Recent Historical Overview of Facial Fillers Available in the United States

An overview of injectable filler substances can be confusing. There are over 120 filler products or devices available. This chapter cannot cover all available fillers in depth but will concentrate on those commonly used or soon to be released for use. As noted, bovine collagen (Zyplast, Zyderm; Inamed Corp., Santa Barbara, CA) dominated the U.S. market for over 2 decades. These fillers contained lidocaine, which mitigated the discomfort of the injection process. Because they were of bovine derivation, allergy testing was a prerequisite. Classically, patients were inoculated in the forearm with the material, and if no local allergic response was seen at 30 days, the material was assumed safe. Some practitioners advocated two successive monthly negative allergy tests. The need for testing proved to be a great drawback, because cosmetic consumers tend to be spontaneous and desire treatment at their convenience and on demand.

There has been a foreign invasion of injectable fillers since December 2003. At the end of 2003, Restylane (Q-Med Inc., Uppsala, Sweden), a hyaluronic acid (HA) filler that has been used in many countries for over a decade, received U.S. Food and Drug Administration (FDA) approval in the United States. In June 2005, the FDA approved a new (to this country) HA-based filler line, Juvederm. Even though such fillers as Restylane, Juvederm (Allergan Inc., Irvine, CA.) and Artefill (Sunveva Medical Inc., San Diego, CA.) were used overseas for decades, it took many years for them to become approved and popular in this country. On March 23, 2006, Inamed Corporation, maker of CosmoDerm and CosmoPlast, was acquired by Allergan and is now a wholly owned subsidiary of the Botox giant. Consistent with the rapid changes in filler technology and usage, Allergan will discontinue the production of its collagen fillers in 2010.

The marketing release of Restylane brought an onslaught of media attention that boosted interest among aging baby boomers. It changed the paradigm in this country for injectable fillers for numerous reasons. First, it is a nonanimal product synthesized from bacteria. Hyaluronic acid is a highly hydrophilic polysaccharide found in all living cells; it attracts and binds more than 1000 times its weight in water and is chemically, physically, and biologically similar in all species.⁴ There is no reason for allergy testing, one of the biggest drawbacks of bovine collagen products. Additionally, continental outbreaks of swine flu, avian flu, and mad cow disease made fillers derived from animal sources unattractive. Second, studies showed that HA fillers last longer than Zyplast. The longevity of Zyplast has long been a problem for patients and injectors. Although the product was easy to use and produced acceptable results, it lasted only several months in most patients, whereas some studies show that HA fillers can last much longer.^5,6 One of the reasons for the extended longevity with the hyalurons (HA fillers) is a process called isovolumic degradation. Normally, collagen fillers are simply phagocytized and degraded, which causes decrease in volume, but in this process, water is drawn into the hydrophilic molecule as the filler degrades. The filler volume is retained longer as more water is continually drawn into the molecule.⁷

Multiple studies have shown HA to be a safe and effective facial filler.^8,9 The Medicis Pharmaceuticals (Scottsdale, AZ) and Allergan HA products are available in various particle sizes. These HA fillers come in larger particle sizes for less viscosity and more robust consistencies.

In 2003, Inamed Aesthetics (Santa Barbara, CA) introduced CosmoPlast and CosmoDerm, which are human collagen derivatives produced from tissue-cultured human infant foreskin. These dermal fillers are sterile devices composed of highly purified human-based collagen dispersed in phosphate-buffered physiologic saline containing 0.3% lidocaine. CosmoDerm is a non-cross-linked formulation used in the treatment of superficial lines, whereas CosmoPlast is cross-linked and is primarily used in the treatment of more pronounced wrinkles. CosmoDerm is a purified human-based collagen, 35 mg/mL, dispersed in saline and indicated for treatment of fine lines, wrinkles, and shallows scars. CosmoPlast is a purified human-based collagen, 35 mg/mL, cross-linked with glutaraldehyde dispersed in saline and indicated for treatment of deep lines, furrows, and scars. Again, because these products are of nonanimal origin, allergy testing is not necessary. These products are very easy to inject because they have excellent flow properties, and I have found them to possess similar longevity as the bovine collagen predecessors. It is rumored, however, that the company may cease production of this filler line.

