An Anatomy-driven Algorithm for Aesthetic Lip Enhancement: Integrating Structural and Volumetric Approaches

BACKGROUND: Aesthetic lip enhancement has traditionally been dominated by volumetric approaches, particularly hyaluronic acid fillers. However, lip aging involves both volumetric loss and structural changes, including elongation of the cutaneous upper lip (ergotrid), which cannot be adequately addressed with fillers alone. Despite the wide range of available techniques, no standardized algorithm currently guides treatment selection based on specific anatomical targets. OBJECTIVES: To propose and evaluate a novel, anatomy-driven therapeutic algorithm for aesthetic lip enhancement, integrating surgical and non-surgical techniques based on the distinction between structural and volumetric components. MATERIALS AND METHODS: A multicentric observational study was conducted over a 9-year period, including 168 patients undergoing aesthetic lip treatment. Patients were classified into four groups according to anatomical presentation: isolated volumetric deficiency (Type 1), isolated structural alteration (Type 2), combined structural and volumetric deficiency (Type 3), and secondary deformities (Type 4). Treatment selection was guided by the proposed algorithm, incorporating hyaluronic acid fillers, autologous fat grafting, lip implants, V-Y mucosal advancement flaps, and lip lift procedures. Outcomes were assessed through standardized photographic analysis, patient satisfaction (5-point Likert scale), and complication rates at a minimum follow-up of 12 months. RESULTS: A structural component was identified in 50% of patients, either isolated or combined. High levels of patient satisfaction were observed, with particularly evident aesthetic improvement in patients undergoing structural correction (Type 2) and combined approaches (Type 3). Combined treatments were performed in 36.9% of cases and resulted in superior aesthetic outcomes in patients with mixed deformities. The overall complication rate was 8.3%, all minor and self-limiting, with no major adverse events reported. CONCLUSIONS: The proposed algorithm provides a practical and reproducible framework for anatomy-based aesthetic lip treatment. By distinguishing between structural and volumetric targets and integrating complementary surgical and non-surgical techniques, this approach allows for more precise, individualized, and predictable outcomes. Combined surgical and volumetric strategies represent the modern standard for managing complex lip deformities. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .