41. Perioral Rejuvenation
Indications and Contraindications
Indications
Congenital or acquired volume deficiency in the lips resulting from aging process
Static and dynamic perioral skin lines
Ptosis of the upper lip and deep nasolabial folds
Patient’s desire to improve aesthetic appearance of the lower face
Contraindications
Allergies to fillers or neuromodulators
Congenital or medication-induced coagulopathy
Body dysmorphic disorder
Unrealistic expectations
Active infection
Preoperative Evaluation
Anatomy
The perioral region is bounded by:
Nasolabial creases
Labiomental crease
Nasal base
Anatomic Landmarks of the Region
Philtrum
Philtral columns
Philtral dimple
Cupid’s bow (a key anatomic feature of the upper lip)
Nasolabial crease
Labiomental crease
Patient Evaluation
The facial mimetics are studied in rest and in motion.
With increasing age, facial asymmetries will become more prominent.
Tip:
Aesthetically, 2 to 3 mm of the upper incisors may show in repose, but the full length of the incisors should show while smiling.
The findings and the treatment options should be discussed with patients.
Treatment regimens should not be based on financial considerations alone, but surgeons should consider the most effective, economically feasible plan that will satisfy patients (Fig. 41-2).
Tip:
The mirror and camera are the most important tools to define, with the patient, what should be modified to obtain a better appearance.
Treatment Options
Chemodenervation with neuromodulators
Soft tissue fillers
Fat grafting
Laser resurfacing
Chemical peels
Surgical rejuvenation
Informed Consent
Well-designed informed consent can help to improve communications when problems arise.
Address preoperatively the possibility of asymmetry or undercorrection.
Patients should be advised that filler longevity can vary based on their metabolism.
Before performing ablative skin resurfacing, patients should be informed of the predicted immediate postoperative skin appearance, which can be temporarily disfiguring (see Chapter 17).
Strategies and Techniques
Chemodenervation
Best addresses perioral rhytids and depressed corners of the mouth
Botulinum neurotoxin type A is the most widely used.
Technique
(see Chapter 21)
The orbicularis oris muscle and depressor anguli oris are targeted.
2-5 units are used on each side.
The needle is inserted into peak of the Cupid’s bow, 2 to 3 mm above the vermilion border.
Injection of the depressor anguli oris muscle will cause elevation of the oral commissure. 4
This muscle can be found by asking the patient to depress the lower lip or frown. The bulk of the muscle is palpable inferolateral to the oral commissure at the level of the mandible.
Tip:
Injecting 1 unit of botulinum toxin into the levator labii superioris muscle at its origin on the maxilla (superolateral to the ala) creates a weakness of the central aspect of the upper lip during smile, which eliminates gingival show.
Soft Tissue Fillers
(see chapter 22)
Hyaluronic acid-based filler (Restylane and Perlane, Galderma; Juvederm, Allergan)
Poly– -lactic acid (Sculptra, Galderma): Option for HIV patients with lipoatrophy
Bovine collagen (Zyderm and Zyplast, Allergan): Concerns for hypersensitivity, requires skin test
Human-based collagen (Cosmoderm and Cosmoplast, Allergan): Safer in terms of all allergic reactions, does not require skin testing
Polymethylmethacrylate (Artecoll, Artefill): Permanent filler
Calcium hydroxyapatite (Radiesse, Canderm Pharma): Long-lasting filler
Anesthesia
For skin injections, topical anesthetic can be used.
For lip injections, infraorbital and mental nerve blocks can be used, as well as fillers containing local anesthetic.
Another option is to infiltrate local anesthetic in the upper or lower anterior vestibule from cuspid-to-cuspid region.
Application Techniques
Linear threading
Serial puncture (Fig. 41-3)
Lips
Cupid’s bow or white roll can be augmented by filler injection to outline a “lazy M” configuration (Fig. 41-4).
Cupid’s bow becomes wider with age and should be made narrower.
Approximately 10%-20% overcorrection is needed.
The lip proper, from the wet-dry junction to the vermilion border, may be injected just deep to the mucosa within the orbicularis oris muscle.
Placement posterior to the wet-dry junction along the wet mucosa may enhance the lip volume and projection.
The depth of the mental fold increases with age and may require correction.
Approximate volume for augmentation of the lips ranges from 0.5-1.0 ml per lip.
Caution:
Radiesse and Sculptra should not be used for lip augmentation because of their high incidence of nodule formation.
Tip:
Use minimal volume in the upper lip above the vermilion border, because any added volume may cause lengthening of the upper lip.
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