Aesthetics speaks to a panel of practitioners who share their top tips for successful rejuvenation of the perioral region
Our Panel:
ER: There are multiple factors involved: there is the intrinsic ageing that we all go through, leading to loss of collagen, hyaluronic acid (HA) and decreased tone in the skin. The underling muscle, which is predominantly the orbicularis oris, is going to slightly lose its tone and tightness contributing to loss of elasticity in the underlying tissues. You get loss of subcutaneous fat as well; again you lose that plumpness and support to the skin and as people age there is a decrease in the bony support. There are also extrinsic factors, so if people smoke, have a lot of UV exposure or use sunbeds, that really accelerates the ageing of the skin.1,2,3
JP: The perioral area has some of its own issues. The mandible itself is thinning with the ageing process, the density of the bone isn’t what it was in youth and that is going to have an impact on the bony support for the mandibular and perioral area. The bone supporting the teeth is also regressing, the teeth are becoming more unstable and you also may have tooth loss, which means that the structural support is missing. The way I explain ageing to my patients is that if you think of the structural bone support as a table and the skin as a table cloth, the table is getting smaller and the table cloth then doesn’t have the support underneath it to look as nice as it once did.1,2,3
DP: Mainly women who are middle-aged and older – I’d say the 40- plus age group and particularly those in their 50s and 60s. For lines around the perioral area it is weighted towards smokers or those who have a history of smoking – but there are also some who have deep static lines in the area and don’t have a history of smoking.
JC: My most common demographic is 40-plus, but for young people in the perioral area, I actually perform a lot of corrections. So many people are doing these treatments now and some aren’t doing it very well. Sometimes patients come in with an uneven lip, lumps and a heaviness and over-protrusion, created when the vermilion border is over-injected.
JC: Three things; firstly the associated buccal fat descent that is creating the marionette fold, the second is the perioral lip lines – created mostly in expression when pursing the lips through expression of the orbicularis oris, and the third would be patients wanting gentle enhancement.
ER: Most of my patients will complain of an aged, sad look to the perioral area, such as down-turned corners of the mouth, the nasolabial folds, the marionette area; they will also complain of thinning of the lips and barcode lines or smoker’s lines.
JC: Do a proper assessment and anatomical diagnosis. Practitioners need to be aware of the dental profile and arcade, the relationship of the teeth, the lips to the nose, and the chin. They need to be looking at the patient from both the frontal and profile view.
JP: Less is more! I think doing smaller treatment modalities but more of them is going to give a better and safer aesthetic outcome. You will have less risk of vascular compression if you aren’t using so much product.
DP: Don’t just look at the perioral area – see it as part of the whole face as, often, particularly in this area, it has become such a focus in the patient’s eyes that it is easy to zoom in and focus on this with them. We have a lot of options for this area, find a nice treatment combination, which is appropriate for that person, based on their wishes and what their expectations are.
JP: The lips thin as we age. Patients often report that their top lip completely disappears when they do a big smile, so to address this, it is important that we don’t lose symmetry; the top lip to bottom lip should be a 1:1:6 ratio. I would use Restylane Kysse, as it’s a cohesive product but also has projection.
JC: It depends on what the patient is trying to achieve, their own perceptions of their proportions and their profile. I look at the patient in expression – kissing, smiling. If they need an increase in their lip height then I’ll consider treating the vermilion border; if they have a flatter cupid’s bow, then I’d inject that; and if it’s just a general lip fullness that they request then I would inject the pink body of the lip. I’d use Juvéderm Ultra Smile or Volbella in the perioral area because they are very cohesive.
ER: You are assessing the relationship of the mandible and the maxilla – consider the symmetry and proportions of the lip with respect to the face and be cautious of the patient’s profile. To replace the loss of true volume within the vermilion, I will use Belotero Intense and a 25G 1.5 inch cannula and will insert the product in the subcutaneous plain, which is the safest way of injecting the product subcutaneously with regards to the risk of injecting the superior labial artery. Another product that I find makes a difference is Profhilo – it can regenerate the tissues and aims to improve the quality of the overlying dermis and the epidermis. It is a very nice treatment that gets a really natural rejuvenation of the marionette lines as well.
