Chapter 16 Filler Injection of the Lips, Oral Commissure, and Mentolabial



10.1055/b-0040-178134

Chapter 16 Filler Injection of the Lips, Oral Commissure, and Mentolabial



Lips



Introduction


Youthful lips are characterized by volume and a well-defined contour. An M-shaped curve of the upper vermilion border is called the Cupid’s bow, and the linear prominence that originates at the two apices of the M toward the nostrils consitutes the philtrum columns.


The characteristics of “ideal” lips have been described in the literature. In Caucasian women, the ratio from the upper lip to the lower lip is 1:1.6, i.e., the lower lip is more voluminous than the upper one, and the Cupid’s bow and the philtrum are evident. The format of the lips should be convex when seen from the side, and the upper lip should project 2 mm over the lower lip. The lips should be parallel to the imaginary line drawn between the pupils; the upper lip should be 18 to 20 mm from the nostrils and the lower lip 36 to 40 mm from the chin.


Lips lose volume with aging, meaning that they lose convexity and take on a flattened look when seen from the side. The esthetic objective of labial filling is to improve the three dimensional relationship with the rest of the face, taking into consideration the ethnic origin of the patient, cultural factors, age, and gender. 1 –. 4



Anatomy


The lips are formed by an internal portion, the oral mucosa (M) (comprising nonkeratinized stratified squamous epithelium, chorion rich in blood vessels, and minor or accessory salivary glands), by a transition zone, called the vermilion border (comprising keratinized stratified squamous epithelium without hair follicles, apocrine or salivary glands, and possibly with sebaceous glands), and by an external portion comprising the skin and its appendages. The internal portion is moist, whereas the other portions are dry. The muscle fibers of the orbicularis oris muscle (OOM) insert into the border between the internal portion,the oral mucosa, and the transition zone, thevermilion border. The OOM in turn delimits two compartments:




  • Superficial fat pad (SFP), below the vermilion border (VB) and above the OOM.



  • Deep fat pad (DFP), below the OOM and above the M. The inferior and superior labial arteries can be found in this fat pad (Fig. 16.116.8). 5



Application Technique


The lips are divided into three anatomical areas. The applica tion technique takes this division into consideration, as a filler injection in each of these areas yields different results, as specified below:




  • Lip contour: Filler injections in this area givedefinitionto the lips. The product is applied into the dermis via retrograde injection at the edge of the vermilion border. This procedure also prevents lipstick from running in patients with vertical “barcode” wrinkles.



  • Vermilion border: Filler injections in this area give the lipsanterior projection,(re)creating a convex format. The filler agent is injected into the SFP, above the OOM. Retrograde injection or bolus can be used.



  • Oral mucosa: Filler injections in this area givevolumeto the lips, as the local dental arch projects the treated area forwards. The filler agent is injected as a bolus into the DFP, below the OOM. As the labial arteries course through this pad, we recommend aspiring before performing the injec tion, and then injecting slowly in order to reduce the risk of intravascular injection. The injection should be interrupted immediately in case of sudden pain or whitening. We prefer using microcannulas for this area instead of needles. 6


We prefer to use hyaluronic acid (HA) combined with lidocaine, applying it to the middermis and superficial dermis (Fig. 16.1916.21,16.2716.31, and16.3316.37).



Complications


Erythema and edema usually occur immediately after the procedure, resulting from needle trauma and the hygroscopic properties of the filler agent. Erythema can last from a few hours to 1 or 2 days. It is essential to warn the patient about this. The number of punctures should be minimized, and ice should be applied after the procedure to help reduce erythema and edema. Ecchymosis may also occur if the needle perforates a vessel. This disappears gradually in 5 to 10 days. Acetylsalicylic acid, oral anticoagulants, nonsteroidal anti-inflammatory drugs, and even vitamin E and herbal supplements can cause ecchymosis. Caution is required when using these medicinal products. Vascular occlusion and necrosis are consequences of embolization of the product in the lumen of the labial artery and can be avoided by using thicker microcannulas, greater than 25 G, when applying filler injections to the deep fat pad of the lips (DFPL).


