The Smackdown on Lip Augmentations

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Detail of Dante Gabriel Rossetti's The Blessed Damozel, 1873.

“The job is really about knowing your limitations,” says Dr. Steven Harris. What the sought-after, London-based aesthetic doctor means is that one has to understand the parameters of injectable fillers.  For example, fillers don’t lift.

Dr. Steven Harris: “As aesthetic practitioners, our duty of care is to first, do no harm and therefore we need to fight damaging trends with everything we have in order to protect our patients.”

This principle is just one part of the doctor’s “less is more” philosophy — an approach which has garnered him clients from all over the globe, including Hollywood, and a year-long waiting list.  Scroll through his Instagram feed — @DrHarrisClinic — and you’ll see why.  With his holistic methodology, novel injection technique and use of ultrasound, Dr. Harris achieves beautifully subtle, optimally-balanced results.

It is perhaps lip augmentations for which Dr. Harris is most renowned. In his relentless quest for a natural outcome and perpetual war against a grossly altered “alienized” look, the South Africa native employs a multi-pronged approach beginning with damage control, i.e. erasing shoddy work. In fact, on the day I spoke with him, he had seen no fewer than six patients in his so-called “Normalization Clinic” aka “Dissolving Clinic.”

Then, even when the patient comes in for lip filler only, he considers the structure of the entire face.  “You can’t just do lips in isolation because no area of the face exists in isolation,” explains Dr. Harris.  “Typically, I start with the facial shape,” and then move inwards.  The lips come last.  You need to ensure that everything around the lips is sound.”

In other words, does the facial structure adequately support the desired larger lips?

After the filler administered by another practitioner was dissolved, this patient and Dr. Harris decided to leave well enough alone: “Before — overfilled cheeks and lips (from another clinic) and After — dissolved and treated chin and jawline. This patient presented to the Dissolving Clinic following mistreatments of her cheeks and lips. Her cheeks were overfilled at the wrong level with too much side projection and her lips were injected in the vermillion border which always leads to migration and distortion. I dissolved the cheeks and lip fillers with hyaluronidase over three sessions and then a week later treated her chin and jawline to restore her ideal facial shape. It was agreed that once her ideal facial shape had been restored there was no need to treat the lips or cheeks. The patient was delighted with her natural looking results. Normalization before Beautification.”

“This patient had a total of three syringes injected into the vermillion border of her lips over a period of two years. The lines above her lips and her philtral columns (between the nose and lips) were also incorrectly treated and required dissolving. One week after the dissolving treatment with hyaluronidase, I used just one syringe to treat her lips and her prejowl area (between the jowl and chin). The patient was delighted with her natural looking results.”

“The Dissolving [Normalisation] Clinic. This patient presented to my Dissolving Clinic after having her lips mistreated at another clinic. Her filler had been misplaced at the vermillion border of the lips and spread (migrated) to form a plateau. Ten days after dissolving with Hyaluronidase we agreed that no new treatment was necessary as her lips were ideally shaped and positioned in their natural state (slide 2). I fairly often find that no treatment can be the best treatment and that when treatment is appropriate, then always — Less is More. The lips are a closed system made of mostly muscle (orbicularis oris) with a relatively superficial thin layer for safe injection. This typically does not require more than half a syringe for beautiful natural looking results.”

Only when Dr. Harris is satisfied that the features will be balanced, does he wield the needle.  But Dr. Harris does not inject into the vermilion border — the juncture where the lips meet the surrounding skin — as many practitioners do. With his Nonsurgical Lip Tubercle Technique (NLTT), Dr. Harris injects directly into the tubercles — naturally occurring pillows which provide the lips with volume and fullness.

“They are part of normal anatomy and contribute to the beautiful natural shape of the lips and their light reflexes,” he explains.  The issue with injecting the vermilion border, according to Dr. Harris, is that this border acts as a natural barrier. “By injecting in there, you open it up,” explains Dr. Harris. “It starts off as a closed system and ends up as an open system from which filler migrates to form a ledge or a shelf.”

Vermillion Border. Illustration courtesy of Prima Center for Plastic Surgery

Tubercles are not only an integral part of lip anatomy, but also of embryology because these tubercles are remnants of development.  An understanding of this developmental anatomy is crucial when it comes to lip augmentation stresses Dr. Harris: “I always talk about embryology and the importance of working with the tubercles because the tubercles not only play a role in terms of structure and shape, but they also facilitate normal movement of the mouth.”

