Introduction

Many patients turn to aesthetic medicine to rejuvenate the appearance of their lips and the perioral area. These patients are usually presented with aging signs such as perioral rhytids (also known as lipstick lines), loss of lip volume, smoker’s lines, and downturned corners of the mouth.

Though aesthetic procedures are famed for the efficacy, patients are sometimes wary of these procedures due to the risks of undesirable side effects such as ‘trout pout’ appearance and potential need for repeated treatments, to achieve the desired look. This article will explain in detail the two most common aesthetic procedures to augment and rejuvenate the lips — hyaluronic acid-based filler injections and ablative lasers. This article will also discuss the appropriate ways to deliver successful aesthetic outcomes to patients while avoiding health complications.

Patient analysis

The ideal lip augmentation technique not only delivers the best aesthetic results, it is also capable of providing the longest period of efficacy at the lowest rate of health complications. Successful treatment sessions with optimal outcomes are only possible with correct initial diagnoses. Patients’ preference must also be taken into consideration so they will be satisfied with the results. While most patients may have a general understanding about the treatment and the aesthetic outcomes they hope to achieve, many are unaware of the full workings of a treatment session. Therefore, 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 mis-alignment between patient expectations and aesthetic outcomes.

Lip treatment using hyaluronic acid-based dermal fillers

Though there are many options available, one of the mosty widely used formulations of dermal filler is hyaluronic acid. Compared to other implantable materials, hyaluronic acid-based fillers can be easily dissolved using hyaluronidase, making them easier to work with, as injected material can be dissolved if needed. Overall, it is best to use hyaluronic acid-based implants to augment the lips as they are 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, instead of treating the lips. This is because CaHA-based fillers fall under the adjustable filler category due to its high elasticity and viscosity features. According to Emer and Sundaram, it is best to avoid injecting areas of high movement such as the lips with CaHA-based fillers – failure to do will only result in increased incidence of nodules.

Tools and techniques

The two most widely used tools for injecting aesthetic fillers are sharp needles and cannulas. One of the biggest advantages of cannula is that it is thought to pose a lowered risk of vascular injury. Note that smaller cannulas are still capable of damaging the blood vessels, especially in areas where tissue resistance to cannula insertion is higher. In addition, erasing rhytids in the perioral area and vermilion borders can be difficult when 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. A cannula is ideal for patients who are worried about developing unappealing post-procedural side effects such as bruising, swelling, and long recovery time. A 25 G or 27 G cannula is considered 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 injection procedure. This is because extracting fat tissues to only augment the lips is not cost-efficient, especially when syringes pre-filled with filler material are readily available. In order to deliver significant pain-numbing and vasoconstricting effects as well as to minimize the risk of unintentional intravascular injections, physicians are encouraged to use a 30 G sharp needle and 2 cc lignocaine with adrenaline during lip augmentation procedures. The filler gel can 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 lip proportion analysis techniques available as treatment guidelines, lip augmentation procedures also require an artistic touch, while also taking into account patients’ outcome preferences.

Generally speaking, 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 borders of the vermilion. As 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 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, to soften the appearance of perioral rhytids, and support the angles of the mouth. Linear threading method may 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 their fair share of complications. Most often than not, patients will experience normal side effects such as redness, tenderness, swelling, and bruising, which should self-resolve within a couple of days. Other more serious complications of soft tissue filler implantations such as product migration, hematoma, fibrosis, thromboembolism, granulomatous inflammation, and infection have also been reported by patients. However, the most serious possible health complication is vascular compromise caused by accidental intravascular injection of filler gel or vascular compression.  In order to reduce the risk of filler complications, regardless of treatment area, physicians are strongly advised to follow these suggestions:

• Apply local anesthetic with adrenaline.
• Aspirate before injecting to prevent intravascular placement.
• Use a blunt cannula if possible.
• Administer the filler with low injection pressure.
• Observe carefully for any signs of blanching. Typically, vascular compromise is preceded by transient blanching of skin, which can occur at the injection site, or even at a point distant from the initial treatment area.
• As part of emergency response plan, keep hyaluronidase on hand.

Another undesirable effect of dermal filler injection is poor aesthetic results, which will result in unsatisfied patients. To reduce the chance of unsatisfied patients, physicians are encouraged to do the following:

• Do not overcorrect and/or overfill a treatment area.
• Select 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.
• Maintain the overall 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 lips and perioral regions can also 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 lesions. Venous lakes in the lips – also known as phlebectasis –  can be successfully treated using long pulsed lasers. Other than that, undesirable aging signs of the skin, such as rough skin texture, fine lines, and wrinkles can be corrected using ablative lasers. The former is an good choice of technique for skin rejuvenating treatment, as it also helps to tighten the skin. CO2 lasers can be adjusted into fractional or pixilated mode in order to treat patients with light or dark skin types, making the technique particularly versatile. On the other hand, full ablative laser resurfacing is suitable for patients with lighter skin tones.

Note that this treatment technique 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. 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 procedures due to its superior effectiveness.

The long-term 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 evidenced that neocollagenesis – the growth of new collagen fibers – begins at the sixth week and progressively increases at six months and one-year marks. Practitioners may not be able to observe significant outcomes immediately 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 area, instead of only treating small and isolated areas.

Another important factor that must be considered by physicians is the device setting as lasers manufactured by different companies come with different energies, patterns, spacing, and pulsing durations. These lasers may deliver aesthetic results of varying degrees, and therefore, the setting for one device may not be 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 during follow-up sessions. The effects of laser pulse on tissues and the resulting responses will also vary on an individual, personal basis. For instance, as the CO2 laser targets tissue water, the hydration level of skin plays an important role in determining the post-procedural results. In addition to the skin’s hydration status, use of local pain numbing agent, either topical or by infiltration, also affects the tissue response. After patients have been treated with fully ablative CO2 laser resurfacing, physicians can make use of various post-operative care methods to encourage fast skin recovery. These wound care techniques are divided into two main categories – 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 matter 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 can be prescribed with anti-viral prophylaxis when they are treated using dermal filler injections or laser resurfacing. 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. Patients may experience the following adverse effects after undergoing laser resurfacing treatment:

• Pain
• Redness
• Post inflammatory hyperpigmentation (PIH)
• Hypopigmentation
• Hyperpigmentation
• Infection caused by bacteria, virus, or fungal.

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

Other treatment methods

Both dermal filler injections and laser therapy work well to get rid of perioral wrinkles and other perioral aesthetic imperfections. Administration of soft tissue implants into an elongated upper lip is not advisable. Elongated upper lip takes place when gravity and biological aging processes 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. Besides lip-lift therapy, healthcare practitioners and patients can choose other suitable rejuvenation treatments, which include carboxytherapy, skin needling and Platelet Rich Plasma (PRP) injections.

Practitioners who specialize in aesthetic medicine should strive to 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, for example.

Summary

The lip augmenting and rejuvenating treatments explained above have their own advantages and disadvantages. These treatments can only be performed after a patient’s conditions have been thoroughly assessed during the consultation session(s). A complete assessment ensures that both the practitioners and the patients share the same treatment goals – and that patients’ expectations, and tolerance to recovery periods are properly addressed. Successfully taking these important steps will result in successful lip rejuvenation and satisfied patients.