Background: Among men, interest in undergoing aesthetic procedures has grown over the years. In particular, men are increasingly seeking lip procedures. However, there are still very few scientific reports involving lip treatments for men.

Objective: The aim of this article is to describe a novel lip-filling technique performed on 23 male patients according to their needs.

Methods: The technique described is a lip treatment developed to serve the male audience. In this technique, three possible treatments (booster effect, volumization, and beautification) are performed according to the patient's desire in synergy with the evaluation of the cosmetic professional. Thus, this study involved 23 male patients who wished to improve the labial and/or perilabial region and who had not undergone any previous lip procedures.

Results: This study presented a novel approach to male lip fillers according to three main demands and successfully adapted to the sexual dimorphism of the lip region. The booster was the most often applied lip-filling treatment, used in approximately 56.5% of patients. On the other hand, the least often applied treatment was volumization, used in approximately 13% of patients. All patients reported being satisfied with the treatment performed. Only five patients experienced adverse reactions/complications post-treatment, which were ecchymosis and edema, but were resolved.

Conclusion: This technique proved to be effective, safe, and personalized, with very satisfactory results, according to most patients. This study also evidenced the need for and importance of developing further studies of lip filling techniques for the male audience.

Keywords: lip treatments, lip fillers, aesthetic procedure, novel lip-filling technique, lip procedure

The lips occupy a central position on the face, being a key element of attractiveness and playing a fundamental role in verbal and nonverbal communication.^1,2 Due to the growing demand among male patients for lip fillers, additional studies are needed to treat the male lip, since there are few scientific reports on these treatments for the public.

The attractiveness of female and male individuals seems to be increased by definition of distinct parameters of the lips and perioral region. Furthermore, it has been proven that gender-related differences prevail regarding the shape of an attractive lower third of the face.³

To achieve an ideal aesthetic result, it is necessary to know the anatomy, sexual dimorphism, and aging process of the lips.⁴ This knowledge is essential for an elegant aesthetic result, as well as for avoiding complications that can occur, including vascular compromise or occlusion, with consequent necrosis, and, in more serious cases, blindness.⁵

In order to facilitate the approach to male lips and considering the needs of the gender, a systematization of existing techniques and their adequacy was described to assist the cosmetic professional and optimize the achievable aesthetic results. Thus, the aim of this article is to describe a novel lip-filling technique in 34 male patients, according to their main needs: hydration and smooth restructuring, beautification, and volumization.

Study sample

The study involved 23 male patients with a desire to improve the lip region, of which the main indications were hydration, beautification, and volumization. Included patients had to be male and could not have undergone any lip procedures. This study was submitted to the Ethics Committee and performed in accordance with the Declaration of Helsinki. Before the start of the study, written informed consent was obtained from the study participants.

 Technique

The developed technique is composed of three possible treatments in order to direct the cosmetic professional: a booster effect (hydration), beautification, and volumization. The choice of one or more of these possibilities is defined according to the assessment of each individual patient. Eversion and lip contouring were not the focus of this technique, since these treatments are uncommon among this audience.

 Description of the technique

This technique consists of two steps. The first step, defined as assessment and anatomy, consists of evaluating all the topographic layers of the region, including the bone structure, dental arch, muscular plane, fat compartments, and lip proportions. This assessment makes it possible to offer a correct and effective diagnosis, in addition to individually defining the mission(s) established for each case.

The aim of the first step, which precedes any intervention proposal, is to understand facial aesthetics and the elements that bring balance and beauty to different face types. The assessment of the balance between the facial thirds, dental and bone projections or retrusions, and deficits or excesses are part of the detailed analysis. This increases the chances of a positive result for the patient.

Based on this detailed assessment, the objective to be addressed is defined. The main objective of the booster effect is to moisturize the lip region and revitalize the local area. Volumization is performed when the treatment is directed to a patient in which volume loss is observed, usually starting from 30 to 35 years of age and/or due to a genetic factor. It is the technique of choice for adjusting the volume between the upper and lower lips when there is a marked disproportion between them.

Beautification is indicated for (usually younger) men who already have a good lip shape in terms of contour, volumization, and projection but who would like to make their lips more beautiful, sensual, and attractive.

Following diagnosis of the areas to be treated and the objectives to be achieved, the second step consists of defining the treatment plan, the technique developed, and the choice of product.

In the booster effect, the product Restylane® Skinboosters™ Vital is applied in the superficial subcutaneous plane, in the dry vermilion area, using a 22–25G cannula. The application must be longitudinal, with lateral entry holes in each quadrant, following a linear path, normally in two lines in each quadrant. A total volume between 0.5 and 1 mL is applied, distributed among the four quadrants, for a total of eight lines (Figure 1).

Figure 1 Cannula Booster Technique – rectilinear application in the very superficial subcutaneous.

