Vermilion Dollar Lips: Lip and Perioral augmentation for the Esthetic Health Care Practitioner [1 ed.] 0979719607

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Vermilion D o l l a r

L i p s

Robert Gordon DDS

Lip and Perioral Augmentation for the Cosmetic Dentist

D edication First and foremost, I would like to dedicate this book to my mother Carol Gordon. The greatest gift she ever gave me was passion: passion to pursue whatever I dreamed possible…she was always supportive and never discouraged me. I will miss her the most, but I’m sure she is looking down and guiding me from above. My children Lance and Sidney who suffered the endless hours of me reading literature and researching this book. There were times they would look at me and ask me something, knowing my mind was miles away in what they called “Book Land.” To my father, for always being there for me. To my staff, patients and colleagues who put up with my endless and tireless conversations on and about everything to do with lips. I also would like to dedicate this book to those who have chosen to engage in this new and exciting journey with me. You all have inspired me with your exuberance, passion and conviction. It is an honor to be a part of something that becomes bigger than oneself everyday.

Vermilion D o l l a r

L i p s

1st Edition

Robert W. Gordon DDS

Vermilion Dollar Publications

Vermilion Dollar Publications Vice Ink Production © 2007 By Robert Gordon DDS All Rights reserved. Printed in the USA. No part of this publication can be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system now known or to be invented, in any form without prior written authorization from Vermilion Dollar Publications. Vermilion Dollar Publications P.O. Box 55006 St. Petersburg, FL 33732-5006 1-877-LIP-FILL (877-547-3455) http://www.vermiliondollarlips.com [email protected] ISBN-13 978-0-9797196-0-8 ISBN-10 0-9797196-0-7 Publisher

Vermilion Dollar Publications

Editorial Staff Photographers

Nicole Palmer, Sue Moen, Chris Jenkins

Cover Photo

Dr. Robert Gordon (augmented lips)

Cover Model

Natalie Delgado

Designer

Jerome Frederick

Technical Advisor and Webmaster

Chris Jenkins

With Special Thanks to

Kenneth Grundset DDS J. Mel Hawkins DDS Ronald Kobernick DDS



Dr. Robert Gordon, John Fisher, Luca Guarneri

Contents Foreword



introduction CHAPTER 1: Vermilion Dollar Lips The Art of Augmentation

The Science of Augmentation Is Augmentation for You? The Business of Oral-Facial Augmentation Your First Seminar Marketing Your Cosmetic Lip and Perioral Practice FDA Guidelines and Regulations The Psychology of the Lips

CHAPTER 2: The Canvas Dr. Gordon’s Lip and Perioral Classification

Zones and Segments of the Lips Anatomy Nerves Oral-Facial Aging Vascularity

CHAPTER 3: Anesthesia Local Anesthesia for Oral-Facial Augmentation

Delivery of Injectable Anesthetic Delivering Local Anesthetic Oral-Facial Anesthesia Techniques

CHAPTER 4: The Medium History of Fillers

Injectable Fillers FDA Classification and Use of Fillers Common Classification and Use of Fillers Permanent vs. Non-Permanent Fillers

3 5 6 7 7 9 11 15 15

23 27 31 40 44 49 49

57 61 67 73 73

81 85 85 86 88 88

CHAPTER 5: The Artist Beautiful Proportions

Fashion Trends of Lips: Past and Present Orthodontics Art of the Fill Photographic Documentation

CHAPTER 6: INJECTION PROCEDURES AND TECHNIQUES Lips

Oral-Facial Skin Technical Considerations Adverse Reactions and Complications

CHAPTER 7: Simply Botox Botox (Clostridium Botulinum Toxin)

109 113 117 121 124 128

135 139 148 148

153 161

Armament Perioral Injection Techniques for Botox

165 168 169

CHAPTER 8: CLINICAL TECHNIQUES – LIP AND PERIORAL, Botox AND FILLERS

181

Clinical Techniques: Oral-Facial Augmentation Ages 20-30 Ages 30-40 Ages 40-50 Ages 50+

185 189 199 213 225

SOME FINAL WORDS

236

REFERENCES

238

INDEX

239

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Robert Gordon

Chapter 1 Vermilion Dollar Lips

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Foreword Vermilion Dollar Lips® is a discipline that focuses on the observation, planning, treatment, and reconstruction of the oral-facial area as a whole, so that the teeth and lips are recreated to complement one another. This specialized triad of treatment merges the “canvas,” “medium,” and “artist”: the human body, fillers, and the cosmetic dentist. There are currently few case studies that focus on the merger of the oral-facial soft tissue and the dental field. Yet these two areas are inseparable and must be addressed as a collective discipline in order to achieve optimal results. Within these pages, this innovative approach will be explained in detail in order to provide you a thorough and supportive guide for diagnosing and creating an appropriate treatment plan to augment your patients’ oral-facial tissue. Due to the diversity of practitioners who conduct oral-facial augmentation, there is a noticeable absence of uniform treatment planning, material selection, and application among the various specialists. In the United States alone, fillers are now being performed by aestheticians, nurses, nurse practitioners, and physician assistants, doctors of osteopathy, medical doctors, and dentists. It is my goal to unite the body of practitioners who perform oral-facial augmentation, to introduce new perspectives that facilitate the planning and treatment of patients who wish to augment their lips and perioral areas, to stimulate debate among active practitioners, and to provide additional research and an organized body of information in this exciting field.

It has been said that when we are born, we are endowed with the secret of creation. So that we do not disclose this information, we are touched on our lips to seal these secrets. To mark this covenant, we are branded with the curvature on our lips from the indentation of our angel’s touch. This forms Cupid’s bow.

Lips: Why are we so fascinated by them? Without a doubt, our lips are one of the

most sensual and sensitive parts of the human body. Our lips are one of the body’s most intimate sensory organs. They allow us to connect with our surroundings. Life-sustaining nutrients pass through our lips during infancy. We rely on our lips to explore and communicate. We use them to capture the mist of the tide’s salts as we walk on the early morning beach. We explore our first love with trembling lips and bite our lips with anticipation, awaiting their return. Through the years, there has always been an intense interest in lip enhancement through cosmetics, fillers—or even by over-the-counter topical ointments that cause a reaction to increase the volume of the lips. Dentists today are becoming more cosmetically savvy because of the social demands for exquisite lips, delving further into the psychosocial realm of a clearly defined aesthetic connection between each individual’s lips and teeth. Dentists are also all too aware of the psychosocial connection between teeth and aesthetics, and the contemporary dentist is now confronted with a paradigmatic change in the practice of dentistry which focuses on lip enhancement. We work with lips and the perioral area every day, redefining smiles through sophisticated treatments in cosmetic dentistry. We anesthetize lips, retract them, and suture them when patients present with oral-facial trauma.1

During the past few years, I have experienced this revolution in my own practice in

Florida. I have seen firsthand a sequela of botched lip jobs, the limitations of lip distention from scar tissue, and the masking of normal dentition that resulted from overfilling the lips. No other medical specialist has as much contact with lips as we do.2,3 Our educational program trains us intimately with the vascular, nerve, muscle, and skeletal components that make up the lips.

We are clearly the experts within this arena, and the lips are the curtains for our

stage.

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Chapter 1

Vermilion Dollar Lips crede quod habes, et habes Believe that you have it, and you do.

The Art of Augmentation The Science of Augmentation The Business of Oral-Facial Augmentation

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While dermatologic and aesthetic journals deal with substances for implantation, these journals do not, in themselves, hold information regarding the proper goal of lip enhancement. Instead, the answer is found in the dental literature where many articles have addressed the proper height, size and location of the lips as produced by dental restorations. Dr. Arnold Klein, Professor

the syringe. Instead, as skilled specialists, we focus on the flow of the material; every fill of space and plane is now carefully scrutinized and measured subjectively, not analytically. At that moment, we become a cosmetic and aesthetic augmenter.

In oral-facial augmentation, the artist must know: Medium (Anatomy) Material (Fillers) University of California School of Medicine Trends / Artistic License Department of Dermatology The scientist, on the other hand, must The Art of Augmentation know: Augmentation of the lips has a significant Anatomy artistic component. Once the dentist is proFillers ficient in his techniques and materials of Techniques choice, the application transcends into an In other words, in this arena, the scientist artist’s creative arena. After learning how and artist must unite. This merger is estabto choose the correct material for the right lished upon a solid foundation comprised application, the art of augmentation takes over. It is sort of like learning to drive a THE ART OF THE FILL car. We don’t think about the mechanics of the engine combustion, we sit in the car and it becomes an extension of us. In dentistry, our “inner scientist” uses instruments to make observations. We are trained to use universally accepted methods to achieve predictable results that can be repeated successfully. The artist, however, works from a more subjective viewpoint in which there is a relative means of expression. Within this creative spectrum of skill and talent lies the art and science of the fill.

Becoming an Oral-Facial Augmenter “Artist” During our first lip and perioral augmentation, the technical expert in us constantly looks at the syringe and the amount of material injected into the lips. With practice and proficiency, however, there soon comes a time when we develop an artistic approach. Halfway through the lip-fill procedure, we don’t even look at

Canvas

Medium (fillers)

Methods (techniques)

of a full understanding of the human body, appropriate fillers, and masterful techniques. The elements of scientist and artist are inseparable in the practice of lip and perioral augmentation.

Enhancing Beauty Just as every face is different, so is every set of lips. It can be rather intimidating and stressful to try to fulfill each patient’s expectations based solely on aesthetics.

Chapter 1 Vermilion Dollar Lips

Artists face this same dilemma each time they apply a brush to an empty canvas.

technical application implemented. Once you become proficient in augmentation, As lip augmentation practitioners, our you’ll devote less attention to the sciengoal is to enhance beauty, not create it. tific aspect of the procedure and will give The fundamental principle is to augment more consideration to the artistic aspect of the natural form. Attempting to create a the augmentation. new shape will only lead to personal frus- When I first started my learning jourtration and patient disappointment. ney with lips and perioral augmentation, Keep in mind that we all interpret there were two distinct camps of thought beauty uniquely, based on what we ob- and instruction. The first were those who serve in our reflections in the mirror. taught based on their personal experiencWhen a lip augmentation specialist/artist es; these individuals related most of their deviates too far from what patients per- professional encounters to their teaching ceive to be a “natural look,” he or she may perspectives. Their approach emphasized indeed change their appearance, but these the quantity of patients they treated, often patients are likely to report that they only noting, “I have done thousands of lips,” look different, not younger or more rest- or “I have been doing lips for 20 years.” ed.

It is equally important to keep in mind the difficulty of duplicating someone else’s lips. If, for example, a patient pleads with you to give her Angelina Jolie’s lips, and you try to recreate this universally recognizable full-lipped smile, you will undoubtedly fail. After all, only one person on Earth has Angelina’s lips.

As you read this book, however, there are new materials awaiting FDA approval and numerous clinical trials now in progress. Techniques used for placing previous materials may no longer apply. Consequently, if our claim to expertise is validated merely by the quantity of patients we have treated, we lose our credibility as oral-facial augmentation experts if we do not stay current in this ever evolving field of cosmetic dentistry.

The key to successful lip augmentation is simple: Concentrate on the uniqueness of each patient’s lips. Focus on how you The second camp was comprised of can enhance each patient’s form and vol- those individuals who were relatively new to oral-facial augmentation and ume or lift her commissure.4 based their treatments on empirical data from a host of clinicians. Most often than The Science of Augmentation There is extensive research material not, members of this camp clung to a paravailable on augmentation materials, as ticular “guru” and his/her philosophy and well as corresponding clinical studies. Yet methodology. Unfortunately, these practithere is no formal standard in the edu- tioners had little experience in the field of cation of lip and perioral augmentation. oral-facial augmentation. Thus, they were Doctors either learn the science in their destined to suffer the growing pains assoresidencies during their continuing edu- ciated with the cosmetic field of lip and cation studies, or simply through trial and perioral augmentation. Their lack of expeerror. There is a definite learning curve for rience resulted in a range of misfortunes, perioral augmentation, and this is primar- such as an inability to identify a patient’s ily based on the materials used and the cosmetic wants or needs, mistreatment, or

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unfortunate and transient post-op mor- guide you through your own personal bidities, such as excessive bruising and journey in learning how to master the art swelling. of the fill. On the other hand, the advantage of being among these practitioners was the pioneering spirit they possessed. They were able to advance in the new cosmetic arena because of the exuberant energy they brought to the art and science of augmentation. In truth, success in the field of oralfacial augmentation lies somewhere between these two camps. Indeed, there should be a time-honored respect and regard for experience. But the reality is that the materials and methods of augmenting lips and the face are changing every year, and we need pioneers to pave the way for developing new and innovative treatment possibilities.

Is Augmentation for You? You may decide to incorporate fillers into your practice and or Botox (botulinum toxin treatment). You may do limited procedures on select patients, or you may advertise your flourishing oral-facial augmentation practice on highway billboard signs. The choice will be yours. However, if you do decide to add oralfacial augmentation to your dental practice, Vermilion Dollar Lips will guide you through a precise sequence of stages that together comprise the educational triad called “The Art of the Fill.” The book has been laid out in a step-by-step format that will provide you, my fellow dentists, expertise and insights into oral-facial augmentation from the viewpoint of one of your peers, who has built a successful and profitable oral-facial augmentation practice. In essence, the Vermilion Dollar Lips’ instructional format will introduce and

In time, you will learn how skills and experience in dentistry gives the oral-facial augmenter a competitive edge in the evolving practice of cosmetic dentistry. There are undoubtedly different ways of placing fillers and Botox than those that have been addressed in this book. In addition, new materials will likely be introduced after you read this book. However, no matter what the method or the material utilized, the foundation for “the art of the fill” will remain the same.

The Business of OralFacial Augmentation Incorporating Fillers and Botox into your Cosmetic Practice We are fortunate to participate in the practice of dentistry today. With the advent of technologically advanced treatments and techniques, we are no longer confined to just pulling teeth. Today, we are truly in a position to claim the title of oral-facial experts. The standard of dental cosmetic work is constantly improving. In contemporary practice, we are treating the teeth, mouth, and lips as they relate to the entire face. We are given opportunities to practice our professional skills daily. Because of this, we are constantly remodeling and improving our treatment methodologies. When considering the addition of oralfacial augmentation to your practice, take advantage of your current patient base. There may be quite a few of your patients that have or are undergoing lip augmentation. Tap into that resource. Ask your patients about their filler and Botox expe-

Chapter 1 Vermilion Dollar Lips

rience. Was it painful? Did they achieve the results they wanted? If not, why?

walls of your practice is especially critical in aesthetic and cosmetic dentistry, par After reading this book, you will ticularly when you begin to practice oralsee the lip and perioral area in a whole facial augmentation. new way, and you will most likely be If you do not have a marketing repreable to immediately identify those pa- sentative, consider consulting with varitients who have undergone lip or facial ous firms within your community for augmentation. their expertise on the most wide-reaching It is also helpful to study your com- and cost-efficient way to promote your munity; I think you will be surprised at practice and your new oral-facial augthe vast number of practitioners—from mentation services. I am certain that they nurses to physicians—who are augment- will agree that it is imperative to develop a thorough understanding of the area in ing lips and injecting Botox. which you will be marketing your prac Always consider the unique experience tice. and training you have as an oral expert and seize the opportunity to add oral-fa- As dentists, we are isolated in a “bubble” of dental professionals, and our cial augmentation to your practice. knowledge of advertising and marketing Internal Marketing is admittedly limited. In order to succeed In planning treatment for new pa- in building our practices or introducing tients, I highly recommend including a new services, we must rely on the experlip and perioral augmentation presenta- tise of local marketing professionals who tion in your initial evaluation. It is also have a thorough knowledge and extensive important to educate all of your patients understanding of the wants and needs of about the advantages of having their lip consumers within the communities they augmentation performed by you, the cos- serve. metic dentist. Hang posters and artwork In my own practice, I have found that that promote lip augmentation aware- hosting local seminars that are targeted to ness in your office. You may even wish to specific groups has been a very successful consider offering a free augmentation to means of promoting oral-facial augmenpatients who have undergone substantial tation services. dental work. There is no doubt that women within The patient’s experience and the num- your community will make up the majoriber of referrals he or she ultimately pro- ty of your oral-facial augmentation patient vides will greatly impact patient reten- base. Research various women’s groups tion and the success of your oral-facial in your area and approach their program augmentation practice. After all, most planners about offering their group memlip fillers you will inject are resorbent. As bers a free seminar. This seminar may professionals, we want every patient’s ex- include a demonstration of an augmenperience to be a positive one, so he or she tation procedure. You may even wish to returns for reaugmentation in 6 months. consider giving a free lip augmentation to one of their members as an added incenExternal Marketing Promoting your skills outside of the tive to booking a seminar.

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Remember: the cosmetic world is one of discretionary dollars. This means you will be competing with other doctors, procedures, and luxury items from which local consumers can choose.

Your First Seminar Setting up your first seminar can be a stressful undertaking. I encourage you to follow the guidelines I have provided, customizing and adapting your own seminars to fit the needs of the members of your community. Before you begin advertising your seminars, invite a group of your friends whom you can trust to be honest and critical to a “dress rehearsal” of your presentation. You may even want to film your presentation for your own selfevaluation. The following are some helpful tips on hosting a seminar that is both educational and engaging: Identify your audience and develop your presentation accordingly. Involve your audience. In order for your presentation to be a success, audience participation is a must. There are various ways to promote audience involvement. For example, I conduct a “Lip Quiz” by projecting slides of celebrities on the wall at the opening of the seminar. The initial photographs are close-up shots of famous mouths and lips. After asking the audience to identify who each smile belongs to, I show a full facial shot of the celebrity. This is an easy, effective, and entertaining way to

Chapter 1 Vermilion Dollar Lips

involve the seminar attendees in your presentation. Offer a gift. You may wish to consider offering a syringe of cross-linked hyaluronic acid (HA) treatment as a giveaway or perhaps a free bleaching that you will perform at your office. The gift you give could also be given as a prize for a lucky “Lip Quiz participant.” Assemble your information in a PowerPoint presentation, with approximately 40 slides. Include before and after pictures of oral-facial augmentation patients in your presentation. Plan a presentation that is approximately 50 minutes in length. Limit your introductory remarks and PowerPoint presentation to 20 minutes to allow 30 minutes to perform a live demonstration. Allow ample time for audience questions. This is the time to relax and fill in any voids in your presentation. Place a reasonable limit to this portion of your presentation, to allow yourself enough time to circulate the room. Keep in mind that you are not a guest speaker at a dental conference. You want the audience to become part of your practice, so it is critical to also allow time to network and connect with attendees. Ask a representative of your staff to attend the seminar with you. While you network with attendees, your staff member should stay by your side and carry an appointment book in which he or she can schedule patients who are interested in pursuing a personal consult. This will allow you to follow up with interested attendees in a definitive way, while allowing

you greater flexibility in circulating throughout the room and connecting with other members and their guests.

The Advantages of Presenting a Live Demonstration Including a live demonstration of oralfacial augmentation techniques during your seminar gives audience members an opportunity to witness firsthand the painless procedure of augmentation, the techniques used to fill certain areas, and the effect of pre-op and post-op fills. Be sure to select a patient that needs limited work so that the results of the demonstration are immediately visible. Select a patient that needs filler augmentation. With fillers, one sees an immediate result. Treatment with botulinum toxin will take days to produce results. Pick a particular facial area, such as the lips, the nasolabial fold, or the commissures. Due to time constraints, you will only want to choose one area, as one cannot justifiably do a good job on a patient’s full face in 20 minutes. If possible, block the audience’s view as you administer anesthesia to the patient. If you elect to do it in full view of all participants, do your best to obstruct view of the needle and its insertion point by rotating the patient in a direction that allows attendees only to see the deposition of the anesthetic. Try not to linger when administering the local anesthetic; the dental-aspirating carpule syringe is rather ominous in appearance. Quick and purposeful movement is always desired in order to ensure patient comfort. However, you don’t need to hesitate in showing the audience the needle or the augmenting syringe. The augmenting

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syringe is usually a 30 G ½ inch needle, you do not know the answer to a particwhich is not very intimidating. ular question. Offer to research the topic Keep in mind that most of the audience and contact the audience member after is probably familiar with dental blocks, so the seminar with the appropriate answer. be sure to refer to them as dental blocks. In fact, using proper terminology throughout your presentation will demonstrate your expertise and inspire questions from attendees who wish to know more about the procedure. Finally, always leave the audience wanting more.

In the cosmetic industry, there is a great deal of misinformation and widespread dissemination of “propaganda” that provides little or no service to the public. Always limit your opinions to your area of expertise, and when you share them, be certain to reveal the sources from which you acquired your facts and statistics.

Key Things to Remember During Marketing Your Cosmetic Lip and Perioral Practice your Presentation/Seminar Take Advantage of Today’s Technology When I conduct a live demonstration, I use a video camera feed on the model’s lips. The live images are projected onto a screen in the front of the room to allow the audience to watch the demonstration from their seats, without the need to crowd around me.

Know Your Stuff

The decision to hire an external marketing professional or firm to handle the successful promotion of a cosmetic practice is a choice that most practitioners will eventually face. Many practitioners will be satisfied with the results of internal marketing, while others will want to impact their communities in a more nontraditional and widespread manner.

If you decide to hire a marketing agen During a live demonstration, you will cy, keep in mind these key points: have the opportunity to answer ques­ ake sure the marketing professionals M tions and communicate with the audience you hire understand your vision and about the different techniques you are emagree to incorporate it in all of their ploying. Compared to most professionals, promotional efforts. as a dentist, you are already an authority on the oral-facial area. You will be asked Ask the professionals you hire to cresome unusual questions, and you must ate a comprehensive 3- to 6-month be prepared to answer them. Be sure to marketing plan. respond to each question as directly and Firmly request a written contract that completely as possible. clearly indicates that all the work the As dental professionals, we are not marketing professional or firm perpoliticians; so when a controversial subforms on your behalf is exclusively ject is broached, it is best to refer to the reyour property and that you have full sults of recent research studies and allow copyright and access to the work, even the individual who asked the question(s) if and when you terminate your relato consider your response and form his/ tionship with the firm. her own opinion. Remember, marketing professionals It is also perfectly okay to admit that

Chapter 1 Vermilion Dollar Lips

are in business to meet your promotional needs and should use their expertise to professionally deliver the results that you have established for your practice. In essence, they need you more than you need them. Consequently, any agreement—whether verbal or written—should have a clearly defined exit strategy available to you if the marketing firm does not perform as promised.

Educating & Training a Competent Staff Having competent and educated staff is critical in all phases of integrating fillers into your practice. They will be instrumental in motivating your patients to elect oral-facial augmentation and in conveying a sense of confidence in patients who undergo the procedure. It is also extremely important to educate and train your key adjunctive personnel in every aspect of your practicespecific augmentation philosophy. Give them the knowledge and tools they need to provide your patients with current information on the latest fillers and those popular in the past. Expose them to your specialized techniques in lip and face augmentation by letting them observe procedures. Finally, invite members of your oral-facial augmentation team to join you in attending continuing education classes that focus on fillers and techniques. (Most seminars will allow the paying doctor to bring a guest or staff members either free of charge or at a discounted rate).

when patients have had cosmetic work that was performed by a practitioner outside of your practice. When the hygienist is trained to interrogate the patient subtly and politely by asking the questions that follow, information can be gathered without offending any of the treating doctors: Have you ever heard of facial fillers? Do you know of the use of Botox in lip rejuvenation? How would you describe the experience? Who performed the procedure? Was it a dermatologist, a plastic surgeon, a nurse, or another medical practitioner? Did you experience any pain during the procedure? If so, did the doctor use anesthesia? What type of anesthesia was used? Were you pleased with the results? If not, what would you do differently the next time the procedure was performed? Armed with this knowledge, your hygienist can become instrumental in identifying potential oral-facial augmentation candidates and assisting you in the growth of your filler practice.

Many of your hygienists may already have been exposed to lip fillers in their hygiene recall appointments, especially if they are conducting comprehensive oral/ soft tissue exams. They may feel palpable lumps or bumps in the patient’s lips and/ Allies Within Your Practice or oral-facial area. Without proper train Your hygienist is your best ally when ing, however, they will be unable to idenintroducing new materials and skills to tify or recognize what they are. your patients that you as a dentist have For this reason, it is critical to introduce acquired and employed. Frequently, a hyyour hygiene staff to facial fillers, so that gienist is also privy to information that as they conduct their exams, they too can the patient does not readily divulge to the be aware of currently used fillers and their dentist. This often holds true most often

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impact on the oral-facial area.

Delegation of Duties Fillers and Botox are cosmetic enhancement materials. Due to the fact that they are cosmetic in nature, many medical and dental professionals are seizing the opportunities now available in the marketplace to develop an adjunct to their existing practices. In many states, nurse practitioners and physician assistants are able to place fillers and/or Botox when working under the guidance or direction of a physician. Nevertheless, be aware that delegating this sensitive part of your practice

to other members of your staff can leave you vulnerable in several ways. So keep the following in mind: Experience the transformation with your patient. This is absolutely imperative. By being present during the procedure, you have the ability and expertise to pick up on the nuances of their expressions that they may be too embarrassed to share with the nurse or other member of your staff who was responsible for taking their medical information. You will also lose valuable contact and interaction with that patient. An oral-facial augmentation specialist is remiss—and clearly

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unprofessional—if he or she merely reads a patient’s post-op notes that were compiled by a nurse after the procedure. If you are not present before, during or after the procedure, you don’t know what information has been communicated to the patient in your operating room. I have experienced this firsthand in my own practice. On several occasions, I have had the misfortune of walking into an operating room and cringing at what I just overheard a member of my staff say to one of my patients. (One also has to wonder how much misinformation may have been communicated prior to my arrival!) I then have to retract any incorrect statements and reassure the patient that what he or she just heard was untrue, which does not reflect well on either me or my practice. For the patient, inaccurate communication can lead to unnecessary apprehension and increased uncertainty about the outcome of the procedure. This can easily be avoided by delegating responsibilities wisely and only to members of your staff who have been thoroughly trained in oral-facial augmentation. You cannot further your skills or training if you are not personally involved in each step of the augmenting procedure. By giving anything less than your full attention to this evolving division of your practice, you are performing a disservice, not only to yourself, but also to your patients. Simply put, if you cannot or do not become intimately involved in growing your oral-facial augmentation practice, how can you expect to delegate and regulate it? It is, after all,

being performed under your license. Ultimately, you are solely responsible for each of your patients.

Medical/Legal Issues Since the explosion of facial fillers and Botox onto the cosmetic market, there has been little public and professional information on the regulation of the material. Because the cosmetic industry is so lucrative, everyone seems to be participating in fillers. Consequently, stories of unqualified, unlicensed persons placing fillers and Botox flood the headlines throughout the nation. With the introduction of nonanimal stabilized hyaluronic acid into the filler market, the morbidity, pretesting and technical applications have become very forgiving. Every state, however, is different. Therefore, each practitioner should consult their local and state laws of practice.

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In 2006, the Joint American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS) Advisory Board published a position paper on injectable fillers and legal/regulatory issues.5 Fillers must be categorized as a drug or device. A drug is any healthcare product that achieves its primary intended purpose by chemical action or by metabolic reaction in the body. Conversely, a medical device does not achieve its primary intended purpose by chemical action or by metabolic reaction. Botulinum toxin Type A (BTX-A), for example, is a drug, while artificial skin injectable fillers such as collagen and hyaluronic acid are classified as devices.

FDA Guidelines & Regulations FDA Labeling All too often it seems as though cosmetic materials and drugs are pushed into mainstream practice before adequate long-term testing on their safety and efficacy are known. These materials are given FDA approval for a specific use and when the material or drug is in the hands of the practitioner, other uses become evident. An example of this is Sculptra, which was put on the FDA approval fast track for HIV-related facial lipoatrophy.6 Sculptra is now being used as cosmetic filler for the face of non-HIV infected patients. Through this type of phenomenon, the term “off-label” has evolved. FDA-labeled drugs or devices will state:

Provider Qualifications

The administration of injectable fillers is considered a medical procedure and, as such, is subject to the same precautions of any medical procedure. Similarly, the supervision of non-physician personnel is regulated by state and local law. The area of delegated duties and supervision guidelines, however, varies greatly from state to state.

Although the dental practitioner is defined as an oral-facial expert in the Dental Practice Act, to date, there have been no position papers on fillers in the current dental literature nor has any regulatory board been established. Today, there are thousands of dentists using injectable fillers in conjunction with their practices of dentistry today and the numbers are increasing. Thus, a position paper and a dental council are needed in this area of cosmetic practice. Due to the ambiguity of oral-facial fillers in the dental field, it is my recommendation that dentists practicing oral-facial augmentation should not delegate filling to anyone else under their employment or supervision.

The Psychology of the Lips

What human features express more emotion than the mouth and the eyes, either alone or as one entity? Even Darwin developed a theory on the psychological/ emotional relevance of a smile. The Darwinian Theory of Antithesis defines the smile as the direct opposite of a frown. 1. Approved for a specific use: labeled The high curvature of the smile and the and approved by the FDA for market- depressed corners of the mouth are coning, which also allows for off-label use). veyed as opposite presentations, possibly 2. Non-approved: not approved by the as a direct action of the nervous system.7 FDA for any purpose and, therefore, in- Yet there is far more in a smile that eligible for off-label use. transcends all words, all gestures, and

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General Guidelines for Use of Filler Devices and drugs 1.

Usage of any non-approved implant devices is a violation of the Federal Food, Drug & Cosmetic (FD&C) Act, which may lead to the invalidation of the practitioner’s professional liability insurance coverage, as well as criminal penalties and action by regulatory agencies.

2.

Two circumstances that allow a practitioner access to non-approved drugs and devices include: — Use in approved clinical studies, and — Use in serious, life-threatening emergencies, if the product is under clinical investigation.

3.

When a practitioner uses an FDA-approved drug for off-label, the patient must be informed of the FDA-approved use, must understand that treatment on any other area specified is off-label use, and must accept the treatment rationale. For example, Restylane is FDA-approved for nasolabial folds, not lips, but it is commonly used in cosmetic lip augmentation.

4.

It is illegal for a practitioner to commercially advertise any non-approved or off-label use filler; only FDA-approved uses may be commercially advertised.

5.

The position of the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS) is that administration of drugs or devices outside the clinical setting may produce: — Inadequate patient selection — Possible peer pressure that leads an individual to consent to treatment — Providers that are not trained to administer the injectable filler or who are unqualified to assess or treat complications — Lack of control over dosage — Inadequate post-treatment supervision — The possibility of mixing alcohol and/or street drugs with injectable fillers or medication used to control post-treatment pain and other side effects.

6.

Reimportation of FDA-approved drugs/products is illegal. Currently, only manufacturers are able to reimport their drugs/devices.

7.

Counterfeit drugs that are copies of name devices are prohibited.

8.

The ASPS and ASAPS’s Joint Code of Ethics states that a member may be subject to disciplinary action if administration of an injectable or filler is raffled off in a fundraiser, contest, or any other promotional event.

The following two Web sites, created by the ASAPS, are a resource where practitioners can find current information on fillers and other relevant and applicable information: http://www.plasticsurgery. org and http://www.surgery.org. Unfortunately, the ASAPS does not incorporate the dental profession into their guidelines. They have published no opinion regarding the injection of fillers in the oral-facial area within the dental profession.

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signs. As dentists, we are accustomed to making life-changing alterations in the appearances of our patients through cosmetic enhancements. It is not unusual to see patients who have had a full set of anterior veneers return to our offices wearing brighter lipstick, a new hairstyle, and exuding a higher level of confidence and self-esteem. Augmenting the lips is a natural extension of a dentist’s expertise and should be treated with the same sensitivity one would use in the discussion of other appearance-altering treatments. When suggesting lip enhancement to a patient, try not to critique their current lip appearance. Instead, concentrate on the potential advantages of lip augmentation and cosmetic dental work. Explain the knowledge and training a dentist has in the oral-facial area and emphasize that dental practitioners have expertise that extends beyond teeth. Attend continuing education classes on lips and augmentation treatments and

share your experience with your patients. Obviously you have earned their trust; now share your enthusiasm about your new specialty. You may be surprised how willing your patients will be to enhance their lips through augmentation procedures provided by a qualified and trusted dental practitioner.

Minimizing Patient Anxiety, Maximizing Patient Comfort As with any cosmetic practice, the doctor will treat a certain percentage of patients that may present with anxiety-related manifestations in conjunction with lip augmentation. Dentists are certainly no strangers to anxiety in the dental chair. Approaching a patient’s face with filler needles during oral-facial augmentation can elicit a strong anxiety response. Comprehensive prescreening and complete disclosure of risks and benefits prior to the procedure, however, can significantly reduce heightened stress.8 Anxiety disor-

Chapter 1 Vermilion Dollar Lips

ders associated with oral-facial augmentation may range from a transient bout of trepidation to a full-scale case of body dysmorphic disorder (BDD).

Body Dysmorphic Disorder: An Overview The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines BDD as a preoccupation with a defect in appearance that is either imagined or slight, which leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. Additionally, the preoccupation cannot be attributed to another mental disorder, such as dissatisfaction with body shape and size, as in anorexia nervosa.9 In all likelihood, patients suffering from BDD will eventually find their way to your practice, and you will need to know how to effectively deal with them.

by characteristic behavior that includes markedly excessive concern when even the slightest physical anomaly is present. Since the evolution of cosmetic dentistry, few articles have been published on BDD. In the field of cosmetic surgery, BDD is prevalent in 6 to 15 percent of patients who present for cosmetic work.10,11 Studies have shown that women and men are equally affected.12 The average age of onset of BDD ranges between 15 and 30 years, with most cases occurring when patients are in their late twenties.13

The dentist needs to be aware of the clinical presentation of patients. How does one determine if a patient has BDD tendencies? Obviously, it is not our specialty to diagnose these patients, yet they present to us more frequently as a manifestation of their condition. Patients presenting with BDD usually have dissat Generally, the work you will be per- isfaction with specific features of their forming as a cosmetic dentist is limited to appearance.14,15 BDD patients manifest the perioral area and dentition. Accord- this specific response in multiple anatomingly, you will draw patients to your prac- ical areas. In fact, 80% of BDD patients tice that may have had significant cosmet- are dissatisfied with more than one area ic work done to other areas of their face. of their anatomy, with an average of three When reviewing their medical history, a to four physical features causing distress red flag should go up immediately when and exaggerated concern.16 you encounter patients who have had numerous cosmetic procedures in the past, Due to the multiple anatomical areas as well as patients who have had a sig- with which BDD patients are obsessed, nificant number of revisions on cosmetic they typically visit a broad spectrum of work previously performed. Patients who specialists for cosmetic correction, often complain of long, disappointing histories requesting inappropriate or ineffective with previous augmentation procedures treatment and medications. This can lead also need to be assessed and evaluated a significant number of patients to your carefully to determine if it is at all possible office when you incorporate oral-facial 17 to fulfill what may be extremely unrealis- fillers into your cosmetic practice. tic expectations. Identifying, Managing and Referring BDD While there are many types of psychological disorders that can impact a patient before, during, and after cosmetic procedures, BDD is both the most common and most severe condition. BDD is noted

Patients Diagnosing BDD patients is difficult due to the secretive and compulsive nature of the disorder.18 There are, however, several screening tools available to diagnose

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this disorder, such as the Body Dysmorphic Disorder Questionnaire (BDDQ),19 which was developed for the psychiatric specialist, but may not be practical for clinical use. The dentist should observe and collect information on the possible presence of BDD during a patient’s initial cosmetic consult for augmentation. The entire office staff should also play a supportive role in assessing patients. It is not unusual for a patient to express or manifest significant BDD behavioral indications to support staff when the dentist is not present.

It is true that refusing to treat a patient can be problematic. However, if the art of augmentation becomes a passion in your life—like it is in mine—it is imperative to constantly analyze and evaluate your motives, goals, and performance. Your skill level, experience, and innate ability to understand the limitations of materials and techniques will serve as your compass in making appropriate decisions.

Keep in mind that patients that exhibit symptoms of BDD or other psychological disorders can thrust the inexperienced augmenter into situations that may have It is generally recommended that all legal and emotional ramifications for both cosmetic augmentation procedures be the patient and the doctor. avoided on patients whom the dentist Listen to your inner voice, choose wiseeither observes or receives information ly, and perform the art and science of augof any type of psychological disorder. mentation for the benefit of each patient There is a high likelihood that these pa- and the community. tients will not benefit from any cosmetic alteration.20,21 Psychiatric counseling is the initial treatment of choice for patients with BDD tendencies or other psychological disorders. These patients should be referred to a cognitive behavioral therapist before initiating any cosmetic procedures. Recommending a psychological evaluation to one of your patients can be quite tricky. It may be helpful to focus on the impairment and resulting distress that their concerns cause, as well as its negative impact on the quality of their life. Reassuring patients that they look fine, attempting to talk them out of cosmetic treatment, and discounting their desires usually is ineffective in this patient population.12 As a cosmetic augmenter, deciding which patients you will treat is ultimately your decision. However, I believe that you truly master the art and science of the fill when you are discernibly able to say “no.”

Chapter 1 Vermilion Dollar Lips

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TIPS

Using various facial calipers before and after augmentation can help guide your treatment planning. When placed near the lips and photographed, you can enroll your patient into proper lip proportions and what to expect as a realistic end result.

Chapter 1 Vermilion Dollar Lips

Chapter 1 Review STUDY Points Art of the fill and supporting basis Relationship between marketing and cosmetic lip and perioral augmentation Difference between internal and external marketing Medical/legal responsibilities of injectable fillers and botulinum toxin Psychological issues with oral-facial cosmetics

STUDY Questions 1) What is the most important step you must complete before launching/developing a marketing plan? 2) From a medical/legal perspective, how are fillers and botulinum toxin defined and how are they classified? 3) Who is legally allowed to perform treatment with injectable fillers and/or botulinum toxin? 4) What does “off-label” mean and how does it pertain to injectable fillers and botulinum toxin? 5) What is BDD and what implication(s) does it pose within the oral-facial augmentation arena?

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Chapter 2

The Canvas

Nemo liber est qui copori servit. No one is free who is a slave to his body.

Chapter 2 The Canvas

Dr. Gordon’s Lip And Perioral Classification Anatomy Oral-Facial Aging

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Through my own personal journey of learning lip and perioral augmentation, I have been exposed to many ideas, philosophies, and techniques. Early on, I became frustrated at the lack of structured teaching in the art and science of oral-facial augmentation. Due to the diversity of practitioners, the art and science transcends through many specialties. Dentists, plastic surgeons, dermatologists, nurse practitioners, and nurses are a few of the licensed individuals practicing oral-facial augmentation. In addition, there is a significant subculture of individuals performing augmentations in America that aren’t licensed to perform oral-facial augmentation, yet they continue to practice to this day. Due to this disparity, it is obvious a uniformed body of practitioners must evolve, and with them, a common language to usher the art and science of oral-facial augmentation into the future. In the new and evolving field of lip and perioral augmentation, we as augmenters require a classification system, a language unique to our work, one in which to communicate and record our efforts for ourselves and the professional community of augmenters. When a common language relating to the architecture of the lips and perioral area (including skeletal, muscular and soft tissue) is realized, we maximize our potential to become simply better in this artistic science. The artist must have complete knowledge of the construction of their canvas and interaction of various mediums as they are applied; this is essential for the cosmetic augmenter in relationship to the oral-facial canvas. Having an intimate understanding of what contributes to the lips and perioral structure is vital in understanding similarities that make them up and how we can enhance these features, thus creating our best cosmetic results. It is vital we have a grasp on the process of aging and how it affects the oral-facial arena. Through this understanding, we are able to reverse the signs of aging. The goal of this chapter is to address these issues and intertwine then into the science and art of lip and perioral augmentation.

Chapter 2 The Canvas

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Oral-facial Classification

amount of fill the planes will facilitate. The two upper lateral planes are cone shaped, with the apex at the corners of the mouth and the base abutting the middle plane. PlaneS of the lips The middle plane of the upper lip is semi The lips are formed by five planes. circular and tapers toward the opening of Three planes form the upper lip, and two the mouth. The lower lip is formed by two planes form the lower lip. Understanding teardrop shapes that taper toward the corthese planes gives the cosmetic augment- ner of the mouth. er insight into location, direction, and the SEGMENTS

Vermilion Border (Zone A)

Body (Zone B) Wet Dry (Zone C) .618 1 C B A SEGMENT (by plane with body and tail) Body

Tail Segment

Light

2

A

3

SEGMENTS (lateral view divided by planes)

B C B

4

A

5 Segments

FIGURE 2.1

Planes and Segments of the Lips

ZONES (lateral view)

Chapter 2 The Canvas

Lips are as diverse as the human face. While no two sets of lips are exactly the same, all lips have these five structural planes in common. It is the different combinations of these planes that lead to the unique appearance of each individual’s lips. These five planes are created by the joining of the developmental facial pro-

cesses of the face in utero. Incomplete union of the medial and lateral nasal processes can lead to cleft lip,22 which has a reported prevalence of 1.00 to 1.82 per 1,000 live births. You can see these planes with the naked eye in patients who suffer from this condition as a result of an isolated defect or hereditary syndromes.

Here are the 5 planes superimposed on the patient’s lips. Remember these planes when augmenting and keep them in your mind’s eye during aesthetic reconstruction or augmentation of a patient’s lips. For successful and aesthetically pleasing augmentation, use these 5 planes as your roadmap.

FIGURE 2.3

Planes and Segments of the Lips As illustrated above, the five planes of the lips begin to develop in utero. Incomplete union of the planes leads to cleft lip and/or palette.

FIGURE 2.2

Planes and Segments of the Lips

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Static

This is a static representations of the lip and perioral tissue. Notice this patient exhibits incompetent lips.

Static Vs. Kinetic

amine our patients in both a kinetic and As dentists we restore to a tooth-to- static position. This can be accomplished tooth or a bone-to-bone relationship which by asking the patient to smile and frown. is both recordable and repeatable. An ex- A simple trick to assist you in establishing ample of this is “Centric Relation.” Even the relative static position of a patient’s in the edentulous patient, we can restore lips is to ask him or her to utter the letto a certain fixed skeletal relationship.23,24 ter “M.” The position of the lips after this With the soft tissue of the face, however, consonant is spoken is considered the we aren’t as fortunate in predicting a re- static position. peatable relationship. The oral-facial lines Dentists naturally ask patients to smile and folds change on a consistent basis. in an effort to evaluate the dentition. In The entire make of the face changes oral-facial augmentation, it is important to with age, genetics, and environment. The focus your attention on the nasolabial (or face and, in particular, the lips, can be mental fold) as the patient smiles. If these viewed in either a static or kinetic state. areas are augmented, it is imperative to As cosmetic augmenters, understanding consider how augmentation will affect the the difference between these two states is kinetic fold of the tissue. Augmenting the essential in planning treatment for our pa- lips in a static position, without viewing the smile line and incisal appearance, can tients. lead to overfilling of the lips and produce During an examination, we must ex- an unpleasant appearance.

Chapter 2 The Canvas

In addition the evaluation of perioral lines (rhytids) must be evaluated in static and kinetic movements for purposes of botulinum toxin therapy; more on this in Chapter 7, “Simply Botox.”

der to the lower border of the columella nasi of the nose. This zone is wider due to the philtrum that is, at times, augmented in this zone. Zone B (ZB) is the area midpoint between the inferior border of the It’s difficult for one to quantify or qual- vermilion border (ZA) and the superior ify the amount of filler needed when eval- border of Zone C. Zone C (ZC) is the area uating the relationship between kinetic from the inferior border of Zone B to the and static tissue. It is in practicing and lower transitional zone (wet/dry line) lip. perfecting the art of the fill that this mea- Most shaping will be performed in Zone surement is incorporated into the aug- A and volume will be added in Zone B. mentation process and becomes easier to Zone C is a label in order to complete the mapping of the extra oral presentation of determine as your experience grows.25,26 the lips. Under no circumstances do we Maxillary Labial augment Zone C. Instead Zone C is used Zone A (ZA) extends from and includes for marking pathology, injuries, and dethe superior aspect of the vermilion bor- scribing the relationship of the bottom of

Kinetic

Even as the lip and perioral tissue is stretched around the skeletal and dental anatomy, the relationship of the ideal proportions still remains. Overfilling the lips may not present as noticeable in the static position, yet when the patient smiles, the overfill may become more evident as the filler material is displaced over the dental profile.

