Introduction
The use of dermal fillers to correct signs of facial aging such as wrinkles and contour defects is the second most commonly performed cosmetic procedure in the United States today, according to the American Society for Aesthetic Plastic Surgery. This is largely due to increased patient demand for less invasive treatment options and product innovations that have allowed for prolonged duration of treatment effects. Dermal fillers can be used to enhance appearance in a subtle, natural way; require short recovery times; and can be safely performed in the outpatient setting. Consequently, they have become a mainstay of minimally invasive facial rejuvenation procedures.
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There are numerous injectable products available for facial soft-tissue augmentation. These products, known as dermal fillers, vary by composition, duration of action, palpability, ease of administration, complications, and other factors. It is not within the scope of this chapter to review all dermal filler products but rather to help primary care professionals get started with products and techniques that consistently achieve good outcomes and have low side-effect profiles.
The most versatile dermal fillers currently available are the hyaluronic acid (HA) products. HA is a naturally occurring glycosaminoglycan in the dermal extracellular matrix that provides structural support, nutrients and, through its hydrophilic capacity, adds volume and fullness to the skin. With aging and photo damage, HA is lost from the skin. Injectable HA can temporarily restore dermal volume and correct facial lines and contour defects.
Dermal filler treatments are where art and medicine truly combine. Desirable outcomes depend equally on providers ' knowledge of filler products and injection skills, as well as an appreciation for aesthetic facial proportions and symmetry. Dermal fillers have a steeper learning curve than botulinum toxin and require practice to consistently achieve desirable results.
HA fillers are used for many facial aesthetic indications; however, treatment of the lower two thirds of the face yields the most predictable results, with the greatest efficacy and fewest side effects. The three essential dermal filler aesthetic rejuvenation treatments (ARTs) for primary care professionals to treat unwanted facial lines and contour defects are: (i) nasolabial folds (melolabial folds); (ii) oral commissures, marionette lines (mandibulolabial folds); and (iii) lip augmentation as shown in 01412520.
Figure 1 View Original Figure 1 View Original
General Injection Guidelines
Position the patient comfortably, at about a 65 degree reclined position, for the procedure. Prior to injection, prime the needle by depressing the syringe plunger until a small amount of filler extrudes from the needle tip. Ensure that the needle is tightly affixed to the filler syringe because excessive plunger pressure may cause the needle to pop off and filler to be extruded from the syringe.
All injections should be in the dermis. Some plunger resistance during injection should be felt when injecting at the appropriate level in the dermis. When injecting too deeply, in the subcutaneous tissues, there is little to no resistance against injection. When injecting too superficially, the gray needle tip is visible in the skin. The filler should be injected using firm, constant pressure on the syringe plunger as the needle is withdrawn in a linear thread. Visible and palpable bumps of filler seen after treating an area should be compressed between the thumb, placed on the skin, and the first finger, placed intraorally. If bumps do not easily compress, the injector may moisten the bumpy area with water and stretch the area between his or her fingers. The more massage done to a treatment area, the more swelling and bruising will occur.
If blanching occurs while injecting, the blood flow to the treatment site has been compromised either by injecting too much filler into the dermis or injecting intravascularly. Discontinue injecting and massage the area until the tissue appears pink. Injections may be continued in other parts of the treatment area.
Treat one area to injector and patient satisfaction before focusing on another area for treatment.
Dosage and Volume
The volume necessary for treatment must be estimated and discussed with the patient prior to injection. Volumes listed in the chapter are recommendations for starting volumes and refer exclusively to hyaluronic acid fillers formulated without lidocaine, such as Restylane and Juvederm Ultra Plus. The best results are achieved through individualization of treatments based on patients ' observed facial anatomy and volume loss in the treatment areas. The maximal volume for Juvederm Ultra Plus is 20 mL/yr. Medicis does not report a maximum annual volume for Restylane; however, the recommended maximal volume per treatment site is 1.5 mL.
Results and Follow-up
Correction of lines and contour defects are seen immediately with filler injections. The treatment area will be swollen for approximately 3 to 5 days postprocedure, and the final appearance of the treatment area will be less full after the swelling resolves. The visible filling effects of Restylane and Juvederm Ultra Plus may persist for 6 to 9 months, and occasionally up to 1 year. Persistence is affected by many factors, including the patient 's metabolism, degree of motion in the treatment area, and facial expressivity, and it should not be guaranteed at the time of treatment.
