Non-invasive aesthetic treatments represent an alternative to the more invasive procedures in today's growing industry (Bertossi et al, 2018). Now an integral part of practice, dermal fillers are essential in creating a soft tissue enhancement, and one of the most popular areas in which they are used is the lips. The lips are one of the major attractive components of the face (Tansatit et al, 2017), and lipenhancing procedures have proven to be among the most popular aesthetics treatments in non-surgical aesthetics. The popularity of this procedure is due to the fact that it can achieve lasting volume, shape and definition in the peri-oral region. This can create a more youthful and pronounced appearance that many find to give an immediately satisfying outcome, often associated with beauty.
For these reasons, this treatment has become one of the most sought after in the medical aesthetic sector. However, this can pose a great challenge at times, in particular, the lack of insight associated with the limits to enhancing natural structures of the lip, along with little to no understanding of the functions of hyaluronic acid (HA) fillers. It is important that both the patient and the practitioner understand the process and limits involved.
A common request in my practice is the request for a sharp and well-defined Cupid's bow. Patients want to see visible change and usually relate this to photos found online. The consultation process is important in establishing exactly what change the patient wants, along with a detailed explanation of what is achievable. There is also weight in understanding the patients journey, if applicable, because the majority of patients looking into having a lip procedure will have either had treatment previously, researched the process or know someone who has an experience of some kind. This detail is the pivotal point in relationship building, allowing the injector to begin to understand any emotional aspects of the patient's expectations of treatment.
Assessment of the lip and peri-oral region
An important process is assessment, planning and implementing (Seitz et al, 2019). As responsible practitioners, we must ask ourselves valuable questions during an examination. Although lip augmentation is one of the first things practitioners learn in their foundation training, and is therefore sometimes considered to be a simple technique to perform, it is a procedure that is often followed by inadequate results (Tansatit et al, 2014). The first step is to find out what the patient wants. The healthcare professional should then ask themselves the following questions, with regard to the patient's needs:
The treatment should be used to improve the peri-oral region with a goal of providing profile harmonisation that complements the patient's unique features (Braun et al, 2010). In order to deliver a safe treatment, a mental and physical examination is essential. Taking a detailed medical history is just as important as effective communication; displaying these skills, as well as a high level of empathy, predicts a higher level of patient satisfaction (Seitz et al, 2019). It is therefore in both the patient's and the practitioner's best interests to take time over this process.
Clinicians should be aware of individuals who may seek cosmetic procedures that are out of proportion to physical findings (Vashi, 2016). BDD effects a large number of the population, with a majority of its population found in individuals who seek procedures in the aesthetics and dermatology sectors (Bewley and Dimitrov, 2015). It is therefore important the clinician is confident in recognising the symptoms of this disorder. The current standard for assessing BDD is the Yale Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) (Wilhelm et al, 2016); however, there are various other guidelines that may also assist practitioners in the assessment of BDD, such as:
Overall, BDD is a complex mental health condition (Dey et al, 2015). It should be discussed with the patient and onwards referral for management is key. Aesthetic practitioners should have a protocol in place for referring patients of concern on to a specialist. In most cases, once the problem is recognised, treatment to resolve the disorder is successful (Bewley and Dimitrov, 2015).
Following a full medical assessment, examination of the peri-oral region should be made at rest and on animation (de Maio et al, 2017). The healthcare professional should examine for volume of the lip body, presence of the vermillion border, philtrum and cupids bow, marking these areas for easy guidance. The teeth and oral cavity should also be examined, and any discrepancies found discussed with the patient.
Anatomy of the peri-oral region during examination should be the priority in understanding where the high-risk areas for injection are. The Cupid's bow is a delicate and sensitive region, therefore position and depth of injection is important for optimal results and safety. Equally just as important is understanding the typical position of the labial artery and how the anastomotic arch provides multiple perpendicular subcutaneous branches to the nasal alar and septum (Tansatit et al, 2014). Penetration of these vessels could lead to severe bruising, or on rare occasions occlusion and tissue death.
Technique for injecting the Cupid's bow
The Cupid's bow is highly sensitive, therefore a topical anaesthetic for a minimum of 20 minutes, followed by a slow injection, is appropriate for optimal patient comfort. Some advanced practitioners may offer a local nerve infiltration or dental block, depending on their background. As per eMC drug guidelines for the use of Lidocaine, appropriate resuscitation equipment should be available when administering local anaesthetic (Medicines.org.uk, 2019). In the author's experience, local nerve filtration is highly effective for injection into this area, with a profound numbness lasting on average 30 minutes.