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Zones and Segments of the Lips 1

2

3

6

5

4

If we analyze the natural planes of the lips and how they are divided, we can divide them into six segments for lip classification.

Chapter 2 The Canvas

the lip to the dentition. Remember, the three parts are divided between the cone zones curve with the lips in a bow shape and tapered semi-bucket shape of the and end at the commissure of the lips. philtrum. The lower lips are also segmented into three parts that correspond to the Mandibular Labial planes that make up the lip. The lower lip Zone C extends from the transitional is composed of a teardrop shape that has zone (wet/dry line) to the border of Zone a ball and a tail. The segments are divided B. Zone B extends from the middle of the at the ball-and-tail junction. lip (border of ZB) to the vermilion border of the lower lip. Zone A extends from— In order to define a constant on which and includes—the vermilion border and the lips are draped, we use the dentition the cleft superior to the metal protuber- as a reference point. To assess a patient’s segments, you have to have them open ance of the chin. their mouths a little to see the maxillary Zone A will have fill room, but the ma- dentition. The segments are simply dividjority of fill will be performed in Zone B. ed by drawing a line down the lips laterZone C is demarcated for completion of ally to the maxillary central incisors (#8, the classification area. There will be no #9). Upper lip and Lower lip: Segment 1 augmentation in Zone C. Since there is is the area extending from thelateral of no distinct vermilion border of the lower #8 to the corner of the mouth. Segment lip like the upper lip, sculpting of Zone 2 is from the lateral of #8 to the lateral of A on the lower lip will usually never be #9. Segment 3 extends from the distal of performed. Remember that Zone A of the #9 to the corner of the mouth. Lower lip: lower lip is a gradual transition from ver- Segment 4 extends from the corner of the milion tissue of the lips to the keratinized mouth to the line drawn down from the epithelium of the oral-facial area. lateral of #9. Segment 5 extends from the line drawn down from the distal lateral of Segments of the Lips (Static) #9 to the distal lateral of #8. Segment 6 ex Lips can be divided into six segments, tends from the line of the distal lateral of which correspond to the planes that con- #8 to the corner of the mouth. stitute the lips. The upper lip is segmented into three parts which correspond to the LARS: Lip Length, Age, Race & Sex planes that make up the upper lip. The As a cosmetic/aesthetic augmenter, you

Zones of the Lips Classifying the lips into specific zones enables the cosmetic augmenter to: — Assess the lips for documentation, whether it is for pre- or post-augmentation or clinical notes — Relate proportions in the static and kinetic motions of the lips — Provide a common language for professional communication — Facilitate teaching methods and reproduction of augmentation techniques — Ensure repeatable results or corrective post-treatment

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Outer Ring: Nasolabial fold, Mental fold, Marionette Lines, Jowl folds Inner Ring: Commissure, Lips

Chapter 2 The Canvas

Table 2.1

Maxillary Lip Length with Relation to Anterior Tooth Exposure27

Maxillary Lip Classification

Maxillary Lip Upper Length (mm)

Exposure of Upper Central Incisor (mm)

Exposure of Lower Central Incisor (mm)

Short

10-15

3.92

0.64

Medium

16-20

3.44

0.77

Medium

21-25

2.18

0.98

Long

26-30

1.95

1.95

the beauty our patients possess, not alter them to subscribe to intercultural or racial stereotypes. Nevertheless studies support that there are marked differences between the lips of each race. For example the lips of African-Americans have a greater incisor inclination and a more protrusive soft Lip Length tissue profile. A more protrusive profile The length of the upper lip ranges from is more accepted in the African-American 10 to 36 mm. The longer the upper lip, the population.29-31 less maxillary dentition is visible and the Sex more mandibular dentition is shown in Usually when we observe an infant, we kinetic movement. are unable to identify whether they are Age male or female. The influence of sex hor As we age, the lips are drawn down mones on the contour of bodies, facial feaand out over the skeletal and dental frame- tures, and lips is no different. The male’s work. The intrinsic and extrinsic effects of face is more rugged and bolder. The feaging are covered in greater detail in the male’s appearance is gentler and rounder. aging section of this chapter (pg. 49). The subtle differences translate to the lips Race and face and will be explored further later A person’s bony structure varies across in the book. Generally males have a lonall racial identities. The skeletal/dental ger maxillary lip than females. The averstructure is the scaffolding for the oral- age maxillary tooth display is 1.91 mm for facial region; and with the addition of men and 3.40 mm for women.28 musculature and overlying skin, we see marked differences in the physical makeup SEGMENTS OF LIPS (KINETIC) of different races. Facial augmenters must The canine teeth are the cornerstone realize these differences and appreciate for the arch form in the maxilla and manthe harmony that lies between the racial dible (Fig. 2). The lip arch form lays itself spectrum. Our main focus is to enhance over the dental arch form. The lip arch possess the understanding that there are many factors that impact the presentation of the oral-facial area. We can categorize a majority of these into four factors identified by the acronym “LARS”: lip length, age, race and sex.28

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form presents as a “U,” “V,” or square shape corresponding to the patient’s dental arch form. The lateral segments (Segs. 1, 3, 4 & 6) on the upper lip and lower lip become wider and elongated as the lips move into a kinetic smile. The central segments flatten and lengthen as the muscles of facial expression contract and pull the lips against the dental arch.

THE DYNAMICS OF KINETIC AND STATIC MOTION IN THE CLASSIFICATION SYSTEM

“Mona Lisa,” is the gold standard in a study of lips. Examine the subject’s facial expression and the line between her lips. Is she smiling? Is she presenting an aloof attitude of superiority, or communicating a passive state of bliss? We may never know for certain what her smile conveys about her mood, which is why this work of art is timeless, captivates our attention, and inspires us, depending on our personal perception of her mood.

The LBL is dictated predominantly by the maxillary lip. It is in the mouth’s re We augment our patients’ lips in the laxed (static position) where we can best static position. We assess the lips for aug- evaluate this line. When we augment, we mentation in both the static and kinetic have a significant impact on the existing positions. The segments and zones we as- LBL. Consequently, a thorough undersign in the static state will translate pro- standing of the different expressions of portionally to the kinetic state (smiling). the LBL is needed. In other words, if we overfill Segment 2 in The expression of this line is in Zone the static state, this will result in an overC in the upper lip. The genetic developfill in Segment 2 in the kinetic state. ment of an individual establishes the form Even though we stretch the lips when of the LBL at lip maturity. An inverse LBL we smile, the proportional relationship of can be viewed as contributing to the aged the lips will still be present in the same look of the mouth. This is partly because segment in the kinetic motion. The bor- the inverse smile line corresponds to the ders for the kinetic segments translate to aging process of the oral facial area, which the curvature of the arch, which develop is a downward and outward growth and at the canines. In a full smile, Segments 2 sagging of the oral-facial tissue. Although and 5 fill the space medial between the ca- an inverse LBL can present as a component nines of the upper and lower dentition. of an aged smile, it does not completely imply an aged smile. A lack of fullness in THE LINE BETWEEN THE LIPS (LBL) the lips presents more of an aged view of The line between the lips (LBL) pres- the face. ents in four ways on the human face. Artists use the LBL as an identifying trait on Patients often come in for consultations all portraits. The line between the lips has because of the loss of volume in their lips. a definite subconscious effect when we The loss of lip volume contributes more to perceive a person’s appearance. Because the development of rhytides and deepenan artist’s job is to facilitate an emotion ing of lines around the lips. We know that without overtly exaggerating facial ex- we very seldom augment in Zone C. pression, this line is very important on Zone C reflects the architecture from Zone mouth presentation. A. After filling in the volume of the lip Leonardo da Vinci’s masterpiece, the (Zone B), we then evaluate the architecture of Zone A. If needed we then sculpt

Chapter 2 The Canvas

This is a two week post augmentation with NASHA and Collagen fillers. It is imperative to understand the planes of the lips. The picture above shows the lips from a semi-profile angle. As the illustration demonstrates the planes of the lips are ever present. The augmenter must be aware of these planes and fill them in relationship to their natural occurring form.

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Lip incompetency is one situation where cosmetic augmenters may have an opportunity to add to Zone C without violating the dental presentation underneath. Adding volume in Zone C is achieved by inserting the needle into the inferior border of Zone B and letting a limited amount of material flow into Zone C. There is a segment of the population that has incompetent lips, or lips that separate in the static position. This can be attributed to dental and/or skeletal malocclusion. The cause of incompetent lips is usually not associated with lip deficiency. Incompetence of the lips is attributed more to a skeletal malformation. This phenomenon is related to excessive interlabial space. At rest a relatively small amount of separation between the lips is normal. The primary measurement of interlabial distance is defined by stms and stmi: stomion Leonardo Da Vinci’s Mona Lisa Reproduction provided courtesy of 1st-Art-Gallery: www.1st-art-gallery.com superius and stomion inferius. The measured normal distance Zone A. Zone C will then reciprocate the ranges from lightly touching to a 3-mm form established by the previous two filldistance between both points.32 Patients ing orders of Zone B and A. with incompetent lips are excellent candi Think of the vermilion border of the dates for augmentation of the lips and or maxillary lip as a curtain rod that is uni- Botox therapy. form in both length and width. When we bend the curtain rod up and down and The jaw rests in a neuromuscular pohang the fabric on the rod, the bottom sition creating a freeway space. The freeedge of the curtain (Zone C) reflects the way space is an approximate 2 mm vertical height separation between the upper shape of the bent rod (Zone A). and lower teeth. In this position, the musIncompetent Lip (Open Lip) cles of the jaws are at their most relaxed This presentation of the LBL is open position. If we are not talking or eating, when the face is relaxed. There are a myrwe maintain this position during which iad of reasons for an incompetent lip, to the lips are naturally closed or competent. include VME (vertical maxillary excess), However, when this inter lip space is exshort lip or chronic air way obstruction.

Chapter 2 The Canvas

Curtain Illustration Illustrated below is the idea of how the inferior border of Zone C reflects the architecture of Zone A, the vermilion border. Therefore, the architecture we establish in Zone A will be reflected in Zone C. This is an additional reason to avoid filling in Zone C.

Zone A

B

C

Zone A

B

C

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Four General LBL Presentations This is the classic presentation of the LBL. The LBL has a downward swoop at Segment 2’s philtrum area. In Segments 1 and 3, there is an upward draw. Segment 2 has a fuller appearance, which accentuates the “Cupid’s bow” effect of the LBL.

Upward Arch This lip line has a straight across presentation, with no discernible upward or downward slope. Segments 1 and 3 are straight across. Notice the lack of architecture in Zone C, Segment 2 on the vermilion border. This lack of curvature reflects itself in Zone C of the upper lip and the LBL.

Straight Across This is the inverse relationship to the upward arch. You can see this downward curve in Segments 1 and 3. The woman pictured here has very voluptuous lips. Correcting this patient’s lip to create an upward arch would distort her natural beauty. We want to augment our patient’s lips (i.e. enhance their natural beauty), not alter their appearance.

Downward Arch This presentation of the LBL is open when the face is relaxed. There are myriad reasons for an incompetent lip, to include VME (vertical maxillary excess), short lip, or chronic airway obstruction. Lip incompetency is one instance where cosmetic augmenters may have an opportunity to add to Zone C without violating the dental presentation underneath. Adding volume in Zone C is achieved by inserting the needle into the inferior border of Zone B and allowing a limited amount of material to flow into Zone C.

Incompetent Lip (open Lip)

Chapter 2 The Canvas

cessive and requires the patient to contract the orbicularis muscle with intention, we classify this as incompetence. This is usually around 4 mm+. Common causes of incompetent lips include: Soft tissue – Short philtrum, where the space between subnasale (base of the nose) and the superior border of the vermilion fails to complete a relaxed seal of the lips. As a result of the amount of interlabial space available, we are able to augment more liberally in Zone B, without obscuring needed incisal dental length for aesthetic appearance. If the patient presents with a full upper lip, other alternative therapeutics may be indicated such as Botox therapy (Chpt 7). Denervating the levator labii superioris alaeque nasi (LLSAN) muscle may length the upper lip in order for the patient to present with more competent lips.

tation of the face as we age. With time the constant contraction of the muscles of facial expression take their toll on the facial skin, leaving it susceptible to deep kinetic folds. Artists have always had a keen interest in the muscles of the face. The thickness of the musculature affects the draping of the skin which in turn relates to the amount and severity of facial folds and wrinkles. The oral-facial musculature is similar in all human beings, yet the variance in their composition is significant enough to give us our own distinct appearances.

There are also notable differences in the oral-facial musculature between males and females. Females reportedly have higher smile lines than males.33 The higher draw of the superior lip is attributed to the morphology of a woman’s levitator muscles.34 Women are also reported to have a larger muscular capacity of the zygomatic major and levator labii 35 Dental – Excessive dental overjet, superioris muscles. Ultrasound studies where the maxillary teeth protrude of the oral-facial muscles, in particular the over the mandibular jaw, forcing the levator muscles, reveal that women have thicker zygomaticus major muscles than lips to separate. men, as well as higher smile lines.36 Skeletal – Relationships attribute to vertical maxillary excess (VME) with Orbicularis Oris and without anterior open bite re- This sphincter-like muscle has no true sulting in down and back rotation of origin or insertion point. Instead it is comthe mandible and excess lower facial prised of associated muscles interdigitating with it as it surrounds the mouth. height. The corners of this muscle are made up of the zygomatic muscle and depressor Anatomy angular oris, which intersect at the angle of the mouth: those from the zygomatic MUSCULATURE major cross the corner of the mouth and Muscles of Facial Expression terminally engage into the lower lip, and The muscles of facial expression are those from the depressor angular oris inunique in several ways; in particular the tersect and terminally engage into the upfacial muscles of expression insert directly per lip. Along the path which they run, into the oral facial skin. This direct inner- these muscles insert into the skin. There vation contributes to the unique manifes- are also fibers from the levitator muscles

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(labii superioris, labii superioris alaeque nasi, zygomatic major, and minor) and the depressor labii (labii inferioris and mentalis); these intermingle with the transverse fibers above. The proper fibers of the lips are oblique and pass from the undersurface of the skin to the mucous membrane, through the thickness of the lip. The effect of the orbicularis oris is closure of the lips.

of this muscle is sneering by contracting the upper lip superiorly. This is the muscle responsible for the mid portion medial to the nasolabial fold. As we mature, this

fold deepens and is often regarded as an undesirable effect of aging.

Levator Labii Superioris Adequate Nasi

The origin of this muscle is the nasal process of the maxilla and it inserts into the orbicularis oris medially as well as the medial nasal ala. This muscle contrib-

The deep fibers of the lips approximate the lips to the alveolar arch. The superficial fibers bring the lips together in a pursing form (kissing motion).

Buccinators Buccinators compress the cheeks so that during the process of mastication, the food is kept under the immediate pressure of the teeth. When the cheeks have been previously distended with air, the buccinator muscles expel the air from between the lips—much like blowing a trumpet, hence its name (Buccina is the ancestor of the trumpet.)

Levator Labii Superioris The origin of this muscle is on the malar prominence below the infraorbital rim. It inserts into the orbicularis oris. The effect

utes least to lifting the upper lip and the muscular wall medial to effect the nasolabial fold. Botulinum Toxin treatment in this muscle will relieve the lip contraction—which is beneficial for patients with “gummy smiles”—and softens the nasolabial fold.

Zygomatic Major

Origin of the muscle starts at the inferi-

Chapter 2 The Canvas

or border of the zygoma and inserts deeply into the orbicularis oris and the modiolus at the corner of the mouth. The effect of the muscle is the smile by elevating the corner of the mouth superiorly and laterally.

Zygomatic Minor

This muscle is medial to both origin and

insertion of the zygomatic major. They zygomatic muscle is absent in two-thirds of cadaver dissections.37 When present this muscle is plays an adjunctive role to the zygomatic major.

sue. The effect of this muscle is the pout look. As the face matures and the dermal tissue loses subcutaneous thickness, a cobblestoning effect can take place upon contraction of this muscle. Many patients do not realize this pitting effect due to the fact that when we look in the mirror, we evaluate ourselves in the static facial posi-

Depressor Anguli Oris The origin of this muscle starts at the inferior border of the mandible anterior to the masseter muscle. The depressor anguli oris (DAO) inserts into the modiolus. The effect of this muscle is frowning. Botox therapy denervates this muscle causing the antagonist perioral elevator muscle to tion or repose. raise the corners of the mouth.

Depressor Labii Inferioris

Nerves

Origin of the DLI is on the inferior bor- The Trigeminal Nerve der of the mandible medial and superior This is the fifth cranial nerve that supto the depressor anguli oris. The effect of plies the majority of sensory innervation the DLI is lowering of the lower lip. to the oral-facial area, as well as a minimal Mentalis amount of motor regulation. The trigemi nal is the largest cranial nerve. The mentalis originates on the mentum and inserts into the mental dermal tis-

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Risorius The risorius rises in the fascia over the masseter and passing horizontally forward—superficial to the platysma—is inserted into the skin at the angle of the mouth. It is a narrow bundle of fibers, broadest at its origin, but varies much in its size and form. The risorius retracts the angle of the mouth and produces an unpleasant grinning expression.38

Table 2.2 Perioral muscles Zygomaticus major

muscles of facial expression Origin/Insert

Effect

Aging sign

Inferior zygomatic Elevates corners Minor arch/modiolus contributor to of mouth (corner of mouth) deepening superiorly and laterally nasolabial fold (NLF) (smiling)

Botox Tx (BTX)

Filler Tx

Not Indicated

Placed medial to NLF

Zygomaticus minor

Medial to same origins and insertions as zygomatic major

Adjunct to zygomatic major (smiling)

Minor contributor to deepening NLF

Not Indicated

Placed medial to NLF

Levator labii superioris

Malar prominence below infraorbital rim/medial orbicularis oris

Lifts upper lip (Sneering)

Major contributor to deepening NLF

Rarely (tendency to flatten out midface appearance)

Placed medial to NLF

Levator labii superioris alaeque nasi

Nasal process of maxilla/medial orbicularis oris

Adjunct in lifting upper lip (sneering)

Lip lengthens

BTX TX: Reduce “gummy smile”

Not Indicated

Rhytid development Vol atrophy

BTX TX: Vermilion

Vermilion Sculpting (Zone A) Lip Filling (Zone B)

DAO BTX-A Lifts corners of mouth

Commissure fill technique

Not Indicated

Placed in fold to reduce severity

Obicularis oris

Depressor anguli oris

Interdigitates with Lip competency Lips pursing surrounding muscles (kissing)

Inferior mandibular Downward pull Drooping of border/modiolus of corners of commisures mouth (frown) Depressor labii Inferior mandibular Lowers the Contributes to border/inferior Inferioris lower lip deepening of orbicularis oris the mental fold

Combo Tx (Filler/ BTX) NO

NO

YES

NO

YES

YES

NO

Chapter 2 The Canvas

Table 2.2 (Cont’ed) MUSCLES OF FACIAL EXPRESSION Perioral muscles

Origin/Insert

Mentalis

Inferior mandibular border/skin of the chin

Risorus

Platysma, parotid fascia/modiolus

Adjunct to platysma functions (grinning)

Buccinator

Pterygomandibular raphe, alveolar process of maxilla & mandible/upper lip and lower lip

Compresses cheek (blowing)

Playsma

Clavical, 1st ribs, acromion/anterior and posterior mandible

Depressor of the mandible

Effect

The motor fibers of the trigeminal nerve supply the masticatory muscles: masseter, temporalis, pterygoideus medialis, and pterygoideus lateralis. Motor nerves also supply the mylohyoid, anterior belly of the digastric, tensor tympani and tensor veli palatine.

Combo Tx (Filler/ BTX)

Botox Tx (BTX)

Filler Tx

BTX-A injections relieve “cobblestoning”

Not Indicated

NO

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Commissure fill technique

YES

Protrudes lip “CobbleCompresses stoning” of chin skin of the chin

Motor Root

Sensory Root

Aging Sign

Hyperfunctional Lifts corners of mouth bands

This nerve is purely sensory. We will be dealing with this nerve and its terminal innervation when we augment the nasolabial line and upper lip. The V2 emerges out of the cranium through the infraorbital foramen and supplies the mucous membrane of the nasopharynx, maxillary sinus, soft palate, tonsil, hard palate, periodontal tissue, and teeth of the maxilla.39

The three divisions of the trigeminal The maxillary division also innervates nerve are: ophthalmic division (V1), max- the: illary division (V2), and the mandibular Middle portion of the face Lower eyelid division (V3). Side of the nose Ophthalmic Division (V1) Upper lip This division is only sensory and exits the superior orbital fissure. The nerve sup- The Mandibular Division (V3) plies the nasociliary, frontal, and lacrimal The V3 is primarily sensory with a nerves. minor motor component. The divided Maxillary Division (V2) branch supplies the lateral pterygoid

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FIGURE 2.4

Facial Nerves Facial nerve (motor nerves), (V7) Nasolabial (V2), long buccal (V3), and mental nerves (V3) muscle, masseter muscle, temporal muscle, auriculotemporal nerve, mylohyoid nerve, inferior alveolar nerve, and incisive branches. The terminal branches that we will deal with when we fill the soft tissue of the oral-facial area include: Long Buccal Branch—this nerve passes between the two heads of the lateral

pterygoid and continues on an anterolateral direction. At the level of the occlusal plane, it crosses in front of the anterior border of the ramus and enters the cheek through the buccinator muscle. The long branch does not innervate the lower lip. It provides sensory fibers to the skin of the cheek. This area needs to be anesthetized when

Chapter 2 The Canvas

doing fills in the corners of the mouth and later to the commissure. Mental Branch—This is the terminal manifestation of the inferior alveolar nerve. The mental nerve exits the mandible out of the mental foramen and provides sensory innervation to the chin and the lower lip.40

muscle.

Vascularity It is critical to be aware of the vascularity of the perioral region to address the following:

Anesthesia: When giving infiltration around the oral area, it is important to Facial Nerve (V7) avoid intravascular injection. Knowing the The facial nerve (V7) exits the skull vascular landmarks and utilizing sound through the stylomastoid foramen. V7 aspirating techniques will minimize the passes inferiorly and anteriorly before possibility of this occurrence. it networks its way through the parotid Bruising: When we inject into or around gland. highly vascular areas, we exponentially This nerve supplies the motor move- increase bruising, which leads to unwantment for the muscles of facial expression ed aesthetic outcomes. Ischemia: When injecting a solid mate(please see the section on musculature). The facial nerve consists of five branches: rial like a filler into—or in close proximity temporal, zygomatic, buccal, mandibular, to—a vascular supply, there exists the potential to occlude the vessel. and cervical.

Temporal

The Facial Artery

Innervates anterior and superior auric- The majority of the blood supply to the ular muscles, the frontalis muscle, and the lips originates from the facial artery (FA). The FA arises from the external carotid arsuperior portion the orbicularis muscle. tery. The FA curves around the surface of Zygomatic Innervates the inferior portion of the the mandible and gives off small muscular orbicularis oculis muscle, superior por- branches to the masseter and the deprestions of the zygomaticus major, levator la- sor anguli oris muscles. The FA then apThe bii superioris, levator anguli oris, nasalis, proaches the angle of the mandible. 41 mean diameter of the FA is 2.6 mm. Usuand orbicularis oris muscles. ally the FA is located 15.5 mm lateral to Buccal the angle of the mouth.42,43 Innervates the buccinators and orbicuUpper Lip and Nasolabial Region laris oris muscles, the inferior portions of zygomaticus major, levator labii superio- The FA supplies the majority of vascularity to the upper lip.44 The average exterris, levator anguli oris, and nasalis. nal diameter of the superior labial artery Mandibular is 1.6 mm at its site of origin. The supe Innervates the depressor anguli oris, rior labial artery (SLA) branches off the FA the depressor labii inferioris, and the menabove the angle of the mouth around 75 talis muscle. percent of the time and at the angle of the Cervical mouth 25 percent of the time. Innervates the platysma, the posterior The FA has three types of major-branch belly of the digastric, and the stylohyoid distribution:

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the middle of the upper lip in the region Type A — bifurcates into the lateral nasal of the vermilion border. The anastomosis and superior labial arteries at the angle of is deep to the orbicularis oris, leaving the the mouth (80-90%) plane between the skin and muscle void 45 Type B — branches off into the supe- of these major vessels. rior labial and lateral nasal arteries, ter- Lateral Nasal Artery (LNA) minating as the angular artery (5-10%) The lateral nasal artery (LNA) branchType C — terminates as the angular ar- es from the nasolabial sulcus and runs totery, but the lateral nasal artery branches ward the dorsum of the nose. The mean off from the superior labial artery (2-5%). external diameter of the LNA is 1.43 mm.

Superior Labial Artery (SLA) The superior labial artery (SLA) branches off into a superficial and deep ascending branch. On average, these branches measure 0.3 to 1.1 mm in diameter. The superficial ascending branch penetrates the orbicularis oris and appears in the subcutaneous tissue at the vermilion border. The deep ascending superior labial artery supplies the oral (wet) mucosa. The SLA connects with the opposite artery in

Figure 2.5 The Facial Artery

Columellar Branches These are branches that continue off the superficial descending superior labial artery.46

Lower Lip Inferior Labial Artery (ILA) The inferior labial artery (ILA) is the artery that supplies the lower lip. The mean external diameter of the ILA is 1.31 mm. The ILA branches off the FA at three

Here are the three variations of the facial artery as it branches off the superior labial artery.

Chapter 2 The Canvas

Superior Labial Artery

Zone B

Zone B

Inferior Labial Artery

Depicted here is a cross-section of the upper and lower lips. Notice how deep the superior labial artery and inferior labial artery are in relationship to the orbicularis oris. The targeted points for the fillers are superficial to the orbicularis oris. Most vascularity interrupted or bruised will be accessory branches of the two main arteries depicted here.

Figure 2.6 - The Labial Artery

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different areas. Approximately 75% of the time, the inferior labial artery branches off at the inferior border of the mandible. In 20% of the cases, the ILA branch occurs at the commissure of the mouth; and in 5% of all cases, the branch of the ILA diverges at the SLA. The SLA then separates into deep descending and superficial descending branches. The superficial descending SLA penetrates the orbicularis oris at the superior edge of the muscle and presents in the subcutaneous tissue and vermilion border.47 The deep descending branch travels into the submucous tissue and into the orbicularis muscle.48,49

tered. The vermilion border is the transition point of the delicate lip tissue and the more robust facial tissue (epithelium). The term “vermilion” means a shade of red, which is imparted on the eye. This is due to the translucency of the skin that enables the color of the blood vessels below to show through. The vermillion border is very distinct on the upper lip, demarcated by Cupid’s bow. The lower lip, however, is made of a smoother transfer of tissue and is not quite as demarcated.

The philtrum is the indentation above the superior edge of the vermilion border Mental Arteries and below the alar of the nose. This sen The vertical and horizontal labiomen- sual facial feature has enjoyed continued tal arteries (VLA and HLA) are located be- popularity and attention. The philtrum tween the lower lip and submental region. forms the peaks of the Cupid’s bow of They are branches of the FA and ILA. the lip. The philtrum starts beneath the nose and merges to the vermilion border Oral-facial Aging of the upper lip. The philtrum widens as Facial skin it lowers to the lip. Although there are no The Nasolabial line (the smile line) is recognized averages for its length, the imthe manifestation of excess skin hanging portant point to realize is the symmetry above a sharp transition line between hav- in the adult that is considered the norm. ing more fatty deposited tissue above an The length from the base of the subspinal area where there is less fatty tissue. The and the superior of the upper vermilion pulling of the musculature associated border should be equal to the commissure with the smile, in particular the zygomatic height to the subspinal.50 muscle and superior labialis. This trough The Effects of Aging deepens as we age. The major dynamics in facial aging Lips include gravity, soft tissue maturation, The skin of the lip makes its transition skeletal remodeling, and muscular facial from the oral mucosa to the keratinized activity.51 At birth the lips and face are the skin of the face. Tissue in the mouth is held epitome of fullness. The young child’s in a unique balance between the need for profile protrudes and the lips are pinched moisture and the lack of keratinization. between the cheeks. Studies have shown that the upper lip is more hydrated than the lower lip. The SKELETAL/DENTAL lips are among the most vascular organs Throughout our adult life, the oralof the human body. This explains why, facial skeletal dimensions continue to 52,53 From late teens to the third dewhen the body is in a diseased state, the grow. cade of life, there is an average increase appearance of the lips is drastically al-

Chapter 2 The Canvas

TIPS

light source

Here is an illustration of how light and surface contours interact in the lip region. The light source is from the upper left, casting a direction down and diagonal. We can see how Zone A, Segments 1-3 pick up what is referred to as the height of contour. Zone B, Segments 1-3 are in the shadow. Upper Lip: This is relevant to filling volume in Zone B, Segments 1-3. If Zone B is overfilled on the upper lip, it will pick up the height of contour and leave an unaesthetic result, which is often perceived as a “duck lip” or “bee sting” appearance. Lower Lip: The opposite is true in filling the lower lip. The lower lip’s height of contour is in Zone B, Segments 4-6. We are at liberty to add volume to the lower lip, accentuating the natural presentation. Adding too much volume in Zone A, Segments 4-6 will produce a beak effect to the lips and distract from the natural teardrop shape that constitutes the lower lip.

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in the vertical dimension of our face from nasion to menton of 2.7 mm.54 Other studies tend to support the idea of anterior facial growth well into the fourth decade of life.55 In addition research has shown that on average, there is a retroclination of the maxillary incisors in females of 1.44 degrees from 22 to 33 years of age.56 The skeletal growth direction and inclination of the maxillary incisors can account for the progressive loss of lip support and volume in women.

tical dimension as the condylar guidance and anterior guidance play an important associative role.60,61

SOFT TISSUE

Orthodontically the dental profession has associated average angles and lengths to craniofacial skeletal and soft tissue landmarks. Orthodontists have traditionally incorporated the soft tissue of the mouth in treatment planning. EH Angle stressed the importance of the oral soft tissue and orthodontics.62 CS Case included Dentally, as a person ages, the occlusal the profile presentation of oral soft tissue surface of the dentition does exhibit wear into the orthodontic treatment consider(approximately 1 mm every 30 years). ation.63 Both Angle and Case relied upon Some authors suggest that this is a sigmore subjective perspectives of the soft nificant contributor to the loss of vertitissue relationship in orthodontics. cal dimension in the lower portion of the Ricketts described the “E plane” (esface.57 thetic plane) as As most expethe area on the rienced dentists face from the tip would agree, if of the nose to there is a substanthe chin when tial loss of dentalviewed from the vertical height, profile.64 Within this is more likely this area lies the to be associated lips; protrusion with pathogenic from this plane occlusal trauma. is unaesthetic. These would inBurstone preclude primary sented the idea tooth trauma A baby’s face is the epitome of fullness. At this age, that the layman from malocclu- we see the pucker of youthful, tonus facial tissue. would be drawn sion and secondto the balance ary occlusal trauma from periodontal or of the upper lip to the nose in the profile, supportive tooth structure disease. this being the nasolabial line angle. The Clenchers and bruxers are classified relationship of the upper lip to the nose into two separate categories. Vertical load- from the profile impacts our judgment of ing during waking hours and eccentric esthetics much more than any other relagrinding during sleep, both will wear the tionship within the “E plane.” vertical dimension of occlusion, thereby There are certain angle relationships reducing the facial profile length.58 that are associated with a pleasing profile, Temporomandibular dysfunctions59 such as the nasolabial angle: 85 to 105 decan contribute to the loss of anterior ver-

Chapter 2 The Canvas

Age

Table 2.3

Aging Tooth Exposure

Maxillary Central Incisor

Mandibular Central Incisor

To 29

3.37

0.51

30-39

1.58

0.80

40-49

0.95

1.96

50-59

0.46

2.44

60 and above 0.04

2.95

Source: Vig RG, Brundo GC. Kinetics of Anterior Tooth Display, J Prosthet Dent. 1978;39(5):502. grees; the distance between the vermilion border of the upper lip to the alar of the nose: 18-20 mm; and the distance between the vermilion border of the lower lip and inferior border of the mandible: 36 to 40 mm.

to the bulk of the lip.

In the male and female face, the nose increases in all dimensions. There is a decrease in the soft tissue at the pogonion, a decrease in the upper lip, and an increase in the thickness of the lower lip. When the Steiner’s Angle is the angle viewed facial profile is straightened, the lips be66 from the profile of the lips. This usually come more retrusive in males. The uprelated to 30 degrees. G-K (Glogau-Klein) per lip seems to rotate down and back Point is described as the slight elevation from the base of the nose, which leads to of the lip from the glabrous skin to the less maxillary incisor exposure at rest and 67 mucosa of the lips. It is also referred to when smiling. As we age, the tooth exas the “ski-jump” point of the upper lip.65 posure at rest decreases in the maxillary Understanding this angle and reestablish- and increases in the mandibular teeth. ing this angle can recreate a more youthIntrinsic Effects ful appearance. There are several key factors that can Augmentation possibilities: For more be attributed to time’s effect on the skin. mature patients, successful augmentation For example, fibroblasts, which are rewill include filling Zone A of the upper sponsible for connective tissue proliferalip and reestablishing the anatomy of the tion, begin to lose their biosynthesis caphiltrum and superior vermilion border. pabilities. This gradually decreases the For younger patients, simply filling in skin’s dermal thickness.68 There is also Zone B will push up the anatomy in Zone a slow breakdown of the cellular memA to reestablish the angle. This is due to brane due to the oxidative process placed the tonality of the tissue and anatomy still on the lipid bilayer of the cell membranes being present, so we are just adding a little and dermal proteins, which has led to the

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push for antioxidant creams and associated supplements in the cosmetic retail business.69 The process of DNA repair is also reduced, and the ability to resynthesize collagen and elastin fibers is decreased.70 Some authors believe that this theory of programmed cellular degradation is due to our genotype makeup.71 The difference in male and female skin is primarily in the thickness of the skin. Skin thickness in a woman reaches its peak in their mid-thirties. Thickness gradually decreases from that time on.72,73 A man’s skin in the middle to lower third of the face is thicker and heavier. The skin is bearded and is more resistant to wrinkles. Due to this thickness, gravity has an increased pull on the skin and lowers the overall jaw line as the man ages. If you follow the careers of anchormen in their younger years, you see them presenting with a high smile line and visible maxillary dentition. Later in their careers, you will notice that the lower dentition is more prevalent when they speak.

overall aging of the skin by trauma from pollutants and damage from ultraviolet rays.75 Photoaged dermis is hyperplasia of elastic tissue with near complete disorganization. Large quantities of thickened, degraded, elastic fibers can be seen under the microscope.76 Gravity—it seems that a great deal of emphasis is placed on gravity’s contribution to the overall drooping of the facial skin. Some authorities, however, hold this theory with lesser regard. They would argue that we spend half our lives recumbent, wondering, why doesn’t our skin sag to our ears? Our other organs and support mechanisms do not drop with age. For example, the diaphragm does not sag and the kidneys do not stretch and fall into the lower pelvis. Our leg skin does not sag to our ankles due to gravity.

Beginning in the mid to late thirties, changes become apparent throughout the face. Wrinkles and fine lines appear around the eyes and mouth. The dermal thickness is still relatively intact as in the earlier years of life, although gravity has Augmenting the nasolabial line on weighed the face down. The telltale signs males requires more filler as the lines are of aging occur in the upper face first.77 It is heavier and thicker. It is also more acceptable for men to present with the matura- commonly believed that the weakest link in the chain of events to cause aging or tion lines. drooping of the facial skin is the cohesive A woman’s skin, however, is thinner ability of the dermis and remodeling of fat and drapes around the anatomy in a fin- distribution around the face.78 er fashion. This leaves the skin prone to more wrinkles and folds. Consequently It is important to note that adding filler, augmenting the facial lines of a woman particularly permanent ones to the cheeks has a more dramatic result on these lines. or lips in overabundance, can accentuRegardless of gender, cigarette smoking ate this effect, increasing the pull effect clearly has a deleterious effect on the ag- of gravity during the late forties. It is our ing face. Furthermore, nicotine, a potent goal as cosmetic augmenters to enhance vasoconstrictor, is known to have an ad- existing facial profiles in a patient’s thirties to forties and not weigh them down. verse affect on wound healing.74 In our forties to fifties, the dermis tends to thin out due to hormonal changes and the Extrinsic Factors Environmental—contributes to the loss of estrogen, which is particularly ap-

Chapter 2 The Canvas

parent in women. We see labial rhytides develop around this time. The constant constriction of the orbicularis forms “sunbeam-like” wrinkles around the mouth. We also may start to develop “marionette lines” or a “Chinese mustache” at the angles of the mouth descending down to the inferior border of the mandible. This is the onset of ptosis that is commonly associated with the skin.79 Therefore, in the forties and fifties, we can start to fill and add volume in the lips and nasolabial areas. As faces mature through the fifties and sixties, the jaw line sags and the corners of the mouth droop down. The lack of tonus from the musculature and the pull of gravity draw the overall expression of the mouth down. The intercommissural distance increases with age, whereas lip The youthful face is all about volume. height decreases. As we mature, photo- Oral-facial augmentation with injectable graphs will reveal that the lower incisors fillers strive to recreate this look by have become more prevalent when we refilling areas of lost volume. talk. In photographs of younger people, on the other hand, the lip line is higher surgical face lift. The surgical face lift is during conversation and the incisal edge significant surgery where there is a relief of deep muscular structures and the repoof the maxillary teeth is present.80 sitioning of the face in a superior lateral A youthful face has a full appearance position. Although this procedure does to it. The thick skin on the face adhering relieve sagging and significant folds of the to the tight musculature of the facial anatface, it leaves a flattened appearance. omy presents with a taut, resilient look. Traditional face lifts leave the patient with As cosmetic procedures evolve, we are a flattened out profile, or a pulled effect, constantly trying to correct or inhibit the aging process as it occurs (immediately), which is what has been done surgically. Everyone ages differently, either rather than resorting to the need for drathrough genetics, the environment, and/ matic face lifts. This is not to suggest that or illness. Restore your patient according face lifts will be eliminated for certain to how he or she presents, not according segments of the population. However, it does indicate that the combination of fillto chronological age. ers and surgical intervention is destined Face lift vs. Filler to become the movement of the future. There has been an evolution of adjunctive and supportive cosmetic procedures Aging & Maturation of the Lips with the emergence of the plastic sur- The same principles that impact the gery culture. Today’s cosmetic society is skin affect the lips. Based on gender, the looking for alternatives to the traditional maxillary and mandibular lips reach their

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TIPS

Prior to initiating the oral-facial augmentation procedure, spend some time talking with your patient. This gives you, the injector, time to lift your eyewear loops and see the patient’s entire face. Fill one side, stop, and evaluate before filling the other side. Take your time to assess as you go to give the patient a sense of security in your technical abilities.

Chapter 2 The Canvas

maximum fill at different times and at different ages. The female maxillary lip reaches its maximum size at around fourteen years of age, while the mandibular lip reaches its maximum dimension at around sixteen years. A male’s maxillary lip, on the other hand, reaches its maximum size at around eighteen and for the mandibular lip, it is shortly thereafter.81-83

Chapter 2 Review STUDY Points Constitution of the lips and corresponding shapes Static vs. kinetic facial movements and their relationship to cosmetic augmentation Aging process of the oral-facial area (intrinsic, extrinsic) and implications in lip and perioral augmentation. Musculature, vascular and neural involvement in oral-facial augmentation.

STUDY Questions 1) Incomplete union of the lips has a prevalence of what? And the phenomena is an incomplete union of what two processes? 2) What constituent is used to acquire a patients static lip position for evaluation? 3) Of the three types of lips zones which one is never filled and why? 4) Describe the acronym LARS. 5) Which branch of nerves is most likely to cause facial distortion when anesthetized and why?

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Chapter 3

Anesthesia

Haud vir est suus professio vinco primoris dies. No man is his craft’s master the first day.

Chapter 3 Anesthesia

Local Anesthesia for Oral-Facial Augmentation Delivery of Injectable Anesthetic Delivering Local Anesthetic

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Just ask any dentist and they can testify that one of the most frustrating parts of practicing dentistry is anesthesia. How many times have we failed to accomplish anesthesia on our patients (and, of course, nine out of ten times, it is on the most pain-/anxiety-ridden patient in our practice)? During the arduous process of administering cartridge after cartridge of anesthetic in hopes of finally getting our patient numb, our waiting room backs up and we silently curse the first day we set foot in dental school. Through my travels, researching this book, and talking to the various specialist that use dental blocks for oral-facial augmentation, I have come to one transcendent truth in the oral-facial augmentation community: all practitioners—irrespective of their specialty—wrestle with the difficult and oftentimes elusive component of practicing oral-facial anesthesia. I have always liked to keep two mantras in mind when administering anesthesia—or any drug for that matter: 1) superior results with minimal discomfort; and 2) maximum effect with minimal dosage. This chapter is formulated to lay a sound basis for lip and perioral anesthesia as applied to cosmetic augmentation of this area. The following are techniques and suggestions designed to assist all practitioners from the multitude of specialties optimize their oral-facial anesthesia.

Chapter 3 Anesthesia

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Local Anesthesia for Oral- Botox and Anesthesia Congruent anesthesia facial Augmentation

with Botox (BTX) therapy is contraindicated. The use With the exception of dentists, there of anesthetic has the potential to impede seems to be reluctance among healthcare the precise location of the targeted anatpractitioners to use dental blocks in con- omy for BTX cosmetic therapy. Block anjunction with injectable dermal fillers. esthesia for placement of BTX around the Since the art of injectable filler overlaps lips and perioral anatomy will leave a cermany specialties of healthcare, a sum- tain degree of flaccidity of the oral-facial mary of practice related to local anesthetic muscles. It is important to understand the and its application is warranted. result of flaccidity that comes with the ap Some clinicians argue against using plication of anesthesia—however signifilocal anesthetic or dental blocks when cant it may present—does not presume injecting dermal fillers because they be- the patient will receive distortion of the lieve that local anesthesia distorts the lips, muscle of facial expression. Yet the limitwhich tends to mask their natural shape. ed loss of any muscular tonus has a large This would lead to an unaesthetic result impact on botox therapy. post augmentation. When a practitioner attempts to locate

the muscle for BTX injection, they will often have the patient constrict the targeted muscle by pursing their lips or biting down. An example of this is the depressor anguli oris. To precisely locate this muscle, we have the patient bite down and we palpate the inferior border of the mandible. We locate the DAO by feeling our way posterior along the mandible until we arrive at the anterior border of the masseter. Whether the loss of muscle control is perceived or actual, anesthesia can encumber our ability to locate the muscles of facial expression. It is difficult enough at times locating specific targeted muscle to denervate. The overlying anatomy of the oral It is also important to realize that as a facial area can be thick and drape more dentist engaged in the practice of lip and than expected over supporting structural perioral augmentation, you have had the anatomy. Additional variables, such as lobasic training to optimize the best of both cal anesthetic, can complicate treatment. worlds: complete anesthesia without distortion and the technical placement of Local Anesthetic Pharmacokinetics fillers via injection techniques. No other Local anesthetics act on nerve cells by healthcare practitioner has more didactic, blocking the transmission of electrical enclinical, and everyday experience in the doneurium, sending impulses across the administration of oral-facial anesthesia cell membrane. The transmission of nociand hands-on treatment of the oral-facial ceptive (pain) impulses is more sensitive to the action of local anesthetics than the area.

