ORIGINAL ARTICLE

A New Classification of Lip Zones to Customize

Injectable Lip Augmentation
Andrew A. Jacono, MD

Objectives: To present a new classification of 15 ana- satisfied). The mean (SD) persistence until lips re-
tomical lip zones used to direct placement of injectable turned to preoperative appearance based on patient sub-
fillers during lip augmentation and to evaluate the new jective evaluation was 4.9 (1.5) months. Patients were
classification’s ability to customize lip contour and size. free of adverse effects.

Methods: Study participants were consecutive pa-
tients presenting to a facial plastic and reconstructive sur-
gery practice for injectable lip augmentation with a non-
animal-sourced stabilized hyaluronic acid (Restylane;
Medicis Aesthetic Inc, Scottsdale, Arizona). A nonran-
domized, prospective case series.
Results: A total of 137 treatments were performed on
lips of 66 patients. The mean (SD) satisfaction score was
4.5 (0.6) on an integral scale of 1 (dissatisfied) to 5 (most
Conclusions: Using a new classification of lip anatomi-
cal zones to direct the injection of a nonanimal-sourced
stabilized hyaluronic acid has increased my ability to bet-
ter control lip shape and size in lip augmentation. This
technique was met with high patient satisfaction and no
adverse effects. Persistence of injected nonanimal-
sourced stabilized hyaluronic acid was similar to that seen
in other studies.
Arch Facial Plast Surg. 2008;10(1):25-29

Author Affiliations: Section of
Facial Plastic and
Reconstructive Surgery,
The North Shore University
Hospital, Manhasset; Division
of Facial Plastic Surgery,
The New York Eye and Ear
Infirmary, New York; and
The New York Center for Facial
Plastic Surgery, Great Neck,
New York.
T
HE LIPS ARE AN ESSENTIAL
component of facial symme-
try and aesthetics. Anthro-
pometric studies have
shown that wider and fuller
lips in relation to facial width as well as
greater vermilion height are a mark of fe-
male attractiveness.1 There has been a dra-
matic increase in cosmetic surgery in West-
ern culture in the past few decades, with an
increasing focus on achieving aesthetic ide-
als and maintaining a youthful appear-
ance. Full lips have become increasingly de-
sirable as they are considered both youthful
and beautiful. Moreover, a trend has been
identified toward fuller and more anteri-
orly positioned lips in models appearing in
magazines over the past century.2
Vermilion lip hypoplasia and thin lips
disrupt facial harmony and can result in
the perception of nasal tip or mandible
overprojection. Such vermilion hypopla-
sia, when not present in youth, is often pres-
ent with aging. Gonzalez-Ulloa3 has de-
scribed the changes of the lip with aging,
including a less exposed vermilion, a rela-
tive loss of vermilion bulk, and lengthen-
ing of the lip.
It is possible to enlarge, refine, shorten,
and reshape the lips with surgical tech-
niques,4-13 most of which can offer long-
term results. The first few generations of
injectable soft-tissue fillers such as bo-
vine collagen (Zyderm and Zyplast; Aller-
gan Inc, Irvine, California) offer patients
a nonsurgical, yet short-term, means of im-
proving their appearance. Although in-
jectable collagen offers greater versatility
to reshape and augment the lip than any
one surgical technique, its short persis-
tence in the mobile lip made it a less de-
sirable choice of treatment.
With the advent of longer-lasting, non-
allergic, nonanimal-sourced stabilized hy-
aluronic acid (NASHA) gel fillers,14-18 in-
jection techniques have evolved. What
follows is my description of a new classi-
fication of 15 anatomical lip zones that I
use to direct placement of injectable fill-
ers and to improve my ability to custom-
ize lip contour and size to the patient’s de-
sire. The depth of injection also varies from
dermal to the deeper mucosal/superficial
muscular interface, creating further cus-
tomized results. I present my experience
using an injectable, NASHA gel product
(Restylane; Medicis Aesthetic Inc,
Scottsdale, Arizona) to augment the lips
in this fashion, including persistence data
based on patient subjective review.
The upper lip is widely classified as hav-
ing 3 subunits—the central philtrum and

