T he effects of time and sun-exposure can leave many patients with a “puckered mouth” effect that’s cosmetically non-pleasing. Throughout the history of medical discoveries many have sought the guidance and advice of dermatologists to reverse these obvious effects. Many of these old and newer techniques focus on the nasiolabial fold and perioral region, which is a growing concern for patients in their 30s to 50s. While the nasiolabial fold becomes deep and furrowed secondary to senescence affects of skin aging, the perioral region has deepened radial lines secondary to hyperkinetic action of the orbicularis oris sphincter muscle. This article will offer different methods for correcting these changes. Cosmetic Fillers Filling agents are the most popular methods used for the correction of perioral changes. The most common modalities include fat, collagen and dermis. Fat transfer is the most popular option since there’s no material cost and no allergy testing required. A metabolically resistant donor site, usually the lateral hip or flank is infused with tumescent local anesthesia. The rhytides are overcorrected with the adipose tissue suspension injections since resorption of saline occurs.1 (See photos at right.) Graft take can vary from 30% to 50%, according to different authors. Unlike with collagen, allergic reaction is not a factor as the fat is harvested from the patient’s own body. Disadvantages include uneven resorption resulting in lumps and sometimes significant swelling initially. Collagen Fillers Collagen is a naturally occurring protein that supports various parts of the body including joints. It’s been used for years as a soft tissue filler. Autologen is an autologous human collagen and fibroblast derived from the patient’s own skin, usually from the excess removed at the time of a procedure involving tissue extraction, such as an abdominoplasty. The patient’s own natural collagen is then processed by a lab, and then preserved and kept frozen in the special cryo-freezers at the lab and then returned to the physicians office for the procedure. Advantages are that no skin testing is required and it’s well tolerated when re-injected into the patient. It is available in the United States. Disadvantages are the expense of preservation and storage in a cryo-freezer at the lab. The implantation must take place within 48 hours of harvesting.2 There’s immediate burning and stinging at the injection site for about 15 minutes.2 In addition, there’s less immediate correction clinically with this filler due to its low viscosity. Zyderm or Zyplast (Resoplast is a similar product used in Europe) are both examples of sterile, purified, reconstituted fibrillar bovine collagen (type I and type III collagen). Human collagenase begins to degrade the foreign substance, and after 3 months none can be detected, although up to 30% of patients report effects lasting 18 months. Patients must have skin tests prior to treatments. A small amount of collagen in injected into the forearm just below the skin surface, and if there’s no adverse reaction after 4 weeks that patient may be treated. Reactions usually occur in the first 3 days. Advantages of this collagen include that it lasts 3 months to 6 months and is available in the United States. Disadvantages of this treatment include hypersensitivity (3% to 5%), erythema, induration, granulomatous responses, pain and bruising at the injection site and serum sickness-like reactions. The physician has a small window to smooth the injected collagen within the site before it hardens. Swelling can occur at the injection site, resulting from the saline carrier of the collagen injection formulation, which can last for about 4 hours or until it’s absorbed by the body. CosmoDerm and CosmoPlast are both human collagen dermal fillers that are made from human tissue, which is grown in a controlled laboratory environment. They contrast by a non-cross linked nature of CosmoDerm in comparison to the cross linked nature of CosmoPlast. The advantage is that the former is reserved for the correction of superficial lines (see photos on page 60), and the latter for deeper lines. Neither product requires skin testing, and the affects last up to 3 months to 6 months. Both products have been FDA approved for use in the United States. Both products are formulated with an anesthetic for comfort. A disadvantage is that CosmoDerm is not as long lasting as CosmoPlast after placement. Artecoll is a 3% to 5% solution of bovine collagen mixed with polymethacrylate beads (non-silicone, carbon-based polymers), the augmentation material, in a ratio of 3:1. This mixture contains 0.3% lidocaine and is injected at the dermal and subcutaneous junction injecting the material as the needle is withdrawn. Using a small needle injection of the microdroplets gives a more even result. It may take two to three sessions before the desired correction is achieved since overcorrection is not desirable. An advantage is that this method produces immediate results and is proposed to be a more permanent filler because the microspheres don’t absorb into the body. This choice is useful for correcting depressions and deeper creases. Disadvantages are that allergic testing for bovine collagen is necessary, and patients may experience lumping or granulomatous skin reactions. Lastly, microspheres can possibly move to other areas of the body. It’s not useful for fine-line corrections, and this filler isn’t yet available in the United States. However, an FDA panel recently recommended its approval. Presently, this filler is available in Europe, Canada and Mexico. Silicone and Hyaluronic Acid Fillers Liquid silicone injections (Silikon 1000, Adatosil 5000, SilSkin) are composed of purified, medical grade polydimethylsiloxane oil used for the correction of moderate-depth lines and depressions. Microdroplets of silicone are dispersed within the dermal tissues. The fibrosis around these droplets localize the material, and it’s seemingly well tolerated in small amounts in the face (see photos on page 62). Advantages are that it’s a permanent filler, and no allergy testing is required because it’s chemically well tolerated. The disadvantage is that it’s not FDA approved yet for cosmetic usage; it is, however, being used in Europe, Mexico and some parts of Canada. SilSkin is presently being considered for cosmetic use in the United States. There are also risks of granuloma formation because the silicone becomes encapsulated as a foreign body by a chronic inflammatory reaction, causing a potential site of infection. Possible migration of the material to other organs and lymph nodes, fibroses and inflammation and discoloration of surrounding tissue are other disadvantages. Restylane is a non-animal hyaluronic acid based filling agent. It comes in three types — Restylane Fine Lines, Restylane, and Perlane, based on the same type of gel from highly concentrated stabilized hyaluronic acid of 20 mg/ml. Hyaluronic acid is a naturally occurring substance found within the body. It’s a clear gel that’s injected into the dermis, deeper for more viscous types and more superficial for less viscous grades. It works