Hylaform (Inamed) gained FDA approval in 2004 and competed with Restylane in the new filler arena. Hylaform is a sterile, nonpyrogenic, viscoelastic, clear, colorless gel implant composed of cross-linked molecules of hyaluronan. Hyaluronan is a naturally occurring polysaccharide of the extracellular matrix in human tissues, including skin. Differences lie in the fact that this HA product is derived from animals (rooster combs) and contains less HA per milliliter than Restylane. Public awareness of avian flu has also caused some patients to be concerned. Hylaform Plus and Captique were also introduced by Inamed in 2004. These fillers took a relative back seat to Restylane and Juvederm, which have led the pack since their introduction. These fillers have made a slight resurgence by incorporating local anesthesia in the mix. Mentor Corp. (Santa Barbara, CA) received FDA approval for Pevelle Silk in 2008. I personally don’t feel that these fillers will occupy a dominant spot in contemporary filler usage. The major filler companies are in the process of incorporating local anesthesia into their fillers. Juvederm XC, released in February 2010 by Allergan, includes lidocaine mixed in with the Juvederm filler. In May 2009 Medicis released lidocaine containing fillers Restylane Lidocaine and Perlane Lidocaine. Coapt Systems (Palo Alto, CA) released Hydrelle, a hyaluronic acid filler that contains lidocaine. Personally, I see no significant advantage, since all practitioners should be masters of local anesthesia technique, which would negate the advantage of filler/local anesthetic combinations. My theory is that the needle and injection have already caused pain by the time the local anesthetic is injected, especially in multiple-injection techniques. In addition, these filler/local anesthesia products are more expensive.

On February 28, 2003, the FDA’s General and Plastic Surgery Devices Advisory Panel recommended that Artefill be approved, with conditions for marketing in the United States. Artefill is expected to become the first permanent aesthetic injectable implant to gain FDA approval. It is a combination of homogeneous precision-filtered microspheres suspended in a solution of purified collagen gel and 0.3% lidocaine to alleviate discomfort during injection. Artefill is designed with dual action to correct facial wrinkles: 20% precision-filtered microspheres made from polymethylmethacrylate (PMMA) and 80% purified bovine collagen. All microspheres have a defined size of 30 to 50 microns in diameter and have a smooth, round surface. Aesthetic results are visible immediately after injection. PMMA is not taken up by scavenger cells (macrophages) and cannot be degraded by enzymes. Thus, the microspheres will remain intact beneath the creases, providing a permanent structure to support the wrinkle and prevent further wrinkling. As with all products using bovine collagen, a skin sensitivity test must be performed prior to use. Artes Medical declared bankruptcy in 2009 and the product was purchased by Seneva Medical and it is back on the market at the time of this writing. Oral and maxillofacial surgeons have used hydroxyapatite products for augmentation for the past 20 years. Radiesse (BioForm, Franksville, Wisconsin) is an injectable filler that consists of hydroxyapatite microspheres in a soluble gel vehicle¹⁰ (Figure 14-1). The author uses Radiesse when requested by patients, primarily in the nasolabial folds. The flow properties are different from other fillers. The most noticeable property of Radiesse is that a little product goes a long way. Because this product is hydroxyapatite based, the longevity is increased. For this reason, overfill or asymmetry can be a problem because it persists for a long time. The author does not recommend this product for the novice injector. Because Radiesse is opaque, lip injection is visible on radiographs; patients and their dentists should be made aware of this (Figure 14-2).

FIGURE 14-1 Radiesse is a hydroxyapatite-based (calcium hydroxylapatite) filler with the consistency of toothpaste. It is intended for deep dermal or subdermal injection and is a popular filler for nasolabial fold and midface augmentation.

FIGURE 14-2 Radiesse is radiopaque and sometimes visible on radiographs. The patient should be aware of this situation.

Finally, a plethora of new products that have been used in other countries are knocking at the doors of the FDA. In 2004, Sculptra (Advantis Pharmaceuticals, Bridgewater, NJ), which has been used abroad as Newfil, was FDA approved for the treatment of human immunodeficiency virus (HIV)-associated facial lipoatrophy. HIV patients are living longer and healthier due to new antiretroviral drugs, but a side effect of these medications is lipoatrophy of the temporal and facial regions. This stigmata makes HIV-positive patients stand out and has many negative social implications. Although this condition is amenable to treatment with multiple fillers, Sculptra has become a popular option. Sculptra is an injectable implant that contains microparticles of poly-l-lactic acid, a biocompatible, biodegradable, synthetic polymer from the alpha hydroxy acid family. Sculptra is reconstituted prior to use by the addition of sterile water for injection to form a sterile nonpyrogenic suspension (Figure 14-3). Since a large part of my practice consists of facial implants, I have not used this filler much; however, many colleagues sing its praises, especially when used in the midface and temporal regions for volume restoration.

FIGURE 14-3 Sculptra (poly-l-lactic acid) must be reconstituted 24 hours before injection and is intended as a subdermal filler.

