Dr Sanjay Gheyi shares his approach to rejuvenating lips with hyaluronic acid and lasers
The rejuvenation of lips and the perioral area is of prime concern to many patients. The usual indications patients present to us with are loss of lip volume, perioral rhytids (many female patients complain their lipstick bleeds into these lines), smoker’s lines and downturned corners of the mouth. Although patients want a solution to these aesthetic concerns, many fear the risks of side effects, such as the ‘trout pout’ appearance, unnatural-looking results and the potential need for repeat treatments.
In this article, I shall explain my technique in treating lip concerns with hyaluronic acid (HA) dermal fillers and ablative lasers – these are the most commonly used treatments for lips and perioral rejuvenation in my clinic. In addition, I shall also explain how to achieve a successful aesthetic result and provide advice on how to avoid complications. The approach described works well for me but may not for other practitioners; it is perfectly acceptable that different practitioners use different techniques, however the main outcome in our field of medical aesthetics should always be patient satisfaction.
The ideal lip augmentation technique provides the longest period of efficacy, lowest complication rate, and best aesthetic result.1 In addition, a good treatment requires correct initial diagnosis. It is important that practitioners listen to the patient and determine what he or she desires at the outset. Our patients are often well informed and most will have an idea of what treatments and/or results they hope to achieve. Sometimes, however, they may not be aware of the intricacies of treatment, so their consultation should be taken as an opportunity for patient education. This will establish a valuable practitioner-patient relationship and avoid a mismatch between patient expectations and results achieved. If you are concerned that the aesthetic results may not reach your patient’s expectations, it is important to remember that you do not have to treat everyone who walks through your door – knowing when to say no is an important part of our job.
HA fillers have one great advantage that no other implantable material provides – reversibility with hyaluronidase.2 Various dermal fillers are available, however, in my opinion, as lips are very mobile, visible and have a vascular structure, there is no reason for using any non-HA injectable implant. Non-HA fillers such as calcium hydroxylapatite (CaHA), can be used for volume augmentation of nasolabial folds and marionette lines but, ideally, should not be used for lip augmentation. It has been suggested that this is due to CaHA’s high viscosity and elasticity, as well as being classified as an adjustable filler rather than being reversible like HA.3According to Emer and Sundaram, evidence-based and experiential consensus suggests its avoidance in highly mobile areas such as the lips, or in areas such as the periocular region where there may be an increased incidence of nodules.3
The debate on the pros and cons of using a sharp needle vs. a cannula has been discussed in great detail before. The advantage of a cannula is that there is supposed to be less risk of vascular injury.4 In my view, however, smaller cannulas are capable of vessel injury, especially in areas where tissue resistance to cannula passage is higher. In the perioral area and vermilion borders, the rhytids can be difficult to efface by using a blunt cannula. Use of cannula also requires more filler volume as the filler is usually deposited in a deeper plane due to less tissue resistance.4 A cannula is very useful for patients who are worried about bruising, swelling and recovery time and, from my experience, a 25 or 27g cannula works well for dermal filler injections. I have used an 18g cannula for lip injections but only at the time of full-facial fat transfer procedure, in which I inject fat to add a little volume to the lips. I do not use fat injections for lip augmentation as an isolated procedure as, in my opinion, harvesting fat is not cost effective when a syringe of filler is readily available and much cheaper. I prefer a 30g sharp needle for lip treatments and use 2cc of lignocaine with adrenaline, distributing it along 3-4 injection points along the junction of the lip and gingival mucosa (Figure 1). This provides profound analgesia and vasoconstriction to minimise risk of intravascular injection. Various facial and/or lip proportion analysis techniques and mathematical models have been proposed. I do not use these as, in my opinion, treating the lips is an artistic procedure and should not be based on pure science or mathematics. I prefer to do what suits each patient and what makes him or her happy, still taking into account the most appropriate method of treatment. Usually only 1-2cc of dermal filler volume is required unless there is more volume loss and the nasolabial folds and/or marionette lines are being treated at the same time. By using a sharp needle at the outer border of the vermilion, sometimes it is possible to see the filler run along the vermillion border and it is possible to treat the entire quarter or half of the length of lip from one injection point. I try to use minimum injection points where possible, as each injection point can increase your chances of causing a bruise. Commonly, I would inject the vermilion border, augment lip volume, attempt to efface perioral rhytids and support the angles of the mouth with 1-2 strands of filler material. Philtral columns can also be enhanced using linear threading.