in conjunction with the body’s own hyaluronic acid, increasing its longevity. The major advantage is that no pre-test is necessary. The disadvantage is that it’s not a permanent filler because it gets absorbed into the body, and so its effects last only 3 to 6 months. It’s not FDA approved for use in the United States. The hyaluronic acid in Perlane is larger in size, and takes longer to dissipate; making it useful for deep facial lines like the nasolabial folds. It lasts from 3 months to 9 months, but isn’t yet FDA approved. Macrolane is the largest of the three in size, and so it takes the longest to dissipate with effects lasting up to 2 years. It’s also not available in the United States. In late November, an FDA advisory panel is scheduled to review data on Hylaform. This filler, which will be marketed by Inamed Corp., is derived from roosters’ combs. More Filler Choices Radiance (Bioform) is a soft tissue filler composed of calcium hydroxyapatite, which is found in bone and teeth. It adds volume via microspheres that are suspended in an aqueous polysaccharide gel via injection by threading of the solution into deep dermis. It corrects when the microspheres are held in place until resorption and collagenation takes place. After Radiance is injected into soft tissue, the fibroblasts work by building a non-scar tissue collagen type, creating a voluminous filler. The advantage is that it is proposed to last 2 years to 5 years with little risk of an allergic reaction. It is available in the United States, but it’s still in the investigational stages for cosmetic use. Disadvantages are clumping, lumping, granulomatous reaction and microsphere redistribution to other parts of the body. Dermalogen is an injectable human tissue matrix from human tissue banks containing only intact collagen fibers and fibrils, elastic fibers and proteoglycans. Since the collagen fibers are well organized, augmentation lasts longer than bovine collagen.9 Skin testing is required, and augmentation may proceed if the test is negative at 72 hours. During injection, the physician must simultaneously pull the skin taut bilaterally allows for even correction. The goal is to inject at the midreticular level until the majority of the gentian lines have been removed or the deepest plane has been reached. 4 Alloderm-acellular allogeneic dermis has been used for aesthetic lip augmentation with good results; it is cadaveric dermis and extracellular cell matrix that has been processed to remove immunogenic components.5 Available in sheets, Alloderm can be rolled or cut into strips. The sheet is rehydrated and trimmed before insertion. Studies show that it provides 6 months to 12 months of augmentation.3 Cymetra is a microparticulate injectable form of Alloderm. PlasmaGel is a plasma emulsion with Vitamin C complex. The physician takes the patient’s blood and spins the protein out of the blood and mixes it with a Vitamin C complex. The doctor then re-injects this mixture into the treatment site that will result in augmentation with the patients’ own serum. The effects usually last about 3 months to 5 months. An advantage is that no skin testing is required. The disadvantage is that the physician needs the facility for creating the mixture. Fascian is a lyophilized human particulate fascia lata from donor cadavers available in particulate and line-like sheets. Particulate size ranges from 0.1 mm to 2 mm and is prepackaged in a freeze-dried, vacuum-sealed syringe. A thick suspension is injected. The sheets may be “diced” and implanted into pocket-like slits.6 Side effects include edema, erythema and ecchymosis for up to 6 weeks post-op. Post-inflammatory hyperpigmentation is a late complication. The larger particle size seems to be associated with more persistent side effects. Gore-Tex is a permanent filler, expanded polytetrafluoroethylene (ePTFE, Gore-Tex) that has been used since the 70s for vascular grafts and soft tissue reconstruction. It has proven helpful for lip augmentation and perioral rhytides. EPTFE is an inert, soft microporous biomaterial that is available in tubular forms and sheets. We tend to use the tubular forms. The appropriate length and width of the implant is inserted to the lip area and inserted at the subdermal area via a 14-gauge to 16-gauge angiocather after local anesthesia has been administered (see photos on page 63). Complications include transient bruising, swelling, and paresthesia; more serious but less common complications include infection of the implant site, fistula formation, induration, implant extrusion, discoloration, and scarring. Other graft sources have been reported in the literature including autologous breast implant capsule, aponeurotic galea and subgalea, and temporal fascia. Strips of dermal graft have been used successfully, with survival rates at 80%, for several years to fill lip contours with the restriction of finding a donor site. A recent technique has been described where a “tissue cocktail” is prepared from an injectable mixture of dermis, muscle strips, fat tissue and fascia obtained from other reconstructive procedures on the same patient. The survival rate is high as 90% to 95%.7 It’s been used to attenuate wrinkles around the lip and to augment lip thickness inside the lip muscle. Surgical Techniques Here’s a review of the surgical procedures that help to improve the perioral regions. The nose base resection/lip lift that’s used to shorten the upper lip and everts the vermilion border allowing the upper teeth to show again when the lips are slightly parted. Many patients opt to have this procedure performed during a face lift. Directly under the nose, a wavy ellipse following the contour of the nasal base is excised ranging from 3 mm to 11 mm in width, averaging 6 mm. Overcorrection by one-third allows for post-operative re-droop.8 The scar is hidden in the shadowed crease. The corner lift is used to elevate the corners of the mouth. At the commissures a rounded arc-like triangle is drawn by extending lines from the commissure vermillion border — 1.2 cm to 1.6 cm medially from the commissure along the skin-vermilion border and another is aimed at the top of the ear stopping short of the nasiolabial crease. The triangle height ranges from 3 mm to 9 mm with 5 mm being the usual amount, and 7 mm to 9 mm to correct a more significant downturn. The triangle is excised and precisely sutured in two layers. Initially, correction will appear overdone but will correct over several days. Sutures are removed in 3 days to 5 days. A fine white line is minimally evident and lies at or within the lipstick border.8 Surgical augmentation of the upper lip creates a fuller upper lip by shifting tissue from the sides and downward to the midline to augment the central vermilion. A V-Y flap approximately 2 cm wide is drawn on the inner surface of the everted upper lip.8 Wider flaps have been described, which enhance the entire vermilion from corner to corner, and multiple V-Y flaps may be used to augment the vermilion in the three areas of natural fullness of the upper lip.8 Incisions are made inside the we-dry line dissecting downward superficially to muscle.8 