Research

JAMA Facial Plastic Surgery | Original Investigation

Determining the 2-Dimensional Threshold for Perception

of Artificial-Appearing Lips
Sang W. Kim, MD; Daniel E. Rousso, MD

Author Audio Interview

IMPORTANCE Recognizing the perceptual threshold for artificial-appearing lips is important to
avoid an undesirable outcome of treatment.

OBJECTIVE To characterize the quantitative measurements for the perceptual threshold of

artificial- and unnatural-appearing lips.

DESIGN, SETTING, AND PARTICIPANTS Photographs of a female model’s lips were digitally
altered incrementally in 5 sets of features (the upper lip, lower lip, upper and lower lips, and
shape of the Cupid’s bow). From December 1, 2013, to January 30, 2014, participants viewed
the photographs in random sequence using an online survey and responded to 2
questionnaires after each photograph. The participants were prompted to respond whether
each altered photograph of the lips appeared to have received any cosmetic treatment, and
whether the lips looked attractive and natural or artificial and unnatural. The measurement of
each lip at which 50% of the observers perceived the lips as being treated and 50% of the
observers perceived the lips as being artificial was determined. The difference in these 2
measurements was defined as dTA50, which represents the threshold differential between
the perception of treated lips and artificial lips for 50% of the observers.

MAIN OUTCOMES AND MEASURES Survey responses of the participants to the appearance of
the lips in the photographs.

RESULTS A total of 98 participants (76 females and 22 males; mean age, 42 years) provided
usable responses to the survey. Each area of the lips had a unique quantitative measurement
at which the observers perceived the lips as being treated and artificial. Enhancement of the
upper lip alone had a narrower margin for artificial appearance (dTA50, 0.9 mm) compared
with enhancement of both the upper and lower lips (dTA50, 1.5 mm). Any alteration to the
Cupid’s bow resulted in the narrowest margin for artificial appearance (dTA50, 0.3 mm). The
difference in the perceptual threshold between the age of the observers was the most
significant for the upper lip.

CONCLUSIONS AND RELEVANCE The perceptual threshold for treated and/or artificial
appearance is unique for each area of the lips.

LEVEL OF EVIDENCE NA.

Author Affiliations: Natural Face

Clinics, Syracuse, New York (Kim);
Rousso Facial Plastic Surgery Clinic,
Birmingham, Alabama (Rousso);
Department of Surgery, University of
Alabama at Birmingham (Rousso).
Corresponding Author: Sang W.
Kim, MD, Natural Face Clinics,
2939 Brittonfield Pkwy, Bldg B,
JAMA Facial Plast Surg. 2017;19(5):392-398. doi:10.1001/jamafacial.2017.0052 Ste 210, Syracuse, NY 13057
Published online April 6, 2017. (sangkim.md@gmail.com).

