Anatomic Considerations of Injectable Fillers

Over the past decade, the average cosmetic facial surgery practice has embraced the art and science of facial fillers. Whereas early filler use was two-dimensional to treat individual lines and wrinkles, contemporary filler use is three-dimensional with larger volumes being injected to enhance volume in much larger cosmetic units. Some 20 years ago, 0.5 mL of a collagen filler may have been used in a single wrinkle, whereas today it is not uncommon to inject 6 mL of hyaluronic acid filler in the midface. “Filler facelifts” (although I personally don’t like that nomenclature) may use 15 syringes to volumize the entire face.

With a long-standing appreciation for volume loss in relation to facial aging and the advancement of filler science, the contemporary cosmetic facial surgeon has new tools to perform minimally invasive facial rejuvenation. Volume loss is one of the prime factors that cause an aged look. Today’s cosmetic surgery patients are extremely savvy on the pros and cons of specific procedures. They want to look younger, not just tighter. The past emphasis from surgeons was to look tighter, and little attention was paid to volume restoration. With the new era of cosmetic sophistication, fillers (and facial implants) serve as the icing on the cosmetic cake. For younger patients, fillers can serve as a sole procedure to disguise aging. For older patients, they can be used with other rejuvenative procedures to refine the treatment results.

It is far more important how the filler is used than which filler is used. A competent injector can achieve aesthetic results from any filler if he or she knows how to use it and where to put it. Conversely, an inexperienced injector can use a premium filler and get poor results. The key to success with all fillers is correct placement in the skin and deeper tissues, and various anatomic sites have specific injection techniques. For optimum results, safety, and longevity the clinician needs to use the “right” filler in the “right” place on the “right patients.”

Most fillers are specifically designed to be placed at a certain level. The exact level of filler placement is a debatable subject. Many fillers say their intended target is the “dermis,” and some injectors describe injecting in the mid- or deep dermis. Biopsies of “dermal” fillers actually show filler in various positions throughout the dermis and subcutaneous tissue, so it is technically impossible to say a filler is monoplanar. The filler needs to be placed where its most optimum action can be exerted, including the dermis and subcutaneous planes, and sometimes on the periosteum. There is no doubt that this varies from patient to patient and is affected by skin thickness, region to be injected, amount of aging, and the specific filler composition. There are some general rules that make sense and can serve as guidelines to tissue placement. The less viscous gel fillers or those with smaller particle sizes are intended for more superficial dermal placement. The medium-particle fillers are meant for the mid-dermis, and the more robust or particulate fillers are intended for deep dermal or subcutaneous placement. Again, an experienced injector can push these boundaries. Placing viscous or particulate filler too superficially may produce contour irregularities or be visible through the tissue. Conversely, placing a small-particle filler in the deep tissue planes can result in premature resorption.

G Prime

Rheology is the study of the flow of matter and G prime is a common measurement. To determine G prime, the filler is placed between two plates, which are then subjected to a lateral force. The measurement of this resistance to deformation is calculated as G prime. G prime is elastic modulus of the filler or the stiffness. To the clinician this translates as viscosity and the lower G prime fillers are less viscous and placed more superficially, while the larger G prime fillers are more viscous and placed deeper in the tissues. Low G prime fillers are used for fine lines and wrinkles and high G prime fillers are used for lifting and support such as cheek filling ( Table 10.1 ). The degree of cross-linking affects the gel hardness (G prime). Although higher G prime is frequently associated with greater ability to lift, some researchers say that this may be true in vitro but not in vivo.

Table 10.1

Relative G prime values for common FDA-approved HA fillers

 

The prime statement, “The key to success is placing the ‘right’ filler in the ‘right’ place in the ‘right’ patient” is often referred to in this chapter as it is so important. This means picking the correct product for the task at hand and then placing it in the proper anatomic plane(s).

Although these fillers as a group are referred to as “dermal” fillers, a common mistake of the novice injector is to place HA gel fillers too deeply or too superficially. This can produce inadequate augmentation and it dissolves faster. There is a “sweet spot” on the skin where the placement of filler produces controlled augmentation, and that differs from patient to patient. Experienced injectors know where to put the filler for maximum result, and this is a learned skill guided more by feel and visual result than by science. Placing fillers such as silicone, Radiesse, fat, and Sculptra or Voluma in the superficial dermis can produce contour irregularities. Placing fillers such as Restylane, Juvederm Ultra or Belotero in the subcutaneous tissues is a less judicious choice than their more robust larger-particle or thicker-gel counterparts.

Although confusing, the tenet of intradermal placement is a good starting place for the novice injector. Injecting in the dermis is an appreciated tactile situation with contributions from the pressure of the needle entry and advancement and the syringe pressure. Again, experienced injectors can sense the correct plane. A pearl for novice injectors as to when the needle is in the dermis is observing the needle bevel upon skin entry. When the bevel of the average injection needle enters the skin and cannot be seen, this is an approximate indication that the tip is in the dermal plane. All injectors must be aware of the intended tissue plane target for various fillers ( Fig. 10.1 ). Experienced injectors will frequently layer fillers in different tissue planes to achieve results and sometimes use different fillers for the same injection. These anatomic tissue targets are discussed in detail throughout this chapter.