Side effects include hardening and discomfort for months after the procedure.8 Advancement of the vermilion is a technique that requires the surgeon to meticulously mark and excise a strip of skin at the vermilion border. Advancing the upper lip is technically more difficult because of “cupid’s bow” and the other architectural features. The slightest asymmetry is easily noted after correction. Hypertrophic scarring is noted when the excision extends all the way across the lip. Excluding the central cupid’s bow region seems to prevent scar hypertrophy.8 In the lower lip advancement, a strip of adjacent skin from corner to corner, twice as wide as the amount of advancement desired is excised, and the vermilion is sutured in a single continuous layer creating the illusion of a fuller lip by eversion.8 Some surgeons may opt to leave a central gap in the excision as in the upper lip to prevent scarring.8 Resurfacing Techniques Resurfacing techniques tend to correct drooping and shallow wrinkles. A resurfacing procedure is the best option for minimizing deeper vertical wrinkles around the lip. Certain factors must be considered in choosing the appropriate resurfacing procedure. These factors include color of skin and eyes, depth of wrinkles, history of previous resurfacing procedure, sun damage, pigment irregularities and a history of facial herpes simplex virus.4 Chemical peels such as trichloroacetic acid (TCA) and phenol have been used depending on the extent of wrinkle depth and sun damage. Peels are helpful for removing fine wrinkles. The entire perioral area may be treated at one time. Surface oils and debris are thoroughly removed from the surface of the skin. With the skin stretched tautly by an assistant, the peeling agent is worked into the wrinkle depth with a cotton swab. After a few seconds of contact with the skin, the peeling agent causes “neutralization” to take place, which is an irreversible reaction. Applying saline-soaked gauze stops the reaction. Significant edema may initially occur but subsides within a few weeks; both peels have unpredictable scarring and depigmentation potential. Patients undergoing phenol peels require simultaneous monitoring for cardiac and kidney toxicity.9 Glycolic acid peels are helpful for treating very superficial peels, mild acne blemishes and scarring and some pigmentation problems. A 70% glycolic acid solution is applied to the affected area initially for one minute.4 With successive peels, the time is increased depending on the patient’s response to maintain the improvement. A topical regimen is continued including retinoid acid, vitamin C and glycolic acid creams/lotions. Dermabrasion is an effective tool for removing “purse string” wrinkles involving the upper lip; approximately 40% to 60%6 to 80% to 90%1 can be removed. Deep dermabrasion can remove nearly 100% of the wrinkling but may result in hypopigmentation or even scarring.1 Other possible side effects include increased risk of infection and redness lasting 3 weeks to 4 months.4 Initially, gentian violet is used to outline the wrinkles. Using a refrigerant spray and simultaneously pulling the skin taut bilaterally allows for even abrasion. The goal is to abrade to the midreticular level until the majority of the gentian lines have been removed or the deepest plane has been reached.4 Laser resurfacing, unlike chemical peeling and dermabrasion, provides a predictable, consistent depth of penetration with each laser pass based on the thermal relaxation principle. Both the pulsed CO2 and Erbium Nd:YAG lasers are used for laser resurfacing, and laser techniques are usually combined with other types of treatments. The technique of laser resurfacing has been described elsewhere.10 In our hands, pulsed CO2 laser resurfacing produces the most predictable outcome in clearing perioral rhytides and seems to be the most beneficial for deep rhytides. The Erbium:YAG laser is helpful for mild to moderate rhytides; post-op erythema is of shorter duration than with CO2 laser. The most common side effects of the lasers include post-inflammatory hyperpigmentation and hypopigmentation, erythema, infections (bacterial, fungal and viral) and scarring, so closely following patients post-operatively is essential. Choosing an Option In conclusion, there are many options in treating perioral signs of aging. Each patient’s treatment plan should be individualized to meet his or her needs and concerns. Most of these procedures when combined give a better outcome. With more and more filler agents being approved for usage we’ll see increased numbers in non-surgical perioral enhancement. However, CO2 laser resurfacing with either combined microfat injections or Goretex implantation provides the best synergistic effect.
Exploring the Options for Treating Perioral Signs of Aging
T he effects of time and sun-exposure can leave many patients with a “puckered mouth” effect that’s cosmetically non-pleasing. Throughout the history of medical discoveries many have sought the guidance and advice of dermatologists to reverse these obvious effects. Many of these old and newer techniques focus on the nasiolabial fold and perioral region, which is a growing concern for patients in their 30s to 50s. While the nasiolabial fold becomes deep and furrowed secondary to senescence affects of skin aging, the perioral region has deepened radial lines secondary to hyperkinetic action of the orbicularis oris sphincter muscle. This article will offer different methods for correcting these changes. Cosmetic Fillers Filling agents are the most popular methods used for the correction of perioral changes. The most common modalities include fat, collagen and dermis. Fat transfer is the most popular option since there’s no material cost and no allergy testing required. A metabolically resistant donor site, usually the lateral hip or flank is infused with tumescent local anesthesia. The rhytides are overcorrected with the adipose tissue suspension injections since resorption of saline occurs.1 (See photos at right.) Graft take can vary from 30% to 50%, according to different authors. Unlike with collagen, allergic reaction is not a factor as the fat is harvested from the patient’s own body. Disadvantages include uneven resorption resulting in lumps and sometimes significant swelling initially. Collagen Fillers Collagen is a naturally occurring protein that supports various parts of the body including joints. It’s been used for years as a soft tissue filler. Autologen is an autologous human collagen and fibroblast derived from the patient’s own skin, usually from the excess removed at the time of a procedure involving tissue extraction, such as an abdominoplasty. The patient’s own natural collagen is then processed by a lab, and then preserved and kept frozen in the special cryo-freezers at the lab and then returned to the physicians office for the procedure. Advantages are that no skin testing is required and it’s well tolerated when re-injected into the patient. It is available in the United States. Disadvantages are the expense of preservation and storage in a cryo-freezer at the lab. The implantation must take place within 