Another reason commonly cited for not using blocks or infiltrates during oralfacial augmentation is that when a patient has complete anesthesia, the injector is using more force in the application of the filler, which can result in lumpiness, bruising, and distortion.84 The key is to realize that the inability to feel the injection pressure (G’) is related to the augmenter’s lack of expertise and/or training. Calibrating your injection pressure by your patient’s discomfort level, rather than using your own tactile and visual perception of the flow of the material, is an indicator of improper augmentation.

Chapter 3 Anesthesia

Here is an example of two stereotypes we face as lip and perioral augmenters…one is obvious, the other not so much. Clearly, the portrayal of a large needle injecting haphazardly into the lips is not a flattering portrayal of our profession. Yet, most disturbing to me is the overly large, nonsymmetrical lips. We have discussed at length the ideal proportion and how it is pleasing to the eye, yet these lips violate the golden proportion. An equal 1:1 lip ratio is the least appealing to our eye and this is a perfect example of this. Naturally, writing “a beautiful set of lips” in this caption would undermine the suggestion of the photo.

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transmission of motor impulses. Injectable local anesthetics consist of amphiphilic molecules, meaning that they dissolve in both aqueous and lipid environments. To achieve this effect, a lipophilic ring structure on one end of the molecule is combined with a hydrophilic secondary or tertiary amino group on the other.

anesthetic is protein and the anesthetic with the higher degree of protein binding will remain attached longer.86 For example, bupivacaine is highly protein bound, which directly correlates with its longevity during a procedure. Local anesthetics are broken down into various classifications based on the duration of their prod Lipid solubility determines potency.85 uct. For the purposes of this book, we will be dealing with duration as it affects the The more lipophilic a local anesthetic is, soft tissue or infiltrate, not profound pulthe greater the penetration into the nerve pal anesthesia. The categories are broken cell membrane, which results in a more efinto short duration (< 60 minutes), interficient blockage of the neural signal. mediate duration (60 minutes) and long Anesthetic Classification duration (> 60 minutes). Local anesthetics are either esters (cocaine, The pKa (which determines the onbenzocaine, procaine, tetracaine, chloroset of neural blockage) of an anesthetic procaine) or amides (lidocaine, mepivais the pH at which equal percentages of caine, bupivacaine, etidocaine, prilocaine), the drug exist in the ionized and the nondepending on the type of chemical bond ionized forms. Local anesthetics are weak joining the two ends of the molecule. Only bases and become positively charged in a amide-type local anesthetics are marketed negative pH environment. On the other in dental cartridges. The benefits of these hand, the nonionized form of the local anparticular anesthetics include a greater efesthetic penetrates (into) the neural memficacy obtaining targeted tissue anesthesia brane. Local anesthetics with a pKa closer with a lower risk of allergic reactions. to the physiologic pH produce higher Anesthetic Characteristics concentrations of the nonionized form, Protein binding potential determines which increases the speed of onset of that the duration of the local anesthesia. The particular local anesthetic. Areas of active idea is that the binding receptor for the infection have a lower tissue pH, which

Table 3.1 Anesthetic Classification Age Lidocaine (Xylocaine) Bupivacaine (Marcaine)

Potency

Duration

PKa

pH (+ epi)

pH (- epi)

Max Dose (mg/kg) 4.5 (- epi) 7.0 (+ epi)

2

Short (- epi) Intermediate (+ epi) 7.9

4

Long

8.1

3.0 - 4.5 4.5 - 6.0 not exceed 90 mg)

Intermediate

7.8

4.4 - 5.2 N/A

7.0

3.0 - 3.5 4.5

6.6

3.0 - 4.0 4.5

6.0

Articaine Mepivacaine

2

Prilocaine

2

Short (- epi) Intermediate (+ epi) 7.6 Short (- epi) Intermediate (+ epi) 7.9

5.0 - 5.5 6.5

1.3 (Max dose does

Chapter 3 Anesthesia

tends to decrease the nonionized form, removed from all local anesthetics circa thus lengthening the onset time. 1985. If an allergy is encountered with a local anesthetic, one may use another andental Anesthetics esthetic with the least amount of molecuChoosing a Dental Cartridge for Local lar similarity.87 Lidocaine is most similar to prilocaine and etidocaine, which is no Anesthetic The standard dental cartridge is the longer available in structure, and mepioptimal carrier for anesthetic used in oral- vacaine is most similar to bupivacaine. facial augmentation. The standard dental Articaine has the most unique molecular 88 carpule is distributed in a 1.8 mL aqueous structure. solution containing various solutions of There are certain requirements needed anesthetic. The dental cartridge is com- from the hardware to inject local anesthetposed of a cylindrical glass tube, stopper, ic in oral-facial augmentation. aluminum cap, and a diaphragm. (See fig) Toxicity The American Dental Association Council on Scientific Affairs developed a color- Toxicity, whereby the cardiovascular or coding system on standard 2 mL dental central nervous system is mainly affected, carpules. The colors on the carpules are is similar in all local anesthetics. Toxicity assigned to the various anesthetic compo- to local anesthetics is related to the potency, total dosage, systemic absorption, prositions used in local anesthetic. tein binding, metabolism, and excretion. Adverse Reactions to CNS toxicity ranges from lightheadedness and tongue numbness to excitability, Anesthetics seizures, and coma at the extreme toxicity Allergy levels. The CNS effects are hypothesized A true allergy to local anesthetics is to be due to the depression of inhibitory rare. When an allergic reaction occurs, it is neurons, leaving the excitatory pathways usually due to the metabolite para-aminunopposed.89 obenzoic acid (PABA) in ester anesthetics and the preservative methylparaben Cardiac toxicity occurs secondary to (MPB) in amide anesthetics, which was

Dental Anesthetic Products and ManufactureRs available on the Market Lidocaine, Mepivacaine: Darby Dental Supply, 865 Merrick Ave, Westbury, NY 11590 Henry Schein, 135 Duryea Road, Melville, NY 11747 Citanest, Polocaine, Xylocaine: Dentsply Pharmaceutical, 570 W. College Ave, York, PA 17404 Carbocaine, Marcaine, Zorcaine: Eastman Kodak, Kodak Dental Products, 343 State St, Rochester, NY 14650-1122 Isocaine, Lignospan, Octocaine, Scandonest, Septocaine-Septodont: 245-C Quigley Blvd, New Castle, DE 19720.

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Carpule Colors Local Anesthetic Solution

Color of Cartridge Band

Articaine HCI 4% with epinephrine 1:100,000

Gold

Bupivacaine 0.5% with epinephrine 1:200,000

Blue

Lidocaine HCI 2%

Light Blue

Lidocaine HCI 2% with epinephrine 1:50,000

Green

Lidocaine HCI 2% with epinephrine 1:100,000

Red

Mepivacaine HCI 3%

Tan

Mepivacaine HCI 2% with levonordefrin 1:20,000

Brown

Prilocaine HCI 4%

Black

Prilocaine HCI 4% with epinephrine 1:200,000

Yellow

Chapter 3 Anesthesia

TIPS

If using cosmetic facial markers, place markings on the face or lips prior to administering perioral anesthesia. This way, one is ensured of the accuracy of marked areas, if there is any slight distortion of the face after oral-facial blocks are applied.

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the blockage of the sodium channels in the cardiac conduction system.90 At high plasma concentrations, myocardial contractility is depressed. Smooth muscle dilation may cause hypertension. Symptoms of cardiac toxicity include palpitations, cardiac dysrhythmias, hyper- or hypotension, and cardiovascular collapse.91 Cardiac toxicity is worsened by the use of epinephrine.92 Hypoxia, hypercarbia, and acidosis are potential risks. Epinephrine has some distinct advantages when incorporated into local anesthetics. It prolongs the duration of the anesthetic by reducing the absorption rate. Epinephrine is a powerful vasoconstrictor that provides excellent hemostasis. Its vasoconstrictive properties lengthen the effect of local anesthesia by decreasing the blood flow in the area of administration, which decreases the anesthetic’s metabolism. When proper technique is applied, oral-facial augmentation requires little hemostasis. In addition, the procedures are short in duration; therefore, an epinephrine-free local anesthetic should suffice for most oral-facial augmentations. It is also helpful to use your ASA reference guide to determine whether or not your patient is a candidate for epinephrine.93-95

Delivery of Injectable Anesthetics There are various techniques that can be used in delivering local anesthetic that will optimize a patient’s comfort and results. Warming the anesthetic to 37 C has been shown to reduce pain in the injection site.97,98 The lower the acidity of the local anesthetic, the greater degree of pain upon deposition in the tissue. Standard packaged anesthetics are dispensed in dental carpules that can have an acidic pH of 3-5.5 (to stabilize the epinephrine component), which can be painful when injected.99

Tip: Using an anesthetic without epinephrine and a pKa close to the physiological pH of the injected site will greatly reduce pain upon injection. Remember: using dental blocks for oral-facial augmentation requires attaining adequate anesthesia for the comfort of the patient without distorting the muscles of facial expression. Using a short acting, fast onset anesthetic is appropriate for most augmenting techniques. An example of an ideal local is lidocaine without epinephrine (see Table 2.1). This particular anesthetic has a pKa of 6.5 without epinephrine, which will It should be noted that all local anes- shorten the onset time and be comfortable thetics are vasodilators. Most vasodilation when injected into the patient (due to its is confined to the area of injection and is pH). related to concentration of particular anesthetic.96 Due to the vasodilation of local an- A local anesthetic buffered with an esthetic without epinephrine the potential agent such as sodium bicarbonate neuexists for the injected bolus of anesthetic tralizes the acidity of the lidocaine soluto spread into adjacent tissue more than tion, whereby making the injection of the with anesthetic with epinephrine. This material less painful. The dilution rate of lidocaine) ratio is recomgreater spread of anesthetic may result in 1:9 (bicarbonate: 100 partially anesthetizing the facial nerves, mended. The disadvantages of using a thereby leading to a greater distortion of buffered solution include the additional time, material, and expertise of mixing the facial muscle during augmentation. the solution—since it’s not commercially

Chapter 3 Anesthesia

available. Furthermore, buffering lidocaine reduces the shelf life of the anesthetic to three to four weeks when prepared;101 and the NaHCO3 disappears within minutes. The combination of warming and buffering the local anesthetic seems to be effective for reducing the pain of lidocaine solutions upon injection.102

to the infraorbital foramina without submerging the needle to the hub. “Needles should not be inserted into tissues to their hubs unless it is absolutely necessary for the success of the injection.”104 The rationale behind this is that if needle breakage occurs, it would be difficult to retrieve the broken segment if the injector has submerged it to the hub. One may use a 30-gauge or 27-gauge for the mental injection. I usually use a 30-gauge needle. It is recommended to change needles after five to six injections, so it is possible to do all thee blocks using one needle for oralfacial augmentations.

Mechanical injection techniques such as pressure application at the site of injection and controlling the speed of injection will reduce the discomfort. The use of relaxation techniques, procedural explanation, an adequate office environment, and staff support will reduce the anxiety of in The use and application of local anesjection procedures. thetics between dentist and physicians var In addition to buffering and warming, ies in some significant ways. According to using the appropriate equipment for inScott—who published a study in the 2002 jection will reduce pain of the procedure. JADA detailing some awareness and use Using sharp, sterile, disposable needles of local anesthetic injections techniques— is paramount. Studies show that patients the use of buffering agents, warming of cannot perceive difference in pain upon injection solution, and vapocoolants reinjection with needle gauges between 23-, sulted in a significant difference of the 25-, 27-, and 30-gauge.103 five parameters selected to differentiate Needle length in oral/ facial augmen- between the specialties. Physicians were tation applies to only three injections tech- more likely to report use of pH buffering, niques. A 27-gauge, 32-mm length needle vapocoolants, and procedural explanais recommended for the infraorbital injec- tions, while dentists were more likely to tion technique. The length of the needle report use of warming, pinching or presallows us to deposit the anesthetic close sure application, controlling the speed of

Pre-op picture before injection of Infraorbital infraorbital, long buccal, and mental block vs. post-op picture after admin of three facial blocks. Markings on the post-op photo indicate areas anesthetized with blocks.)

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injection, relaxation techniques, topical techniques, I am frequently asked why anesthetics and aspiration.105 professionals outside the practice of dentistry experience failure when administerBlock injection vs. Infiltrate ing block anesthesia. In fact, there are two Injection of Local Anesthetic primary reasons why a cosmetic augment Studies have shown that block anes- er might fail to receive proper anesthesia thesia is more of a perceived distortion of from a block: limited knowledge or a lack facial soft tissue, rather than actual clini- of understanding of human anatomy and cal interference with muscular tonus.106 nerve innervations of the oral-facial area; Keep in mind that we are anesthetizing and technical error, which is often a result sensory nerves of V2 and V3. The facial of limited experience in administering lonerve V7 controls the muscles of facial ex- cal anesthesia and/or not placing the lopression. By precise blocking of the nerve cal anesthesia at the right exit point of the at the exiting foramina, we maximize the nerve. effect of anesthesia on the targeted facial As a result, the following may occur: soft tissue, while minimizing the distor• Over-injecting the amount of anestion. When we inject infiltrate into the tisthesia on a block and receiving distortion sue of the general area, the muscle tonus from the percolation of anesthesia into we want to augment is adversely affected. surrounding musculature. Over-administration of anesthesia will force the fluid to percolate away from the • Injecting an infiltrate anesthetic and, foramina and affect either the zygomatic, due to lack of knowledge and/or experibuccal or mandibular branch of the fa- ence, believing one has achieved anesthecial nerve. This will in turn cause loss of sia. muscle tonus of the face resulting in a dis- • Placing infraorbital and mental blocks tortion of its appearance. The facial folds, and still generating nerve pain in the lips. wrinkles, and architecture will relax and This pain is usually generated from the we are left with a less than accurate por- buccal nerve that was not anesthetized. trait of the face and lips. It is critical to keep in mind that as cos When we as dental practitioners ap- metic oral-facial augmenters, we are not ply an anesthetic, the goal is to attain pro- performing dental surgery. Consequently found anesthesia in the area in which we the amount of anesthesia administered will be working. There are many times we can be considerably less. To ensure sucneed to reinject to maintain the appropri- cess, place the blocks at precise foramina ate level of anesthesia so that the patient points in order to eliminate facial distordoes not feel any discomfort. Therefore, tion. we must be keenly aware of the maximum amount of injectable anesthesia allowable per body weight. The amount of anesthesia needed is considerably less when augmenting a patient’s oral-facial area with injectable fillers. With the proper techniques, we can achieve profound anesthesia with minimal distortion.

When I teach oral-facial augmentation

Intraoral vs. Extraoral Injections of Anesthesia There is definite evidence of a widespread lack of education in the medical community on the proper administration of dental blocks. This may be due to an unspoken, yet apparent “taboo” of exploring a territory that has been traditionally navigated by dentists.

Chapter 3 Anesthesia

facturer protocol when applying topical Dentists are typically trained to give anesthetic to ensure maximum tissue ananesthetic intraorally and most other esthesia. healthcare professionals will administer injectable anesthetic extraorally, due to Topical Antiseptic their lack of familiarity of the oral cavity. Extraoral—If one is choosing to inOne of the benefits of using intraoral is ject the local anesthetic extraorally, a precise block placement due to the rela- topical antiseptic is recommended. Betative ease of anatomic location. Moreover, dine (povidone-iodine) and merthiolate injecting intraorally does not need to pen- (thimerosal) are just two of the several etrate as much anatomy as extraorally, available forms of topical antiseptic. Antileading to a reduced incidence of bruis- septics that contain alcohol may produce ing, hematomas, and pain. The draw- tissue irritation. Additionally, caution backs to performing intraoral injections should be taken when using iodine-based includes learning the various techniques, compounds due to the significant risk of understanding anatomy of the oral-facial iodine allergies by patients.109 region, and the time needed to develop an Intraoral—Using a topical antisepexpertise that comes with continued prac- tic intraorally is an accepted practice betice of these blocks. fore injecting local anesthetic intraorally, Injecting extraorally is advantageous because of the ease of the technique: point and inject. However, the disadvantages of this technique are bruising, hematomas, pain, the inability to acquire adequate anesthesia, and unwanted percolation of anesthesia to facial nerve, whereby negatively affecting the muscles of facial expression.

Topical Anesthetic Extraoral—When dental blocks are not used, many practitioners use topical analgesic to reduce injection site discomfort. The most popular topical agent is a 5% benzocaine cream that is applied to the oral-facial area. Clinically the applications are messy and must be kept out of the oral cavity. Anesthesia is apparent for approximately 20 minutes.107 Intraoral—There are a variety of topical anesthetic compounds available for use. When a topical anesthetic is applied, studies show there is a significant reduction of discomfort in initial needle penetration.108 It is important to follow manu-

but the majority of dentists do not use topicals.110 Some practitioners will have patients rinse their mouths with an oral astringent rinse before starting dental procedures in order to reduce the bacterial load of the mouth.111

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Recreating the Canvas

Direction of needle insertion in order to facilitate filling in this plane.

Chapter 3 Anesthesia

Up until now we have illustrated the natural planes that occur in the lips. By augmenting them, we are able to reestablish the natural representation of the lips, thus producing an aesthetically pleasing result. What if a patient presents with lips where there seems to be a lack of a natural plane? The above illustration illustrates such a case. This model has beautiful lips, yet they lack the fullness of the rhomboidal shape or halfbucket shape in Segment 2 (the middle of the upper lip). In planning our treatment for a patient presenting with such lips we have two options: 1) Filling Segment 2 in hopes of creating this plane; and 2) Filling Segments 1 and 3 and then filling Segment 2 in relationship to what the patient previously presented with. If you elect option 1 in our treatment plan, be aware you will be changing the look of the lips that this patient has grown accustomed to. You will open yourself up to a greater dissatisfaction potential. So complete communication of this potential is warranted in the initial consultation to the patient. In addition, one does not know exactly how and where the filling material will flow. This is primarily due to the fact that the potential plane that does exist will saturate rather quickly and one will be forcing material into the plane in hopes of expanding it. The material injected will take the path of least resistance and may flow into an undesired area. Points to remember in electing to proceed with option 2 and filling this plane are: the half-bucket shape does exist in every lip, although in this particular model, it is not very apparent. Picture in your mind’s eye this shape and augment bilaterally on both sides of Segment 2 to augment the shape. It may take several visits to release the tissue to fill the desired plane. A sequential fill method will work best.

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Delivering Local Anesthetic Armament Syringe The ideal syringe for the injection of local anesthetics has the following characteristics: It is made of metal or similar material that can be sterilized for reuse. Disposable syringes can be more expensive, yet they offer the optimal compliance with sterilization.112 It has a chamber, where standard anesthetic carpules can be placed. It is breech-loading, which means that the cartridge is loaded in from the side. It is an aspirating tool. The syringe has a plunger/harpoon device in the piston that enables the syringe to draw back. This is critical when injecting into highly vascular areas to avoid intravascular injection, prevent systemic overdose, and minimize hematomas

at the site (Although rare occurrences, they can happen if the wrong technique or tool is used.) All syringes use ring plungers for aspiration capabilities. Determine your own comfort level in deciding the type and amount of anesthetic to use. In my own oral-facial augmentation practice, I use as little as one-quarter of a carpule of anesthetic for my infraorbital, mental, and buccal blocks. Keep in mind that like so much in dentistry, the effectiveness of medicine is directly related to dose and technical proficiency.

Oral-facial Anesthesia Techniques When standard dental blocks are used before injecting filler agents in the lips, there are three types that can be used to deliver complete anesthesia to the lips.

The Nasolabial and Upper Lip Generally only one block is required to achieve complete anesthesia of the nasola-

Chapter 3 Anesthesia

Outlined on this patient’s face are the lip and perioral innervations of the infraorbital (V2), long buccal (V3), and the mental (V3) nerves. Precise blocks of these nerves as they exit their corresponding foramina (circled on the face) will provide anesthesia within the outlined area in red. The long buccal nerve (V3) does not exit a foramina, so we cannot block the nerve in its true sense. The long buccal enters the perioral area of augmentation around the area designated with the circle. Placing an infiltrate amount of anesthesia at this point will anesthetize this nerve sufficiently to provide anesthesia to the corners of the mouth. bial fold and upper lip. This injection gives profound anesthesia of the mid-facial soft tissue, including the inferior palpebral, the lateral nasal, and the superior labial.

Procedure: Standard Infraorbital block The infraorbital foramen lies 8 to 10 mm below the infraorbital rim.113 Place your index finger on the inferior orbital rim and palpate to locate the infraorbital notch. Draw an imaginary line vertically down the face. Inject distal to the premolar; keep the needle tip 10 mm below the orbital rim on this plane, and insert a 25gauge, long needle superior to the halfway

point. With the bevel of the needle placed towards the bone and within a 30- to 40second time period, aspirate and inject a 0.9 to 1.2 mL carpule by the infraorbital foramina. Using an anesthetic containing epinephrine, the minimal amount of deposited solution is required. With this minimal amount of anesthesia, little or no distortion of the lip occurs. Keep the needle as close to the periosteum as possible. The facial artery runs in this area and, although rare, complications of technique can cause hematomas. If this occurs, apply pressure over the foramina for 2 to 3 minutes to reduce hematomas.104

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This picture depicts the classic approach to administering the infraorbital nerve block as described in this chapter. The classic infraorbital nerve block is very effective in providing profound anesthesia to the mid-facial soft tissue. Although its use is excessive for lip and perioral augmentation, I have found that using this modified infraorbital block will produce adequate anesthesia for lip and perioral augmentation.

Here is a ring comparison of the affected areas of anesthesia when comparing the standard infraorbital injection and the Gordon Modified Block (GMB). As illustrated, the traditional infraorbital block has a greater dispersion area, whereby anesthetizing facial tissue well outside the area needed for lip and perioral augmentation. The GMB targets a more constricted area, which includes the nasolabial fold and upper lip. In addition, the GMB significantly reduces facial drooping or distortion by reducing peripheral anesthesia of the facial nerve that sometimes occurs with the traditional infraorbital block.

Standard Infraorbital Blockd Infra orbital Gordon Modified Block

Chapter 3 Anesthesia

Gordon Modified Block

Approximate infraorbital foramen Proposed injection site for soft tissue augmentation

Traditional infraorbital block

This picture depicts the classic approach to administering the infraorbital nerve block as described in this chapter. The classic infraorbital nerve block is very effective in providing profound anesthesia to the mid-facial soft tissue. Although its use is excessive for lip and perioral augmentation, I have found that using this modified infraorbital block will produce adequate anesthesia for lip and perioral augmentation.

Modified infraorbital block

15 mm 10 mm

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This picture displays where the mental foramina lies on the mandible. Orienting your injection needle between the mandibular premolars will deposit the bolus of anesthetic approximating the foramina.

Chapter 3 Anesthesia

Modified infraorbital block

branes anterior to the mental foramen to the midline of the skin of the lower lip and chin. The location of the foramen predominantly lies between the mandibular premolars. Studies have shown that the foramen is at the apex of the second molar 52.8% of the time and between the premolars 32% of the time. The foramen was slightly posterior to the second premolar in 14% of studied cases.114 Inject between both premolars, being careful to aspirate first. Deposit one-half of a carpule in the designated areas to achieve the desired effect.

By definition this is not a true block for we are not directing our anesthetic at the exiting formaina, so I have termed it a modified infraorbital block. Using the standard block above may result in dissiminating of anesethetic into the areas where the facial nerve resides. With the modified infraorbital block we move our target sight medial in respect to the normaly established landmarks of the traditional infraorbital block. The dental landmark for insertion point of the needle is distal to the maxillary canine and mesial to the first premolar. The infraorbial rim is 2) Long Buccal Nerve Block: Patients can still a necessary landmark to prevent over- still feel pain in this area when filling the shooting our targeted area superiorly. commissure or augmenting lateral to the The advantages of the modified in- corners of the mouth. Feeling remains because of the innervation of the long buccal fraorbital are: off of the trigeminal V3 branch. TraditionLess later spread of anesthetic, thereby ally dentists will administer anesthesia reducing loss of muscle tonus lateral to the mandibular molars. This is Reduction in the area of anesthesia, intended to block the accessory innervawhereby focusing our effect on our tion to the buccal mucosa for the intendtargeted areas to be agmented. ed purposes of dental surgery. Attaining Patient’s perception of profound an- complete anesthesia to the corner of the esthesia is remarkably reduced. With mouth requires blocking the nerve in difthe traditional infraorbital block the ferent locations intra and extraorally. patient may feel profound numbness There are several techniques to anesover the entire mid-facial area and that thetize the commissure area. These incan be uncomfortable or very unfaclude: miliar to what they have experienced Type 1: Injecting intraorally superior before with dental blocks. The modiand lateral to the retromolar will anesfied version reduces lateral spread and thetize the long buccal before it innerthe potential negative feelings of total vates the cheek.115 The potential locamid-face anesthesia. tion in which we can block the long Lower Lip and Commissure buccal is if we follow the nerve’s origin farther back into the oral cavity. Lacou Due to the cross innervations of the lip ture studied the long buccal nerve and and perioral tissue the lower lip and comshowed that when the mouth is open, missure may require two injections: the the buccal nerve passes parallel to the mental nerve block and the long buccal occlusal surfaces of the maxillary posnerve block. terior molars.116 Blocking the nerve lat1) Mental Nerve Block: This technique eral to the molars allows us to place a anesthetizes the buccal mucous mem-

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Type 1 — Buccal infiltrate lateral to the occlussal surfaces of the maxillary molars.

Type 2 — Buccal infiltrate lateral to the commisure of the mouth.

Chapter 3 Anesthesia

small amount at a location of relatively thin mucous membrane for maximum effect. This intraoral application of the block will minimize percolation of anesthesia to the facial nerve, whereby maintaining muscular tonus. Type 2: Placing a small amount of anesthetic extraorally or intraorally, 10 mm distal lateral to the corner of the mouth will provide adequate infiltrative anesthesia. Giving anesthesia to the long buccal nerve at the corner of

the mouth can lead to distortion of the muscular tissue. This is due to the percolation of the anesthetic to the buccal branch of the facial nerve. The effect will be an inability to raise the corners of the mouth in a smile and may cause a drooping of the corners of the mouth.

Chapter 3 Review study Points Role of local anesthetic in oral-facial augmentation; guidelines for usage of local anesthetic. Differences between block anesthesia and infiltrate anesthesia as they relate to oral-facial augmentation. Types of dental anesthetics; anesthetics ideally suited for lip and perioral augmentation. Injection techniques used in oral-facial augmentation: Gordon Modified Block, mental block, and long buccal infiltrate.

study Questions 1) Under what conditions would the usage of local anesthetic be advised for botulinum toxin injection cosmetic therapy? 2) What are the two most common reasons cited for not using local anesthetic in conjunction with lip and perioral augmentation? 3) According to the author, which local anesthetic is ideal for lip and perioral augmentation and why? 4) What are the advantages of the Gordon Modified Block (GMB) in lip and perioral augmentation? 5) What are the advantages and disadvantages to block anesthesia and infiltrate anesthesia as they pertain to lip and perioral augmentation?

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Chapter 4

The Medium

Naturam primum cognoscere rerum First, to learn the nature of things.

Chapter 4 The Medium

History of Fillers Common Classification of Fillers FDA-Approved Fillers

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As outlined in the first chapter, the medium is one of the legs of

the tripod that is key in our fulfillment of being a lip and perioral augmenter. Renaissance artists took great pride in their mediums of expression. Many cherished their mixtures of paints and pigments to such an extent that they took their valued, treasured secrets with them to their graves. In modern times, this is not different. Many manufacturers guard and protect their material under patents and proprietary secrets. It is up to us as the applicators, practitioners, and doctors to maintain the integrity of our professions and apply temperance in the practice of our craft. Our patients and community entrust us to protect them, and we must always weigh the benefits in their favor. Hopefully, this chapter will facilitate and aid you in your organization of material and applications and inspire you to continue literature review and debate, ultimately leading you to provide safe, satisfactory treatment to your patients.

Chapter 4 The Medium

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History of Fillers The earliest published medical records of oral-facial implants date back to 1893, when Neuber used autologous fat for tissue augmentation.117 Neuber harvested free fat-block grafts from patients’ arms and transplanted them into their lips.

direct result of Botox, which is a superb upper-face wrinkle remover and cosmetic enhancer. The need for lower facial rejuvenation soon followed. In the meantime, independent researchers and companies simultaneously were developing safer and longer lasting filler materials.

Today there is a widespread movement to add volume to the face rather than to undergo a face lift. The cost of this treatment is far more affordable and the healing time is significantly reduced. The implant material selected should be based on the location of desired augmentation, permanence of material, and the patient’s Silicone eventually found its way into desired treatment result. the fill market in the 1950s.119 Used for medical purposes, silicones are long poly- Injectable fillers mers of dimethylsiloxane. They provide There is a wide array of fillers now a very pleasing aesthetic result, but they available for cosmetic augmentation. In do have their drawbacks. Silicones have a selecting the proper filler, the augmenter high abuse rate associated with them, and must select which filler to use in the same because they are not FDA-approved for manner an artist chooses his or her macosmetic filling, there has been an aban- terial of expression on a canvas. It is imdonment of continued development and portant to note that there are no good or regulation of this substance for cosmetic bad materials, just different fillers that are purposes in North America. Unfortunate- intended for various applications and efly this leaves a gap for the administration fects around the face. of “back-alley” applications, where there is no control over substance purity or pro- The nasolabial fold, for example, has fessional responsibility. Hence, there have remarkable features. The fold is deep and been reports in the news of appalling the malar fat and associated anatomy is lateral to the fold. This contrasts the meproblems with silicone-filler injections. dial aspect of the fold significantly, where Injectable bovine collagen appeared in this area has less bulk and is more tightly the cosmetic marketplace circa 1977. Bo- laid around the orbicularis oris and levitavine collagen has been coined the “gold tor muscles. The filler of choice must be standard” of fillers. Because this filler resilient enough to be placed in an area originates from another species, testing is that experiences persistent kinetic moverequired before receiving tissue. Current ment. advancements have led to materials manufactured from sources without immune The lips, in contrast, are in constant motion. It is paramount that the injected complications or donor sources. filler be placed in the natural planes that Facial fillers manifested themselves constitute the lips. Proper plane placestrongly on the cosmetic market as an in- ment will stabilize and insure the dura In the early 1900s, injectable paraffinand-oil combinations were used for lip augmentation. However, it soon became evident that there were significant side effects that resulted from placing these fillers, including a high incidence of granulomas and material migration.118

Chapter 4 The Medium

tion of the implanted filler and sculpted shape.

Off-Label Use

In November 1997, a new provision Placing different types of fillers in the was added to the Federal Food, Drug and lips will result in different cosmetic re- Cosmetic (FD&C) Act that allows any sults. A prime example is hyaluronic acid legally marketed, FDA-approved prod(HA). HA placed in the lips will keep its uct to be administered for any condition injected shape, dependent on the plane within a doctor-patient relationship. This placement and flow of the material. The is termed as “off-label use” of an FDAproperties of HA will tend to displace tis- approved product. An example of an offsue (Chpt. 5) around the injected site. This label product is AlloDerm, which was effect can be exploited to sculpt and shape FDA-approved for extraoral grafts. In the field of dentistry, some clinicians use it for the lips. periodontal surgery and oral-surgery apThe Ideal Filler plications. An ideal filler meets the following cri- Caution should be exercised when usteria: ing fillers for off-label usage. In the cosIt is safe to use and allows ease of placement without trauma, scarring or irrefutable damage to the host tissue or immune system. It is technically able to be retrieved, dissolved or reformed to shape a particular area to achieve the desired effect. It is also easy to handle and simple to both learn and incorporate into the clinical practice. It lasts long enough to satisfy the immediate cosmetic correction or desire, yet does not maintain its duration or migrate to the extent that it would affect the dynamics of the facial presentation in a negative manner as it matures. It is pleasing in form, texture, and touch It is cost effective for all patients.

FDA Classification and Use of Fillers The Food and Drug Administration (FDA) has determined that collagen is a Class III.A device and injected particles are a Class III.B device. They are regarded as implants into the human body.

metic industry, the companies marketing the various fillers may lead the practitioner to believe that a material is indicated for something other than its FDA-approved usage.

If you choose to use a product under an “off-label” usage you should observe the following guidelines: Have a complete understanding of the product you intend to use, including the history of the product, FDA-approved usage, current mainstream usage, and possible future side effects or complications that may be associated with the product. Consult with the patient on the above information before engaging in the treatment. Govern yourself accordingly. You are dealing with patients who may tempt you to go beyond your comfort boundaries. Temperance in your own exuberance will foster your continued growth in the art of facial filling.

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TIPS 1 .618

Above is an example of the ideal proportion and how it is pleasing to the eye. The photo on the left arranges the water flasks and the shot glass in an ideally proportionate way. The photo on the right demonstrates how the movement of the shot glass in the middle rearranges the composition of the same items, and dramatically affects the presentation. The photo on the right is not as pleasing visually as the left, which is arranged in an ideal proportion.

Chapter 4 The Medium

Common Classification of Fillers and Use Today, dermal fillers are being classified into several groups depending on source and/or desired outcome. Generally the classification systems are based on: 1) source 2) duration of implant in tissue 3) mechanism of action, and 4) intended use. This chapter follows this format in exploring the various augmentation materials. Dermal fillers categorized by source include: Autograft is the process of moving tissue from one place to another in the body. Examples of an autogenously conducted graft are lipotransfers, which consists of taking fat from one part of the body and injecting it into the patient’s oral-facial area. Advantages of auto grafts are no promotion of an immune response, excellent incorporation into targeted site, and superior esthetics and feel for patient. Disadvantages include the need for adequate harvesting tissue and trauma from the harvested site. Allograft is tissue harvested from the same species and implanted into the patient’s lips. Examples of allografts are CosmoDerm/CosmoPlast. Advantages of an allograft are species compatibility. Disadvantages are that strict screening protocol standards must be continually developed and monitored. Social and psychological concerns of transplanting tissue from an unknown donor are also a consideration. Xenograft is a transplant from another species. Crosslinked hyaluronic acid (HA) products such as Restylane, and Juvederm are bacterial derived and Zyplast and Zyderm, which are harvested from cows, are examples of xenografts. The benefit of xenografts in-

clude: large amount of source material available, long history of use with little adverse reactions, and if side effects occur, they are usually short-lived. The disadvantages of this group are possible immune response to transplanted material. Alloplastic material is an inert foreign body (synthetic) used for implantation into tissues. Radiesse is an example of an alloplastic material. Benefits of alloplastic materials include lower cost of filler material, consistency in formulation of filler, longevity of material in implantation site and a limited sensitivity. The drawbacks of using alloplastic material are that the techniques of application are very sensitive and the permanency of material and extraction of material usually requires surgical intervention with possible scarring and disfigurement.

Permanent vs. NonPermanent Fillers Due to the recent influx of so many fillers and the lack of long-term studies, there are three categories of filler classification that have evolved. These categories are assigned in relationship to their permanence and biodegradability. The three categories are temporary biodegradable, semi-permanent biodegradable and permanent nondegradable.120

Temporary Biodegradable Fillers Temporary biodegradable fillers last from 3-8 months. Included in this category of fillers are collagen (human, bovine and porcine) and Hyaluronic Acid (avian and bacterial).

Semi-Permanent Fillers This category of fillers usually last one to two years and includes fillers that incorporate material to provide a scaffold-

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ing effect and/or are designed to elicit an induction of collagen to augment an injected area. Nevertheless, the initial filler is supposed to disappear after two years and the patient’s own collagen replaces the previous filler. Semi-permanent fillers usually consist of CaHa (Calcium Hydroxylapatite), DEAE (Sephadex particles), Dextran, PLLA (Polylactic acid), PVA (Polyvinyl alcohol), Chitosan, HEMA (Hydroxyethyl methacrylate), human fibroblasts (cultured) and autologous fat.121

Permanent Fillers As the name describes this filler remains in the tissue permanently. This category of fillers includes PMMA (polymethylmethacrylate), PAAG (polyacrylamide Gel) and silicone.

The Inherent Drawback of Permanent Fillers The idea of undergoing a cosmetic procedure that utilizes permanent filler that eliminates the need to maintain and/ or reconstitute the site of implantation is especially appealing to many patients. By definition, permanent filler lasts forever. The advantages of such an implant may seem to be cost effective and convenient, but let’s examine the following ramifications that also exist: Technological Advances: with everevolving advances in science, the permanent placement of any substance for cosmetic reasons would not be advisable. Potential risks that patients may be willing to assume now may not be necessary in the near future as new treatments and technologies evolve. Patients should not be encouraged to consent to any device, material or procedure that presents possible longterm and/or negative side effects that may exist with the use of permanent fillers.

Fashion Trend Changes: as previously discussed, facial cosmetics are ever changing. What was “in” five years ago is “out” today. Host Immune Response: as we mature, we develop an entire library of antigens that have the potential to create an immunologic response to a material or materials that previously did not affect our bodies.122 Facial Aging: due to the intrinsic and extrinsic effects of aging, permanent fillers that were placed in what was considered an ideal position 10 years ago may migrate to an area that is no longer considered an ideal location. Technical Error: the reality is that there is a learning curve associated with all filling agents on the market today; some are more forgiving than others. No matter where you are on the learning curve or how much injection experience you have, the possibility for suboptimal technical placement exists. With temporary fillers that only last four to six months, the technical error will subside and no longer be evident within a short period of time. This is one of the obvious benefits of utilizing temporary fillers.123

Histology of Injectable Fillers Histologically, fillers are classified into two groups according to their histological reaction in the surrounding tissue: Volumateurs, which offer little cellular invasion of surrounding tissue; and Stimulateurs which have a strong cellular reaction in and around the adjacent tissue where they are placed.124 It is important to realize that all injectable fillers elicit a normal inflammatory response.125 Host defense mechanisms react differently to the various filler materials, but all substances—resorbable or nonresorbable—appear to be clinically

Chapter 4 The Medium

and histologically safe. Inevitably it is the Microspheres below the size of 15 microns host’s defense mechanism that dictates are phagocytosed and can be transported the success of the placed mechanism. to the lymph system. Microspheres larger than 15 microns, with a smooth surface, It has been published that granulomas occur in patients at a rate of 0.01 to 1.0% are encapsulated with129fibrous tissue and based on the chemical composition, shape are not phagocytosed. Studies show miand surface structure of the particles.126,127 crospheres of a diameter of 100 µm proThe main complications for fillers are the mote only about 56% connective tissue; occurrence of granulomas and hypersen- microspheres of a diameter of 40 µm prositivity at the injection site.128 All fillers mote about 78% connective tissue. This run the risk of eliciting these responses, fibrous network then becomes the permabut most research on current fillers cat- nent filler. egorize these as small occurrences. Generally every material elicits its own unique resorptive response on its host. Ideally with resorbable fillers, the process of breaking down and excreting the material will leave no trace of the initial substance, not affect any other body physiology, and will leave no negative immune memory for the initial material or crossover therapeutic materials.

In the United States there are no FDAlabeled injectable fillers for the true body of the lips (Zone B). Why is there a consensus among most doctors for particular lip fillers and what are the common ideals of these fillers for the lips? By far the most commonly used fillers for the body of the lips (Zone B) are crosslinked HA products.

In the United States, all crosslinked HA Microspheres are agents placed into products approved by the FDA are indifillers to retard desorption and/or stimu- cated for correction of moderate to severe late encapsulation to maintain volume. facial wrinkles and folds, including naso-

Five Filler Classifications and their Histological Responses Autologous Fat Quick to resorb, unpredictable stability, with no long-term study on transplanted cell longevity. Natural Filler Substances (collagen, hyaluronic acid) Slow absorption with minimal histological reactions. Fluid Filler Substances (silicone, acrylamides) Dislocate larger volumes through muscle movement and gravity with little fibrosis. Particulate Materials (PMA gravel and PMA microspheres) Powdered material microspheres (2-50 microns) packed to induce minimal foreign body reaction. Pure fillers that absorb more slowly. Microspheres (non-resorbable, PMMA) (Artecoll, Radiesse) Designed to stimulate encapsulation and scaffolds of permanent or temporary connective tissue formation; considered “Living Implants.”

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labial fold and marionette lines. All other uses are considered off-label usage.130-133 The use of crosslinked HA products for Zone B of the lips is considered an off-label application. The most popular crosslinked HA products used are Restylane, Juvederm, Captique and Hylaform derivatives. These are all resorbable materials with tissue duration of approximately 3 to 6 months.134 One of the esthetic advantages of using crosslinked HA fillers in the lips is their ability to add volume without distortion of the vermilion border. When the filler is injected into the right plane, the vermilion border may be lifted to reestablish the nasolabial line angle. Other fillers tend to obscure this relationship. An example is silicone which, when placed in the upper lip, tends to migrate into the tissue. The gel dissipates into millions of micro-droplets126 that blur the vermilion border by infiltrating above and below its demarcation line.65 As discussed in Chapter 2 (see “Anatomy” section, p. 40), there is no clear demarcation line in the lower lip. There is a slow, gradual transition between the red vermilion tissues to the stratified squamous tissue of the face. Silicone fill would be more suitable here. Some fillers, such as CosmoPlast, have been approved for rhytids around the lips and the vermilion border (Zone A), but not for the true vermilion tissue of the lips (Zones B and C).

ican Association of Tissue Banks (AATB), where FDA standards are implemented. All of the materials presented in the book are regulated under such standards. If, however, the practitioner goes outside of North America for harvested material, be aware of the potential medical/legal ramifications that may arise. As a side note, autologous and allogenic products are not approved by the FDA. This is due to the fact that because they are derived from human tissue, these products are not required to undergo FDA-approval processes. Consequently patients should be educated about the filler material, source and safety protocols of their donor materials prior to their oralfacial augmentation procedures.135

In addition to the filling component of allografts, transplanting processed human tissue from one person to another is theorized to initiate fibro-induction and or fibro-conduction. This phenomenon is called inductive interaction,136 which is where the connective tissue affects the surrounding tissue cells. Epithelial cells have the genetic potential to differentiate into keratinized or nonkeratinized forms. Fibro-induction is a process that causes inductive interaction. Fibro-conduction provides the scaffold for the connective cells to proliferate. The dental specialty of oral surgery uses a substantial amount of allografts (ie, AlloDerm: see section below for more detail.) as an alternative for lip augmentation137 and in periodontics, there Off-label Lip Fillers are constant ongoing studies on the idea Human Collagen Allograft & Human Colof fibro-induction with respect to gingival lagen (Allograft, Semi-Permanent) grafts. Using these materials has some dis- Current periodontics therapy includes tinct advantages, but some precautions using cadaver tissue from a tissue bank to may need to be taken. The tissue acquired graft intraorally for gingival recession and must be subjected to a donor-screening defects. Manufactured by LifeCell Corp, process of viral deactivation. The materi- AlloDerm is a tissue graft prepared from als also need to be regulated by the Amer-

Chapter 4 The Medium

cadaver-donated skin.

