Treating Lips

Introduction

A lot of patients resort to aesthetic medicine to rejuvenate the appearance of their lips and the perioral area. These patients are usually presented with aging signs like perioral rhytids (also known as lipstick lines whereby the lipstick tends to bleed into those lines), loss of lip volume, smoker’s lines, and downturned corners of the mouth. Though aesthetic procedures are famed for the efficacy, patients are still wary of these procedures due to the risks of undesirable side effects such as ‘trout pout’ appearance and potential need for repeated treatments. This article will explain in detail the two most used aesthetic procedures to augment and rejuvenate the lips which are hyaluronic acid-based filler injections and ablative lasers. This article will also explain the appropriate ways to deliver successful aesthetic outcomes to patients while avoiding health complications.

Patient analysis

The ideal lip augmentation technique does not only deliver the best aesthetic results, it is also capable of providing longest period of efficacy at the lowest rate of health complications. [1] However, successful treatment sessions are only possible with correct initial diagnoses. Patients’ preference must be taken into consideration so that they will be satisfied with the end results. While most patients may have a general understanding about the treatment and/or the aesthetic outcomes they hope to achieve, many are unaware of the workings of a treatment session. Hence, the pre-procedural consultation session should be used as an opportunity for patient education. It will also help to establish a strong practitioner-patient relationship and avoid mismatch between patient expectations and aesthetic outcomes attained.

Lip treatment using hyaluronic acid-based dermal fillers

Though there is a great variety of filler material available, one of the widely used types of dermal filler is hyaluronic acid. Compared to other implantable materials, hyaluronic acid-based fillers can be easily dissolved using hyaluronidase. [2] It is best to use hyaluronic acid-based implants to augment the lips since the lips are visible, and highly movable with a complex vascular structure. Other filler materials like calcium hydroxylapatite (CaHA) should be used to correct facial creases such as marionette lines and nasogenian furrows, instead of treating the lips. This is because CaHA filler falls under the adjustable filler category due to its high elasticity and viscosity features. [3] According to Emer and Sundaram, it is best to avoid injecting areas of high movement like the lips with CaHA-based fillers; failure to do will only result in increased incidence of nodules. [3]

Tools and techniques

The two most widely used tools for injecting aesthetic implants are sharp needle and cannula. One of the biggest advantages of cannula is that it is thought to pose lesser risk of vascular injury. [4] Unfortunately, smaller cannulas are still capable of damaging the blood vessels, especially in areas where tissue resistance to cannula insertion is higher. Not only that, erasing rhytids in the perioral area and vermilion borders can be difficult if a blunt cannula is used. Physicians may also end up injecting more filler volume when a cannula is used as the injected implant tend to be deposited deep into the skin layers. [4] A cannula is ideal for patients who are worried about developing unappealing post-procedural side effects such as swelling, bruising, and long recovery time. A 25 G or 27 G cannula is best suited for dermal filler injections. While smaller gauge cannulas (18 G) can be used for lip injections, they should only be used during full-facial fat transfer procedure instead of an isolated procedure. This is because extracting fat tissues to just augment the lips is not cost-efficient, especially when syringes pre-filled with filler material are readily available on the market. In order to deliver significant pain-numbing and vasoconstricting effects as well as to minimize the risk of intravascular injections, physicians are encouraged to use a 30 G sharp needle and 2 cc lignocaine with adrenaline during lip augmentation procedure. The filler gel should then be injected uniformly in a series of three to four injection points along the junction of the lip and gingival mucosa. Though there are numerous mathematical models and facial and/or lip proportion analysis techniques available as treatment guides, lip augmentation procedure actually requires an artistic touch, while taking into account patients’ preferences. Generally, patients require 1 to 2 cc of soft tissue implant volume for adequate lip correction, unless there is a significant volume deficit present, or other facial wrinkles (e.g., marionette lines, nasolabial folds, etc.) are treated at the same time. Sometimes the filler can be visibly seen along the vermillion border when a sharp needle is used at the outer border of the vermilion. Since it is also possible to treat the entire quarter or half of the length of lip from only one injection point, physicians are advised to use the minimum number of injection points whenever possible to reduce patients’ risk of developing bruises. Using just one to two strands of injectable gel, experienced aestheticians may not only augment the lip volume, they can also inject the vermilion border, soften the appearance of perioral rhytids, and support the angles of the mouth. Linear threading method can also be used to enhance the philtra columns for a well-sculpted pair of lips.

Complications of dermal fillers injections

Despite its efficacy, dermal filler injections are not without its fair share of complications. Most often than not, patients will experience normal side effects like redness, tenderness, swelling, and bruising, which should abate within a couple of days. Other more serious complications of soft tissue filler implantations like product migration, hematoma, fibrosis, thromboembolism, granulomatous inflammation, and infection have been reported by patients. [5] However, the most serious health complication is vascular compromise caused by accidental intravascular injection of filler gel or vascular compression. [6] In order to reduce the risk of filler complications, regardless of treatment area, physicians are strongly advised to do the following. [6, 7]

1. Apply local anesthetic agent with adrenaline.
2. Aspirate before injecting to prevent intravascular placement of filler.
3. Use a blunt cannula whenever possible.
4. Administer the filler with low injection pressure in small aliquots.
5. Observe carefully for any signs of transient blanching. Usually, vascular compromise is preceded by transient blanching of skin, which may occur at the injection site, or even at a point distant from the initial treatment area.
6. As part of emergency response plan, keep hyaluronidase nearby.  

