Best practices when injecting the perioral area

It is vital to consider other aspects of the face when using cosmetic products for rejuvenation of the lips and perioral area, say panelists here at the annual meeting of the Canadian Association of Aesthetic Medicine.

Murad Alam M.D."The main thing is you want to keep an eye on the patient's overall look," said Murad Alam M.D., professor of dermatology, otolaryngology, and surgery, and chief of the Section of Cutaneous and Aesthetic Surgery at Northwestern University's Feinberg School of Medicine in Chicago, Ill.

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"Don't inject laterally, on the sides of the oral commissure. You can get bumps that protrude and look unnatural,” he says. “Youthful people do not have bumps next to the corner of their lips. As always, the goal is not eradication of every line and wrinkle, but a normal, natural appearance that works for a particular patient."

Vince Bertucci M.D.Vince Bertucci M.D., F.R.C.P.C., a dermatologist, president of the Canadian Dermatology Association, and Medical Director at Bertucci MedSpa in Woodbridge, Ontario, stressed that it is key to evaluate the lips in the context of the whole face.

"You can't look at the lips in isolation," Dr. Bertucci says. "You have to consider how the lips fit with the rest of the face: nose, cheeks, teeth, mandible. It's important to walk around the table and assess the perioral region from multiple angles."

Fillers for structural support

For patients that might benefit from enhanced vermillion show or lip eversion, Dr. Bertucci suggests the use of a structural filler such as Juvederm Volift (Allergan), Restylane (Galderma) or Emervel Lips (Galderma, not approved by the U.S. Food and Drug Administration) as each of those fillers provides structural support, allowing more pink show.

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"Fillers such as Restylane Fine Lines  (known as Restylane Silk in the United States) and Juvederm Volbella (Allergan) are best used for lip hydration and effacement of fine lines and wrinkles in the lips and perioral region," Dr. Bertucci says. "These latter two fillers tend to offer less structural support."

NEXT: HA vs. non-HA considerations

HA vs. non-HA considerations

The choice of hyaluronic acid (HA) filler versus non-HA filler should take into account several parameters. Fillers with high lift capacity can be injected into marionette lines and nasolabial folds, for example, but Dr. Bertucci suggests using a cannula, rather than a needle, if such a filler is injected.

"When I use Radiesse (Merz Aesthetics), I often prefer to inject it with a cannula because, unlike for HA fillers, we don't have an eraser for Radiesse," Dr. Bertucci says. "Intuitively, it makes sense that use of a cannula might decrease the risk of intravascular injection."

Sonya Cook M.D.Sonya Cook M.D., F.R.C.P.C., a dermatologist in Toronto and co-founder of Compass Dermatology, cautioned against using a filler like Radiesse close to the oral commissure.

"I don't use Radiesse in the lips or close to the lips in the corner of the mouth because it can result in the formation of nodules," Dr. Cook says. "You should inform the patient of this potential complication."

Still, a long-lasting filler like Radiesse offers longevity and can be more cost-effective for patients requiring dramatic change, Dr. Alam says.

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"If you need a lot of filler, it may be more economical to use filler like Radiesse because it will often last longer (than an HA filler)," Dr. Alam tells Dermatology Times. "Additionally, if a patient has relatively more volume loss, thicker filler placed deeper provides a pleasing lift and correction."                                                                                                                                                                                                 

Pain reduction

In terms of reducing pain through the perioral rejuvenation process, Dr. Alam says it is wise to ask patients if they have undergone injection with fillers before and if they had experienced pain. In using Radiesse, Dr. Alam says he may mix lidocaine with the filler, adjusting the concentration of lidocaine to get adequate pain relief while also ensuring that the filler viscosity is just right for the area being injected. When a patient is particularly anxious about injection, Dr. Alam may use nerve blocks.

NEXT: Avoiding complications

Avoiding complications

Dr. Bertucci provides tips to avoid unnatural projection of the lips.

"Don't over- fill the lateral lips," he says. "Filling in too much creates unusual lip projection and proportion."

To create upper lip projection, Dr. Bertucci suggests clinicians position themselves at the head of the bed with the patient lying nearly flat and inject small aliquots downwards into the upper lip, avoiding overly deep injection so as  to prevent cannulation of the labial artery.

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To define Cupid's bow, he advised injecting small aliquots at several points.

"After filling the rest of the lips, re-assess the area to see if there is appropriate projection and proportion," he says.

To minimize the risk of bleeding, Dr. Cook suggests clinicians change their needles after every six pokes. Most patients will find topical anesthesia is sufficient for tolerating pain associated with injecting filler in the lips, but stronger pain management may be appropriate if they have expressed previous unsatisfactory experiences with injections.

"If a patient is very sensitive to pain, I perform a lip ring block prior to filler treatment of the lips. I anesthetize the mucosa at the injection sites along the gingivobuccal margin with topical anesthetic to further aid in pain relief," Dr. Cook says.

For inexperienced injectors approaching the perioral region, the easiest technique is to inject just inside the vermilion border, using a linear threading technique, Dr. Bertucci says.

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"Define the vermilion border and give volume," Dr. Bertucci says. "But don't overdo it in individuals who have an elongated cutaneous upper lip so as to avoid creating a 'ski jump' appearance of the upper lip."

Both a cannula and a needle have their utilities in perioral rejuvenation.

"You don't want to become religious about particular adherence," Dr. Alam says. "Sometimes a cannula is better, and sometimes a needle is better."

Disclosures: Dr. Bertucci has been a speaker, consultant, and/or investigator for Allergan, Evolus, Galderma, Merz, Prollenium, and Revance. Dr. Alam reported no relevant financial disclosures. Dr. Cook has done consulting for or been a member of advisory boards for Merz, Allergan, Galderma.