If ongoing treatments are desired, patients should follow-up when the filler appears to be diminishing, at about 6 months. Less volume is typically required for subsequent treatments, provided some volume from the initial treatment is still present.
General Anesthesia Techniques
Providing adequate anesthesia is an essential part of successfully incorporating fillers into practice. Minimizing discomfort improves provider results and offers the patient a better experience. The goal with anesthesia for filler treatments is to achieve maximal anesthesia while minimizing distortion of the treatment area. Four main anesthetic techniques are used prior to filler treatments:
- Regional nerve blocks are ideal for treatment of lips because anesthetic is remote from the treatment area and does not significantly distort lip anatomy (see the Lip Augmentation section).
- Local lidocaine injection is used for treatment of the nasolabial and oral commissure areas. Care should be taken to use the smallest anesthetic volumes possible because infiltration of the anesthetic will result in some distortion of the anatomy. A maxillary nerve block should be used instead of local infiltration in the nasolabial folds when both the upper lip and nasolabial folds are being treated. A mandibular nerve block should be used instead of local infiltration in the oral commissures when both the lower lip and oral commissures are being treated.
- Topical anesthetics may be used in the nasolabial and oral commissure areas. In-office application of a topical anesthetic, such as benzocaine 20%/lidocaine 6%/tetracaine 4% (BLT), with a maximum dose of 1 g applied for 15 minutes, may be used prior to treatment. BLT causes lip edema and is not advised for lip treatments.
- Ice is a good anesthetic and may be used adjunctively with the other methods or alone. Anesthesia is achieved by applying ice immediately before injecting for approximately 5 minutes or until the skin is blanched.
Preprocedure Checklist
- Perform an aesthetic evaluation and review the patient 's medical history (see Aesthetic Procedures Introduction).
- Prophylax with antiviral medication if there is a history of herpes simplex for 2 days prior to procedure and continue for 3 days postprocedure.
- Minimize bruising by discontinuation of aspirin, vitamin E, St. John 's wort, and other dietary supplements including ginkgo biloba, evening primrose oil, garlic, feverfew, and ginseng for 2 weeks prior. Discontinue other nonsteroidal anti-inflammatory medications 2 days prior.
- Take preinjection photographs.
- Document and discuss any notable asymmetries prior to treatment.
- Obtain informed consent.
- Estimate filler volume necessary for treatment and cost.
- Prepare the skin with alcohol.
- Anesthetize the treatment area using the minimal necessary anesthetic volumes so as not to obscure the treatment area.
Equipment
Anesthesia
- 5.0-mL syringe
- Lidocaine HCl 2% with epinephrine 1:100,000
- 18-gauge, 1.5-inch needles
- 30-gauge, 0.5-inch needles
- Benzocaine/lidocaine/tetracaine (20:6:4) ointment
Filler Treatment
- Filler syringes of Restylane (20 mg HA/mL) or Juvederm Ultra Plus (24 mg HA/mL)
- 30-gauge, 0.5-inch needles
- Gauze, 3 3 inches, nonwoven
- Ice packs
Handling
HA is supplied in individual treatment syringes of 0.8 mL and is a clear colorless gel. Syringes should be stored at room temperature (up to 25 °C or 77 °F) prior to use.
Aesthetic Indications
HA fillers are approved by the U.S. Food and Drug Administration for treatment of moderate to severe facial wrinkles and folds using mid- to deep dermal injections. HA treatment of lips and other cosmetic areas are off-label use.
Contraindications
Absolute
- Pregnancy and nursing
- Previous anaphylactic reaction
- Multiple severe allergies
- Keloid formation
- Active infection or inflammation in the treatment area
- Previous allergic response to HA products
- Patient younger than 18 years of age
Relative
- History of easy bruising
- History of poor healing
- Body dysmorphic disorder or unrealistic expectations
The Procedure
Nasolabial Folds
01412520 shows a 38-year-old patient with moderate nasolabial folds prior to treatment.01412520 shows the same patient 1 week after treatment with an HA filler, Juvederm Ultra Plus, using 0.8 mL (one syringe) in each nasolabial fold for a total volume of 1.6 mL.