Sculptra is intended for restoration and/or correction of the signs of facial fat loss, but many practitioners use Sculptra off label for filling lines and wrinkles. The mechanism of Sculptra is different from other fillers in that the response is not immediate, but rather the poly-l-lactic acid particles serve to initiate an inflammatory reaction and induce the production of collagen in the area. A typical treatment course for severe facial fat loss involves three to six injection sessions, with the sessions separated by two or more weeks. Full effects of the treatment course are evident within weeks to months. The patient should be reevaluated no sooner than 2 weeks after each injection session to determine if additional correction is needed. Patients should be advised that supplemental injection sessions may be required to maintain an optimal treatment effect.

Injectable silicone is a filler of historic significance that has been both praised and scorned over the past 50 years and will be discussed separately in this chapter. I use silicone frequently and feel that it is one of the most overlooked fillers by seasoned injectors.

Autologous fat is another common filler technique and will also be discussed later in this chapter.^11,12

Evolence is the newest non-HA filler to hit the market and was FDA approved in 2008 for filling nasolabial folds. Evolence has been most popular in Israel and has been used with success for over a decade, since it is a medical treatment considered Kosher. This filler consists of porcine collagen with proprietary cross-linking. The manufacturing process removes many of the immunogenic substances, and therefore no allergy testing is required, which is different from previous collagen fillers. Porcine collagen is very close to human tissue and is used in heart valves and skin grafts. Since this filler is a collagen derivative, it has hemostatic properties that are said to reduce bruising. In addition, the substance is not as hydrophilic as HA fillers and produces less swelling. At the time of this writing, Johnson and Johnson has stopped the production and marketing of Evolence in the United States, but like other fillers that have been discontinued, I anticipate another company reintroducing Evolence in the near future. Older surgeons have seen a paradigm shift from having a single filler product to having many choices, and this will increase yearly as filler science continues. In my early days of practice, I dictated the filler choice, but today’s cosmetic consumers are much more informed and frequently request the type or brand of filler they prefer. The contemporary filler injector is a “bartender” of sorts and must have expertise in all commonly available injectable fillers (Figure 14-4). With the older, faster-absorbing fillers, overcorrection was a necessity, but with the newer fillers, the what-you-see-is-what-you-get technique is employed.

FIGURE 14-4 The contemporary cosmetic surgeon must be a “filler bartender” in that many types of fillers are available and the choice is often patient driven, requiring a broad inventory of product.

Tissue Deposition of Injectable Fillers

It is far more important how the filler is used than which filler is used. A competent injector can achieve aesthetic results from any filler if he or she knows how to use it and where to put it. Conversely, an inexperienced injector can use a premium filler and get poor results. The key to success with all fillers is correct placement in the skin, and various anatomic sites have specific injection techniques. Figure 14-5 shows common areas of filler injection.

FIGURE 14-5 Common areas of filler injection in the maxillofacial area.

Most fillers are specifically designed to be placed at a certain level (Figure 14-6). The exact level of filler placement is a debatable subject. Many fillers say their intended target is the “dermis,” and some injectors describe injecting in the mid or deep dermis. Obviously this is a histologic determination, and in reality, the filler needs to be placed where its most optimum action can be exerted, including the dermis and subcutaneous planes. There is no doubt that this varies from patient to patient and is affected by skin thickness, region to be injected, amount of aging, and the specific filler composition. There are some general rules that make sense and can serve as guidelines to tissue placement. The less viscous fillers with smaller particle sizes are intended for more superficial dermal placement. The medium-particle fillers are meant for the mid-dermis, and the more robust or particulate fillers are intended for deep dermal or subcutaneous placement. Again, an experienced injector can push these boundaries. Placing viscous or particulate filler too superficially may produce contour irregularities or be visible through the tissue. Conversely, placing a small-particle filler in the deep tissue planes can result in premature resorption. A common mistake of the novice injector is to place HA gel fillers too deeply in the nasolabial fold region. This produces inadequate augmentation and dissolves faster. There is a “sweet spot” on the skin where the placement of filler produces controlled augmentation, and that differs from patient to patient. Experienced injectors know where to put the filler for maximum result, and this is a learned skill guided more by feel and visual result than by science. In reality, histologic examination shows that the injected filler occupies multiple planes, including dermal and subcutaneous regions. Placing fillers such as silicone, Radiesse, fat, and Sculptra in the superficial dermis can produce contour irregularities. Placing fillers such as Restylane or Juvederm Ultra in the subcutaneous tissues is a less judicious choice than their more robust larger-particle counterparts.

FIGURE 14-6 Most common fillers are placed intradermally. The approximate intended target.

(Courtesy Surgiform Technology Ltd., Columbia SC.)