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 Two-Dimensional Threshold for Perception of Artificial-Appearing Lips
A
s one of the central components of facial aesthetics, full
and well-defined lips impart a sense of youth, health,
attractiveness, and sensuality. With the aging pro-
cess, the lips undergo stereotypic changes including loss of vol-
ume and flattening of the philtrum. There is widening and ef-
facement of contours of the Cupid’s bow, and loss of the natural
“pout” of the vermillion.1 In addition, bony resorption asso-
ciated with advanced age leads to thinning of the mandible and
a decrease in the distance from the lips to the chin.2 The loss
of dental height leads to the perception of vertical lengthen-
ing of the lips and downward laxity at the lip commissures. For
patients presenting with aging lips, the goal of lip augmenta-
tion is to restore lost volume and reestablish the natural, youth-
ful profile. In contrast, younger patients often seek lip aug-
mentation to achieve the trendy voluptuous, full lips seen in
celebrities.3,4
Although extensive quantitative measurements and analy-
sis have been published in the literature, these studies em-
phasize what constitutes ideal or attractive dimensions for the
lips.1,5-9 The ideal proportions and measurements of the lips’
dimensions and their relation to the whole face have been stud-
ied in dental, dermatologic, and plastic surgery literature. In
these studies, various methods have been described to mea-
sure changes in the lips after enhancement, including vali-
dated photonumeric rating scales, volume measurement as-
sisted by magnetic resonance imaging, computerized
3-dimensional stereophotometry, and objective lip index
measurement.1,5-9 Many of these studies demonstrate fea-
sible and reliable methods to quantify the changes in the pro-
portion and measurements of the lips.
However, in practice, to what extent the lips should be aug-
mented to achieve the patient’s goal is mostly subjective and
qualitative, based on the experience of the clinicians and the
desire of the patients. The “ideal lip” is described as having full
volume and proportional balance of the upper and lower lips,
with a well-defined vermillion border.2,10 The challenge of lip
enhancement is avoiding overtreatment, which crosses the per-
ceptual threshold of artificial- and unnatural-appearing lips.
What constitutes the perception of artificial and unnatural lips
and the quantitative perceptual threshold for such lips has not
been described in the literature, to our knowledge. We de-
scribe a quantitative 2-dimensional threshold for the percep-
tion of artificial- and unnatural-appearing lips.
Methods
High-resolution digital photography of a 35-year-old white
woman was performed using a digital camera (Canon EOS T2i
at 1/160 F10 ISO Auto; EFS 18-55) with umbrella lights for il-
lumination. Although we began with a photograph of a 35-
year-old female patient’s lips, in reality, it is an extensively digi-
tally morphed, deidentified photograph altered to create a
baseline photograph based on ideal measurements. There-
fore, we determined that consent from the woman was not war-
ranted. We cropped the frontal view of the photographs to show
only the lower one-third of the face. The limits of the lower
one-third of the face are the malar eminence as the lateral limit,
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Original Investigation Research
Key Points
Question What are the 2-dimensional quantitative measurements
for lips that are perceived as attractive vs artificial?
Findings This survey study provides quantitative data to support
that a balanced augmentation of the upper and lower lips is the
key to achieving attractive and natural lip enhancement. The study
also shows that there is a measurable difference between people
of different age groups and their perceptual threshold for artificial
lips.
Meaning Although relying on fixed guidelines for lip
augmentation may not be practical or realistic, these findings
provide some guidance in helping clinicians counsel their patients
who are seeking lip augmentation.
the supranasal tip as the superior limit, and the menton as the
inferior limit. The baseline lip photograph was generated using
software (Uniplast for Windows; United Imaging Inc). The base-
line dimensions of the lips were derived from mean measure-
ments from textbooks and the literature.2,3,5,6,11 Based on the
study design, we determined that institutional review board
approval was not necessary because the study did not collect
any identfiable data on the participants. Individuals con-
sented to participate in the study by clicking “Yes” on the in-
troduction page of the survey. If “Yes” was selected, the sur-
vey began. If “No” was selected, the survey was terminated
and no data were collected.
In the first set of photographs, the height of the upper lip
was altered at 1-mm increments up to 5 mm. The upper lat-
eral commissure angle increased to correspond with the in-
crements of the height of the upper lip, while the depression
of midline Cupid’s bow was maintained at 1.4 mm. On the sec-
ond set, the lower height was altered at 1-mm increments up
to 5 mm, with corresponding adjustment to the lower lateral
commissure angle. On the third set, the heights of both upper
and lower lips were altered at 1-mm increments up to 5 mm.
For the fourth set, we altered the shape of the Cupid’s bow. The
distance between the peaks of the Cupid’s bow was set at 17.3
mm. This measurement makes the distance between the lat-
eral commissure to the peak of the Cupid’s bow and the dis-
tance between the 2 peaks of the Cupid’s bow equal. The lat-
eral commissure angle was 46° to accommodate the change
of width of the Cupid’s bow. From the baseline lips, the heights
of both the upper and lower lips were then altered simultane-
ously at 1-mm increments up to 5 mm.
For the fifth set of baseline lips, we extensively altered the
shape of the Cupid’s bow. The distance between the peaks of
the Cupid’s bow was set at 26 mm. This measurement makes
the length of the entire Cupid’s bow equal to one-half of the
entire length of the upper lip. The lateral commissure angle was
60° to accommodate the change in the width of the Cupid’s
bow. Next, the heights of both the upper and lower lips were
altered simultaneously at 1-mm increments up to 5 mm. In all
sets of photographs, the overall width of the lip was main-
tained at 52 mm.
Photographs were uploaded to an internet-based ques-
tionnaire survey service (https://www.surveygizmo.com;
393