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There are two methods for providing anesthesia to the nasolabial folds: (i) local infiltration adjacent to the folds (shown in 01412520) or (ii) an infraorbital nerve block (see the Lip Augmentation section). When treating lips and nasolabial folds in the same visit, an infraorbital nerve block should be used without local infiltration, because this will anesthetize both treatment areas. Topical anesthetic and ice may be used as alternatives to these methods or may be used adjunctively (see Field Block Anesthesia). Step 1 shows an overview of injection points and doses for local infiltration of anesthetic for treatment of the nasolabial folds. After preparing the skin with alcohol, lidocaine is injected subcutaneously, superior to the nasolabial fold, with 0.1 mL placed at each injection point. After injecting, compress the injection sites to minimize edema from the anesthetic.
- Pearl: Sensitivity increases with proximity to the nose, and injections should start at the inferior injection point first and move superiorly toward the nose.
- PITFALL: Placing anesthetic into the nasolabial fold will blunt the fold and make filler treatment volumes more difficult to determine accurately.
Figure 3 View Original Figure 3 View Original
An overview of HA injection points for the treatment of nasolabial folds is shown in 01412520, where number 1 is the first injection site. The needle is advanced superiorly towards the nose and the filler product is fanned medially at the nasal ala. Mild nasolabial folds typically require 0.4 to 0.8 mL (half to one syringe) of filler per side, and moderate to severe folds require 0.8 to 1.2 mL (one to one and a half syringes) per side. All injections should be placed just medial to the nasolabial fold using a 30-gauge, 0.5-inch needle with the dermal filler syringe.
- PITFALL: Care should be taken not to inject lateral to the folds because this can accentuate the folds.
- PITFALL: Injections placed too superficially may result in an unsightly visible ridge of filler that can persist in the superficial dermis (see the General Injection Techniques section).
- PITFALL: Avoid overfilling the treatment area because the goal of treatment is to blunt, not to eliminate, the nasolabial fold. This is a natural, desired contour of the face.
- Pearl: Compress the treated area as described in the General Injection Guidelines section to ensure that the filler is smooth. Threads of filler should not be visible or distinctly palpable after treatment.
Figure 4 View Original Figure 4 View Original
Step 1
The first injection is placed medial and at the inferior point of the fold. The needle should be inserted at a 30 degree angle to the skin and advanced to the hub. Filler should be injected using firm constant pressure on the syringe plunger as the needle is withdrawn.
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Step 2
The second injection point is approximately 1 cm superior to the first injection point and is placed medial to the fold. The needle should be inserted to the hub and the filler injected upon withdrawal.
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Step 3
The third injection point is superior to the second injection point, closer to the nose. Use the fanning technique to place filler adjacent to the nasal ala (see Oral Commissures section for fanning technique). First direct the needle toward the lateral wall of the nasal ala (Step 3A), withdraw the needle to the tip, redirect it counterclockwise toward the philtrum, insert it to the hub, and repeat (Step 3B). Repeat injections 1 to 3 for the contralateral side of the face.
- PITFALL: This is the most sensitive area of the fold, and patients may experience discomfort if not adequately anesthetized.
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01412520 shows the angular artery which lies at the superior lateral edge of the nasal ala. Tissue ischemia associated with intravascular injection of the angular artery may be seen as a violaceous reticular pattern of the skin along the lateral wall of the nose and/or nasolabial fold. Ischemia can rapidly progress to tissue necrosis, and this complication should be managed urgently. If ischemia occurs, revascularize by massaging the violaceous area and the ala artery, apply heat packs, and give the patient two 325-mg enteric coated aspirins orally. If not improving, apply nitropaste (1-inch dose of Nitro-BID) to the affected area, monitor for hypotension, and contact your local emergency room and/or plastic surgeon.
Figure 5 View Original Figure 5 View Original
Oral Commissures and Marionette Lines
The corners of the mouth where the upper lips meet the lower lips are called the oral commissures. Volume loss in these areas can lead to depressed oral commissures with downturned corners of the mouth. Skin folds which descend from the oral commissures towards the jaw are known as marionette lines or mandibulolabial folds. Assessment and treatment of the lower facial area should concurrently address both the oral commissures and manionette lines. For the purposes of this chapter, oral commissures and manionette lines will collectively be referred to as the lower face folds (LFF).01412520 shows a 70-year-old woman with moderate volume loss in the LFF and downturned corners of the mouth prior to treatment, and 01412520 shows the same patient 1 week after treatment with a HA filler, Juvederm Ultra Plus, using 0.8 mL (one syringe) per side for a total volume of 1.6 mL. Note the improvement in the downturned corners of the mouth oral commissures, and marionette lines.
