More than lip service: Lower face options minimize downtime

"I love the hyaluronans in lips because they feel really natural to the patient and the patient's significant other," says Jean D. Carruthers, M.D., clinical professor of ophthalmology at the University of British Columbia. "One doesn't want to have something in the lips that's hard, uncomfortable or embarrassing for the person."

"It tends to give a very nice plumping effect to the red lip, as opposed to the more traditional collagen products, which actually outline the lips much better than Restylane (Q-Med), for example," Dr. Carruthers explains.

Natural lip

When injecting Restylane, she says, "I like to see the lip as it is naturally, so we use topical betacaine or ELA-Max (lidocaine, Ferndale Laboratories) to numb the surface of the lip."

Dr. Carruthers also uses a massager held on the opposite side of the lip being injected in about 80 percent of cases to distract patients from any discomfort.

Potential complications from Restylane injections include occasional bruising, swelling (in 5 to 10 percent of Dr. Carruthers' patients) and gathering of the material into transient lumps (in about 20 percent of cases), Dr. Carruthers adds. Ensuring that patients avoid aspirin, vitamin E and non-steroidal anti-inflammatory drugs before the procedure can reduce bruising, she says.

Other products

Other HA products include Hylaform and Captique (both made by Inamed).

"I find Hylaform lasts probably two-thirds as long as Restylane. I've pretty much stopped using (Hylaform) for that reason," Dr. Carruthers says. Additionally, she says the fact that Hylaform is made from nongendered chicken combs gives many patients pause in light of the H5N1 avian flu threat, in similar fashion to the concern about prion disease in bovine-based collagen products.

Conversely, she says Captique's manufacturing process relies on laboratory bacteria. Dr. Carruthers adds that Perlane (Q-Med) offers larger particles than Restylane and lasts longer in areas including the lips and perioral region.

In the future, Dr. Carruthers says manufacturers will offer a wider array of particle sizes. Additionally, she says Juvederm (HA, Corneal), available in Canada, one day will be marketed stateside. With an increasing array of options, she says, "Layering is going to be the trend."

When using Botox (Allergan) to lift the corners of the mouth, Dr. Carruthers says, "If one weakens the depressor anguli oris, one allows the muscles that work against it to have more play."

When performing such injections, she says, "It's important to get the anatomy right, because if one injects too far forward, one can get diffusion into depressor labii," which can create phonation problems that last up to eight months. To avoid this problem, she says she asks patients to tense their jaws because this helps her locate the anterior border of the masseter muscle.

Going forward

Going forward, Dr. Carruthers predicts that other neurotoxins will become available. Reloxin (Inamed/Ipsen) and Xeomin (Merz Pharma) already are approved in Europe, she notes. In North America, Mentor continues clinical trials of Puretox, adds Dr. Carruthers.