Anesthesia

In general the perioral area can easily be numbed by a double nerve block of both infraorbital and mental nerves. This usually does not anesthetize the philtrum and the oral commissures, which need additional infiltrative anesthesia. The specific areas to be microfat grafted are additionally infiltrated with a solution of lidocaine and adrenaline to provoke vasoconstriction.

Perioral Rejuvenation Techniques

Correction of the Nasolabial Fold

The nasolabial fold has historically been corrected with a multitude of techniques, which is most often a sign that none of them is perfect. In particular the “lifting” techniques, for which the nasolabial fold was seen as a component of the descent of the midface, were prone to relapse. Some techniques even described very extensive undermining from the facelift incision progressing under the nasolabial fold or even more medially, but they could not guarantee long-lasting results. If the nasolabial fold is considered as an atrophying area, because of repetitive movements over the years, the logical treatment is filling. In theory another option would be to stop the movement in this area with toxins. This can be observed in the case of facial paralysis, in which the affected hemiface nasolabial groove is completely eradicated. However, clinically this is impossible, because all mimic activity of the face would be disturbed. Therefore correction of the nasolabial fold is better achieved by microfat grafting.

The deep filling of the crease is accomplished with classic 0.7 to 0.9 mm fine blunt cannulas via a puncture hole with an 18-gauge intravenous needle. A crisscrossing approach is used, starting perpendicularly to the crease in the deep plane to build up a foundation. This is important to prevent a sausagelike deformity, as seen in parallel lipofilling techniques. Most volume goes into the canine fossa, with a triangular blending extension toward the corner of the mouth (Video 4-1). Next a second, more superficial layer is deposited parallel into the fold. Finally a subdermal subcision maneuver is executed with an 18-gauge needle, used as an internal knife.

This procedure cuts all the ligament attachments from the skin to the deeper structures (Fig. 4-3). A small volume of microfat (0.3 to 0.5 cc) is then injected into the created cavity, not as much as a filler but rather as a spacer to prevent reattachment of the skin to the deep tissues.

The average injected volumes are 1 to 3 cc of microfat per side. Undercorrection is preferable to overcorrection in this area. Effective, natural, and long-term correction is expected with this technique.

Female Lip Aesthetics

The proportion of upper to lower lip volume must be respected (Fig. 4-4 and Table 4-1). In most people the lower lip is slightly larger than the upper lip in the frontal view. When this proportion is violated by augmenting only the upper lip, an unnatural appearance may occur. Therefore the upper and lower lip are typically augmented simultaneously.

In patients of Western European descent, in the frontal view the upper to lower lip height ratio is approximately 1:1.618, in accordance with the golden proportion. In other words, the lower lip is roughly 50% larger than the upper lip. These proportions are important, and must be preserved when enhancing the lips. Often patients ask for an isolated upper lip augmentation. In most cases this disturbs the natural proportions of the upper to lower lips. The surgeon should explain to these patients that the lower lip needs to be enhanced in proportion to the upper lip. Often a higher volume is needed in the lower lip than in the upper. Failure to respect these observations may result in an unnatural appearance (Fig. 4-5).

Ideal lip aesthetic proportions may cause some confusion:

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  In the frontal view the lower lip should be approximately 60% higher than the upper lip (the golden proportion of 1:1.618).

  
  
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  In the profile view the upper lip should project slightly (1 to 2 mm) further anterior than the lower lip.

In the young lip, the vermiliocutaneous border, or white roll, is well defined and pouted, with a distinct Cupid′s bow in the frontal view. In profile view the youthful upper lip should project 1 to 2 mm anterior to the lower lip. The contour from the nasal base to the vermilion border should be slightly concave. The philtral columns are prominent and well-defined. The oral commissures should be horizontal or curve slightly upward. The mucosa is soft with a distinct turgor. The skin surface is smooth, equally toned, and without rhytids.

Aging disturbs these parameters to a certain degree: The vermiliocutaneous border loses its definition and flattens out. The definition of the Cupid′s bow fades in the frontal view. The projection of the upper lip decreases and becomes level or even posterior to the lower lip. The contour from the nasal base to the vermilion border becomes straight to convex because of lengthening of the lip and subsequent inversion of the vermilion. The philtral columns lose prominence and definition. The oral commissures tend to turn downward. The vermilion mucosal surface becomes dryer and atrophic and loses turgor. The skin surface becomes rough, pigmentary irregularities occur, and vertical rhytids appear (the barcode appearance).

Harmonic lip enhancement should ideally treat all of these aesthetic features. A combination of several treatment modalities will work synergistically toward a natural enhanced appearance. The tools are volume enhancement, liplift, and resurfacing.