The formation of noninflammatory papules is rare and results from injecting the product into the incorrect plane (very superficial) and not massaging the area after the injection.


The common “duck bill” is another undesirable effect that occurs due to excessive application of the filler agent or an inadequate filling indication. Filler injections are contraindicated when the distance between the nasal septum and the vermilion border is very large, i.e., when the superior dental arch of the patient is not easily visible when they smile. If the procedure is performed, the upper lip would become “heavy,” below the ideal height, projecting forward, and patients’ teeth would not be visible when they smile. In these cases, curvilinear resection of the excessive skin below the nostrils is recommended, using the gull-wing technique. After correction, the implant may be performed.



Oral Commissure and Mentolabial Sulcus



Introduction


The signs of aging in the perioral region are the result of a combination of factors, including subcutaneous tissue volume loss, thinning of the dermis due to a reduction in collagen and elastin, and bone remodeling. Repetitive movements of the depressor muscle of the angle of the mouth and the platysma muscle also contribute to signs of aging. Clinically, ptosis of the oral commissure and deepening of the mentolabial sulcus, also called the marionette line, are visible. 7 ,. 8


Carruthers et al classified the mentolabial sulcus into the following five classes 9 :




  • Class 0: No visible folds; continuous skin line.



  • Class 1: Shallow but visible folds with slight indentation. These are easier to treat by applying HA to the middermis using a linear retrograde injection.



  • Class 2: Moderately deep folds, visible at normal appearan ce, but not visible when stretched.



  • Class 3: Very long and deep folds.



  • Class 4: Extremely long and deep folds. More diffcult to correct and generally requires application of HA in various layers, including the deep dermis and subcutaneous tissue.



Technique


If the aim is to lift the oral commissure and/or treat the mentolabial sulcus, the product is applied using a retrograde injection in the lateral part of the lower lip and the surrounding skin, thereby forming a horizontal pillar that supports the commissures. This is followed by three vertical supporting pillars created via retrograde injection, which form an inverted triangle in which the base is the contour of the lower lip that has already been filled. A small bolus can also be applied to the modiolus to help lift the commissure. Injection of type A botulinum toxin in the depressor muscle of the angle of the mouth and the platysma muscle is also helpful.


Vertical “barcode” wrinkles can be filled with a linear retrograde injection. Better results are obtained by injecting type A botulinum toxin to relax the OOM. Very deep wrinkles require a prior treatment with fractional laser or dermoabrasion.


In order to enhance the columns of the philter, it is important to remember that they are not parallel as they have an inverted V shape that narrows as it approaches the columella (Fig. 16.2216.26,16.32, and16.3816.41).