Although confusing, the tenet of intradermal placement is a good starting place for the novice injector. Injecting in the dermis is an appreciated tactile situation with contributions from the pressure of the needle entry and advancement and the syringe pressure. Again, experienced injectors can sense the correct plane. A pearl for novice injectors as to when the needle is in the dermis is observing the needle bevel upon skin entry. When the bevel of the average injection needle enters the skin and cannot be seen, this is an approximate indication that the tip is in the dermal plane. All injectors must be aware of the intended tissue plane target for various fillers. Experienced injectors will frequently layer fillers in different tissue planes to achieve results and sometimes use different fillers for the same injection.

Injectable Fillers: Treatment Considerations

“Doctor, how long will my filler last?” This is a question asked by many patients and is not an easy one to answer. For sure, the newer fillers outlast Zyplast and previous collagen fillers. Although companies quote slightly optimistic lengths of time, it is all variable. It depends upon the type of filler, the patient’s metabolism, the area of the face the filler is placed, and other variables. As a general rule, fillers placed in areas of extreme motion such as the lips will not last as long as fillers placed in a more immobile area such as the zygoma. Silicone will last many years, and Radiesse or Sculptra can last over a year. This author makes no guarantees to his patients but merely explains that the new fillers last longer than the previous ones and hopefully will maintain result from 6 to 12 months. This estimate has served accurately when using HA fillers and Evolence. Although the industry is pushing permanent fillers, it must be remembered that permanent fillers can cause permanent complications! In the case where the filler is not to the patient’s or surgeon’s liking, resorption is a good thing. One huge advantage of using the HA fillers is that they can be reversed with hyaluronidase; this serves as an “insurance policy” for nervous patients or surgeons. This technique will be discussed later in the chapter.

Filler injection has grown to be a major portion of my practice, and I personally inject all filler and neurotoxin patients. I believe my nurse would be a competent injector, but I enjoy this treatment and find it an excellent one-on-one doctor/patient bonding time. I have converted many filler patients to eyelid and facelift patients.

Adhering to the “bartender” analogy, I stock all contemporary fillers. My choice is guided by patient requests, area to be treated, and personal experience. My most popular choices for nasolabial folds are Juvederm, Restylane, and Radiesse in that order. For lips, HA fillers (Juvederm and Restylane) and silicone are most commonly used in my practice.

Due to the marketing hype, some patients confuse fillers with Botox. In addition, some patients desire massive rhytid injection, but because they have such a large amount of wrinkling, this would not be practical. These patients are informed that they would be better treated with lifting or resurfacing procedures. In theory, fillers can be injected anywhere on the face; however, blindness has been reported with the periorbital injection of Zyplast and fat due to intravascular injection.^13–15 This rare but devastating complication calls attention to the care that must be exercised in this area. The surgeon should always inject very superficially, use the smallest-gauge needle possible, and never use extreme plunger pressure on the syringe. Although the injection of fillers is simple, many problems can result in terms of patient expectations and satisfaction. The main consideration is to accurately explain what can be realistically expected as a treatment result. Showing patients a series of before-and-after images for specific anatomic areas is one way to provide a reasonable expectation. In addition, the injection of fillers should not be presented as a one-time procedure but as a sculpting treatment sequence to approach a result. Especially for HA fillers—which because of their hydrophilic properties cause immediate swelling in the lips—judging the endpoint and symmetry can be difficult (Figure 14-7).

FIGURE 14-7 Hyaluronic acid fillers cause immediate swelling that can make judging the endpoint difficult for the novice injector. Patient preinjection (A), immediately after injection (B), and 14 days after injection (C). Follow-up appointments to judge results are beneficial.

Having the patient return in 1 to 2 weeks gives both surgeon and patient an opportunity to critique the result. Any areas of underfill or asymmetry can be corrected and postinjection images can be taken for marketing. The novice injector should begin with “appetizer-sized” portions of filler; there is nothing wrong with the treatment requiring multiple visits. Patients must be educated on the advantages of sculpting over multiple visits as opposed to the “wham-bam” mentality of a single treatment session. This is especially true with fillers that cannot be reversed.

Informed Consent Process

The communication that occurs before filler injection can be paramount to a success or failure in the eyes of the patient. It is the time to detail many other critical issues, including expected longevity, what the filler will or won’t do, who will be responsible for the cost of revision filler, and how much filler needs to be used. Many “parafiller” problems can be easily resolved by showing the patient the consent if postinjection problems arise.

Prefiller photography can also be invaluable for situations where the surgeon is blamed for an existing preinjection problem. These photos not only serve to assist in adverse situations, they serve as a teaching and learning tool for the surgeon and are invaluable for marketing.

