Injectable Fillers: Treatment of the Lips and Around the Mouth

Management of Lips and Mouth Corners

With age, sun damage and smoking worsen lipstick lines (the vertical wrinkles around the lips) and the loss of fullness of the lips. The loss of skin resiliency leads to sagging skin accentuating the folds running from the mouth corners to the chin.

Patient selection
Fillers using a bovine collagen (Zyderm, Zyplast, Artecoll, Artefill) need skin testing. A new porcine (pig) product Evolence does not need skin testing. Patients with connective tissue diseases like systemic lupus erythematosis should not get fillers. Patients with a history of herpes should get antiviral therapy like valacyclovir before implant to avoid herpes reactivation and subsequent scarring.

Superficial wrinkles around the mouth do best with Botox, laser resurfacing treatments, and superficial fillers. Improvement usually lasts 3-4 months. Deeper lines may require layering fillers in different depths of the skin to completely fill them in. The combination of laser resurfacing techniques and layered fillers can give the best results. For the lips fillers can be injected into the border roll for better definition and into the lip body for improving fullness. Injected nerve blocks and anesthetic creams are needed for most filler injections around the mouth.


Nerve blocks for the upper and lower lip

Overall Treatment Strategy
A long preprocedure discussion is necessary so that the patient’s expectations are the same as the physicians. The patient must be made aware of what realistically can be done and what cannot. Therapies have their limits. The point in time when improvement is first seen, its maximum, and how long it lasts should be discussed. It should be emphasized that these procedures need to be repeated to maintain benefit. They should know about other laser or surgical applications as well. Patients should be aware of the costs.

Patients can be classified according to the Glogau scale and treatments planned. Glogau I patients may have fine wrinkles and this can be taken care of with laser resurfacing and Botox injections. Glogau II patients may have more prominent lipstick lines. Thinning lips and drooping mouth corners. Fillers injected into the outer and mid layers of the skin can be used to fill these lines along with laser and Botox treatments for further smoothing effects. Glogau III patients have deeper lipstick lines, drool lines running down from the mouth corners, and thinning lips. Again combination of fillers, Botox and laser resurfacing is used. Glogau IV patients have severe wrinkles and folds in the skin, severe volume loss in the lips with drooping skin. They may need all the above therapies with cosmetic surgery as well.

Golgau I patients commonly request lip augmentation. There are two parts to this treatment. One is to improve the definition of the lip border by injecting filler into the lip margin. This may also help people whose lipstick bleeds into the vertical wrinkles coming off the lip. The second part is to make the lips bigger by injecting into the body of the lip. One can also inject the arch in the middle of the upper lip to create the pouting look or Paris lip.


Examples of injection sites for lip augmentation

Before and after lip injections

The patient should take Arnica Montana 2-3 days before to decrease bruising and valacyclovir 2 gms two times daily if they have a history of herpes infections. The lips are very sensitive areas and a nerve block is needed to numb the area enough for most injections. To improve the lip line definition the needle is inserted into the mouth corner and pushed along the upper border of the upper lip. Once the needle is all the way in , it is slowly pulled back and the filler injected leaving a line of it along the lip margin. Similar injections are done to outline the entire edge of the upper and lower lips. Filler can also be injected into the two vertical ridges in the skin running from the upper lip to the nose (the philtral crests). To plump the lips, filler can be injected into the lip body along the border where the wet inside of the lip meets the dry outside. Another technique involves injecting a medium depth filler like Restylane just below the white roll along the lip border, then injecting superficial filler like Restylane Fine Line into the white roll at the lip border.

Significant swelling and bruising commonly occur. Kissing the ice and keeping the head up will help. Swelling may decrease in 1-2 days, but bruising may not go away for 7-10 days. A short course of nonsteroidal anti-inflammatory drugs can be used for a lot of swelling. Rarely, a herpes injection can occur and is treated with a round of antiviral medications. One of the worst complications is injecting filler into an artery. This cuts off blood supply to the skin and can cause skin ulceration. It is more common with thicker fillers. If pain or extreme whitening of the lip skin is seen, the injection should be stopped. Warm packs or injection of Wydase (to break up hyaluronic acid fillers) is used. Other rare complications include allergic reactions that can be treated with steroid injections or laser treatments.

Glogau II patients may have more prominent lip stick lines. Fine lines can be treated with Botox, but deeper lines may require fillers. The skin above the lip is less sensitive than the lip itself and is usually alright with anesthetic cream alone without nerve block injection. A small needle is run under the wrinkle and a small amount of filler is injected to fill in the line. Thinner fillers like Restylane, Restylane Fine Line or Juvederm Ultra is used. If the implant is placed too superficially, beading can occur with bluish color showing through. It may be possible to massage this away. Use of hyaluronidase (Wydase) to dissolve the filler or a QS1064nm laser can help. Herpes infection in a patient with previous cold sores is possible. Again skin ulceration with injecting a blood vessel can happen. Combinations of Botox and fillers for the lips and lipstick lines gives the best overall look.

The fold running down from the corners of the mouth are treated with Restylane or Juvederm Ultra if they are superficial. Thicker fillers like Peralane or Juvederm Ultra Plus are for deeper folds, followed by the thinner fillers injected into a layer on top. Chin drooping can be treated with Botox. Complications for treatment in this area include movement of the filler, and injection into a blood vessel with skin ulceration and breakdown. Some treatments can be done on the same day as filler injection.


Examples of injection sites for treating the melomental folds

Before and after injections for the melomental folds

Glogau III patients will need combination therapy. They have deeper lipstick lines, lip thinning, and mouth corner droop with drool lines. Fractional laser resurfacing can be done first for the spider blood vessel lesions and fine wrinkles. Botox can be used for lip lines and the chin. Then, the melolabial folds (drool lines) can be injected with a deeper filler like Perlane with a superficial or medium depth filler on top. Filler can then be injected just under the corner of the mouth to raise it for a happier look. This may not all be done on the same day. The most obvious problems can be treated first and the rest on a follow up visit.



Glogau IV patients often require plastic surgery and aggressive laser resurfacing procedures first. Then the lip lines, thinning lips, and drool lines can be addressed with Botox and fillers.