48 hours of harvesting.2 There’s immediate burning and stinging at the injection site for about 15 minutes.2 In addition, there’s less immediate correction clinically with this filler due to its low viscosity. Zyderm or Zyplast (Resoplast is a similar product used in Europe) are both examples of sterile, purified, reconstituted fibrillar bovine collagen (type I and type III collagen). Human collagenase begins to degrade the foreign substance, and after 3 months none can be detected, although up to 30% of patients report effects lasting 18 months. Patients must have skin tests prior to treatments. A small amount of collagen in injected into the forearm just below the skin surface, and if there’s no adverse reaction after 4 weeks that patient may be treated. Reactions usually occur in the first 3 days. Advantages of this collagen include that it lasts 3 months to 6 months and is available in the United States. Disadvantages of this treatment include hypersensitivity (3% to 5%), erythema, induration, granulomatous responses, pain and bruising at the injection site and serum sickness-like reactions. The physician has a small window to smooth the injected collagen within the site before it hardens. Swelling can occur at the injection site, resulting from the saline carrier of the collagen injection formulation, which can last for about 4 hours or until it’s absorbed by the body. CosmoDerm and CosmoPlast are both human collagen dermal fillers that are made from human tissue, which is grown in a controlled laboratory environment. They contrast by a non-cross linked nature of CosmoDerm in comparison to the cross linked nature of CosmoPlast. The advantage is that the former is reserved for the correction of superficial lines (see photos on page 60), and the latter for deeper lines. Neither product requires skin testing, and the affects last up to 3 months to 6 months. Both products have been FDA approved for use in the United States. Both products are formulated with an anesthetic for comfort. A disadvantage is that CosmoDerm is not as long lasting as CosmoPlast after placement. Artecoll is a 3% to 5% solution of bovine collagen mixed with polymethacrylate beads (non-silicone, carbon-based polymers), the augmentation material, in a ratio of 3:1. This mixture contains 0.3% lidocaine and is injected at the dermal and subcutaneous junction injecting the material as the needle is withdrawn. Using a small needle injection of the microdroplets gives a more even result. It may take two to three sessions before the desired correction is achieved since overcorrection is not desirable. An advantage is that this method produces immediate results and is proposed to be a more permanent filler because the microspheres don’t absorb into the body. This choice is useful for correcting depressions and deeper creases. Disadvantages are that allergic testing for bovine collagen is necessary, and patients may experience lumping or granulomatous skin reactions. Lastly, microspheres can possibly move to other areas of the body. It’s not useful for fine-line corrections, and this filler isn’t yet available in the United States. However, an FDA panel recently recommended its approval. Presently, this filler is available in Europe, Canada and Mexico. Silicone and Hyaluronic Acid Fillers Liquid silicone injections (Silikon 1000, Adatosil 5000, SilSkin) are composed of purified, medical grade polydimethylsiloxane oil used for the correction of moderate-depth lines and depressions. Microdroplets of silicone are dispersed within the dermal tissues. The fibrosis around these droplets localize the material, and it’s seemingly well tolerated in small amounts in the face (see photos on page 62). Advantages are that it’s a permanent filler, and no allergy testing is required because it’s chemically well tolerated. The disadvantage is that it’s not FDA approved yet for cosmetic usage; it is, however, being used in Europe, Mexico and some parts of Canada. SilSkin is presently being considered for cosmetic use in the United States. There are also risks of granuloma formation because the silicone becomes encapsulated as a foreign body by a chronic inflammatory reaction, causing a potential site of infection. Possible migration of the material to other organs and lymph nodes, fibroses and inflammation and discoloration of surrounding tissue are other disadvantages. Restylane is a non-animal hyaluronic acid based filling agent. It comes in three types — Restylane Fine Lines, Restylane, and Perlane, based on the same type of gel from highly concentrated stabilized hyaluronic acid of 20 mg/ml. Hyaluronic acid is a naturally occurring substance found within the body. It’s a clear gel that’s injected into the dermis, deeper for more viscous types and more superficial for less viscous grades. It works in conjunction with the body’s own hyaluronic acid, increasing its longevity. The major advantage is that no pre-test is necessary. The disadvantage is that it’s not a permanent filler because it gets absorbed into the body, and so its effects last only 3 to 6 months. It’s not FDA approved for use in the United States. The hyaluronic acid in Perlane is larger in size, and takes longer to dissipate; making it useful for deep facial lines like the nasolabial folds. It lasts from 3 months to 9 months, but isn’t yet FDA approved. Macrolane is the largest of the three in size, and so it takes the longest to dissipate with effects lasting up to 2 years. It’s also not available in the United States. In late November, an FDA advisory panel is scheduled to review data on Hylaform. This filler, which will be marketed by Inamed Corp., is derived from roosters’ combs. More Filler Choices Radiance (Bioform) is a soft tissue filler composed of calcium hydroxyapatite, which is found in bone and teeth. It adds volume via microspheres that are suspended in an aqueous polysaccharide gel via injection by threading of the solution into deep dermis. It corrects when the microspheres are held in place until resorption and collagenation takes place. After Radiance is injected into soft tissue, the fibroblasts work by building a non-scar tissue collagen type, creating a voluminous filler. The advantage is that it is proposed to last 2 years to 5 years with little risk of an allergic reaction. It is available in the United States, but it’s still in the investigational stages for cosmetic use. Disadvantages are clumping, lumping, granulomatous reaction and microsphere redistribution to other parts of the body. Dermalogen is an injectable human tissue matrix from human tissue banks containing only intact collagen fibers and fibrils, elastic fibers and proteoglycans. Since the collagen fibers are well organized, augmentation lasts longer than bovine collagen.9 Skin testing is required, and augmentation may proceed if the test is negative at 72 hours. During injection, the physician must simultaneously pull the skin taut bilaterally allows for even correction. The goal is to inject at the midreticular level until the majority of the gentian lines have been removed or the deepest plane has been reached. 