The question of how much filler to use frequently arises. The novice injector or the novice patient may be unaware of what to expect in terms of how much area can be effectively treated with a single syringe. Due to the high cost of a syringe of filler, many new filler patients desire to test the waters by purchasing a single syringe. For the nasolabial folds in adult patients, I almost never use only a single syringe. The average adult could tolerate three to four syringes and would have better results when finance is not an issue. The problem is that a single syringe is usually insufficient to augment bilateral nasolabial folds in the older patient. Attempting this to save money will usually produce an unhappy patient, because the result is minor. This can reflect on the expertise and reputation of the surgeon. When adults in the late 4th decade and beyond present for nasolabial fold treatment and request a single syringe, I explain the pitfall to them and ask them to save their funds until they can afford the proper amount, which is usually at least two syringes.

When treating the lips, many patients are very nervous about overcorrection. In these patients, a single syringe is usually sufficient for augmentation of both lips. Patients who need volume outline and lipstick-line treatment will require more than a single syringe. It is important to advise patients to not expect their nasolabial folds to be gone; they will be lessened. I explain that the nasolabial fold is a valley, and the filler will make it shallower, not reverse it. I also explain that although the nasolabial fold (or other wrinkles) may look much better in repose, they will still show upon smiling and animation.

To give the patient an idea of anticipated result, I use the following method to demonstrate an approximate goal of nasolabial and lip injections. For the nasolabial folds, I place my index finger lateral to the patient’s nasolabial fold and gently push in on the skin. This elevates the nasolabial fold, simulating an augmentation (Figure 14-8). I let them know that the fold will improve but not disappear.

FIGURE 14-8 By depressing the lateral nasolabial fold, the central region is elevated and can give the patient a preview of an anticipated result.

For the lips, I take both gloved index fingers and roll the upper lip up and the lower lip down. This allows increased vermilion show, similar to injecting filler, to increase pout and volume (Figure 14-9).

FIGURE 14-9 By rolling the upper lip border up and the lower lip border down, the patient can be shown an approximate goal for volume augmentation.

Injection Techniques

Having taught hundreds of injectors over the years, I open my lectures in jest by saying that if you can decorate a cake or caulk a bathtub, you can become proficient in filler techniques (Figure 14-10). There is actually some truth in this, since there is a distinct similarity of injection pressure and continual movement with the cake and caulk examples. Push the plunger too hard or fail to maintain a continuous motion, and you will get blobs instead of controlled lines. It is this combination of tactile pressure sensation and motion the novice injector needs to develop.

FIGURE 14-10 The injection of filler is comparable to “calking a bathtub” or “decorating a cake”. The application of pressure while advancing or withdrawing the injectable produces smooth and continuous filling.

Diagnostic Decisions and Patient Expectations

Although it sounds painfully simple, the surgeon has to (1) ask the patient what changes they desire, (2) make an accurate diagnosis of the problems that exist, and (3) decide how to treat them (Figure 14-11). Patient input is extremely valuable. There have been times when I was about to augment the upper nasolabial fold, and the patient was not bothered by this region but expected lower-fold augmentation. The price of the treatment and the expected outcome warrant careful prefiller conversation.

FIGURE 14-11 Accurate injectors will ask the patient exactly what they want to correct and consider these expectations in the diagnosis and treatment.

Some patients may want only a single lip (usually the upper) treated, whereas most patients desire both. Specifics are important. Do they want more defined lips? Do they want bigger lips? Do they want to show more vermilion? Do they want their “lipstick lines” improved? Many patients rely on the surgeon to decide. I begin conservatively with patients who have never had fillers and tell them before injecting them that when we are done, their lips are going to look overdone due to the local anesthesia, the filler, and edema and will settle in usually by the following day. I further explain that very infrequently a patient may have unusual swelling that could last for days. Finally, I explain that bruising is very hard to predict; most lip filler patients do not bruise, but some will bruise significantly. I make sure they do not have important social or work plans in the first several days. It is not unusual for patients to procrastinate getting filler before some event like a wedding or reunion, and this is a slippery slope in terms of them possibly looking worse (edema and ecchymosis) instead of better. Last minute filler injections before and important function should be discouraged and rescheduled. Sugar coating a recovery and causing the patient distress, embarrassment, or lost work is not a practice builder.

Treating young patients without significant photodamage is usually straightforward. They may simply need a touch of volume to plump the lips or some basic vermilion outline for definition. Treating the senescent lip, on the other hand, can be very challenging. The youthful lip is shorter, curvaceous, and has volume (Figure 14-12, A). The aging lip lengthens for numerous reasons, including volume loss from skin, muscle, and fat changes (see Figure 14-12, B).

FIGURE 14-12 The youthful lip (A) is curvaceous and volumized. The senescent lip (B) becomes elongated and loses volume and form.