Each filler product has specific properties and is intended for precise tissue targets. Some fillers are intended for superficial dermal injection (A), while others are intended for mid-dermal (B), deep dermal (C), or at the level of bone (D) on periosteum.

Patient Selection

The rate of advancement of filler technology has proved to be confusing for patients (and some doctors) so it is imperative to “choose the right patient” for a given application. Many patients do not understand the difference between fillers and neuromodulators (neurotoxins), so education and comprehension are the two prime factors. Although fillers have broad aesthetic applications, they are not miracle treatments. Many patients present with abundant and severe wrinkling that would better be treated with skin resurfacing or facelift. Although these patients may be temporarily improved with $4000–5000 worth of filler, it is not in their best interest in the long run. Some patients may not desire surgery or not care about the filler expense, but acting in the patient’s best interest is always the first rule of medicine.

In theory, fillers can be injected anywhere on the body; however, blindness, stroke, and severe tissue loss and disfigurement is becoming more common with the increased use of fillers. The main consideration is to accurately explain what can be realistically expected as a treatment result. Showing patients a series of before and after images for specific anatomic areas is one way to provide a reasonable expectation. In addition, the injection of fillers should not be presented as a one-time procedure but as a sculpting treatment sequence to approach a result. This is especially true for HA fillers because their hydrophilic properties can cause immediate swelling in the lips, which makes judging the endpoint and symmetry difficult. One huge advantage of HA fillers is that there is no need to over-correct as with older fillers that resorbed quickly. It is also very helpful to have the patient return 2 weeks after injection to review the result. Any areas of underfill or asymmetry can be corrected and post-injection images can be taken for marketing and education. The novice injector should begin with “appetizer-sized” portions of filler and remember that there is nothing wrong with a treatment requiring multiple visits to achieve optimum results. Having patients return can be very helpful as I see patients who are happy, but I may also see deficiencies. Also, from time to time the inverse occurs where the patient is not happy but the result is adequate. Discussing all possibilities before injection is imperative as is having the proper informed consent. This is especially true with older females who may expect unrealistic results from treatment to lips or wrinkles. The best candidates for novice injectors are younger patients with small deficiencies.

Informed Consent Process

The communication that occurs before filler injection can be paramount to a success or failure in the eyes of the patient and or the law. This is the time to detail many other critical issues, including expected longevity, what the filler will or will not do, who will be responsible for the cost of revision filler, and how much filler needs to be used. Many “para filler” problems can be easily resolved by showing the patient their signed consent if post-injection problems arise. My consent is a dynamic instrument. I add to it regularly to preempt potential problems that may arise or new problems not on the current consent. Consents should be accurate and include extremely rare but possible problems such as blindness and tissue loss. “Better to have and not need than to need and not have.” Preinjection photography is also invaluable for situations where the surgeon is blamed for an existing preinjection problem. These photographs not only serve to assist in adverse situations, they serve as a teaching and learning tool for the surgeon and are invaluable for marketing.

The question of how much filler to use is always part of the preinjection discussion. Due to the high cost of a syringe of filler, many new filler patients desire to test the waters by purchasing a single syringe. For the nasolabial folds in adult patients, I almost never use only a single syringe. The problem is that a single syringe is usually insufficient to augment bilateral nasolabial folds in the older patient. The average adult could tolerate three to four syringes and would have better results if finance was not an issue. Attempting this to save money will usually produce an unhappy patient, because the result is minor and the patient can spend $600 and see no results. This can reflect on the expertise and reputation of the surgeon. When adults in the late fourth decade and beyond present for nasolabial fold or oral commissure treatment and request a single syringe, I explain the drawback to them and ask them to save their funds until they can afford the proper amount, which is usually at least two syringes.

It is important to advise patients to not expect their nasolabial folds or wrinkles to be eradicated; they will be improved, but not gone. I explain that the nasolabial fold is a valley, and the filler will make it shallower, not eliminate it. I also explain that although the nasolabial fold (or other wrinkles) may look much better in repose, they will still show upon smiling and animation. This is important because some patients will return after injection and complain that when they smile, they still see their wrinkles or folds. When treating the lips, a single syringe may be split between the lips of younger patients, but older patients, especially those with lipstick lines and perioral wrinkles, can take several syringes.

To give the patient an idea of the anticipated result, I use the following method to demonstrate an approximate goal of nasolabial and lip injections. For the nasolabial folds (NLF), I place my index finger lateral to the patient’s nasolabial fold and gently push in on the skin. This elevates the nasolabial fold, simulating an augmentation ( Fig. 10.2 ). I let them know that the fold will improve but not disappear. For the lips, I take both gloved index fingers and roll the upper lip up and the lower lip down. This allows increased vermilion show, similar to injecting filler, to increase pout and volume ( Fig. 10.3 ).

Placing the index finger lateral and parallel to the nasolabial fold (NLF) and gently pushing the skin will elevate the NLF and serve as a prediction for treatment.

Predicting lip filler result in younger patients can be performed by placing two fingers on the lips and rolling them outwards to expose more vermilion.