The freeze-drying phase of the tissue preparation removes all viable cells from AlloDerm is a human-derived graft the donor tissue. The resultant graft is an material that is surgically placed into the acellular matrix of type IV and VII collahost dermas or overlying grafts for larger gen, laminin and elastin.138 areas like burn victims. The donor material comes in a variety of shapes, depend- Cymetra: Allograft (LifeCell Corp) ing on usage. For the lips, 3.0 x 7.0 cm This is an acellular, freeze-dried der-

AlloDerm: Allograft (LifeCell Corp)

Table 4.1

Types of Off-Label Lip Fillers

Material

Potency

Cross-linked HA Allopast Restylane Perlane Touch Captique Juvederm

Duration 4-6 months 6-8 months 4-6 months 4-5 months 6 months

Indications Face, rhytids Off-label lips

CosmoPlast CosmoDerm

Allograft

4-5 months

Face, rhytids Off-label lips

Zyderm/ Zyplast

Xenograft

4-5 months

Face, rhytids Off-label lips

Cymetra

Allograft

1-2 years

Face, rhytids Off-label lips

graft segments are available. Trimming the graft is required prior to its placement in the lips via incision sites in the corners of the mouth. The tissue graft is from an allograft source, so the source of origin must be screened for Hepatitis B antigens (HBsAg), Hepatitis C, HIV types 1 and 2, syphilis (RPR or VDRL), and T-lymphotropic virus (HTLV) type 1 and 2 antibodies. Additional steps for purifying the donor tissue of viruses include incubating the tissue in solutions for viral inactivation.

mal graft. The injectable filler is made from processing human tissue acquired from cadavers screened by the American Association of Tissue Banks (AATB). The graft tissue is separated from its epidermis and the dermal cells. This tissue is then processed to remove major histocompatibility complex (MHC). These antigens are removed to prevent immune responses in the recipients. The remnant tissue is collagen types IV and VII, lamina, and elastin residue. Cymetra is a particulate form of this

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matrix processed by nitrogen freezing (cryofracture). The micro-particles are dried and placed in a 5-cc syringe for refrigerant storage. The average particulate size of the powder is 123 µm and the range of powdered particles range from 59 µm to 593 µm. Seventy-seven percent of the particulates are under 52 µm, which subject them to phagocytosis by the host scavenger cells.139 This is delivered in a powder form to be reconstituted for injection with saline, lidocaine for injection. The reconstitution of the powder-to-liquid ratio can deliver volumes up to 330/mL. Indications are for lips, nasolabial folds and rhytids. The longevity of this substance is longer than other interdermal collagen.140

has been halted due to pending FDA approval. This filler is currently unavailable in the US.

CosmoDerm & CosmoPlast: Allograft (Allergan Aesthetics) These are the only FDA-approved human collagens that are commercially available. The collagen is derived from human neonatal foreskin cells. Through a sophisticated tissue-engineering process, the resulting implant material is filtered for bacterial and viral components. Due to the original source of tissue, no allergy testing is required as is mandated for xenografts.

CosmoDerm is 35 mg/mLmL of solubilized collagen. This filler is most effec With Cymetra and AlloDerm (a nontive when placed in superficial dermis. water-based graft material), it is specuAlthough only a few studies have been lated that there is epithelial induction at conducted on this substance, it clearly the site of implantation, thus stimulating shows long-term potential. growth or replacement of graft with host connective tissue. This theory is one pos- CosmoPlast has 35 mg/mL of solubilized collagen cross-linked with glutaralsible explanation for its longevity.23,141 dehyde. This filler’s preferred placement Autologous Fat is in the deeper dermis. The practitioner Autologous cellular therapy is a promust be aware that there is the potential cess where a patient’s own cells are exfor a negative reaction to occur in patients tracted, cultured, and expanded expowith glutaraldehyde sensitivity. The idea nentially for reintroduction to the patient is to transplant a scaffold matrix for the for the treatment of specific cosmetic and conduction/induction of fibrocytes to promedical applications. duce a collagen fill by the patient’s own Isalogen (Isalogen Corp; Exton PA) cells.142 This filler consists of autologous fibro- Both of these fillers have a low viscosblasts. In this process, a 3-mm punch biop- ity and, therefore, an exceptional flow. Besy of skin is acquired from the patient. It cause of the ease of flow, these filler prodis sent to the receiving lab and processed. ucts have the potential to be massaged The processing lab then returns the culti- into the superficial dermis.143 These mavated cells in a vial containing 20 million terials come hydrated in 0.3% lidocaine. cells. The solution is then injected into the The advantage is the ease of use and the epidermis to augment the tissue. The treat- ability to use a 30- or 32-gauge needle. ment is repeated every two to four weeks Several leading authorities now posfor three sessions. The transplanted cells tulate that these two filler products will are placed to produce fibroinduction (col- eventually replace Zyplast and Zyderm lagenisis). Production of this substance

Chapter 4 The Medium

(due to their bovine constitution) and due HA was discovered in 1934 by Karl and to the inherent benign immune response John Palmer, scientists at Columbia University, New York. Isolating the substance potential.144 from a cow’s eye, they named it after “hy When either of these filler products is alos,” the Greek word for glass and the placed in the lips, patients should be inuronic sugar found in the substance. HA’s structed not to pucker for a day. Due to incorporation into medicine has been very the low viscosity of the filler, it has a tenimpressive.147 dency to migrate away from the original The human body contains approxideposited area within the first day. mately 15 grams of HA. Our bodies proHyaluronic Acid (HA): Xenograft duce and house HA in our vitreous hu HA is a naturally occurring glymor, synovial fluid, umbilical cord, and cosaminoglycan biopolymer composed of connective tissue, where the highest conlinked alternating residues of the monosaccentration is found—especially in the skin. charides D-glucuronic acid and N-acetylIts role is to add volume by binding to waD-glycosamine, and produced by various ter and mediate cell growth.148 Hyaluronic cell types within the cell membrane.145,146 acid is highly hydrophilic (water-loving) Through continued research and de- and tends to form extended molecular velopment, it is now extensively used in formations that occupy a tremendous ophthalmic surgery and as an ingredient volume relative to its injected mass. One in over-the-counter cosmetics. It can also gram of HA has the potential to bind to 3 be used in drug delivery, orthopedics, L of water. cardiovascular aids, and wound healing. HA is a nonprotein molecule, which

Figure 4.1 HYALURONIC ACID

HA is a naturally occurring glycosaminoglycan biopolymer composed of linked alternating residues of the monosaccharides D-glucuronic acid and N-acetyl-D-glycosamine.

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virtually eliminates a cell-mediated adverse reaction and the potential for immunogenic hypersensitivity. The product is naturally integrated into the tissue, allowing important nutritive agents to pass freely through the implant and cells to pass between fragments of the gel. To stabilize, or avoid early breakdown, HA needs to be cross-linked with a neighbor molecule.

chemical and molecular properties in all mammalian species, making this material a promising filler.151 The main disadvantage to Hylan is its short half-life, one to two days, in all connective tissue in the human body. The natural state of this filler does not have sufficient resistance to break down for use in soft tissue augmentation procedures.152 Hylan B implants are produced by using sulfonyl-bis-ethyl cross-links between hydroxyl groups of the polysaccharide chains. This cross-linkage adds to its longevity and stability.153 Numerous studies were performed with hylan “B” (hylaform) and the studies show that there is substantial evidence that Hylaform is a safe and effective material for soft tissue augmentation.154 Hylaform comes in three forms: Hylaform, Hylaform Plus (larger particle size, lower dermis) and Hylaform Fine Line (smaller particle size, upper dermis).

As we age, the concentration of HA in the dermis decreases. Because of the reduction of HA, there is a decrease in the amount of water retained by the dermis, leaving the skin thinner and more prone to wrinkles.149 HA is marketed and incorporated into many over-the-counter cosmetics as a hydrophilic medium, yet because of HA’s high molecular weight it will not penetrate the dermis of the skin. Due to its affinity to attract moisture and hold its form, it is a very efficient filler. Most adverse reactions to HA are associated with its injection, and are a result of Hylaform Plus: Allergan (xenograft) delayed hypersensitivity reactions.150 It is derived from the same source as HA is derived from animal and bacte- Hylaform (avian combs). The bond is the rial sources, which makes it a xenograft same divinyl sulfone cross-linkage, apsource material. The difference from the proximately 20% by composition of matwo sources is predominantly the length terial. The particle size is larger with this of the final processed chain. The molecu- product: around 750 µm. It is dispensed lar weight of the bacterial source is 1.0 in a 5.5 mg/mL volume of Hylan B. to 2.0 DA. At this weight, there are 4 to Cross-Linked Hyaluronic Acid (Restylane/ 7 thousand repeating units (monomers). Perlane – Medicis, Inc.) (Juvederm, The molecular weight of the animal-based Captique - Allergan) HA is 4 to 6 M DA, composed of 10 to 15 Cross-linked HA is very biocompatthousand repeating units (monomers). ible with a 0.06% adverse reaction to treatHylaform: Xenograft (Allergan) ment, in which the major reaction is hy This substance is derived from rooster persensitivity, occurring in 1 out of every combs. The gel particle size is 500 µm. It 5,000 patients.150 Most hypersensitivity reis dispensed in a concentration of 5.5 mg/ actions are theorized to be caused by injecmL of Hylan B gel. Due to its xenograft tion technique and the speed of injection, nature and originating source of rooster rather than authentic immune reactions.156 combs, hylaform has been studied for 10 There have been very isolated occurrencyears.150 Hyaluronic acid has the same es of foreign body reactions.157 However,

Chapter 4 The Medium

TIPS

Massaging of injected filler around an injected site works particularly well for the commisure area. After injecting a Hyaluronic Acid filler one can manually displace it into the surrounding tissue. Be advised that over massaging of injected filler can completely displace its presence thereby eliminating its intended purpose.

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a process in which the individual chains of hyaluronic acid are chemically bound together. The resultant material is a gel product in which its viscosity is dependent on the amount of cross-linkage. The degree of this process is calculated by the Crosslinked HA products have a very percentage of HA that undergoes crossgood clinical reliability in both a 3-month linking. For example, Juvederm has a destudy, with an effective improvement of gree of cross-linking of 6-8% degrees and 96.4% using the 5-grade Global Aesthet- Restylane has a degree of cross-linking of ic Improvement Scale,159 and a 6-month less than 5%. study with Juvederm. The filling effect of Uncross-Linked HA cross-linked HA (Restylane) was notably Almost all cross-linked HA products longer in the areas less affected by anima- have a certain percentage of uncrosstion. Due to the activity and vascularity of linked HA in the composition of the filler. the lips, there is usually a 6-month, 50% The uncrossed HA adds to lower the G’ satisfaction rate for results.160 Compara- and aids in the flowability of the material. tive studies show crosslinked HA to pro- Uncrossed-linked HA is absorbed within duce a longer lasting cosmetic result than a couple of days and does not contribute bovine collagen. The frequency, intensity, to the overall persistency of the filler. and duration of local injection-site reac- Gel Hardness (G’) tions were similar for the two products.124 Restylane composition is set to balance to This characteristic of gel formulation normal tissue pressure. When the tissue is relevant to the amount of force required pressure is raised due to swelling or low- to initiate the flow of the HA filler out of ered from dehydration, the cross-linked the syringe. Factors to consider when analyzing elements that affect G’ are: HA swells and shrinks in relation.161 The higher the cross-linkage of HA, Formulation of Cross-Linked the higher the G’ HA Products The higher the concentration of HA, the higher the G’ The cross-linked HA gel formulation is characterized by the total HA concenThe larger the size of the gel particle, tration, concentration of cross-linked HA, the higher the G’ concentration of uncross-linked HA, and How the cross-linked HA is sized gel mass sizing. These properties influence Amount of uncross-linked HA the handling properties of the particular crosslinked HA filler. The handling prop- The G’ for Juvederm is around 190 Pa erties influence the texture, persistence, a and the G’ for Restylane is around 400 Pa, at 1.6 H2. and injection pressure needed (G’). leading authorities have argued that these reactions were most likely due to a protein contaminate of the treatment, rather than the hyaluronic acid itself.158 Current processing of crosslinked HA has significantly decreased these contaminants.

Cross-Linking Unbound HA forms a liquid made of highly hydrated individual polymers (chains) that are metabolized in the body within 24-48 hours. Cross-linking refers to

TIP: the lower the G’ the more tactile feel the augmenter has of the material. The advantage of an increased tactile perception is superior feel of the material flow and resistance mounting in a plane when it be-

Chapter 4 The Medium

comes saturated. This advantage greatly of the filler in the dermis and anatomical reduces the complication of overfill. sites leads to superior results and a maximizing of the materials. Hydrostatic Equilibrium HA has a great affinity to water. The amount of HA in an injectable form will affect the augmentation site. For example, Captique is dispensed in a solution close to hydrostatic equilibrium, which is 5.5 mg/1mL water. When injected into the dermis it will not want to attract additional water to bind to itself. Your fill with this material will remain stable: what you fill is what you get. Juvederm and Restylane are dispensed in 24- and 20-mg/1 mL, respectively. At this ration, these fillers will want to attract and bind to water in the dermis. After augmentation the filler will have the propensity to slightly increase in volume.

Restylane (Medicis) Restylane, a nonanimal stabilized hyaluronic acid, is a cross-linked, carbohydrate-based molecule that comes in a concentration of (20 mg/mL).162 Restylane is obtained from the culture of nonpathogenic bacteria (S. equi or ) through a proprietary process (Medicis). The bacteria are unicellular organisms without chlorophyll secretion, thus a nonplant organism. The bacteria belong to the class Monera. It is a pure class of HA because the bacteria are without a nucleus and live on sugar and plant amino acids.163 The stabilizing process for cross-linkage uses 1.4-butandiol diglycidylether Bonds.

Crosslinked HA from Medicis Aesthetics is available in three forms: 1. Restylane: 1 x 105 HA particles of N250 µm size in HA fluid, or 100,000 gel beads/ mL. This translates into 20 mg/mL. Used for medium-sized lines. 2. Perlane: 8 x 103 gel particles/mL of approximately 500 µm in diameter or 8,000 gel beads/mL. Used for deep wrinkles, folds and scars, offers longer lasting results for lip enhancement or enlargement. 3. Fine Lines: 2 x 105 gel particles/mL of 20-30 µm in diameter or 200,000 gel beads/ mL. Used for superficial facial lines. At six months post-treatment, a higher proportion of patients showed a greater than or equal to 1-grade improvement in the Wrinkle Severity Rating Scale (WSRS) score with Restylane/Perlane (75%) than with Hylaform (38%).164 Restylane/Perlane was considered superior in 64% of patients, whereas Hylaform was superior in 8% of patients. Due to the viscosity of Perlane, a 27-gauge needle is recommended.

FDA-Approved Fillers Captique (Allergan)

Captique passed FDA approval for filling in corners of the mouth, nasolabial fold, and lips. This is a cross-linked, nonanimal hyaluronic acid gel. The cross Restylane claims to cross link the man- linkage is via a divinyl sulfone bond. Gel ufactured HA at 1-3% of the whole sub- particle size is 500 µm. This is dispensed stance. Nevertheless, stabilization of the in 5.5 mg/mL HA gel. filler is the most important contributor to Juvederm (Allergan) its longevity, an aspect that must be clear Juvederm is a cross-linked HA product ly defined. When using filler, the goal is to that was FDA approved in 2006. Juvederm maximize the correction duration, not to is cross-linked by 1,4-butanediol diglycimaximize the time that the filling material dyl ether in a phosphate buffered solution remains in the tissue. Correct placement

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of 6.5-7.3 pH. Juvederm’s unique property is the softness of the filler as compared to other hyaluronic acids. Three types of Juvederm are available: Juvederm 18 for fine lines, Juvederm 24 (Juvederm Ultra) for the forehead and cheeks, and Juvederm 30 (Juvederm Ultra Plus)for the lips and nasolabial folds. Juvederm Ultra and Ultra Plus are available in the US. Juvederm has not been made available in the US at this time.

Initial research on collagen started with Gross and Kirk at Harvard Medical School on extracted fresh calf skin in 1958. Under the right conditions, a solid gel was produced from the calf skin specimen.167 Through years of continued research, the bovine collagen was purified and refined, until Zyderm collagen was developed by Collagen Corp and tested by 728 physicians in the Zyderm Clinical Verification Program. Sam Stegman and Ted Tromovich (dermatologists) and a California cooperative study group managed a study on corrections of facial scars and depression in 5,109 patients. In 1981, Zyderm collagen received the stamp of approval by the FDA for soft tissue augmentation. This was the first substance the FDA approved for soft tissue augmentation.

Juvederm sets itself apart by its proprietary method of manufacturing HA. The Hylacross™ technique has two components. One is the crosslinkage technique, which consists of 90% crosslinked HA/1mL syringe and 10% unlinked HA. The cross-linked HA in a 24 mg/mL syringe would be 21.6 mg/mL. Another way this substance sets itself apart is its This study started the surge of modadvanced sizing technique that reduces ern-day collagen corrections, later evolvthe G’ (G’ at 1.6 Hz) (170-200 Pa), which ing into cosmetic facial fills.168,169 To date, increases the tactile feel of the material more than 1.3 million individuals have when injected. received injectable collagen treatments.143 This bovine collagen-based filler is harCross-Linked HA Degradation vested from the hides of specially bred A significant advantage of nonanimal cows sequestered since the initial producstabilized hyaluronic acid is its prolonged tion began in the 1970s. Zyderm collagen resident time in the tissue. Cross-linked is available in three preparations: Zyderm HA is slowly broken down after injection. 1, which is the original material, it is comThere is no trace of the original implant posed of 3.5% bovine collagen by weight material in the site of implantation after (35 mg/mL); Zyderm 2, which is 6.5% bohost resorption. Finally the degraded hy- vine collagen by weight (65 mg/mL); and aluronic acid is transferred from the der- Zyplast, a glutaraldehyde bovine collamis and degraded in the liver to carbon gen, which is a manufactured cross-linked dioxide and water.165,166 bovine collagen. The glutaraldehyde produces covalently bonded, cross-linked Bovine Collagen (Xenograft) bridges between approximately 10% of There are pure bovine collagen fillers the available lysine sites on the bovine on the market, such as Zyplast and Zycollagen molecules.170 derm. Likewise, there are combinations before of bovine collagen and other alloplastic Zyplast lasts four to six months 171 clinical corrections diminish. Zyplast is sources, such as Artecoll and ArteFill. injected in a phosphate-buffered, physiZyplast and Zyderm (Inamed) (Resorbable ological saline solution containing 0.3% Filler) lidocaine for reduced injection pain. Hy-

Chapter 4 The Medium

persensitivity is a risk because of the xenographic nature of these fillers.172 Testing is required with the use of these xenographs. The testing procedure recommended by the manufacturer is that four weeks prior to the procedure, a Collagen Test Implant is administered intradermally into the inner forearm to determine if a patient has a sensitivity to the implants. The reported incidence of allergic response to Zyplast ranges from 3-10%.173 This material has been noted as the “gold standard” in dermal fillers.

Allergy Testing Protocols Proper skin testing is of the utmost importance with xenographic injectable fillers, such as Zyplast and Zycore. Any person with a history of sensitivity to lidocaine, prior bovine collagen or any anaphylactic history is not a candidate for cosmetic bovine injections. Skin-test syringes are manufactured to test for allergies to all forms of injectable collagen. The process of testing is a tuberculin-like test on the inner forearm. A spot penetration into the dermis of 0.1 cc of Zyderm collagen

is administered. The patient is asked to return within 48-72 hours to evaluate for possible reaction.174 A positive reaction is defined as swelling, palpable induration, or persistent or evanescent tenderness, as well as intermittent or persistent erythema and any redness that persists or occurs six hours or longer after the test was performed. Allergy testing is also recommended to retest individuals who have previously undergone collagen therapy, more than one year earlier.175

Fillers for Facial Augmentation (Not for Lips) ArteFill (Artes Medical; San Diego, CA) (Alloplast/Xenograph) It is a permanent, injectable cosmetic filler composed of polymethylmethacrylate (PMMA). Microspheres (20% by volume) between 30-50 microns in diameter are suspended in a solution of 3.5% bovine collagen, 80% by volume. Dentistry uses PMMA quite often in fabrication of prosthetic devices. Additionally, PMMA has long been known as bone cement and

Material

Source

Duration

Indications

ArteFill, Artecoll

Alloplast/Xenograph

Semi-permanent

Face; Lips contraindicated

Radiesse

Alloplast

Semi-permanent

Face; Lips contraindicated

Lipotransfer

Autograft

Semi-permanent

Face, Rhytids

Isolagen

Autograft

Semi-permanent

Face; Lips contraindicated

Table 4.2

Fillers Recommended for Nasolabial Folds (Artecoll, ArteFill, Radiesse, Lipotransfer, Autologen)

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has been used in cosmetic surgery with a very good safety record. PMMA microspheres are biologically inert and nondegradable. The treatment results are permanent, therefore technical errors as well as incorrect injections will last.176

diameter, 20% by volume, that are suspended in a bovine collagen solution with a volume of 80%, and 0.3% lidocaine to alleviate discomfort during injection. Collagen is the vehicle with which the permanent PMMA spheres are injected into Following the subdermal injection of the skin. As the Artecoll is a collagen that ArteFill, the collagen suspension liquid is is absorbed, it is replaced by the person’s reabsorbed by the body within one to three own collagen as the microspheres act as a months leaving the PMMA microspheres stimulus for new collagen formation. in place. The microspheres stimulate the Since bovine collagen is used, the stanbody to lay down a layer of connective tis- dard protocol for preinjection testing is sue, which encapsulates the microspheres. required. This process is permanent and This process will be completed within two is essentially completed approximately to four months after the injection. This three to six months after the area is inlayer of connective tissue combines with jected. It is used for wrinkles, such as the the microspheres to produce a long-last- smile lines, frown lines and lip lines, as ing correction. Duration is quoted by the well as for acne scarring. It usually takes manufacturer as 10 years.177 This is a pro- two to three treatments to complete this cess where the implant carrier is actually procedure. Because Artecoll is a permareplaced by the body’s own tissue. The re- nent filler—unlike Restylane, Hylaform, sulting induction of connective tissue cre- Juvederm, and the collagen products— ates a living implant. The injected size of complications can occur. If placed in the the PMMA microspheres must be isolated wrong plane, the material is very unforspheres and range between 30-42 µm. This giving. Deposition into muscle may cause is the ideal size that escapes phagocytosis. nodule development.180 Artecoll has been The microspheres also have to be small associated with granulomas and nodules enough to pass through a 27-gauge needle around the lips.181 Since this is a new matewithout too much back pressure.178 rial, no long-term studies have been done Since ArteFill is a permanent filler and and migration of any permanent filler is tissue migrates with aging, there are con- possible as the face ages. This material is cerns about its placement. In addition, not FDA approved for lip enhancement. there are long-term studies on the justification of placing a hard substance like polymethylmethacrylate microspheres into soft tissue.179

Artecoll (Rofil Medical International) (Alloplast/Xenograph) This product is formulated and marketed for distribution in Europe and the world, but it isn’t distributed in Japan and the United States. Artecoll is a product which combines bovine collagen with PMMA microspheres between 30-42 microns in

The differences between ArteFill and Artecoll are primarily due to the technology used to fabricate the microspheres and the resultant PMMAs. ArteFill has a very smooth surface, attributable to its PMMA microspheres, which reduces the associated granulomas.

Techniques for PMMA Placement PMMA fillers are more technique sensitive than collagen or hyaluronic acid, which requires a bit of patience to become proficient in its use. Most clinicians rec-

Chapter 4 The Medium

ommend a “tunneling technique,” where the needle is moved back and forth when injecting material into the dermis. Artecoll should be implanted deep intradermally only into the reticular dermis, just above the junction between dermis and subcutaneous tissue.182 Significantly more pressure is required to fill with Artecoll since the viscosity of Artecoll is three times higher than Zyplast.183 Due to its viscosity, a 27-gauge needle will be needed. A tunneling effect is most effective for depositing into the dermis.

Other PMMA Fillers

Calcium hydroxylapatite has been used in many forms for the last 15 years in reconstructive surgery, orthopedic surgery, and dentistry.185 Radiesse is marketed as a subcutaneous or deep tissue filler. The mechanism of action in Radiesse is primary through the product being encapsulated by surrounding tissue and then being replaced by the body’s own collagen (collagenisis).186 The remaining calcium hydroxyapatite particles are broken down by an enzymatic process into calcium and phosphate until complete phagocytosis is achieved. Because of the calcium hydroxylapatite granules, it is proposed that this material will last longer; however, concern over particle migration and ossification exist. Results of calcium hydroxylapatite show clinical improvement with minimal side effects.187 In the skin, especially in the lip, Radiesse does not “remain soft” but exhibits a clear hardening of the implant, which resolves over time. Therefore, it is not recommended for lip augmentation.

Aphrodite Gold (European Medical contract Manufacturer; Nijmegen, The Netherlands) is the former Artecoll in a new package, distributed outside Europe and the United States. Metacrill (Nutricel Laboratorios; Rio de Janeiro, Brazil) is polymethylmethacrylate microspheres 1-80 µm in diameter. Bioplasty (Dr. Almir Nacul; Porto Alegre, Brazil) is similar to Metacrill, as is Precise (Clinica Estetica; SPECIAL NOTE: If reaugmenting lips Tijuana, Mexico). previously injected with Radiesse, the Calcium Hydroxylapatite Microspheres augmenter must be aware of the follow Radiesse, formally known as Radiance, ing: Radiance FN (calcium hydroxylapatite) After the degradation of the filler ma(BioForm Medical, Inc., San Mateo, Calif.), trix of Radiesse, the calcium particles is a semi-permanent filler. It is composed may remain. Injecting a different type of 55.7% calcium hydroxylapatite (CaHA): of filler into the lips may bring the cal25- to 45-µm microspheres suspended in cium particles to the surface of the mu36.6% water for injection USP, 6.4% Glyccosal again, making them visible. erin USP, and 1.3% sodium CarboxymethThis material is very technique sensiylcellulose.184 The implant compound hytive. Radiesse must be injected deep droxylapatite has already received FDA intramuscularly or deep glandular approval for laryngeal augmentation, soft into the lip mucosal; otherwise the matissue marketing and filling/augmentaterial will be visible and/or palpable. tion of dental intraosseous defects and Therefore, Radiesse is contraindicated oral/maxillofacial defects. It has also been for used as a transurethral bulking agent for augmentation. stress related urinary incontinence. The use of Radiesse for facial aesthetics is “off label.”

Lipotransfer Modern fat transplantations began

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in the late 1700s, ultimately leading to the liposuction movement spearheaded by Fischer and Fischer.188 In 1986, during the American Society for Dermatologic Surgery, Pierre Fournier presented the micro lipoinjection technique with 13-gauge needles for fat transplantation.189 Lipotransfer is most successful when viable fat cells are transferred to areas already occupied by fat cells. The results of autogenous fat injections are mixed with the transplantation, yielding results of near to total resorption in several years.190,191

Complications associated with the use of silicone include foreign body type siliconomas lasting over 10 years and immune related complications.193,194 Medical grade silicone is sterile, apyrogenic, clear, colorless and can have viscosity ranges from 350 to 1,000 centistokes (cs). Water has a viscosity of 100 cs. Mineral oil has a viscosity of 350 cs.

As you can imagine, injecting a silicone with the viscosity of 5,000 requires great force and special injection syringes. In North America, silicone was cleared for use during postoperative retinal tamponade during Patient presents 7 months post-injection of vitreo-retinal surOther Radiesse in lips by a plastic surgeon. Notice gery. In Europe, Synthetic nodules in Segment 4 and 5. Patient reports select silicones are Filler feeling nodules generally around lingual of allowed for lip Materials and facial filling. labia. Silicone particles Alloplast have an irregular Silicone (Silikon surface and cannot be phagocytosed, 1000s, Alcon Lab Inc, Ft. Worth TS,) but may eventually form foreign (Adatosil 5000, Bausch and Lomb, body granulomas due to “frustrated Rochester NY) (PMS-350) macrophages.”195 Silicone is not an ap A purified polydimethylsiloxane, siliproved filler for the lips in the US for a cone is a highly purified, long chain variety of reasons. In some states, it is trimethylsiloxy-terminated polydimagainst the law to possess silicone with ethylsiloxane silicone oil. Silicones the intent to inject into human skin.196 are synthetics and do not occur in the Due to the controversial efficacy of body naturally. The earliest recorded silicone in the human body, it is only silicone usage was published in the approved for ophthalmic treatment. 1950s.192 Silicones in general give a More important is the regard to pergreat aesthetic result; nevertheless, manent fillers in the cosmetic augmensome serious medical complications tation community, whereas placement have occurred with their use and abuse.

Chapter 4 The Medium

of a long-term filler is not conducive with comprehensive cosmetic enhancement. The dynamics of the lips change with age, as do the trends that may have influenced the original augmentation.197

Additional Silicone Fillers198 • Silikon (Alcon Laboratories; Fort Worth, TX), approved by the FDA for retinal reattachment since 1998. It has a viscosity of 1,000 cs. • SilSkin (Richard-James Development Corp; Peabody, MA), not approved by the FDA. It has a viscosity of 1,000 cs. • PMS (Vikomed; Germany), it has a viscosity of 350 cs.

facial fat loss by replacing lost volume. Sculptra provides an increase in skin thickness, helping to create a more natural facial appearance in those with facial lipoatrophy.199 Sculptra is contraindicated for lip augmentations. It has shown great results in treating facial lipoatrophy with HIV patients. However, long-term studies still need to be concluded.

Polytetrafluoroethylene (e-PTFE) (Gortex),

Sculptra (Dermik, Berwyn, Pa.)

This product is a polylac-

This particular patient presented to my office with an asymmetrical augmentation of her lips. Her lips had been augmented with silicone. After 3 years, notice that the material is unforgiving. This deformation has a significant impact on the patient, and it stains the community of professionals who pride themselves on the science. tic acid (PLLA). PLLA is a biodegradable synthesized from corn materials which has been used in surgical sutures (Vicryl, Dextran) for years in surgery. The mechanism of action is to stimulate a foreign body reaction (neocollagenesis). Due to the nature of collagen induction from this product there is a significantly higher risk of granulomas. This is an injectable product that restores and corrects the signs of

(Softform, Ultrasoft, Ultrasoft-RC, Tissue Technologies, San Francisco CA)

Gortex has been used in millions of vascular surgeries since 1970. The pore size of the particular Gortex graft being used influences how the implant is integrated into the adjacent tissue. The greater the porosity in the material, the more surface area is available for nearby tissue incorporation, which results in a more

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stable, natural feeling implant. Reduced porosity associated with the graft diminishes tissue incorporation. This leads to more of an encapsulation of the graft, which increases the potential for tissue migration.201,202 Various forms of e-PTFE are available, such as Soft, Ultrasoft (Tissue Technologies), and Advanta (Atrium Medical).

are discreet, single, well-defined locations and do not grow. A true granuloma appears late, usually after 6 to 24 months. Granulomas manifest themselves at all injected sites around the same time, they grow fast and respond well to intralesional steroid therapy. Foreign body granulomas have been reported in the literature with all fillers at a rate of 0.01-1.0%.203

Immune Responses to Dermal Implants

Hyperplastic granulation tissue is composed of multinucleated giant cells. These giant cells are derived from macrophages.

Granulomas

As augmenters we need to differentiate between lumps or nodules and granu- All implants undergo an inflammaloma. Lumps present immediately within tory response which integrates, isolates the first four weeks. Lumps and nodules or rejects the implant or a combination of

This patient formed a granuloma in her right lateral nasolabial fold. Notice the indentation from scarring from surgical removal and associated reduction in volume due to concurrent steroid therapy.

Chapter 4 The Medium

Points to ponder on Using Filler Agents Get informed on the particular filler you intend to use. Include testing, success/failure rates of the particular material. Get safety data for material. Suggested material may not be cleared for lip augmentation. Check your peer-reviewed journals and documents. Look beyond the scope of dental journals and national publications. Don’t jump on the bandwagon. When you start practicing lip augmentation, lots of marketers will be showing up. Use your professional compos to guide your purchases. Sometimes it takes years for negative side effects of materials to occur. Research the CDRH database (http://www.fda.gov/cdrh/databases.htmL) for device indications. Use discretion when using a device for OFF-LABEL indications. Off-label use: In the United States, FDA regulations permit physicians to prescribe approved medications for other than their intended indications. This practice is known as off-label use. Great care should be taken using such devices and procedures, espe-cially in the cosmetic arena. Report adverse reactions and product problems to the FDA MedWatch system (http:// www.fda.gov/medwatch). Report treatment successes to colleagues, study groups and professional journals. Attend continuing medical education courses on fillers and subscribe to various journals with emphasis on lip augmentation. these. The skin is one of our first line organisms against environmental attack. We have developed an evolutionary system of defense that has to be respected when injecting substances into the dermis. The majority of the immune system is based on T cells and a class of lymphocytes consisting of functionally and phenotypically distinct groups that mount a response. There are many theories that attribute to the granuloma formation and the intermediate steps postulated are greatly related to the constitution of the implant used and/or delivery mechanism. Nevertheless, as soon as the implant is in place, there is a “race for the surface” between

macromolecules, bacteria, and tissue cells.204,205 The importance of sterile, pure, conspicuously regulated filling material is paramount in reducing host reactions. Good injector experience in needle placement and injection technique will greatly reduce the potential for granuloma formation. The term pathergy seems to be cited for a significant amount of studies relative to long-term formation of granulomas. Pathergy Theory is defined as an exaggerated, altered, uncontrolled response to nonspecific stimuli, a process that probably involves memory T cell activation and is operant in the multiplicity of pathologic process.206

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TIPS

Tactilely feeling filler material is an important process during any augmentation. I stop several times during an augmentation appointment to feel where I have placed filling material. This is particularly advantageous in the nasolabial fold, commissure and marionette lines. The advantages to intermittent breaks during injection are: Allows augmenter to manually locate area filled and distribution of filler. Gives perspective into how the patient may be feeling the material in their dermis. Is the first step prior to manually massaging filler into the tissue if one has overfilled in a particular area or wishes to redistribute filler in the plane manually.

Chapter 4 The Medium

Treatment for Granulomas Intralesional corticosteroids and minocycline are traditionally used. Blanching injections form a 10 mg/mL Kenalog ampule into the inflammation, and intralesional injections form a 40 mg/mL Kenalog ampule in the granuloma. Both pathologic conditions require as much of the triamcinolone as possible to be injected. Steroid therapy has a 20-30% atrophy

of surrounding tissue rate associated with it. This steroid atrophy can be leveled out with hyaluronic acid or collagen until normal recovery occurs. Another approach is to inject intralesional normal saline from 5-20 mL per session.207 Lastly surgical incision of hard and well-defined granulomas may be indicated. This is usually performed after intralesional therapy is performed.

Chapter 4 Review study Points History of injectable fillers Properties of fillers: what constitutes an ideal filler, FDA classification of fillers. Five histological responses to fillers according to their classification “Off-label fillers,” “label-usage filling,” and the various products that these applications affect Formulation of cross-linked hyaluronic acid Relevant immune responses to dermal fillers and complications

study Questions 1) What are the four inherent drawbacks of permanent fillers? 2) What is the main role of microspheres in dermal fillers? 3) What are the advantages to using cross-linked hyaluronic acid? 4) Filling in Zone B of the lips is considered an “off-label” or “labeled” usage? Is Zone A of the lips considered “off-label” or not? 5) What are the properties of cross-linked hyaluronic acid that are affected in the formulation process? 6) What is the incidence of foreign body granulomas in relationship to injectable hyaluronic acid? 7) Define pathergy.

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Chapter 5

The Artist

Omnia mutantur nos et mutamur in illis All things change, and we change with them.

Chapter 5 The Artist

Beautiful Proportions Orthodontics Art of the Fill

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Chapter 5 The Artist

After lecturing, I often field many questions from the participating audience. The questions I receive usually focus on the technical aspect of augmentation. Yet when the dust of “post-lecture classroom style” questions settles, I am intrigued at some of the straggling, one-to-one questions I receive. One persistent question I address time and again goes a little something like: “now that I know how….why?” What are the fashions trends of lips? What are my guidelines? What are the varieties of lips and how do I augment a patient’s lips when I have so little knowledge of the fashion of lips? To me these questions are the most revealing areas of interest pertaining to the specialty practice of lip and perioral augmentation. They set the tone for the impact of lip and perioral augmentations in the practice of dentistry and oralfacial cosmetics. You see until recently it was the fashion industry that dictated fashion trends of the lips. They do this in a very similar way clothing designers introduce new fashions. This is done through marketing and product development. With the advent of cosmetic injectable enhancement of the lips we (the practitioners) are significantly altering the traditional way of marketing fashion. We as professional doctors are held to an entirely different standard of care, for they are our patients first and consumer last. We must base our techniques and treatments on science and proven repeatable and predictable methods and lesser on trends. The good news is the science and studies are there, we need nothing more than to arm ourselves with them for the benefit of our patients and profession. I wrote this chapter with those questions in mind. There are sources from scientific literature and anecdotal evidence I have summarized on my own personal journey through lip and perioral augmentation.

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Beautiful Proportions Facial Symmetry (Divine Proportion) The space between the slit of the mouth and the base of the nose is one-seventh of the face…the space from the mouth to below the chin will be a quarter part of the face, and similar to the width of the mouth…

1 1.618

1 1.618

As illustrated, the lip can be divided up in the divine proportions accordingly.

Chapter 5 The Artist

Here is an example of the reverse relationship of lips. Even though the model’s lips are symmetrical from a frontal view, the photographer shot the photo perspective from an inferior view. What makes the picture pleasing is the inverse relationship of the lower lip being slightly smaller than the upper lip: the 1-1.618 or “golden proportion.”

This passage was included in Leonardo da Vinci’s notes on facial symmetry written 800 years ago. The divine proportion has many different names, including “the golden section,” “the golden mean,” and the “golden ratio.” The divine proportion is represented by the mathematical symbol of phi, which was named after the Greek sculptor, Phidias (Phi= 1.6180339887…), which was introduced by the ancient Greeks around 500 BC. The divine number is the reciprocal of Δ[(Δ51)/2]. This proportional relationship is evident in architectural work like the Parthenon in Athens and with the building of the great pyramids. In the 1500s, the renaissance brought about further exploration of its numeric value. Da Vinci used these proportions when painting “The Last Supper,” and he illustrated for a dissertation by Luca Pacioli, titled “De Devina Proportione,”208 which means “di-

vine proportion.” Artists of the Renaissance constantly sought to replicate its value. There seems to be an arrangement of space that people find pleasing. This arrangement is pleasing to look at, exist in, and create by. The divine proportion is a compilation of positive and negative spaces. It’s the silence between the notes. It is an asymmetrical balance that balances our eyes. The divine proportion implies an innate beauty we, as human beings, find pleasing. This type of beauty is not subjective, but transcends all our learned or conditioned bigotry, which we are subjected to on a conscious and unconscious basis. Divine proportion has a definite mathematical relationship, which is simply 1 to 1.618 or 1 to 0.618. If we use a calibrator, we can measure out select cuts of the human anatomy which fall into this arrangement. The face falls into this relationship as illustrated. Facial symmetry has a significant role in the overall appeal of the human face. Some studies suggest that symmetrical attractive faces from both sexes are reported to present a greater emotional and psy-

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Chapter 5 The Artist

chological hook: the asymmetry grabs our eyes and attention and we are pulled in our attempt to comprehend the imbalance. This inverse proportion of the lips is okay and can look very pleasing, if the divine proportions are kept. The trick is in not allowing the reversal of the relationThe Divine Proportion and Lips ship of the lips to overly exaggerate the How does the divine proportion apply upper lip. The lip reversal captures our to lips? If we look at the lips, we see this attention, the subconscious relates the inrelationship as normal and pleasing to the version, it registers okay with us, and we eye. When we disrupt this proportional move on. All of this is done in a matter of arrangement, the lips look unsettling, seconds and during that time the lips are even unnatural. The arrangement of the the center of our attention. Because the dilips according to the divine proportion al- vine proportion is kept, our subconscious lows the eye to flow from focus point to makes sense of it and we accept it. Artists play with these variations all the time, as focus point. does Mother Nature. Remember these re Currently there are trends to fill lips lationships hold true to them. so that the superior lip has more volume than the lower lip, a trend you may see As cosmetic dentists placing fillers, we in some “Hollywood” lips. This is a psy- want to incorporate ideal proportions to chological health.209-211 The introduction of the divine proportion was introduced in dentistry by Lombardi in 1973.212,213 These studies related the age-old formula to the anterior display of the maxillary dentition.

This is a computerized replication of the face. Both sides are mirrored to comprise a perfectly symmetrical face. Although this is not an unattractive face, symmetry is not the first thing we’re attracted to. It’s the averageness that is culturally biased.

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enhance our patient’s natural beauty, not disrupt it.214-217

Beauty and Society What is the relationship between beauty and society? No doubt there is certainly a population among us obsessed with beauty, yet even the most non obsessed person will wake up and comb and style their hair before going off to work. Researchers show us that we see attractive people conveying social skills, social adaptability, and absence of shyness and anxiety.218 In the American culture, we see early conditioning towards the relationship between beauty and ugliness. In children’s books we see the bad witch and evil giant are ugly and the good witch and virtuous prince attractive. The media portrays attractive people in successful positions. It has also been shown that the facial proportions consistently judged to be attractive are those proportions near the mean of the population, within their racial group.219,220 The idea is that an average face is thought of as occupying a central location in a multidimensional face space, whose dimensions correspond to the characteristics people use to mentally represent faces.221,222 Even though “averageness” is not the sole discriminate factor for attractiveness, it appears to have a significant impact unto which gender selection is based or perceived.223,224 The symmetrical face is also associated with an attractive face.225 Bilateral blending of the symmetrical proportions of the face have a pleasing effect on the viewer.226 Symmetry is independent of attractiveness or averageness in the overall face.227 Symmetry adds to the overall pleasing effect of a face.

Fashion Trends of Lips: Historic and Present

Actress Gloria Swanson’s Cupid’s bow set the trend in the 1920s. The look was heart-shaped, dark red, and matte lips. 1930s women’s lips evolved into curved lips with a satin finish. In the 1940s, the lips were curved more deeply and a darker ruby color of lip shade was applied. The 1950s ushered in a very soft feminine shape with satin sheen. The 1960s set the trend with lips that were poutier with a fuller look. The 1970s focused on clearly drawn lip lines, orange gold, and high gloss. Lips of the 1980s were very earthy, metallic and frosty. In the 1990s lips were hot red glossy, had a matte satin finish, and a deep outline. Today women’s lips have a natural and vital quality. They suit their faces while improving overall looks. Excess volume is out. Well-defined lines are in. Just a small amount of filler is often all that is needed. All around the world, women adorn their lips. Some cultures augment their lips beyond our traditional ideals. Yet there is no doubt that celebrities and their Hollywood makeovers have had an impact on American culture. One orthodontic study confirmed that the lips of Caucasian fashion models were considered more aesthetically pleasing than those of nonmodel Caucasians.228 Historically most women have enhanced their lips with various cosmetic products and procedures in an effort to attain a more youthful appearance with the application of permanent and nonpermanent color agents. It wasn’t until currently that scientific means have led us to the age where we can manipulate the form of the lips without significant surgery and cost. According to the 2005 statistics on the American Society for Aesthetic Plastic Surgery’s Web site, women had nearly

Chapter 5 The Artist

10.7 million cosmetic procedures in 2004, enhancement and rejuvenation traditionan increase of 8% from 2003 to 2004.229 ally held for women.