4 Alloderm-acellular allogeneic dermis has been used for aesthetic lip augmentation with good results; it is cadaveric dermis and extracellular cell matrix that has been processed to remove immunogenic components.5 Available in sheets, Alloderm can be rolled or cut into strips. The sheet is rehydrated and trimmed before insertion. Studies show that it provides 6 months to 12 months of augmentation.3 Cymetra is a microparticulate injectable form of Alloderm. PlasmaGel is a plasma emulsion with Vitamin C complex. The physician takes the patient’s blood and spins the protein out of the blood and mixes it with a Vitamin C complex. The doctor then re-injects this mixture into the treatment site that will result in augmentation with the patients’ own serum. The effects usually last about 3 months to 5 months. An advantage is that no skin testing is required. The disadvantage is that the physician needs the facility for creating the mixture. Fascian is a lyophilized human particulate fascia lata from donor cadavers available in particulate and line-like sheets. Particulate size ranges from 0.1 mm to 2 mm and is prepackaged in a freeze-dried, vacuum-sealed syringe. A thick suspension is injected. The sheets may be “diced” and implanted into pocket-like slits.6 Side effects include edema, erythema and ecchymosis for up to 6 weeks post-op. Post-inflammatory hyperpigmentation is a late complication. The larger particle size seems to be associated with more persistent side effects. Gore-Tex is a permanent filler, expanded polytetrafluoroethylene (ePTFE, Gore-Tex) that has been used since the 70s for vascular grafts and soft tissue reconstruction. It has proven helpful for lip augmentation and perioral rhytides. EPTFE is an inert, soft microporous biomaterial that is available in tubular forms and sheets. We tend to use the tubular forms. The appropriate length and width of the implant is inserted to the lip area and inserted at the subdermal area via a 14-gauge to 16-gauge angiocather after local anesthesia has been administered (see photos on page 63). Complications include transient bruising, swelling, and paresthesia; more serious but less common complications include infection of the implant site, fistula formation, induration, implant extrusion, discoloration, and scarring. Other graft sources have been reported in the literature including autologous breast implant capsule, aponeurotic galea and subgalea, and temporal fascia. Strips of dermal graft have been used successfully, with survival rates at 80%, for several years to fill lip contours with the restriction of finding a donor site. A recent technique has been described where a “tissue cocktail” is prepared from an injectable mixture of dermis, muscle strips, fat tissue and fascia obtained from other reconstructive procedures on the same patient. The survival rate is high as 90% to 95%.7 It’s been used to attenuate wrinkles around the lip and to augment lip thickness inside the lip muscle. Surgical Techniques Here’s a review of the surgical procedures that help to improve the perioral regions. The nose base resection/lip lift that’s used to shorten the upper lip and everts the vermilion border allowing the upper teeth to show again when the lips are slightly parted. Many patients opt to have this procedure performed during a face lift. Directly under the nose, a wavy ellipse following the contour of the nasal base is excised ranging from 3 mm to 11 mm in width, averaging 6 mm. Overcorrection by one-third allows for post-operative re-droop.8 The scar is hidden in the shadowed crease. The corner lift is used to elevate the corners of the mouth. At the commissures a rounded arc-like triangle is drawn by extending lines from the commissure vermillion border — 1.2 cm to 1.6 cm medially from the commissure along the skin-vermilion border and another is aimed at the top of the ear stopping short of the nasiolabial crease. The triangle height ranges from 3 mm to 9 mm with 5 mm being the usual amount, and 7 mm to 9 mm to correct a more significant downturn. The triangle is excised and precisely sutured in two layers. Initially, correction will appear overdone but will correct over several days. Sutures are removed in 3 days to 5 days. A fine white line is minimally evident and lies at or within the lipstick border.8 Surgical augmentation of the upper lip creates a fuller upper lip by shifting tissue from the sides and downward to the midline to augment the central vermilion. A V-Y flap approximately 2 cm wide is drawn on the inner surface of the everted upper lip.8 Wider flaps have been described, which enhance the entire vermilion from corner to corner, and multiple V-Y flaps may be used to augment the vermilion in the three areas of natural fullness of the upper lip.8 Incisions are made inside the we-dry line dissecting downward superficially to muscle.8 Side effects include hardening and discomfort for months after the procedure.8 Advancement of the vermilion is a technique that requires the surgeon to meticulously mark and excise a strip of skin at the vermilion border. Advancing the upper lip is technically more difficult because of “cupid’s bow” and the other architectural features. The slightest asymmetry is easily noted after correction. Hypertrophic scarring is noted when the excision extends all the way across the lip. Excluding the central cupid’s bow region seems to prevent scar hypertrophy.8 In the lower lip advancement, a strip of adjacent skin from corner to corner, twice as wide as the amount of advancement desired is excised, and the vermilion is sutured in a single continuous layer creating the illusion of a fuller lip by eversion.8 Some surgeons may opt to leave a central gap in the excision as in the upper lip to prevent scarring.8 Resurfacing Techniques Resurfacing techniques tend to correct drooping and shallow wrinkles. A resurfacing procedure is the best option for minimizing deeper vertical wrinkles around the lip. Certain factors must be considered in choosing the appropriate resurfacing procedure. These factors include color of skin and eyes, depth of wrinkles, history of previous resurfacing procedure, sun damage, pigment irregularities and a history of facial herpes simplex virus.4 Chemical peels such as trichloroacetic acid (TCA) and phenol have been used depending on the extent of wrinkle depth and sun damage. Peels are helpful for removing fine wrinkles. The entire perioral area may be treated at one time. Surface oils and debris are thoroughly removed from the surface of the skin. With the skin stretched tautly by an assistant, the peeling agent is worked into the wrinkle depth with a cotton swab. After a few seconds of contact with the skin, the peeling agent causes “neutralization” to take place, which is an irreversible reaction. Applying saline-soaked gauze stops the reaction. Significant edema may initially occur but subsides within a few weeks; both peels have unpredictable scarring and depigmentation potential. Patients undergoing phenol peels require simultaneous monitoring for cardiac and kidney toxicity.9 Glycolic acid peels are helpful for treating very superficial peels, mild acne blemishes and scarring and some pigmentation