Lip-Enhancement Techniques

Treating young patients without significant photodamage is usually straightforward. They may simply need a small amount of volume to plump up the lips or some basic vermilion outline for definition. Treating the senescent lip, on the other hand, can be very challenging. The youthful lip is shorter, curvaceous, defined, and volumized ( Fig. 10.7A ). The aging lip lengthens for numerous reasons, including volume loss from skin, muscle, minor salivary gland and fat changes ( Fig. 10.7B ). Loss of tooth structure (attrition) also contributes to postural differences of the lips.

(A) The normal anatomy of a youthful lip and (B) an older patient. Youthful lips are volumized, curvaceous, pouty, and project. Senescent lips are longer, flat, thin, and without curvature.

A successful injector is a student of lip form and function and needs to be cognizant of the differences between youthful and senescent lips. In youth, the upper lip constitutes about one-third of the total lip volume, and the lower lip constitutes about two-thirds of the mass. This applies to the “golden ratio” of 1 : 1.61 for the upper and lower lip, respectively. This varies among patients and ethnicity ( Fig. 10.8 ). The youthful perioral region is defined by numerous anatomic components that undergo changes with aging. The astute injector is aware of normal lip volume, outline, philtrum, and philtral columns ( Fig. 10.9 ).

In young Caucasian patients the upper lip is one-third of the total lip volume and the lower lip is two-thirds of the total. This also applies to the golden ratio of 1 : 1.61.

Understanding normal youthful anatomy is critical to aesthetic lip treatment. A, Cupid’s bow (or light reflex at the vermilion/cutaneous junction); B, the philtrum; C, the philtral column(s); D, the parenchyma or volume of the lip; and E, the lower lip vermilion/cutaneous margin.

As with many other body parts, some patients exhibit outstandingly aesthetic lips. These patients may exhibit three distinct prominences or tubercles in the upper lip and two in the lower lip. On the upper lip, one “pillow” lies centrally and one is present on each lateral region. On the lower lip, the two prominent tubercles lie on each side of the midline. Some injectors strive to duplicate these prominent regions. My experience is that this looks good on some patients, but most patients feel that the discontinuous tubercles look less aesthetic than simply having full, contiguous lips.

Every practitioner has his or her specific filler injection techniques. The two most popular are linear threading and serial puncture ( Fig. 10.10 ). Linear threading involves inserting the needle and injecting the filler in a straight line while continuously moving in a backward direction. This process would be analogous to placing a line of toothpaste on one’s toothbrush, laying down a seam of calking, or decorating a cake. Although I personally inject while withdrawing, other injectors advocate injecting antegrade to push structures out of the way. I feel that the latter can be more prone to vascular injection. The other injection method is known as the serial puncture technique. This involves placing small boluses of filler with multiple punctures along the lip or wrinkle. In reality, many instances call for a combination of both techniques.

(A) Linear threading and (B) serial puncture in the lower lip. Most injection techniques use a combination of both methods of filling.

Lip Outline

Each patient is evaluated for specific areas of filler enhancement. Some patients (young and old) lack the specific outline of a “Cupid’s bow” or “white roll.” The Cupid’s bow of the upper lip is a lazy-“M” shape, and the corresponding vermilion/cutaneous border (VCB) of the lower lip is curvilinear. In patients with well-defined lip borders, a pleasing light reflex is visible and contributes to maximum aesthetics. If a patient has adequate lip volume, they may only need border outline, but some patients need both volume and outline as well as vertical rhytid injection.

It is important to inject patients in an upright position; gravity will distort a supine patient’s normal anatomy ( Fig. 10.11A ). In addition, many doctors only inject from one side of the chair and this can lead to unrealized asymmetries. It is important to rotate around the patient and inject each side independently for the most accurate results ( Fig. 10.11B ).

(A) It is important to inject patients in as upright a position as possible as the supine position will distort anatomy and produce inaccurate results. (B) Improved accuracy by changing position during injections, so the surgeon is on the same side as the area being injected.

While performing any injection of any product in or around the face, the injector should have expertise on vascular anatomy and injection techniques. As stated earlier, intravascular injection can and has caused blindness, stroke, and severe tissue loss.

Creating the Vermilion Outline

When injecting the lip borders for outline, needle placement is critical. A potential space exists between the mucosa and orbicularis oris muscle, and this space is the target of border outline ( Fig. 10.12 ).

A cadaveric specimen and representation of a cross-section of the lip showing the filler placed in the potential space between the orbicularis oris muscle and the mucosa (A). Deep filler injection in the mid-lip (B).

Injecting in this target space is both visual and tactile. When the needle is in the correct plane, the filler will visually flow both antegrade and retrograde. This can be seen and also palpated by the non-injecting hand. By pinching the border between the non-injecting thumb and index finger, the injector can feel the free-flowing filler, as well as confine the filler to stay within the border. If the needle is in the correct plane (the described potential space), the filler will flow freely with minor syringe pressure. This is confirmed by observing the border being properly created. If the needle is too deep, no distinct outline is seen. If the needle is too superficial, the filler will not flow but instead “ball up,” and the syringe pressure will increase. In this case, the needle must be redirected into the proper potential space.