In volumization, the product Restylane® Kysse™ is applied in the anteromuscular plane, subcutaneously, in a “V Rectilinear” pattern, using a 22–25G cannula. Linear path 1 is positioned 2 mm below the white roll, and linear path 2 is positioned 1 mm above the wet/dry vermilion transition. A total volume between 0.5 and 1.0 ml is distributed among the four quadrants (eight linear paths) (Figure 2).

Figure 2 Volumization technique.

In beautification, the product Restylane® Kysse™ is applied in the anteromuscular plane, subcutaneously, using a 22–25G cannula. The application takes place in two steps: straight lines and triangles. In straight lines, the product is applied subcutaneously according to the image with a cannula with 0.1 mL in retroinjection in both the upper and the lower lip lines. In the triangles, the application occurs subcutaneously in a microbolus according to the image with a cannula, with a volume of up to 0.2 mL per triangle. Thus, a total product volume of 0.4 to 0.6 mL is applied (Figure 3). If the intention is to maintain the lip width, it is necessary to fill the linear path from tubercle to tubercle. On the other hand, if the objective is to increase the width of the lip, it is necessary to fill the linear path from commissure to commissure.

Figure 3 Beautification technique.

The 23 male patients were treated according to the three described treatment possibilities of the Kissability Men® technique (booster, volumization, and beautification) and with the abovementioned products. The ages of these patients ranged between 24 and 56 years. Patients were followed up for 6 months.

The most frequently applied lip-filling treatment was the booster, in approximately 56.5% of patients. On the other hand, volumization was the least frequently applied treatment, used in approximately 13% of patients. The second most frequently applied treatment was beautification, used in approximately 30.5% of patients.

Following the procedure, the patients evaluated the treatment according to their level of satisfaction. The result of this evaluation was very positive; all patients reported a high satisfaction rate. Thus, 57% of patients said they were highly satisfied with the treatment, and 43% of patients reported being satisfied. Figures 4, Figure 5, and Figure 6 depict patients before and after undergoing lip filling using the techniques described. Post-treatment adverse reactions/complications were observed in only five patients, of which two patients had ecchymosis, and three patients had edema for more than 3 days, which were resolved in 8–14 days.

Figure 4 A 34-year-old male patient before (Left) and after (Right) lip filling via the booster technique.

Figure 5 A 39-year-old male patient who underwent lip filling with the technique of volumization. Patient before performing lip filling (A and C). Patient after performing lip filling (B and D) with associated volumization treatment of the perioral frame: commissures, nasolabial fold, and Marionette lines (0.8 ml Kysse + 2.0 ml Defyne).

Figure 6 A 30-year-old male patient who underwent lip filling with the beautification technique. Patient before performing lip filling (A, B and D). Patient after performing lip filling with beautification treatment (C and E). A 0.8-ml volume of Restylane Kysse was used in the subcutaneous and a 0.6-ml volume of Restylane in the commissures.

Treatment of the male lips requires a gender-specific approach. While the female lips have greater volume, vertical diameter, and definition, more evident tubercles, and greater projection, the male lips are much thinner and rectified, have little design of the filters, and have greater lateral extensions (i.e., a wider mouth)⁶ (Figure 7).

Figure 7 (A) Female lip. (B) Male lip.

Despite a lower incidence of use in clinics compared with that of other procedures, treatment for the labial region is increasingly sought by the male public. Knowledge of the anatomical differentiation between the sexes is essential, as is the understanding of the ideal result, since volumization is more popular with the male audience than eversions and lip contours.

All anatomical layers of the labial and perilabial region directly interfere with lip projection and may contribute to the treatment result.¹ Structural assessment, including that of bone and muscular aspects, is key. The bone compartment undergoes a remodeling process with aging, becoming more absorbed over the years, which decreases the vertical diameter of the entire face, especially the lower third. The appearance in profile of this perioral region in an aged person is of greater obliquity, which worsens when tooth loss occurs in these patients. Another deep structure that interferes greatly the perioral profile is the dental arch. The loss of one or more dental elements provides a local soft-tissue invagination, giving the impression of a withered lip without projection. The dental articulation between the upper and lower arches also modifies the profile of the region. For example, class II bites project the upper lips more, while class III bites project the lower lips⁷ (Figure 8).

Figure 8 Tooth joint.

The lip vermilion has fat compartments divided by septa, on both the upper and lower lips. Furthermore, an important deflation of these fat deposits is observed after 40 years of age. Lip volumization, therefore, is crucial for volumetric restoration, leaving lips rejuvenated and more attractive. The vermilion is considered by pathologists to be a skin and not a mucosa, and the skin tissue of this region has much fewer layers of cells than the rest of the face, making it appear more reddish (vermilion), without the presence of glands, which is the reason why it has a strong tendency toward dehydration. For this reason, it is often a treatment target. In a side view (profile), there is a greater projection of the lips in relation to the rest of the face.^6,8

By drawing the Ricketts’ aesthetic line, which is the line tangent from the nasal tip to the anterior extremity of the chin (pogonion),⁹ one can observe that the lower lips touch this imaginary line or are up to 2 mm from this line. The upper lips are up to 4 mm from this line.