A degree of swelling, redness, tenderness and bruising can be considered normal side effects of dermal filler injections and usually settle within a matter of days. A number of complications such as infections, fibrosis, granulomatous inflammation, haematoma, thromboembolism and product migration have been reported.5 The most feared complication is vascular compromise due to vascular compression or inadvertant intra-arterial injection.6 By following the measures listed below, I believe you can minimise the risk of filler complications, irrespective of where it is being injected. To do so, I advocate the following:6,7
Non-ablative lasers have a limited use, if any, in treatments of the lip and perioral area; mainly because we have better options available and results are often subtle and unpredictable. Vascular lasers are useful when patients present with a vascular abnormality or lesion. One such example would be venous lakes in the lips where long pulsed lasers can be used successfully (Figures 2 & 3). For skin rejuvenation, treatment of fine lines, wrinkles and skin textural improvement, ablative lasers are useful and erbium and CO2 lasers are commonly used. My choice is a CO2 laser because of the additional provision of skin tightening. CO2 laser can be used in fractional mode in light skin or darker skin types, such as patients of Asian or Mediterranean origin. Lighter skin types are suitable for a full ablative laser resurfacing.8 This, however, does require use of lip blocks and/or oral sedation and requires a longer period of recovery.8 Fully ablative CO2 laser resurfacing involves the removal of the entire epidermis and upper portion of the dermis, providing significant stimulation to dermal nerve fibres.8 Prior to the advent of ablative lasers, mechanical dermabrasion was a widely used treatment and provided excellent results. Laser ablation has, however, become a more widely used technique in recent times. A prospective study of the clinical efficacy of the 950 microsec dwell time CO2 laser, to that of a manual tumescent dermabrasion in the treatment of upper lip wrinkles showed that both are equally effective.9
Long-term histologic effects of the CO2 laser have been well documented. In a prospective study, biopsy specimens from the upper lip were taken preoperatively, then at six weeks, six months, and one year after CO2 laser resurfacing. Neocollagenesis
Non-ablative lasers have a limited use, if any, in treatments of the lip and perioral area; mainly because we have better options available and results are often subtle and unpredictable
began at six weeks and progressively increased at six months and one year.10 I have also personally observed this effect numerous times. An early follow-up appointment may not show outstanding results but, with time, results should improve.
With ablative lasers, it is important to treat the entire cosmetic unit rather than the isolated small areas to avoid lines of demarcation. It is imperative to know the settings of your device, as lasers made by different manufacturers have different energies, pulse durations, spacing and patterns. It is not a good idea to transfer settings of one device and use them on another, as they may not necessarily produce the same results. The best way to learn about laser resurfacing is through careful observation of tissue response, clinical endpoints and observing your patient’s results at follow-up appointments. The tissue’s response to the laser pulse may vary in different patients even though you’re using the same settings. This is due to the hydration levels of the patient’s skin as the target for C02 lasers is tissue water, and may be affected by use of local anaesthesia, either topical or by infiltration.11 For fully ablative CO2 laser resurfacing, a variety of post-operative wound care techniques has been devised.12 These are, broadly speaking, closed and open techniques and involve wiping the lasered char away. The open technique means that no dressings are used, while occlusive dressings are used for the closed technique. I personally tend not to wipe the char away, as it can act like a biological dressing and flakes off when the underlying skin has healed up.
In patients with prior history of herpes labialis, anti-viral prophylaxis is useful for filler injections or laser resurfacing.13 I do not prescribe antibiotics for fractionated resurfacing, but for full laser resurfacing I prescribe antibiotic, antifungal, anti-viral prophylaxis. Although widely used, the role of prophylactic antibiotics has been questioned.14 Adverse effects of laser resurfacing include pain, erythema, bacterial, viral or fungal infections, milia, pigment alterations such as post inflammatory hyperpigmentation (PIH), hyperpigmentation and/ or hypopigmentation. Overly aggressive treatments can result in scarring.15 It is very important to minimise sun exposure and use sunscreens in the post-operative period to minimise pigment issues.16 Hyperpigmentation can be transient and can be treated with use of hydroquinone,17but hypopigmentation can be very difficult or impossible to treat.18
With increasing age the length of the upper lip increases.19 Gravity not only causes sagging of the lower face and neck, it can elongate the upper lip too.19 Pumping the lip with more filler can make this condition worse and should be avoided. A lip-lift procedure, however, can restore the original length of the upper lip (Figure 4). This is a surgical procedure that can be done under local anaesthesia.19 Practitioners and journals have described a variety of treatments for perioral rejuvenation. These include; mesotherapy, carboxytherapy, skin needling and PRP. I often use botulinum toxin for treatment of dynamic rhytids, almost always in combination with other treatment modalities discussed above. From my experience, two to four units along lip borders and five to ten units of botulinum toxin injected along each depressor anguli oris can produce some nice results in terms of lifting the downturned lip corners and softening perioral lines. One of the benefits of working in a well-equipped clinic with a variety of devices is that I can use treatments that are likely to give the most visible results. The combination of PRP with other therapies is particularly interesting, with studies indicating it may play a role in reducing the downtime associated with laser resurfacing.20 In my opinion future studies should include controls, including incorporation of split-face comparisons, to reduce intersubject variability.
Each of the modalities presented has their unique advantages and disadvantages when used for lip rejuvenation. However, through proper assessment and a thorough consultation to establish our patients’ expectations, fears and tolerance to recovery periods, we can determine the best treatment or combination treatments for their concerns. Doing so should allow us to achieve successful lip rejuvenation and happy, satisfied patients.