ER: You need to know what has caused the lines and make a proper diagnosis to determine whether they have just genetically inherited the lines, whether they smoked or continue to smoke, use vapourisers, or are real sun worshippers, which will all encourage perioral lines to form. If they currently do, they are not good candidates for treatment.
JC: It depends on the underlying diagnosis, some patients need support around the vermilion border to get good results; I’d do a small injection into the vermilion border to support that. If it’s just early lines, I’d get the patients to express and purse their lips and do micro injections into the line itself with Juvéderm Ultra 2 or Volbella.
DP: There are lots of options depending on the severity. If it’s very early and there are a lot of dynamic lines then botulinum toxin A may prevent them forming. I also might use the Needle Shaping/ Vibrance device, which triggers collagenases and production of elastic fibres and will give subtle improvement to those early lines. Once they have static lines, if they want a quick fix, I’d use the blanching technique with Belotero Soft. Skin resurfacing by remodeling the skin would give them longer improvement and the type would depend on the patient. My options are fractional ablative laser, I use iPixel; vertical microneedling such as Dermapen, or peels – I use Enerpeel MA because they have a specific peel for the perioral area. Soft surgery is also an option – Plexr is good for working on the deep static lines that are already there, you use it by treating the area immediately adjacent to the line and one or two treatments will give you really good results.
Figure 1: Patient before and immediately after 1ml of Belotero Balance, 1ml of Volume and 1ml of Intense, treated at ACE 2017. Images courtesy of Dr Emma Ravichandran.
JP: We are moving more away from treating the individual nasolabial folds and instead we are augmenting areas to give you lift in the mid-face, which again will correct areas of volume loss further down the face without adding weight to the lower face.
ER: You need to know what’s caused the nasolabial fold – the nasolabial fat compartment is probably the last fat compartment to lose fat in the face and most of the descent comes from loss of the mid and lateral cheek fat compartments so they need to be addressed first. We also get widening of the nasal aperture as we age, loss of bone, a widening of the nose and deepening in the alar triangle. Often, it’s the shadow in the triangle that gives the impression that the nasolabial line is bigger than it is. If we lift and push that triangle forward with a bolus of filler we reduce the shadow, impacting on that depth or the apparent depth of the nasolabial fold.
JC: Most patients presenting with a marionette fold usually have some degree of descent in the mid-face – so assess the mid-face and see if it needs treating, adopting an indirect approach to treatment. If the patient wants a direct approach, I tell them the results won’t be as good, but I will treat the marionette fold directly.
DP: My approach would be to use a simple HA filler – Belotero Volume or Intense – and I would put it in and around the problem areas and follow the principals of not just filling a line, and certainly not just filling a fold, but replacing the support around the area giving them a lift.
ER: It’s important to have adequate support for the lower and upper lip and ensure that there is a nice blend from the cheek into the chin area – you don’t want to overfill. Choose the right product that has the right level elasticity, plasticity and cohesiveness so that it doesn’t migrate and will move on animation. You want to place it subcutaneously using a cannula to minimise the risk of bruising – it’s about pushing the marionette area forward so there is a nice colour refraction.
JC: It starts with a diagnosis and medical history, followed by an assessment. Is the skin dehydrated, oily, rough and dull? Is there increased pore size? In office, I love Juvéderm Volite because we can improve skin texture, elasticity and hydration with a single session. I also use different strengths of TCA chemical peels for skin texture improvement. I find that they offer an enhanced smoothness that is difficult to achieve with other modalities.
JP: I might consider a laser peel for rejuvenating the skin to stimulate collagen production and tightening pore size; it’s important that we utilise different modalities for treatment because there are so many treatment options which work in harmony to give the best outcome. You can also consider Restylane Skin Boosters to add hydration in the area of concern for patients, to give an improvement around the perioral area, especially for acne scarring as we know the chin especially can be affected.