When augmenting the vermilion border for outline or white roll enhancement, I begin with the central “V” of the Cupid’s bow. The finger and thumb contain the filler and assist in palpation of the augmentation ( Fig. 10.13 ). If the patient does not have a well-defined Cupid’s bow, it is drawn with a marking pencil before the injection to serve as a guide for filling. Care is used to form crisp, angular contours in the downward legs of the lazy M in the area of the central lip.

When performing lip outline, the needle is placed in the described potential space and injected while confining with the fingers to stay in the desired space. The finger pinch also helps keep the filler contained in the injected area.

The next step is to continue the vermilion outline augmentation laterally across the entire upper lip ( Fig. 10.14 ). Some patients require the white roll to extend all the way to the commissures while others only need this augmentation more centrally and gently tapering several millimeters short of each commissure. The needle is inserted all the way to the hub, and the filler is injected with even syringe pressure upon withdrawal. Most filler needles are half an inch long, and the border is augmented at half-inch intervals, taking care to not leave a gap between needle insertion points.

The white roll (Cupid’s bow) on the lateral lip is augmented by injecting between the mucosa and muscle while containing the filler with the finger and thumb. The result should be a homogenous roll across the anatomy of the lip.

The white roll is similarly created in the lower lip, which is more curvilinear than in the upper lip ( Fig. 10.15 ). Reestablishing the light reflex accentuates the lip form and outline, especially in women that wear shiny lip gloss.

The outline created in the upper and lower lip to restore the angular anatomy and provide outline.

A single syringe is usually more than adequate to outline the vermilion on both lips. The lower-lip central vermilion outline is a small but powerful augmentation. Outlining the vermilion border in both lips as described is sometimes all a patient needs for lip enhancement, especially those who do not desire larger lips. Many patients also require “plumping” by adding volume to the central lip.

Increasing Lip Volume (Pout)

Although vermilion border augmentation is a powerful means of enhancing the lip, many patients have adequate outline and a defined white roll or Cupid’s bow and do not require outline. The most common presentation in my practice is the patient who presents with the desire for more lip volume. These patients request plumper, fuller, pouty, and more voluptuous lips. Many are younger and already have adequate vermilion border. These patients will benefit from deeper fill that will increase the general lip volume and pout. By augmenting the deeper portion of the lip, the actual lip will roll out and produce increased pout. The target for volumizing the lip is basically the center of the lip. This is deep to the muscle and contains connective tissue, minor salivary glands, and fat ( Fig. 10.12B ). For younger patients with minor volume loss, I describe this as “putting a little air in the tires.” A single syringe split between both lips can reestablish youthful volume. Older patients will require more filler and it is not uncommon to use two syringes for plumping.

When volumizing, the needle is inserted at the wet/dry line, deep into the central lip. The center of the lip is generally a safe plane, because the labial artery lies at the posterior third of the lip. The target for injection when performing deep volumization is the central lip. Central lip refers to the deep tissues midway between the outer mucosa and skin and the intraoral mucosa, literally the center of the lip when considering the lip in cross-section, as shown in Fig. 10.12A . The needle and filler is anterior to the labial artery and is generally a safe zone (see Fig. 11.1 ). The needle is inserted to the hub and slowly withdrawn while continuous, steady injection is performed (linear threading). In this area, the goal is to produce a “tube” of filler to enhance the volume ( Figs. 10.12B and 10.16 ). As noted earlier, some injectors reproduce the prominent lip tubercles seen in some aesthetic lips, and instead of a continuous tube of filler, the tubercles are reconstructed by placing three boluses in the upper lip and two in the lower lip. Some patients have atrophic lips that require projection of the region from the nose to the vermilion. This region can be injected with filler to increase the pout in conjunction with conventional lip fill, as described above.

For deep volumization the needle is inserted at the wet/dry line (dashed white line) with the target as the middle of the lip t (A). The needle is inserted in the middle of the lip (B) and the filler is injected as the needle is withdrawn.

After filler is injected, the region is inspected for symmetry and fill. I strongly believe massaging the injected filler is a critical (and often overlooked) step in obtaining natural and aesthetic results. Most fillers have the consistency of soft gels or paste and when injected, will not always be homogenous. Massaging the filler more evenly distributes and forms it and produces a smoother, more homogenous result ( Fig. 10.17 ). In addition, the injector can actually level out an area of excess by moving the filler through the tissues. My assistant keeps a small bolus of petroleum jelly on the back of her glove during all filler injections, and I dab this and coat the lip and skin just prior to massage.

Gently massaging the lips immediately after injection will smooth and homogenize the filler and prevent a “string of pearls” that can be seen or felt.

Some injectors carry vermilion and deep volume injections all the way to the corner of the mouth, but I generally do not. In my opinion, one of the most common unnatural filler results is the “ducky” lip, due in part to an eversion of the lateral lip reminiscent of the familiar rubber duck bath toy, which is unfortunately visible on many female celebrities ( Fig. 10.18 ). This can be a variable decision, as some patients benefit from mild to moderate fill all the way to the commissure and others do not.

Placing excess filler in the lateral commissure and not tapering both sides can produce a very unnatural appearing lip.