Figure 1 View Original Figure 1 View Original
There are two methods for providing anesthesia to the LFF: (i) local infiltration in the treatment area and (ii) a mental nerve block (see the Lip Augmentation section). When treating lips and LFF in the same visit, a mental nerve block should be used without local infiltration, because this will anesthetize both treatment areas. Topical anesthetic and ice are alternatives to these methods or may be used adjunctively.
Step 1
Shows an overview of injection points and doses for local infiltration of anesthetic for treatment of the LFF. After preparing the skin with alcohol, 0.1 mL of lidocaine is injected subcutaneously, in the middle of the LFF area, approximately 0.5 cm inferior to the vermillion border and 0.5 cm medial to the marionette line. For patients with moderate and severe LFF that extend inferiorly toward the jaw, a second injection point may be added approximately 1 cm inferior to the first point. To anesthetize the corner of lower lip, inject 0.1 mL of lidocaine intraorally in the mucosa at the inferior corner of the mouth (see the Anesthesia section in the Lip Augmentation section). Repeat for the contralateral LFF and corner of the mouth. After injecting, compress the injection sites to minimize edema from the anesthetic.
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Step 2
There are two injection techniques for placing filler in the deep dermis that add support to the LFF: fanning and cross hatching. An overview of HA injection points for fanning and cross-hatching techniques for the treatment of the LFF is shown in Step 2.
Fanning utilizes one needle insertion point, whereby a series of adjacent linear threads are injected so that filler is placed in a triangular area in the dermis. From the initial needle insertion point, the needle is advanced to the hub, filler is injected in a linear thread, and the needle is withdrawn to the tip, redirected, and inserted to the hub again.
Cross hatching involves multiple injection points whereby filler is placed in a square area in the dermis. A linear thread of filler is placed, the needle is fully withdrawn and reinserted in an adjacent area, and another linear thread is placed parallel to the first thread. This is repeated at 90 degrees to the first filler threads to form a square area of filler.
Mild LFFs typically require 0.4 mL (half a syringe) of filler per side, and moderate to severe folds require 0.8 mL (one syringe) per side. A 30-gauge, 0.5-inch needle with a dermal filler syringe is used for all injections.
- Pearl: Compress the treated area as described in the General Injection Guidelines section to ensure that the filler is smooth. Threads of filler should not be visible or palpable with either technique after treatment.
- PITFALL: Avoid overfilling the treatment area because abnormal lip contours, particularly in the lateral upper lip, may result.
- PITFALL: Watch for tissue blanching. If this occurs, the area has been overfilled. Manage as described in the General Injection Guidelines section.
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Step 3
The first injection point is in the corner of the lower lip (Step 3A). The needle should be inserted at a 30 degree angle to the skin and advanced to the hub (Step 3B). Filler should be injected using firm constant pressure on the syringe plunger as the needle is withdrawn.
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Step 4
The second injection point is one needle length below the lower lip vermillion border, just medial to the LFF. The needle is directed toward the vermillion border (Step 4A). Fan the product by withdrawing the needle and redirecting 30 degrees counterclockwise (Step 4B). This is repeated to place a triangular area of filler inferior to and abutting the vermillion border. Note that the blanching seen in Step 4A and 4B is due to the vasoconstrictive epinephrine effect from the local anesthetic.
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Step 5
The patient required placement of additional filler product to achieve maximal correction of the LFF. This was achieved using the cross-hatching technique in the previously treated area. The third injection point is just inferior to the vermillion border. The needle should be parallel to the vermillion border and directed toward the LFF. The needle tip should end just medial to the fold.
- PITFALL: Extending the needle too far into the LFF may result in lateral filler placement and accentuation of the fold.
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Step 6
Cross hatching is continued. The fourth injection point is 1 cm inferior to the vermillion border with the needle parallel to the vermillion border and directed toward the LFF. The needle tip should end just medial to the fold.
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Step 7
The remaining inferior portion of the LFF is typically treated using the fanning technique. The fifth injection point is approximately one and a half needle lengths inferior to the vermillion border, with the injection point just medial to the LFF and directed toward the vermillion border (Step 7A). Filler is placed using the fanning technique, where the needle is redirected approximately 30 degrees counter clockwise, and this is repeated, filler is placed in a triangular area in this inferior portion of the LFF (Step 7B).