References

1 Klein AW. In search of the perfect lip: 2005. Dermatol Surg 2005;31(11 Pt 2):1599–1603 2 Carruthers A, Carruthers J, Hardas B, et al. A validated lip fullness grading scale. Dermatol Surg 2008; 34(34, Suppl 2):S161–S166 3 Sarnoff DS, Saini R, Gotkin RH. Comparison of filling agents for lip augmentation. Aesthet Surg J 2008;28(5):556–563 4 Fulton JE Jr, Rahimi AD, Helton P, Watson T, Dahlberg K. Lip rejuvenation. Dermatol Surg 2000;26(5):470–474, discussion 474–475 5 Rohrich RJ, Pessa JE. The anatomy and clinical implications of perioral submuscular fat. Plast Reconstr Surg 2009;124(1):266–271 6 Mukamal LV, Braz AV. Preenchimento labial com microcânula. Surg Cosmet Dermatol 2011;3(3):257–260 7 Braz AV, Louvain D, Mukamal LV. Combined treatment with botulinum toxin and hyaluronic acid to correct unsightly lateral-chin depression. An Bras Dermatol 2013;88(1):138–140 8 Weinkle S. Injection techniques for revolumization of the perioral region with hyaluronic acid. J Drugs Dermatol 2010;9(4):367–371 9 Carruthers A, Carruthers J, Hardas B, et al. A validated grading scale for marionette lines. Dermatol Surg 2008; 34(34, Suppl 2):S167–S172
Fig. 16.1 A. Anterior view of the lips and perioral region. B. Same region after the skin has been folded back.C. Anterior view of the right side of the face after the skin has been folded back and anterior view of the left side of the face after the skin and the superficial fat pads (SFPs) have been folded back.D. Anterior view of the right side of the face after the skin, SFPs, and the suborbicularis oculi fat (SOOF) have been folded back. Anterior view of the left side of the face after the skin, superficial and deep fat pads, zygomatic major muscle, and, inferiorly, the depressor muscle of the angle of the mouth have been folded back.
Fig. 16.2 A. Anterior view of the anatomy of the lips and the perioral region after the skin, superficial fat pads (SFPs), and depressor muscle of the angle of the mouth have been folded back. Left side of the face, the zygomatic major muscle, deep fat pads (DFPs), and orbicularis oculi muscle (OM) have been folded back.B. Left side of the face showing the orbicularis oris muscle (OOM) after removal of the levator muscle of the upper lip and the depressor muscle of the lower lip on the right side of the face.C. The entire OOM is visible after removal of the depressor muscle of the lower lip, bilaterally. The levator muscle of the angle of the mouth is visible on the right side of the face.D. Veins and arteries emerging from the infraorbital foramen (IOF) and mental foramen (MF) on the right side of the face, and the infraorbital nerve (ION) and mental nerve (MN) on the left side of the face.
Fig. 16.3 Anterior view of the vessels and nerves of the lips and perioral region.
Fig. 16.4 Anterior view of the face focusing on the perioral region.A. Corresponding arterial vascularization.B. Corresponding venous vascularization.C. Corresponding innervation.
Fig. 16.5 A. Lateral view of the right side of the face.B. Same region after removal of the skin.C. Same region after removal of the skin and the superficial fat pads (SFPs). The levator muscles of the upper lip and the zygomatic muscles are visible above the deep fat pads (DFPs), and the parotid gland is visible in the preauricular region, above the masseter muscle.D. The buccinator muscle is visible after removal of the zygomatic major and minor muscles, DFPs, platysma muscle, and part of Bichat’s fat pad.E. Bone structure of the perioral region.
Fig. 16.6 Right profile view with focus on the perioral region.A. Corresponding vascularization and innervation.B. Corresponding arterial vascularization.C. Corresponding venous vascularization.D. Arterial and venous vascularization integrated in the orbicularis oculi muscle (OM), nasal muscle, levator muscle of the upper lip, buccinator muscle, depressor muscle of the angle of the mouth, depressor muscle of the lip, mentalis muscle, and masseter muscle.E. Corresponding innervation.
Fig. 16.7 A andB. Lips and perioral region.C. Close-up of Figs.A andB.
Fig. 16.8 A. Lateral view of the lips and perioral region after removal of the skin.B. Same region after removal of the skin and the fat pads. The facial artery and vein are visible more laterally, both coursing around the inferior edge of the mandible, at the level of the anterior edge of the masseter muscle, and can then be seen penetrating the face.C. A cadaver specimen showing the facial artery (FA) and its two branches that supply the lips: the inferior labial artery (ILA) and the superior labial artery (SLA).