In general, the lips do not obey the same proportion. The “Golden Ratio” is commonly found and desired, in which the vertical height of the lower lips is greater than that of the upper lip (1:1.6); however, it is not necessarily a rule. Harmony with the other facial regions is the most important aspect. There is also an ideal proportion of the lips in relation to the lower third of the face, with the height of the upper lip being equivalent to 1/3 and that of the lower lip and chin being equivalent to 2/3 of the entire lower third of the face.⁶

Most recent studies of cadaver dissections and those carried out on ultrasound images, although they show different percentages, indicate that the arteries are more commonly distributed behind the orbicularis oris muscles and often inside them, and the arteries remain in the subcutaneous plane in a clear minority of cases. For these reasons, lip treatment via superficial injection is recommended.^1,2,10 The superior labial arteries are generally thicker and enter more laterally in the vermilion than the inferior ones. The average depth of location is about 3 mm along the vermilion.^1,11 Anatomical changes are commonly found.

In this technique, we combine the choice of the ideal product, the tactical strategy to be achieved and the aesthetic and functional result obtained. Thus, the technique was divided into Booster, volumization, and beautification.

The main objective of the Booster effect is to enhance the moisturizing properties of the lip region, which is so commonly dehydrated, and to revitalize the local area. This treatment is not only anti-aging but also increases the activity of the extracellular environment. In addition to its important moisturizing action, hyaluronic acid, even with its very small particle size, acts on the regional fibroblasts, restructuring and revitalizing the number of fibers and amount of local glycosaminoglycans. In this way, Kyssability Booster is not a filling treatment; it is normally used for lips that already have good volume, bringing more shine, hydration, and luminosity to the vermilion, which are desired by most people. It acts as an entry-level procedure for male patients to treatments in the region, since many of them show minimal signs of local aging or are afraid of a more artificial result.

The Booster technique is a great alternative treatment. The treatment protocol specifies a single application and, unlike treatments performed on other facial areas, reassessment is only required 6 months later, making this treatment simple and effective. Perioral assessments are also crucial for aesthetic improvement, and this region should be treated at the first sign of dehydration, discrete volumetric losses, and the formation of perioral lines (bar codes). Restylane® Skinboosters™ Vital and Vital Light (hyaluronic acid) are the products of choice for the Kyssability™ Boosters technique. The choice of a product depends on the treatment goals.

Restylane® Skinboosters™ Vital contains hyaluronic acid at 20 mg/ml, which gives it a high hydration capacity, and is recommended for patients with thicker, more dehydrated skin or for a greater aesthetic effect on the region (luminosity and brightness). By contrast, Restylane® Skinboosters™ Vital Light Lidocaine has a hyaluronic acid concentration of only 12 mg/ml, making it very useful for lips with very thin skin and little need for rehydration or when a greater aesthetic effect is not desired. Both are very-small-particle hyaluronic acids (NASHA® technology).    

From the age of 30 onwards, it is possible to observe a slow but gradual deflation of the lip fat compartments. Lip volumetric treatment tends to use products that are more flexible. The total amount injected depends on the individual’s needs, and the result must always appear natural. When the goal is lip volumization, the product of choice is hyaluronic acid (Restylane® Kysse™) derived from a technology called Optimal Balance Technology™ (OBT™). In addition, it has a lot of flexibility, the ability to integrate with labial tissues, and a small particle size; moreover, it can be applied very superficially, such as when defining the contour of the vermilion, and a degree of crosslinking of III. Thus, it is a very resistant product, useful for areas with a high frequency of motion, such as the lips. It is therefore the recommended product for the vast majority of lip treatments, including beautification.

Beautification is the treatment performed when the objective is lip embellishment, even when restoration is not needed. Typically, older and/or more conservative patients request this treatment. Its main intent is to enhance the beauty of the lips. This trend has become more evident in the digital age and is present in many countries around the world. Without exaggeration, the enhancement of the beauty of the lips makes the region more attractive and sensual, enhancing the volume, contour, and projection.

Therefore, knowledge of the different treatment objectives is key because it enables assertive results and helps in the treatment of challenging cases, such as asymmetries or lips with retractions, for example, the “M-Lip” shape or scarring.

This study demonstrated a novel lip filler technique for males, which was tested successfully to serve male patients. This technique was developed to meet the growing demand by male patients for this treatment and the great need in view of the very few reports in the literature of lip treatments for the male audience.

The experience allowed us to classify patients’ needs into three large groups and treatment possibilities (booster effect, volumization, and beautification) chosen on the basis of the patient's desire in synergy with the evaluation of the cosmetic professional. This technique proved to be effective, safe, and personalized, with very satisfactory results, according to most patients. This study also evidenced the need for and importance of developing additional studies on lip-filling techniques for the male audience.

None.

Authors declare there is no conflict of interest.

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