problems. A 70% glycolic acid solution is applied to the affected area initially for one minute.4 With successive peels, the time is increased depending on the patient’s response to maintain the improvement. A topical regimen is continued including retinoid acid, vitamin C and glycolic acid creams/lotions. Dermabrasion is an effective tool for removing “purse string” wrinkles involving the upper lip; approximately 40% to 60%6 to 80% to 90%1 can be removed. Deep dermabrasion can remove nearly 100% of the wrinkling but may result in hypopigmentation or even scarring.1 Other possible side effects include increased risk of infection and redness lasting 3 weeks to 4 months.4 Initially, gentian violet is used to outline the wrinkles. Using a refrigerant spray and simultaneously pulling the skin taut bilaterally allows for even abrasion. The goal is to abrade to the midreticular level until the majority of the gentian lines have been removed or the deepest plane has been reached.4 Laser resurfacing, unlike chemical peeling and dermabrasion, provides a predictable, consistent depth of penetration with each laser pass based on the thermal relaxation principle. Both the pulsed CO2 and Erbium Nd:YAG lasers are used for laser resurfacing, and laser techniques are usually combined with other types of treatments. The technique of laser resurfacing has been described elsewhere.10 In our hands, pulsed CO2 laser resurfacing produces the most predictable outcome in clearing perioral rhytides and seems to be the most beneficial for deep rhytides. The Erbium:YAG laser is helpful for mild to moderate rhytides; post-op erythema is of shorter duration than with CO2 laser. The most common side effects of the lasers include post-inflammatory hyperpigmentation and hypopigmentation, erythema, infections (bacterial, fungal and viral) and scarring, so closely following patients post-operatively is essential. Choosing an Option In conclusion, there are many options in treating perioral signs of aging. Each patient’s treatment plan should be individualized to meet his or her needs and concerns. Most of these procedures when combined give a better outcome. With more and more filler agents being approved for usage we’ll see increased numbers in non-surgical perioral enhancement. However, CO2 laser resurfacing with either combined microfat injections or Goretex implantation provides the best synergistic effect.
T he effects of time and sun-exposure can leave many patients with a “puckered mouth” effect that’s cosmetically non-pleasing. Throughout the history of medical discoveries many have sought the guidance and advice of dermatologists to reverse these obvious effects. Many of these old and newer techniques focus on the nasiolabial fold and perioral region, which is a growing concern for patients in their 30s to 50s. While the nasiolabial fold becomes deep and furrowed secondary to senescence affects of skin aging, the perioral region has deepened radial lines secondary to hyperkinetic action of the orbicularis oris sphincter muscle. This article will offer different methods for correcting these changes. Cosmetic Fillers Filling agents are the most popular methods used for the correction of perioral changes. The most common modalities include fat, collagen and dermis. Fat transfer is the most popular option since there’s no material cost and no allergy testing required. A metabolically resistant donor site, usually the lateral hip or flank is infused with tumescent local anesthesia. The rhytides are overcorrected with the adipose tissue suspension injections since resorption of saline occurs.1 (See photos at right.) Graft take can vary from 30% to 50%, according to different authors. Unlike with collagen, allergic reaction is not a factor as the fat is harvested from the patient’s own body. Disadvantages include uneven resorption resulting in lumps and sometimes significant swelling initially. Collagen Fillers Collagen is a naturally occurring protein that supports various parts of the body including joints. It’s been used for years as a soft tissue filler. Autologen is an autologous human collagen and fibroblast derived from the patient’s own skin, usually from the excess removed at the time of a procedure involving tissue extraction, such as an abdominoplasty. The patient’s own natural collagen is then processed by a lab, and then preserved and kept frozen in the special cryo-freezers at the lab and then returned to the physicians office for the procedure. Advantages are that no skin testing is required and it’s well tolerated when re-injected into the patient. It is available in the United States. Disadvantages are the expense of preservation and storage in a cryo-freezer at the lab. The implantation must take place within 48 hours of harvesting.2 There’s immediate burning and stinging at the injection site for about 15 minutes.2 In addition, there’s less immediate correction clinically with this filler due to its low viscosity. Zyderm or Zyplast (Resoplast is a similar product used in Europe) are both examples of sterile, purified, reconstituted fibrillar bovine collagen (type I and type III collagen). Human collagenase begins to degrade the foreign substance, and after 3 months none can be detected, although up to 30% of patients report effects lasting 18 months. Patients must have skin tests prior to treatments. A small amount of collagen in injected into the forearm just below the skin surface, and if there’s no adverse reaction after 4 weeks that patient may be treated. Reactions usually occur in the first 3 days. Advantages of this collagen include that it lasts 3 months to 6 months and is available in the United States. Disadvantages of this treatment include hypersensitivity (3% to 5%), erythema, induration, granulomatous responses, pain and bruising at the injection site and serum sickness-like reactions. The physician has a small window to smooth the injected collagen within the site before it hardens. Swelling can occur at the injection site, resulting from the saline carrier of the collagen injection formulation, which can last for about 4 hours or until it’s absorbed by the body. CosmoDerm and CosmoPlast are both human collagen dermal fillers that are made from human tissue, which is grown in a controlled laboratory environment. They contrast by a non-cross linked nature of CosmoDerm in comparison to the cross linked nature of CosmoPlast. The advantage is that the former is reserved for the correction of superficial lines (see photos on page 60), and the latter for deeper lines. Neither product requires skin testing, and the affects last up to 3 months to 6 months. Both products have been FDA approved for use in the United States. Both products are formulated with an anesthetic for comfort. A disadvantage is that CosmoDerm is not as long lasting as CosmoPlast after placement. Artecoll is a 3% to 5% solution of bovine collagen mixed with polymethacrylate beads (non-silicone, carbon-based polymers), the augmentation material, in a ratio of 3:1. This mixture contains 0.3% lidocaine and is injected at the dermal and subcutaneous junction injecting the material as the needle is