 Research Original Investigation
Widgix LLC). Participants in the analysis and the survey, which
took place from December 1, 2013, to January 30, 2014, were
males and females from the lay public between the ages of 13
and 73 years. The link to the survey led to background
introduction and instructions of the study. The next page
displayed a set of sample photographs of the lips and explained
that each photograph would be presented after 5 seconds. Next,
sample questions were provided asking participants to
determine whether the lips appeared natural or artificial.
Additional information was collected on the age and sex of
participants. Fields were provided to allow comments on
technical problems and questions about the study.
Thirty images (5 sets each with baseline, 1, 2, 3, 4, and 5
mm of increment) were presented for 5 seconds in a random-
ized sequence. In addition, the baseline image was presented
5 more times in a randomized sequence to serve as a dupli-
cate to determine intraobserver consistency. Photographs were
presented at a resolution of 842 × 368 pixels. The photo-
graph was displayed on the screen for 5 seconds on a timer.
After 5 seconds, the next screen containing 2 questions with
binary answer choices was displayed automatically. The first
question stated, “Do you think these lips received any type of
treatments to enhance their appearance?” The participants
were prompted to select 1 of the 2 answer choices: “Yes” or
“No.” The second question asked, “Do you feel that these lips
appear attractive and natural, OR artificial and unnatural?” The
participants were prompted to select 1 of the 2 answer choices:
“Attractive and Natural” or “Artificial and Unnatural.” Partici-
pants were able to proceed to the next set of photographs and
question sets only after they completed the 2 questions.
The data set was downloaded into an Excel spreadsheet
(Microsoft Corp) for analysis. Based on the demographic in-
formation, participants were divided into 2 groups based on
their ages. The χ2 test was performed to determine statistical
significance of the difference between the 2 age groups. P val-
ues were 2-tailed and considered significant at P < .05.
Results
A total of 101 complete responses with unique IP addresses
were collected during a 27-day period. The mean time for
volunteers to complete the survey was 6.8 minutes. Three
responses were excluded from the analysis because the
duration of the survey exceeded 30 minutes, which was 2
SDs beyond the mean duration of the survey. Among the 98
participants with usable responses, there were 76 female
and 22 male participants, with ages ranging from 17 through
73 years. Forty-nine participants (50%) were in the age
group of 17 to 40 years (mean age, 33 years), and the other
49 participants were in the age group of 41 to 73 years (mean
age, 52 years).
The participant responses were plotted against each 1-mm
increment of lip height. The first part of the response was re-
lated to whether the observers thought that the model’s lips
“received any types of treatments to enhance their appear-
ance.” The response choice was binary, as already described.
The second part of the response was whether the observers
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Two-Dimensional Threshold for Perception of Artificial-Appearing Lips
thought that the model’s lips “appear artificial and unnatu-
ral,” again with a binary response choice as already de-
scribed.
We determined the measurement of each lip at which 50%
of the observers perceived the lips as receiving treatment and
50% of the observers perceived the lips as being artificial. The
difference in these 2 measurements was defined as dTA50; this
value represents the threshold differential between percep-
tion of treated lips and artificial lips for 50% of the observers.
For each subset of lip alterations (upper lip only, lower lip only,
upper and lower lips together, alteration of the Cupid’s bow,
and extended alteration of the Cupid’s bow), we determined
the dTA50 (Figure 1). Figure 2 shows the actual photographs
of each subset of lip alterations when 50% of the observers per-
ceived them either as treated and attractive or as artificial and
unnatural.
We wanted to determine whether the age of the observ-
ers would have any effect on the perception of the lips. The
responses were divided into 2 groups based on the age of the
observers. Group 1 consisted of younger observers between the
ages of 17 and 40 years (mean age, 33 years; n = 49). Group 2
consisted of older observers between the ages of 41 and 73 years
(mean age, 52 years; n = 49). Similar to part 1, we plotted the
data for each subset of lip alterations (upper lip only, lower lip
only, upper and lower lips together, alteration of the Cupid’s
bow, and extended alteration of the Cupid’s bow). Next, we de-
termined the dTA50 values for each subset of lip alterations for
each group.
Small differences were noted between the perception of
the lips for each age group, but the statistically significant dif-
ference was observed when only the upper lip was altered
(Figure 3). The difference in responses of those who per-
ceived the lips as treated and enhanced was statistically sig-
nificant at 3 mm between the 2 groups (P = .005 using χ2 test
at 8 with 1 df). The difference in responses of those who per-
ceived the lips as artificial and unnatural was statistically sig-
nificant at 2 mm between the 2 groups (P = .03 using the χ2 test
at 4.9 with 1 df).
Next, we wanted to examine the effect of the upper to lower
lip ratio on the perceptual threshold. The height of the lower
lips ranged from 9.3 to 14.3 mm and the height of the upper
lips ranged from 7.2 to 12.2 mm. The height ratio of the lower
to upper lips ranged from 0.76 to 1.99. There was no differ-
ence in perceptual threshold for either the treated or the arti-
ficial-appearing lips between the 2 age groups. Fifty percent
of observers in both age groups responded that the lips ap-
peared treated if the ratio of lower to upper lips was either less
than 0.92 or greater than 1.48. Meanwhile, 50% of respond-
ers in both age groups perceived that the lips appeared artifi-
cial if the ratio of lower to upper lips was either less than 0.85
or greater than 1.7 (Figure 4).
Discussion
Aesthetic augmentation of lips is a challenging procedure that
requires technical and artistic prowess for facial plastic sur-
geons. Numerous types of filler products and surgical tech-
jamafacialplasticsurgery.com
 Two-Dimensional Threshold for Perception of Artificial-Appearing Lips Original Investigation Research

