Fig. 2. The pull-through procedure for the lower-lip multistrand Gore-Tex graft, with toothed alligator forceps, is demonstrated here.

Lubrication of the implant with sterile KY gel (Johnson & Johnson) during placement is helpful.

After placement of the implant, the lip is stretched from the center laterally while both ends are held with a small hemostat. Uniformity and symmetry are evaluated. The tapered ends of the implant are then tucked laterally into the muscle pocket. No sutures are used to secure the implant; muscle and vermillion prevent exposure. Closure is accomplished with 5-0 Chromic or 6-0 Prolene sutures (Ethicon Inc., Somerville, NJ).

Upper lip
For the upper lip, I prefer the AlloDerm graft, measuring 3-cm wide and 7-cm long. I use a 0.04- to 0.07-inch (40/70) thickness if significant enhancement is desired. For modest improvement, I have used thinner material. Graft preparation involves soaking for 5 minutes in sterile normal saline solution or lactated Ringer's solution, removing the backing, and soaking for an additional 5 minutes in a second dish. Implant shaping is more easily accomplished before full hydration.

My usual upper-lip AlloDerm graft is a 3-layer stack constructed by cutting a 3-cm-wide graft into 3 strips measuring 1 × 7 cm. The ends are tapered and the graphs are stacked and sutured together with a 4-0 chromic mattress suture approximately 1 cm from each end. The stacked graft is then pulled through the upper lip subvermillion tunnel with special attention to grasping all 3 strips during the pull-through maneuver. These graphs may be customized for lip asymmetry or for less fill at the center (cupid's-bow area) if desired. Each end is then held firmly with forceps while the lip is stretched out for proper symmetric placement. The tapered ends are tucked laterally into the muscle pocket.

Postoperative care includes a multilayer Steri-Strip dressing (Seaway Surgical, Toledo, OH) placed along the vermillion border, cold packs for 24 hours, and avoidance of unnecessary lip motion. Antibiotics and antiherpetic medications are begun a day before surgery.

Discussion

I have found that the multistrand Gore-Tex provides desirable and long-lasting lower-lip enhancement. Complications are unusual, and long-term postoperative complaints about sensation and firmness, made by the patient or the patient's partner are rare. In the short term, there will be some limitation of lip motion and some initial concern about firmness. According to my patients, these concerns usually fade after 3 or 4 weeks. The advantages of Gore-Tex implants over AlloDerm for the lower lip are long-term persistence and somewhat lower cost.

Late in 1996, I first tried AlloDerm for upper-lip augmentation because it was observed that with Gore-Tex, an upward lateral displacement of the implant occurred, resulting in fullness above the vermillion border of the upper lip.(26,27) It is notable that I found the same complication with SoftForm (Collagen Corp., Palo Alto, CA), which I rarely use.(27) I have found Alloderm to be soft; patients and their partners have accepted it, describing it as having a natural feel.

The disadvantages of AlloDerm have been primarily a lack of volume persistence and the cost. Others have reported 80% to 85% persistence at 7 months and a volume diminution of 30% to 40% at 1 year.(22) At 2 years I have found that most of my patients have about 50% of the augmentation they had at 4 months (Figures 3 to 6).

Fig. 3. A, Preoperative view of a 75-year-old woman. B, Postoperative view 5 months after laser resurfacing and upper- and lower-lip augmentation. C, Postoperative view after 27 months. The patient demonstrates about 50% maintenance of upper lip volume and 100% maintenance of lower lip volume.