Lip Injection Cannula Technique

Another convenient means of deep lip volume augmentation is using a specially designed blunt rounded injection cannula instead of the standard half-inch needles that are supplied with filler. Numerous companies produce disposable, flexible 4-cm, blunt cannulas with the orifice set proximal to the tip. These cannulas have a standard Luer Lock connection and are packaged with an “entry” needle of the same gauge ( Fig. 10.19 ). They are blunt and therefore less traumatic, flexible for better negotiation, and can be used in virtually any filler application as conventional needles. Many injectors have switched to using cannulas only. I prefer a 23-gauge cannula for most filler applications.

Blunt flexible cannulas have become welcomed and useful technology for filler injection and can be used in virtually every application that a conventional needle is used. The right image shows a typical filler needle tip and a blunt cannula tip.

Many clinicians feel that cannulas have numerous advantages over needle injection. The tip is blunt and easily moves through the lip without lacerating tissues and vascular structures and therefore produces less bruising and swelling. This type of blunt cannula may reduce the chance of intravascular injection, but this has still been reported with cannulas. In addition, this technique only requires a single puncture. The cannula is passed through the entirety of the lip, negating the need for multiple needlesticks. The size of the cannula and orifice allow a larger deposition of filler with minimal syringe pressure, making the injection process much faster. Since the cannula is blunt, an entry point is first made with a supplied half-inch 22-gauge needle at the lateral lip ( Fig. 10.20 ). The cannula is inserted into the puncture and threaded through the center of the entire lip ( Fig. 10.21 ).

A small needle of the same gauge as the cannula is used to make a puncture medial to the commissure. The cannula is then threaded through the center of the lip.

The cannula is inserted in the mid-lip and advanced to the hub. The filler is then injected by pushing the syringe while withdrawing the needle.

The filler is then injected in a single smooth action while simultaneously withdrawing the cannula. Since more filler is deposited in the center than at the lateral border, the syringe pressure is increased as the midline is approached to deposit more filler, and then backed off as the cannula approaches the puncture insertion point. This forms a natural taper from one side across the center to the other side ( Fig. 10.22 ). The same procedure is performed on the other lip in most cases. Some patients require increased pout and this can be accomplished by injecting filler (with cannula or needle) in the cutaneous portion of the lip (the area under the nose and above the vermilion). This cutaneous augmentation can produce an extremely aesthetic lip, especially in the lateral view.

The flexible, blunt-tipped cannula is inserted to the contralateral side and the injection is performed while the cannula is withdrawn (A). If increased pout is desired, the filler can also be injected in the upper lip in the region below the nose and above the vermilion (B).

The final step is to massage the filler. Since a puncture hole was made one commissure, it is important to pinch this hole when massaging, so the filler is not expressed out of the hole when massaging toward that side. It is helpful for the assistant to place their little finger in one commissure to stretch the lip, which facilitates the massage ( Fig. 10.23 ). As noted, having a dollop of petroleum jelly on the back of the assistant’s hand is convenient for lubricating the mucosa and skin for massage, without interrupting the process. Some injectors also use the cannula for vermilion outline as well as deep volume injection.

When massaging the filler after cannula injection it is important to pinch the insertion puncture site so filler is not expressed from the lip. Having the assistant use their little finger to stretch the lip assists in access and massage.

Philtral Columns

Although the lips are frequently the requested region of improvement, there are numerous perioral indications that can make patients look younger as well as enhance the result of the lip augmentation. Philtral column enhancement is one of the most overlooked aspects of lip rejuvenation. It may never occur to many injectors to address this region, and others may be intimidated. The philtrum is a subcolumellar depression with well-defined columns on either side . In youth, this complex is angularly defined and contributes to youthful aesthetics. As we age, the architecture of these structures frequently changes, and the central upper lip becomes devoid of this pleasing topography. In treating this area, the injector can enhance existing philtral columns or create new ones.

The philtral columns are not vertically straight but rather at a 10–20 degree angle from vertical; the base of the column is lateral to the tip ( Fig. 10.24A ). There are numerous ways to augment the philtral columns. A very simple technique is when treating the lips, conserve the last bit of filler in the syringe and simply place a small peak at the vermilion cutaneous junction at the base of the existing column. This filler is injected in the dermis while the other hand pinches the skin to allow a triangular deposition. This technique does not extend superiorly up to the nostril, but rather becomes a small peaked extension of the angular Cupid’s bow. It only takes a small amount of filler to create this peak and in younger patients it gives the semblance of normal anatomy without treating the entire column. For older patients or those with no defined philtral columns, a more complete reconstruction can be performed. The goal is to replicate the normal angled, conical-shaped philtral column. This is merely a bigger version of the previously described technique but more aggressive; it extends to the nostril just lateral to the columella on both sides. It is important to keep the column tapered and angled 10–20 degrees to appear natural. Pinching the upper portion of the skin helps create the taper ( Fig. 10.24B ).

(A) The normal taper on a patient with defined philtral columns. (B) The entire column can be reconstructed with filler (right philtral column) or just the base of the column can be created for accent (left philtral column). (C) Pinching during injection can contain or shape the filler.