Figure 1. Threshold Differential Between Perception of Treated Lips and Artificial Lips

A Upper lip B Lower lip

100 100
Treated
90 Artificial 90
dTA50 = 0.9 mm
80 80

70 70
Observers, %

Observers, %
60 60

50 50

40 40

30 30
Treated
20 20 Artificial
10 10 dTA50 = 1.5 mm

0 0
Baseline 1 mm 2 mm 3 mm 4 mm 5 mm Baseline 1 mm 2 mm 3 mm 4 mm 5 mm
dTA50 dTA50

C Upper and lower lips D Alteration of Cupid’s bow

100 100

90 90

80 80

70 70
Observers, %

Observers, %
60 60

50 50

40 40

30 30
Treated Treated
20 Artificial 20 Artificial
dTA50 = 1.5 mm dTA50 = 0.6 mm
10 10

0 0
Baseline 1 mm 2 mm 3 mm 4 mm 5 mm Baseline 1 mm 2 mm 3 mm 4 mm 5 mm
dTA50 dTA50

E Extended alteration of Cupid’s bow

100

90

80

70
Observers, %

60

50

40

30
Treated
20 Artificial
10 dTA50 = 0.3 mm

0
Baseline 1 mm 2 mm 3 mm 4 mm 5 mm
dTA50

The blue line represents the percentage of observers who thought that the lips participants, indicated by the grey area between the 2 vertical black lines.
appeared treated. The orange line represents the percentage of observers who dTA50 = 0.9 mm for upper lip only, 1.5 mm for lower lip only, 1.5 mm for upper
thought that the lips appeared artificial. dTA50 indicates the threshold and lower lips together, 0.6 mm for alteration of Cupid’s bow, and 0.3 mm for
differential between perception of treated and artificial lips for 50% of extended alteration of Cupid’s bow.