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Upper Lip Lower Lip
A. Philtral zone I. Vermilion lateral zone
B. Vermilion lateral zone J. Vermilion medial zone
C. Vermilion cupid’s bow apex zone K. Subvermilion lateral zone
D. Vermilion philtral/central zone L. Subvermilion medial zone
E. Subvermilion lateral zone M. Peristomal lateral zone
F. Subvermilion medial zone N. Peristomal medial zone
G. Peristomal lateral zone O. Commisural zone
H. Peristomal medial zone
Figure 1. Diagram representing the 15 anatomical lip zones for injection
during lip augmentation. Notice their lamellar appearance.
2 lateral subunits and the lower lip, 1 subunit. The cuta-
neous and mucosal portions of the lip meet at the vermil-
ion that has a variable prominence called the white roll. Lip
augmentation is classically performed by inserting a needle
along the vermilion-cutaneous junction while stabilizing
the skin and lip with the other hand, and injecting into a
potential space that exists along this border.
Driven by the desire of patients to achieve specific goals
for lip shape, I found that there are 15 separate anatomi-
cal zones that I regularly injected with fillers (Figure 1).
The major zones are vermilion/white roll, subvermil-
ion, peristomal, philtral column, and commissural. The
subvermilion zone corresponds to the dry mucosal lip,
and the peristomal zone at the junction of dry and wet
mucosal lip. The distance separating the vermilion, sub-
vermilion, and peristomal regions is significant enough
so that a 30-gauge needle can easily be directed into each
of these zones specifically. Fifteen anatomical zones for
injection are the result of further subdividing these zones.
The vermilion/white roll can be further subdivided in the
upper lip to include lateral, Cupid’s bow apical, and cen-
tral philtral zones, while the lower lip vermilion is di-
vided into medial and lateral zones. The subvermilion is
subdivided into medial and lateral zones, and the peristo-
mal, into medial and lateral zones (Table).
METHODS
Study participants were consecutive patients presenting to my
facial plastic and reconstructive surgery practice. All patients
signed an informed consent for the procedure.
The NASHA gel used for tissue augmentation consisted of
NASHA, 20 mg/mL, in a physiologic sodium chloride solution
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Table. Classification of 15 Anatomical Lip Zones
for Injection During Lip Augmentation a
Major Lip Zone for Presence in Presence in
Lip Zone Injection Upper Lip Lower Lip
Vermilion Vermilion lateral X X
Vermilion Cupid’s bow apex X
Vermilion central philtrum X
Vermilion medial X
Subvermilion Subvermilion lateral X X
Subvermilion medial X X
Peristomal Peristomal lateral X X
Peristomal medial X X
Philtral column Philtral column X
Oral commissure Commissure X
a This table identifies their location in the upper or lower lip.
buffered to pH 7 in gel form (250-µm gel bead size and 100 000
U/mL) preloaded in a 1.0-mL or 0.4-mL syringe with a Luer-
Lok. A 30-gauge, 1.27-cm needle was supplied in the package.
The amount injected into the lips depended on the goals of
the patient for shape and size, and the anatomical deficiencies
present.
The patient’s desire for lip shape and size was then re-
viewed, using a mirror and pointer, and a treatment plan in-
cluding the subunits to be treated and the depth of injection
was determined. Before treatment, local nerve blocks were ad-
ministered with 1% lidocaine without epinephrine to mini-
mize tachycardia and to shorten the duration of anesthesia af-
ter treatment. Infraorbital nerve blocks were given for the upper
lip and mental nerve blocks for the lower lip.
Filler injection depth varied from more superficial dermal/
mucosal to the deeper layers at the junction of the orbicularis oris
muscle with the cutaneous skin, red lip mucosa, and minor sali-
vary glands, depending on the segment of the lip. Care is taken
to inject while withdrawing the needle, and not injecting in the
deeper substance of the muscular lip to prevent labial artery em-
bolization. Massaging of the injected area was performed when
necessary to attain the desired contour. Immediately after the in-
jections, to minimize the potential for ecchymosis, direct, con-
stant pressure with ice compresses was applied to the injection
sites until there was no evidence of bleeding.
After injection, patients were given a follow-up question-
naire that asked them to quantitate in 2-week intervals when
their lips returned to pretreatment appearance, and their sat-
isfaction with the results in shape and size with the treatment
without consideration for longevity on an integral scale of 1
(dissatisfied) to 5 (most satisfied). A record of adverse reac-
tions and sensitivities was also included. Data were retrieved
at routine follow-up visits for another treatment, or by fol-
low-up calls made at 6 months and 9 months.
RESULTS
A total of 137 NASHA treatments were performed on the
lips of 66 patients (62 women and 4 men) from January 1,
2004, to January 1, 2006. The mean age was 45.8 years,
with a range from 20 to 76 years. Follow-up on question-
naires of 118 NASHA treatments performed on lips of 53
patients was obtained (80% follow-up). The mean (SD) sat-
isfaction score was 4.5 (0.6), with 5 representing most sat-
isfaction. The mean (SD) persistence until lips returned to
preoperative appearance based on the patient’s subjective
evaluation was 4.9 (1.5) months. Aside from transient ery-
WWW.ARCHFACIAL.COM
 thema at the injection sites and infrequent bruising, these
A
patients were free of adverse effects.