DP: I find chemical peel and fractional ablative laser treatments give very minimal downtime of two to three days. They have really fantastic results, addressing skin texture, pigmentation and even some of the vascular changes you get with ageing and sun damage.
ER: Before other treatments like IPL, laser or peels, I would get the patient onto a good skin health programme for about two to four weeks. We would then introduce maybe a combination of either a hydroquinone product, a non-hydroquinone product or a retinol product, in order to even the texture and to try to improve any pigmentation.
DP: Skincare at home is important. My top ingredients, especially if the patient has lines, are retinol, vitamin C and epidermal growth factor (EGF) – retinol is in the vitamin A family and has been proven to increase fibroblast activation leading to collagen production. We have three key brands in clinic: Tebiskin, Image Skincare and AlumierMD, which I have recently introduced as there is some really advanced science in their range.
JP: I would bring a patient into the clinic for a Visia scan to analyse their skin quality and I would likely get them on to vitamin A to stimulate cell renewal and to bring the life back to dull skin – we use Environ because it allows for a step-up process with different levels of vitamin A. It’s also important to educate our patients on the importance of SPF usage because the SPF prevents more pigmentation issues which are going to give a further ageing effect.
JC: Prescribed skincare is my go-to for long-term maintenance. I use the ZO range extensively in my clinic and I advocate the use of exfoliators, salicylic acid pads, vitamin C and retinol as the cornerstones for textural-related concerns.
Figure 2: Patient before and two weeks after 1ml of Belotero Intense. Images courtesy of Dr Emma Ravichandran.
ER: It’s an incredibly vascular area so there is a high risk of haematoma, bruising, and swelling. It’s important to minimise the trauma to the tissues during product placement. The other risks are vascular occlusions, risk of product being placed into the superior labial or inferior labial artery, which can have catastrophic consequences for patients, so using a cannula is going to minimise the risk of intravascular injections.
JC: Knowledge of vascular compromise is very important, the superior and the inferior labial arteries; be very mindful what layer you are injecting in and I think you should always check with aspiration.
JP: Bruising and swelling are two things that are common in the perioral area as it’s very vascular. It is really important to explain the risks of vascular occlusion and necrosis. All risks need to be discussed with the patient before they can give an informed consent to treatment. There is also risk of hyper- and hypo-pigmentation when resurfacing with lasers.
DP: You need to be aware of the potential variations of anatomy from human to human – there are some good studies that suggest that there is quite a lot of variation in the area so you may think ‘there is an artery here’ but actually, it’s somewhere else.
DP: Really try and identify the patient’s expectations and give them the real picture of the results that can be achieved. The most common request I get asked when treating the lips is to get rid of the deep lines – I tell patients that you’re not going to get rid of them, you’re going to soften them, and it’s important that they understand that.
JC: Don’t inject large amounts inappropriately – there is a lot of over injecting going on and that damages our specialty because it makes people think that it’s what the lips should look like.
ER: Make sure the function of the lips are kept – coming from a dental background, I am very concerned with maintaining the integrity and functionality of the lips – there seems to be a real desire to make lips look sexy by having a space in the middle, but they are designed to close the mouth and to keep the teeth healthy.
The application of pigment into the skin can also enhance the natural appearance of the lip. Laura Kay, a semi-permanent makeup specialist who runs her own training academy, says, “As people get older, unfortunately, the natural lip line tends to age and fade and they lose the definition and fullness here. Semi-permanent makeup gives you definition in the lip line, which can create the appearance of more volume.”
When performing the treatment, Kay says, “I like to stay on the natural lip line and I like to do a lip blush, which is a lip line that is blended into the lips so you look like you have a wash of colour as well as definition. I personally don’t like doing the lip line on its own as I think it looks quite false.” If a patient wants more volume in the lip itself, she says dermal filler can be used in combination, “I have relationships with quite a few practitioners that either inject the lips first and then wait six weeks for it to settle and then I will do the permanent makeup, or I will do the permanent makeup first – so it can work hand-in-hand together quite well.”
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