- Pearl: Filler should be placed such that it is continuous with filler already in the dermis and should feel smooth.
- Pearl: Successful correction of the LFF is achieved when the lateral lower lip is supported and buttressed by adequate volume and placement of filler as described above.
Step 7 View Original Step 7 View Original
Lip Augmentation
01412520 shows a 38-year-old patient prior to lip augmentation (A), immediately after treatment (B), and 1 week after treatment (C) with a total of 1.6 mL of Juvederm Ultra Plus (two syringes) to the vermillion border and the body of the lips. Note that swelling is most marked immediately after treatment and has resolved by 1 week, leaving only the filler effect. The goal of lip augmentation is to restore a natural fuller appearance to the lip with slight eversion of the vermillion border without overtreating. The desirable proportions for lips are a larger lower lip relative to upper lip with a ratio of approximately 1:2 in lip height.
- Pearl: Volume loss is more apparent in the upper lip than the lower lip, and many patients may only need or desire treatment to the upper lip.
- Pearl: Track filler volumes closely and administer equal volumes on both sides of a lip unless gross asymmetry is present prior to treating.
Figure 1 View Original Figure 1 View Original
On lateral projection, the angle between the upper lip and nose (nasolabial angle) for women should be 95 to 110 degrees and for men 90 to 95 degrees.01412520 shows the lateral projection prior to treatment, and 01412520 shows the nasolabial angle after treatment for the previously mentioned patient.
- Pearl: Patients with diminutive upper lips are not good candidates for treatment, and filler injections may result in an unnatural anterior projection of the upper lip or a "duck " lip.
Figure 2 View Original Figure 2 View Original
Adequate anesthesia of the lip region prior to filler injection is essential to the success of lip augmentation treatments. Anesthesia for the upper lip requires an infraorbital nerve block and additional mucosal infiltration at the corners of the mouth and at the gingivo-buccal junction of the upper lip frenulum. Treatment to the lower lip requires a mental nerve block and additional mucosal infiltration at the corners of the mouth. 01412520 shows an overview of injection points and doses for fully anesthetizing both the upper and lower lips.
Figure 3 View Original Figure 3 View Original
The location of the infraorbital and mental nerves is shown in 01412520 and can be identified by palpating the nerve foramina. First, palpate the supraorbital notch, which lies along the upper border of the orbit approximately 2.5 cm lateral to the midline of the face, and draw a vertical line down from the supraorbital notch to the mandible. The infraorbital foramen lies on this line and is palpable approximately 1 cm inferior to the infraorbital boney margin. The mental nerve also lies on this line and is palpable just above the margin of the mandible.
Figure 4 View Original Figure 4 View Original
01412520 shows the intraoral technique for infraorbital and mental anesthetic nerve blocks to be used prior to lip augmentation.
Figure 5 View Original Figure 5 View Original
Figure 6 View Original Figure 6 View Original
The infraorbital nerve innervates most of the upper lip, the lower eyelid, lateral portion of the nose, and medial cheek, and an infraorbital nerve block can anesthetize all of these regions (see 01412520). However, the philtrum and the corners of the mouth are typically poorly anesthetized, because they are at the distal nerve branches, and additional local infiltration is required in these areas.
Step 1
Comfortably position the patient upright at about 65 degrees, with their chin tipped upward. Lift the upper lip for good visualization of the gingivobuccal margin, and insert a 30-gauge, 0.5-inch needle at the gingivobuccal margin just lateral to the maxillary canine. Direct the needle superiorly towards the pupil, advance the needle to the hub, and inject 0.5 to 1.0 mL of lidocaine. The anesthetic should flow easily. After removing the needle, compress the deep palpable wheal of lidocaine superiorly towards the infraorbital foramen. Repeat for the contralateral infraorbital nerve. The onset of anesthetic effect is typically 5 to 10 minutes.
- Pearl: Test the lip prior to initiating filler treatment. If adequate anesthesia is not achieved, repeat the procedure, injecting an additional 0.5 mL of lidocaine, and wait an additional 10 minutes.
- PITFALL: If the needle is angled too anteriorly, lidocaine may be placed in the dermis, and resistance during injection will be encountered.
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The mental nerve innervates most of the lower lip, and a mental nerve block can anesthetize this region (as shown in 01412520). However, the corner of the mouth is typically poorly anesthetized, and additional local lidocaine infiltration is required.