COMMENT

It is not necessarily accurate to discuss facial aesthetics

in terms of universal ideals, as the characteristics that are
valued vary across individuals, cultures, and eras; lip ap-
pearance is no different. With the dramatic increase in
the number of patients having aesthetic facial treat-
ments, and the diversity of ethnicities represented, the
traditional method of augmenting the lips by injecting
the vermilion border with the pinch-and-roll method alone
limits the ability of the treating physician to shape and
augment the lip to the patient’s desires. Lip contours vary
widely, from patients with thin lips with a flat Cupid’s
bow, to patients lacking lateral lip fullness with an ad-
equately full lip centrally and appropriately curved Cu-
pid’s bow, to patients with a flat philtrum and flat Cu-
pid’s bow with good overall lip fullness, and other
combinations.
I described a new classification of 15 anatomical lip
zones that I use to direct placement of injectable fillers
and to improve my ability to customize lip contour and
size during augmentation with the NASHA gel. This ap-
proach was developed to better direct injectable filler
placement, as traditional methods allowed me to aug-
ment the lips in a generalized way, but did not allow me
to differentially augment specific patient problem areas,
or to customize lip shape. Patient satisfaction was high
when using this method, 4.5 on a 5-point scale. These
concepts can be applied when using other temporary in-
jectable fillers, but considering the varied locations and
depth of injection, I would caution against using this
model when using permanent synthetic fillers.
The 5 major zones are vermilion/white roll, subver-
milion, peristomal, philtral column, and commissural.
The subvermilion corresponds to the dry mucosal lip, and
the peristomal at the junction of dry and wet mucosal
lip. Fifteen anatomical zones for injection are the result
of further subdividing these zones. The vermilion/white
roll can be further subdivided in the upper lip to in-
clude lateral, Cupid’s bow apical, and central philtral
zones, while the lower lip vermilion is divided into me-
dial and lateral zones. The subvermilion is subdivided
into medial and lateral zones, and the peristomal, into
medial and lateral zones (Figure 1).
In my experience, these zones of injection correspond
to specific needs in lip contouring and augmentation. I have
found that these zones can easily be separated and in-
jected specifically with a 30-gauge needle (a fraction of a
millimeter in width), as the vermilion is separated from the
subvermilion by 3 to 4 mm, and the subvermilion simi-
larly is separated from the peristomal zone by 3 to 4 mm.
Speaking in generalities, we use subvermilion and peristo-
mal injections (both medial and lateral) to increase the full-
ness and roundness of the mucosal/red lip in these re-
gions (Figure 2). Obviously, if a patient is deficient only
medially or laterally in one of these regions, then only
that zone is injected. With an overall thin lip, subver-
milion and peristomal injections are given at the same
B
Figure 2. Patient’s lips before (A) and after (B) injection of
nonanimal-sourced stabilized hyaluronic acid gel (Restylane; Medicis
Aesthetic Inc, Scottsdale, Arizona) into the subvermilion and peristomal
zones of the upper and lower lips only to create a fuller, rounder lip without
change in lip curvature.
time to achieve the most fullness. There is a subset of pa-
tients that I see with adequate lip fullness but a slight con-
cave depression in the mucosal lip in the subvermilion
zone; therefore, this depression is injected and no peristo-
mal zone injections are required. I often inject the peristo-
mal zone laterally alone to create a lateral lip pout in pa-
tients who request a lip more like the actress Angelina
Jolie (a common request).
I inject the vermilion/white roll zones to increase the
size of the lip as well as modify the curvature of Cupid’s
bow. In the severely thin lip, vermilion zone injections
are combined with subvermilion and peristomal injec-
tions. To increase the curvature of Cupid’s bow in a flat
vermilion, the vermilion lateral and vermilion Cupid’s
bow apical zones are injected while the central philtral
zone is not. In an overly curved Cupid’s bow, injecting
the lateral vermilion and central philtral vermilion sub-
units and not the Cupid’s bow apical will flatten its
curvature.
Philtral column zone injections are used to create more
central lip pout and anterior projection, and this effect can
be synergized with medial subvermilion zone injection.
Commisural zone injections are added when the cor-
ner of the mouth turns downward, and injections in this
zone, which is immediately below the commissure, el-
evate the corner of the mouth.
Another degree of complexity is added with injection
depth. Superficial injection depth in the dermis is often used

