Abstract
Background
Social media platforms, particularly Instagram appear to be influencing contemporary beauty standards, especially concerning lip enhancements. Understanding the prevalent lip types showcased can offer valuable insights into evolving aesthetic ideals to inform both patients and practitioners.
Objectives
This study aims to analyze lip types associated with minimally invasive lip enhancements on Instagram (Meta, Menlo Park, CA) and compare these findings with classifications from a patient clinic using the Lip Classification of Tubercles system.
Methods
A within-participants design was employed to examine 120 “before and after” images from 4 trending Instagram hashtags related to lip enhancements. Four expert examiners performed the classification, and interrater reliability was assessed. Data from a previous study involving patients from an aesthetic clinic (n = 214) were incorporated to compare the frequencies of lip types in the clinic and on Instagram.
Results
The interrater reliability for lip classification on Instagram was very good (Fleiss’ Kappa: pretreatment k = 0.817; posttreatment k = 0.837). The most common lip-type pretreatment was 1A, which dramatically shifted to Type 3A posttreatment. The comparison with the patient clinic revealed that although Type 1A was the most prevalent in both datasets, Instagram exhibited lower variability, with only 10 unique types identified pretreatment and a predominant Type 3A posttreatment.
Conclusions
The representations of lip enhancements on Instagram reflect a narrower range of lip types compared with clinical findings, including a dramatic shift toward a Type 3A lip shape. This standardization of beauty ideal highlights the need for further exploration of social media's influence on lip enhancement preferences and the associated risks, as well as how these trends shape patient expectations in aesthetic practices.
Level of Evidence: 4 (Diagnostic)
In recent years, social media platforms, particularly Instagram (Meta, Menlo Park, CA), have significantly influenced beauty standards and cosmetic trends, with a notable emphasis on lip enhancements. Because social media users express their preferences for specific aesthetic outcomes, understanding the most popular and prevalent lip types becomes increasingly important. Although a number of studies have previously described various lip classification systems, to our knowledge none have looked at the prevalence of different lip types.1-6 This study investigates various lip types through the lens of minimally invasive lip enhancements, utilizing the Lip Classification of Tubercles (LCT) system (Figures 1, 2).7 We incorporate data from a previous study (n = 214), which assessed the reliability of the LCT system in a clinical patient population and compare the frequency of different lip types with those presented on Instagram. By categorizing lip types based on tubercle morphology, this research aims to evaluate Instagram's impact on lip enhancement preferences while contrasting these findings with data from a patient clinic to highlight differences in lip-type prevalence and variability.
Figure 1.
The LCT system. Panels 1 to 4 show the upper lip pattern and A-D show the lower lip pattern with vertical lines added to divide the lip into thirds. With respect to the upper lip, (1) Type 1, shown in a 26-year-old female, represents a single large middle tubercle occupying the full mid-third; (2) Type 2, shown in a 35-year-old female, represents a small middle tubercle occupying less than the mid-third; (3) Type 3, shown in a 27 year-old female, has an inverted tubercle; and (4) Type 4, shown in a 53-year-old female, is flat. With respect to the lower lip, (A) Type A, shown in a 33-year-old female, is represented by a central indentation. (B) Type B, shown in a 31-year-old female, has no central indentation and is full but level. (C) Type C, shown in a 30-year-old female, has no central indentation and curves upward with more fullness than Type B. (D) Type D, shown in a 49-year-old female, is flat due to thinness or deflation from volume loss. This figure originally appeared within Harris et al,7 published by Oxford University Press under a CC BY-NC license agreement, which permits reproduction of the image with proper attribution to the original work.
Figure 2.
The LCT outlining the position of the tubercles for the upper lip (1-4) and lower lip (A-D) to form the patterns for the upper lip and lower lip. This figure was adapted from Harris et al,7 published by Oxford University Press under a CC BY-NC license agreement, which permits reproduction of the image with proper attribution to the original work.
METHODS
We employed a within-participants design to analyze a sample of 120 “before and after” images from 4 trending Instagram hashtags: “lip filler” (5.1 million posts), “lip injection” (2 million posts), “lip augmentation” (1.5 million posts), and “lip enhancement” (1.1 million posts) on August 31, 2024. The LCT system was utilized to categorize lip types (between September 2, 2024 and September 8, 2024) based on their morphological features. Each image was classified independently by 4 expert examiners (3 medical doctors and 1 dentist) to ensure a rigorous assessment. Our study was performed in adherence to the Declaration of Helsinki (1996), and in accordance with regional laws and good clinical practice for studies in human participants. To complement our analysis of the Instagram group (IGG), we incorporated data from our previous study (gathered between August 1, 2022 and October 29, 2022) that assessed the interrater reliability of the LCT system within a clinical population, referred to here as the clinical group (CG). The 4 experts (including a “lead” expert) were the same for both studies. We reanalyzed the data from our previous study to calculate the frequency of different lip types from the CG for comparative analysis with the frequency of lip types from Instagram data. Statistical methods included calculating Fleiss’ Kappa to determine interrater reliability (k < 0.2 = “poor”; 0.2-0.4 = “fair”; 0.4-0.6 = “moderate”; 0.6-0.8 = “good”; 0.8-1.0 = “very good”)8 and conducting a marginal homogeneity (MH) test to compare the distributions of lip categories before and after treatment (where P < .05 indicates a statistical significance and P > .05 indicates a nonsignificant result) for each expert separately across all images and for all experts together across images where 100% agreement was observed. A χ2 test was utilized to explore the association between the lead expert's lip classification and the agreement across other experts.