Perception of Beauty Women There is a consensus within the scientific community on broad features of a woman’s face that are attractive to men. There are neonatal or nondominant qualities that are implanted in our psyche. Having a large forehead, large, wide-set eyes, a small nose, and thick lips are all neonatal qualities. These characteristics stimulate the nurturing side in us. These are facial qualities that infants possess, and it is hypothesized that as humans, we react receptively to them.230 Men respond to a combination of these neonatal expressions, as well as mature, expressive features that include higher, wider cheekbones. Expressive facial features add to the perceived attractiveness, which would include a wider smile, higher eyebrows, and larger pupils. The expression of these ideals on the female face promotes a sense of availability to mate.231

Men A female’s perception of attractiveness leans more toward mature features. These would include a wide jaw, strong chins, and thin lips.232 The most attractive males had a combination of neonatal qualities mixed in the facial expression.233 Men are increasingly turning to lip and facial augmentation to reestablish a more youthful, vital appearance. The term “metrosexual,” coined in 1994, is an urban male with a strong aesthetic sense who spends a great deal of time and money on his appearance and lifestyle. There are many connotations to the word, some narcissistic and some flattering; nonetheless, this term exemplifies the movement of men into the cosmetic arena and the increasing popularity of men partaking in cosmetic

The society for Aesthetic Plastic Surgery reports that men had 1.2 million cosmetic procedures in 2004 (10% of total), an increase of 8% from 2003 to 2004.229 Unlike females, men have different goals when they request lip or facial corrections. The ideal is not as important to them. Typically they are seeking a more rejuvenated or rested look.

Ideal Lips Omnia mutantur nos et mutamur in illis: “All things change, and we change with them”…this Latin quote applies mostly to lips and trends in cosmetics. Here is “the rub,” as Shakespeare would say. Although we refer to the “ideal lips” in literature and art, there’s no documented standard. Clinicians are supposed to recreate this ideal, but there is no guideline. Of the hundreds of journals, magazines, and photos I have researched, I have yet to come across the perfect lips. Dental and medical literature has ambiguous and varied data on what constitutes perfect lips. Understanding there are no ideal lips, we cannot deny that our lips portray certain perceived emotions to others. What constitutes the ideal set of lips? The answer is based on cultural upbringing, public awareness, and personal preference. Ideal lips seem to have symmetry associated with them. The natural relationship between upper and lower lip is a 1:3 ratio. There is symmetry in common with all pleasing lips, which can be attributed to the divine proportion, as I will discuss in greater depth later. When we look at a person’s face, we focus on two things, eyes and mouth.234,65 Even though we may look at the eyes first, it is the mouth that impacts our first

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PresenCe

Mood

The first area of the face we notice is the eyes for presence, then the oral-facial is recognized second. Yet, the oral-facial is the most descriptive of the two on first impression.

Chapter 5 The Artist

impression of an individual the most.235 When the lips are full and well-defined, they impart a sense of youth, health, and attractiveness. Thin, frail lips project fragility and senility.236

Studies show there is a perceived difference in judging a person’s attractiveness, when those persons being looked at are in a static or kinetic state of facial expression.226 As oral-facial augmenters, we Studies show that a face with a greater must understand the concept of kinetic vermilion-to-skin ratio in both upper and and static beauty and how they relate to lower lip always ranks higher in aesthetic one another. The face can be viewed in a preference.237 The layperson will select a static or kinetic state. A subconscious recmedium, full upper lip in complement ognition of a face as attractive in a kinetic to a slightly fuller lower lip.238 There are position does not always correlate with a of the same face in a strong academic studies to complement pleasing recognition 240-242 the general perceived advertised ideal static position. that fuller lips are more pleasing to the During our examination, we must exlayperson’s eye.239 Findings in these stud- amine our patients in a kinetic and staties also concluded that the dentists polled ic position. Have the patient smile and seemed to pick the same relationship as frown; dentists naturally have patients the lay public as far as medium upper smile to evaluate the dentition. Now draw lip volume and lower lip volume in the your attention to the nasolabial or mental vermilion-to-skin ratio. Plastic surgeons fold during the smile or the frown. Ask had a tendency towards overall fuller lips. yourself the question: if I augment these Studies also show that dentists incorpo- areas now, will it affect the kinetic fold rate the dentition more into evaluating the of the tissue? Augmenting the lips in a mouth presentation, whereas the general static position, without viewing the smile public was less impacted by the dental line and incisal appearance, can lead to variable in contrast to the lips. Fuller lips overfilling of the lips which leaves an unare associated with a significantly higher pleasant post-augmentation appearance. degree of sexual attractiveness and femi- It’s difficult for this author to quantify ninity, but they are also associated with or qualify the amount of filler to be used perceived feelings of friendliness, intelli- when evaluating the relationship between gence, success, and honesty. Thinner lips kinetic and static tissue. It is in “the art of portray aggressiveness, unattractiveness, the fill” that you as the augmenter (artist) and masculinity.239 will develop a sense of the amount of filler When augmenting the lips we are at needed to achieve a cosmetic correction will develop as your experiliberty to shape the upper lip more and and this skill243,244 add volume to the lower lip. This may ence grows. be due to the natural presentation of the upper lip and the philtrum and defining structures that surround it. Although current trends seem to regard the upper lip as fuller in volume, this may be attributed to the increase of prosthetic implants and fillers.

Kinetic vs. Static

Projection pro•jec•tion 1. The act of projecting or the condition of being projected. 2. The attribution of one’s own attitudes, feelings, or suppositions to others. In art school, models sit in the middle of the room and students with sketch

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pads and pens surround them. As the students draw, the instructor walks around them and guides their pen, but does not influence their style. Work is placed on the wall and critiqued at the end of a sitting. One event stands out and most any observer can see this when guided to look for it. Without knowing who sketched which portrait, nine times out of 10, we can identify who drew it. Simply put, look for details of the artist’s face in their subject’s portrait. This projection is more difficult to detect in the advanced artist, yet there are still telltale signs of them in their work. Nevertheless, students with long noses project longer noses on their portraits. A thinner artist’s portrait will have more sculpted facial appearances. The lesson is that we see beauty in relationship to ourselves. When doing portrait work, the professional artist has trained himself to separate himself from this bias. In the actual business of painting portraits, clients are greatly offended if the artist fails to represent their family’s broad chins or distinctive noses. In keeping with that idea, when augmenting your patient’s lips, do not project your vision of what is good looking onto them. Two results will come from that scenario. One, their look will be changed opening the opportunity for them to be displeased with the results. Two, you will have an entire town filled with your lips; and as the filler in your patient’s lips shrink, so will your patient base. Cosmetic dentists definitely perceive facial aesthetics differently than the layperson.245 Not only do we need to be cognitive of our natural inclination to project our discrimination, but we have been conditioned professionally as to what is the standard acceptable aesthetics.246,247 The answer is between the two extremes and that is the balance the artist in us weighs with every patient.

Aesthetic Vs. Cosmetic Aesthetic signifies “natural,” a quality that comes from within. It can be defined as the science of beauty that is applied in nature and in art. Cosmetic refers to substances and procedures that are used to enhance or correct defects in the face, skin, and hair. Cosmetics are the preparations to change the appearance or enhance the beauty of the face, skin or hair. The practice of lip augmentation is truly a combination of both these terms. Aesthetic and cosmetic are separate distinct definitions, yet they are inseparable.

Orthodontics Up until now we have discussed the subjective part of beauty: how do we translate these proportions into a scientific method (a true method reflecting accuracy, precision, and reproducibility)? In addition to the method of obtaining information, we have to be able to statistically analyze the information by ways of standard deviations and means. No other medical specialty deals in such analysis in detail from birth to adult as the dental field. In particular, the orthodontic specialists have pioneered advances in quantifying and qualifying oral-facial parameters. Indeed the dental/skeletal relationship affects the lips and associated soft tissue. When we do our soft tissue assessment for augmentation, it is important to realize that there are a significant number of cases where lip asymmetry needs to be orthodontically corrected and not augmented with fillers to reestablish lip symmetry.248 With the advent of orthodontic, cranial/facial measurements, most of the facial research has been done using lateral cephalometry.249 Lateral cephalometry is a great tool for establishing and projecting

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Illustrated above are the landmark points of the lips from a side profile future oral-facial growth, but it has its limitations. Lateral cephalometry simplifies a 3-dimensional structure to a 2-dimensional radiograph. Soft tissue and structures out of the mid-sagittal plane are subject to increased errors of magnification and identification.250 If we take a cephalogram from the posterior to anterior view, in combination with lateral cephalometry, we produce a 3-dimensional view of the skeletal structure yet no reliable soft tissue replication.251 Anthropometry is a 3-dimensional measurement of the face. It is a statistical base of measurements carried out during 1967-1984, with 2,500 people as the information source.252 One hundred sixtyseven indices involving cranial and facial measurements are incorporated into this body of information. This means of measurement enables us to group distinct fa-

cial proportions into the mean of a population. The drawback to anthropometric studies is that it is time consuming when it comes to implementing the measurements. In addition, we must be cognizant of the genotypical expression of the sample population from where the data was gathered and how that relates to the patient we are currently analyzing. With the advent of computer technology, we are able to scan 3-dimensional studies of the face and project soft tissue growth into a more predictable, speedy outcome.253 Orthodontically we have identified landmark points of soft tissue on the face. These points are helpful in gathering information on a patient to assess treatment planning of possible soft tissue augmentation or muscular denervation (Botox). For purposes of this book, we will limit these dental/alveolar points to the lips and pe-

Chapter 5 The Artist

rioral tissue. A complete orthodontic workup is not indicated for lip and perioral augmentation, although a practitioner should be familiar with basic guidelines to help the patient in their treatment planning.

we have historical and cultural views of perceived attractiveness. In addition we are aware of the psychological implications of perceived attractiveness. It is the composition of these ideas, data, and perspectives that lead us to the fulfillment and The classic points of reference for cat- understanding of beauty from an oral-facial augmenter’s viewpoint. Through the egorizing lip proportions are: understanding of these ideals, we are lead • vermilion to their implementation. This is known as • subnasale (Sn) the Art of the Fill. • labrale superius (LS) • labrale inferius (LI) Art of the fill • stomion superius (stms) • stomion inferius (stmi) Vermilion Dollar Lips® • commissures As a dentist we have the ability to in• interlabial gap clude a complete cosmetic oral-facial soft • gnathion (Gn) tissue exam in conjunction to our dental • pogonion (Pg) exam. One of the benefits of coming to

a dentist for oral-facial augmentation is our ability to give a complete diagnosis on the soft tissue presentation. Just as the dentist looks at the radiograph and then clinically at the tooth, we can look at the dental, skeletal form then the soft tissue PROFILE LIP POSITION overlying these structures. This part of MEASUREMENTS the chapter will guide you on how to ap This is evaluated by drawing a line proach the diagnosis, treatment planning, from the subnasale (Sn) to the soft tissue and augmenting therapy. It is our goal to pogonion (Pg). The amount of lip protru- achieve the maximum oral-facial cosmetic sion or retrusion is measured from the potential for all your patients. line perpendicular to this Sn-Pg line. It is Pre-Treatment Consultation normal for the upper lip to be slightly pro- Due to the subjective results of costrusive in comparison to the lower lip on metic procedures, it is important to evaluthis plane. The average adult’s upper lip ate several points. Document all current is 3.5 mm anterior to the Sn-Pg line and facial features via a recordable reference the lower lip is 2.2 mm anterior to this chart. This documentation will give you line.254 The vertical lip length is defined and your patients a baseline to start and by measuring the upper lip from the Sn to a reference to refer to for post-treatment the stomion superius (stms) and the lower results. During a pre-treatment consultalip is measured from the stomion inferius tion, you should: (stmi) to the gnathion (Gn). Assess patient’s expectations. The We have established a statistical data term “full correction” is applied in base of parameters for the skeletal, dental plastic surgery. The definition is better and soft tissue of the oral-facial area and described as “optimal correction triNote: The Gordon classification is an adjunct to these previously established landmarks. It develops a more detailed mapping of the lips for the purposes of lip augmentation.

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Common Name and Dose

Common Uses (Marketing)

Sugical Cautuion

Perioperative Recommendations

1

Chondroitin (400800mg BID)

Osteoarthritis

Perioperative bleeding

Discontinue 23 weeks before augmentation

2

Ephedra (2.7-3.0 g QD)

Energy, weight loss, asthma

Hypertensive, cardiac instability with anesthetics

D/C 1 day before augmentation

3

Echinacea (2.7-3.0 g QD)

Infections, ulcers, arthritis, prevention of bruising

Potentiate barbiturate and halothane toxicity, allergic reaction, immunosuppression

D/C 2-3 weeks before augmentation

4

Glucosamine (1500 mg QD)

Osteoarthritis

Hypoglycemia

D/C 2-3 weeks before augmentation

5

Ginkgo biloba (120-240 mg QD)

Cognition (dementia), vascular disease, tinnitus, asthma, colds, anti-inflammatory

Postoperative sedation, perioperative bleeding

D/C 1.5 days before augmentation

6

Goldenseal (125-500 mg BID)

Laxative, antiinflammatory, infection

Volume depletion, postoperative sedation, photosensitization

D/C 2-3 weeks before augmentation

7

Milk thistle (100-300 mg TID)

Hepatoprotective, anti-inflammatory

Volume depletion (choleretic activity)

D/C 2-3 weeks before augmentation

8

Ginseng (0.5-2.0 g QD root) (200-600 mg QD extract)

Antioxidant, energy, lowers blood glucose

Perioperative bleeding; avoid use in children and pregnant women

D/C 1 week before augmentation

9

Kava (2.7-3.0 g QD)

Anxiolytic, muscle relaxant

Postoperative sedation

D/C 1 day before augmentation

Perioperative bleeding

D/C 1 week before augmentation

10

Garlic (600-900 mg Infection, hypertension, QD) (8 mg QD oil)(4g hypercholesterolemia, QD cloves) cancer prevention

Adapted from Heller J. et al.

TABLE 5.1 Top Ten List of Medicinal Herbs/Supplements

Chapter 5 The Artist

FACIAL ANALYSIS Checklist Before adding volume, one must analyze the lip. Here are some of the questions one must ask of their patients: Male or Female? Age? Is there any dental reconstruction treatment planned in the future and, in particular, anterior aesthetic reconstruction? If so then IDEALLY, the dental work must be completed first. Remember the teeth are the framework for the lips and our limits of fill are dictated in part by the borders of our teeth. Look at the appearance of tissue for any signs of trauma, and/or congenital aberrations. Thin lips may require multiple visits; analyze the lips, palpate them. Are they thin, fibrotic, senile (thin) lips that may have atrophied over time or are they congenitally thin? The resultant fill will be a result of the quality of lips. Is the philtrum well defined? Is there the desired form of the Cupid’s bow? When the patient is in the neuromuscular rest position, is the mouth open or closed? When the patient smiles, is their dentition showing and if so, how much? Is the commissure of the mouth depressed or angulated down? Are there rhytids and facial lines? Kinetic motion: how do the lips look in motion? A patient’s lips may look thin when in a static position; but when they talk, the relative thickness of the lips may flatten out over the curvature of the dentition, giving way to a fuller look in kinetic movement. Mental lines: are there any lines above the mentalis (usually in men) that can be augmented to relieve their severity? Nasolabial folds: the facial line that extends from the alar of the nose to the corners of the mouth. As we age, this crease deepens and is a telltale sign of age. View the patient form profile. Is the patient a class 2 skeletal, where adding volume may produce a duck-like appearance to the lips? As a dentist, we are acutely aware of the oral-facial, skeletal/dentition and how the lips relate to them. We are in the unique position to offer a patient different treatment options to correct their soft tissue appearance. A patient may benefit from orthognathic surgery, orthodontic treatment or simple anterior dental reconstruction. These treatment modalities may offer a patient a more pleasing aesthetic result.

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ad,” which includes the patient’s desires, ideal proportions, and the doctor (material propensity and technical expertise). Explain to your patients this triad and what results can be expected. Educate your patient on treatment processes and outcome possibilities for their augmentation. It is important that all patients have realistic expectations for their augmentation. Lips may be refined and volume added, but the overall presentation should not be changed. (see “The Psychology of the Lips,” Chapter 1, pg. 15) Do NOT combine a dental restorative appointment with an oral-facial augmentation. This is a critical mistake the beginner augmenter will make. My worst facial fills were done in conjunction with a dental appointment. Reasons not to combine appointments: When we augment a patient’s oralfacial area, we are in a more creative mode of working than when we are restoring teeth or surgically manipulating the mouth. Altering attention from oral-facial augmentation and dental restorations diverts one’s attention away from the freer artistic mode of operation one needs to be in when augmenting a patient’s lips or face. We tend to use more dental anesthesia to achieve a full, pain-free, dental appointment. This is more than is necessary for soft tissue augmentation and it has a greater propensity to spread and distort the musculature tonus of the muscle of facial expression. The post-operative sequelae of a dental appointment can be painful at times; this can translate into an unpleasant augmentation experience for the patient.

Work on your timeframe. All too often, patients want lip enhancement two days before a wedding or they are leaving on vacation for two weeks the next day. These patient-dictated timetables have the potential to put you into a bind, especially if post-operative complications arise. Some sequelae of events that can occur are a longerthan-normal swelling or bruising. No matter how much you warn your patient, you will be to blame. Take a thorough history of your patient’s lips, including accidents, disease, and prior augmentations. There may be scar tissue deep in the lip that may present itself in a clefting fashion upon fill. Also take a history of over the counter medication and herbal meds that may influence treatments. Perform a thorough dental exam. Doctors augmenting patients with dental/ alveolar abscesses have reported a higher incidence of asymmetric swelling post injections. Inform your patient that there is a possibility that there will be more post-op swelling due to dental/periodontal infections orally. There are two ways to present financial estimates to your patients. You may give an estimate based on cost per vial and number of vials estimated for total correction. Or you may present a fee for total correction, letting your patient know there will be an additional fee if more correction is wanted. Whatever you decide, Do Not Bargain with patients. In dentistry, when we may give “deals” to patients, it usually comes out of our time in the profit margin. This is a material and a definite measurable amount is needed for a complete correction. We fill for effect, not amount of material

Chapter 5 The Artist

I have some patients hold a mirror and evaluate intermittently between injections. NOTE: make sure you choose your patients wisely for this technique. Not all patients are able to be as active in this type of treatment. A significant number of patients will have an aversion to the needles and the slight amount of blood that comes with injecting into the vascular area of the lips. Discontinue aspirin two weeks before treatment. 24-48 hrs before treatment, avoid a diet high in sodium, sugar, caffeine, alcohol, and spicy foods. Avoid any chemical peels, laser treatments or cosmetic treatments one to two weeks prior to treatment.

Photographic Documentation Pre-fill documentation is a must for a complete lip augmentation treatment, and with the advent of digital photography, shots can be taken and compared pre- and post-treatment to illustrate the desired result to the patient. This process enlightens patients on actual changes, because all too often patients fail to see how much fill was achieved until they compare the results to the preoperative photos.255 Once you have begun your treatment, you can’t turn back; therefore, dentally/legally, it is prudent to have documentation. Moreover, you will want to have a catalog of your success and the ability to share your difficult cases with others for everyone’s benefit.

ity to produce instant photos to show our patients; thus, we should already be using photos for documentation of dental work. There are many kinds of cameras on the market today. The body and lens for intraoral photography needs to be outfitted with additional flashes and lenses.256 Soft tissue photography of the oral-facial area requires less equipment. Most cameras sold to the average consumer are calibrated for portrait photos. You can purchase a high-grade pixel camera at a relatively inexpensive price. Try to make taking photos of your patient a habit. Once again, if you delegate this task, you cannot rely on your assistant to capture all the angles you may see from your trained eye. In addition, when you as the dentist are the one taking the photos, it conveys a personal touch to the entire cosmetic process, which conveys confidence and commitment to the patient.

Most pictures of the face can be done on autofocus. Setting the camera for ‘portrait’ mode is required. Aiming the autofocus on the patient’s lower eyelid will usually encompass the tip of the nose to the ear in the depth of field,257 that being the area in which the image is in focus. Using a dark, matte finish material for your backdrop is essential. This will absorb aberrant flash rays and eliminate background noise, such as office furniture, office equipment, and other objects that may distract from the subject. In addition, use of the same backdrop will ensure consistency in pa Be sure to have your patient remove tient imaging pre- and post-operative. all makeup and do all photos before anes- Photographing the nasolabial fold and thetic is applied. Make sure your camera fine lines of the face can be challenging. is capable of realizing facial blemishes, Too much flash or direct lighting will scars, and facial color. With the advent of blend in the lines you marked for correcdigital photography, we have the capabil- tion. I shoot most of my facial pictures

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40-60 cm away from the patient’s eyes. I use a zoom lens to acquire a closer shot so I don’t blanch out the facial lines earmarked for correction. Remember, we

Full head shot with kinetic smile.

Soft tissue in static position.

want to capture the lines, wrinkles, and folds in our pictures that are ordinarily unwanted in conventional photography. If a patient complains of a wrinkle or fold

Chapter 5 The Artist

that comes out in certain photos or lighting, try to recreate the lighting for them by using a separate handheld or dental light.

Profile shot in static position.

Semi-profile shot of oral-facial and kinetic.

Measurement Tools For Aesthetic Quantification And Qualification

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It’s hard to develop a nonsubjective gauge for cosmetic results. A multitude of factors play a part in our perspective as discussed previously in this chapter. I have provided five assessment scales below that have been published in various studies as a baseline classification. You can choose to incorporate or modify them for your pre-op and post-op augmentations. The idea is to have a consistent, repeatable form where you can gauge progress

The Global Aesthetic Improvement Scale258 1

Very much improved: optimal cosmetic result for the implant in this patient.

2

Much improved: marked improvement in appearance from the initial condition, but not completely optimal for this patient. A touch-up would slightly improve the result.

3

Improved: obvious improvement.

The Wrinkle Severity Rating Scale The Wrinkle Improvement Scale

1

Absent: no visible fold; continuous skin lines

2

Mild: shallow but visible fold with a slight indentation; minor facial feature; implant is expected to produce a slight improvement

0

No Improvement

1

Mild Improvement

2

Moderate Improvement

Moderate: moderately deep folds; clear facial feature visible at normal appearance but not when stretched; excellent correction is expected from injectable implant.

3

Significant Improvement

3

4

5

Severe: very long and deep folds; prominent facial feature; less than 2 mm visible fold when stretched; significant improvement is expected from injectable implant. Extreme: extremely deep and long folds, detrimental to facial appearance; 2- to 4-mm visible V-shaped fold when stretched; unlikely to have satisfactory correction with injectable implant alone.

The WSRS is a photograph-based outcome instrument that is designed specifically for quantifying facial folds.

As you can see this scale is rather subjective in nature.

Rated Numeric Kinetic LIne Scale259 0

No Wrinkles

1

Wrinkles not present at rest, fine

2

Wrinkles not present at rest, deep lines with facial expression

3

Fine wrinkles present at rest, deeper lines with facial expression

4

Deep wrinkles at rest, deep furrows with facial expression.

This scale shows statistically significant inter observer reliability for rating hyperkinetic lines.260

Chapter 5 The Artist

in your patient augmentation.

Rubin Smile Classification

The Rubin classification generalizes the smile into three categories. The categories are rather broad, but for a quick analysis, it will suffice in pre-augmentation records.261 Mona Lisa smile: dominated by the zygomatic major, which is characterized by sharply elevated corners of the mouth. Canine smile: dominated at the levator labii superioris, which manifests itself by strong raising of the medial portion of the upper lip. Full denture smile: where there is a simultaneous contraction of all upper lip elevators and lower lip depressors.

Armament for Injectable Fillers Syringes Injectable syringes for fillers and injectable syringes for anesthetic are quite similar. The injectable syringe is composed of a body, plunger, thumb presser and needle. The syringe is held in the same manner as local anesthetic syringe. Due to the viscosity of the fillers (or G’), aspiration of the material is ineffective. The various injectable fillers are packaged without the needle being attached. The operator must attach the needle. Care must be taken to

Here is a picture of the standard injecting syringes for cross-linked hyaluronic acid. Notice that the syringes have no aspirating rings. This is due to the inability to aspirate because of the low viscosity of the materials. The marketed syringes can be distributed in volumes of .2 mL to 1 mL.

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screw in the needle tightly. If the needle is not secured tightly, one will express a significant amount of material out and it will be wasted.

Needles Syringe needles must be appropriate for the filler. Usually injection needles are packaged with the fillers. After multiple injections—particularly in the more heavily keratinized epithelium of the nasolabial fold or vermilion border—the needle tends to dull or bard. Using several needles when augmenting the lips can reduce bruising and ease your patient’s comfort.

Needle Gauge A larger gauge may assist in flow and application of filler. Needle gauges range from 27-32. Each gauge and length has its advantages with different fillers. The use of a 27 gauge allows for easy flow and less dulling of needles. The use of a 32 gauge has been proposed by some for rhytids fills and cross-hatching techniques. Because of the viscosity of some fillers, needle selection is significant. The smaller the gauge (ie, the larger the diameter), the easier the expression of the filler will be; however, more pain (if no anesthetic used) and bruising are associated with the injection site. Conversely, the longer the needle, the more back pressure required to fill. The advantage to this is that less puncture sites are required due to needle length; one can fan around in the dermis and have a greater area available for deposit of filler.

These are the 3 types of needle gauges one may apply to a standard filler syringes. Green is the 32 Gauge, Tan is the 30 gauge and brown is the 27 gauge.

Chapter 5 The Artist

Chapter 5 Review study Points Divine proportion and its relationship to lips, face, and augmentation. Comprehend neonatal, averageness, symmetry, and male vs. female perception of beauty. Orthodontics and relevance to lip and perioral augmentation. Incorporating photography into your practice of oral-facial augmentation

study Questions 1) What is the calibrated golden proportion number? 2) Which is most appealing to the onlooker: the averageness of a face or the more symmetrical face? 3) What are neonatal qualities of the face and how do they affect our perception of beauty? 4) What is the average upper and lower lip projection related to Sn-PG line? 5) What is anthropometry and what is its inherent drawback in the context of statistical analysis? 6) Is it best to combine conventional dental appointments with lip and perioral augmentation?

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Chapter 6

Injection Techniques and Procedures Ventis secundis Go with the flow

Chapter 6 Injection Techniques and Procedures

Lips Oral-Facial Skin Technical Considerations

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Now that we have reviewed the Canvas (anatomy) and the Medium (injectable fillers), we are now completing the third leg of the triad: the artist. The third leg of the triad is comprised of two separate yet equally dependent parts. Part 1 is composed of the artist’s internal and external understanding and vision of beauty which was discussed in Chapter 5. Part two are the technical skills the artist uses in application of their vision and the application of their art. In this following chapter, my goal is to lay the groundwork pertaining to the techniques of lips and perioral augmentation. As you grow and develop your augmentation practice, you will inevitably incorporate pieces of philosophy and techniques from many practitioners—as well as you should. The techniques I have included are sound treatment options and delivery methods. I have put my personal touches on these techniques and they have yielded safe, predictable, and outstanding results consistently. These will be your building blocks for you to initiate and develop a successful and long lasting lip and perioral augmentation practice. “Men are wise in proportion, not to their experience, but to their capacity for experience.” George Bernard Shaw

Chapter 6 Injection Techniques and Procedures

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Lips

There are three potential places fillers can go when we are injecting filling material into the lips for augmentation.

Chapter 6 Injection Techniques and Procedures

Natural Plane

This is the plane that naturally exists in the patient’s dermis. The junction of the dermal layer that the needle is placed in is right below the vermilion epithelium. This plane will relieve itself laterally to host the fillers as pressure is applied. The resistance in this layer to separation differs from skin type. The more keratinized the tissue, the more resistance and vice versa. The lips have very little resistance in the dermal plane. The fill can be easily distorted by expressing too much pressure in the fill. The distortion comes from the material flowing into undesired zones of placement.

Acquired Plane This plane has been established by a previous fill of a material that has occupied the space for a time. This plane may divert your filling material away from your planned augmented areas.

Path of Needle Insertion

This plane is created by the needle as it was injected into the dermis. If we apply very little pressure and withdraw the filler as we express the material, we will fill this space.

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tion site is needed in Segment 3 of the upper lip is due to the change in angle that may present as the Cupid’s bow arch form bows down. This plane in Segment 3 orients itself downward and anteriorly. Some patients may not need this additional injection point because the flow of the Plan Ahead filler material will extend into Segment 2. Remember to plan for the minimal Segment 5 of the lower lip does not rediamount of injection points to achieve ef- rect its plane so dramatically. Segment 5 fect. Before we lay a needle to the lips or is more of a union of two planes coming to the oral-facial area, we must have en- together. Usually an injection site in Segvisioned in our minds the final cosmetic ment 4 and 6 will adequately direct mateoutcome and the processes we have to go rial into Segment 5. through to attain the desired result. Plan Lower Lip out in your mind how many injection points you will use, the direction of needle Initial injection starts in the corner and amount you will deposit, and envi- of the mouth. Place needle to hub, inject slowly and monitor flow. On the lower sion the plan in the lips you want to fill. lip, a maximum of three points of injec Start with reestablishing volume. Ini- tion will be needed. Since the lower lip tial volume fill should be done in Zone B. has only two planes contralateral to each It is important to inject in the middle of other, the material tends to flow easier. Zone B to allow the flow of the material to go superior, inferior and anterior, and INJECT SLOWLY posterior. This is a three-dimensional pro- There are three reasons to inject slowly. cess of adding volume to the lips. Start at 1) Potentiating the plane requires relievthe corners of the lips and work inwards ing connective tissue of the vermilion to in order to provide scaffolding for the mehouse the filler. This should be done slowly dially placed filler. A minimum of two to maximize natural potential. Fillers will injection points are needed for this techtake the path of least resistance. When the nique for upper and lower lip. If you are filler has filled the plane, it will distort the not able to achieve the desired flow, more natural plane, resulting in an unaesthetic injection points may be needed, usually a result. Injecting filler too fast can obscure total of four on the upper lip and three on visually and tactilely the natural terminal the lower. fill of the plane.

INJECTION TECHNIQUES FOR THE LIPS When augmenting the lips, our goal is to maximize the cosmetic result with the least amount of material and with the minimal amount of trauma to tissue during the process.

Upper Lip

Initial injection starts in the corner of the mouth. Place the needle to the hub. Inject slowly and watch flow. If you aren’t getting a satisfactory flow, then more injection sites are needed to properly fill the lips. You may need to inject in six sites within segments 1, 2 and 3.

The reason why an additional injec-

2) Post op swelling—hastily injecting will initiate an overexuberant inflammation response. This will obscure your present filler process as well as lead to significant postoperative pain, bruising, and swelling. 3) Edema race—as we inject the filler, we are displacing the natural tissue and fluid to compensate for the filler. Pushing

Chapter 6 Injection Techniques and Procedures

Here is a general guide for mapping out injection points for the upper and lower lip. Remember to start at the outermost injection point first and inject your fill sequence medially.

Filling in segment 5 of the lower lip should be injected as the illustration at left shows. Enter on both sides of the segment to ensure proper flow and form of the plane.

Segment 2 should be augmented by injecting bilaterally and the direction of the needle downwards and medial. this will insure proper potentiating the plane.

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TIPS

Reducing a prominent jowl line indentation can be effectively accomplished with dermal fillers. The intra oral mental block will provide substantial enough anesthesia for this augmentation technique. A sound diffential diagnosis is warranted for this procedure. Although one may relieve the prominence of the jowl indentation, other cosmetic treatments may be a better long term alternative, such as conventional face lifts. Yet initial filler therapy is a great introductory relief of this age defining oral-facial manifestation.

Chapter 6 Injection Techniques and Procedures

the filler in the lips too quickly can lead the augmenter into a false perception of where the filler is or how much one has

material and tacitly feel the material saturate the plane when injecting. One needs to visually see the flow of the material and its saturation of the plane. Here is an example of a lip where the plane is saturated. We now pull the needle out and reinsert in another plane to continue augmentation.

Vermilion Border Filling (Zone A) The goal of augmenting in Zone A is to accentuate or creDepicted here is an example of plane saturation. ate anatomy. Zone A incorpoNotice the blanching of the lips medial to the needle. rates the transition from the vermilion tissue of the lips to At this point, one needs to remove needle and reinsert the stratified squamous tissue into another plane if additional fill is planned. of the oral-facial. Due to the transition in the keratinization saturated the plane. This is due partly to of the tissue, there will be a great reducthe edema of the tissue that projects tight- tion in the flow of filler in this transitional ness in the lip. Pushing the filler slowly zone. Because of the buttressing effect of into the lips gives the tissue time to allow a the thicker keratinized tissue of the oral/ certain amount of hydrostatic equilibrium facial area, we need to watch the flow of in the lip. Slowly injecting filler facilitates filler at the vermilion border, for it has a better assessment of the fill and the ability tendency to flow to the path of least resistance. The path of least resistance will to place more filler in the plane. be towards Zone B and if we have already Determining Plane Saturation added to Zone B, this can lead to overfill We determine plane saturation by vi- ing of the lips. When filling the vermilsual and tactile perception. We determine ion border, we will fill by potentiating this by watching the material flow into the the space made by the needle. We inject, tissue or zones of the lips, and by feeling withdraw, and inject at a constant presthe back pressure of the filler as we in- sure and recoil of the needle. Our goal is ject into the plane or zone of the targeted to place a uniform tubular fill of material area. The skill of tacitly feeling the injec- in the vermilion border. tion pressure (G’) is still developing in the beginning augmenter, so they may need Philtrum Filling to rely on visually observing plane satu- The purpose of augmenting in the ration. Ultimately it is the goal of the aug- philtrum is to accentuate existing anatomenter to both visually see the flow the my or create anatomy in the patient. The

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philtrum is composed of stratified squamous epithelium. The filler will not flow as well in the philtrum area as it does in the lips. The technique used is deposit and withdrawal. We will be depositing the filler as we withdraw the needle.

way of the insertion point. Slowly inject contents in a superior-to-inferior direc Indications: Where there is a signifi- tion under even, constant pressure. Apply cant lack of anatomy in Zone A and aug- to both sides evenly. Remember that the menting Zone B of the lip would produce philtrum is slightly wider at the bottom, a flattened look or “beak effect.” then superior by the nose. If anatomy is overfilled, lips will look too “worked.” To achieve definition, we are able to insert the needle into the tip of the Cupids’ bow along the philtrum line. Before injecting, gently lift the needle length to assure path of injection. This should line up evenly and to the height of contour of the philtrum line angle. This particular injection potentiates the space by the needle diameter. This means that there is no plane for the material to flow extensively into like the lips. The plane or space is made by the needle and we inject the filler as we pull our needle back the

Perioral Lines (Rhytids) These lines around the mouth have been described as hyperkinetic lines, smokers’ lines or bleeder lines. There are many contributing factors to the development of these lines. If they occur in patients around the ages of 30-40, they are usually associated with chronic contraction of the orbicularis oris muscle. These patients usually have incompetent lips and as the patient compensates through their lifetime to close their lips to complete a lip seal, these perioral lines develop. In

Chapter 6 Injection Techniques and Procedures

addition, the normal competent lip may develop rhytids. With the effects of aging, loss of lip volume and redistribution of fat rhytids develop. A rhytid extends perpendicular from the vermilion border of the lip in an outward, fanning fashion. When stretching the vermilion tissue of the lip, one may observe a softer, less calloused tissue deep in the fissure of the rhytid. The color may be lighter deep in the rhytid due to underexposure to the ultraviolet rays of the light. The majority of rhytids will be present on the upper lip. These lines can usually be eliminated by augmenting the volume of the lips first in Zone B. If after filling Zone B there are still some rhytids present, one may fill them by utilizing some fairly simple techniques. Approach the lines inferiorly with the needle insertion point at the vermilion border. Insert the needle underneath the rhytid along its full path. We have now potentiated the plane underneath the rhytid. Express the filler as you withdraw the needle. On the lower lip, it is usually not necessary to eliminate rhytids. Filling in Zone B usually eliminates most of the rhytids due to the amount of filler the lower lip can accept without looking distorted. If there are remaining rhytids in the lower lip after Zone B fill, then they need to be filled in a similar fashion as with the upper lip.

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We should always strive for minimal injection points to optimize cosmetic results. One technique is to inject lateral to the commissure and utilize the same injection point fill superior and then inferior to commissure. Remember to place more filler inferior to corner of mouth to give a slight rise to the commissure. advantage of the single site injection tech Filling of the commissure of the mouth nique is less trauma of site, because only is desired for two reasons: 1) to add ad- one area is injected into. Another benefit of ditional support for the lips, and 2) to re- this technique is the ability to take advanverse the effects of aging that causes the tage of the natural plane that exists in that corners of mouth turn down. This down- patient for filling, whereby we augment ward turn of the commissure is a result of the patient’s natural anatomical presentathe overall movement of the facial tissue tion. The disadvantage is when we cannot in the outward and downward direction attain the flow of filler in a uniform way or during aging. With certain filling tech- we are not able to potentiate the space for niques, we are able to lift the corners of our basis to fill the lips. the mouth to reverse this sign of a droop- The second is to inject lateral to the ing commissure. commissure and direct the needle supe Sometimes it is necessary to fill the rior and inferior to establish fill, while uticorners of the mouth for additional scaf- lizing one injection point. The key to this folding in order to add volume to the lips. technique is to inject slightly more filler Failing to fill the corners of the mouth if below the angle of the commissure, than needed and continuing on to the lips may we do above the commissure. This will produce a beaking effect of the lips. There lend the corners of the mouth to lift slightare two techniques for this augmentation ly.

Corners of the Mouth

fill: single injection point and flow and serial injection points and flow.

Multiple injection points

Three injections may be needed to establish the corner of the mouth. You can Single injection techniques With this technique, we inject lateral try and enter the dermis in one point and to the commissure and watch the material inject filler into the plane, slowly withflow superior and inferior to the lips. The draw and reinsert the needle into the other plane. The advantages of this technique

Chapter 6 Injection Techniques and Procedures

are that we can direct the flow of the material more precisely. The disadvantage is more injection sites and intradermal needle trauma is required.

of the flow is greater in the keratinized, stratified squamous epithelium tissue of the face. When placing fillers into the nasolabial or mental fold, we achieve a better effect by layering the material or crossLifting the corners of the mouth hatching. For example, in areas like the Lifting the corners of the mouth can be apex of the nasolabial fold (puriform), one accomplished with all of the above menmay be able to place a pearl and receive tioned techniques. The key is to place a a limited amount of flow of the material. little more filler in the inferior plane of the Crosshatching the filler over the nasolabilower commissure. Filling in the commisal fold will be a process of potentiating the sure will naturally lift the corners of the plane by the needle. Since we are placing mouth; however, we want to add a little fine lines over the nasolabial fold and the more to the inferior plane to ensure the dermis is thicker here, the potential for lift. filler to flow is rather limited. We create a space for the filler by displacing tissue by Oral-facial skin the diameter of the needle we are using The same three potential spaces exist for our augmentation. for the oral-facial skin, although resistance

Illustrated on the left is a pearl-drop form of filler placment. On the right is the crosshatching technique that one can implement of filler placement medial to the nasolabial fold. In addition, when filler is applied to the mental fold, it must be placed superior to the crease with supplementary cross-hatching over it.

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by the needle. In the crosshatching tech In the apex of the nasolabial fold (pu- nique, we will be depositing the filler as riform), one can place a teardrop form of we remove the needle, so several injection filler. Filler material will flow well at the will be needed. apex of the nasolabial fold. This is due to MENTAL FOLD the nature of the attached epithelium at We will place the fill medial to the the junction of the nasolabial fold and the fold, which is located superior to the menalar angle of the nose. This epithelium is a tal fold. Depending on the severity of the supple tissue and easily filled. Be careful arch of the fold, you may have to make not to overextend the fill here, for it will two separate injection points lateral to the leave a bubble effect. distal extent of the mental fold and fill one-half of the arch at a time. This area is Crosshatching Layering the filler over the pearl drop comprised of a very thick dermis. Most form in the puriform allows us to ap- (if not all) filling in the mental fold will ply more filler to the area and facilitate a be done by potentiating the space by the smoother appearing fill. This is due to the needle of the filler.

Pearl Placement

ability to taper the filler out into the face more and not being limited by the anatomical constraints of the puriform recess. In addition by layering we are creating a scaffolding of filler across the nasolabial fold which reduces the propensity for the invagination of the kinetic fold. The results of cross-hatching are a more pleasing fill in the static as well as kinetic movement of the nasolabial fold.

NASOLABIAL FOLD We always place the filler medial to the nasolabial fold. If we placed the filler on or lateral to the fold, we would increase the depth of the fold. The filler will not flow to a great extent in this area of the face. In this case we are filling in the space potentiated by the needle.

Another technique is to continue a troth of filler medial to the nasolabial fold all the way down to the corners of the mouth if needed. Crosshatching the nasolabial fold after placing a line of filler medial to the fold will smooth out the fold during static and kinetic positions. Unlike the puriform recess the potential plane for this technique will be created more so

After the initial inner fold fill, we want to crosshatch over the fill diagonal to the arch of the mental fold.

Technical Considerations There are several factors to consider with injection fillers, such as: Magnification—using loupes or some other magnification device when injecting will help you visualize the plane of placement and flow of material. Speed of Injection—Inject slowly, inject slowly, inject slowly. This will allow material to flow and the practitioner to visualize where it is going. Fillers will take the path of least resistance. When the filler has filled the plane and cannot flow laterally, it will inflate. This is immediately visual as an isolated localized lump forming. At this point, you must stop and reinsert to another area. If the filler materials go into an unwanted space, stop. Evaluate and place in another area. The reasons for this abrupt flow stoppage is multifaceted (see “Potentiating the Plane,” Chapter 6, pg.141). In addition, there could be a history of trauma in that particular area of

Chapter 6 Injection Techniques and Procedures

the lip where scar tissue (not visual) has made the tissue more adherent between the dermis. Moreover, going slowly will greatly reduce swelling.

the clinician and their ability to move into the realm of artistry in their fill technique. The point is to let the initial compression of the body fill subside until you can better assess the lips and add definition to the newly filled lips. Swelling is different between materials and patients, although two days generally will suffice for substantial swelling to diminish.

Time Allotment for Injection—schedule enough time to fill, especially in the beginning. Rushing your fills will create negative results including: bruising, clumping of material, and wrong placement in the dermis. Lip/Face Swelling During Selecting Layer for Injection Site—which Augmentation—tissue distortion during layer should you inject into? With fillers facial augmentation occurs from two poin general, it seems that the deeper one in- tential sources: jects into the dermis, the less definition is 1) Distortion from improperly placed present, the more bulking of the existing anesthesia, usually when an inexperilook is achieved, and the shorter the sub- enced practitioner uses infiltrate anesthestance lasts before it is resorbed. Deeper sia around the lips. In addition to acquirfills require more material. The more su- ing only infiltrate anesthesia, the fluid perficial one layers, the more definition is from the anesthesia distorts the lips present and the longer the substance lasts. 2) Initial swelling of lip post injections. Regardless of the filler used, when the ap- Initial swelling after injections differs bepropriate plane is located, the material tween patients, although it usually hapwill flow easier and more uniform instead pens within a couple of seconds. The secof being clumped into muscular structures ond can lead to uneven, asymmetric fills. or connective tissue. This is a tactile sense Stop the procedure if distortions are leadthat will develop over time, with repeated ing to inability to perceive fill. Sculpt andeposition of the filler. other day. Some fillers, like cross-linked Sequential Fill Technique—a different HA products, offer you a week before it is paradigm of filling procedure, whereby no longer manipulative and it is attached we expand the lips over sequential vis- via hydro bonds to connective tissue. Paits by filling the body of the lips with a tients are very amenable to sequential fillhighly cross-linked filler, then finishing ing if the doctor explains the rationale for the treatment sequence with contours in it.

the vermilion border.262 Remember, the changes of aging have occurred over time; therefore, reestablishing fullness and/or definition of the lips may require multiple visits. In my personal experience sequential filling can be accomplished in as little as two office visits. Or for the more advanced case the entire process may take up to 6 months to potentiate a space in the lips in order for them to be adequately filled. However, this depends solely on

Combination Fill Technique—because our skin is a mixture of different viscoelastisity and anisotropic properties (combination skin), combining different material at different sites in different locations can optimize the filler’s effect and longevity.262 An example of combination technique would be placing a cross-linked HA filler in Zone B of the lips and injecting CosmoPlast into Zone A. Cross-linked HA filler displaces and adds volume to

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the lips well, although they tend to be stiff and present an unnatural appearance to the vermilion border. CosmoPlast is more subtle when injected and leaves a more pleasing appearance and feel to the vermilion border. Stretching the Lip—potentiates the plane to the flowability of most fillers. Wipe off all topical anesthetic and makeup thoroughly so you can stretch the tissue sufficiently to inject in the proper plane. Material Expression—when injecting, be careful to terminate expressing the material before the pullout. If one prolongs expression all the way up to and beyond withdrawal of needle, a papule of material will remain under the epidermis leaving a raised appearance at the injection site.

entation. Massaging of the Material—massaging in the injection site may be necessary after injection to achieve desired effect. Be aware this is usually painful and patients should be blocked to perform this. • NOTE: When we massage our filler, it is usually because the flow we attained was not satisfactory. The lips have gone through life with the patient suffering cuts, burns, and bruises. Upon original observation of the lips, these manifestations may not present. When we inject and fill the lips, we may bring these aberrations to the surface. Massaging may give the filler a false sense of evening out the defect by inducing immediate swelling. It suffices to say the only perfect, fillable lips we ever possess are given to us at birth.