Fig. 16.9 A. Illustration showing the branches of the facial artery (FA): the inferior labial artery (ILA) (pink arrow) and the superior labial artery (SLA) (green arrow). Both are below the orbicularis oris muscle (OOM).B. Note how on the fresh cadaver specimen, the branches of the facial artery (FA) are visible: the inferior labial artery (ILA) (pink arrow) and the superior labial artery (SLA) (green arrow).
Fig. 16.10 A. Illustration showing the facial artery (FA) (dark blue arrow), inferior labial artery (ILA) (light blue arrows), superior labial artery (SLA) (purple arrow), and angular artery (green arrow).B. The FA (dark blue arrow), ILA (light blue arrows), and SLA (purple arrow) are visible on the fresh cadaver specimen. After branching off from the lips, the FA becomes the angular artery (green arrow).
Fig. 16.11 A. Illustration of the right side of the face of a fresh cadaver specimen showing the facial artery (FA)(pink arrows), inferior labial artery (ILA)(light blue arrows), and superior labial artery (SLA)(black arrows). B. Same fresh cadaver specimen showing the ILA(light blue arrows) below the orbicularis oris muscle (OOM).C. Note the course of the ILA.
Fig. 16.12 A andB. Illustration and fresh cadaver specimen showing the facial artery (FA)(pink arrows),inferior labial artery (ILA)(light blue arrows), superior labial artery (SLA)(black arrows), angular artery(green arrows), septal artery (orange arrows), and lateral nasal artery (white arrows).
Fig. 16.13 A. Right side of the face of a fresh cadaver specimen showing the inferior and superior labial arteries entering the lower and upper lips, respectively.B. Lower lip being pinched to demonstrate the location of the inferior labial artery (ILA), in the deep fat pad of the lips (DFPL), above the oral mucosa (M).C andD. ILA seen through the M, demonstrating its depth in relation to the vermilion border.
Fig. 16.14 A. Right side of the face of a fresh cadaver specimen showing the inferior and superior labial arteries entering the lower and upper lips, respectively.B. Upper lip being pinched to demonstrate the location of the superior labial artery (SLA), in the deep fat pad of the lips (DFPL), above the oral mucosa (M).C. SLA seen through the M, demonstrating its depth in relation to the vermilion border, located above theM and below the orbicularis oris muscle (OOM).
Fig. 16.15 A andB. Illustration and fresh cadaver specimen showing the facial artery (FA) (black arrows), superior labial artery (SLA) (green arrows), septal artery (purple arrows), angular artery (blue arrows), and dorsal nasal artery (orange arrows). The FA becomes the angular artery (blue arrows) after branching off the SLA, and ascends to the medial region of the orbit to anastomose with the dorsal nasal artery (orange arrows), a branch of the internal carotid artery.
Fig. 16.16 A. Illustration showing the facial artery (FA) coursing around the inferior edge of the mandible, at the level of the anterior edge of the masseter muscle, and then penetrating the face. The inferior labial artery (ILA) originates next to the oral commissure, continues posteriorly to the depressor muscle of the angle of the mouth, and crosses the orbicularis oris muscle (OOM). It has a tortuous course along the edge of the lower lip and ascends to branch off into the superior labial artery (SLA).B. Fresh cadaver specimen showing the ILA between the two forceps, below the depressor muscle of the angle of the mouth.
Fig. 16.17 Sagittal section of a fresh cadaver specimen showing the orbicularis oris muscle (OOM), superficial fat pad (SFP), and vermilion border (VB). Below, the deep fat pad (DFP) and the oral mucosa (M).
Fig. 16.18 Sagittal section of the lip on two samples showing the superficial fat pad of the lips (SFPL) (blue circles) below the vermilion border, orbicularis oris muscle (OOM) (red circles), and deep fat pad of the lips (DFPL) (green circles) above the mucosa.
Fig. 16.19 Classification of the areas of the lips to be filled: junction between the vermilion border and the skin; vermilion border; and oral mucosa (M).
Fig. 16.20 A. Filler injection technique for the lip contour at the junction between the vermilion border and the skin, with cannula and needle. Both are positioned between the skin and the vermilion border.B. Filler injection technique for projecting the lips, with cannula and needle. Both are positioned in the superficial fat pad (SFP), above the orbicularis oris muscle (OOM).C. Filler injection technique for lip volume with cannula and needle. Both are positioned in the deep fat pad (DFP), below the orbicular muscle. Needles should be used with caution, as the labial artery is in this pad.
