Indications
Indications
Aging results in progressive generalized perioral sagging, lip deflation, anterior mandible rotation in males, posteroinferior mandibular rotation in females, downturning of the corners of the mouth, and maxillary retrusion resulting in posterior upper lip and nasolabial fold positioning.92 Moreover, aging causes philtral elongation and flattening, decrease in lip height, and increase in intercommissural distance.93 The perioral region is a highly dynamic area that is optimally treated with HA and BTX-A to reduce HA degradation by attenuating muscle contraction. A clinical trial of 90 female patients showed BTX-A and 24-mg/mL cohesive HA are effective and safe treatments either alone or in combination to rejuvenate the lower face with superiority demonstrated for combination therapy compared to either on its own.94
The injector should keep in mind normal proportions and anatomy when correcting the lip and perioral area. The philtral columns are located just inside the peaks of Cupid’s bow.89 In addition, Cupid’s bow is in the center of the two lower lip tubercles. The ideal lip length is such that the red vermillion body show is found between two vertical lines drawn down from the medial iris border or, in individuals with greater lower facial width, the medial pupil. The ideal ratio between the upper and lower lip vermillion body show is 1:1.618 (Phi) for Caucasian white patients and closer to 1:1 for all other races.89 The red vermillion lip height should be more prominent medially with tapering and minimal projection in the lateral third of the upper and lower lips.
The ideal youthful feminine lower lip should be fuller, but the upper lip should project more on profile by 1 to 2 mm.89 Medial one-third shadowing inferior to the lower lip is typical due to mild lip eversion caused by the two tubercles. Age-related volume loss in the perioral region causes shadowing to extend beyond the medial third of the lower lip.
Augmentation of the vermillion and cutaneous lips can ameliorate volume loss due to bony and soft-tissue loss. Correction should also center on restoring the natural curves of the tubercle, cupid’s bow peaks, and philtral crests. Smoker’s lines can be treated conservatively with BTX.
Fillers Soft and malleable fillers are recommended in order to maintain natural contours and movements. HA safety and effectiveness have been demonstrated in double-blind clinical trials for Juvéderm Ultra XC, small-gel particle HA (Restylane),96–98 and 24- mg/mL cohesive HA.94 Juvederm Volbella was noninferior to Restylane-L at 3 months in a clinical trial of 280 subjects.99
Injections are performed slowly with either blunt cannulas (1½ in, 27 or 25 gauge) or needle injections (30 gauge or smaller). A clinical study showed less bruising, ecchymosis, pain, and faster recovery with blunt cannula when compared to needle injections.100
The cutaneous lip is approached differently from the vermillion lip. Filler is best placed in the subcutaneous layer and above the orbicularis oris muscle to volumize the cutaneous lip (through threading, cross-hatching, or fanning); in the subdermal layer to correct the philtral crests and trace perioral rhytides (through threading or microaliquots); and in the submucosal layer for the vermillion mucosal lip (through microaliquots). This helps to avoid intravascular injection in the superior labial artery, which runs between the orbicularis oris muscle layer and the mucosa, and inferior orbicularis oris muscle running between the orbicularis oris muscle and the lip depressors.101
Techniques for cutaneous lip needle injections can include threading, fanning, and cross-hatching. Anterograde threading can theoretically reduce injection complications in that filler can delicately dissect tissue in front of the sharp needle. Blunt cannulas, through fanning or threading, can place fillers through an entry point placed approximately 2 cm lateral to the oral commissure. The vermillion mucosal lip can be approached through blunt cannula microaliquots using the same entry points or points placed on the vermillion body just medial to the lateral commissures; however, intramucosal or cutaneous lip white roll serial puncture needle injections might provide more precision in filler placement.
A global consensus opinion on the combined use of HA and BTX-A suggested
superficial Vycross, Hylacross, or dilution–reconstitution of Hylacross HA for perioral rhytides, and submucosal implantation of superficial Vycross or Hylacross for the lips. In addition, same-session and sequential treatment were both considered viable options for combination treatment of the lips and perioral region, jawline, and neck.27
Botulinum toxin The global aesthetics consensus recommends an equivalent total of 1 to 5 units of intradermal onabotulinumtoxin A injected over two to five injection sites per side split between the upper and lower lips with 0.5 to 1 unit per injection point.