Vertical Lip Rhytids

Vertical lip rhytids (lipstick lines) bother women significantly. This is one of the most commonly requested perioral procedures and one of the more difficult conditions to remedy. These vertical lines are problematic from the standpoint of aesthetics and due to the fact that applied lipstick will leech out and follow the lines onto the skin. These lines are perpendicular to the orbicularis oris muscle and are largely a result of this muscle’s function over the years. Lip rhytids can be vertical, angular, and radial ( Fig. 10.25 ). It is suggested that men are less affected because they have more and denser hair follicles in the lips. Smokers and chronic drinking from a straw probably accelerate formation.

Perioral aging produces vertical lipstick lines. This patients has severe aging and lines that cannot be improved by filler alone.

I personally feel that vertical lip rhytids represent one of the greatest challenges of lip rejuvenation. Patients must understand that the wrinkle can be improved at rest but is usually better but visible during animation. To truly improve vertical lipstick lines they are injected in conjunction with lip volumization or vermilion outline. One commonly encountered problem is that many older women have lipstick lines but do not want “bigger lips.” They refuse any other filler except treatment of the actual lipstick lines. This ties the hands of the injector, as it is difficult to improve the entire situation with only localized wrinkle injection.

Patients with severe lines are best treated with combination therapy, with Botox, filler, and laser resurfacing. Patients must understand that these lines will not be eradicated, but rather mitigated. Although lines can be individually injected, this procedure has the liability of creating a series of “speed bumps” or ridges across the lip.

My preferred method for treating vertical lip rhytids is to first volumize the lips with deep fill and outline. Virtually all patients who have enough aging to have lipstick lines also have generalized volume and vermilion border loss. It is explained to the patient that by restoring volume and border to the lip, the skin will stretch and improve the appearance of perioral lines. After the lip is plumped and the white roll reestablished, the lipstick lines are injected. Low G prime and less viscous fillers such as Restylane Silk, Volbella, and Belotero perform well in this area as their target is superficial dermis. The needle is inserted barely into the dermis and a small bolus of filler injected. This bolus is then massaged over the length of the vertical wrinkle, which smooths it ( Fig. 10.26 ).

(A) A low G prime hyaluronic acid filler injected in the superficial dermis to improve vertical rhytids. (B) Intra- and extraoral massage to smooth the filler.

Figs. 10.27–10.32 show before and after images of lip augmentation with injectable fillers.

This patient was treated with 1 mL of hyaluronic acid filler in each lip.

This younger aged patient was treated with 1.5 mL of hyaluronic acid filler in each lip.

This older patient was treated with 1.5 mL of hyaluronic acid filler in each lip.

This patient was treated with 0.5 mL of hyaluronic acid filler in each lip.

Side view of a patient treated with 0.5 mL of hyaluronic acid filler in each lip.

Front view of a patient treated with 0.5 mL of hyaluronic acid filler in each lip.

Most patients with lipstick lines also have melomental (marionette) lines, downturned oral commissures, and generalized volume loss of the lips along with photodamaged skin. To improve these more severe cases, a significant amount filler can be required, but frequently, this age group is averse to spending a lot of money to correct this region.

Oral Commissure Injection (Downturned Corners of the Mouth)

When addressing the perioral region for filler rejuvenation, the corners of the mouth are a commonly requested treatment area. This can be a difficult region to enhance and can be a “black hole” for filler, requiring a lot of product. Due to the numerous muscles merging at the modiolus, this is a complex anatomic area. Many patients also have a dimple in this region that is accentuated upon smiling. It is important for these patients to realize that although the commissure may be improved in repose, the dimple and hence the depression may still be visible when smiling or animating. Most young patients have crisp, tight, horizontal, or upward-turning oral commissures. As patients age, tooth structure is lost, which decreases the vertical dimension of the jaw. Tooth attrition also causes overclosure of the jaws, which increases the perioral soft tissue drape and in part results in downturned oral commissures ( Fig. 10.33 ). Also contributing to this aging is muscle atrophy, loss of fat, photoaging of the skin, and jowling. Older patients with heavy jowls can have very deep melomental folds (or marionette lines) and be under the impression that the filler will lift and improve the jowl. It is imperative to explain to the patient the best and worst case scenario for treatment result, so they can have a reasonable idea of what to expect. One of the most hated aging changes is “permafrown” or downward turning corners of the mouth. This is one aging change that can be dramatically improved with neurotoxins and fillers.

(A) The youthful perioral complex includes slightly upturned commissures and the absence of melomental folds. (B) The aging and ptotic changes on an older patient. Rejuvenating this region must address numerous planes and anatomic units.

Patients with severe tooth wear or dentures may need to have their vertical dimension increased by a restorative dentist or have dentures remade to lengthen the intermaxillary space.

Combining neuromodulator (neurotoxin) treatment of the depressor anguli oris muscle with injectable fillers in the area can be symbiotic. When injecting the commissure, it is important to control the flow of the filler, as it has a tendency to spread laterally in this region. If the injector is not cognizant of this, lateral pouches can form, which worsens the deformity ( Fig. 10.34 ).

A patient that was injected by another surgeon. She presents with lateral pouches (arrows) from the migration of the filler when injecting. Careful observation during injection will prevent lateral filling.