withdrawn. Using a small needle injection of the microdroplets gives a more even result. It may take two to three sessions before the desired correction is achieved since overcorrection is not desirable. An advantage is that this method produces immediate results and is proposed to be a more permanent filler because the microspheres don’t absorb into the body. This choice is useful for correcting depressions and deeper creases. Disadvantages are that allergic testing for bovine collagen is necessary, and patients may experience lumping or granulomatous skin reactions. Lastly, microspheres can possibly move to other areas of the body. It’s not useful for fine-line corrections, and this filler isn’t yet available in the United States. However, an FDA panel recently recommended its approval. Presently, this filler is available in Europe, Canada and Mexico. Silicone and Hyaluronic Acid Fillers Liquid silicone injections (Silikon 1000, Adatosil 5000, SilSkin) are composed of purified, medical grade polydimethylsiloxane oil used for the correction of moderate-depth lines and depressions. Microdroplets of silicone are dispersed within the dermal tissues. The fibrosis around these droplets localize the material, and it’s seemingly well tolerated in small amounts in the face (see photos on page 62). Advantages are that it’s a permanent filler, and no allergy testing is required because it’s chemically well tolerated. The disadvantage is that it’s not FDA approved yet for cosmetic usage; it is, however, being used in Europe, Mexico and some parts of Canada. SilSkin is presently being considered for cosmetic use in the United States. There are also risks of granuloma formation because the silicone becomes encapsulated as a foreign body by a chronic inflammatory reaction, causing a potential site of infection. Possible migration of the material to other organs and lymph nodes, fibroses and inflammation and discoloration of surrounding tissue are other disadvantages. Restylane is a non-animal hyaluronic acid based filling agent. It comes in three types — Restylane Fine Lines, Restylane, and Perlane, based on the same type of gel from highly concentrated stabilized hyaluronic acid of 20 mg/ml. Hyaluronic acid is a naturally occurring substance found within the body. It’s a clear gel that’s injected into the dermis, deeper for more viscous types and more superficial for less viscous grades. It works in conjunction with the body’s own hyaluronic acid, increasing its longevity. The major advantage is that no pre-test is necessary. The disadvantage is that it’s not a permanent filler because it gets absorbed into the body, and so its effects last only 3 to 6 months. It’s not FDA approved for use in the United States. The hyaluronic acid in Perlane is larger in size, and takes longer to dissipate; making it useful for deep facial lines like the nasolabial folds. It lasts from 3 months to 9 months, but isn’t yet FDA approved. Macrolane is the largest of the three in size, and so it takes the longest to dissipate with effects lasting up to 2 years. It’s also not available in the United States. In late November, an FDA advisory panel is scheduled to review data on Hylaform. This filler, which will be marketed by Inamed Corp., is derived from roosters’ combs. More Filler Choices Radiance (Bioform) is a soft tissue filler composed of calcium hydroxyapatite, which is found in bone and teeth. It adds volume via microspheres that are suspended in an aqueous polysaccharide gel via injection by threading of the solution into deep dermis. It corrects when the microspheres are held in place until resorption and collagenation takes place. After Radiance is injected into soft tissue, the fibroblasts work by building a non-scar tissue collagen type, creating a voluminous filler. The advantage is that it is proposed to last 2 years to 5 years with little risk of an allergic reaction. It is available in the United States, but it’s still in the investigational stages for cosmetic use. Disadvantages are clumping, lumping, granulomatous reaction and microsphere redistribution to other parts of the body. Dermalogen is an injectable human tissue matrix from human tissue banks containing only intact collagen fibers and fibrils, elastic fibers and proteoglycans. Since the collagen fibers are well organized, augmentation lasts longer than bovine collagen.9 Skin testing is required, and augmentation may proceed if the test is negative at 72 hours. During injection, the physician must simultaneously pull the skin taut bilaterally allows for even correction. The goal is to inject at the midreticular level until the majority of the gentian lines have been removed or the deepest plane has been reached. 4 Alloderm-acellular allogeneic dermis has been used for aesthetic lip augmentation with good results; it is cadaveric dermis and extracellular cell matrix that has been processed to remove immunogenic components.5 Available in sheets, Alloderm can be rolled or cut into strips. The sheet is rehydrated and trimmed before insertion. Studies show that it provides 6 months to 12 months of augmentation.3 Cymetra is a microparticulate injectable form of Alloderm. PlasmaGel is a plasma emulsion with Vitamin C complex. The physician takes the patient’s blood and spins the protein out of the blood and mixes it with a Vitamin C complex. The doctor then re-injects this mixture into the treatment site that will result in augmentation with the patients’ own serum. The effects usually last about 3 months to 5 months. An advantage is that no skin testing is required. The disadvantage is that the physician needs the facility for creating the mixture. Fascian is a lyophilized human particulate fascia lata from donor cadavers available in particulate and line-like sheets. Particulate size ranges from 0.1 mm to 2 mm and is prepackaged in a freeze-dried, vacuum-sealed syringe. A thick suspension is injected. The sheets may be “diced” and implanted into pocket-like slits.6 Side effects include edema, erythema and ecchymosis for up to 6 weeks post-op. Post-inflammatory hyperpigmentation is a late complication. The larger particle size seems to be associated with more persistent side effects. Gore-Tex is a permanent filler, expanded polytetrafluoroethylene (ePTFE, Gore-Tex) that has been used since the 70s for vascular grafts and soft tissue reconstruction. It has proven helpful for lip augmentation and perioral rhytides. EPTFE is an inert, soft microporous biomaterial that is available in tubular forms and sheets. We tend to use the tubular forms. The appropriate length and width of the implant is inserted to the lip area and inserted at the subdermal area via a 14-gauge to 16-gauge angiocather after local anesthesia has been administered (see photos on page 63). Complications include transient bruising, swelling, and paresthesia; more serious but less common complications include infection of the implant site, fistula formation, induration, implant extrusion, discoloration, and scarring. Other graft sources have been reported in the literature including autologous breast implant capsule, aponeurotic galea and subgalea, and temporal fascia. Strips