Enhancing lip esthetics: Investigating lip volume, texture, and color with liplase treatment

INTRODUCTION

Lip esthetics significantly influence a youthful look and attractiveness.¹ Ideal lips are characterized by symmetry, a balanced proportion between upper and lower lips, and a well-defined vermilion border with natural fullness and volume.^2,3

Aging causes changes in the lips, resulting in increased lip length, decreased volume, flattened philtrum, and decreased nasolabial tissue thickness.⁴ Factors such as sun exposure, stress hormones, nicotine, and alcohol use influence these changes.⁴ Lip color is influenced by redness and melanin content.⁵ Redness of lips decreases significantly with age due to decreased blood vessel number and total area, and melanin content increases with age as identified by increased melanin index.^5-8 Histopathological changes include decreased epithelium thickness, collagen and elastic fibers fragmentation, flattening of rete ridges, increased subcutaneous tissue, and atrophy of Orbicularis oris muscle, causing perioral wrinkles.^3,9

Lip rejuvenation treatment includes injections, topical therapy, surgical lip lifts, and laser treatment. Hyaluronic acid injections, though efficient, may have adverse effects such as tenderness, bruising, injection site swelling, foreign body granuloma, angioedema, and do not target lip color.⁹ Topical treatments, such as retinoids, chemical peels, have a lower cost but minimal results.^2,10 Invasive lip lift significantly improves lip appearance; however, it leaves scars.¹¹ Among all, laser treatments are popular for their safety and minimal downtime.^3,11

Liplase^® is a non-surgical, non-invasive treatment for patients who desire lip augmentation and lip lightening. It involves the use of the thermal mode of non-ablative Er:YAG (Smooth mode) and super long pulse Nd:YAG (Piano mode) laser, causing collagen regeneration resulting in a fuller, more natural appearance of the lips.² The results typically last 4–6 months and are suitable for all skin types.¹²

Despite its potential, only limited studies and single-case reports exist on Liplase,^2,12 with no published case studies involving the skin of the color population to date.

Hence, this study aims to assess the safety and efficacy of Liplase^® in the Indian population for lip rejuvenation, focusing on improvement in lip color, volume, and texture. In addition, outcomes include patient satisfaction and pain visual assessment score, and physician assessment score for observed improvement.

MATERIAL AND METHODS

This prospective interventional study was conducted at Cutis Hospital, Bengaluru, over 6 months from December 2023 to May 2024. Approval was obtained from the institutional ethics committee. Written inform consent was obtained from all patients. Eligible candidates include males and females aged 18–54 seeking a non-invasive treatment for lip fullness and color enhancement. Exclusion criteria included a history of lip tattoo, use of photosensitive or immunosuppressive medicines, lichen planus, active herpes labialis or zoster, skin malignancy, or previous lip injections.

RESULTS

A total of 15 patients (8 females, 7 males) aged 29–48 years (mean age 32.7 ± 1.3 years) participated in this study. All patients had Fitzpatrick skin types IV–V, with average daily sun exposure of 22.69 min (range: 5–60 min/day). Thirteen patients completed the study; two discontinued after 1^st session due to skin dryness and peeling.

Lip volume showed noticeable improvement, as indicated by naso-labial angles in 8 out of 13 patients (mean-baseline value – 123.83 and follow-up –124.06) and labio-mental angles in 10 out of 13 patients (mean-baseline value – 139.64, follow-up – 136.47), while lip wrinkles and evenness improved across all the patients, as depicted in quantificare images clinically [Figures 1-7].

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Figure 1:

Clinical images of lips at (A) baseline, (B) session 1, (C) session 2, (D) follow up.

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Figure 2:

Quantificare 3D images of Naso-labial angles (A) baseline-116.86, (B) session 1-117.15, (C) session 2-110.32, (D) followup-104.3.

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Figure 3:

Quantificare 3D images of mentolabial angles- (A) baseline-137.54, (B) session 1-137.36, (C) session 2-133.56, (D) followup-136.28.

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Figure 4:

Quantificare 3D images of Wrinkles – (A) baseline, (B) session 1, (C) session 2, (D) follow up.

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Figure 5:

Quantificare 3D images of Lip evenness – (A) baseline, (B) session 1, (C) session 2, (D) follow up.

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Figure 6:

Naso-labial angle (where X axis shows 13 male and female candidates, Y axis shows degree of Naso-labial angle).

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Figure 7:

Mento-labial angle (where X axis shows 13 male and female candidates, Y axis shows degree of Mento-labial angle).

