Combination of injection methods in the correction of age-related changes in the lips

What do we know today about skin aging? A modern approach to the aging process can be formulated in the following postulates:

• age-related skin changes are the result of many factors, which are conventionally divided into two groups - internal and external;
• the most effective solution to the problem of skin aging is the use of combined techniques;
• Skin aging should be approached from a three-dimensional (3D) perspective and in the context of soft tissue volume loss.

Modern technologies and products used in aesthetic medicine have specific indications (Table 1).

Table 1. Indications and methods for solving problems in aesthetic medicine

One of the delicate areas of the face where age-related changes appear is the perioral zone and, in particular, the lips.

Criteria for youthful lips

Lips are the main aesthetic focus of the lower third of the face. Clearly defined, voluminous lips are a sign of youth, health, attractiveness and sexuality. Despite the fact that different historical eras have their own aesthetic standards, which means that the shape of the lips is also subject to fashion, it is still possible to determine the main criteria that reflect the most natural shape of the lips.

These criteria include:

• the presence of a “Cupid’s arch” in the central part of the upper lip;
• the lower lip is normally 1.6 times thinner and longer than the upper lip;
• The corners of the mouth should normally be raised upward.

Proportional lips must meet the following anatomical criteria:

• the line of the eyes and the line of the lips should be parallel;
• distance from the nose to the upper lip – 18–20 mm;
• the distance from the lower lip to the chin is 36–40 mm.

The following guidelines also help a specialist assess the proportions, volume and shape of the lips:

• Steiner's line - a line from the tip of the nose to the chin (should touch the upper and lower lips);
• the nasolabial angle varies between 85–105°;
• at the central point the upper lip is slightly upturned (Glogau-Klein point).

Age-related changes

The aging process of the lips is determined, first of all, by the anatomy and physiology of this zone, as well as the increased sensitivity of the lips and perioral area to the effects of external and internal factors.

The action of external factors (exposure to UV rays, smoking) causes the formation of “purse-string” wrinkles and perioral linear hyperpigmentation along the upper lip. Aging of the lips due to external factors is also manifested by the loss of a clear border of the red border. At the same time, patients complain that the lipstick on the border of the red border is not fixed and is blurred in the direction of the vertical wrinkles of the upper lip in the form of rays.

Signs of age-related changes include loss of volume, fullness of the lips, flattening of the red border (loss of relief), lengthening of the upper lip. To the loss of volume should also be added a persistent spasm of the orbicularis oris muscle (m. orbicularis oris) and shortening of the muscle that lowers the angle of the mouth (m. depressor anguli oris).

As a result of a competent integrated approach, age-related changes in the lips can be corrected.

An effective combination

Optimal correction of age-related changes in the lips is achieved using a combination of botulinum toxin A injections and fillers.

The question of choosing a filler - absorbable or non-absorbable - is no longer a subject of debate. The argument in favor of absorbable fillers is the minimal risk of side complications. And since there is a fashion for the shape of lips, like many other things, lips that have been formed once and for all can look like a caricature in 10–15 years. Working with absorbable fillers allows the specialist to be flexible and change the filling technique depending on the degree of evolutionary changes in a given specific age period. Of the absorbable fillers, hyaluronic acid gels provide the required volume, are safe, and easy to use.

When introducing the gel into the lip area and perioral zone, almost all techniques are used: linear, retrograde, serial papular, mesh. At the same time, do not forget the main principle of injection: inject slowly and control the result upon close examination.

During the research, it was found that the introduction of hyaluronic acid gel can increase the synthesis of type I collagen. A possible mechanism for this process is indirect stimulation of fibroblasts by hyaluronic acid. An increase in collagen synthesis in response to the introduction of hyaluronic acid can explain the fact that with repeated procedures, the gel filler is retained in the tissues longer, and the volume required with repeated injections decreases.

Carruthers J. et al (Dermatol. Surg., 2003, 2010) showed that when working with the lips and in the perioral zone, botulinum toxin and hyaluronic acid in combination give a better and more lasting effect than any of these methods used in isolation. It has been proven that hyaluronic acid gel is absorbed 2 times slower if botulinum toxin is administered simultaneously with the gel.

Injections of botulinum toxin and filler can be performed on the same day, or the filler can be injected first, and botulinum toxin 10–14 days later.

Moreover, relaxation of the orbicularis oris muscle with botulinum toxin helps maintain a fixed position of the gel, and the risk of its displacement is minimized. There is also an opinion that you can get a good result without the injection of filler, with just one injection of botulinum toxin. However, patients often refuse botulinum toxin injections in the perioral area, citing difficulties in articulation and eating against the background of pronounced relaxation of the orbicularis oris muscle. Definitely, the administration of botulinum toxin is unacceptable for actors, lecturers, and public people. In real life, a specialist more often has to refuse botulinum toxin or reduce the dose of botulinum toxin to a minimum, and solve the problem of wrinkles using various methods of introducing filler, as well as combining gels of different densities.

Another argument in favor of the simultaneous use of fillers of various densities is as follows. As histological studies have shown, the division of techniques according to the depth of introduction (upper or deep part of the dermis) is quite arbitrary. The injection technique, unfortunately, does not allow us to guarantee precise localization and fixed location of the gel at a certain depth. As a rule, the entire thickness of the dermis becomes involved in the filling process, so it is very important to use a plastic filler that will not overcorrect and will look natural.

In patients receiving filler for the first time, the first injection may not always give an immediate and ideal result. The formed fibrosis prevents the uniform distribution of the filler. The gel can form something like granulomas, alternating with “voids” in the soft tissues. In such cases, the filler injection procedure should be repeated after 2–3 months. The second procedure will allow you to correct and supplement the missing volume.

In cases where there is no clear line of the red border of the lips, the patient should be recommended to first get a tattoo, and only then restore the lost volume of the lips using filler. In this case, working with filler is much easier, and the dermatocosmetologist does not need to “invent” the contour of the red border himself.

Botulinum toxin injections, which relax the orbicularis oris muscle, help “set” the filler and allow the gel to take the desired shape. It is optimal to inject botulinum toxin into standard points on the upper lip in the projection of purse-string wrinkles (1.25 units per point). It is also advisable to treat m. depressor anguli oris and m.mentalis.

Lifting the corner of the mouth complements the lip rejuvenation effect. However, spasm of the mental muscle can also appear at a young age, thereby contributing to the early formation of purse-string wrinkles.

Persistent and prolonged spasm of the mentalis muscle can lead to the formation of chin asymmetry. In this case, volumetric correction of the chin with hyaluronic acid gel may be required, which must also be supplemented with botulinum toxin fixation. The gel is injected in a large volume (at least 1.5 ml) and is located above the periosteum. It is possible to use the technique of supporting columns along the arch of the lower jaw. An additional rejuvenation effect is also created by smoothing out irregularities in the perioral area.

Thus, correction of age-related changes in the lips should not be limited only to the introduction of filler into the area of the red border of the lips. An integrated approach is required using at least two techniques - botulinum toxin and contouring, as well as a combination of filler injection into the middle, deep part of the dermis, subcutaneously or supraperiosteally.

First published:

KOSMETIK international journal, No. 4 (46), 2011

Author: Yana Goncharova – Candidate of Medical Sciences, Associate Professor of the Department of Dermatovenereology and Cosmetology of the FIPO Donetsk National Medical University. M. Gorky, director of the aesthetic medicine clinic “Lege Artis” (Ukraine, Donetsk).