Steven Harris discusses how to create natural looking results using the natural lip anatomy as a guide 

Steven Harris, MB BCh, MBCAM, MSc completed his medical studies in Johannesburg, South Africa in 1997. He has been practising Aesthetic Medicine at his clinic in North London since 2004 and has gained an international reputation for producing entirely natural looking results. He is one of the original members of the British College of Aesthetic Medicine (BCAM) and is recognised by Allergan as the largest single user of Juvederm Voluma in the U.K. Dr Harris is also a trainer and educator; his regular educational posts may be viewed on Instagram
@drharrisclinic


email info@harrisclinic.co.uk

The Non-surgical Lip Lift (NLL) is an artistic approach to non-surgical lip enhancement involving hyaluronic acid dermal fillers. It works with the natural presenting anatomy, in particular, the lip tubercles to gently and subtly enhance them alongside linear and curved thread techniques to restore the ideal lip shape and rotation. Depending on the aspects injected, the tubercles may be shaped or ‘shifted’ in a process termed ‘tubercle shifts’ toward the desired overall result. The ideal position of the tubercles may be identified with H-lines (Harris lines, or H-planes) while the ideal curvature of the lower lip may be determined using H-curves (Harris curves).

Lip enhancement procedures involving hyaluronic acid dermal fillers have become one of the most popular non-surgical treatments worldwide and nowhere is this more evident than on social media. However, natural-looking lip results are difficult to find because they require a deep understanding of natural anatomy as well as great technical skill and artistic acumen. Most existing techniques tend to involve the vermillion border (VB) in some form. The VB is a transitional zone (between the thin lip skin and the thick facial skin) rather than an actual divide. Direct injections here (either in the VB or through it as in the ‘tenting’ technique) lead to distortion of the natural lip anatomy with filler ‘migration’; the lips linearly project forwards or upwards with the formation of an unnatural ‘ledge’ or ‘shelf’. In extreme cases, the lips protrude to such an extent that they are referred to as the ‘duck’ look.

Assessment

Figure 1 Treatment of the lips starts with Facial Reshaping, here involving the chin leading to ‘indirect beautification’

During the assessment phase, it is very important to consider and treat the face as a whole. As we age, the facial skeleton shrinks towards the midline with internal rotation. The unsupported soft tissues weigh in on the lips, which collapse due to loss of their own intrinsic and extrinsic support. Treating the lips directly without restoring the surrounding supportive framework will invariably lead to an unnatural and unsatisfactory outcome. A more balanced and natural aesthetic result can be achieved by restoring the peripheral outline (facial reshaping) and the areas immediately around the mouth, including the teeth where a malocclusion can affect the shape of the lips. By considering and addressing the surrounding areas, the lips themselves will, to a large extent, correct through a process of ‘indirect beautification’ (Figure 1). It is only then that they would be treated directly (‘direct beautification’) for a more natural, balanced and harmonious result1.

Figure 2 (A) Before treatment and (B) results of Non-surgical Lip Lift (NLL) using 0.4ml of Hyaluronic Acid dermal filler—  showing the lower tubercle light reflexes (white circles) and the rotation of the lips (blue arrows)

The Non-surgical Lip Lift (NLL) was developed as an alternative to procedures directly involving the VB. The NLL consists of linear thread, curved thread and bolus injections to work with the natural anatomy of the lips — their lines, curves and tubercles to restore their ideal shape and rotation. All the injections are performed on the lip side of the VB to gently press the soft side of the border against the hard side. As the lips rotate upwards, the philtrum is shortened and defined too (Figures 2–3).