Figure 7 View Original Figure 7 View Original
Step 2
Comfortably position the patient upright at about 65 degrees, with their chin tipped downward. Lift the lower lip for good visualization of the gingivobuccal margin. Insert a 30 gauge, 0.5 inch needle at the gingivobuccal margin just lateral to the first mandibular bicuspid. Direct the needle inferior laterally. Advance the needle halfway to the hub, and inject 0.5 to 1.0 mL of lidocaine. The anesthetic should flow easily. After removing the needle, compress the deep palpable wheal of lidocaine inferiorly towards the mental foramen. Repeat for the contralateral mental nerve. The onset of anesthetic effect is typically within 5 to 10 minutes.
- Pearl: Test the lip prior to initiating filler treatment. If adequate anesthesia is not achieved, repeat the procedure, injecting slightly more laterally using an additional 0.5 mL of lidocaine, and wait an additional 10 minutes.
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Step 3
The lateral corners of the mouth require additional infiltration of local anesthetic to achieve adequate anesthesia. Inject 0.1 mL of lidocaine intraorally in the mucosa at the corner of the mouth. After the needle is removed, compress the injection site to disburse the lidocaine, and repeat for the contralateral corner of the mouth.
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Step 4
The philtral area requires additional infiltration of local anesthetic to achieve adequate anesthesia. Inject 0.1 mL of lidocaine intraorally just lateral to the upper lip frenulum at the gingivobuccal margin. After the needle is removed, compress the injection site, and repeat for the contralateral side of the frenulum.
Step 4 View Original Step 4 View Original
Vermillion Border
Lip augmentation involves enhancing the border of the lip with filler injection along the vermillion cutaneous junction, referred to as the vermillion border. Depending on the patient 's lip shape and desired fullness, filler may also be injected into the mucosa or "body " of the lip. An overview of HA injection points for lip augmentation of the vermillion border is shown in 01412520 where number 1 is the first injection point. Treatment of the upper and lower lip vermillion borders require approximately 0.8 mL (one syringe) of Restylane or Juvederm Ultra Plus. A 30-gauge, 0.5-inch needle should be used for injections.
Figure 8 View Original Figure 8 View Original
- Pearl: The top lip should be injected before the bottom lip.
- Pearl: Lip edema can occur fairly rapidly, particularly with Restylane. After completion of treatment to both sides of the lip, the first side that was injected may appear larger. Do not retreat the second side at this time, because this asymmetry likely is due to edema. Re-evaluate the patient 1 week posttreatment.
Step 1
The first injection should be placed such that the tip of the needle ends at the peak of the "M " of the cupids bow. Identify the needle insertion point by measuring with the needle against the lip, as shown in Step 1A. The plane for injection is along the vermillion border in the potential space that exists just below the skin. Insert the needle to the hub, and inject as the needle is withdrawn, as in Step 1B. The filler should flow easily into the potential space of the vermillion border, enhancing the white rolled border of the lip.
- Pearl: Vertical lip lines that abut the vermillion border can be effectively treated by augmenting the vermillion border.
- PITFALL: Filler should not be visible or palpable as discrete lumps. Compress the treated area as described in the General Injection Guidelines section to ensure that the filler is smooth.
- PITFALL: If filler is seen outside of the vermillion border above the lip during injection, stop injecting, compress/massage until no product is visible above the vermillion border, and resume treatment.
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Step 2
The second injection point is one needle length lateral to the first injection point. Again, the needle is inserted to the hub, and the filler is smoothly injected as the needle is withdrawn.
- Pearl: Do not overfill this lateral-most portion of the lip because this can result in undesired contour changes of the lip.
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Step 3
The third injection point is in the cupid 's bow. The needle should be inserted in the peak of the "M " of the cupid 's bow and the tip advanced to the nadir of the "M. " Smoothly inject filler as the needle is withdrawn. Proceed with filler injections to the lip body if desired; otherwise, complete the vermillion border treatment for the contralateral side of the upper lip.
- Pearl: Use small volumes in this area to accentuate the "M " contour.
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Step 4
The first injection in the vermillion border of the lower lip begins at the corner of the lip. The needle is inserted to the hub, and filler is smoothly injected as the needle is withdrawn.
Step 4 View Original Step 4 View Original
Step 5
The second injection point in the vermillion border is placed one needle length medial to the initial injection point, shown in Step 5A. The needle is inserted to the hub, shown in Step 5B, and filler is smoothly injected as the needle is withdrawn.
