The use of botulinum toxin A in upper lip augmentation

Accepted Article
Running title: BTA in lip augmentation

Yunzhu Li1 MD, Yuming Chong2 MD, Nanze Yu1 MD, Ruijia Dong2 MD, Xiao Long1* MD
1Department of Plastic Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and

Chinese Academy of Medical Sciences, Beijing, China

2Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

*Author to whom correspondence should be addressed

Xiao Long

Email: pumclongxiao@126.com

Address: Peking Union Medical College Hospital, No.1, Shuaifuyuan, Dongcheng District,

Beijing, China

Yunzhu Li and Yuming Chong contributed equally to the manuscript.

ACKNOWLEGEMENT

The authors report no conflict of interest.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JOCD.13731
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Accepted Article
DR. YUNZHU LI (Orcid ID : 0000-0003-1667-7908)

DR. YUMING CHONG (Orcid ID : 0000-0001-9307-3046)

DR. RUIJIA DONG (Orcid ID : 0000-0002-9303-8707)

DR. XIAO LONG (Orcid ID : 0000-0003-0136-2508)

Article type : Master Case Presentation

ABSTRACT

Background: Full lips are beauty standards. Botulinum toxin A (BTA) paralyzes the

orbicularis oris muscle to achieve the eversion of the lip, and thus makes the lip look plump.

Objectives: This study presents three cases of BTA injection to the lip and evaluates the

possible changes of the labial morphology and the lip surface area.

Methods: Three patients received a total of 4U BTA injection at the vermilion border of the

upper lip. Vectra® H1 3D imaging system was used to capture 3D photographs of the lips

before injection and two weeks after injection. Eight linear distances and the upper lip surface

area were measured. Anthropometric measurements before and after injection were

compared.

Results: Patients displayed a larger upper vermillion height (p=0.038) and a smaller

cutaneous upper lip height (p=0.024). There was a trend for a larger upper lip surface area,

but not statistically significant (p=0.109). Symptoms of slight perioral muscular palsy and

mouth incompetence lasted about one month in three patients.

Conclusion: BTA helps to enlarge the upper lip and shorten the philtrum. The BTA injection

can be an option for lip enhancement with caution.

Keywords: botulinum toxin A, lip augmentation, 3D photography

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Introduction

A plump lip is the symbol of youth and glamorousness. Influenced by sun damage, genetic

factors, and smoking, aging will cause volume loss and perioral wrinkles to the lip1. Lip

augmentation with dermal filler is frequently performed to offset the age-related changes and

provides a more attractive appearance2. Botulinum toxin A (BTA) is a naturally occurring

polypeptide chain molecule derived from the Clostridum botulinum bacterium. By blocking

the release of acetylcholine at the myoneural junction, BTA inhibits the contraction of

orbicularis oris muscle and improves perioral wrinkles3. The paralyzed effect that BTA has

on the orbicularis oris muscle results in the eversion of the lips and achieves an augmented

outcome4. This study presents three cases of BTA injection to the lip and evaluates the

possible changes of the labial morphology and surface area.

Case report

Three individuals (two females and one male) with no previous BTA treatment, with a mean

age of 28.7±5.5 received a total of 4U BTA (BOTOX®, Allergan; 40 U/mL) with 1 unit at

each site. The injection sites were located symmetrically at the vermilion border of the upper

lip at the dermis level (Figure 1). Vectra® H1 3D imaging system (Vectra M3, Canfield

Scientific Inc, USA) was used to capture 3D photographs of the patients with mouth gently

closed in a neutral expression before injection and two weeks after injection. Images were

then imported into the Canfield Mirror® imaging software. Nasolabial landmarks used in this

study were manually identified onto the 3D photographs (Figure 2). Eight linear distances

and the upper lip surface area were measured (Figure 3). The same author did all

measurements for two times with a two-week interval. The intra-class correlation coefficient

(ICC) was adopted to evaluate the intra-observer reliability. ICC value above 0.75 was

considered excellent reliability. Paired samples t-tests or Wilcoxon tests were carried out

according to the data normality to evaluate differences in labial morphology. Data were

processed using the Statistical Package for Social Sciences (SPSS®, version 23.0, MAC®).

