Cosmetic procedures have steadily increased over the past few decades and many new and effective products are available in today’s cosmetic market. Hyaluronic acids (HAs) represent one of the best tools that dermatologists have to treat facial aging.
Usually, patients come to their physician seeking treatments for improvement in their facial features, such as volume loss in the cheek area or thinning of the lips. Among the factors that contribute to aging in the lower face and lips, are retraction of the vermillion, loss of volume, bone resorption, smoking, elongation of the upper cutaneous lip, and flattening of the philtral columns.1 It is recommended that dermatologists perform a detailed analysis of the face and lips so that balanced facial proportions are ensured. Dermatologists can use noninvasive techniques with HAs fillers that contain glycosaminoglycan, native components of the connective tissue which starts decreasing with age, causing increased rhytids and folds. Because it is a naturally occurring element in our body, HA has no immunogenic potential.2
Various types of HAs fillers with different characteristics including viscosity, elastic modulus (G’), cohesivity, concentration, and cross-linking are available. In June 2016, a new HA, Juvéderm Volbella XC, was approved by the FDA to increase lip fullness and soften the appearance of perioral lines.3 This soft gel has a lower concentration of HA (15 mg/mL) making it ideal for the delicate area of the lips and perioral region.
This article discusses a case of lip and perioral rejuvenation combining Juvéderm Ultra and Volbella XC with excellent cosmetic results and more natural, fuller looking lips.
A 46-year-old woman presented with the complaint of thin lips. Her past medical history was noncontributory. Physical examination showed thinned lips and prominent sulci on her bilateral mentolabial lines (Figures 1A and 1B). After a lengthy discussion of the options, side effects, and expected outcomes, the patient decided to proceed with lip rejuvenation.
Topical lidocaine was applied for 20 minutes before the procedure. Previous aseptic measures were used to clean the area. Initially, Juvéderm Ultra was used to increase the volume of the upper and lower lips with depot injections in each of the subvermillion lateral and medial zones and tunneling through both philtral ridges from a superior to inferior fashion. Then, a fanning technique on the commissures of both sides of the upper and lower lip was performed. Juvéderm Volbella XC was then applied with a microdroplet technique filling the upper cutaneous lip rhytids and through the vermillion in a tunneling fashion in both the upper and lower lip. Finally, the filler was injected on bilateral commissures in the form of an inverted “letter K” to fill the lateral part of the upper and lower cutaneous lips.
The patient tolerated the procedure well and was very satisfied with the results (Figures 2A and 2B). Minor ecchymoses and swelling were experienced the next day but they resolved completely in 2 to 3 days. The patient was very pleased with the final results.
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The hallmark of the aging face is loss of associated subcutaneous volume overtime. Clinically, with this loss, the signs most clinicians see are an increase in the lines and wrinkles of the skin. HA fillers play an integral part in the correction of changes associated with aging, especially those associated in the lower half of the face, from the nasolabial fold to the vertical lip lines of the lips, the marionette lines around the mouth, and in the thinning of the lip. Extensive knowledge of the dynamics of movement and how aging occurs allows the practitioner to render natural results. It is imperative for dermatologists to know the anatomy of the area that will be treated to avoid vascular occlusion or nerve damage.
In this case, the treatment was the perioral area. The boundaries of the perioral area are formed by the nasolabial folds and nose superiorly and the mentolabial lines and labiomental crease inferiorly. The superior part is formed by the upper cutaneous lip, which lies between the nose and the pink mucosal part of the lip that is called vermillion. In the center a linear depression, the philtrum, is formed by the 2 philtral columns. A V-shaped depression, the cupid’s bow, is found at the inferior part of the philtrum, where it meets the vermillion. A lighter skin line, the white roll, surrounds the vermillion. On the center of the upper lip, there is a thicker zone called the tubercule. The lower part is formed by the vermillion and the lower cutaneous lip.4,5
When rejuvenating the area, effort should be focused on keeping these landmarks very similar to the patient structure. Another important aspect is to be familiar with the anatomic layers of this area, which are formed by the epidermis, dermis, subcutaneous tissue, muscle, and mucosa. The important structures to be aware in this case are the superior and inferior labial artery, which are both branches of the facial artery and anastomose with the contralateral artery. They travel deep to or within the orbicularis oris muscle, never superficial to it. Hence, if injections are done above the muscle, the complications are minimal.2
HAs fillers are safe and excellent tools for the dermatologist to enhance facial features. Different characteristics such as concentration, cross-linking, and rheological properties define the type of HA, which will dictate in which area on the patient they will be used. HA is a highly charged polymer, which allows it to bind to water extensively. It is a glycosaminoglycan disaccharide composed of alternating units of N-acetyl-D-glucosamine and D-glucoronic acid. The molecular weight of HA is proportional to the number of repeating disaccharides in the molecule. The molecular weight of commercial fillers is usually too big to measure and it has little effect on the final properties of the product. Natural HA is cleared rapidly, thus, some modifications are necessary to increase the time it gets degraded. Cross-linking of the carboxyl group is one of the techniques used to increase the degradation time, which is directly proportional to the amount of cross-linkage in the gel.
Another important characteristic is the concentration of HA found in the filler expressed in milligram/milliliter. Higher concentration fillers are harder and last longer. The majority of HA gels have viscous and elastic components. The former is named the viscous modulus (G”) and the latter the elastic modulus (G’) and the sum of both results in the complex modulus (G*). The elastic modulus G’ is used to define the firmness of a filler. The degree of cross-linking of a gel and concentration is directly proportional to the elastic modulus G’. Gels with higher G’ resist more the dynamic forces during facial movement and provide longer duration of correction. On the contrary, gels with low G’, such as Juvéderm Volbella XC, are better for areas with static and superficial wrinkles where softness is more important such as the lips.6 The new filler was developed specifically for the lips, with a patented technology (Vycross) that incorporates short- and long-chain HA to provide a more efficient cross-linking. This also gives more viscosity to the gel and a longer duration than the products that only have long-chain HA, such as Juvéderm Ultra.7
In conclusion, lip rejuvenation is an option for patients seeking to improve the lower part of the face using a combination of high and low viscosity gels, such as Juvéderm Ultra and Juvéderm Volbella XC to obtain excellent results. Knowledge of potential anatomical structures is also important to minimize complications. With a broader array of HA fillers available, dermatologists now have many tools they can use to create tailored results for the cosmetic patient.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Dane is a board-certified dermatologist in private practice at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Grob is a board-certified dermatologist in private practice at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
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