Figure 3 The Non-surgical Lip Lift (NLL) results using 0.3ml of Hyaluronic acid dermal filler (A) before (B) after

The NLL technique in classic form involves ten steps with no more than 0.05 ml of filler required per step. The steps include bolus injections into the tubercles and linear threads which extend from the lower and middle ones; curved threads, which involving a curving version of the linear threads are injected above the upper lateral tubercles (Figure 4). The steps vary in terms of number and order depending on the presenting anatomy. As the VB is avoided, there is no migration of the filler so that rarely more than 0.5ml is required for the entire procedure2. Any reputable ‘soft’ filler (with low viscosity) may be used, and injections should ideally involve a needle as opposed to a cannula; the former allows greater control and precision. It is the author’s opinion that in this particularly delicate area of the face aspiration should not be carried out. It is impossible to completely stabilise the syringe in this location so that during aspiration, the needle may be repositioned inside an artery and increase the risk of vascular occlusion. In order to maximise safety, the steps involve only small amounts of product placed very gently, slowly and superficially (no deeper than 1–2 mm below the surface). Common side-effects associated with lip treatments, in general, such as swelling and bruising (and the risk of more serious ones involving vascular compromise) are therefore kept to an absolute minimum. 

Tubercle shifts

An integral part of the NLL technique involves ‘tubercle shifts’ that allow the projection or ‘reshaping’ of the lips in different planes depending on which aspects of the tubercles are injected. Thus, injecting on the medial aspects augments or ‘shifts’ them toward the midline (narrowing the relevant section of the mouth and increasing their curvature) whereas placing filler on the lateral aspects shifts them away from the midline (to widen the relevant section). Placing filler on the anterior or posterior aspects of the tubercles allows forward or backward movement, respectively. In this way, the tubercles (one or more) may be recruited and shifted in multiple planes and directions depending on the desired result. 

Figure 4 The ten steps of the Non-surgical Lip Lift involving bolus injections into the lateral tubercles (steps 1,5,6,10) linear threads (steps 2,4,7,9) with placement of filler in the central tubercle (steps 4 and 9) and curved threads (steps 3 and 8). The H-planes (white lines) identify the ideal location of the tubercles while the H-curves (yellow curves) determine the optimal curvature of the lower lip in relation to the chin.

In many instances, the lip tubercles may not be readily identifiable and the practitioner may have difficulty determining their ideal position. While there are many measures and planes to decide the ideal size of the lips (horizontal thirds and the golden ratio) and their projection (developed by Steiner, Ricketts, Burstone, Sushner and Holdway)3, none specifically exist for the lip tubercles. In order to determine their ideal position, the author has developed H-planes (Harris planes, or H-lines) to locate the centre of each on a frontal view. Lip tubercles are naturally occurring soft dermal projections; there are five in total — three on the upper lip (upper right, upper left and central) and two on the lower lip (lower right and lower left). A line drawn from the top of the right philtral column at the base of the nose through the right peak of the Cupid’s bow will traverse the centres of the upper right and lower right tubercles. A line drawn from the top of the left philtral column at the base of the nose through the left peak of the Cupid’s bow will traverse the centres of upper left and lower left tubercles. Finally, a line drawn down the middle (from the base of the nose) will traverse the central tubercle. If the lateral H-lines are extended to the jawline, then the ideal curvature of the lower lip will match that of the chin; the author has named these H-curves or Harris curves (Figure 4).

In summary, the Non-surgical Lip Lift (NLL) with tubercle shifts works with the natural anatomy of the lips to safely and reliably restore their ideal natural shape. In classic form, it consists of ten steps involving linear thread, curved thread and bolus injections; the number and order of steps vary according to presentation. The tubercles may be reshaped and repositioned by the process of tubercle shifts; their ideal position and the curvature of the lower lip may be determined using H-planes and H-curves respectively..

  Declaration of interest None

  Figures 1-4 © Dr Harris

REFERENCES
  1. Harris, S. Facial Reshaping. Aesthetic Medicine September, 72-74 (2017)
  2. Harris, S. The Nonsurgical Lip Lift with Tubercle Shifts. Prime Journal, July, 24-28 (2019)
  3. Joshi, M., Wu, L.P., Mahrajan, S., Regmi, MR. Saggital lip positions in different skeletal malocclusions: a cephalometric analysis. Progress in Orthodontics, May 16(1). 2015