#IFAAS faculty Dr Hyeonseob Byeon shares his exclusive video on lip enhancement using soft & reversible hyaluronic acid fillers.
The lips are not only an important part of the central facial triangle, but they also play an essential role in facial expression, articulation of speech, masticatory competence, maintaining oral seal and defining soft tissue boundaries for the teeth. Shape and thickness differs between the upper and lower lip, and varies significantly between individuals and ethnic groups.
When performing lip rejuvenation, reversible hyaluronic acid fillers pre-filled with lidocaine are the product of choice for most practitioners. The products he usually choose to use are:
When selecting a suitable filler for the lips, the following factors must be taken into consideration:
Longevity: it is important to advise the patient how long a product is expected to last for, and explain that this is not guaranteed in order to successfully manage their expectations
Crosslinking technology: relates to longevity and propensity to swell
Cost: patient needs to be aware of financial commitment
Company support: specific product knowledge and training/marketing is essential
Reversibility: ensures a safety net incase of vascular accident or other filler-associated complications; you should have an emergency kit including hyaluronidase on site
Strong clinical study evidence: ensures a safe, evidence-based choice
Previous patient experience of product: if a patient has had good clinical results with a certain product and is happy with it, do not use something else as they may be unhappy with the new product
Cannula or Needle?
The decision to use a cannula or a needle depends on the part of the lip that is being treated. As needles are thinner, they are best used to define the vermillion border, recreate the philtral columns, lift the oral commissure, volumise the lip in the sub vermillion area, efface oral rhytids and create lateral protrusions in the lower lip. Cannulas are best used in patients with thin lips where product needs to be placed behind the muscle; the rationale behind this decision is based on the position of the labial arteries, which usually reside behind the muscle.
Step-by-step Lip Enhancement Techniques
1) Visually assess the lip in 3D: i.e. the lateral and frontal view. This will give an idea of projection required. For an attractive lip, the upper lip should project around 2mm further than the lower lip.
2) Assess the smile: if the patient has a ‘gummy’ smile and the lip disappears upon smiling then consider botulinum toxin injections to soften the action of the lip elevators. It should be a deep injection, 1cm lateral to the lateral alar of the nose. If the patient has an active depressor anguli oris, contributing to a downturned mouth, also consider treating this muscle with botulinum toxin to prevent a downward pull of muscle on the corners of the mouth.
3) Consider the vermillion border: consider using low viscosity filler when treating the vermillion border. This can create a very sharp and well-defined demarcation by creating maximum light reflection without distorting the delicate lip architecture.
4) Cupid’s bow: Do not injecting the Cupid’s bow with filler. Instead injecting the Glogau-Klein point in the vermillion border. Injection directly into the Cupid’s bow may lead to a flattening of this delicate and desirable feature
5) Cannula use: use cannulas to place filler behind the muscle in thin, older lips. When it comes to cannula use, it is best to first volumise and then shape, which can take 3-4ml to achieve adequate support, which physician should perform over multiple visits. The patient must understand the progressive nature of restoring thin, aged lips and that treatment may take as long as 12-18 months. When it comes to size, please use a 25g cannula for lip treatment.
6) Everting upper lip: if the goal of treatment is to evert the upper lip, treat the vermillion border and the area 2mm below it (subvermillion). An amount of 0.4ml in total usually suffices but this can be patient dependent.
7) Treating ‘lipstick bleeds’: treat by injecting the vermillion border with a ‘firmer’ filler. This approach can be very effective and usually has the added benefit of everting the lip and defining the Cupid’s bow (Figure 4).
8) Increasing pout: if the patient requests a more defined pout, please mark out the boundary of the pout. This usually equates to the line drawn from the external nares. Filler is then placed inside the lines to accentuate the pout. Centrelines are also drawn to ensure symmetry.
9) Vermillion border treatment: when treating the vermillion border from its lateral aspect, the needle must be placed superficially. The superior labial artery runs along the vermilion border of the upper lip to the facial sagittal midline at a depth of 3mm.
10) Philtral column injection: injection of the philtral columns must also be superficial due to the position of the columellar vessels.
References: Lee Walker, "Lip Augmentation", Aesthetics Journal, 12 Sept 2016
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