Fig. 16.21 A. Injection technique with needle for filling the lip contour.B. Injection technique with needle for filling the vermilion border.C. Injection technique with needle for filling the oral mucosa (M).
Fig. 16.22 Injection technique with needle for treating the philtrum and Cupid’s bow.
Fig. 16.23 Injection technique with needle for treating the oral commissure and the mentolabial sulcus.
Fig. 16.24 Left side of the face of a fresh cadaver specimen showing the injection technique with needle for filling the oral commissure. The red gel indicates that the needle is inserted prior to the commissure to support the skin at the site and, posteriorly, below the commissure, with a linear retrograde fanning injection, creating an inverse triangle, in the superficial subcutaneous plane.
Fig. 16.25 Left side of the face of a fresh cadaver specimen showing the injection technique with needle for filling the mentolabial sulcus. The green gel indicates that the application was fan-shaped, in the superficial subcutaneous plane.
Fig. 16.26 Before and after a filler injection with hyaluronic acid (HA) in the oral commissure and mentolabial sulcus.
Fig. 16.27 Injection techniques with needle for lip filling.A, B, andC. Three steps for filling the oral commissure.D, E, andF. Filler injection of the lip contour, philtrum, and Cupid’s bow.G andH. Filler injection of the vermilion border and the oral mucosa (M) in the upper lip.I, J, andK. Filler injection of the contour, vermilion border, and M in the lower lip.
Fig. 16.28 Before and after a filler injection in the commissures, lip contour, and superficial and deep fat pads of the lips.
Fig. 16.29 Filler injection technique of the lips with cannula.A. Filler injection of the lip contour.B. Filler injection of the vermilion border.C. Filler injection of the oral mucosa (M). The tip of the cannula is visible through the M—deep fat pad (DFP).
Fig. 16.30 A. Right lip of a fresh fresh cadaver specimen showing the filler injection technique of the lips with cannula in the lip contour, i.e., at the junction between the vermilion border and the skin.B. Right lip of a sample showing the filler injection technique of the lips with cannula in the vermilion border, i.e., in the superficial fat pad of the lips (SFPL), above the orbicularis oris muscle (OOM).C. Right lip of a sample showing the filler injection technique of the lips with cannula above the oral mucosa (M), i.e., in the deep fat pad of the lips (DFPL), below the OOM.
Fig. 16.31 A. Injection technique with cannula for filling the lip contour.B. Injection technique with cannula for filling the vermilion border.C. Injection technique with cannula for filling the oral mucosa (M).
Fig. 1.2 Injection technique with cannula for filling the oral commissures and the mentolabial sulcus in the superficial fat pad (SFP), above the depressor muscle of the angle of the mouth.
Fig. 16.33 A. andB. Injection technique with cannula for filling the lip contour.C. Injection technique with cannula for filling the vermilion border.D. Injection technique with cannula for filling the oral mucosa (M).
Fig. 16.34 Frontal and oblique views before and after a filler injection in the lip contour, vermilion border, and mucosa of the upper lip.
Fig. 26.35 Frontal and profile views before and after a filler injection in the lip contour, vermilion border, and mucosa of the lips.
Fig. 16.36 Injection technique with needle for filling the commissures, philtrum, and Cupid’s bow. The contour and superficial and deep fat pads were filled with a cannula.
Fig. 16.37 Before and after a filler injection.
Fig. 16.38 Injection technique with needle for filling the supralabial region. The commissure and Cupid’s bow were also filled with a needle. The contour and vermilion border were filled with a cannula.
Fig. 16.39 Before and after a filler injection in the supra labial region.
Fig. 16.40 Injection technique with needle for filling the supra labial region. Cupid’s bow was also filled with a needle. The contour and vermilion border were filled with a cannula.
Fig. 16.41 Before and after a fillers injection in the right supralabial region.

Only gold members can continue reading. Log In or Register to continue

Sep 28, 2020 | Posted by in Aesthetic plastic surgery | Comments Off on Chapter 16 Filler Injection of the Lips, Oral Commissure, and Mentolabial
Premium Wordpress Themes by UFO Themes