In the second of his two-part article, Dr Lee Walker provides technique advice for treating the perioral area

As detailed in my previous article, the clinical outcomes for lip augmentation are defined by the patient’s unique anatomy, injection technique and the type and amount of filler used.

I have discussed why it is vital to consider the relevant anatomy for lip augmentation and how careful considerations must be made when selecting patients. This article will look at some of the different types of fillers that can be used to treat the perioral area and will explain the techniques for enhancement.

Product and instrument selection

When performing lip rejuvenation, reversible hyaluronic acid fillers pre-filled with lidocaine are the product of choice for most practitioners. Some of the brands of fillers available and suitable for lip augmentation, which I have used, are detailed below.

Juvéderm VOLBELLA

Juvéderm VOLBELLA is a soft product, designed for subtle lip enhancement. It incorporates short and long chain hyaluronic acid to enhance the crosslinking without increasing stiffness. This makes it a good filler choice for those patients seeking a subtle look with a softer feel. The manufacturer claims that results last 12 months.¹

Belotero Intense

Belotero Intense is a thicker yet elastic product that can still be injected through a small gauge needle. I have used this product in patients requesting ‘fuller’ more voluptuous lips. The manufacturer claims that results last six to nine months.²

Emervel Lips

Emervel Lips is formulated to enhance, define or augment the lip body and border. The product is designed to be altered via a combination of factors, including the levels of cross-linking and particle sizes, which aim to have a maximum effect in the different layers of tissue into which they are injected. In my experience, this can be suitable for those patients who want a ‘fuller’ appearance without looking too big. The manufacturer claims that results last six to nine months.³

Teosyal RHA

Resilient hyaluronic acid (RHA) is a dynamic gel with high strength and stretch capacity. Teosyal RHA comes in 1,2,3 and 4 according to its simplicity, but for lips, I recommend using RHA 2 and RHA 3. According to the manufacturer, RHA 2 should be used in patients wanting a ‘natural’ appearance as it has less viscosity and firmness than RHA 3, whilst those demanding ‘fuller’ or ‘pouty’ lips are better treated with RHA 3. The manufacturer claims that results last approximately 12 months.⁴

Filler suitability

When selecting a suitable filler for the lips, the following factors must be taken into consideration:

• Longevity: it is important to advise the patient how long a product is expected to last for, and explain that this is not guaranteed in order to successfully manage their expectations
• Crosslinking technology: relates to longevity and propensity to swell
• Cost: patient needs to be aware of financial commitment
• Company support: specific product knowledge and training/marketing is essential
• Reversibility: ensures a safety net incase of vascular accident or other filler-associated complications; you should have an emergency kit including hyaluronidase on site
• Strong clinical study evidence: ensures a safe, evidence-based choice
• Previous patient experience of product: if a patient has had good clinical results with a certain product and is happy with it, do not use something else as they may be unhappy with the new product

Cannula or needle?

In my opinon, the decision to use a cannula or a needle depends on the part of the lip that is being treated. As needles are thinner, I believe they are best used to define the vermillion border, recreate the philtral columns, lift the oral commissure, volumise the lip in the sub vermillion area, efface oral rhytids and create lateral protrusions in the lower lip. In my experience, cannulas are best used in patients with thin lips where product needs to be placed behind the muscle; the rationale behind this decision is based on the position of the labial arteries, which usually reside behind the muscle. The use of a 25g cannula will help to reduce the risk of intravascular accident in this highly perfused area. I have found that placement of filler behind the muscle gives a forward projection, helping to evert the lip.

Lip augmentation techniques

There is no single technique that fits every lip, and each practitioner will have his or her own approach to treatment. Below are the factors of which I follow when it comes to lip augmentation:

Visually assess the lip in 3D: i.e. the lateral and frontal view. This will give an idea of projection required. For an attractive lip, the upper lip should project around 2mm further than the lower lip.⁵ 

Assess the smile: if the patient has a ‘gummy’ smile and the lip disappears upon smiling then consider botulinum toxin injections to soften the action of the lip elevators. I have found that for best results, it should be a deep injection, 1cm lateral to the lateral alar of the nose. If the patient has an active depressor anguli oris, contributing to a downturned mouth, also consider treating this muscle with botulinum toxin to prevent a downward pull of muscle on the corners of the mouth.

Determine the amount of filler: agree with the patient the amount of filler that will be used. It is important to not over or underfill the lip (amount is case dependent). For example, overfilling the upper lip can create a ‘duck lip’ appearance, which is usually not regarded as aesthetically appealing. I do not use more than 1ml per visit to prevent overcorrection and reduce the risk of vascular compression.

Enhancement or restoration: ask if the patient is seeking enhancement or restoration – this usually depends on the patient’s age – to ensure that you understand their expectations of treatment.

Age appropriateness: ensure that the lips are ‘age appropriate’. I advise not to try to create the lips of a 25 year old on a 60-year-old patient.

In patients showing signs of ageing: treat the perioral complex and not just the lip. To do this, use filler to turn up the corners of the mouth at the oral commissure, to treat oral rhytids and to restore volume in the cutaneous lip and chin area. Botulinum toxin in the mentalis and depressor angular oris can be used to reduce hyperkinetic activity of mouth depressors.

Consider the vermillion border: consider using low viscosity filler when treating the vermillion border. This can create a very sharp and well-defined demarcation by creating maximum light reflection without distorting the delicate lip architecture (Figure 1).

Consider single lip treatment: only treat the upper lip as a single unit if there is significant volume discrepancy with the lower lip (Figure 2).

Cupid’s bow: I do not recommend injecting the Cupid’s bow with filler. I instead recommend injecting the Glogau-Klein point in the vermillion border. In my experience, injection directly into the Cupid’s bow may lead to a flattening of this delicate and desirable feature (Figure 3).

Cannula use: use cannulas to place filler behind the muscle in thin, older lips as, in my experience, placement in this area acts as further dentoalveolar support to the inverted lip. When it comes to cannula use, I find it is best to first volumise and then shape, which can take 3-4ml to achieve adequate support, which I would perform over multiple visits. The patient must understand the progressive nature of restoring thin, aged lips and that treatment may take as long as 12-18 months. When it comes to size, I use a 25g cannula for lip treatment. I have found that any gauge smaller than this has the potential to ‘skewer’ larger vessels.

Everting upper lip: if the goal of treatment is to evert the upper lip, treat the vermillion border and the area 2mm below it (subvermillion). In my experience, an amount of 0.4ml in total usually suffices but this can be patient dependent.

Treating ‘lipstick bleeds’: treat by injecting the vermillion border with a ‘firmer’ filler. This approach can be very effective and usually has the added benefit of everting the lip and defining the Cupid’s bow (Figure 4).

Increasing pout: if the patient requests a more defined pout, I first mark out the boundary of the pout. This usually equates to the line drawn from the external nares. Filler is then placed inside the lines to accentuate the pout. Centrelines are also drawn to ensure symmetry (Figure 5).

Vermillion border treatment: when treating the vermillion border from its lateral aspect, the needle must be placed superficially. The superior labial artery runs along the vermilion border of the upper lip to the facial sagittal midline at a depth of 3mm.5

Philtral column injection: injection of the philtral columns must also be superficial due to the position of the columellar vessels.