niques have been described to achieve youthful and volup-
tuous lip enhancement.4,11-19 One of the main challenges for
clinicians is to know when to stop treating the lips before the
results appear artificial and unnatural. In the clinical setting,
guidelines for lip augmentation are mostly determined by the
subjective assessment and experience of the clinician and the
wishes of the patients. Despite the best intentions, this deci-
sion can sometimes lead to misguided and unintended con-
sequences. This study aimed to determine the quantitative
measurement of the ideal profile for lip augmentation where

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 Research Original Investigation Two-Dimensional Threshold for Perception of Artificial-Appearing Lips

Figure 2. Photographs of the Lips Used in the Survey

Baseline

Upper lip

Lower lip

Both lips

Alteration of
Cupid’s bow
The images in the red boxes were
considered treated and attractive.
1 mm 2 mm 3 mm 4 mm 5 mm The images in the blue boxes were
considered unnatural and artificial.

Several key findings from this study have direct clinical im-
Figure 3. Effect of Age of the Observers on the Perceptual Threshold
of the Lips plications. For filler treatment of senile lips, we typically in-
ject between 0.5 and 1 mL of hyaluronic acid gel injection filler
100 via either a 27-gauge syringe needle or blunt tip microcan-
Group 1
90 nula. The advantages of using a microcannula for lip augmen-
Treated
80 Artificial tation include reduced risk of bleeding and bruising and intra-
70 Group 2 arterial injection.17,20 The treatment always starts with the
Treated
upper lip because if the upper lip is unintentionally injected
Observers, %

60 Artificial
50
P = .005 with too much filler, one can compensate by slightly over-
treating the lower lip to maintain the ideal proportion. Based
40
on our study, overtreatment of the upper lip alone presents with
30
a narrow margin (dTA50, 0.9 mm) for artificial appearance com-
20
pared with when both the upper and lower lips are over-
10 P = .03 treated (dTA50, 1.5 mm).
0
Baseline 1 mm 2 mm 3 mm 4 mm 5 mm There are 2 distinct groups of patients who inquire about
dTA50 lip enhancement: younger patients who want more full and vo-
luptuous lips and older patients with poor definition of the ver-
Group 1 consisted of younger observers between the ages of 17 and 40 years (mean million contour and atrophic lips who want improvement in
age, 33 years; n = 49). The dashed blue line indicates observers in group 1 who
definition and vertical rhytids. The data from this study sug-
considered the lips in the images to be treated; the solid blue line indicates
observers in group 1 who considered the lips in the images to be artificial. The gest that there is a measurable difference between people of
threshold differential between perception of treated and artificial lips for 50% of different age groups and their perceptual threshold for over-
participants (dTA50) in group 1 was 0.89 mm. Group 2 consisted of older observers treated and artificial lips. The difference in the perceptual
between the ages of 41 and 73 years (mean age, 52 years; n = 49) The dashed
orange line indicates observers in group 2 who considered lips in the images to be
threshold between the 2 age groups (20-40 years vs >40 years)
treated; the solid orange line indicates observers in group 2 who considered the lips is most significant for the upper lip measurement. As ex-
in the images to be artificial. The dTA50 in group 2 was 1.15 mm. pected, the younger group’s perception of natural and attrac-
tive appears to be for a bigger lip than the older group.
observers perceived the lips as treated and natural. Beyond this One interesting finding is that the artificial appearance of
measurement threshold, the lips may be perceived as unnatu- an overenhanced upper lip can be corrected by overenhanc-
ral and artificial. ing the lower lip, as long as the height of the lower lip is 1.6 times

