not inexpensive to go in, but there is a convenience factor. Absolutely. You know, you don't you don't have this lengthy rehabilitation, you know, recovery period. You come in, you get your lips done, you go back to work, you ice it a little bit, and you kind of go on with your life.

SPEAKER_01 17:49

Right. It's like getting your your roots done or your hair done, right? You or the the dry bar.

unknown 17:54

Exactly.

SPEAKER_02 17:54

So you talk about the cost involved, but think about the costs, you know, every time a woman goes to a salon and gets her hair dyed and cut. Then, in terms of that second patient, the experienced patient with a lot of scarring, we have a lip rehab protocol that they go through where they'll actually come in for multiple sessions of dissolving first, where um there'll be two or three sessions of lip dissolving before any additional filler is even put in. The key is to try to get rid of um as much of that filler as you can. And as you know, with some higher molecular weight hyaluronic acid fillers, it's hard to dissolve them, particularly if they get scarred in there. So it can take multiple sessions to dissolve all that product, but getting rid of it before you attempt any additional treatment, which should be subtle moving forward, but is is really important. What about lip flips? You mentioned that term lip flip, um, which I think you know more commonly refers to a procedure done with Botox to try to elevate the lip. Um, what do you think about that?

SPEAKER_01 18:53

Do you find that it works? Um, no, I mean, I I am not a big fan of injecting neuromodulators in and around the mouth or the lips. I think it's really easy to overcorrect that and have a pivotal mouth talking like this. Yeah. I think it's hard to predict exactly where that that Botox is going to go. And I think you have to be really experienced. And in my hands, as a surgeon, when you're a hammer, the whole world's a nail, right? So I think my surgical technique far, far uh goes beyond my my injectable technique for cases like that. But I will say, you know, I have a a great group of cosmetic dermatologists and laser specialists, injectable specialists uh that I work with all the time. And those are those are cases that'll fundamentally uh pass to my good friend, Dr.

SPEAKER_02 19:42

Vic Ross. I love that. Does a lot of this. Yeah, I I agree with your assessment. I think lip flips, um they're kind of unpredictable. I've seen a couple in that that have been done where I'm very impressed with how much it elevates the upper lip. It's you know typically done to raise the upper lip. And other times it's it's so subtle I can't even appreciate it. But in terms of uh avoiding neuromodulators around the mouth, it does remind me of an anecdote involving you or me. Do you know where I'm going with this? So uh during COVID, um I had the misfortune of developing avascular necrosis of one of my central incisors of my mouth. And um I had a little, I was getting an implant put in because um because I was a plastic surgeon missing a tooth in the center of their face. And um I broke my little um my little flipper, so I couldn't camouflage the fact that I was missing a tooth. So I got the bright idea of trying to Botox the depressors of my lower lip to raise it. And we were doing another podcast, and I remember you just said, What the did you do to your mouth?

SPEAKER_00 20:50

What's wrong with your lip? Did you have a stroke?

SPEAKER_02 20:52

Yeah, and I couldn't move my mouth. What do you mean? I couldn't move my mouth normally for about nine months. So uh be careful of neuromodulators around the mouth. It can really be problematic, particularly if you inject them yourself. Exactly. Yeah.

SPEAKER_00 21:07

That's a good place to end, Dr. Jajurakar. So, once again, I want to thank you guys for tuning in. Uh, it's all about the lips. Peace out.