of dermal graft have been used successfully, with survival rates at 80%, for several years to fill lip contours with the restriction of finding a donor site. A recent technique has been described where a “tissue cocktail” is prepared from an injectable mixture of dermis, muscle strips, fat tissue and fascia obtained from other reconstructive procedures on the same patient. The survival rate is high as 90% to 95%.7 It’s been used to attenuate wrinkles around the lip and to augment lip thickness inside the lip muscle. Surgical Techniques Here’s a review of the surgical procedures that help to improve the perioral regions. The nose base resection/lip lift that’s used to shorten the upper lip and everts the vermilion border allowing the upper teeth to show again when the lips are slightly parted. Many patients opt to have this procedure performed during a face lift. Directly under the nose, a wavy ellipse following the contour of the nasal base is excised ranging from 3 mm to 11 mm in width, averaging 6 mm. Overcorrection by one-third allows for post-operative re-droop.8 The scar is hidden in the shadowed crease. The corner lift is used to elevate the corners of the mouth. At the commissures a rounded arc-like triangle is drawn by extending lines from the commissure vermillion border — 1.2 cm to 1.6 cm medially from the commissure along the skin-vermilion border and another is aimed at the top of the ear stopping short of the nasiolabial crease. The triangle height ranges from 3 mm to 9 mm with 5 mm being the usual amount, and 7 mm to 9 mm to correct a more significant downturn. The triangle is excised and precisely sutured in two layers. Initially, correction will appear overdone but will correct over several days. Sutures are removed in 3 days to 5 days. A fine white line is minimally evident and lies at or within the lipstick border.8 Surgical augmentation of the upper lip creates a fuller upper lip by shifting tissue from the sides and downward to the midline to augment the central vermilion. A V-Y flap approximately 2 cm wide is drawn on the inner surface of the everted upper lip.8 Wider flaps have been described, which enhance the entire vermilion from corner to corner, and multiple V-Y flaps may be used to augment the vermilion in the three areas of natural fullness of the upper lip.8 Incisions are made inside the we-dry line dissecting downward superficially to muscle.8 Side effects include hardening and discomfort for months after the procedure.8 Advancement of the vermilion is a technique that requires the surgeon to meticulously mark and excise a strip of skin at the vermilion border. Advancing the upper lip is technically more difficult because of “cupid’s bow” and the other architectural features. The slightest asymmetry is easily noted after correction. Hypertrophic scarring is noted when the excision extends all the way across the lip. Excluding the central cupid’s bow region seems to prevent scar hypertrophy.8 In the lower lip advancement, a strip of adjacent skin from corner to corner, twice as wide as the amount of advancement desired is excised, and the vermilion is sutured in a single continuous layer creating the illusion of a fuller lip by eversion.8 Some surgeons may opt to leave a central gap in the excision as in the upper lip to prevent scarring.8 Resurfacing Techniques Resurfacing techniques tend to correct drooping and shallow wrinkles. A resurfacing procedure is the best option for minimizing deeper vertical wrinkles around the lip. Certain factors must be considered in choosing the appropriate resurfacing procedure. These factors include color of skin and eyes, depth of wrinkles, history of previous resurfacing procedure, sun damage, pigment irregularities and a history of facial herpes simplex virus.4 Chemical peels such as trichloroacetic acid (TCA) and phenol have been used depending on the extent of wrinkle depth and sun damage. Peels are helpful for removing fine wrinkles. The entire perioral area may be treated at one time. Surface oils and debris are thoroughly removed from the surface of the skin. With the skin stretched tautly by an assistant, the peeling agent is worked into the wrinkle depth with a cotton swab. After a few seconds of contact with the skin, the peeling agent causes “neutralization” to take place, which is an irreversible reaction. Applying saline-soaked gauze stops the reaction. Significant edema may initially occur but subsides within a few weeks; both peels have unpredictable scarring and depigmentation potential. Patients undergoing phenol peels require simultaneous monitoring for cardiac and kidney toxicity.9 Glycolic acid peels are helpful for treating very superficial peels, mild acne blemishes and scarring and some pigmentation problems. A 70% glycolic acid solution is applied to the affected area initially for one minute.4 With successive peels, the time is increased depending on the patient’s response to maintain the improvement. A topical regimen is continued including retinoid acid, vitamin C and glycolic acid creams/lotions. Dermabrasion is an effective tool for removing “purse string” wrinkles involving the upper lip; approximately 40% to 60%6 to 80% to 90%1 can be removed. Deep dermabrasion can remove nearly 100% of the wrinkling but may result in hypopigmentation or even scarring.1 Other possible side effects include increased risk of infection and redness lasting 3 weeks to 4 months.4 Initially, gentian violet is used to outline the wrinkles. Using a refrigerant spray and simultaneously pulling the skin taut bilaterally allows for even abrasion. The goal is to abrade to the midreticular level until the majority of the gentian lines have been removed or the deepest plane has been reached.4 Laser resurfacing, unlike chemical peeling and dermabrasion, provides a predictable, consistent depth of penetration with each laser pass based on the thermal relaxation principle. Both the pulsed CO2 and Erbium Nd:YAG lasers are used for laser resurfacing, and laser techniques are usually combined with other types of treatments. The technique of laser resurfacing has been described elsewhere.10 In our hands, pulsed CO2 laser resurfacing produces the most predictable outcome in clearing perioral rhytides and seems to be the most beneficial for deep rhytides. The Erbium:YAG laser is helpful for mild to moderate rhytides; post-op erythema is of shorter duration than with CO2 laser. The most common side effects of the lasers include post-inflammatory hyperpigmentation and hypopigmentation, erythema, infections (bacterial, fungal and viral) and scarring, so closely following patients post-operatively is essential. Choosing an Option In conclusion, there are many options in treating perioral signs of aging. Each patient’s treatment plan should be individualized to meet his or her needs and concerns. Most of these procedures when combined give a better outcome. With more and more filler agents being approved for usage we’ll see increased numbers in non-surgical perioral enhancement. However, CO2 laser resurfacing with either combined microfat injections or Goretex implantation provides the best synergistic effect.