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 Two-Dimensional Threshold for Perception of Artificial-Appearing Lips
Figure 4. Effect of the Upper and Lower Lip Ratio on Perceptual Threshold
A Ratio perceived as treated
100
Group 2
90
Group 1
80
70
Observers, %
60
50
40
30
20
10
0 0
0.5 1.0 1.5
Ratio of Lower to Upper Lip Height, cm
A, Ratio of lower lip to upper lip heights that were perceived as treated. The
blue line represents group 1 (mean age, 32.5 years; n = 49) and the orange line
represents group 2 (mean age, 52 years; n = 49). B, Ratio of lower lip to upper
the height of the upper lip. The ideal ratio in heights of the up-
per to lower lips as 1:1.618 has often been described in text-
books and the literature as the divine proportion or the golden
ratio.7,13,21 Based on our study, the perceptual threshold for at-
tractive lips and artificial lips is not determined strictly on the
dimension of the lips alone. The key to achieving an attrac-
tive and natural lip enhancement is to perform a balanced aug-
mentation of the upper and lower lips.
Because the lips are complex 3-dimensional structures, any
enhancements, either nonsurgical or surgical treatments, will
influence the height, the width, the projection, the change in
the angle of the lip commissure, the curvature of the Cupid’s
bow, and the contour of the philtrum and vermillion lines. Our
study was designed to determine how the layperson would per-
ceive the appearance of various lips. The most natural setting
for viewing lips during a routine encounter is the frontal view.
We decided to limit the effect of changes to the height of the
upper and/or lower lips and the shape of the Cupid’s bow be-
cause those alterations can be generated and controlled more
precisely on frontal view photographs.
Limitations
We recognize several limitations with this study. Cultural and eth-
nic background can influence aesthetic perception.22,23 Because
we demonstrated differences in the perception of lips between
different age groups of observers, we expect that there will be sig-
nificant differences in perception for observers based on their cul-
tural and ethnic backgrounds. We also considered that geographi-
cal background will influence observers’ perceptual threshold.
The dynamic characteristics of the lips and their effect on
the perception of lips were not discussed in this study. Fol-
ARTICLE INFORMATION Published Online: April 6, 2017.
Accepted for Publication: December 23, 2016. doi:10.1001/jamafacial.2017.0052
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Original Investigation Research
B Ratio perceived as artificial
100
90
80
70
Group 1
Observers, %
60
Group 2
50
40
30
20
10
2.0 0.5 1.0 1.5 2.0
Ratio of Lower to Upper Lip Height, cm
lip heights that were perceived as artificial. The blue line represents group 1 and
the orange line represents group 2.
lowing lip enhancement procedures, particularly after surgi-
cal treatments such as V-Y lip advancement, one may experi-
ence some changes in the natural movement of the lips.
Whether asymmetric movement or an unnatural contour of the
moving lip plays a key role in perceived artificiality is an im-
portant and complex problem that warrants further investi-
gation. Application of neurotoxins around the mouth and their
effect on perception of dynamic lip movement is another area
that needs further investigation.
Conclusions
The lips play a major role in the overall aesthetic appearance
of the face. As with all facial structures, the relative propor-
tions of all the various components contribute to our collec-
tive concept of beauty. If any of the individual components,
whether the eyes, nose, ears, or lips, become too large (or too
small), then the harmony is disturbed and the end result falls
outside the limits of aesthetic norms.
In practice, the burden lies with the clinician to counsel
the patient and inform him or her when more enhancement
is too much, which can be challenging, particularly when pa-
tients, often misguided by popular trends, insist on more en-
hancement. We recognize that quantitative measurement of
the lips as a fixed guideline for lip augmentation is neither prac-
tical nor realistic. There are too many variables to assume that