Bevel Orientation—the needle bevel can Filler Material—will almost always be be placed up or down. If the practitioner palpable to the touch. You should explain is in the correct plane, the material will this to your patient. The fill should not be flow just fine without regard to bevel orivisible.

Chapter 6 Injection Techniques and Procedures

TIPS

During the augmentation process the patient must be set in an upright position. The reason for this is mainly due to soft tissue positioning. If the patient is laid in a supine position the lips and perioral tissue will displace laterally. Also, the targeted line and fold will dissipate, leaving an obscured representation of the patient’s normal facial presentation.

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Filler Amount—the amount of filler used is sometimes more important to the patient’s pocketbook than its effect. Keep an eye on the amount of filler material placed. With experience, you will be able to assess the amount of filler needed and cost of augmentation more precisely.

Adverse Reactions and Complications Reported adverse reactions are less than 2%, and usually include erythema, ecchymosis, and acne. Friedman et al. reported that in 2000, an estimated 262,000 patients were treated with Restylane. Of those, 144 (0.06%) were reported as having adverse events.

Normal Adverse Reactions Acneiform eruptions, lumps, asymmetry, over and under corrections, needle marks, bruising, erythema and pain.

Anatomic Skin thickness: Dermal thickness under 0.4 mm thick, like the eyelids, is usually a contraindication for all fillers. This situation usually presents around the eyes and cheeks with fine lines. Laser resurfacing or chemical peel is the treatment of choice in these areas. Scar tissue: There may not be any visible scarring or lumping in the area you intend to augment. The filler you’re placing can cause enough pressure to distort or bring previous scars to light. This puts the new augmenter in a precarious situation. No matter how you explain to the patient afterwards what happened, you run the risk of losing the patient’s confidence. Explaining to patients beforehand about possible filler reactions can alleviate this situation.

Acne scars: Not contraindicated.

Prior permanents fillers: Even with a complete patient history of oral-facial fillers, one can’t account for the augmenter’s placement skill and/or choice of fillers that were used. Explain the various complications that may occur if lips were previously filled with nonconventional materials or treatment modalities. Arterial embolism: This author’s research revealed one documented case of Arterial embolism on a patient after Restylane was placed. (Schanz S, Schippert W, Ulmer A, et al. Arterial embolization caused by injection of hyaluronic acid (Restylane). Br J Dermatol. 2002;146:928929.) The filler was placed in the glabellar region where the dorsal nasal artery was affected. This is a very remote occurrence and may have to do with technical placement error.

Systemic Adverse Reactions Recurrent herpes: HSV-1 poses a complication in oral-facial augmentation. HSV-1 serum antibodies can be found in up to 90% of Americans who have been tested.22 Approximately 3040% of patients exposed to HSV will develop recurrent infections.263 Recurrent HSV infections have been associated with exposure to sunlight, stress, fatigue, menstruation, and oral-facial trauma.264 It is recommended to postpone oral-facial augmentation with patients who have a current outbreak of herpes lesion on and around the tissue to be augmented. In addition, patients with a significant history of recurrent herpetic outbreaks should be premedicated with antiherpetic medications. Some various premedication protocols include: Valacyclovir 500 mg Q12 starting two days before treatment and continu-

Chapter 6 Injection Techniques and Procedures

rary filler: There are no contraindications for placing a temporary filler over a permanent. In many other countries, where the restrictions for permanent fillers are much less severe, temporary fill Autoimmune Disease: Prior lawsuits ers are placed over permanent fillers (eg, have come against augmenters relating to silicone) without any documented negaa relationship between collagen and poly- tive reactions. Although outside the US, myositis and dermatomyositis in some pa- physician and/or patients reporting adtients. The FDA examined the relationship verse reactions are not as thorough as in and decided in 1995 “a casual relationship the US between collagen injections and PM/DM or other connective tissue diseases listed has Blanching of skin after filling: not been established.” This ruling by defi- Superficial placement of filler: The nition would include systemic lupus, which gray of the needle should never be seen is an autoimmune disease characterized by during augmentation. Blanching is noranti-DNA antibodies. mal for treatment of superficial scars Rheumatoid Disease, Scleroderma: and will disappear within 5-10 min. Not a contraindication for dermal fillers if Smoothing the filler is recommended. This should be done with a finger, in wound healing is normal. order for the patient to feel the amount Diabetes: Not a contraindication for fillers. of pressure being applied. The pressure Immunodepressed patients: Generally should be firm and a down and outward wound healing is not delayed with these motion applied to blanched area. Superpatients. Immunosuppressive therapy ficial placement of filler in the lips may needs to be tenfold higher in concentra- produce nodules. tion to affect the fibroblasts in the healing Tyndall Effect: On occasion, I get a process. Fillers are not contraindicated for call from a patient and they explain they these patients in general, yet good commu- have a nodule that has formed on their nication with the attending physician pre- lip post augmentation, and it has a bluish scribing the protocol is recommended. color in appearance. This is termed the ing three days after.265 Acyclovir (400 mg) 14 caps, two capsules QD, starting one day before anticipated augmentation.26



Combination permanent and tempo-

Tyndall Effect

Tyndall effect. The Tyndall effect is an optical effect of light that passes through a clear substance and is refracted back through the surface of a thin membrane. A bluish tint will appear to the nodule. The Tyndall effect is caused by: Too superficial placement of filler in the dermis Placing filler in an area where the dermis is too thin (usually at or below 0.4 mm) When the plane of injection is saturated, the filler material will try to

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escape the plane on the path of least resistance. This path may be directed towards the superficial epidermis, creating the Tyndall effect. I explain the color phenomenon to the patient and that due to the swelling that occurs with some patients during the augmentation process, areas where this effect may occur may not be immediately visible. When the swelling subsides is when this phenomenon may present itself visually. If the nodule is still present, I either massage the material into the deeper dermis or lance the nodule and milk the filler out. Either of these techniques usually takes care of this undesirable effect.

the vermilion plane—that is if segments of the filler were placed too deep into the musculature—lumping of material can occur. These lumps can be resolved through manual manipulation, post-filling is of voids between lumps or drainage. Prevention is all in the art of placement. Injecting in the correct plane and not too deep will significantly reduce this occurrence. Nodules present in the lips when the augmented plane is saturated and the filler looks for the path of least resistance. If the path of least resistance is towards the vermilion epithelium, nodules will begin to appear. STOP, ASSESS and REINJECT IN ANOTHER PLANE.

Here is example of when a plane becomes Underfill of the lips/voids in lips: saturated and nodules may start to ex- When filling in the lips from the lateral press superficially at the vermilion tissue. segments towards the midline, the filler Overfill of the lips: Overfilling the lips material will usually only flow a couple millimeters in front of the needle bevel. results in: The filling material will create a hydrodyBeaking of lips namic force of fluids building up medial Lumps to the outer edge of the injected material. This phenomenon may create resistance Nodules and a false sense of saturation of the plane Beaking of the lips is caused by overly targeted to be filled. Injecting slowly will augmenting a patients lips, thereby dislet the hydrostatic pressure of the intertorting their natural presentation. Followstitial fluid subside a little before pushing ing the ideal proportions and guidelines more filler in the plane. Voids or underset out in earlier chapters will prevent this filled areas can occur in the injected plane occurrence. if one rushes the fill and perceives the Lumps in the lips are largely due to plane is filled when it is not. Clinically the improper placement of the filler into the plane will look filled due to the pressure targeted plane. If the augmenter does not of the fluid that can build up in the unadhere to the proper plane placement or augmented plane. After the swelling subif the filler is placed too deep and into the sides, the result will be a “crater effect” muscularity, the muscular contraction of just medial to the terminal end of fill. If the orbicularis oris during the first week this occurs a touch-up fill is required. of implantation will squeeze and distort Causes of underfilled voids: the filler. During the initial week of filler Rapid injection of filler g pressure placement, it resides in the lips as a paste, buildup in plane not fully incorporated into adjacent tisTraumatic needle injection g swelling sue. If the filler is not uniformly placed in

Chapter 6 Injection Techniques and Procedures

Improper plane placement of needle, filling practitioners were polled about which may traumatize deeper ana- their touch-up visits, the results were as tomical structures g bleeding follows: Fifty-six percent of the group routinely Techniques to prevent underfill or voids: recommended touch-ups Inject slowly Forty-four percent of the group selProper injection plane placement dom or never recommend touch-ups Palpate the lips during injection of filler. Manual palpation will help the When touch-ups were prescribed: augmenter assess where the material Sixty percent recommend waiting less is dispersed in the intended plane. than one week Ten percent suggested waiting one to Post injection tissue asymmetry: 2 weeks Swelling begins within minutes of injecThirty-three percent recommend waittion of fillers. Due to the vascularity of the ing more than 2 weeks lips, this occurs rapidly and dramatically. The swelling can last days in some cases. It is interesting to note that in the It is advised to wait one week for evalu- group of facial-filling practitioners who ation of asymmetrical presentation of the infrequently did touch-ups, all emphaaugmentation site. sized the importance of utilizing proper technique during the first visit.267 Patient Instructions Following the augmentation procedure, patients should be given specific instructions on post-op care. Advise your patients to: Avoid taking contraindicated analgesics, such as acetaminophen or aspirin, as directed. Apply an ice compress lightly around the tissue of the lips before, during, and after augmentation. (Most practitioners apply ice for 15 minutes following the augmentation). Avoid engaging in any strenuous activity immediately for 24 hours following the procedure. Avoid manipulation of tissues (In other words, don’t touch the augmented areas). Restrict alcohol consumption for 24 hours.

Touch-Up Techniques

When a group of well-known, facial-

Post-Augmentation Corrections Despite our best efforts, there are times that undesirable results are achieved. Typically these unwanted results are visible 3 to 7 days after the initial augmentation. Post-augmentation corrections may be needed to remedy lumpiness, overfills or overall asymmetry.

Resterilization or Recapping Syringe There are a significant number of augmenters that routinely recap previously used cross-linked HA syringes. The rationale behind recapping is to save the patient money and/or the ability to reuse a previously injected syringe on a patient for a follow-up visit. A pilot study was recently published focusing on the incidence of bacterial contamination on non-animal stabilized hyaluronic acid stored after initial injections.268 After use of a specific sterile sequence, nonanimal stabilized hy-

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aluronic acid from 30 previously used sy- mentation patients to avoid: ringes was stored at room temperature for Cosmetic tattooing 2 to 9 months. No bacteria were cultured Microdermabrasion from any of the samples. Bhatia reported Additional cosmetic procedures, such similar results in their study.269 as chemical peels, laser treatments or Panel members from the ConsenRetin A applications. sus Recommendations for Cross-Linked HA 2006267 were asked how they usually Follow-Up Visits handle unused cross-linked HA. Forty- According to the Health Insurance Porfour percent of the members discard the tability and Accountability Act (HIPAA) unused product, and 13% store it for lat- of 1996, patients in the United States er use in the same patient. Thirty-eight should sign a release giving medical propercent of the panel used the remaining viders permission to use their medical product in another area of the face during information and/or pass it from one prothe same office visit. Reuse of previously vider of care to another. After oral-facial augmentation procedures, follow-ups apinjected Restylane is discouraged. pointments should be handled carefully. Post-Augmentation Care Most patients want their cosmetic work The following tips should be shared handled discreetly. Simply calling up with the patient following their oral-facial patients after their augmentation proceaugmentation procedure: dures is unacceptable. The doctor should Hydration is instrumental in maintain- ask the patient for his or her permission ing healthy lips. Some fillers, such as to make a follow-up telephone call. Afcross-linked HA, are maintained with ter all, you performed the cosmetic work, hydration. Insufficient hydration will and you have an honest desire to not only diminish the outcome of the augmen- see the outcome of the procedure, but to tation. provide continued care to your patients. Protective barriers, such as lip balm This doesn’t mean the doctor has to call and/or lipstick, will assist in maintain- personally, yet if he paves the way by asking lip moisture. Patients should also ing permission, the follow-up call is not be advised to choose a lipstick that an intrusion, but a welcome expectation. provides sun block protection. Damage to the lips can be avoided by ap- Techniques for Postplying a lip sunblock with SPF-15. Augmentation Correction Dentists should dispense lip protector Palpable Redistribution of Filler (masand hydrators to oral-facial augmenta- saging fill)—this technique can be eftion patients in the same manner that fectively used with certain fillers, most toothbrushes are given to dental pa- notably cross-linked HA. According to tients. Matarasso’s poll of leading facial augRegular maintenance of facial-filling menters with Restylane, most panel memprocedures is required. These proce- bers (60%) massage Restylane during and dures can be held in conjunction with after treatment. The majority of practitiodental hygiene recalls. Schedule these ners do not recommend patients self-massage. Restylane can be massaged up to appointments accordingly. It is also wise to advise oral-facial aug- two weeks after injection. The substance

Chapter 6 Injection Techniques and Procedures

This patient presented with an overfill of cross-linked HA. Insertion of a 27-gauge needle into thickest part of the filler and withdrawal of the needle will allow draining of excess filler. This technique works particularly well with cross-linked HA. of Restylane will not be disrupted or de- Treatment of Visible and Nonvisible Scars Without a doubt, treatment of nonvisnatured via manual manipulation.270 ible scars is the most challenging and frus Aspiration—to correct small areas of trating experience in cosmetic augmentaundesired overfills, as well as larger areas tion. These scars or adhesions develop in which there is an asymmetric fill, insert from trauma and pathology suffered by a 27 gauge needle into the middle of the the lips or oral-facial area. The lips seem nodule to extract the desired amount of to hide these scars until the moment of fillfiller out to reduce overfilled area. ing, when the adhesions become visible.271 Incision—if an unpleasant nodule Filling areas that have scar tissue can exthat needs to be eliminated appears, take acerbate the depressed or cleft appeara small scalpel with a 15-c blade and make ance. As a general rule, the patient should an incision at the center of the nodule to al- be consulted on the additional complexity low material to express out. Although the of correcting such affected areas. Small inlips are very resilient, we should strive not durations or clefts can be treated by using to make incisions. This is not the standard some simple techniques, which include: protocol for treating these nodules, unless Subcision—this is a process of using other methods have proven unsuccessful. a needle to undermine a subcuticular ad-

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TIPS Positioning is paramount in visualizing landmarks for injecting anesthesia for soft tissue. Here the injector is located behind the patient in order to visualize the landmarks for the mental block. In addition, the injector is able to distract the patient by jiggling the lips during the injection process.

For the infraorbital injection, one may lay the patient in a more supine position for better visualization of the intraoral landmarks.

Chapter 6 Injection Techniques and Procedures

hesion.272 This technique involves using a disposable 1”, 22 to 27 G, hypodermic B-D needle. These are tribeveled needles that facilitate puncture of the skin. Inserting the needle below the adhesion, the bevel is oriented upward on insertion. The entry point acts like a pivot point, and the needle is maneuvered underneath, cutting the adhering fibers.273 The surface skin is minimally affected, and the release of this tissue alone potentiates the elevation of the skin without directly introducing filler. The subcision technique also promotes an inflammatory reaction, which promotes the formation of renewed connective tissue to fill in bounddown scar tissue.274 Contraindications for subcision are: active inflammation; patients

with a history of keloid scarring; and sequelae, such as infection, altered physical consistency of treated site whereas the relieved area may produce a firmer area to the touch, yet still have an overall improved appearance, discoloration or hyperpigmentation, suboptimal response, excess response, and keloid scarring. Sequential Filling—through sequential filling, the pressure from the filling material will gradually release the adhesions. In time, this will produce a more aesthetic appearance.

Chapter 6 Review STUDY Points Three potential places filler can be injected into Lip injection points and techniques Plane saturation Cross-hatching techniques with respect to oral-facial filling Adverse reactions and complications

STUDY Questions 1) Of the three potential spaces where fillers can be injected, which one can be the most frustrating for lip and perioral augmenters and why? 2) When augmenting the lips, we want to first establish or reestablish what? Once established, what is the second goal of augmentation? How do these techniques relate to the zones of the lips and perioral arena? 3) What are ways we can identify plane saturation and what is involved technically when we have acquired plane saturation? 4) What is the Tyndall effect? 5) List three possible post-op corrections for injectable fillers.

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Chapter 7

Simply Botox Uti, non abuti. To use, not abuse.

Chapter 7 Simply Botox

Botox (Clostridium Botulinum Toxin) Armament Perioral Injection Techniques for Botox

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Chapter 7 Simply Botox

Over the past 30 years, the field of minimally invasive soft tissue augmentation has undergone a vast explosion and at no time has the list of injectable agents been greater than what it is today. With the recent FDA approval of several injectable fillers and many more on the horizon, the timing of this book could not be better. While many injectables have left their mark on the field of aesthetics, none have been more significant than the approval of botulinum neurotoxin Type A for cosmetic indications—which today is the most common cosmetic procedure in the United States. Soft tissue augmentation is no longer the sole territory of the plastic surgeon and cosmetic dermatologist. Instead, aesthetic surgery has become a fixture in multiple areas of practice. One of the most recent specialties is cosmetic dentistry, and it is in the dental literature that I made my initial observations on restoring the lower third of the face, as it is through the process of aging that we lose bony support and dental structural support. It is essential to reconstruct the structures of the lower face in order to achieve an aesthetically pleasing, natural and superior result. Optimal outcome should reflect careful observation and subtle correction. Most patients do not want to have a “done” or “frozen” look and frequently, less is more. Minimally invasive soft tissue augmentation is both art and science. It is paramount that the practitioner— regardless of their specialty—has a thorough understanding of the procedures and techniques involved with soft tissue augmentation, as well as current knowledge of the medical/ dental literature. In what follows, Dr. Robert Gordon has written a thought out, heavily referenced, authoritative text on the evolution and current use of botulinum neurotoxin Type A in cosmetic dentistry. Furthermore, Dr. Gordon lays out in a clear and concise fashion the art and technique of injection. Vermilion Dollar Lips should serve as the reference guide for cosmetic dentists who are practicing or considering soft tissue augmentation in their practice. What we did yesterday is not of importance today. We are only as good as what we have done today. We must all strive to be the best at what we do and the chapter that follows will enable serious-minded cosmetic dentists to achieve this standard of practice. Arnold W. Klein, MD Professor of Medicine and Dermatology David Geffen School of Medicine, University of California at Los Angeles, CA About Dr. Arnold W. Klein Few people have made as profound an impact on facial cosmetics as Dr. Arnold W. Klein. In short, Dr. Klein revolutionized facial cosmetic rejuvenation. He has published over 100 papers and books. He is an editor at the Archives of Dermatology and Cosmetic Dermatology and the Journal of Dermatologic Surgery—and he sits on the advisory boards of countless others. He lectures extensively on soft tissue augmentation and Botox, both domestically and internationally. Dr. Klein is recognized as a world-renowned dermatologist who has pioneered numerous minimally invasive procedures.

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Botulinum Neurotoxin (clostridium botulinum toxin)

Botulinum neurotoxin has developed significantly in perioral facial aesthetics and the combination of fillers and Botox will usher in a new era of cosmetic rejuvenation in the oral-facial region.275 It is vital that we as dentists understand the potential of botulinum neurotoxin as a monotheraputic device in oral-facial cosmetics, as well as its new evolving combinational application it is used in. Botulinum neurotoxin is regarded as the facial cosmetic therapy that has ushered in the evolution of oral-facial fillers. Perioral Botox cosmetic therapy is increasing as art and science. The adjunctive therapy of injectable fillers and perioral Botox optimizes the cosmetic potential of oral-facial augmentation. Traditional monotherapy limits creative alternatives in restoring lip and facial presentations. This chapter’s goal is to expose the cosmetic dentist to botulinum neurotoxin and current applications, including its history, mechanism, current perioral cosmetics therapies and techniques.

HISTORY

peutic value for BTX-A. Soon after, Dr. Shantz developed the first batch of what is commonly known today as “Botox” in 1979. Dr. Shantz formulated a 150 mg batch labeled 11-79, which served as the source of all BTX-A used in humans in the USA until 1997. The FDA-approved BTX-A source is currently produced by Allergan (Irvine, CA).276 Today this neurotoxin has been attenuated and processed for countless medical and cosmetic therapies.

TYPES OF BOTULINUM NEUROTOXIN There are eight serotypes of botulinum neurotoxin: A, B, C1, C2 and D-G. Type A is the most potent and commonly used in clinical practice.277 Currently two available forms of Botox are in use in North America: botulinum toxin Type A (BTX-A; Botox9) A and botulinum toxin Type B (BTX-B, MYOBLOC). Although not as popular, botulinum Type B is reported to be more stable on a long-term basis, requires less preparation before use, and has a different antigen specificity. The antigen specificity allows Type B to be used when there is a tolerance that develops to Type A.278,279

MECHANISM OF ACTION

The molecule of clostridium botulinum toxin consists of 150 kD dichain polypeptides composed of heavy and light chains linked by disulfide bonds. Both compounds of Botulinum form neurotoxin-protein complexes (900 and 700 kD complexes).280 After injection into the muscle, the molecule’s heavy chain binds to the motor nerve terminal. This process takes a couple of hours so we instruct patients not to disturb the injection site for Medical use of botulinum began in the three hours or the potential for the move1950s by Dr. Vernon Brooks. Around the ment of the toxin is possible, possibly par1970s, Dr. Alan Scott revealed the thera- alyzing a muscle not desired. The toxin is The history of botulinum neurotoxin started in 1895, when 34 members of a music club in Elezelles, Belgium, fell ill and three of them died after eating a meal of raw salted ham. Professor E. Ermengem isolated the cause of the outbreak and named the bacteria Clostridium botulinum. The neurotoxin produced by this bacteria is one of the most deadly on the planet.

Chapter 7 Simply Botox

then internalized via receptor-mediated endocytosis when the plasma membrane of the nerve invaginates around the toxin receptor-complex. A vesicle inside the nerve terminal is formed. The neurotoxin molecule is then released into the cytoplasm and the light and heavy chains are cleaved.

store functional muscle activity takes 3 to 6 months.279

Dilution volumes vary for desired effect. Dilutions are generally based on the spread of the toxin. Higher doses or less diluted solutions (50-100 U/mL) localize the effect of the paralysis more with many experienced clinicians. Lower doses or With Botox-A, the light chain cleaves more diluted solutions (5-10 U/mL) fan a 25 kD synaptosomal-associated protein out the paralysis more and clinicians may (SNAP-25). The SNAP-25 protein is vital use this to affect the platysma more. A to the successful attaching and releasing norm for dilution is 100 U/mL. of acetylcholine from vesicles at the nerve ending. With Botox-B the light chain IMMUNOGENICITY cleaves the vesicle-associated membrane The development of antibodies is a protein (VAMP). The nerve recovers by concern for the use of Botulinum toxsprouting finger-like projections. What in.283 When Botulinum toxin resistance role these projections play is still under has been reported, it has been less than investigation, for they disappear soon af- 5%.284 Factors that potentially contribute ter the effects of the botulinum wears off. to botulinum resistance include: dose and The process of the Botulinum molecule frequency of treatment intervals.285 Pabinding and interfering with nerve trans- tients treated with high doses (300 units mission takes six to 36 hours after initial of Botox or higher) at frequent intervals injection.281,282 The duration of effect to re- seem the most likely to develop antibod-

Contraindications to Botulinum neurotoxin Patients with peripheral motor neuropathic diseases or neuromuscular functional disorders like myasthenia gravis. Co-administration with aminoglycoside, cholinesterase inhibitors, succinylcholine, curare-like depolarizing blockers, magnesium sulfate, quinidine, calcium channel blockers, lincosamides, polymyxins, or other agents that interfere with neuromuscular transmission, which may potentiate the effect of botulinum toxin Type A. Patient with hypersensitivities to product ingredients. Active inflammatory skin diseases (psoriasis, contact dermatitis, eczema) at the time of proposed injections. Pregnancy (pregnancy category C). Breastfeeding mothers, for it is not determined if the toxin is excreted in humans or what the effects are on a developing infant.

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ies. Patients treated with Botulinum toxin typically ranging from 25-75 units at intervals of several months are not likely to develop resistance.276 It is recommended to limit the total amount of toxin to less than 100 U per session and avoid booster injections for a minimum of 3 months.286

ADVERSE REACTIONS Botulinum toxin Type A (BTX-A) has a long history of safe use. If any adverse reactions occur, they are usually mild and transient.287 One long-term retrospective study pertaining to the safety of botulinum toxin explored the various outcomes of 50 patients receiving facial injection. The most significant adverse reactions associated with botulinum toxin were ptosis of the eyelids, various asymmetrical cosmetic results, bruising, pain in injection site, and functional alterations. These adverse reactions can be overcome by careful selection of injections sites and application techniques.288

PRE-TREATMENT PRECAUTIONS To reduce ecchymosis, the patient should refrain from aspirin, aspirin-containing products, and nonsteroidal agents for seven days before Botox treatment.289 Consult with your patient over-the-counter drugs they may be taking that might affect their post-injection bruising.

CURRENT USAGE Most of the usage of Botox is for “offlabel” therapy. In April 2002, Botox was approved for cosmetic use limited to the glabellar (frowning areas between the eyes) for patients 65 and younger. Up until this time all cosmetic usage was off-label therapy. The fact that the entire process of FDA approval takes a significant amount of time may delay appropriate therapy with a new drug. One example of this is

aspirin and how it is used routinely for anticoagulant therapy and heart disease. Countless numbers of patients have benefited from the off-label use of aspirin. A general rule is Botulinum toxin Type A (BTX-A) for the upper face and fillers for the lower face. With the advancing science of lip and perioral augmentation, there are exceptions. There are new areas and techniques developing for the mid- and lower face region.290 In addition, there have been some good results from therapies with patients exhibiting “gummy smiles,”291 oral rhytids, and mentalis. Not only can Botox remove excessive perioral rhytids, the same technique can be applied to facilitate eversion of the lips. Botulinum toxin therapy in the mid face presents with a trade off: although patients do receive great cosmetic results, there are some significant adverse effects to be aware of when the proper technique is not applied. Most all of these negative side effects will resolve within a couple of months; nevertheless, your patients will be quite unsatisfied with their experience and applicator. Injecting in the muscle of the lower face requires a great deal more accuracy as compared to the upper face. The muscles of the upper face are fewer in number and are anatomically easier to identify than the lower face. This is partially because the muscles of the upper face lie over more pronounced body landmarks as opposed to the lower face muscles suspending and encompassing the mandible.292 If there is an unwanted migration of the Botox, paralysis of muscles attending speech and lip competency can be affected. This reinforces the psychological aspect of the face. Botox in the mid- and lower face has the propensity to change the look if not applied correctly in the specific area targeted in the goal to enhance

Chapter 7 Simply Botox

the existing facial features. Many patients are upset by the appearance of their treatment if their facial features or natural expression are significantly changed. Over treatment of the perioral area can produce: Difficulty in pursing lips Speech impairments: the inability to pronounce “b” and “p” Loss of lip competency, which can affect eating, brushing, and drinking Diminished proprioception

cular activity, which weakens the muscle. This block works on striated muscle and eccrine glands. Botulinum Type A weakens the overactive underlying muscle contraction. This action produces a flattening of the facial skin and an improved cosmetic appearance.294

Botulinum toxin Type A (BTX-A) therapy on nasolabial lines (marionette lines) and on the mentalis is also being accepted into mainstream oral-facial cosmetic therapy. We all manifest different tissue expression, particularly when we are talking. There is a population group that exhibits strong contraction of the mentalis, whereas botulinum toxin Botulinum toxin is traditionally injected with insulin is being used to treat these mental syringes. Here are two such examples: the top indentations (or “cobblestoning”) syringe is a 1 CC tuberculin syringes with a 32below the lower lip due to the hy- gauge needle attached. The bottom syringe is perkinetic contraction of the menta- an ultrafine syringe: 3/10 CC, 8-milimeter, 31lis muscle.293 Here botulinum toxin gauge needle. is placed superficially and not deep. When the botulinum is placed too deep, lip and speech competency is affected. Success relies on technical exper- Armament tise and anatomical precision. Botulinum toxin type therapy for select patients with RECONSTITUTION AND HANDLING chronic TMD appears to be beneficial. This Botox Type A (Allergan Inc.; Irvine, is an off-label use and patients undergo- CA) is supplied in a vial containing 100 U ing this therapy usually have exhausted a of vacuum-dried neurotoxin complex. The conventional therapy. In addition, recommended reconstitution is 2.5 mL of one can lift up the corners of the mouth 0.9% nonpreserved saline to final concenby injecting botulinum toxin into depres- tration of 4.0 U/0.1 mL.295 Preserved saline sor angular oris. can be used to reconstitute a Botox vial. Botulinum toxin Type A (BTX-A) works The advantage to using preserved saline on the peripheral blockade of neuromus- is diminished pain upon injection of Bo-

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tox, up to 54% with 0.09% preserved benzyl alcohol. The results of a study showed that 100% of the patients injected with preserved isotonic saline reported less pain than when injected with nonpreserved isotonic saline (P < .001).296

served saline maintains its efficacy up to four to six weeks before use, when stored at 4°C.303,304 Recent studies suggest that there is no significant difference in Botox stored in a refrigerator rather than a freezer.305

A study of clinicians and their dilution ratio yielded the result that the most used dilution ratio was 2.5-3.0 mL per vial.297 A dose-dilution study was performed in which a total dose of 30 U was reconstituted with 1, 3, 5 or 10 mL and no differences between efficacy or safety were observed in treating glabellar rhytids.298 Reconstitution ratios for the perioral region need to be considerably less. The main objective in dilution ratio of the Botox is to allow effective control of the administering dose.299 In addition, due to the dense musculature of the orbicularis oris, injecting larger volume units cause unnecessary pain. The usual reconstitution ratio for the perioral region is 1.0 mL to 2.5 mL nonpreserved saline per vial of 100 U of Botox. This dilution ratio gives a dispersion area of 1 to 1.5 cm, so this is the minimum spacing of injections.300 There seems to be anecdotal and published reports that relate the greater the volume, the shorter the duration of the effect.301 There has been some debate over handling of reconstituted Botox, in particular the shaking or agitating of the solution after its reconstitution with saline. Recent studies show that reconstituted Botox agitated to allow bubble formation was just as effective in therapy as Botox handled extremely gently.302

PATIENT ASSESSMENT As discussed previously, we need to have a plan before initiating Botox treatment. Ultimately the end result will be perioral shaping of the tissue by means of select paralyzing of the muscles associated with animating the undesired perioral presentation. Most wrinkling is associated with excessive muscular contraction or a combination of both.

Gender Selection There is a distinct difference in the amount of units given for select therapy between the genders. In general, males require more units per injection site to accomplish the same cosmetic result. This is due to the increased muscular mass males experience in the oral-facial area.287

Perioral Injection Techniques for Botox PERIORAL INJECTIONS

There are ultimately three goals in perioral Botox injections: 1) removal of kinetic rhytids 2) increase in lip surface area, and 3) establishing a desired eversion of the lip. Botox treatment of oral rhytids is the most common new area for which patients request treatment.306 Botox has been proven to reduce the perioral lines around the lips. Injecting adjacent to the fine lines SHELF LIFE around the mouth results in a smoother Prescribing information included in appearance of the lips and an eversion of botulinum Type A suggest that reconsti- the vermilion border of the lips.307,308 It is tuted Botox should be used within four important to understand that the perioral hours. Clinical studies indicate that a re- lines around the mouth have both a static constituted Botox solution with nonpre- and dynamic relationship, which is differ-

Chapter 7 Simply Botox

Additional Considerations for Patient Assessment Assess facial expression at rest and during animation Evaluate the range of motion of involved muscles Palpate muscles during repose and contraction Assess brow position. In women, be sure to consider whether the brows have been plucked or tattooed Evaluate any asymmetries Exercise caution in patients who have undergone surgery that can alter the underlying anatomy Begin with recommended starting doses and add more units or additional sites if necessary at a 2-week evaluation Do not completely paralyze the muscles Consider patient expectations as well as cultural viewpoints in planning the overall effect Assess the need for treatment with other modalities, such as soft-tissue augmentation, dental, orthognathic or surgical intervention Modified from Consensus Recommend Plastic and Reconstr Surg.

the rhytids do not correspond or deepen when the patient purses their lips, these lines are a manifestation of loss of lip volume and would be better suited for filler therapy. More injection sites are required The first step is to analyze the oral rhytids to distinguish between dynamic for the upper lip in contrast to the lower rhytids acquired from muscular contrac- lip, for the upper lip is where the majority tion of the underlying orbicularis muscle of rhytids manifest in patients. and static rhytids from the aging process Eversion of the vermilion border of the lips can be acquired by precise injection of the skin. This is done by having the patient con- of Botox in the perioral area (Zone A). By tract the lips in a pursing movement and weakening the superficial orbicularis oris, observing the rhytids. If the rhytids deep- there is an eversion of the G-K line angle and a corresponding increase in surface en and coincide with the contraction of the mouth, then they are most likely due to area of the lips proper (Zone B). ent than the lines and folds of the upper face. The upper face line and folds manifest themselves in the kinetic motion predominantly.

the hyperkinetic action of the orbicularis Dilution and Dosage and can be treated with Botox therapy. If The consensus of dosage ranges from

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approximately 5-6 U around the vermilion border with 1-2 U per injection point. The injection points are at or just above the vermilion border (Zone A).309

Technique Introducing Botox cosmetic therapy around the mouth to your patients can be intimidating. Improper techniques or dosage can lead to partial paralysis, lip incompetence or an unaesthetic result. By following the guidelines outlined in this chapter, you can achieve maximum effect of perioral rhytid removal or lip eversion without distorting lips competency or function. Due to the robustness of the orbicularis oris this treatment usually lasts six to eight weeks. Material needed: an eyeliner (preferably cheap) and a measuring ruler or a

dental explorer will suffice. Start with drawing a line down from the lateral corners of the nose through the upper lip. Inject within the borders of this line and you will receive desired lip eversion and/or increased surface area of vermilion (Zone B). Inject lateral to these border lines and you have a greater chance of effecting lip competency. Measure your planned injection points out so they are symmetrical and mark them. In general, the injection point

Chapter 7 Simply Botox

Pictured above is the horizontal line drawn in the middle of the chin. We inject below the horizon of this line. This ensures we do not compromise lip competency.

Alternatives for perioral rhytid removal Chemical peel Laser resurfacing Filler injections should be kept symmetrical and superficial. Spread the vermilion border with your fingers so the tissue is taut. This will reduce pain upon needle insertion and stabilize the lip. You will not lose your reference point since it is already marked with the eyeliner. Insert and inject 1 U at the vermilion border. Inject superficial rather than deep. Some authors recommend not injecting in Segment 2 of the upper lip for fear

of losing the tonus to the Cupid’s bow, others disagree. In my experience, if you have a very toned Cupid’s bow, 1 U injected midpoint will facilitate a fuller eversion of the lip.

Combination Therapy When deciding to do a combination technique of Botox and fillers around the mouth, you have to set up the sequence of treatment modalities and desired effect for them individually and in combination (See Table 7.1, pg. 178). Botox treatment should be done first. Think of Botox treatment periorally the same way as an artist prepares the canvas for his medium. The canvas has to be framed, stretched, and primed for the artist to work on. Botox treatment will create more of a surface area of the lips (Zone B). Botox will not add volume to the lips, only fillers will do this. The results from the Botox take a cou-

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ple of weeks to manifest. When the results of the perioral Botox therapy are present, then one can add volume and sculpt the mouth with fillers.

Sequence of Botox and Filler Therapy

Botox

1-Week Evaluation 2nd Treatment

perioral therapy, one may find there is no need for additional augmentation-like fillers. There are times that I am surprised at the post-injection results of perioral botulinum toxin therapy where the lips and perioral tissue have smoothed out, which

Botox

G-K Line Angle

Surface Area

Add Volume (Zone B)

Sculpt Vermilion (Zone A)

My typical sequence for preparing a patient for Botox and filler therapy is as follows: Botox appointment first, post-op visit, and evaluation one week later. At the 2nd week post-op visit, I add fillers. There are three main reasons for this: 1. In allowing the Botox to shape the lips for accurate assessment and placement of fillers, you may find you do not need as much filler as initially suspected for treatment. 2. If we inject filler around the lips immediately after placement of Botox, we run the risk of displacing the Botox injection fluid to other anatomical areas. Remember, it takes 3 hours for the injected botulinum to acquire a stable location in the muscle tissue. The flow of filler has the potential to displace the Botox one has carefully injected in precise locations. 3. Following a 1-week assessment post-

Figure 7.1

Sequence of Combination Therapy for the Lip

Sculpt Vermilion (Zone A)

leads to a very aesthetically pleasing result.

Elevating The Corners Of The Mouth Part of the aging process can lead to the over development of the depressor angular oris (DAO). This muscle can cause the downward droop of the mouth with time. Injecting Botox into the bottom of this fanshaped muscle will relieve the contractile effect of this muscle and create a subtle lift in the corners of the mouth. This is in part because the antagonistic levator muscles maintain their tonus adding to the lift of the corners of the mouth. It is suggested that the DAO doesn’t work alone in this effect and that the platysma muscle has an adjunctive effect in depressing commissures of the mouth. When we inject into the targeted DAO, the platysma in that area also receives denervation because the platysma overlays itself upon this muscle.

Chapter 7 Simply Botox

This is a representation of a straight line drawn from the puriform recess to the inferior border of the mandible. At the bottom of this line is the injection point for Botox injection. This point is midpoint in the fan-shaped DAO. This targeted area reduces complication of oral competency inherent in the improper placement of perioral Botox injections. dible where the fan-shaped DAO muscle is the widest. The dose of 2-4 units may be Technique The DAO is fan-shaped and controls administered depending on the age, sex, the frowning of the corners of the mouth. and muscle tonus of the patient. Ask the patient to bite down and palpate COMBINATION THERAPY: the masseter muscle on the inferior mandible. Just anterior to the masseter lies COMMISSURE the posterior border of the DAO. Target The combination of Botox and fillers to the posterior inferior border of the DAO; raise the commissures of the mouth is suthis will keep you clear of the depressor perb. The sequence is less important, Boangular oris muscle that can cause lip in- tox therapy and filler therapy can be apcompetency if injected into. By drawing plied simultaneously. Remember: for the an imaginary line from the corner of the lips, BTX therapy purpose is to increase nose to the mandible, you arrive at the the surface area for filling. With the corbase of the depressor angular oris muscle. ners of the mouth, we aren’t so dependent One can use a cosmetic pencil, ruler or on the resultant BTX result to evaluate for any other straight-lined device to estab- commissure lift. lish this line. When we establish the line, Mentalis we inject lateral to it. The injection point Botox injection can be very effective in will be located by the angle of the man-

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TIPS Dilution

r

Diamete

Saline Relative r Diamete

4 ml

2 ml

Quarter

Dime

1ml raser Pencil E

The concept of Botox dilution can be confusing for the beginner. It helps to think of 100 units of Botox like the shot glass pictured above. The red water represents 100 units. If we pour the shot glass into the small glass container and another equal shot glass into the large container, we have diluted the Botox into a larger and smaller medium. Now each container holds 100 units of Botox. If we draw 1 syringe cc out of the large container or 1 cc syringe out of the small container, we are injecting the same amount of Botox per unit. The medium, in this case water, is only relevant to the dispersal of the Botox in the tissue. In the clinical setting, a dilution of 100 units of Botox with 4mL saline will affect a quarter-sized diameter from the center point of injection. A dilution of 1 mL of saline will affect a pencil eraser.

Chapter 7 Simply Botox

reducing the cobblestone appearance of the chin. The dimpled appearance of the chin results from the aging process described in Chapter 2, which includes loss of subcutaneous fat and long-term contraction of the mentalis muscle. The majority of patients fail to see the significance of their pebbly chin, due to the fact that most people view themselves in the static form (repose) in the mirror.

Technique One or two injection points are necessary for the weakening of this muscle. Remember, we want to weaken the mentalis, not paralyze it. Muscles to watch out for around the mentalis include the orbicularis oris and depressor labii. Overtreatment of this area can lead to lip incompetency and associated side effects.

a cosmetic pencil before injecting. Assess the degree of contraction first and err on the lighter side of injecting units used. If the desired effect is not realized after the two-week, post-injection period, re-administer a couple more units in the same location. Before injecting, pinch the chin to facilitate deep placement into the mentalis of the Botox. Remember, the platysma runs superficially over the mentalis and we want to penetrate deep to this muscle to the mentalis. Usual duration of this treatment is three to four months.

Combination Therapy: Mental Fold

Combining Botox and filler to relieve the mental fold will extend the duration of the filler. Filler placed in the mental fold First, establish if there is clefting in the has the tendency to wash out quicker due chin. This will determine if one or two in- to the fact that the duration is less there jections will be required. If there is a cleft, than in other anatomical spots. This is due two injections will be performed bilateral to the strength of the mentalis and associated perioral muscles. Injecting Botox into to the cleft in symmetrical points to the mentalis will weaken the one another. If no clefting is constricting muscle, wherepresent, then one injection by reliving the severity site should suffice. of the fold and subse Injection points quent filling will last will be no higher longer. Patients exhibiting an than midpoint to inverse LBL may not be Reducing Gummy the center of the candidates for denervaSmile Or Nasolamentalis. Any tion of the LLSAN. Botox bial Therapy for these patients may higher than this esexaggerate their inverse The above two tablished horizon LBL in an unacceptable therapies are interline may affect lip way. changeable because competency. Start the technique to acout with one injecquire the effect is the tion point inferior to same. The targeted musthe horizon. If two injeccle of denervation is the letion points are to be used, vator labii superioris alaeque make sure they are symmetrinasi (LLSAN). This area of the face cally placed at or below the midpoint horizon. Inject 2-6 units on females and is significant in facial presentation. If one 2-8 units on males. Mark your points with inadvertently affects other areas of facial

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Injection point for LLSAN denervation.

Targeted areas for perioral injections. The blue circle demarked at the tip of Cupid’s bow may flatten out the cupids bow if injected with Botulinum toxin. Reserve this injection point for patients with severe perioral rhytids of overly exagerated Cupid’s bow architecture.