Another undesirable effect of dermal filler injection is poor aesthetic result, which will result in unsatisfied patients.  make patients be unsatisfied with the procedure. Physicians are encouraged to do the following.

1. Do not overcorrect and overfill a treatment area.
2. Choose filler gel that is made of fine hyaluronic acid molecules instead of large particle fillers to augment the lips to ensure that the lips remain soft.
3. Maintain the facial balance and harmony by also treating other perioral regions affected by volume deficit, instead of solely correcting the lips.  

Lip treatment using laser

Aesthetic imperfections in the lip and perioral regions can be treated using non-ablative laser therapy, though there are other better treatment methods available which can deliver significant and effective results. Vascular laser method is best reserved for treating vascular abnormality or lesion. Venous lakes — also known as phlebectasis — in the lips can be successfully treated using long pulsed lasers. Besides that, undesirable aging signs of the skin such as rough skin texture, fine lines, and wrinkles can be corrected using ablative lasers, especially via erbium CO2 lasers. The former is an exceptionally good choice of skin rejuvenating treatment as it also helps to tighten the skin. CO2 laser can be adjusted into fractional or pixilated mode in order to treat patients with light or dark skin types, like patients of Asian or Mediterranean descent. On the other hand, full ablative laser resurfacing is suitable for patients with lighter skin tones. [8] However, this treatment modality requires the usage of lip blocks and/or oral sedation since it involves removing the entire epidermis and upper portion of the dermis layer to significantly stimulate the dermal nerve fibers. [8] Following the treatment session, patients may require a longer downtime. Though mechanical dermabrasion was widely used in the past, laser ablation therapy is now the preferred treatment method in the field of aesthetic medicine due to its superior effectiveness. That being said, a prospective clinical research done to compare the efficacy of 950 microsecond dwell time CO2 laser and manual tumescent dermabrasion in the treatment of upper lip wrinkles demonstrated that both methods are equally effective. [9]

The long-term histologic effects of CO2 laser treatment have been well documented in various prospective studies. For example, biopsy specimens taken from the upper lip at four different periods of time during CO2 laser resurfacing session (e.g., pre-procedure, at six weeks, at six months, and one year after the procedure) evidenced that neocollagenesis — the growth of new collagen fibers — begins at the sixth week and progressively increases at six months and one-year marks. [10] Practitioners may not be able to observe significant outcomes soon after the treatment session, but with enough time, skin improvements will be significantly noticeable. It is imperative that the ablative laser therapy is performed on an entire cosmetic unit area, instead of only treating small and isolated areas which prevents the appearance of demarcation lines. Another important factor that must be considered by physicians is the device setting as laser manufactured by different companies come with different energies, patterns, spacing, and pulse durations. These lasers may deliver aesthetic results of varying degrees, and hence, the setting for one device should not be used on another device. Physicians can learn in depth about laser resurfacing by carefully observing the tissue response, clinical endpoints, and assessing patients’ results at follow-up sessions. The effects of laser pulse on tissues and the resulting responses vary on an individual basis. For instance, since the CO2 laser targets tissue water, the hydration level of skin plays an important role in determining the post-procedural results. In addition to hydration status, use of local pain numbing agent, either topical or by infiltration, also affects the tissue response. [11] After patients have been treated with fully ablative CO2 laser resurfacing, physicians can make use of various post-operative wound care methods to encourage fast skin recovery once the lasered char had been wiped away. [12] These wound care techniques are divided into two main categories which are closed and open techniques. While the former involves the usage of occlusive dressings, the latter simply refers to when no dressings are used. Some physicians prefer not to wipe the char away as it acts as a biological dressing, which will eventually flake off when the underlying skin heals.

Complications of laser

To prevent the reactivation of herpes labialis (cold sore) infection, patients with history of this disorder can be prescribed with anti-viral prophylaxis when they are treated using dermal filler injections or laser resurfacing. [13] While fractionated skin resurfacing treatment may not require antibiotic prescription, patients who are treated with full laser resurfacing therapy should be prescribed with antibiotic, antifungal, anti-viral prophylaxis. The usage of prophylaxis antibiotics had been criticized. [14] Patients may experience the following adverse effects after undergoing laser resurfacing treatment.

1. Pain
2. Redness
3. Milia
4. Post inflammatory hyperpigmentation (PIH)
5. Hypopigmentation
6. Hyperpigmentation
7. Infections caused by bacteria, virus, or fungal.