Starting with the vermillion border and Cupid's bow will allow for better judgement of product placement prior to the onset of trauma oedema. This will also provide lift and shape to the structure of the lips. Using a retrograde linear thread, the healthcare professional should inject superficially into the white roll, paying respect to the potential of anatomical variances of the vermillion border. One cadaver study of Asian head specimens found that in 25% of cases, the superior labial artery (SLA) ran on top of the orbicularis oris, with the other 75% showing the SLA running behind the orbicularis oris (Cotofana et al, 2017). Another study found the majority running behind the obicularis oris and adjacent to the oral mucosa (Tansatit et al, 2014). There are also cases where the SLA runs intramuscular. This said, the most frequent position found was the submucosal position (Cotofana et al, 2017).
The use of a superficial injection along with fine linear threads or micro-aliquots to the Cupid's bow and white roll will help achieve projection; 0.1–0.2 ml is usually adequate. Equal amounts should be placed into each side, unless there is a noted asymmetry (de Maio et al, 2017), in which case it would be appropriate for the healthcare professional to ‘dose adjust’ in accordance with their judgement. It is also possible to place a vertical strut of filler from the top of the Cupid's bow to the wet–dry border to give greater surface area (Miller, 2018). This is useful for structuring diagonal lip body in patients with thin lips. Cadaveric studies have shown there to be greater risk to vascular damage using this technique due to the vermillion borders sitting closely together and the overall findings of vascular lay out presenting in a tortious manner (Tansatit et al, 2017). A very cautious approach is required in this instance. When inserting the needle diagonally from the tip of the vermillion into the central tubercle, the healthcare professional must pay careful attention to the syringe and avoid injecting the intra-oral submucosal plane. The practitioner should avoid overcorrecting, as this may lead to poor product placement and sub-optimal treatment outcomes. Following this step, a slow and steady injection into the lip body is recommended.
The philtrum column plays an important role in scaffolding the structure of the Cupid's bow (Penna et al, 2015). The needle can be inserted sub-dermally at the tip of each Cupid's bow and inserted upwards towards the septum. A small retrograde linear thread should be slowly injected while pinching the outline of the needle placement with the opposing hand. This technique helps to prevent an unpredictable spread of dermal filler into surrounding planes and provides a solid firm thread of filler resulting in definition of each column. Approximately 0.025–0.05 ml is adequate for improvement.
Precise identification of the red and white rolls, arc of the Cupid's bow, philtrum and dental examination gives the injector a framework for constructing precise and symmetrical lip enhancement (Surek et al, 2015).
Product selection and product volume
The author's product of choice for this procedure is Juvederm (Allergan), which is a range of injectable filler suitable for soft tissue rejuvenation. Juvederm is a soft HA gel, based on stabilised HA of non-animal origin, crosslinked with butanediol diglycidyl ether (BDDE) (Sharma and Sharma, 2011). Great for contouring, volumising and correction, the range of HA fillers have a high degree of cross-linking accounting for its longevity as a gel (Allemann and Baumann, 2008). The gel is highly cohesive and integrates well within the dermis. Volumes for injection are person dependent. Some extremes of peri-oral volume loss may take several treatments ranging from suitable volumes of 0.5–4.0 ml, depending on the areas of the region to be filled. However, enhancing the cupids bow needs to be conservatively treated.
The author chooses to inject 0.05–0.1 ml from the vermillion up and into the Cupid's bow. A further 0.05 ml may be used to enhance the philtrum. For example, Volbella 15 mg/mL HA, for use in the older lip, is effective and because of its low lifting capacity, beneficial in tissue lacking volume and strength. This product will improve oral rhytids and enhance the tissue naturally. On the other hand, Volift 17.5 mg/mL HA has a higher lifting capacity and is therefore appropriate to use in younger tissue for volume and fullness, while still maintaining tissue flexibility and a natural appearance. The Vycross range is versatile across the entire face and boasts long lasting results (Goodman et al, 2015). In some cases, a combination of high G-Prime filler for sharp definition to bow and border with lower G-Prime for subtle lip volume to the body. This has worked well in the author's practice, with a high rate of patient satisfaction.
Conclusion
Precise identification of the red and white rolls, arc of the Cupid's bow, philtrum and dental examination gives the injector a framework for constructing precise and symmetrical lip enhancement. The injector should also have a good knowledge of their product choice, its longevity, gel structure and ability to effectively integrate, and should also ensure that any off-license use of HA fillers is discussed explicitly with the patient, with supporting documentation completed. Overall, the treatment should be used to improve the peri-oral region with a goal of providing profile harmonisation that complements the patient's unique features.