Statistical significance was set at 0.05.

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Accepted ArticleICC values of all measurements ranged from 0.779 to 0.990, indicating excellent

intra-observer reliability (Table 1). The mean difference of all linear measurements did not

exceed 1 mm, indicating high precision. Patients displayed higher value of upper vermillion

height (p=0.038) and lower value of cutaneous upper lip height (p=0.024). The cupid’s bow

height was reduced (p=0.047), while the right vermillion margin lateral height increased

(p=0.034). There were trends for larger vermillion margin lateral height and larger upper lip

surface area but were not statistically significant (p=0.149 and p=0.109, respectively) (Table

2, Figure 4).

Notably, all three patients complaint about slight perioral muscular palsy and mouth

incompetence. One especially felt unable to hold the water in her mouth when drinking and

gargling. No facial asymmetry or drooling was reported. The symptoms together with the

effects relieved gradually one month after injection.

Informed consent was obtained from the patient to present the case and images.

Discussion

Although aesthetic standards differ among different ethnicities and cultures, the

universally recognized beauty of the lip is a proportionally larger upper lip with more

protruding projection and a shorter philtrum5,6. Lip augmentation with hyaluronic acid,

silicone, or fat graft restores the lip fullness. Lip lift shortens the philtrum and increases the

exposure of dry red lip. However, severe complications such as vascular embolism and

hypertrophic scar hinder the operative effect 7,8. As a more minimally invasive treatment,

conventionally, BTA is used to reduce the perioral wrinkles4.

Orbicularis oris muscle is a circular muscle that lies around the lip and is the target of

BTA injection. It is composed of deep and superficial fiber with multiple functions. The deep

fiber is a constrictor muscle that helps to hold food and water when eating, while the

superficial fiber is a retractor muscle that works together with other muscles in speech and

facial expressions9. As is confirmed in the study, once the constricting function is restrained

by BTA, the lip becomes more everted and thus, a larger upper lip and a shorter philtrum are

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Accepted Article
achieved. The increased vermillion margin lateral heights bilaterally further support the

lip-lift-alike effect that BTA injection has on the lip. While the lip-lift-alike effect is achieved,

the lip is flattened with reduced cupid’s bow height. Yin’s study found that, instead of the

accumulation of soft tissues, the philtrum ridge is formed by muscle strength around the lip10.

We believe BTA disrupts the original tension lines of the upper lip and as a result, flattens the

cupid’s bow. But on the whole, the therapeutic effects conform to the aesthetic trend of the

lip and thus, the BTA injection can be an option for lip enhancement. But because of the

rather small amount of BTA that we injected, the effects lasted fewer than a month. Further

investigation is needed to the evaluate the relationship between the injection dose and the

effect duration.

However, the same as our finding, BTA achieves lip augmentation while interferes with

the regular functions of the lip. It should be avoided among those patients with high oral

function requirements, such as singers and wind instrument musicians. In addition, the lip

might be flattened slightly since the cupid’ s bow height is reduced, which should be

informed to the patients before operation.

Acknowledgement

The authors would like to thank Ms Aizhen Li for her support.

References

1 Paes EC, Teepen HJLJM, Koop WA, et al.Perioral Wrinkles: Histologic Differences

Between Men and Women.Aesthetic Surgery Journal.2009.29:467-472.

2 Luthra A.Shaping Lips with Fillers.Journal of Cutaneous and Aesthetic

Surgery.2015.8:139.

3 Niamtu J, III.Botulinum toxin A: A review of 1,085 oral and maxillofacial patient

treatments.Journal of Oral and Maxillofacial Surgery.2003.61:317-324.