Chapter 7 Simply Botox

Gummy Smile (Nasolabial)

Perioral

Target Muscle

levator labii superioris alaeque nasi (LLSAN)

Orbicularis Oris

Mentalis

Injection Points

1 point / bilaterally

Upper lip 4 max Lower lip 3 max

1+2

1 point / bilaterally

Units/Injection Point

1 unit

4-10 U distributed evenly (symmetrically)

2-6 (female) 2-8 (male)

1 - 3 units / bilaterally

Location

piriform aperture

At vermilion of the lip

Below midpoint horizon of mentalis

Inferior mandibular border/ posterior border of DAO

Depth of Needle

Superficial

Superficial Muscular

Superficial Muscular

Deep Muscular

Mentalis

Depressor Angular Oris Depressor angular oris (DAO)

Table 7.1 Injection points expression, the patients “look” can be dramatically affected. Botox is largely unpredictable for these areas of treatments, resulting in author published success rates of 64%.310 When an overuse of mid-facial Botox therapy occurs, the patient’s main complaints are that they don’t look like themselves and/or they have some loss of lip control.311 A result of denervating the LLSAN muscle is the desired lip lengthening, which in itself is a sign of aging. As a result of this potential problem, patient selection is critical. Patients who will benefit the most are those with a “gummy appearance” to their smile. The nasolabial fold is best treated with filler agents.

this depression can help you visualize the spot of injection. The targeted muscle is the levitator labii (LLSAN). Keep the injection point medial in orientation. Lateral to the levitator labii are the zygomatic minor and major. If the Botox spreads to these muscles, the facial expression will be affected more dramatically. Keep the injection point superior to the orbicularis muscle in order to keep lip competency. Inject 1 unit bilaterally for effect. I use a 1 mL dilution to keep the area of dissolution with in a pencil eraser diameter.

Technique

Combination Botox and Fillers

Duration

Place your patients in a recumbent Advantages of combination therapy position. View the kinetics of the smile as included: well as the static view. Mark on the paSuperior aesthetic result tient’s face with a cosmetic pencil the tarLess material used to attain result (ie, geted injection points. Mark lateral to the filler to augment) nasolabial fold and just inferior to the naIncreased treatment options to achieve sial columna. This area is called the piridesired outcome(s) form aperture and placing your finger in Longer lasting results

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TIPS

1 1

Here is a case of mine from the beginning of my lip augmentation days. In this particular case, I made several pinnacle mistakes. 1) Violation of the ideal lip proportion of 1:1.618. We can see after augmentation that this patient presents with a 1:1 lip ratio. This is most unpleasing to the eye aesthetically. 2) Overfilling the lips in volume, upper and lower leading to a “duck lip” presentation. 3) Failure to adhere in filling the natural planes of the lips. This led to an overall distortion of the lips and a blending of the planes into one uniform shape. Fortunately, the choice of filler for this case was a cross-linked HA. The advantages to using cross-linked HA for the beginner is the resorbability of the material. We certainly don’t plan for failure in our cases, yet these are the trials of passage we must face. Thereby it is important to encompass materials that are forgiving in our armament, when we begin on our path of lip and perioral augmentation.

Chapter 7 Simply Botox

Chapter 7 Review study Points History of Botulinum neurotoxin Botulinum neurotoxin mechanism of action Contraindication(s) to Botulinum neurotoxin Adverse reactions to Botulinum neurotoxin Lip and perioral injection techniques with Botulinum toxin

study Questions 1) How many serotypes are there of botulinum neurotoxin? 2) Which forms of Botulinum neurotoxin are most prevalent in North America? 3) If one is to treat a patient with Botulinum toxin and filler therapy periorally, what is the ideal sequence of treatment? 4) What two results can be expected from lip botulinum toxin treatment? 5) True or False. Generally with male and females the same amount of botulinum toxin is sufficient. 6) Which dilution will have a longer duration of effect when injected into the same muscle and amount: A) dilution of 4 mL saline to 100 U of Botox or B) dilution of 1 mL saline to 100U Botox ?

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Chapter 8

Clinical Techniques: Lip and Perioral, Botox and Fillers Docendo discimus. We learn by teaching.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Clinical Techniques: Oral-Facial Augmentation Ages 20-30 Ages 30-40 Ages 40-50 Ages 50+

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Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Less is More If a picture is worth a thousand words, this chapter is priceless. The art of lip and perioral augmentation is so hard to convey in mere words. The art of augmentation is best learned in an apprentice-like atmosphere. An artist must progress through the “rites of passage,” mentored and guided by instructors who in all reality are only one step ahead of their students on the same journey. The lip and perioral community has yet to reach a consensus on a uniform and cohesive educational curriculum. Thus, the beginning augmenters are subject to suffering the trial and error method of learning and, unfortunately, so are their patients. When reviewing the following cases, examine the photographs closely. Realize the angle of attack; observe the needle in its plane of injection and watch the flow of the material. Keep in mind there are many ways to hold a paintbrush; likewise, there are various ways to inject and augment the lips and perioral area. Establishing a consecutive sequence of steps is critical in oral-facial augmentation. To achieve optimal results, it is highly recommended that oral-facial fillers first be placed in the outer ring first before addressing the lips in the inner ring. The order of fill will be outermost first, which encompasses the nasolabial fold, mandibular jaw line, and mental protuberance. The inner ring encompasses the zones of the lips. In addition, we fill the lips from the outside in with our planed injection points.

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Clinical Techniques: Oral-Facial Augmentation

Outer Ring: Nasolabial fold, Mental fold, Marionette Lines, Jowl folds Inner Ring: Commissure, Lips

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

COMMISSURE Step 1: augment the commissure of the mouth first if needed. If we do not follow the outer ring to inner ring order, we can potentially overfill or create a beak effect to the lips. Fill the lips first and if there is significant commissure drop, we can add to the beak effect of the augmented lips.

LIPS Step 1: fill from the corners of the lips inward. Failure to fill outwards inwards on the lips potentiates lip beaking, overfills, and asymmetry. Step 2: We will always start by filling in volume first (Zone B). This means that we will fill

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in Zone B first. By filling in Zone B, we will allow the lips to reestablish volume. In addition, we can resolve a significant amount of rhytids that have developed from loss of volume in the lips. If there is still a significant amount of tonicity in the lips, the natural anatomy will reestablish itself around the vermilion border and philtrum columns. If we were to fill in Zone A first, we may overstate the anatomy in this area when we add volume to Zone B.

Step 3: Define anatomy if needed 2nd (Zone A). Never Fill Zone C; for anatomical and pathologic classification only.

Needle Size One of the most often asked questions I receive when I lecture is: what needle size do you use when injecting fillers? The majority of the augmenting community will use needle sizes from

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Gauge

Flow

Sculpt

27 Gauge

Yes

No

No

30 Gauge

Yes

No

50 / 50

32 Gauge

No

No

Yes

Table 8.1

Correction

A

Select Needle Sizes 27-30 gauge. I will often switch between 30 gauge and 32 gauge needles during my augmentations. Generally, if I want to observe the flow of the material, I will use a larger diameter or smaller gauge needle. If I am potentiating the plane by the needle or sculpting tissue, I will use a 32 gauge needle. When correcting previous fills, I will use a 32 gauge the majority of the time, although if the defect needs significant material, I may use a 30 and 32 gauge interchangeably. For example; when placing a pearl drop cross-linked HA in the puriform recess of the nasolabial fold, I will use the 30 gauge needle that comes with the syringe. When I use the crosslayering technique over the pearl drop and fold, I will use the 32 gauge needle.

B

Upper Lip

Picture 8.1

C Age

A) 32 Gauge B) 30 Gauge C) 27 Gauge

Lips

Commissure Marionette Lines

Nasolabial Fold

Philtrum Mental Fold

20-30

Zone B frequently Zone A rarely

Rarely

Rarely

30 - 40

Zone B frequently Zone A less frequently

Less frequently

Less frequently Less frequently

40 - 50

Zone B and A frequently

More frequently in conjunction with lips for support

Frequently

Frequently

50+

Zone B and A more frequently

Frequently in conjunction with lips for support

More frequently

More frequently

Table 8.2

Relationship Between Augmentation Areas and Age

Rarely

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20 30

Ages

thru

This patient group usually has very robust oral-facial features. Very seldom will you need to perform any augmentation in the nasolabial lines or rhytids in this age group. Instead, you will be more likely to add volume to the lips. Plan for the minimal amount of injection points per lip on these patients. Usually two to four injection points per lip will suffice. This population group will most likely consist primarily of females. In youthful lips, the material will flow easily, which potentiates the augmenter to err on overfilling the lips.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

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KEY POINTS TO REMEMBER Greater overfill potential in this age group. Less is more when filling the lips Plan to augment isolated planes to achieve natural appearance (ie, Segment 2, Zone B of the upper lip). Will present an overall full upper lip Due to this young age group, a differential diagnosis is warranted. A complete oral-facial evaluation may be needed to evaluate if the patient will benefit from dental, orthodontic or orthognathic treatment to achieve the desired cosmetic result of oral-facial soft tissue Zone B is where most of the material will be added. Start from the lateral segments (1, 3, 4 and 6) and fill inwards. Put the needle into the hub and fill slowly (Picture 8.2). Zone A and C fills are not needed for this age group. Most patients in this age group want volume, and that is all they need. The connective tissue, muscle tonus, dental, and skeletal support is intact. Filling and defining anatomy in the philtrum and vermilion border will give a “worked on” look and would not com-

Picture 8.2

plement the presentation of tissue at this age.

Lower Lip Zone B is where most of the material will be added, utilizing a slow filling technique. In youthful lips, the material will flow well. Maintain constant pressure; observe the flow of filler as it saturates the targeted plane of the lip.

Injection technique for filling and shaping segment 2 zone B.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Case Presentation (Select Volumizing)

Outer Ring: None, Remarkable Inner Ring History Zone B: volume segments 2 This patient presents with the desire to increase the volume in her upper lip. Zone A: N/A This patient is an amateur model and is Treatment

Picture 8.3

Post-augmentation of this patient’s lips reveal a harmonic lip relationship as evidenced by the ideal proportion caliber. Restylane was placed in Segment 2, Zone B in the upper lip on this patient. Two small pearl drops were placed in the upper lip on this patient. This slight augmentation may not be visible to the average person, although this patient was very pleased (as were her photographers). This patient is in a profession where deCosmetic Diagnosis Evaluation of this patient showed near- tails may keep them working or not. I was perfect proportions, although the upper more than happy to serve her career adlip presents slightly disproportionate to vancement…it’s that simple. the lower lip. periodically contracted to perform photo shoots for commercial products. It has been suggested to her that some minor facial augmentation would increase her photo desirability for advertisement layouts.

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these segments. Although I didn’t fill a lot A consideration of cost comes into play of cross-linked HA into Segments 1 and 3, when we plan treatment of patients in this the filling of Segment 2 supports the drapgroup. After all, a syringe of cross-linked ing of the lips as they taper outwards. HA can be very costly and for this type of This technique is particularly effective augmentation, only a quarter of a syringe for cross-linked HA products, where they is usually used. I use a 0.4 mL touch-up displace and support adjacent tissue. syringe distributed by Restylane. These On a personal note: this patient has syringes are designated for post-augmen- undergone two photo shoots within the tation corrections of asymmetry or areas week of initial injection (Picture 8.4) and of under fill. she and the photographers were very pleased. Such a minimal amount of fill Result One week post-clinical evaluation re- makes a big difference in some of these veals a fuller upper lip. Segments 1-3 have cases.

Note

increased in volume and we have reacquired the natural planes associated with

Picture 8.4

One-week post-augmentation evaluation.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

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Case Presentation (Gummy Smile) History The patient illustrated here is a 29year-old female. Her chief complaint is that when she smiles she displays too much gingiva. Patient presented with a normal health history without any contraindications to Botox or filler therapy.

Cosmetic Diagnosis Upon evaluation of her facial proportions, we see that her lips are in ideal proportion. The lips are full, vital, and she presents with a slightly upward curved LBL. Upon brief skeletal/soft tissue exam, we find that this patient’s anterior skeletal relationship is within normal limits, without exhibiting an overly exaggerated maxillary relationship. The clinical findings draw more attention to the soft tissue

Picture 8.5

component of the maxillary smile, in particular the lift of the upper lip by the levator labii superioris alaeque nasi (LLSAN). Augmenting the lips to correct the problem in hopes of covering more gingiva is contraindicated: it would increase lip volume, yet since our patient has a relatively ideal upper to lower lip proportion, we run the risk of overfilling the lips. This is a classic mistake the beginner augmenter will make in efforts to correct this cosmetic presentation. Differential diagnostic treatment options would include: periodontal surgery to remove excess gingiva, which was rejected for the potential increase in tooth length, whereby producing an unaesthetic result. Orthodontic/orthognathic treatment was considered overtreatment on the basis of time, post-operative healing, and expense.

Notice high smile line produced by a heavy contraction of the LLSAN muscle.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Picture 8.6

Pre-augmentation evaluation demonstrates ideal proportions of lips.

Picture 8.7

Pre-augmentation ideal proportion evaluation reveals ideal relation of dentition to Sn to Me.

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Picture 8.8

Demonstrated here are the injection point landmarks for denervating the LLSAN. Notice injection is directed towards the most medial part of the puriform recess. Outer Ring: nonremarkable Inner Ring: excessive gingival display Therapy: Botox therapy at a dilution of 1 mL of non-preserved saline to 100U of Botox (Allergan).

Treatment Botox therapy in this case will denervate the LLSAN and release the pull of the upper lip, thus draping the anterior maxillary more inferiorly and providing more gingival coverage. The first step is locating the LLSN in the puriform located at the superior aspect of the nasolabial fold. Inject medial to the nasolabial fold.

Potential Adverse Effects and Complications Botox therapy for the LLSAN is not indicated for everyone that presents with a “gummy smile.” In fact, it is the most technique sensitive and requires a great deal of differential diagnosis before po-

tential treatment. There are other therapies that can possibly produce a better cosmetic result, such as orthodontics, oral, periodontal surgery, and cosmetic dental restorations. The adverse effects of this treatment are significant and can last for several months. We must also be diligent in the differential diagnosis in this area, for when using a large dilution ratio (3 mL or greater), the diameter of the injected Botox will be much greater, leading to a wider dispersion of the effect. The larger the dispersion, the greater the potential that other perioral muscles may be affected. This may lead to increased flaccidity of the lips where the patient appears to have Bell’s palsy syndrome. Stay above the zygomatic arch and lateral to the nasolabial fold, in order to keep distance from the zygomatic muscle, which is the primary muscle of lip elevation.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

overly denervate these muscles in hopes Two weeks post-injection reveals a gen- of achieving this effect. I usually keep my tle relieving of the upper lip. We see that dosage at 1 U in the puriform. the inferior border of Zone C lies across This patient can feel a difference in the cervical margin of the maxillary denti- the post-treatments results. Her ability to tion. You may also realize a slight relaxing lift her upper lip is not compromised, yet of the nasolabial fold and flattening of its normal muscle contraction of the LLAN presence. In some cases, this is an example muscle does not pull her lip superiorly to of where Botox can be used to lessen the such an extent as to display such a “gumnasolabial fold. Care must be taken not to my smile” anymore. She is very pleased.

Result

Picture 8.9

Post BTX-A treatment. We have successfully brought down the high smile line, where Zone C of the upper lip drapes over the gingival line.

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30 40

Ages

thru

This patient age group will make up the bulk of your lip augmentation practice. They are by far the most discerning in their opinions about their lips. In addition, they are heavily influenced by the media and peers pertaining to current fashions and trends in lip augmentation. They aren’t too shy to sit in your chair and demand Angelina lips, yet they have the potential to build your practice immensely if treated appropriately. The majority of this group of patients will still have a significant tone to their oral-facial tissue; thus, adding volume will reestablish their natural anatomy.

A four – six point per lip injection technique with this patient group is recommended. Remember to start in the corners of the mouth first and work your way inwards. Some additional sculpting of anatomy may be needed in Zone A with the older segment of this age group, but it will usually be limited to the vermilion border of the upper lip. We do not want the lips to look overworked. Less is always better: one can always add more filler in subsequent follow-up appointments.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

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KEY POINTS TO REMEMBER Differential diagnosis for dental and lip augmentation in congruent therapy. Patients can receive fantastic results from anterior dental reconstruction and lip augmentation If nasolabial fold or any other outer ring augmentations are planned, do them first If the commissures need lifting, fill first then augment the lips We start laterally and move our injection points medial Start in Zone B then Zone A Stay away from Zone C. Filling this zone is not needed and can easily obscure the anterior dentition, violating the natural presentation of the teeth. In addition, when filler is placed in Zone C, the potential to violate the wet/dry line exists and the patient will feel the filler with their tongue due to the thin mucous membrane of the oral cavity Plan for the minimal injection points. Eight total injection points in the body of the lips (Zone B) were planned: four in the upper lip and four in the lower. facial trauma. I decided to include in her dental treatment planning additional lip Case Presentation and perioral soft tissue cosmetic alternaPatient history tives. The patient voiced a desire to al The patient presented originally for ways have “more lips” and was thinking anterior cosmetic dental work due to oral-

Picture 8.10

Pre-augmentation evaluation reveals less than ideal proportions of the lips. The upper lip presents with the opportunity to add additional volume.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Picture 8.11

Proportional evaluation of the patient’s smile reveals a pleasing relationship that falls within the calibers relationship. about having silicone injected into her lips. After a brief consultation, I assured her we could increase the volume in her lips while preserving and enhancing her lip’s natural anatomical form.

material technique of filler products to include collagen (CosmoPlast) and crosslinked HA (JuvédermTM). CosmoPlast was treatment planned for Zone A (vermilion borders). We want to augment Zone A with a subtle, soft, filler (eg, CosmoPlast). Cosmetic Diagnosis This is due to the youthful tonus texture The patient has had no prior lip or peof a younger patient’s Zone A. Our objecrioral augmentation. Her lips fit into ideal tive is to accent or recreate a slight G-K proportions, although they were lacking line angle. For more mature lips, it may in volume compared to the rest of the face. be necessary to use a stiffer filler material Her smile line and lower facial proportion like cross-linked HA in Zone A in order to are within ideal proportions. create this effect. Remember: cross-linked Outer Ring: nonremarkable HA products will displace the tissue that Inner Ring: lack of lip volume it is injected into more so than collagenbased fillers like CosmoPlast. Zone B: add volume to Segments 1 – 6 Zone A: sculpt vermilion border segments First injection point starts in the corner 1,2,3 of the mouth: Segment 1, Zone B. After insertion of the needle, we visuTreatment Objective Lip augmentation using a combination alize our plane by tenting out the needle. We want the material to potentiate the

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space slightly in front of the needle and then saturate the natural plane as we slowly remove the needle while expressing the filler. The second insertion point will be medially placed in Segment 1.

Picture 8.12

Picture 8.13

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Zone B (Picture 8.12, 8.13). This picture illustrates Segment 1 immediately after augmentation (Picture 8.14).

Picture 8.14

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After finishing Zone B fills, the patient’s vermilion border (Zone A) was filled with CosmoPlast, a collagen filler. This particular collagen filler has a shorter needle and

Picture 8.15

Picture 8.16

multiple injection points are needed to fill in the border (Picture 8.15, 8.16). Remember to always work your way from the outer ring in or from the corners of

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

the mouth inward. When injecting into the vermilion directly, we potentiate the plane by the needle. The direction of the needle must be in line with the vermilion

Picture 8.17

Picture 8.18

line to be augmented (Picture 8.17, 8.18). After augmentation of the upper lip Zones B and A in that order, we proceed to the lower lip.

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The sequence of injecting is important. My general rules are • Fill in Zone B first • If I am to augment the vermilion bor-

Picture 8.19

Picture 8.20

der I fill in Zone A on the upper lip first before proceeding to the lower lip. The reason for this is that if we move to the lower lip and finish Zone B for both upper and lower lip, the vermilion may distort

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

from swelling, which may alter the perception of fill in Zone A of the upper lip • Fill Zone B of the lower lip. The lower lip will require only four injection points. Start at the corner of the mouth and work

Picture 8.21

Picture 8.22

inwards (Picture 8.19, 8.20, 8.21). Again, make note of the slightest amount of blanching on the lower lip (Picture 8.22). When this occurs:

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Stop, withdraw, and reacquire another plane to inject.

mediately after augmentation at times. They are great for building your augmen Any further injection of material will tation library and you can show potential cause distortion, excessive swelling, and lip patients what to expect immediately after augmentation (Picture 8.23). bruising of the lips.

I like to take post-injection photos im-

Picture 8.23

Result

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Patient presented for photography two weeks post augmentation. You can see this patient has significantly fuller lips (Picture 8.24). In addition, a more acutely recreated G-K line angle is visible from a

Picture 8.24

Picture 8.25

semi profile angle (Picture 8.25). If we examine Zone A on this patient, we are still able to distinguish between the demarcation line form of the vermilion and surrounding perioral skin. With

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imagine if we did not separate the planes in our injection technique. What if we laid a consistent semilunar shape of filler in the maxillary lip from Segments 1-3? The result would be an obscuring of the lip planes, whereby a loss of the natural shape of the lip. As augmenters, we have At this position (Picture 8.26), we can to constantly monitor the “wants” of our see the planes of the lips clearly. Just patients. injectables such as silicone, we lose this demarcation due to the migration of the filler into the surrounding perioral skin. With cross-linked HA and collagen fillers, we displace the surrounding tissue more, leaving the integrity of the lip line angles.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Picture 8.26

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40 50

Ages

thru

Patients in this age group will begin to exhibit deeper nasolabial lines and rhytids. Using the correct technique, one is able to decrease the severity of these folds and lines substantially.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

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KEY POINTS TO REMEMBER Perform a complete cosmetic history; patients with prior augmentation require slow potentiating of the planes to be filled. If the augmenter is overzealous, the filler may be displaced into previously filled planes. The filling of this prior potentiated space may leave an unwanted esthetic result Introduce this patient age group to combination therapies such as Botox/filler augmentations Nasolabial Folds No facial structure hints at aging more than the nasolabial fold. As we mature, the crease from the lateral edges of the nostrils to the lower edge of the commissure deepens.

Picture 8.27

The severity of the nasolabial fold depends on: Genetics, and the thickness of the facial dermal tissue. Thick facial skin generates deeper folds and less accessory

Illustrated here is the planned injection point for deposition of filler in the puriform recess. Ideal placement should be in a teardrop shape.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Picture 8.28

If additional filling is required, crosshatching of filler should be layered in the following manner. wrinkles while thin facial skin leads to shallower nasolabial folds and more accessory facial wrinkles. With men, we see deeper, more distinct nasolabial fold due to the thicker facial skin men have. Gravity. Thicker facial skin tends to draw the nasolabial fold down in a vertical direction on the face. Thicker facial skin usually requires more filler by volume to correct, although the correction is more forgiving that is less visible if the filler is placed incorrectly. Filling the fold in can be executed using one of four techniques as described in Chapter 6: Inject a pearl form in the apex of the triangle that forms the nasolabial fold and the lateral nasal. Perform a line fill on the inside of the nasolabial fold. This technique reduces

the fold in static situations and somewhat in kinetic movement and works best with thin skin. Perform lateral cross lines perpendicular to the fold; pinch the fold periodically to see fill. This particular method will reduce nasolabial fold in static mode as well as in kinetic. More volume of filler is required for this method. Several passes may be required. Combination Fill Technique—this technique is particularly effective for deep nasolabial folds. Start by filling in the nasolabial line with the filler and crosshatching underneath the filler you just applied to the fold. This lifts the filler just applied to the fold and provides a surface area for the kinetic

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reduction of the fold.

Case Presentation (BTX-A Lips) (Filler Lips) History

This patient was interested in lip aug-

Picture 8.29

Picture 8.30

mentation. Her chief complaint was the loss of volume in her lips and the development of lines around her upper lip.

Cosmetic Diagnosis Select BTX-A therapy around the lips to establish increased surface area of lips

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

and subsequent filler therapy to fill lost volume. During the lips and perioral evaluation, have the patient purse their lips and relax them. If the rhytids correspond in the kinetic as well as static positions of the mouth, then this patient is a good candidate for BTX-A perioral therapy. (Picture 8.29, 8.30) This particular patient exhibits deepening of the rhytids in kinetic pursing of the lips. In addition to relieving the kinetic rhytids, this patient needs more surface area of the lip (Zone B) exposed on the upper compared to the lower. At the 1 mL/100 U Botox dilution ratio, the area of effect will be the diameter of a pencil eraser. This diameter will denervate the vermilion area alone. Outer Ring: nonremarkable Inner Ring Zone B: volume segments 1,2,3,4,5,6 Zone A: fill rhytids segment 1,2,3

Therapy Botox

Picture 8.31

Dilution: 1 mL of unpreserved saline was used to reconstitute 100 U of Botox. Filler: cross-linked HA filler (Restylane) planned for Zone B volume fill. Rhytid fill with cross-linked HA if needed after revolumizing the lips and Botox (Pic 8.31 Use an eyeliner pencil to draw the facial landmark borders. The eye liner is easily cleaned off and will not smear when working on the face.)

Treatment BTX; Dilutions 1 mL nonpreserved saline to 100 U Botox. There are two objectives for BTX-A therapy in relationship to the lips on this patient. One is to reduce the rhytids around the lips and two, to create more surface area for subsequent lip augmentation. Before injecting Botox in the lips, it is best to mark the desired injection locations. As a rule, I do not inject Botox lateral to the ala of the nose. Keeping the injections within the ala borders greatly reduces the potential for lip incompeten-

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cy (Picture 8.31). I then mark my planned points of injection around the vermilion border. This particular case, I opted for two injections in the lower lip and four injections on the upper lip. (Picture 8.32) There are significantly more rhytids in the

Picture 8.32

Picture 8.33

upper lip than lower lip, which is usually the case. Facial Markings: You may notice the asymmetry in this patient’s face (Picture 8.33). This asymmetry becomes more evident when we mark our landmarks on the face.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

The injection points around the vermilion are asymmetrical, which are in appropriate relationship to the face. This is the advantage of facial marking before any BTX, particularly perioral. Facial marking ensures we keep the integrity of the patient’s face appearance and that we do not alter their appearance, we enhance it.

Picture 8.34

Procedure: Inject 1 U into the superficial orbicularis oris muscle and 6 injection sites on the vermilion border. The lips are one of the most sensitive areas of the face. Injection technique is particularly important, since anesthesia is contraindicated with Botox. Placing an ice pack on the lips before injections can relieve some of the

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pain upon injection. (Picture 8.34)

jecting into Zone B, Segment 1 (Picture 8.35). Lay your needle over the proposed plane of Filler injection. Inject your needle into the plane Juvéderm was selected as the cross-linked and tent the lip out over the needle to reasHA filler to be placed in this patient, one week sure plane placement (Picture 8.36). Slowly after initial BTX-A therapy. We begin with in- inject to saturate the plane. Remember the

Picture 8.35

Picture 8.36

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

cone shape of this plane and taper your filler jection is tented over the lip. Notice after as you exit the tail of the cone. augmenting Segment 1, Zone B alone, the The second injection point is in the rise in the vermilion border and establishmedial part of Segment 1. The tip of the ment of the G-K line angle (Picture 8.38). needle will reach into Segment 2. This is At this point, we can move to the contraldemonstrated in Picture 8.37 as the in- ateral side and augment Segments 2, Zone

Picture 8.37

Picture 8.38

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B or move to the lower lip and augment Segment 6, Zone B. I elected to move to Segment 6, Zone B and—after adding volume here—to evaluate the lips with one side augmented and the other not (Picture

Picture 8.39

8.39). Place the needle over Segment 6, Zone B to approximate plane and inject. Remember the form of this plane is teardrop

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

shape with the head of the tear in Segment 5 and the tail in Segment 6. Notice on the final injection the blanching of the lip. Again, this indicates plane saturation… stop at this point.

Results

Picture 8.40

Patient presented two weeks post-augmentation. Her lips are full and natural in appearance. I have eliminated her perioral rhytids through a combination Botox and filler lip therapy. Due to the inherent tonicity of her lips, filling in the planes

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Ages

50+

Typically the oral-facial skin in this patient group is thin and fibrotic tissue. The lips are thin and indurated, which is a result of loss of volume. In addition, there may also be a lack of anatomy in areas such as the vermilion borders. The maturity of the skin (intrinsic and extrinsic), as well as skeletal and dental changes, are contributing factors within this age group that will prompt Zone A fills.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

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has created a slightly upward LBL with- patient about the potential of this occurout having to augment the corners of the rence. With time, the epithelium will mamouth. ture or weather itself comparable to the adjacent tissue. Lips Upper Lip: Fill in volume first (Zone B) as described in previous fills. Augment Zone A as needed for sculpting the vermilion borders.

Cupid’s Bow

If the patient has no Cupid’s arch, we can establish one with fillers. Even with the age group of 50+, we first inject into Lower Lip: Zone B fill for volume. Zone B to fill the mass of the lips, and then Augmenting Zone A on the lower lip can if the anatomy is not realized, we begin to be technique sensitive. The lower lip has a fill in the anatomy of Zone A. Sometimes natural roll as it transitions from the ver- you may be surprised at the realization of milion color to the facial epithelium. There the Cupid’s arch after filling Zone B, even are no clear demarcations of borders like in this age group. If the bow is not realthat of the upper lip. Injecting filler into ized, then filling Zone B will reduce the the transitional zone of the lower lip can potential of overstating Zone A anatomy. leave an unnatural appearance. Combination technique: In order to realize or recapture the natural appearRhytids There are three ways of using fill- ance of the border, a combination of filler ers and BTX-A to reduce and eliminate may be used. Cross-linked HA products rhytids around the mouth: 1) Volumizing displace tissue and when injected into the lips in Zone B will distend the vermil- the vermilion border, the material tends ion border and reduce rhytids, 2) Filling in to distend the border and leave an unthe rhytid line directly with an augment- natural hardened appearance and feel. ing product like collagen, or cross-linked Fillers such as CosmoPlast recapture the HA, and 3) Botox therapy around the ver- anatomy with a more subtle presentation, milion border; this is more effective for ki- whereby leaving a natural feel. One can expect superb results from the combinanetic rhytids. tion technique. Rhytids present on patients in this age group can be challenging to eliminate. Procedure: Begin injection in the red When a patient presents with significant area of the transitional color zone. Set rhytids at this age group, from either your needle more superficially in the static or kinetic, the deep invagination of dermis and on an even plane. Tent your skin around the lips has been developing needle out to reaffirm path of placement for a long time. Sometimes it is difficult and verify planar depth. Inject slowly and to distinguish between kinetic and static with constant pressure and finish at the rhytids. Filling the rhytid may bring the medial point. Attempt to place the filler deeper covered epithelium to the surface, in a manner that only one congruent line which may not be the same color or tex- lays on the vermilion border. ture due to many years of being protected Layering is not a very effective techfrom ultraviolet rays and normal dermal nique on this anatomical structure. Very abrasion. Always distend the vermilion little material is necessary to achieve this border before augmenting to examine the effect. The space for the flow of the filling tissue of the rhytid and consult with the

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

material is potentiated by the needle. We insert the needle to produce our path for filler then we inject the filler when we withdraw the needle. When working with patients in this age group, it is also essential to be clear on the dynamics of the patient’s smile. Look beyond the lips to the supporting dental structure.

Commissure Augmenting the corners of the mouth on this patient creates a fuller corner of the mouth. The result of the fullness is that

Picture 8.41

Here I am demostrating Zone A filling in the vermilion border. Notice the direction of placement: I follow the natural contour of the vermilion border as I inject. Several injections are needed around the vermilion border when performing this technique. the corners of the lips will lift upwards. Most injections will need to be directly below the epidermis and superior to the deep anatomy, because the corner of the mouth is a vital insertion point for many of the muscles of facial expression. The filler material will almost naturally flow towards the lip due to the firmness of the underlying anatomy.

Two filler techniques are available for turning up the corners of the mouth. First, pull the corner of the mouth Picture 8.42 Here I am augmenting the commissure of the lips. I enter lateral up and lateral. Start into the commissure and stretch the tissue as I inject. This technique jection point around 10 mm lateral to the allows me to better visualize the flow of material. corner of the mouth.

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Inject a linear amount in the above lateral corner and then a little greater than equal amount in the lower lip. Second, start injection 10 mm lateral to corner of mouth, directly medial. The flow of material will express itself above and below the corner of mouth.

Marionette Lines Marionette lines are just a continuance of the fall of the commissural corners of the mouth. Approach this area similar to the nasolabial folds. Inject a buttressing amount medial to the fold and then layer over the fold. Injecting in layers across the lines will add sufficient resistance to the kinetic fold of the marionette line.

Nasolabial Fold The nasolabial folds are one of those anatomical structures that display the telltale signs of aging. They also require a significant amount of filler to correct (usually a 1 mL syringe). When the nasolabial folds are augmented, they can reverse the signs of aging tremendously. There are several techniques that can be implemented, depending on the depth of the fold. For light folds a simple pearl drop placed in the puriform recess will tent out the facial tissue. For moderate to severe folds a combination technique is optimal for cosmetic correction.

has been debating over more significant cosmetic procedures such as a face lift, but she feels she’s not ready for them yet. The patient had a history of Botox in the forehead region and wanted her lips and perioral area evaluated for cosmetic treatment. As you can see, from (Picture 8.43, 8.44) the patient’s lower proportion is not ideal. Nose to incisal edge, this patient is close to ideal. From incisal edge to chin, there is a defiant elongation in appearance. In addition, the patient manifests with significant jowl folds. These two presentations of the lower face support the excessive drooping of the lower facial dermis. Obviously a conventional face lift would correct this more dramatically, but this patient isn’t quite ready for this therapy yet. Filler and Botox therapy are a gateway into this realm for some of these patients. They are able to appreciate small improvements and later may very well undergo more substantial plastic surgery.

Cosmetic Diagnosis

Outer ring This patient has fairly thick oral-facial dermal skin, with the combination effects of aging and environment. This is reflected in the marionette and sagging jowl lines. There will be a significant number of cases where the augmenter can use a combination of Botox and filler therapy. This The first step on both techniques is particular patient is one such case. Denersimilar with a pearl placement. In the com- vation of the DAO will lift the corners of bination technique, one overlays thread- the mouth. Augmenting the patient’s jowl like filling over the pearl drop form and fold will lesion the degree of indentation. descending fold. Nasolabial fold: fill cross-linked HA Case Presentation (Botox Marionette lines: fill with combination of LLSAN)(Fill Nasolabial, lips, BTX Mental lines: N/A commissure) Jowl fold: limited fill History This patient presented with interest in Inner ring rejuvenating her facial appearance. She

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Zone B: volumize segment 1, 2,3,4,5 and 6 Zone A: Sculpt segments 1, 2,3,4,5 and 6

Therapy Combination Botox and Filler

Picture 8.43

Picture 8.44

augmentation BTX, Dilution: 1 U of Botox at 1 mL dilution per 100 U bottle. Filler: Juvéderm for zone B and CosmoPlast for Zone A.

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best. I continue to palpate the region with Botox—objective: to raise corners of my thumb up to final injection of Botox mouth. Therapy to lift up on the corners of (Picture 8.45). I injected 1 unit bilaterally the mouth was selected. The patient’s face into the DAO. Since this was the patient’s was marked. It is important to palpate the first exposure to perioral BTX, I decided DAO’s posterior border. With this patient, to use only 1 unit. If desired results aren’t we see significant facial drooping and if realized with this dose, I can always add we would simply use a straight edge and an additional unit at the 1- to 2-weeks soft tissue landmarks to locate the direc- post-op. tion and origination of the DAO, we can Filler be misled. A combination of palpation and It was decided to place filler in the straight edge location of landmark serves nasolabial fold, commissures, marionette

Treatment

Picture 8.45

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

lines, and lips. As stated in the Botox chapter, I usually wait one to two weeks after the BTX-A treatment to initiate filler treatment. I do make exceptions for areas in the outer ring more often. In my expe-

Picture 8.46

Picture 8.47

rience, the low level of BTX-A placed in the DAO will not significantly distort the filler placement in the commissures and marionette lines.

Commissure Lift

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I chose to lift the commissures on this patient with placement of cross-linked HA. I selected a single injection technique in filling the area I previously marked with a cosmetic pencil. I marked the area on the patient to be

Picture 8.48

Picture 8.49

filled for demonstration purposes, but it is totally appropriate for the beginner/novice augmenter to mark intended areas of augmentation on the face. On this patient, through one injection point I injected lateral and inferior

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

to the corner of the mouth (Picture 8.46, 8.47). This technique is referred to as fanning. I mark quite frequently on patients, in particular when I am doing combination filler and BTX-A therapy. To increase the buttressing effect of the filler, I will lay down layers over previously placed filler (Picture 8.48) and continue them down along the marionette lines (Picture 8.49) The objective of this technique pertaining to this patient is to provide a buttress of filler at and below the commissure in order to displace the tissue upward. This will in turn raise the corners of the mouth. Placing filler above the horizon of the LBL will direct the commissure’s angle down. Mark your area of intent and fill this area. Multiple injection directions are used to layer and saturate this plane at and just immediately below the commissure. The filler agent of choice must have substantial tissue displacement properties. Crosslinked HA products have this quality and are my choice for this treatment technique.

ing index finger. This stabilizes the lip and allows a nontraumatic precise injection into the targeted plane. Insert needle and inject filler as you draw the needle out.

Zone A

Two weeks post-augmentation, we evaluated this patient. Photographs show an increase in lip volume and decrease in rhytid presentation. We have a bilateral elevation of the corners of the mouth. The marionette line has been smoothed out as well and a less pronounced mental fold. The nasolabial folds have also been relieved.

CosmoPlast was placed in the vermilion border for the purpose of sculpting existing anatomy. Collagen is usually my selected material for Zone A because of its softness, malleability, and cosmetic presentation. Collagen in the vermilion border has a natural, subtle presentation without looking too worked or sculpted. I use cross-linked HA product when I wish to create architecture in Zone A that has disappeared completely. We potentiate the plane by the needle on the vermilion border. Place your needle over the anticipated plane. Hold the corner of the mouth with your noninject-

Philtrum I also sculpted the philtrum with CosmoPlast. The philtrum anatomy was present, so collagen was the filler of choice to accent its form. We potentiate this plane by the needle. Insert the needle to the hub. Tent the dermis out a little to reconfirm plane placement. Inject the filler material as you withdraw the needle. Cross-linked HA products can be used here to establish a philtrum.

Zone B The objective of Zone B fills is to add volume. For this technique, I selected Juvéderm, which is a cross-linked HA product. We start at the corners of the mouth and work inwards. Remember the natural plane of the lips and taper the fill in Segments 1, 3, 4 and 6.

Result

The total syringes used on this patient were 3 cross-linked HA syringes, 1 collagen syringe and 2 units of Botox treatment. We have achieved some significant

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results, yet one may question the amount of money invested in this particular therapy that will disappear around 6 months. Fillers and conjunctive Botox therapy are an ideal introductory therapy for facial

Picture 8.50

cosmetics. Patients are able to see an immediate positive cosmetic result, which in turn potentially leads them down the path of more substantial corrective cosmetic work on their face such as traditional face lifts. When they finish permanent facial revisions, the addition of supplemental filler and Botox therapy is often needed to maintain their new look.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

Chapter 8 Review Points

Points

Importance of outer ring towards inner ring augmentation. Direct fill augmentation from commissure toward midline of lips. Treatment planning, outcomes, and cosmetic therapy for varying age groups Importance of needle placement and plane augmentation. Observance of combination of botulinum toxin cosmetic therapy and cosmetic filler augmentation therapy.

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SoME FINAL WORDS. . I am often asked (during lectures, conversations and patient consultations) how I would enhance a set of lips. More often than not, I respond by sharing what I wouldn’t do…which made me realize that there are a significant number of instances in which I will do nothing. This may sound strange, but have you ever attended a lecture where the presenter showed a list of cases and his treatment plan was to do nothing? Remember, it is your right to refuse to perform an elective cosmetic treatment. If you question your patient’s motives, or if you do not have a clear endpoint in mind (where you will be at the conclusion of treatment with your patient), stop. Reevaluate and communicate this to the patient. Cosmetic lip and perioral augmentation is just that: cosmetic. Patients can live their whole lives with thin and wrinkled lips. When we augment, our goal is to improve or reestablish the patient’s natural look. Nothing draws more attention or criticism than a botched lip job. Poorly done lip and perioral augmentations cast a dark shadow over our specialty and culture, and mars your good name as the practitioner. Most importantly, let us not forget that the patients we treat with haste, ill-preparedness and self indulgence will suffer the most from public scrutiny. There were several instances where I have had some prominent personalities in my chair wanting work done. And despite the fact that it would have been a great ego boost and/or potential referral source, I refused to perform cosmetic treatment for that patient. Sure, there are times that I heard that they went to another practitioner and had work done, but the point is that I in all good consciousness could not see what I could do to improve their lips. And that is the crux of this field. Only in performing great lip augmentations and holding oneself to a standard will you be ensured a long, successful practice. I hope this book inspires you to learn, grow, and develop a lip/cosmetic practice of your own. It is a passion of mine that has given me great joy and it is my sincerest hope you will find similar rewards.

crede quod habes, et habes Believe that you have it, and you do.

Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers

I am often asked (during lectures, conversations and patient consultations) how I would enhance a set of lips. More often than not, I respond by sharing what I wouldn’t do…which made me realize that there are a significant number of instances in which I will do nothing. This may sound strange, but have you ever attended a lecture where the presenter showed a list of cases and his treatment plan was to do nothing? Remember, it is your right to refuse to perform an elective cosmetic treatment. If you question your patient’s motives, or if you do not have a clear endpoint in mind (where you will be at conclusion of treatment with your patient), stop. Reevaluate and communicate this to the patient. Cosmetic lip and perioral augmentation is just that: cosmetic. Patients can live their whole lives with thin and wrinkled lips. When we augment, our goal is to improve or reestablish the patient’s natural look. Nothing draws more attention or criticism than a botched lip job. Poorly done lip and perioral augmentations cast a dark shadow over our specialty and culture, and mars your good name as the practitioner. Most importantly, let us not forget that the patients we treat with haste, ill-preparedness and self indulgence will suffer the most from public scrutiny. There were several instances where I have had some prominent personalities in my chair wanting work done. And despite the fact that i t would have been a great ego boost and/or potential referral source, I refused to perform cosmetic treatment for that patient. Sure, there are times that I heard that they went to another practitioner and had work done, but the point is that I in all good consciousness could not see what I could do to improve their lips. And that is the crux of this field. Only in performing great lip augmentations and holding oneself to a standard will you be ensured a long, successful practice. I hope this book inspires you to learn, grow, and develop a lip/ c o s m e t i c practice of your own. It is a passion of mine that has given me great joy and it is my sincerest hope you will

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47 Niamtu J. The use of Restylane in cosmetic facial surgery. J Oral Maxillofac Surg. 2006;64:317-325. 48 Edizer M, Magden O, et al. Arterial anatomy of the lower lip: a cadaveric study. Plast. Reconstr Surg. 111: 2176-2181. 49 Kawai K, Imanishi N, Nakajima H, Aiso S, Kakibuchi M, Hosokawa K. Arterial anatomy of the lower lip. Scand J Plast Reconstr Surg Hand Surg. 2004;38:135-139. 50 Sarver DM. Esthetic orthodontics and orthognathic surgery. St Louis: Mosby;1998. 51 Donofrio L. Fat distribution: a morphologic study of the aging face. Dermatol Surg. 2000;26:11071112. 52 Forsberg CM. Facial morphology and aging: a longitudinal cepha-

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55 Bishara SE, Treder JE, Jakobsen JR. Facial and dental changes in adulthood. Am J of Orthod. 1994;106:175-186.

64 Ricketts RM. Esthetics, environment, and the law of lip relation. Am J Orthod. 1968; 54:272-289.

56 Bondevik O. Growth changes in the cranial base and face: a longitudinal cephalometric study of linear and angular changes in adult Norwegians. Eur J of Orthod. 1995;17:525532. 57 Klein AW. The art and science of injectable hyaluronic acids. Plast Reconstr Surg. 2006;Mar suppl.

65 Klein AW. The Art and Architecture of Lips and their Enhancement with Injectable Fillers. Tissue Augmentation in Clinical Practice, 2nd edn. Taylor and Francis; 2005. 66 Formby WA, Nanda RS, Currier GF. Longitudinal changes in the adult facial profile. Am J Orthod Dentofacial Orthop. 1994;105:464-476.