Numerous injection techniques are used to treat the oral commissures or the melomental folds and in my opinion, both regions need simultaneous treatment for maximum improvement. Some patients may present with a downturned commissure but without deep melomental folds and just the corner of each lip can be treated. More often, a “hockey stick” configuration is formed by the horizontal commissure and the vertical melomental fold; treating both of these regions simultaneously is the key to improving them separately ( Fig. 10.35 ).

Downturned oral commissures and accentuated melomental folds are often co-deformities, which are best treated simultaneously to achieve a synergistic effect.

In the described dual deformity the melomental fold is treated first to establish a base or pillar to support the sagging commissure. As stated earlier, filler can have a tendency to migrate laterally, so the injector must carefully control the deposition. To create a base, a broad band of filler is placed in the deeper subcutaneous tissues under the fold. A second layer is placed in the mid-subcutaneous layer and a final layer is placed in the dermal layer ( Fig. 10.36 ).

(A) Multiplanar layering of the filler in the melomental fold creates a base and support column for the oral commissure. The blue represents the deep layer, the magenta represents the mid-subcutaneous level and the yellow represents the mid-dermal level; (B) enforces the support column concept.

The nasolabial fold and melolabial fold can also be treated with a flexible blunt cannula. Some patients can be treated solely with the cannula ( Fig. 10.37 ). Extremely deep folds may also require intradermal injection with a needle. The cannula can be used to create the base and the needle used to finish the augmentation intradermally.

The flexible blunt-tipped cannula is an effective way to augment the melolabial folds but deep folds may also require intradermal injection with a needle, as the cannula is less effective for extremely superficial injection.

Once the melolabial fold has been addressed, the depressed or downturned commissure is treated. A small amount of filler can be injected directly into the fold in the commissure but this is a region where the filler can move laterally, so only a small amount is injected. The goal is to fill this crevice and upturn the corner of the mouth without creating a puffy appearance.

After a small amount of filler is placed directly in the commissure, the distal corner of both lips are filled at the commissure. It is important to have a distinct angle at the commissure and this also helps elevate the mouth corners ( Fig. 10.38 ). Fig. 10.39 shows a patient with severe aging of the commissures and melolabial regions before and immediately after injection. These techniques of establishing the melomental pillar and filling the lip corners are used to elevate the commissures. It is important to stop after filling the first side and show the patient the result ( Fig. 10.40 ). The reason this is done is to they can appreciate the difference. If both sides are treated before the patient looks in the mirror they may not be able to note the significant difference. Figs. 10.41 and 10.42 show actual cases, where I stopped on the first side to show the patient the difference.

(A) The filler injected directly into the sunken commissure. (B) The corners of each lip injected for fullness and lift. The combination of the melomental pillar and these three injection sites can improve this region substantially.

A patient before and immediately after filler injection of four syringes of hyaluronic acid filler in the nasolabial folds, commissures, melomental folds, mentolabial fold, and lipstick lines.

Stopping in the middle of the procedure to show the patient the difference in improvement on the first side is very effective in reinforcing their realization of the treatment. If they look at the result after both sides are treated, their impression may not be as accurate.

This patient is shown after uplifting the commissure on one side and before the other side was treated.

This patient is shown after uplifting the commissure on one side and before the other side was treated.

Although most filler injection is performed solely for aesthetic reasons, there is a functional application for commissure and melomental fold treatment. Filler in this region can improve or sometimes prevent Candida albicans infection. Angular cheilitis (also called “perlèche”) is a common irritation/infection in the oral commissure area and can extend into the melomental folds. This occurs when “drool lines” form and entrap saliva, which causes irritation and creates a “yeast-friendly” environment. This is especially common in older patients who have skeletal and dental tissue loss that collapses the soft tissues. This is treated with antifungal medications, but in the presence of deep or redundant soft tissue, it can be very resistant.

By filling the crevices, there is less moist, deep, and dark yeast-friendly areas. Fig. 10.43 shows a before and after filler injection for perioral rhytids that were associated with angular cheilitis. The condition cleared within 1 week after filling.

Chronic irritation from angular cheilitis, resulting from accumulation of saliva in the “drool lines,” which was cured by augmenting the melomental folds.

Augmenting the Mentolabial Fold

The mentolabial fold represents the region below the lower lip and above the chin. In youth, this fold has a pleasing S curve that deepens with aging. In addition, this fold is greatly affected by the position of the jaw, chin, and teeth. In patients with microgenia, retrognathia, or lower facial vertical-third height deficiency, this fold can be very deep, with an overhanging lower lip. Some patients present with a simple deepened fold from aging and, as in any other facial fold or wrinkle, the region is augmented with filler ( Fig. 10.46 ). A deep fold can take several syringes to correct or improve. The first injections are placed in the deeper subcutaneous regions to buttress the augmentation, and the remaining injections are layered in the mid-subcutaneous layer and finally in the dermis. This layering support can significantly improve the depression, lift the ptotic lip, and give an appearance of increased lower facial third vertical height ( Figs. 10.47 , 10.48 ).

Injecting the mentolabial fold can improve the short face appearance of the overhanging lip. This is performed in multiple layers to serve as a base to support the deep fold.

A patient before and after 2 mL of hyaluronic acid filler.