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4 Semchyshyn N, and Sengelmann R.Botulinum Toxin A Treatment of Perioral

Rhytides.Dermatologic surgery : official publication for American Society for

Dermatologic Surgery [et al].2003.29:490-495; discussion 495.

5 Baldasso R, Damascena N, Deitos A, et al.Morphologic alterations ear, nose and lip

detected with aging through facial photoanthropometric analysis.The Journal of

forensic odonto-stomatology.2019.2:25-34.

6 Baudoin J, Meuli J, Di Summa P, et al.A comprehensive guide to upper lip aesthetic

rejuvenation.Journal of Cosmetic Dermatology.2019.18.

7 Ghannam S, Sattler S, Frank K, et al.Treating the Lips and Its Anatomical Correlate

in Respect to Vascular Compromise.Facial Plast Surg.2019.35:193-203.

8 Weston GW, Poindexter BD, Sigal RK, et al.Lifting lips: 28 years of experience using

the direct excision approach to rejuvenating the aging mouth.Aesthet Surg

J.2009.29:83-86.

9 Nicolau PJ.The orbicularis oris muscle: a functional approach to its repair in the cleft

lip.British Journal of Plastic Surgery.1983.36:141-153.

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Surg.2014.25:48-54.

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Figure Legends

Figure 1. Four injection sites. The injection sites were located symmetrically at the

vermilion border of the upper lips at the dermis level (shown in black dots).

Figure 2. Display of anthropometric landmarks. Midline landmarks: subnasale (sn);

labiale superius (ls); stomion (sto). Bilateral landmarks designated (R) for right and (L) for

left: crista philtri (cph); chelion (ch); the midpoint of vermillion margin (mvm).

Figure 3. Diagram of the linear and area measurements of the lip; (A) PW: philtrum

width (cph-cph); ULH: upper lip height (sn-sto); CULH: cutaneous upper lip height (sn-ls);

UVH: upper vermilion height (ls-st); CBH: cupid’s bow height (cph-ls); RVMLH: right

vermilion margin lateral height (mvmR-sto); LVMLH: left vermilion margin lateral height

(mvmL-sto). (B)The surface area of the upper lip (shown in dotted lines).

Figure 4. Photographs of a patient receiving a total of 4 U BTA at the upper lip; (A)

Pre-injection view. (B) Post-injection view.

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Accepted Article
Table 1. ICC and mean differences of intra-observer reliability.

ICC Mean difference

Philtrum width 0.779 0.85296

Lip wide 0.942 -0.9155

Upper lip height 0.990 0.04612

Upper cutaneous lip height 0.933 0.26646

Upper vermillion height 0.982 -0.22034

Cupid’s bow height 0.862 -0.19086

Vermilion margin lateral height (right) 0.966 -0.5552

Vermilion margin lateral height (left) 0.960 -0.1459

Upper lip surface area 0.974 -35.8

The mean difference of upper lip surface area is recorded in mm2, while the mean differences of other

linear parameters are recorded in mm.

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Table 2. Results of pre- and post-operative anthropometric parameters.

Case 1 Case 2 Case 3

p value
pre post pre post pre post

Philtrum width 11.14 11.99 9.91 11.21 9.85 10.19 0.096

Lip wide 48.55 48.14 46.63 46.93 49.96 50.28 0.798

Upper lip height 22.03 22.09 19.58 20.30 20.10 21.04 0.162

Upper cutaneous lip height 15.06 13.95 13.65 12.91 13.94 12.63 0.024

Upper vermillion height 6.97 8.13 5.93 7.39 6.15 8.41 0.038

Cupid’s bow height 2.00 1.16 1.52 0.91 1.83 1.46 0.047

Vermilion margin lateral height (right) 3.45 4.53 2.57 4.00 3.62 4.34 0.034

Vermilion margin lateral height (left) 4.55 4.95 2.42 4.31 4.41 5.19 0.149

Upper lip surface area 437 485 291 356 419 483 0.109

Upper lip surface area is recorded in mm2 and other parameters in mm.

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