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A
B the aged patient; and (3) injections of the oral commis-
Figure 3. Patient’s lips before (A) and after (B) injection of
nonanimal-sourced stabilized hyaluronic acid gel (Restylane; Medicis
Aesthetic Inc, Scottsdale, Arizona) into the philtral, vermilion lateral,
vermilion Cupid’s bow apex, medial subvermilion, lateral subvermilion, and
lateral peristomal zones of the upper lip to create a more curved Cupid’s bow
and pouty lip with more anterior projection.
in the senile atrophic lip to efface vermilion notching. Deeper
injections are often placed at the junction of the orbicu-
laris oris muscle with the skin in the vermilion/white roll.
Deeper injections are also placed in the subvermilion and
peristomal zones in the superficial aspects of the orbicu-
laris oris muscle, as more superficial injections in the mu-
cosa alone often leaves visible lumps.
While there are hundreds (511) of subunit injection
combinations that can be performed, for demonstrative
purposes I will review 2. The combination that might be
used for a thin-lipped young patient with the goal of a
stylized, full, pouty lip with a more curved Cupid’s bow
would include the following: (1) injections in the sub-
vermilion lateral and peristomal lateral zones to add ver-
tical height, roundness, and fullness to the mucosal/red
lip at the junction of the mucosa and superficial orbicu-
laris oris muscular layer; (2) injections of the philtral col-
umn subunit in the mid dermis and the subvermilion me-
dial subunits in the superficial muscular layer (leaving
out the peristomal medial subunit) to pout out the lip
creating more anterior projection; and (3) injections of
vermilion lateral and vermilion Cupid’s bow apical zones
in the potential space deep to the vermilion/white roll
(leaving out the vermilion central philtral zone) to cre-
ate a more curved Cupid’s bow. In my practice I refer to
this as French lips as it is often seen in youthful runway
models (Figure 3).
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Another example is the thin senile lip, with an atro-
phic vermilion, lip notching/rhytids (lipstick bleed lines),
and down-turned oral commissure. The subvermilion re-
gion involutes, creating a concavity below the vermil-
ion. Here the patient might desire rejuvenation of the lip
and removal of rhytids for a subtle result. The combina-
tion of subunit injection would include the following: (1)
injections in the medial and lateral subvermilion and me-
dial and lateral peristomal subunits to add height, cor-
rect concavities, and add fullness to the mucosal/red lip
in the superficial muscular layer; (2) injections of lat-
eral, Cupid’s bow apical, and central philtral vermilion
zones equally in the more superficial dermis to mini-
mize lip notching and augment the white roll without
overemphasizing curvature that might look unnatural in
sure subunit in the deep dermis to elevate the corner of
the mouth.
In this series, the mean (SD) lip persistence of NASHA
gel was 4.9 (1.5) months. This correlates well with other
studies.16-18
Aside from transient erythema at the injection sites
and infrequent bruising, these patients were free of ad-
verse effects. European studies show satisfactory results
with NASHA gel used as a temporary soft-tissue ex-
pander.19-22 Erythema and mild induration are the most
common adverse effects reported to date and are tran-
sient. There is 1 report of arterial embolization23 and 3
reports of granulomatous foreign body reaction24 after in-
jection of hyaluronic acid.25,26 In my study, aside from
transient erythema at the injection sites and infrequent
bruising, these patients were free of adverse effects.
I presented my experience using a new classification
of lip anatomical zones to direct the injection of a NASHA
gel to augment and shape lips. This technique was met
with high patient satisfaction and no adverse effects.
Accepted for Publication: June 5, 2007.
Correspondence: Andrew A. Jacono, MD, The New
York Center for Facial Plastic Surgery, 900 Northern
Blvd, Ste 130, Great Neck, NY 11021 (drjacono
@newyorkfacialplasticsurgery.com).
Author Contributions: Dr Jacono had full access to all
the data in the study and takes responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
REFERENCES
