Smaller procedures achieve big results

"Sometimes around the mouth," says James H. Carraway, M.D., "I'll use CosmoDerm (human collagen, Inamed) for the finer lines, Botox (botulinum toxin, Allergan) to prevent smoker's lines in the lip and to smooth out the perioral creases, fat grafts underneath the perioral creases to underlift them, fat grafts to the anterior cheeks and lips, upper and lower as needed, and Restylane (hyaluronic acid, Q-Med) to the white roll. These treatments can make a remarkable difference." Dr. Carraway is professor and chairman, division of plastic surgery, Eastern Virginia Medical School.

Quick fix

"There's a whole market of people who could never afford big plastic surgery, but who can afford Botox, Restylane and fat grafting."

These procedures provide quicker recovery times and are easier on the pocketbook, he notes.

For fat grafts in the perioral and anterior cheek areas, Dr. Carraway says he harvests fat with an open-bore, 14-gauge needle. He processes the fat by placing it in a container with small neurocottonoids (Codman) to draw out the serum and local anesthetic.

Using a TB syringe (Luer-loc) and a 20-gauge, 1.5-inch needle, Dr. Carraway says he injects fat into multiple areas around the hollows and defects created by fat atrophy.

To treat creases, he says, "I use the bevel of the needle to undercut or underlift the creases to smooth them out. That can give a very dramatic result."

Conversely, he says he uses liposuction with a 1 mm single-hole cannula to remove perioral fat bulges that are difficult to treat any other way.

For Restylane in the white roll of the upper or lower lip, Dr. Carraway says he usually begins with a (local anesthesia) lip block, "then I run a 1.5-inch, 27-gauge needle along the white roll. And as I withdraw, I inject the Restylane," he explains. If the resulting area is tense and tight to the touch, he adds, "That's probably enough. If it's still soft, I make another pass."

Dr. Carraway says that sometimes, he will use fat grafts in the white roll.

"But it's not as distinct and pretty as Restylane," he says. "However, to give more bulk to the upper lip and to widen the vermilion and cause it to turn out, I'll inject (fat grafts) in transverse rows in the submucosal area, beginning at the wet line of the lip."

Typically he uses three rows and 2 cc of fat total, injected with a TB syringe and a 20-gauge needle.

Lip lift

Sometimes, Dr. Carraway says, he performs a lip lift in conjunction with fat grafting.

To perform this procedure, he says, "Make an incision in the perialar crease at the end of the nostril sill and across the columella, undermine two-thirds of the way down the lip, and lift that skin up."

He says this procedure rolls up and exposes the vermilion, whose excess can be trimmed appropriately and sutured in place to essentially shorten the vertical height of the lip while improving the width of the vermilion.