RESULTS
Lip Classification Pre- and Posttreatment in the Instagram Group
Fleiss’ Kappa was used to explore the interrater reliability between 4 experts for pre- and posttreatment classification ratings separately. The results indicated a very good and statistically significant agreement between expert judgments on lip-type pretreatment, κ = 0.817 (95% CI, 0.816-0.819), P < .001, and posttreatment, κ = 0.837 (95% CI, 0.836-0.839), P < .001. Furthermore, a MH test was applied to compare the distribution of lip categories between pre- and posttreatment for each expert. The findings showed a statistically significant change from pre- to posttreatment in distribution of lip categories for all experts with MH statistic ranging from 175.00 to 180.00, and P < .001 for all comparisons. The frequency analysis of pre- and posttreatment classification ratings for each expert separately revealed that the most prevalent lip-type pretreatment was 1A which gave the following figures for 120 images across 4 experts—nexpert1 = 83 (69.2%), nexpert2 = 88 (73.3%), nexpert3 = 83 (69.2%), and nexpert4 = 80 (66.7%). In contrast, the most common lip-type posttreatment was 3A, with the following figures across 4 experts—nexpert1 = 82 (68.3%), nexpert2 = 79 (65.8%), nexpert3 = 84 (70.0%), and nexpert4 = 77 (64.2%).
Additionally, a follow-up analysis was conducted on 92 images which yielded 100% agreement among experts pre- and posttreatment. An MH test result provided evidence of significant change in the most common lip categories from pre- to posttreatment, MH = 108.00, P < .001. Similarly, as in the analysis for each expert separately, the overall frequency analysis pretreatment indicated that the most prevalent lip type was 1A (n = 69, 75.0%), whereas the most common lip-type posttreatment was 3A (n = 66, 72.7%; Figures 2, 3).
Figure 3.
Bar chart of frequency of lip types pre- and posttreatment in IGG. IGG, Instagram Group.
Lip Classification in the Clinical Group
A study analyzing lip classification data from 214 patients was conducted to assess the agreement between expert judgments. Fleiss’ Kappa was used to measure the interrater reliability, revealing a good level of agreement that was statistically significant, κ = 0.774 (95% CI, 0.773-0.775), P < .001. The frequency analysis of lip classification performed by the lead expert and 3 other experts identified lip Type 1A as the most common among patients, followed by lip Type 2A and lip Type 3A (Table 1, Figure 4).
Table 1.
Frequency and Percentage of Lip Classification for the 3 Most Common Lip Types Across Experts in Patient Study
| Lip type | Lead expert | Expert 1 | Expert 2 | Expert 3 | ||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| 1A | 60.0 | 28.0 | 48.0 | 22.4 | 53.0 | 24.8 | 56.0 | 26.2 |
| 2A | 43.0 | 20.1 | 47.0 | 22.0 | 43.0 | 20.1 | 43.0 | 20.1 |
| 3A | 31.0 | 14.5 | 28.0 | 13.1 | 26.0 | 12.1 | 33.0 | 15.4 |
Figure 4.
Bar chart of frequencies of lip types in the CG by lead expert. CG, clinical group.
Additionally, the association between the objective classification of lip types by the lead expert and agreement (no/yes) across experts was explored using a χ2 test. The findings showed a statistically significant association between the variables, χ2(13) = 26.584, P = .014, with a large effect size, Cramer's V = 0.352. Descriptive analysis further showed that lip Type 1A had a higher agreement rate (73.3%) compared with disagreement (26.7%), whereas lip Type 4D exhibited more disagreement (53.8%) than agreement (48.2%).
Comparison of Lip Classification in the Instagram Group vs the Clinical Group
The pretreatment IGG findings were compared with those from the CG. It was discovered that the most common lip type in both was 1A. Furthermore, it was found that lip types on Instagram had lower variability, as only 10 unique lip types were reported by experts with Types 2C, 2D, 4A, 4B, 4C, and 4D absent. On the other hand, in the CG, only lip Types 1C and 4C were not present, with the rest reported. In the IGG, the prevalence of the most common lip Type 1A ranged from 66.7% to 73.3%; however, in the CG, the prevalence of lip Type 1A as determined by the lead expert who served as a reference standard, was only 28.0%, with other lip types, such as 2A and 3A also being fairly common at 21.1% and 14.5%, respectively.