Besides the reactions listed above, patients may also develop scarring if they are subjected to overly aggressive treatments. [15] They must be educated to follow important aftercare methods during the post-operative period such as minimizing exposure to sunlight and applying good quality sunscreens in order to reduce the risk of pigment alterations. [16] While hyperpigmentation is temporary in nature and is relatively easier to treat using hydroquinone, hypopigmentation can be quite difficult to manage. [17, 18]

Other treatment methods

Both dermal filler injection and laser therapy work ideally to get rid of perioral wrinkles and other perioral aesthetic imperfections. Administration of soft tissue implants into elongated upper lip is not advisable. Elongated upper lip happens when gravity and biological aging process cause the skin on the lower face and neck region to sag. This condition can be effectively reversed, and the original length of the upper lip can be restored via lip-lift procedure, a surgical procedure that requires local anesthesia. [19] Besides lip-lift therapy, healthcare practitioners and patients can choose other suitable perioral rejuvenation treatments, which include carboxytherapy, skin needling and Platelet Rich Plasma (PRP) injections. Not only, dynamic perioral rhytids that appear during muscle movements can always be treated via botulinum toxin injections, together with the treatment approaches listed above. To optimally lift downturned lip corners and erase perioral lines, aestheticians can inject two to four units of reconstituted botulinum toxin solution into each depressor anguli oris muscle. Practitioners who specialize in aesthetic medicine should strive to have or work in a well-equipped clinic with variety of devices so that the most suitable treatment (or combination of treatments) can be easily performed on patients. For example, combining PRP with other lip rejuvenating modalities is very effective, with various studies indicating that it may help to shorten the recovery time associated with laser resurfacing. [20]

Summary

The lip augmenting and rejuvenating treatments explained above have their own advantages and disadvantages. These treatments can only be performed after patients’ conditions have been thoroughly assessed during the consultation session. A complete assessment ensures that both the practitioners and the patients share the same treatment goals; and that patients’ expectations, fears, and tolerance to recovery periods are addressed. Doing so will result in successful lip rejuvenation and satisfied patients.  

References

1. San Miguel Moragas J et al, ‘Systematic review of “filling” procedures for lip augmentation regarding types of material, outcomes and complications’, J Craniomaxillofac Surg, 43 (2015) p.883-906.
2. Pierre A, Levy PM, ‘Hyaluronidase offers an efficacious treatment for inaesthetic hyaluronic acid overcorrection’, J Cosmet Dermatol, 6 (2007), pp.159-62.
3. Emer J, Sundaram H, ‘Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidencebased review and discussion of current concepts’, J Drugs Dermatol, 12 (2013) pp.1345-54.
4. DeJoseph LM, ‘Cannulas for facial filler placement’, Facial Plast Surg Clin North AM, 2 (2012), pp.215-20.
5. Grippaudo FR et al, ‘Diagnosis and management of dermal filler complications in the perioral region’, J Cosmet Laser Ther, 16 (2014), pp.246-52.
6. Beleznay K et al, ‘Vascular Compromise from Soft Tissue Augmentation’, The Journal of Clinical and Aesthetic Dermatology, 7 (2014), pp.37-43.
7. Kim DW et al, ‘Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management’, J Plast Reconstr Aesthet Surg, 12 (2011), pp.1590-5.
8. Gaitan S, Markus R, ‘Anesthesia methods in laser resurfacing’, Semin Plast Surg, 3 (2012), pp.117-24.
9. Gin et al, ‘Treatment of upper lip wrinkles: a comparison of the 950 microsec dwell time carbon dioxide laser to manual tumescent dermabrasion’, Dermatol Surg, 6 (1999), pp.473-4.
10. Rosenberg GJ et al, ‘Long-term histologic effects of the CO2 laser’, Plast Reconstr Surg, 7 (1999) pp.2245-6.
11. Goldman MP, ‘The use of hydroquinone with facial laser resurfacing’, J Cutan Laser Ther, 2 (2000) pp.73-7.
12. Duplechain JK, ‘Novel post-treatment care after ablative and fractional C02 laser resurfacing’, J Cosmet Laser Ther, 16 (2014), p.77-82.
13. Gazzola R, ‘Herpes virus outbreaks after dermal hyaluronic acid filler injections’, Aesthet Surg J, 6 (2012), pp.770-2.
14. Walia S, Alster TS, ‘Cutaneous C02 laser resurfacing infection rate with and without prophylactic antibiotics’, Dermatol Surg, 11 (1999) P.857-61.
15. Metelitsa A, Alster TS, ‘Fractional laser skin resurfacing treatment complications: a review’, Dermatol Surg, 3 (2010), pp.299-306.
16. Wanitphakdeedecha R, ‘The use of sunscreen starting on the first day after ablative fractional skin resurfacing’, J Eur Acad Dermatol Venereol, 11 (2014), pp.1522-8
17. Goldman MP, ‘The use of hydroquinone with facial laser resurfacing’, J Cutan Laser Ther, 2 (2000), pp.73-7.
18. Dover JS et al, ‘Lasers in skin resurfacing’, Semin Cutan Med Surg, 4 (2000), pp.207-20.
19. Waldman SR, ‘The subnasal lift’, Facial Plast Surg Clin North Am, 4 (2007), pp.513-6.
20. Leo MS et al, ‘Systematic review of the use of platelet-rich plasma in aesthetic dermatology’, J Cosmet Dermatol, 23 (2015).