58 Ramfjord SP, Ash MM. Occlusion. Philadelphia: Saunders; 1971.

67 Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1972;39:502.

59 Christensen G. Abnormal occlusal conditions: a forgotten part of dentistry. J Am Dent Assoc. 1995;126:1667-1668.

68 Uitto J. Connective tissue biochemistry of the aging dermis. Agerelated alterations in collagen and elastin. Dermatol Clin. 1986;4:433446.

60 Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems. 2nd edn. St. Louis: Mosby; 1989. 61 Mcintyre F. Restoring esthetic and anterior guidance in worn ante-

69 Uitto J. Molecular mechanisms of cutaneous aging: connective tissue alterations in the dermis. J Invest Dermatol Symp Proc. 1998;3:41-44. 70 Goukassian D. Mechanisms and

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278 Markey, A. C. Botulinum A exotoxin in cosmetic dermatology. Clin Exp. Dermatol. 25: 173, 2000.

287 Ahn, KY, et al. Botulinum toxin A for the treatment of facial hyperkinetic wrinkle line in Koreans. Plast. Reconstr. Surg. 2000;105:778.

279 Humeau Y, et al. How botulinum and tetanus neurotoxins block neurotransmitter release. Biochimie 82: 427, 2000. 280 Sakaguchi G. Clostridium botulinum toxin. Pharmacol Ther 1982;19:165-194. 281 Carruthers, A. et al. Use of botulinum toxin A for Facial enhancement. Tissue augmentation in clinical practice 2nd edition, AW Klein. Taylor and Francis 2006. 282 Meunier FA, et al. Botulinum neurotoxins: from paralysis to recovery of functional neuromuscular transmission. J Physio. Paris 2002; 96:105113. 283 Jankovic J, Schwartz K. Response and immunoresistance to botulinum toxin injections. Neurology. 1995;45:1743-1746. 284 Ludlow CL, et al. Therapeutic use of type F botulinum toxin [letter]. N Engl J Med. 1992;326:349-50. 285 Sankhla C, et al. Variability of the immunologic and clinical response in dystonic patients immunoresistant to botulinum toxin injections. Mov Disord 1998;13:150-154. 286 Matarasso, S. Complications of botulinum A exotoxin for hyper-

288 Carruthers, A. and Carruthers, J. Long-term safety review of subjects treated with botulinum toxin Type A for cosmetic use. In proceedings of the 13th Congress of the European Academy of Dermatology and Venereology, Florence, Italy, November 17-21, 2004. 289 Klein AW. Complications with the use of botulinum toxin. Dermatol Clin. 2004;22:197-205. 290 Matarasso, A. New indications for botulinum toxin Type A in cosmetics: Mouth and neck (discussion). Plast Reconstr Surg. 2002;110(2):612. 291 Polo M. Botulinum toxin Type A in the treatment of excessive gingival display. Amer. J Orthod Dentofacial Orthop, 2005;127:214-218. 292 Lehrer M. et al. Botulinum toxin – an update on its facial rejuvenation. Journal of Cosmetic Dermatology. 4:285-297. 293 Rod J. The cosmetic use of botulinum toxin. Plast. Reconstr. Surg. 112 (suppl.):177S, 2003. 294 Klein AW. Cosmetic therapy with botulinum toxin: anecdotal memoirs. Dermatol Surg. 1996;22:757759.

References

295 Allergan, Inc. Botox Cosmetic (botulinum toxin Type A) purified neurotoxin complex (package insert). Irvine, Calif: Allergan, Inc. 296 Alam, M. et al. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: double blind, randomized controlled trial. Arch. Dermatol. 138: 510, 2002. 297 Klein AW. Dilution and storage of botulinum toxin. Dermatol. Surg. 24: 1179, 1998. 298 Carruthers A, et al. Dose dilution and duration of effect of botulinum toxin Type A (BTX-A) for the treatment of glabellar rhytides. Poster presentation, AAOD, New Orleans, LA, Feb 22-27,2002 299 Matilde M, Sposito M. New indications for botulinum toxin Type A in cosmetics: mouth and neck. Plast and Reconstr. Surg. 110:601, 2002. 300 Benedetto, AV. Et al. The cosmetic uses of botulinum toxin Type A. Int. J. Dermatol. 1999;38:641. 301 Klein AW. complications and adverse reactions with the use of botulinum toxin. Dis Mon. 200;48:336. 302 Trindade de Almeida, et al. Foam during reconstitution does not affect the potency of botulinum toxin Type A. Dermatol. 2003;29:530. 303 Hexsel, DM. et al. Multicenter, double-blind study of the efficacy of injections with botulinum toxin Type

A reconstituted up to six consecutive weeks before application. Dermatol Surg. 2003;29:523. 304 Garcia A, and Fulton JE, Jr. Cosmetic denervation of the muscles of facial expression with botulinum toxin: A dose-response study. Dermatol Surg. 1996;22:39. 305 Carruthers Alastair and Jean. Botulinum Toxin. Procedures In Cosmetic Dermatology. Elsevier Saunders. 2005 306 Fagien, S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: Adjunctive use in facial aesthetic surgery. Plast Reconstr Surg. 1999;103:701. 307 Fagien, S. Extended use of botulinum toxin A in facial aesthetic surgery. Aesthetic Surg. J. 1998;18:215. 308 Foster, J. A. et al. The use of botulinum toxin to ameliorate dynamic lines. Int. J Restor Surg. 1996;4:137. 309 Carruthers, J et al. Consensus recommendations on the use of botulinum toxin Type A in facial aesthetics. Plast and Recon Surg. 114(6) Suppl. 310 Rohrich R. et al. The effect of botulinum toxin injections on the nasolabial fold. supplement to Plastic Reconstr Surg. 2003;112(5). 311 Kane M. The Effect of botulinum toxin injections on the nasolabial fold. Plast Reconstr Surg. 2003;112(Suppl):66s.

256

257

Vermilion Dollar Lips

Index A

adatosil, 103 administration techniques for anesthesia, 66-70, 73-80, 159 for filler placement, 148, 149, 155, 197, 202-204, 205-208, 216, 221-223, 227-229, 231-234 adverse reactions, 88, 95, 106, 153, 154, 167, 248, 256 normal, 88, 95, 153 acne, 153 ecchymosis, 153 erythema, 100, 153 systemic autoimmune disease, 154 diabetes, 154 immunosuppressed patients, 125, 154 recurrent herpes, 153 rheumatoid disease, scleroderma, 154 Tyndall effect, 154 post-augmentation corrections, 156, 157 techniques for post-augmentation corrections, 157, 158, 160 aesthetics cosmetic dentistry, 8, 28, 34, 40, 50-52, 61, 72, 85, 93, 97, 98, 102, 103, 117, 118, 120, 121, 126, 141, 160, 164, 165, 171, 173, 178, 179, 195 practitioners, 2, 6, 121 quantification and qualification, 131 age. See LARS, 34, 56 aging and maturation of the lips, 49, 53, effects, 34, 49, 51-53 extrinsic, 34, 53, 54, 89, 225 environmental, 53 gravity, 53 intrinsic, 34, 52, 53, 89, 225 skeletal/dental, 51 soft tissue, 51

tooth exposure (Table 2.3), 52 face lift vs filler, 54 facial skin, 49 lips, 49 nasolabial line, 49, 51-54 oral-facial, 49, 51 allergy, 64, 93, 100 skin-test for collagen, 100 testing protocols, 100 allies within your practice, 12 AlloDerm, 86, 91-93, 246, 247, 249 allograft, 88, 91-93 alloplastic material, 88 American Association of Tissue Banks (AATB), 91, 92 American Dental Association Council on Scientific Affairs, 64 American Society for Dermatologic Surgery, 103 American Society for Aesthetic Plastic Surgery (ASAPS), 15, 16, 117, 239, 252 Joint Code of Ethics, 16 legal/regulatory issues, 15 American Society of Plastic Surgeons (ASPS), 15, 16, 239 amphiphilic molecules, 63 anaphylactic history, 100 anatomy, 5, 18, 30, 40-43, 52-54, 61, 69, 70, 85, 91, 114, 137, 144, 145, 170, 187, 191, 199, 225, 227, 228, 234, 241, 245, 254 arteries, 46-49 lower lip, 49 upper lip and nasolabial region, 46, 47 musculature, 40 buccinators, 41 depressor anguli oris, 42 depressor labii Inferioris, 42 levator labii superioris, 41 levator labii superioris alaeque, nasi, 41

Index

mentalis, 42 orbicularis oris, 42 risorius, 42 zygomatic major, 42 zygomatic minor, 42 nerves, 44 facial nerve, 45, 45 trigeminal nerve, 44 skeletal/dental, 51 soft tissue, 51, 52 vascularity, 46 anesthesia administration techniques, 46, 66-70 adverse reactions to, 64 allergy, 64 toxicity, 64, 67 armament, 73 Botox and, 61 oral-facial augmentation, 61, 64, 67 lower lip and commissure, 78 buccal nerve block, 78, 79 mental nerve block, 78 nasolabial and upper lip, 73, 74, 78 anesthetic block injection vs infiltrate injection, 69 classification, 63 characteristics, 63 intraoral vs extraoral injections, 69 pharmacokinetics, 61 pKa, 63, 67 topical, 70 Angle EH, 51 antiseptic, topical, 70 antithesis, Darwinian theory of, 15 anthropometry, 123, 252, 253 anxiety disorders, 17, 18 anxiety-related manifestations, 17 Aphrodite Gold, 102 armament, anesthesia, 73 injectable fillers, 132 art of augmentation, 5, 19, 183

Artecoll, 90, 99-102, 249 arteries facial artery (FA), 46, 47, 74, inferior labial artery (ILA), 48, 49 horizontal labiomental artery (HLA), 49 lateral nasal artery (LNA), 47 superior labial artery (SLA), 47-49 columellar branches, 47 vertical labiomental artery (VLA), 49 ArteFill, 99-101, 249 arterial embolism , 153 artist art of augmentation, 5, 6, 19, 25, 35, 183 beautiful proportions, 113, 114 becoming an oral-facial augmenter, 5 enhancing beauty, 5, 6 injection techniques and procedures for filler placement, 43, 44, 85, 140-153 inner placements, 5, 140, 148 asymmetry, 116, 121, 153, 156, 186, 193, 219, 251, 253 audience, 9-11, 111 augmentation art of, 5, 19 business of oral-facial, 7-19 advantages of presenting a live demonstration, 10, 11 external marketing, 8 internal marketing, 8 lip, 6-8, 16, 17, 85, 91, 102, 104, 106, 121, 124, 128, 179, 199, 201, 202, 217, 218, 237, 243, 246, 248, 249, materials, 6, 88 methods, 5, 7, 112, 158 oral-facial, 5-8, 10, 12-15, 17, 22, 25, 55, 56, 59, 61, 64, 67-69, 73, 80, 91, 100, 118, 124, 127, 134, 150, 153, 157, 165, 184, 185,192 perioral, 5, 6, 8, 25, 56, 61, 75, 76, 80, 112, 124, 134, 137, 167, 137, 167, 179, 184, 202, 237

258

259

Vermilion Dollar Lips

learning curve, 6, 89 science of, 6, 7, 19 techniques, 10, 32, 69 augmenter, 5, 7, 19, 25, 27, 29, 32, 34, 36, 37, 39, 53, 61, 62, 69, 83, 85, 97, 102, 105, 107, 120, 124, 127 autograft, 88, 100 autologous cellular therapy, 249 fat. See also lipotransfer, 85, 89, 90, 93, 247 fibroblast, 93 authority, 11 averageness, 116, 117

B

bacteria, 70, 88, 93, 95, 98, 106, 156, 157, 165, 245, 254 beauty enhancing, 5 perception of, 118 beautiful proportions, 113 facial symmetry, 113, 114 divine proportion and lips, 113, 114 beauty and society, 117 becoming an oral-facial augmenter “artist,” 5 bioplasty, 102 blanching of skin after filling, 144, 154, 223 Body Dysmorphic Disorder (BDD) Patients, 18 identifying, managing and referring, 18 questionnaire (BDDQ), 18 Botox additional considerations, 170 adverse reactions, 167 armament, 168, 169 combination therapy, 172-178 contraindications, 166, 195 cosmetic therapy, 165, 168, 171 current usage, 167 history, 165 immunogenicity, 166, 167 and fillers in your cosmetic practice, 7, 8 injection techniques, 169-178 elevating the corners of the mouth

combination therapy, 173 technique, 174 mentalis combination therapy, 174 technique, 176 reducing gummy smile combination therapy, 176 technique, 178 mechanism of action, 165 perioral injection techniques, 169 172 combination therapy, 172- 174 dilution and dosage, 170, 171 technique, 171 pre-treatment precautions, 167 reconstitution and handling, 168 shelf life, 169 gender selection, 169 patient assessment, 169 types, 165 botulinum toxin type A, 15, 165-168 botulinum toxin type B, 165 bovine collagen, 85, 97, 99-101, 248 Brooks V, 165 buttressing effect, 144, 229, 233

C

calcium hydroxyapatite microspheres. See also Radiesse, 89, 90, 102 canvas facial aging, 49 oral-facial anatomy, 40, 52, 53, 54 oral-facial classification, 27-40 planes of the lips, 27, 28, 31, 32 Captique. See also NASHA, xenograft, 91, 92, 95, 98, 246 Carbocaine, 64 carpule, 10, 64, 65, 67, 73, 74, 78 Case CS, 51 case presentation cosmetic diagnosis, 192, 195, 202, 217, 229 history, 192, 195, 201, 217, 229

Index

potential adverse effects and complications, 197 result, 193, 198, 210, 223, 224, 234 therapy, 197, 218, 221, 224, 227, 229, 230, 233, 234, 235 treatment centric relationship, 192, 193, 195, 197, 198 cephalometry, lateral, 121, 123 Chinese mustache. See also marionette lines, 54 Citanest, 64 classification system, dynamics of kinetic and static motion, 26, 35 cleft lip, 28 clinical studies, approved, 16 clinical techniques oral-facial augmentation, 185 outer ring, 186, 192, 197, 201, 202, 206, 218, 229, 231 nasolabial fold, 185, 188, 197, 201, 215, 216, 229, 231, 234, 246, 248 mental fold, 188, 234 marionette lines, 188, 228, 229, 231, 233, 234 jowl folds, 185, 229 inner ring, 186, 192, 197, 202, 218, 229 commissure, 186, 188, 201, 215, 228, 229, 231, 232, 234 lips, 186 clostridium botulinum. See also Botox, 165, 255 Code of Ethics, ASPS and ASAPS’s Joint, 16 cognitive behavioral therapist, 19 collagen, 15, 36, 53, 85, 88-93, 97, 99-101 collagenisis, 93, 102 columella nasi, 30 combination therapy, 172-174, 176, 178 commissure, 6, 10, 32, 33, 43, 44, 46, 49, 78, 124, 126, 147, 148, 173, 174, 185, 186, 188, 201, 215, 228, 229, 231, 232, 234 common fillers, 88

communication, inaccurate, 14 consensus recommendations for NASHA 2006, 157, 254 corners of the mouth, 15, 27, 42, 46, 54, 74, 78, 80, 92, 98, 126, 132, 147 multiple injection, 147 single injection, 147 copyright, 11 cosmetic allies within your practice, 12 dentistry, 6-8, 18, 164 enhancement materials, 14 field, 6 incorporating fillers and Botox, 7 industry, 11, 14, 86 market, 14, 85 minimizing anxiety, maximizing comfort, 17 practice, 7, 11, 15, 17, 18, 237 procedure, 18, 19, 54, 89, 117, 118, 124, 157, 164, 229, 243, 254 cosmetic diagnosis CosmoDerm. See also allograft, 192, 195, 202, 217, 229 CosmoPlast. See also allograft, 88, 92, 93, 247 counterfeit drugs, 16 crosshatching, 148, 149, 216 cross-linkage, for HA production, 97, 99 cross-linking, 97 Cupid’s bow. See also philtrum, 2, 39, 49, 117, 126, 141, 172, 177, 227 Cymetra, 92, 93, 246

D

Da Vinci, 35, 37, 114 delegation of duties, 13 demonstration. See also seminar advantages of presenting a live, 10 tips to remember during your, 11 dental practice, 7 allies within your practice, 12 Dental Practice Act, 15 dentistry, 5-8, 15, 18, 59, 69, 73, 86, 101, 102, 111, 116, 127, 163, 242-

260

261

Vermilion Dollar Lips

245, 252 lip and perioral augmentation, 5, 6, 8, 11, 61, 111, 137 practitioners, 6-8, 11, 12, 14-17, 25, 61, 69, 70, 86, 91, 93, 111, 124, 146, 149-151, 156, 157, 163, 237 dental blocks, 11, 59, 61, 67, 69, 70, 73, 78 dentist, 1, 5, 7, 8, 11, 12, 15, 17-19, 25, 29, 51, 59, 61, 68, 70, 78, 116, 120, 121, 124, 126, 128, 157, 163, 165 dentition, 2, 18, 29, 32, 34, 35, 51, 53, 116, 120, 126, 196, 198, 201 dermal fillers by source, 92 allograft, 88, 91-93 alloplast, 92, 100, 101 autograft, 88 xenograft, 88, 92-95, 99 divine proportion and lips, 113, 114, 116, 118, 134, 251 dynamics of kinetic and static motion in the classification system, 35

E

educating & training a competent staff, 12 Ermengem, E, 165 emergencies, 16 endocytosis. See also Botox, 166 enhancing beauty, 6, 34, 39, 117, 121 environmental effects of aging, 53 epinephrine. See also toxicity, 65, 67, 74 ethics, ASPS and ASAPS’s Joint Code of, 16 evaluation of patient, 8, 156, 170, 173, 191-193, 195, 196, 201, 202, 217 eversion of lips, 167, 169-172 expertise, 6-8, 11-13, 17, 61, 67, 70, 127, 168

F

face lift, defined, 54, 56 facial, 2, 5-18, 21, 22, 25, 27-29, 32, 34, 35, 40, 42-47, 49, 51-56, 59, 61, 64, 66-70, 73-76, 78, 80, 85, 86, 88, 89, 91, 98-100, 102-104, 112-114, 117- 121, 123, 124, 126, 127, 129-131, 134, 141, 143, 144, 148, 150, 152,

153, 156-158, 160, 164, 165, 167- 170, 176, 178, 185, 189, 191-193, 195, 199, 201, 202, 215, 216, 218- 220, 225, 227-230, 234, 235, 239- 243, 246-256 aging, 49, 89 analysis, 126, 132 symmetry, 49, 113, 114, 117, 118, 134, 251-253 nerve, 2, 44-46, 56, 67, 69, 70, 74, 75, 76, 78, 80, 165, 166, 241, 244 buccal, 45, 46, 69, 78, 80 cervical, 46 mandibular, 44-46, 69 temporal, 44 zygomatic, 46, 69 fashion trends of lips, 112 , 117 FDA (Food & Drug Administration), 6, 16, 66, 85, 86, 90, 91, 93, 98, 99, 101, 102, 104, 106, 108, 154, 164, 165, 167, 239, 249 guidelines & regulations, following, 16 off-label drugs or devices, 15, 16, 22, 86, 91, 92, 106, 108, 167, 168 MedWatch system, 105 FD&C (Federal Food, Drug & Cosmetic Act), 16, 86 fibroblast, 52, 89, 93 fibro-conduction, 91 fibro-induction, 91, 93 filler, 2, 5, 7, 8, 10, 12-18, 22, 30, 36, 43, 44, 46, 48, 53, 54, 61, 59, 73, 85, 86, 88, 89-108, 116, 117, 120, 121, 132, 133, 137, 139, 141, 143-151, 153- 158, 164, 165, 167, 170, 174, 176, 178-180, 184, 187, 191, 195, 199, 201, 202, 203, 205, 211, 215-218, 220, 221, 224, 227-229, 231, 233- 236, 239, 242, 245, 246, 247, 249, 250, 254 armament for injectable, 132, 133 syringe, 132 needle, 133 needle gauge, 133 classification, 86, 88-90, 108

Index

source, 88, 92, 99, 100 duration of implant in tissue, 63, 100, 101 temporary biodegradable, 88 semi-permanent, 88, 89, 91, 100, 102 permanent, 53, 89, 90, 100, 101, 104, 108, 153, 154 mechanism of action, 88, 102, 104, 180 stimulateurs, 89 volumateurs, 89 intended use, 88 combination therapy, 172, 173, 176, 178 devices, 15, 16, 106 drugs, 15, 16, 167 facial augmentation, 5-8, 10, 12-14, 15, 17, 22, 25, 29, 54-56, 59, 61, 64, 67-69, 73, 80, 91, 100, 118, 124, 127, 134, 150, 153, 157, 165, 184, 185, 192 FDA classification and use of, 86, 108 histology, 90, 246 history, 85, 86, 88, 108 ideal, 86, 108 injectable dermal, 61 injection techniques, 61, 68, 80, 139-160 combination with Botox, 165, 169, 172-174, 176, 178, 180, 215, 216, 224, 229 elevating the corners of the mouth, 15, 42-44, 132, 173, 174, 234 reducing gummy smile, 43, 176, 195, 197, 198 reducing oral rhytids, 167, 171, 172, 224 nasolabial folds, recommended for, 16, 93, 100 off-label use, 15, 16, 86, 91, 106 permanent vs nonpermanent, 88 PMMA, 89, 90, 100, 101, 102, 249 synthetic materials, 89, 90

Fischer A, 103, 249 flaccidity, from anesthesia, 61, 197 follow-up visits formulation, 88, 97, 108 cross-linking, 10, 92, 93, 95, 97, 98, 99, 108, 132, 150, 156-158, 179, 188, 193, 202, 211, 218, 220, 227, 229, 232, 234, 246, 248, 254 uncross-linked, 97 Fournier PF, 103, 249 freeway space, 40 frustrated macrophages, 103

G

gauge, 68, 74, 93, 98, 101-103, 131-133, 158, 168, 188, 244, gel hardness (G’ @ 1.6 Hz), 61, 97-99, 132, 144 genotypic expression, 123 G-K (Glogau-Klein) point, 52, 170, 173, 202, 210, 222 glycosaminoglycan biopolymer, 94 Global Aesthetic Improvement Scale, 97, 131 glutaraldehyde, 93, 99, 248 Gordon classification, 75, 80, 124 Gordon Modified Block, 75, 80 gortex, 104, 105 granuloma, 85, 90, 101-106, 108, 245-248 pathergy theory, 106, 108 treatment, 108 gravity effect on aging, 49, 51 Gross J, 99, 248 guidelines & regulations, following labeling, 15 general guidelines for use of filler devices, 16 gummy smiles, 42, 43, 167, 176, 178, 195, 197, 198

H

histology, 246 stimulateurs, 89 volumateurs, 89 five filler classifications, responses, 90

262

263

Vermilion Dollar Lips

history of fillers, 85 HIV, 15, 92, 104, 239, 250 infected patients, 15 related facial lipoatrophy, 15 human collagen, 91, 93 hyalos, 94 hyaluronic acid (HA). See also NASHA, xenograft, 10, 14, 15, 86, 88, 90, 94- 99, 102, 108, 132, 153, 156, 157, 242, 247, 248, 254 hydrostatic equilibrium, 98, 144 hygienist, 12 Hylaform. See also NASHA, xenograft, 91, 95, 98, 101, 246-248 hylan. See also NASHA, xenograft, 95, 246, 247 hypersensitivity reactions, 90, 95, 100

oral-facial skin, 148, 149 pearl placement, 149 crosshatching, 149 nasolabial fold, 149 mental fold, 149 technical considerations, 149-151 injector, 55, 61, 68, 106, 159 intralesional corticosteroids. See also granuloma, 108 isalogen, 93, 100

I

kinetic, 29, 30, 35, 40, 52, 85, 120, 129, 130, 131, 149, 169, 178, 227, 229, 240, 242, motion, 32, 35, 169 movements, 30, 34, 56, 85, 126, 149, 216 position, 35, 120, 149, 218 smile, 35, 129 state, 29, 35, 120 Kirk D, 99, 248

immune reactions, 97 responses to dermal implants. See also granuloma, 85, 90, 101-106, 108, 245-248 incompetent lip, 29, 37, 39, 40, 145 causes, 40 dental, 40 skeletal, 40 soft tissue, 40 inductive interaction, 91 injection, block injection vs infiltrate, 69 delivery of injectable anesthetics, 67-70 perioral injection techniques, 169-178 injection techniques and procedures, 139- 160 adverse reactions and complications, 153, 154 injection techniques for the lips, 141 lower lip, 141 upper lip, 141 inject slowly, 141 philtrum filling, 144, 145 vermilion border filling, 144 perioral lines (rhytids), 145, 146 corners of the mouth, 147, 148

J

Juvéderm. See also NASHA, xenograft, 88, 91, 92, 95, 97-99, 101, 202, 220, 229, 234

K

L

LARS, 34, 56 lip length, 34 age, 34 race, 34 sex, 34 LBL (line between the lips), 35, 37, 39 presentations, 37, 39 downward arch, 39 incompetent lip (open lip), 39 common causes dental skeletal soft tissue straight across, 39 upward arch, 39

Index

learning curve, 6, 89 journey, 6 legal/regulatory issues, 15, 16, 239 Leonardo da Vinci, 35, 37 lidocaine, 63, 67, 68, 93, 100, 101, 244, 245 lip augmentation, 6-8, 16, 17, 85, 91, 102, 104, 106, 121, 124, 128, 179, 199, 201, 217, 218, 237, 243, cleft lip, 28 commissure and lower, 78-80 divine proportion and, 113, 114, 116, 118, 251 fashion trends, 113, 117 Gordon classification, 124 ideal, 118, 179 incompetent, 29, 37, 39, 40, 145 LARS: length, age, race, sex, 34, 56 line between (LBL), 35, 37, 39 nasolabial and upper, 46, 47 philtrum, 32, 49, 191, 234 planes, 27, 28, 31, 32, 36, 72, 85, 141, 179, 191, 193, 211, 215, 224 profile position measurement, 124 projection, 121, 133 psychology of the, 15, 17-19 quiz, 9, 10 scars, 98, 99, 128, 153, 154, 154, 158 segments, 27, 28, 31, 32, 35, 39, 50, 72, 141, 155, 191-193, 202, 211 218, 222, 229, 234 static or kinetic state, 29, 35, 120 vermilion border, 27, 30, 32, 37-39, 47, 49, 52, 91, 133, 144, 146, 150, 151, 169-172, 187, 191, 199, 202, 205, 207, 218, 220, 222, 225, 227, 234 lipoatrophy. See also Sculptra, 15, 104, 239, 250, lipotransfer, 88, 100, local anesthetics. See also anesthetics, 61, 63, 64, 67, 68, 73, 243, 244 armament for delivering, syringe, 67, 68,

73 techniques, 61, 67, 68, 73, 74, 78, 80, nasolabial and upper lip, 73 modified infraorbital nerve block, 75, 76, 78 lower lip and commissure, 78, 80 mental nerve block, 78 long buccal nerve block, 78 Lombardi RE, 116, 251 lower lip, 27, 32, 34, 35, 41-44, 46, 48, 49, 50, 52, 78, 91, 114, 116, 118, 120, 124, 132, 134, 141, 142, 146, 168, 170, 178, 191, 192, 195, 207-209, 219, 222, 227, 228, 241

M

marcaine, 63, 64 marionette lines, 33, 54, 91, 107, 168, 185, 229, 231, 233, 234 marketing, 8, 11, 12, 15, 22, 86, 102, 113, 125 external, 8, 11, internal, 8, 11, 22 your cosmetic lip and perioral practice, 11, 12 maxillary, 32, 34, 35, 37, 39, 40, 44, 51, 52, 78-80, 116, 195, 197, 198, 211, 243, 245, central incisors, 32, 34, 52, 54, 56 dentition, 32, 34, 35, 51, 53, 116, 120, 126, 198, 201, division (V2), 44 labial, 30 lip length, 34 maximizing patient comfort, 17, 18 medical/legal issues, 22, 91, 165 medium, the, 81-108 Botox, 85 categorized by source, dermal, 88 common fillers, 88 FDA classification and use of fillers, 86 history of fillers, 85 ideal filler, 86 off-label use, 91 measurement tools

264

265

Vermilion Dollar Lips

profile lip position aesthetic quantification and qualification Global Aesthetic Improvement Scale, 97, 131 Rated Numeric Kinetic Line Scale, 131 Rubin Smile Classification, 131 Wrinkle Severity Rating Scale, 98, 131 Wrinkle Improvement Scale, 131 mepivacaine, 63, 64 Metacrill, 102 metrosexual, 118, microspheres, 90, 100-102, 108, 249 minimizing patient anxiety, 17, 18 minocycline. See also Granuloma, 108 Mona Lisa, 35, 37, 132 muscles of facial expression, 35, 40, 43, 44, 46, 61, 67, 69, 70, 228, 256 musculature, 34, 40, 46, 49, 54, 69, 127, 155, 169, 241 buccinators, 41, 44, 46 depressor anguli oris, 42, 43, 46, 61, 173, 174, 178, 229-231 depressor labii inferioris, 41, 42, 46 levator labii superioris, 40, 41, 43, 46, 132, 176, 178, 195 levator labii superioris alaeque nasi, 40, 43, 176, 178, 195 mentalis, 41, 42, 46, 126, 167, 168, 176, 178 orbicularis oris, 41-43, 46-49, 85, 145, 155, 169-171, 176, 220 risorius, 43, 44 zygomatic major, 40-43, 46, 132, 178 zygomatic minor, 42, 178

N

NASHA (non-animal stabilized hyaluronic acid), 98, 99, 157 degradation, 99 formulation, 97 cross-linking, 10, 92, 95, 97-99, 108 uncross-linking, 97 hydrostatic equilibrium, 98, 144

products. See also xenograft, 16, 64, 88, 90, 91, 93, 94, 97, 101, 108, 117, 150, 167, 192, 193, 202, 227, 234 nasolabial line (the smile line), 44, 49, 51, 53, 91, 168, 189, 213, 216 nasolabial or mental fold, 10, 16, 29, 33, 41- 43, 75, 85, 91, 93, 98-100, 105, 107, 120, 128, 133, 148-150, 176, 178, 184, 185, 188, 197, 198, 201, 215, 216, 229, 231, 234, 246, 248, 253, 256 needle gauges. See also gauges, 68, 133, nerves, 44-46, 67, 69, 74, 241 facial nerve, 45, 46, 67 trigeminal nerve, 44 ophthalmic division (V1), 44 maxillary division (V2), 44 mandibular division (V3), 45 motor root, 44 sensory root, 44 neocollagenesis, 104 Neuber F, 85, 245

O

octocaine, 64 off-label, 15, 16, 86, 106, 108, 167, lip fillers, 92 use, 86, 91, 106, 168 oral-facial, 2, 5-8, 10-18, 22, 25, 54-56, 59, 61, 64, 66, 80, 112, 113, 123, 126, 130, 134, 143, 153, 160, 165, 184, 185, 189, 191, 199, 225, 229, aging 49, 89 facial skin, 40, 53, 148, 168, 215, 216, 225 lips, 34, 35, 41, 49 the effects of, 34, 49, 89, 146, 147, 229, skeletal/dental, 51 soft tissue, 51, 52 anatomy, 15, 18, 30, 40, 52-54, 61, 69, 70, 85, 91, 114, 137, 144, 145, 170, 187, 191, 199, 225, 227, 228, 234, 239, 241, 245, 254 arteries, 46-48, 49, 74, 153, 241,

Index

245 musculature, 34, 40, 46, 49, 54, 69, 127, 155, 169, 241 nerves, 2, 44-46, 56, 61, 63, 67, 69, 70, 74-76, 78, 80, 166, 241, 244 skeletal/dental, 34 soft tissue, 12, 25, 29, 34, 40, 45, 49, 51, 52, 63, 69, 74-76, 95, 99, 101, 102, 121, 123, 124, 126-129, 151, 159, 164, 170, 191, 195, 201, 230, 239, 240, 243, 246 250, 254 vascularity, 46, 48, 97, 156 augmentation, 5-8, 10, 12-15, 17, 22, 25, 55, 56, 59, 61, 64, 67-69, 73, 80, 91, 100, 118, 124, 127, 134, 150, 153, 157, 165, 184, 185,192 clinical techniques, 184-236 perioral, 5, 6, 8, 11, 18, 22, 25, 29, 30, 42, classification, 27-40 planes of the lips, 27, Gordon lip and perioral classification, 75, 80, 124 inner ring, 33 outer ring, 33 static vs kinetic lips, 29, 30 segments of lips (kinetic), 35 dynamics of kinetic and static motion in the classification system, 35 line between the lips (LBL), 35, 37 segments of lips (static), 32 zones and segments of the lips, 31 zones of the lips, 27-33 maxillary labial, 30 mandibular labial, 32 skin, 148, 149 pearl placement, 149 crosshatching, 149 nasolabial fold, 149

mental fold, 149 trauma, 2, 51, 53, 86, 88, 126, 141, 147, 148, 150, 153, 158, 201, orthodontics, 51, 121-124 overfill of the lips, 2, 30, 29, 35, 98, 120, 144, 145, 155, 189, 195,

P

Pacioli, Luca, 114 Palmer, Karl and John, 94 Pathergy Theory, 106, 108 Patient assessment, 169, 170, 243, BDD, identifying, managing and referring 18,19 interaction with, 13 minimizing anxiety, maximizing comfort, 17 perception of beauty, 118-121 periodontics, 91 perioral, augmentation, 5, 6, 8, 22, 25, 56, 61, 75, 76, 80, 112, 124, 134, 137, 167, 179, 184, 202, 237 learning curve, 6, 89 lip and, 5, 6, 8, 11, 22, 25, 29, 30, 56, 59, 61, 62, 74-76, 78, 80, 83, 112, 124, 134, 137, 160, 167, 179, 180, 184, 201, 237 Botox cosmetic therapy, 165 injection techniques for Botox, 169- 178 rhytid removal, 171, 172 chemical peel, 172 filler injections, 172 laser resurfacing, 172 permanent fillers, inherent drawback, 89 fashion trend changes, 89 host immune response, 89 facial aging, 89 technical error, 89 technological advances, 89 Phidias, 114 philtrum, 30, 32, 39, 40, 49, 52, 120, 126,

266

267

Vermilion Dollar Lips

144, 145, 187, 188, 191, 234 photoaged dermis, 53 photographic documentation, 128-130 pharmacokinetics, 61 pKa, 63, 67 planes of the lips, 28, 31, 36, 179, 211 PMMA (polymethylmethacrylate), 89, 100- 102, microspheres, 90, 100 techniques for PMMA placement, 102 PMS, 103, 104 points to ponder on using filler agents, 106 Polocaine, 64 post-augmentation care, 157 post-treatment supervision, 16 Polytetrafluoroethylene (e-PTFE), 104, 105, 250 practitioner, 6-8, 11-17, 25, 59, 61, 69, 70, 83, 86, 91, 93, 112, 124, 137, 149 151, 156, 157, 164, 237, 244 pretreatment, 124, 167 consultation, 124, 125 precautions, 15, 91, 167 precise, 7, 61, 69, 70, 74, 102, 170, 173, 234, presentation, lip and perioral augmentation, 8 procedures, 5-15, 17, 18, 67-70, 74, 89, 91, 95, 100, 101, 106, 117, 121, 124, 143, 150, 156, 157, 164, 220, 227, 229, 241, 245, 250, 254, 256 delivering anesthetic, 73 profile lip position measurement, 124 projection, 120, 121 proportion. See also Gordon classification, 21, 30, 32, 62, 87, 98, 113, 114, 116, 117, 121, 123, 124, 127, 134, 137, 155, 179, 192, 195, 196, 201, 202, 229, 251 divine, 113, 114, 116, 118, 134 points of reference for lip, 124 protrusion, 51, 124, provider qualifications, 15 psychological disorders, 18, 19 psychology of the lips, 15

ptosis, 54, 167

Q

qualifications, provider, 15

R

race. See also LARS, 34 Radiesse. See also Alloplastic, 88, 90, 100, 102, 103 Rated Numeric Kinetic Line Scale, 131 re-importation, 16 recurrent herpes, 153 resterilization or recapping syringe, 156 Restylane. See also NASHA, xenograft, 16, 88, 91, 92, 95, 97, 98, 153 retrusion, 124 rheumatoid disease, scleroderma, 154 rhytids, 30, 92, 100, 126, 133, 145, 146, 167, 169, 170, 186, 187, 189, 213, 217-219, 224, 227 Ricketts RM, 51, 242, 251 Rubin Smile Classification, 132 canine smile, 132 full denture smile, 132 Mona Lisa smile, 132

S

scandonest, 64 scales Global Aesthetic Improvement Scale, 97, 131 Rated Numeric Kinetic Line Scale, 131 Wrinkle Improvement Scale, 131 Wrinkle Severity Rating Scale, 98, 131 scars, treatment of visible and nonvisible, 158, 160 sequential filling, 150, 160 subcision, 158, 160 tissue, 2, 12, 153 science of augmentation, 6, 7 scientist, inner, 5 Scott A, 165, Sculptra, 15, 104, 239 segments of the lips, 27, 28, 31

Index

seminar. See also demonstration. See also presentation, 8-12, external marketing, 8 lip and perioral augmentation, 11 sensitivity, 17, 88, 90, 93, 95, 100, 244 Septocaine-Septodont, 64 sex. See also LARS, 34 Shantz, Dr. 165 silicone, 85, 89-91, 103, 104, 154, 202, 245, 250 silikon, 103, 104 Silskin, 104 skeletal, 2, 25, 29, 30, 34, 37, 40, 49, 51, 121, 123, 124, 126, 191, 195, 225, 239, 243 ski-jump, 52 skin test, 100 skin thickness, 53, 104, 153 smile, 2, 6, 9, 15, 29, 30, 35, 40, 42, 43, 49, 53, 80, 101, 118, 120, 126, 129, 132, 167, 176, 178, 195, 197, 198, 202, 228, 240, 241, 253, 254 Darwinian Theory of Antithesis, 15 Rubin Classification, 132 Society for Aesthetic Plastic Surgery, 15, 16, 117, 118, 252 soft tissue, 12, 25, 29, 34, 40, 45, 49, 51, 52, 63, 69, 74-76, 95, 99, 101, 102, 121, 123, 124, 126-129, 152, 159, 164, 170, 191, 195, 201, 230, 239, 240, 243, 246-250, 254 softform, 104 squamous epithelium. See also philtrum, 145, 148 staff, 10, 12-14, 19, 68 delegation of duties, 13 educating & training a competent, 12 hygienist, 12 static, 29, 30, 32, 35, 37, 56, 120, 126, 129, 130, 149, 169, 170, 176, 178, 216, 218, 227, 252 motion, 32 position, 29, 30, 35, 37, 56, 120, 126, 129, 130, 149, 218 state, 14, 15, 29, 35, 49, 95, 120

Stegman SJ, 99, 248 Steiner’s Angle, 52 steroid therapy, 105, 108 studies, approved clinical, 16 supervision, 15 post-treatment, 15, 16 non-physician personnel, 15 symmetry, 49, 113, 114, 116-118, 134, 251, 252, 253 synthetic filler materials, 103 systemic adverse reactions, 153-156 syringe, 5, 10, 11, 73, 93, 97, 99, 100, 103, 132, 133, 144, 156, 157, 168, 175, 188, 193, 229, 234, 254

T

Tables 2.1 maxillary lip length, 34 2.2 muscles of facial expression, 43, 44 2.3 aging tooth exposure, 52 3.1 anesthetic classification (dental), 63 4.1 types of off-label lip fillers, 92 4.2 fillers recommended for nasolabial folds, 100 5.1 top ten list of medicinal herbs, 125 7.1 injection points, 178 8.1 select needle sizes, 188 8.2 relationship between augmentation and age, 188 technical considerations with injection fillers, 149-151, 153 bevel orientation, 151 combination fill technique, 150 filler amount, 151 filler material, 153 lip/face swelling during augmentation, 150 magnification, 149 massaging of the material, 151 material expression, 151 selecting layer for injection site, 150 speed of injection, 149 sequential fill technique, 150 stretching the lip, 151 time allotment for injection, 150

268

269

Vermilion Dollar Lips

Techniques, 135-153, 161-169 clinical, oral-facial augmentation inner ring, 192, 197, 201, 218 commissure, 186 lips, 186 outer ring, 192, 197, 201, 218 jowl folds marionette lines, 168, 185, 228 mental fold, 149 nasolabial fold, 149 corners of the mouth, 147 multiple injections, 147 single injection, 147 cross-linkage, for HA production, 95 injections for the lips, 141 lower lip, 141 philtrum filling, 144 perioral lines (rhytids), 30, 145 upper lip, 141 vermilion border filling (Zone A), 144 injection techniques with Botox, 169 combination with fillers, 172 elevating the corners of the mouth, 173 reducing gummy smile, 176 reducing oral rhytids, 167, 169, 170, 177, 224 oral-facial anesthesia, 59, 61-70, 73 perioral injection for Botox, 169 establishing a desired eversion of the lip, 169 increase in lip surface area, 169 removal of kinetic rhytides, 169 PMMA placement, 102 post-augmentation correction, 157 aspiration, 158 incision, 158 palpable redistribution of filler, 157 resterilization or recapping syringe, 156 subcision, 158, 160 touch-up, 131, 155, 156, 193 technology, take advantage of today’s, 11 temporomandibular dysfunctions, 51

Tips combination therapy, 172-178 delivery of injectable anesthetic, 67 gel hardness (G’ @ 1.6 Hz), 97 topical anesthetic, 70, 151 topical antiseptic, 70 extraoral, 32, 69-70, 78, 80, 86 intraoral, 69-70, 78, 80, 92, 128, 159 toxicity, 64, 67, 125 training a competent Staff, 12 trigeminal nerve, 44 mandibular division (V3), 44-45 long buccal branch, 46 mental branch, 46 maxillary division (V2), 44 motor root, 44 ophthalmic division (V1), 44, 94, 103 sensory root, 44 Tromovich TA, 99 Tyndall effect, 154, 155, 169

U

Ultrasoft, 104, 105 underfill of the lips/voids in lips, 155 upper lip and nasolabial region, 27, 32, 34 35, 39-44, 47, 49-52, 72-75, 91, 114, 116, 120, 124, 132, 141, 146, 170 172, 178, 191-193, 197-199, 201, 206-208, 217, 219, 227

V

Vermilion Dollar Lips art of the fill, 5, 7, 22, 30, 110, 120, 124 border, 27, 30, 32, 35, 37-40, 42-44, 46-47, 49, 52, 54, 61, 91, 126, 133, 144, 146, 150-151, 169-172, 174, 178, 187, 191, 198-199, 202, 205, 207, 218-220, 222, 225, 227, 230, 234 business of oral-facial augmentation, 7 instructional format, 7 medical/legal issues, 14 perioral augmentation, 1, 5-6, 8, 22, 25, 56, 61, 75-76, 80, 112, 134,

Index

137, 167, 179, 184, 202, 237, 238 philtrum, 30, 32, 39, 40, 49, 52, 120, 126, 144-145, 187-188, 191, 234 psychological issues, 22 sequential filling, 150, 160 subcision, 158, 160 visible and nonvisible scars treatment, 158, 160

W

Wrinkle Improvement Scale, 131 Wrinkle Severity Rating Scale, 98, 131

X

xenograft, 88, 92, 93, 94. 95, 99 Xylocaine, 63, 64

Z

zones of the lips, 32, 144 mandibular labial, 32 maxillary labial, 30 Zyderm. See also xenograft, 88, 92, 93, 99 100 Zyplast. See also xenograft, 88, 92, 93, 99, 100, 102

270