Marking the Patient

I am a big proponent of marking all filler patients with a fine-tipped surgical marker. This includes lips, nasolabial folds, and wrinkles. Degreasing the skin with alcohol prior to marking helps the ink adhere. These ink lines must be made prior to local anesthetic injection so they are accurate and not distorted.

Anesthetic Considerations

Pain control is of utmost importance. Patient comfort and easing apprehension should be kept in mind throughout the entire procedure, similar to the painless dentistry model. I see patients who were treated elsewhere, had a painful injection experience, and switched to my practice because of their friends’ comments about how the procedure did not hurt. Never underestimate the power of marketing from painless procedures.

Some fillers contain inherent local anesthesia, but I strongly recommend using topical and local anesthetics when treating ultrasensitive areas like the lips and skin around the mouth. Local anesthetic technique for pain control is covered in Chapter 4. I truly believe that many injectors are simply lazy and do not invest the proper time and effort to make patients numb. Giving a patient a ball squeeze is not competent anesthesia. Undoubtedly, anesthesia care takes time and lengthens filler procedures, but this extra time spent will come back to the surgeon many times over in happy, painless patients and referrals. I like to supplement traditional anesthesia by having compassionate staff hold the patient’s hand (“handesthesia”) and conduct a relaxed, comforting conversation with the patient during the more painful portions of the injection procedure (“talkesthesia”).

Pharmacologic anesthesia should begin with an application of topical anesthesia on the skin if wrinkles or folds are to be treated. If the lips are to be treated, the inside and outside are covered with a thin coat of topical anesthetic, with care to include the upper and lower sulcus (Figure 14-13). I prefer 20% benzocaine, 6% lidocaine, and 4% tetracaine in a combination cream formulation. This is left in place for at least 5 minutes. The patient is then allowed to rinse their mouth; the anesthetic stimulates saliva and also will cause numbness in the pharynx, which is disconcerting for some patients (Figure 14-14).

FIGURE 14-13 The lip vermilion, intraoral mucosa, and sulcus are coated with a thin layer of topical anesthetic.

FIGURE 14-14 Patients should rinse their mouths out after 5 minutes, because saliva is stimulated and the pharynx can become numb, which many patients don’t like.

Although many surgeons employ local anesthetic blocks,¹⁶ I no longer use them, because they are more difficult and less dependable than infiltration techniques.¹⁷ Blocks are more technique sensitive, can be difficult in some patients, and will affect distant anatomy. Most patients do not like this. Using an infiltration I refer to as the “miniblock” technique, a series of injections is performed across the upper and/or lower sulcus. A 1-mL syringe with a 32-gauge needle is used with 2% lidocaine and 1 : 100,000 epinephrine (which can be electively omitted). Lidocaine in 0.2-mL aliquots is injected just above the upper sulcus (Figure 14-15) and just below the lower sulcus (Figure 14-16). This is generally performed in four to five areas from the canine tooth on one side to the canine tooth on the other side. The patient is then allowed 5 minutes for the anesthetic to take action. The local anesthetic will affect lip animation, which may become asymmetric, and this is another important reason for marking the patient prior to local anesthesia so landmarks are not lost. In addition, some of the wrinkles that existed with animation may not be visible if the lip is not moving normally (Figure 14-17).

FIGURE 14-15 The upper miniblock technique is a series of four or five infiltrations across the mucosal surfaces of the upper and/or lower lip. About 0.2 mL of 2% lidocaine with epinephrine are injected at each region between the cuspid teeth.

FIGURE 14-16 Miniblock technique for the lower lip.

FIGURE 14-17 When using infiltrative local anesthetic techniques, it is important to mark injection landmarks before local injection. Anesthesia can temporarily affect motor movement of the lip, and normal landmarks such as wrinkles can be changed.

Lip-Enhancement Techniques

Which areas to treat will have been decided before the patient is actually injected. I have a folder on my computer called “great lips,” and in that folder I keep pictures of beautiful lips on various age groups. Some of these are actual patients, some are taken from magazines. I studied these pictures in my learning phase and now have them etched in my brain. A mental template of what you are about to create and what proportions are pleasing is vital to the end result.