DISCUSSION
The Influence of Instagram on Lip Enhancement Preferences
The findings suggest a notable influence of Instagram on popular lip enhancement preferences, showcasing a narrower range of lip types with a higher prevalence of Type 1A lips in the IGG before images (66.7%-73.3%) compared with the CG (22.4%-28%). Conversely, the after images on social media displayed a marked shift toward Type 3A lips, which were only the third most common in the CG (64.2%-70% vs 12.1%-15.4%). Although our study did not incorporate a specific lip fullness scale, we observed that nearly all Type 3A lips in the IGG after images appeared overfilled compared with the untreated lips in the CG (Figure 5).
Figure 5.
Digitally created lips simulating the commonly found Type 3A in the Instagram group. Image created using Adobe Express by Adobe Inc. (San Jose, CA).
These disparities underscore the influence of social media in shaping and reinforcing narrow beauty ideals that often diverge from more diverse clinical presentations. The predominance of Type 3A lips on social media may inadvertently marginalize the natural variety present in normal lip anatomy, leading aesthetic practitioners to encounter patients with unrealistic expectations shaped by these portrayals.
The Role of Practitioners in Managing Expectations
In response to these challenges, it becomes crucial for practitioners to engage in thorough consultations with patients, educating them about realistic outcomes while celebrating the diversity of lip aesthetics. This approach can ultimately improve patient satisfaction and reinforce the importance of individual anatomical differences in treatment planning. Additionally, aesthetic practitioners must remain vigilant regarding the increased risks associated with certain injection techniques popularized on social media and adjust their practices accordingly to prioritize patient safety.
The Risks Associated With Current Techniques
The process of converting lip types to an “ideal” Type 3A lip not only underscores diversity but is also associated with both physical and psychological risks.9,10 The lip filler injection technique of “tenting” and its variants, such as the “Russian lip” technique, involve injections close to the wet-dry border—dangerously close to the labial arteries in 60% of cases.9 The multiple “vertical” type injections (from the vicinity of the vermillion border to the wet-dry border) are not only associated with an increased risk of vascular adverse events, but also given the number of injections (up to 60 in 1 treatment) increase the risk of fibrosis, overfilling and filler spread beyond the borders (wet-dry border and vermillion border) into the wet mucosa (“mucosal” spread) or the cutaneous lip (“cutaneous” spread). Indeed, cutaneous lip filler spread is very commonly observed on Instagram in association with these techniques. Further complicating this landscape, there is concern that the results may negatively affect lip animation, a factor that is rarely showcased in social media portrayals. There is also a paucity of long-term results raising concerns about long-term effects and further unrealistic expectations among patients. Because individuals pursue aesthetic enhancement shaped by social media portrayals, there is the risk of homogenizing beauty standards that do not celebrate diverse lip shapes and features. This pressure can lead to an increased incidence of dissatisfaction among individuals whose natural features do not align with the dominant narratives presented online. Individuals may feel compelled to conform to unrealistic standards, potentially resulting in body image issues, anxiety, and/or depression. In a study exploring the motivations of 24 women for overfilling their lips, most described Instagram impacting perceived aesthetic norms.10 A process of “perception drift” was identified mediated by exposure to repetitive images of larger lips on social media.
Study Limitations
Our study, while comprehensive, does have several limitations. The reliance on images from the CG and IGG limits the generalizability of our findings due to sample size (n = 214 and n = 120, respectively) and selection which may not represent the larger diverse patient populations in the community (with respect to the CG), or Instagram (with respect to the IGG). The analysis focused on only 4 trending hashtags related to lip enhancement. This selective approach may overlook important trends or variations observed under other relevant hashtags. Although the study aims to assess the influence of Instagram on lip enhancement preferences, it may not consider other significant factors that contribute to these trends, such as celebrity endorsements, traditional media, or changes in beauty norms over time. The study's cross-sectional design assesses a current trend on Instagram; a longitudinal study would provide valuable insights into this trend and others over time. Although we assessed the lip types using the LCT system, we did not assess the differences in lip fullness. As mentioned above, the Type 3A lips in the IGG appeared commonly overfilled. A more formal assessment with a lip fullness scale would offer further insights into the popular lip type on Instagram. Finally, the study did not incorporate patient-centered measures, such as satisfaction with results or perceived changes in self-esteem, which are essential to gauge the efficacy and psychological impact of lip enhancements.
CONCLUSIONS
Our study highlights the profound impact of Instagram on shaping perceived beauty standards in lip enhancement. The stark disparity between the lip types commonly represented on social media vs those found within a patient clinic underscores a troubling trend toward a narrow definition of beauty dominated by a Type 3A lip. Practitioners must balance the aspiration inspired by platforms like Instagram with an ethical responsibility to promote realistic beauty standards that honor the uniqueness of each individual. Ultimately, the conversation surrounding lip enhancement should center on informed choices involving patient safety, individualized outcomes, and the recognition of the diverse beauty inherent in all lip types. Because social media continues to play a pivotal role in shaping perceptions of beauty, ongoing dialogue between practitioners, patients, and the broader community will be essential in ensuring that minimally invasive lip enhancements promote both aesthetic satisfaction alongside psychological and physical well-being.
Acknowledgments
During the preparation of this work, the authors used Adobe Express by Adobe Inc. (San Jose, CA) to digitally simulate the commonly found Type 3A lips in the Instagram group (Figure 5). After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article.
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