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Step 6
The third injection point with filler placement in the middle portion of the lower lip is one needle length medial to the second injection point. Proceed with filler injections to the lip body if desired; otherwise, complete the vermillion border treatment for the contralateral side of the lower lip.
Step 6 View Original Step 6 View Original
Lip Body
After the vermillion border has been treated, additional dermal filler may be placed in the body of the lip. The top lip should be injected before the bottom lip. An overview of HA injection points for lip augmentation to the body of the lip is shown, where number 1 is the first injection point as shown in 01412520. Treatment of the body of the upper and lower lips requires approximately 0.8 mL (one syringe) of Restylane or Juvederm Ultra Plus. A 30-gauge, 0.5-inch needle should be used for injections.
Figure 9 View Original Figure 9 View Original
Step 1
The first injection point to the body of the upper lip is placed 2 mm inferior to the vermillion border, directed medially with the tip of the needle ending below the peak of the "M " of the cupid 's bow. The needle should be parallel to the vermillion border. Inject filler smoothly as the needle is withdrawn.
- PITFALL: Do not inject in the central-most portion of the body of the lip. Filler in the area between the two peaks of the "M " will result in an unnatural protrusion of the upper lip, which is difficult to correct.
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Step 2
The second injection point to the body of the upper lip is one needle length lateral to the first injection point.
- Pearl: Unlike filler placement in the vermillion border, which typically extends to the corner of the lip, injections in the body of the upper lip do not need to extend to the corner of the lip.
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Step 3
The first injection point the body of the lower lip is 2 mm medial to the corner of the mouth and 2 mm superior to the vermillion border.
- Pearl: Inspect the shape of the lower lip and administer filler volume to match the lip contour as far as possible.
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Step 4
The second injection point in the body of the lower lip is one needle length medial to the first injection point, shown in Step 4A. Insert the needle to the hub, as shown in Step 4B, and use a more generous amount of filler in this medial portion of the lower lip.
Step 4 View Original Step 4 View Original
Complications
Common
- Bruising
- Palpable or visible filler
- Asymmetry, overcorrection, or undercorrection
- Prolonged swelling, tenderness, or pain
- Prolonged erythema
- Hyperpigmentation
- Infection
- Allergic reaction
- Migration or extrusion of filler
- Unpredictable persistence of filler, either shorter or longer than anticipated
- Bluish discoloration (Tyndall effect) when filler is placed too superficially in thin skin
Rare and Idiosyncratic
- Hematoma
- Acneic outbreak or milia
- Granulomatous nodules
- Vascular occlusion with skin necrosis
- Extremely rare: immediate hypersensitivity reaction with signs of urticaria, edema, and a remote possibility of anaphylaxis
Pediatric Considerations
This procedure is contraindicated for cosmetic uses in pediatric patients.
Postprocedure Instructions
Ice each injection site for 10 to 15 minutes every 1 to 2 hours for 1 to 3 days or until the swelling and bruising resolve. Avoid activities that cause facial flushing until the swelling resolves, including application of heat to the face, alcohol consumption, exercising, and tanning. Remind the patient not to massage the filler in the treated areas. Acetaminophen may be used if needed for discomfort.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 11950 Subcutaneous injection of filling material; ≤1 mL $285.00 0 11951 Subcutaneous injection of filling material; 1.1 " 5.0 mL $426.00 0 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
HCPCS Code
View Large Miscellaneous supply A9999
Average fee: $500 per syringe. These procedures are not reimbursable by insurance.
Supply Sources
- Juvederm Ultra Plus: Allergan, Inc., 2525 Dupont Drive, Irvine, CA 92612. Phone: 1-800-377-7790.
- Restylane: Medicis Aesthetics, Inc., 812 N. Hayden Road, Scotsdale, AZ 85258. Phone: 1-866-222-1480.
- Benzocaine/lidocaine/tetracaine (BLT) (20:6:4) ointment: American Health Solutions Pharmacy, 3463 Overland Avenue, Los Angeles, CA 90034. Phone: 310-838-7422.
Bibliography
1
Born T. Hyaluronic acids.
Clin Plas Surg
. 2006;33(4):525 " 538. [View Abstract]
2
Brandt FS, Boker A. Restylane and perlane. In: Klein A, ed.
Tissue Augmentation in Clinical Practice
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