a strict set of measurements can predict the subjective per-
ception of the lips. The goal of this study was to provide some
quantitative measurements to help guide clinicians in coun-
seling their patients who are seeking lip augmentation.
397
 Research Original Investigation
Author Contributions: Dr Kim had full access to all
the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data
analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Kim.
Drafting of the manuscript: Kim.
Critical revision of the manuscript for important
intellectual content: Both authors.
Statistical analysis: Kim.
Administrative, technical, or material support:
Rousso.
Study supervision: Rousso.
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Segall L, Ellis DAF. Therapeutic options for lip
augmentation. Facial Plast Surg Clin North Am.
2007;15(4):485-490, vii.
2. Ferrario VF, Sforza C, Serrao G.
A three-dimensional quantitative analysis of lips in
normal young adults. Cleft Palate Craniofac J.
2000;37(1):48-54.
3. Sawyer AR, See M, Nduka C. 3D
stereophotogrammetry quantitative lip analysis.
Aesthetic Plast Surg. 2009;33(4):497-504.
4. Sarnoff DS, Gotkin RH. Six steps to the ‘perfect’
lip. J Drugs Dermatol. 2012;11(9):1081-1088.
5. Rossi AB, Nkengne A, Stamatas G, Bertin C.
Development and validation of a photonumeric
398 JAMA Facial Plastic Surgery September/October 2017 Volume 19, Number 5 (Reprinted)
© 2017 American Medical Association. All rights reserved.
Downloaded From: by a Kaohsiung Med Univ User on 03/25/2018
Two-Dimensional Threshold for Perception of Artificial-Appearing Lips
grading scale for assessing lip volume and
thickness. J Eur Acad Dermatol Venereol. 2011;25
(5):523-531.
6. Carruthers A, Carruthers J, Hardas B, et al.
A validated lip fullness grading scale. Dermatol Surg.
2008;34(suppl 2):S161-S166.
7. Kane MA, Lorenc ZP, Lin X, Smith SR. Validation
of a lip fullness scale for assessment of lip
augmentation. Plast Reconstr Surg. 2012;129(5):
822e-828e.
8. Jacono AA, Quatela VC. Quantitative analysis of
lip appearance after V-Y lip augmentation. Arch
Facial Plast Surg. 2004;6(3):172-177.
9. Jacono AA. A new classification of lip zones to
customize injectable lip augmentation. Arch Facial
Plast Surg. 2008;10(1):25-29.
10. Mandy S. Art of the lip. Dermatol Surg. 2007;33
(4):521-522.
11. Rohrich RJ, Reagan BJ, Adams WP Jr, Kenkel JM,
Beran SJ. Early results of vermilion lip augmentation
using acellular allogeneic dermis: an adjunct in facial
rejuvenation. Plast Reconstr Surg. 2000;105(1):
409-416.
12. Guerrissi JO. Surgical treatment of the senile
upper lip. Plast Reconstr Surg. 2000;106(4):938-940.
13. Lassus C. Restoration of the lip roll with
Gore-Tex. Aesthetic Plast Surg. 1997;21(6):430-432.
14. Glogau RG, Bank D, Brandt F, et al.
A randomized, evaluator-blinded, controlled study
of the effectiveness and safety of small gel particle
hyaluronic acid for lip augmentation. Dermatol Surg.
2012;38(7, pt 2):1180-1192.
15. Lemperle G, Sadick NS, Knapp TR, Lemperle
SM. ArteFill permanent injectable for soft tissue
augmentation, II: indications and applications.
Aesthetic Plast Surg. 2010;34(3):273-286.
16. Maloney BP, Truswell W IV, Waldman SR. Lip
augmentation: discussion and debate. Facial Plast
Surg Clin North Am. 2012;20(3):327-346.
17. DeJoseph LM. Cannulas for facial filler
placement. Facial Plast Surg Clin North Am.
2012;20(2):215-220, vi-vii.
18. Niamtu J III. Filler injection with micro-cannula
instead of needles. Dermatol Surg. 2009;35(12):
2005-2008.
19. Wong WW, Davis DG, Camp MC, Gupta SC.
Contribution of lip proportions to facial aesthetics
in different ethnicities: a three-dimensional
analysis. J Plast Reconstr Aesthet Surg. 2010;63(12):
2032-2039.
20. Keller G. Considerations in V-Y lip
augmentation. Arch Facial Plast Surg. 2004;6(3):179.
21. Lemperle G, Anderson R, Knapp TR. An index
for quantitative assessment of lip augmentation.
Aesthet Surg J. 2010;30(3):301-310.
22. Klein AW. In search of the perfect lip: 2005.
Dermatol Surg. 2005;31(11, pt 2):1599-1603.
23. Bisson M, Grobbelaar A. The esthetic
properties of lips: a comparison of models and
nonmodels. Angle Orthod. 2004;74(2):162-166.
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