Before and after 3 mL of hyaluronic acid filler. Note that not only is the mentolabial fold improved, but the lip is pushed up and the chin is pushed down. This combined augmentation can actually increase a deficient lower facial third.

Midfacial Filler Treatment

Filler Augmentation of Nasolabial Folds

The nasolabial folds (NLF), which are sometimes called the melolabial folds, are very popular injection options and treatment is faster and has fewer nuances than the lips. The nasolabial folds are a complex anatomic structure caused in part by the merging of various tissue planes from skin to bone. The descent of the malar fat pad, decades of facial animation, and numerous other factors influence the deepening of the NFL.

Before treating this area, it is important to give the patient an accurate idea of what to expect and an opportunity to provide their own input, as to how they want the fold changed. In most adults, the fold extends from the lateral nasal region and can merge with the melomental folds (marionette lines). Other patients exhibit anatomy where the NLF merges with the “smile dimples” lateral to the oral commissures. Some patients desire augmentation high on the fold to correct the paranasal depressions, whereas this region does not bother other patients, whose desire may lie in augmentation lower on the fold or even in the perioral region. I explain that the NLF will not “go away”; our goal is to soften it. I further explain that the NLF is a valley, and we want to blunt the fold, not eliminate it. Finally, I never inject an adult with a single syringe of product. In reality, most adults in their fifth decade could easily accommodate three or four syringes. Filler is expensive and it is only natural for patients to want to economize. The pre-filler consult and communication can be as important as the final result.

When treating the NLF, all makeup is wiped off with alcohol, the folds are marked, and topical anesthesia is applied to the skin. I am an absolute proponent for painless injections and I use local anesthetic infiltrations for all filler injections. The anesthetic technique for the NLF is simple. A 1-mL syringe with a 33-gauge needle (same set up as neurotoxins) is used with 2% lidocaine with 1 : 100,000 epinephrine. We keep a container of these filled syringes in each treatment room, since we use them for many procedures. When using local anesthesia for folds or wrinkles, it is important to inject it deep to prevent distorting the anatomy of the fold or wrinkle, which can affect the accuracy of the result. I generally inject 0.1 mL of local anesthetic at several points along the fold. The first injection is in the area of the nasal ala (a painful region to inject filler), another injection is placed in the mid-fold, and frequently a third injection is placed at the inferior portion of the fold. I make a point to the patient that pain control is very important in our practice and this has paid off many times over in new referrals. The skin does not need to be totally numb, only enough to take the edge off the discomfort.

Patients should not be positioned supine for filler injections because gravity will significantly affect the anatomy of the fold, making accurate treatment difficult. I use a combination of the two methods of linear threading and serial puncture for treating the NLF. Needle position is important, as injecting too deep will not improve the fold and injecting too superficially can produce a bumpy or unnatural appearance. In younger patients, an intradermal injection plane is acceptable to improve a shallow fold ( Fig. 10.49 ). In patients with moderate aging changes, a deep dermal/subcutaneous and superficial dermal layer may be warranted. In older patients with deeper folds, I prefer to layer the filler in three planes. I first perform a deep subcutaneous layer to provide a base, then more superficial subcutaneous injections to create midlevel support, and finally dermal injections to fill the surface layer ( Fig. 10.50 ). The combination of this layering improves longevity and result, as it addresses the fold in multiple layers.

Younger patients with shallow nasolabial folds can be corrected with superficial injection.

The concept of trilevel filler layering. The blue layer is deep subcutaneous, the red layer is more superficial subcutaneous layering, and the white is dermal layering. This combination has proven to provide the best base, support, result, and longevity. Younger patients may not need multiple layers.

Some patients have paranasal depressions on the lateral nose at the superior portion of the fold and request treatment in this area as well. This is a normal anatomic contour, even in young people, so complete filling is not usually advisable. Older patients, denture patients, or patients with maxillary deficiency may benefit from filling this area. It can be filled as an isolated area but more commonly in conjunction with the entire fold ( Fig. 10.51 ).

Augmentation of the paranasal depressions as an isolated unit (yellow), but more commonly this area is treated in conjunction with the entire fold (yellow and white). Not all patients require or benefit from augmenting this region.

A huge pearl to remember when treating the NLF (or any fold or wrinkle) is that if you cannot see immediate improvement, the needle is probably in an incorrect plane. Many novice injectors place the filler too deep and it does not plump out the fold. If immediate noticeable improvement is not seen, the needle needs to be positioned more superficially. Due to the unique anatomic planes of the NLF, even while injecting in the center of the crease, the filler can migrate laterally and create a lateral ridge ( Fig. 10.52 ). This can actually make the NLF bigger. If the filler migrates laterally during the injection, the needle is directed more medially before continuing the injection. Remember with this, what you see is what you get.

Even with the tip of the needle in the central portion of the fold, the filler can migrate laterally and worsen the fold. If the surgeon sees the filler migrating laterally, the needle needs to be repositioned so the filler enters the intended target. The injector should always see the immediate improvement of the injection.

Another means of facilitating NLF filler is to put the cheek on stretch with the non-injection hand. This tension will turn a curvilinear structure into a straight line, making it easier to inject ( Fig. 10.53 ).

Placing the nasolabial fold on stretch while injecting, is a method of controlling the fold and filler.

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