A successful injector is a student of lip form and function and needs to be cognizant of the differences between youthful and senescent lips. In youth, the upper lip constitutes about a third of the total lip volume, and the lower lip constitutes about two-thirds of the mass. This varies among patients and ethnicity (Figure 14-18). Another way of measuring the average ratio is 1 : 1.6 for the upper and lower lip, respectively. The youthful perioral region is defined by numerous anatomic components that undergo changes with aging. The astute injector is aware of normal lip volume, outline, philtrum, and philtral columns (Figure 14-19). Like any other body part, some patients exhibit outstandingly aesthetic lips. This patients may exhibit three distinct prominences or tubercles in the upper lip and two in the lower lip. On the upper lip, these natural “pillows” lie in the midline, one centrally and one on each lateral region. On the lower lip, the two prominent tubercles lie on each side of the midline. Some injectors strive to duplicate these prominent regions. My experience is that this looks good on some patients, but most patients feel that the discontinuous tubercles look less aesthetic than simply having full, contiguous lips.

FIGURE 14-18 The upper lip contributes less volume than the lower lip in the average patient. The difference is frequently described as one-third for the upper and two-thirds for the lower, or a ratio of 1 : 1.6.

FIGURE 14-19 Important components to understand and duplicate when necessary. A and E, Cupid’s bow and white roll. B, Philtrum, C, Philtral column. D, Lip parenchyma or “volume.” The border of the upper lip is M shaped, and the lower is curvilinear.

Every practitioner has his or her specific lip-enhancement techniques. The two most popular are linear threading and serial puncture (Figure 14-20). Linear threading involves inserting the needle and injecting the filler in a straight line while continuously moving in either a forward or backward direction. This process would be analogous to placing a line of toothpaste on one’s toothbrush, laying down a seam of calking, or decorating a cake. Although I personally inject while withdrawing, other injectors advocate injecting antegrade to push structures out of the way. The other injection method is known as the serial puncture technique. This involves placing small boluses of filler with multiple punctures along the lip or wrinkle. In reality, many instances call for a combination of both techniques.

FIGURE 14-20 Linear threading involves laying down a controlled line of filler with continuous motion and syringe pressure. Serial puncture involves injecting small boluses or pillows of filler in a given area.

Lip Outline

Each patient requires different filler techniques based upon their specific needs. Some patients (young and old) lack the specific outline of a “Cupid’s bow” or “white roll.” The Cupid’s bow of the upper lip is a lazy-M shape, and the corresponding border of the lower lip is curvilinear. In patients with well-defined lip borders, a pleasing light reflex is visible and contributes to maximum aesthetics. If a patient has adequate lip volume, they may only need border outline, but some patients need both volume and outline as well as vertical rhytid injection. Each patient is different (Figure 14-21).

FIGURE 14-21 Each patient has different indications for lip enhancement and requires different treatment scenarios. A, This patient needs only volume plumping, especially in the upper lip. B, Another patient is in need of both volume plumping and vermilion border outline. C, A third patient needs volume, outline, and vertical rhytid filling.

It is important to inject patients in a more upright position; gravity will distort a supine patient’s normal anatomy (Figure 14-22).

FIGURE 14-22 Patients are more accurately treated sitting upright (A). Injecting in the supine position (B) can be inaccurate because of gravitational influences.

When injecting the lip borders, needle placement is critical. A potential space exists between the mucosa and orbicularis oris muscle, and this space is the target of border outline (Figure 14-23). The guide for novice injectors is both visual and tactile. When the needle is in the correct plane, the filler will visually flow both antegrade and retrograde. This can be seen and also palpated by the noninjecting hand. By pinching the border between the noninjecting thumb and index finger, the injector can feel the free-flowing filler as well as corral the filler to stay within the border (Figure 14-24).

FIGURE 14-23 Using the noninjecting hand to pinch the lip border while injecting serves to provide a “feel” for the filler flowing correctly and also serves to corral the filler into the proper region.

FIGURE 14-24 Cadaveric dissection illustrating the plane of the potential space in the lower lip, beneath the mucosa and above the orbicularis oris muscle, marked “outline.”

If the needle is in the correct plane (the described potential space), the filler will flow freely with minor syringe pressure. This is confirmed by observing the border being properly created. If the needle is too deep, no distinct outline is seen. If the needle is too superficial, the filler will not flow but instead “ball up,” and the syringe pressure will increase. In this case, the needle must be redirected into the proper potential space (Figure 14-25).

FIGURE 14-25 Injecting in the potential space between the mucosa and orbicularis oris muscle is the proper plane for vermilion outline. A too superficial injection will be realized by the filler balling up and the syringe pressure increasing.

Creating the Vermilion Outline

When augmenting the vermilion border for outline or white-roll enhancement, I begin with the central V of the Cupid’s bow. If the patient does not have a well-defined Cupid’s bow, I draw it on during preinjection marking as a guide for filling. Care is used to form crisp, angular contours in the downward legs of the lazy M in the area of the central lip (Figure 14-26, A).