Dr. Harris explains the relevant anatomical embryology: “The lip tubercles — part of normal anatomy (showing an embryo at 6 weeks and natural lips at 28 years). As our faces develop, a series of prominences form (nasal, maxillary and mandibular) which fuse at the midline to form a continuous central structure, the remnants of which are tubercles. The lip tubercles which appear as little pillows are really the building blocks or ‘structural units’ of the lips and should never be ignored during lip enhancement procedures when normal looking results are sought.”

And to illustrate that the function of the lips has remained intact, Dr. Harris is careful to show patients smiling — something not often seen in the Before & After pictures illustrating other techniques. For example, one of Dr. Harris’ bêtes noires is the trendy, so-called Russian lips.

The term “Russian lips”’ is derived from the heart-shaped lips often seen on Russian stacking dolls. This “tenting” technique tends to lift the lip rather than add volume, giving a flatter appearance from the side.

Based on the technique of “tenting” whereby filler is injected vertically all along the vermilion border, Russian lips are flat with a ledge.  However, that flatness disappears and the flat lips soon turn into more of a duck lip over time, explains Dr. Harris. “With Russian lips, you rarely get any movement.  The practitioners won’t show the patient smiling and they won’t show long term results because that flat lip doesn’t last.”

Dr. Harris: “[The Nonsurgical Lip Tubercule Technique] works with the lip tubercles to bring out the individual’s natural ideal lip type. As it does not flatten the lips or introduce a new ledge, the lips not only look normal, but function normally as well.”

The basic errors with that technique, continues the doctor, are that first, this technique doesn’t recognize tubercles, flattening the anatomy and second, it doesn’t take into account that “fillers tend to organize along the path of least resistance and in the lips, that’s more horizontal, not vertical.

“So, the filler can’t hold the lip up.  It’s a fundamental error in thinking.  In fact, fillers can barely hold themselves up.  So, this idea that filler is vertically holding up the lip — that’s not what we see in reality.  I use ultrasound images regularly to show how the filler does not stay vertical.”

Dr. Harris demonstrating the use of ultrasound on beauty journalist, Olivia Falcon. “If I’m doing fillers for a patient, I will not do it without the help of ultrasound either in vascular mapping to see where all the blood vessels are or for ultrasound guided-treatments,” says the aesthetic doctor.

“Ultrasound can be very helpful in facial reshaping — in placing the filler and/or confirming its placement. Filler migration is extremely common; ultrasound-guided injections help to position filler in the correct layer while lowering the risk of migration.”

The use of ultrasound is a relatively new technique in aesthetic medicine. “The advantage is that it shows you what lies beneath.  It acts as our eyes on the inside so we can actually see the anatomical variability because no two people are the same,” says Dr. Harris.

“It allows for more effective injecting because you can see exactly where the filler is being placed, and it’s safer because you can view all the arteries and all the veins and you can avoid them.”

Dr. Harris is on the warpath against “Alienization” which refers to the process of exaggerating features with dermal fillers and botulinum toxin, to the point where patients look like extra-terrestrials. “With so many people, both patients and practitioners presenting in this manner, it would appear that the alien morphotype is the new normal. What are we doing? We know that Body Dysmorphic Disorder is relatively common amongst our patients at 8-15%, but it is even more common in practitioners at 16%.” A peer-reviewed study, conducted in part by Dr. Harris and published in the prestigious Aesthetic Surgery Journal looked into the motivation of why women in particular distort their lips. “We found that Instagram is a very big motivator and they are rewarded with likes and followers.”

So, if injecting small amounts of filler into the tubercles produces such natural results, why don’t more practitioners employ this method?  “It’s not an easy thing to do,” reveals Dr. Harris.  “It requires, in my opinion, a great degree of skill, technicality and also artistry.”  Not to mention knowledge of anatomy.  “Whereas something like the Russian look is a very easy thing to do.  There’s no particular artistic side to it.  You just make everyone look the same which is what’s happening.”

All hope is not lost, however, as there does seem to be the beginning of a move away from over filling.  Even some of the Kardashians, by the look of things, have minimized their, um, assets.  “I think there is a slow but sure trend towards a more natural look,” acknowledges the doctor, “but I think it’s going to take many more years.”

In the meantime, those unable or unwilling to travel to north London for Dr. Harris’ revered corrective work, would do well to consider going to a practitioner well-versed in lip anatomy and preferably, one wielding an ultrasound device.

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