1. Farkas LG, Kolar J. Anthropometrics and art in the aesthetics of women’s faces.
Clin Plast Surg. 1987;14(4):599-616.
2. Auger TA, Turley PK. The female soft tissue profile as presented in fashion maga-
zines in the 1900’s: a photographic analysis. Int J Adult Orthodon Orthognath
Surg. 1999;14(1):7-18.
3. Gonzalez-Ulloa M. The aging upper lip. In: Marchac D, Hueston JT, eds. Trans-
actions of the Sixth International Congress of Plastic and Reconstructive Sur-
gery. Paris, France: Masson; 1975:443-446.
4. de Benito J, Fernández-Sanza I. Galea and subgalea graft for lip augmentation
revision. Aesthetic Plast Surg. 1996;20(3):243-248.
5. Fanous N. Correction of thin lips: “lip lift.” Plast Reconstr Surg. 1984;74(1):
33-41.
6. Hinderer U. Aging of the upper lip: a new treatment technique. Aesthetic Plast
Surg. 1995;26(2):146-150.
WWW.ARCHFACIAL.COM
 7. Linder RM. Permanent lip augmentation employing polytetrafluoroethylene grafts.
Plast Reconstr Surg. 1992;90(6):1083-1092.
8. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77(6):990-994.
9. Tobin HA, Karas ND. Lip augmentation using an alloderm graft. J Oral Maxillo-
fac Surg. 1998;56(6):722-727.
10. Chajchir A, Benzaquen I. Fat-grafting injection for soft-tissue augmentation. Plast
Reconstr Surg. 1989;84(6):921-934.
11. Samiian MR. Lip augmentation for correction of thin lips. Plast Reconstr Surg.
1993;91(1):162-166.
12. Leaf N, Firouz JS. Lip augmentation with superficial musculoaponeurotic sys-
tem grafts: report of 103 cases. Plast Reconstr Surg. 2002;109(1):319-326.
13. Jacono AA, Quatela VC. Quantitative analysis of lip appearance after V-Y lip
augmentation. Arch Facial Plast Surg. 2004;6(3):172-177.
14. Olenius M. The first clinical study using a new biodegradable implant for the treat-
ment of lips, wrinkles, and folds. Aesthetic Plast Surg. 1998;22(2):97-101.
15. Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, Smith S. A randomized, double-
blind, multicenter comparison of the efficacy and tolerability of Restylane ver-
sus Zyplast for the correction of nasolabial folds. Dermatol Surg. 2003;29(6):
588-595.
16. Carruthers A, Carey W, De Lorenzi C, Remington K, Schacter D, Sapra S. Ran-
domized, double-blind comparison of the efficacy of two hyaluronic acid deriva-
tives, Restylane, Perlane and Hylaform, in the treatment of nasolabial folds. Der-
matol Surg. 2005;31(11, pt 2):1591-1598.
17. Godin MS, Majmundar MV, Chrzanowski DS, Dodson KM. Use of radiesse in com-
bination with Restylane for facial augmentation. Arch Facial Plast Surg. 2006;
8(2):92-97.
18. Bosniak S, Cantisano-Zilkha M, Glavas IP. Nonanimal stabilized hyaluronic acid
for lip augmentation and facial rhytid ablation. Arch Facial Plast Surg. 2004;
6(6):379-383.
19. Bosniak S, Cantisano-Zilkha M. Restylane hyaluronic acid gel for facial rejuve-
nation: a 4 1/2 year experience. J Cosmet Laser Ther. 2001;3:192-193.
20. Carruthers J, Carruthers A. A prospective, randomized, parallel group study ana-
lyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA,
Restylane) in combination compared with NASHA (Restylane) alone in severe
glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides
with a hyaluronic acid derivative compared with the derivative and BTX-A. Der-
matol Surg. 2003;29(8):802-809.
21. Pollack S. Some new injectable dermal filler materials: Hylaform, Restylane, and
Artecoll. J Cutan Med Surg. 1999;3(suppl 4):S27-S35.
22. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectable hyaluronic acid
gel for soft tissue augmentation: a clinical and histological study. Dermatol Surg.
1998;24(12):1317-1325.
23. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial embolization
caused by injection of hyaluronic acid (Restylane). Br J Dermatol. 2002;146
(5):928-929.
24. Fernández-Aceñero MJ, Zamora E, Borbujo J. Granulomatous foreign body re-
action against hyaluronic acid: report of a case after lip augmentation. Dermatol
Surg. 2003;29(12):1225-1226.
25. Hönig JF, Brink U, Korabiowska M. Severe granulomatous allergic tissue reac-
tion after hyaluronic acid injection in the treatment of facial lines and its surgical
correction. J Craniofac Surg. 2003;14(2):197-200.
26. Rongioletti F, Cattarini G, Sottofattori E, Rebora A. Granulomatous reaction after
intradermal injections of hyaluronic acid gel. Arch Dermatol. 2003;139(6):
815-816.

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