FIGURE 14-26 A, Central portion of the Cupid’s bow is filled first to make a distinct V in the central upper lip. B, Vermilion border augmentation is carried laterally but generally not all the way to the lateral commissure. C, Vermilion border or white roll is augmented in a similar manner, targeting the potential space described previously. As with the upper lip, border augmentation is limited to the central third or two-thirds and does not continue to the lateral commissure of the lip.

The next step is to continue the vermilion outline augmentation laterally (see Figure 14-26, B). In the average patient, the white roll only needs to be augmented in the central one- to two-thirds of the upper lip that corresponds with the “pucker area.” I rarely carry this out to the lateral commissure. The needle is inserted all the way to the hub, and the filler is injected with even syringe pressure upon withdrawal. Most filler needles are inch long, and the border is augmented at -inch intervals, taking care to not leave a gap between needle insertion points. The white roll is similarly created in the lower lip, which is more curvilinear than in the upper lip (see Figure 14-26, C).

A single syringe is usually more than adequate to outline the vermilion on both lips. The lower-lip central vermilion outline is a small but powerful augmentation. A little bit of filler goes a long way here and creates a very pleasing light reflex, especially in women who wear lip gloss.

Outlining the vermilion border in both lips as described is sometimes all a patient needs for lip enhancement, especially those who don’t desire larger lips.

Increasing Deep Lip Volume

Although vermilion border augmentation is a powerful means of enhancing the lip, many patients have adequate outline and a defined white roll or Cupid’s bow and do not require outline. The most common presentation in my practice is the patient who presents with the desire for more lip volume. These patients request plumper, fuller, pouty, and more voluptuous lips. Many are younger and already have adequate vermilion border. These patients will benefit from deeper fill that will increase the general lip volume and pout. By augmenting the deeper portion of the lip, the actual lip will roll out and produce increased pout. The target for deep lip augmentation is basically the center of the lip. This is deep to the muscle and contains connective tissue, minor salivary glands, and fat (see Figure 14-24, “deep”).

For deep augmentation, the needle is inserted at the wet/dry line, deep into the central lip. The needle is inserted to the hub and slowly withdrawn while continuous, steady injection is performed. In this area, the goal is to produce a “tube” of filler for deep volume (Figure 14-27, A). As noted earlier, some injectors attempt to reproduce the prominent lip tubercles seen in some aesthetic lips, and instead of a continuous tube of filler, the tubercles are reconstructed, three in the upper lip and two in the lower lip (see Figure 14-27, B).

FIGURE 14-27 Deeper parenchymal lip injection is performed to provide volume, pout, and increased vermilion show. Needle enters the lip at the wet/dry line, and the target is the center of the lip. A, Author’s preferred means of deep lip augmentation. B, Alternate deposition technique to reconstruct tubercles in both lips.

The center of the lip is generally a safe plane, because the labial artery lies at the posterior third of the lip (Figure 14-28). Generally a single syringe will treat the average patient requiring deeper volume and is appropriately split between the upper and lower lip based upon volumetric need.

FIGURE 14-28 Cadaveric specimen illustrating approximate position of the labial artery (arrows) in the posterior third of the lower lip.

A lumpy result with visible and palpable nodules of filler is frequently the result of not massaging the filler after injection. I strongly believe massaging the injected filler is a critical (and oftentimes overlooked) step in obtaining natural and aesthetic results. Most fillers have the consistency of soft gels or paste and when injected will not always be homogenous. Massaging the filler more evenly distributes and forms it and produces a smoother, more homogenous result (Figure 14-29). In addition, the injector can actually level out an area of excess by moving the filler through the tissues. Since there is friction between the skin and surgical gloves, massage is difficult and jerky without a lubricant. My assistant keeps a small bolus of petroleum jelly on the back of her glove during all filler injections, and I dab this and coat the lip and skin just prior to massage. Again, controlled massage is a critical part of filler injection.

FIGURE 14-29 Massaging the lips to evenly distribute and homogenize the filler immediately after injection is an important step in achieving a smooth, natural result. On each lip, the central lip is grasped with both hands (A–B), and the filler is massaged laterally (C–D). The same massage procedure is performed on each lateral lip (E–F). This is performed in both lips regardless of what area is filled. Petroleum jelly is used to lubricate the lips and skin.

Some injectors carry vermilion and deep volume injections all the way to the corner of the mouth, but I generally do not (Figure 14-30). In my opinion, one of the most common unnatural filler results is the “ducky” lip, due in part to an eversion of the lateral lip reminiscent of the familiar rubber duck bath toy, which is unfortunately visible on many female celebrities.

FIGURE 14-30 Most lip augmentation is confined to the central third of the lip to accent the “pucker” area when using outline and/or deep fill. There are, however, patients who benefit from more lateral augmentation, and t/>

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