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Colorimeter showed reduction in melanin and improvement in erythema in all patients throughout the sessions and 3 months after the final treatment, as depicted by baseline upper and lower lip melanin and erythema index (upper lip-baseline mean–melanin index – 520.15, mean erythema index – 420.46 lower lip-baseline mean–melanin index – 445.76, mean erythema index – 460.03) and after 3 months of follow-up (upper lip-baseline mean–melanin index – 496.76, mean erythema index-460.53 lower lip-baseline mean– melanin index – 404.76, mean erythema index – 493.53) [Tables 1 and 2]. Color chart assessment by visual inspection showed consistent improvement in pigment score in all patients. Two patients, who inconsistently used SPF lip balm, maintained erythema index; however showed an increase in melanin content, which resolved after topical depigmenting agents.

Patients satisfaction scores revealed that 53% noted improvement in lip volume (Likert score = 2), 100% saw improvement in lip color (Likert = 2 and above), 76.9% reported improvement in lip texture (Likert = 2 and above), and 100% observed overall improvement in lip appearance (Likert = 2 and above; [Table 3]).

Physician satisfaction scores revealed that 53% noted improvement in lip volume (Likert score = 2), 100% saw improvement in lip color (Likert = 2 and above), 76.9% reported improvement in lip texture (Likert = 2 and above), and 92.3% observed overall improvement in lip appearance (Likert = 2 and above; [Table 4]) (P < 0.001).

Pain levels (visual analogue scale) varied, with 38% patients reporting level 2 while 23% reported level 3, 15% level 5, and 8% reported level 0, 1, and 8 each [Table 3].

Eight patients observed lip and peri-oral peeling for 3–4 days posttreatment, managed with moisturizer, and two patients with severe dryness and peeling were prescribed fluocinolone acetonide 0.01% cream twice daily for 3 days.

DISCUSSION

Lip augmentation procedures are gaining popularity, as noted by the American Society of Plastic Surgeons in 2023.¹³ Aging typically leads to thinning and lengthening of the lips due to decreased forward curvature and thickness of orbicularis oris. It is often accompanied by a drooping angle with increasing lip width due to changes such as atrophy of the levator labii superioris, bone resorption of the alveolar ridge, increased perioral soft-tissue envelope redundancy, and intrinsic soft tissue. Overall, it produces an inverted U-shaped appearance.^6-8

Our study included 15 participants (8 females, 7 males) aged 29–48 years, marking the first effort to assess the male patients. While most prior studies focused on patients over 40 years old^2,12 or comprised case reports,^12,13 we included a younger age group of both male and female patients.

Clinical images and Quantificare 3D imaging depicted noticeable improvement in lip volume, wrinkles, and evenness. Our findings on lip esthetic improvement align with other studies^2-4,12 that relied on clinical images^2,3,12 or pixel tip measurements.³ This study uniquely assessed wrinkle and evenness, showing greater benefits with mild-moderate lip volume enhancement. We recommend performing the procedure every 2–3 weeks for optimal results.

Lip color assessment showed a significant reduction in lip melanin and consistent with findings in previous studies.^3,4 In addition, we noted a significant improvement in lip erythema, a marker of increased vascularity. This parameter has not been previously reported in the literature. Lip color assessments in earlier studies relied on subjective clinical evaluation, whereas we employed an objective tool like a colorimeter for better accuracy.² Two patients experienced temporary darkening of the lip after the procedure due to inadequate SPF use, which resolved after topical depigmenting agents for 4 weeks.

Patient satisfaction scores for lip color, volume, and texture were 100%, 53%, and 76.9%, respectively, with noticeable color improvement in all patients. Compared to a prior study by Ifrah et al.,⁴ satisfaction scores were higher (94% for color, 72% for volume, and 91% for texture). In our study, pain scores ranged from 2 to 5 in 76% of patients, which were higher than those reported in a previous study, where 84% of patients reported zero pain score.³ Thus, topical anesthetic cream was applied for 30–40 min pre-procedure.

Lips and peri-oral peeling lasting 3–4 days occurred in 8 patients, a more prominent observation compared to other studies.^{2, 3,12} Hence, patients should be informed about potential downtime. Follow-up assessment at 3 months showed sustained improvement in lip volume, color, and texture, a parameter not evaluated in previous studies.^2,3,12 Two patients reported immediate plumpness post-procedure, which lasted for a few hours.

Our study has a few limitations, including a small sample size, short follow-up duration, and the lack of a control group. Future studies should address these limitations by conducting randomized controlled trials with larger and more diverse patient populations. In addition, there is a need to develop standardized tools for assessing lip esthetics, particularly in skin of color. Existing studies predominantly focus on female participants and lack long-term outcomes.

CONCLUSION

This study establishes a foundation for incorporating Liplase^® as a safe, non-ablative tool for lip rejuvenation, to enhance lip color, texture, volume, and wrinkles. Lip augmentation through Liplase^® treatment remains an underexplored area, particularly in the Indian population and among male patients.

This study uniquely incorporated objective tools such as 3D imaging and colorimeters to measure improvements. It also assessed patient and physician satisfaction scores and pain levels, aspects often overlooked in earlier research. Our findings emphasize the need for further studies with larger, diverse populations and standardized protocols to validate these observations and refine treatment protocols.