Chiu_2016_Lip Injection Techniques Using Small-Particle Hyaluronic Acid Dermal Filler

September 2016 1076 Volume 15 • Issue 9
Copyright © 2016 ORIGINAL ARTICLES Journal of Drugs in Dermatology
SPECIAL TOPIC
Lip Injection Techniques Using Small-Particle Hyaluronic Acid
Dermal Filler
Annie Chiu MD,a
Sabrina Fabi MD,b
Steven Dayan MD,c
and Alessandra Nogueira MDd
a
Private Practice, Redondo Beach, CA
b
Cosmetic Laser Dermatology, San Diego, CA
c
Private Practice, Chicago, IL
d
Galderma Laboratories L.P., Fort Worth,TX
The shape and fullness of the lips have a significant role in facial aesthetics and outward appearance.The corrective needs of a patient
can range from a subtle enhancement to a complete recontouring including correction of perioral rhytides. A comprehensive under-
standing of the lower face anatomical features and injection site techniques are foundational information for injectors. Likewise, the
choice of filler material contributes to the success of the injection techniques used, and facilitates a safe, effective, and natural ap-
pearing outcome. The small-particle HA 20 mg/mL with lidocaine 0.3% (SP-HAL, Restylane®
Silk; Galderma Laboratories, Fort Worth,
Texas) is indicated for submucosal implantation for lip augmentation and dermal implantation for correction of perioral rhytides. Due to
its rheological properties and smaller particle size, SP-HAL is a well-suited filler for the enhancement and correction of lip shape and
volume, as well as for the correction of very fine perioral rhytides.This work is a combined overview of techniques found in the current
literature and recommendations provided by contributing authors.
J Drugs Dermatol. 2016;15(9):1076-1082.
ABSTRACT
INTRODUCTION
T
he use of injectable fillers for the enhancement of facial
aesthetics is among the most frequent nonsurgical cos-
metic procedure performed in the U.S., second only to
the use of injectable neuromodulators to relax the dynamic lines
and wrinkles of the brow and eye area.1
Lip shape and fullness
plays an integral role in the overall composition of facial aesthet-
ics. As a primary component of outward appearance, facial aes-
thetics are intrinsically linked to self-perception of attractiveness,
self-esteem, and social confidence.2,3
Lip shape also communi-
cates emotion, even while the face is at rest; therefore, lips and
perioral attributes have a significant role in the facial aesthetics
equation, similar to the eyes and brow.4,5
Thecorrectiveneedsofapatientcanrangefromsubtleenhancement
of an already adequate shape and volume to a more comprehensive
recontouring, including correction of perioral rhytides.6,7
Because
the lip and perioral region experience regular dynamic movement,
adding filler to enhance shape while still maintaining a natural ap-
pearance (during movement and at rest) is technically challenging.
The lip and perioral region are also densely vascularized and vul-
nerable to injection site reactions, such as edema and bruising.8
A comprehensive understanding of the anatomical features and
appropriate injection site techniques is important foundational in-
formation for an injector. Likewise, the choice of filler material is
equally important because it facilitates the success of the injection
techniques used; and therefore, promotes a safe, effective, natural-
looking outcome, as well as patient comfort.
Effective fillers for lip and perioral rhytid correction are the
small-particle hyaluronic acid (HA) gels. The particle size and
rheological properties of these gels are well-suited to the con-
straints of fine gauge needles, and the superficial injection
techniques required for lip enhancement.9-12
The small-par-
ticle HA 20 mg/mL with lidocaine 0.3% (SP-HAL, Restylane®
Silk; Galderma Laboratories, Fort Worth, Texas) is the first
FDA approved (2014) filler formulated with lidocaine that is
indicated for submucosal implantation for lip augmentation
and dermal implantation for correction of perioral wrinkles in
patients over the age of 21.13,14
The purpose of this manuscript
is to provide guidelines regarding ideal injection techniques
for different corrective needs using the SP-HAL Restylane Silk
filler.
Lip and Perioral Anatomy
Whether the goal is to enhance youthful lips or restore
shape and volume to aging lips, an understanding of the
relevant anatomy and the ability to employ a suitable cor-
rective need is foundational. The evaluation process for
correcting lip shape and volume ideally should consider lip
proportion in context with the whole face. Facial proportions
can be divided into thirds as upper, middle, and lower face.
The lowest third of the face, is further divisible into thirds,
as upper lip, lower lip and chin, and there are general met-
rics to consider for achieving the most aesthetically pleasing
proportions (Figure 1).
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Journal of Drugs in Dermatology
September 2016 • Volume 15 • Issue 9
A. Chiu, S. Fabi, S. Dayan,A. Nogueira
As a consequence of cutaneous ageing, the vermillion border
can lose definition and the once prominent tubercle and cupid’s
bow can become blunted. With gradual loss of dental and bone
support, existing lip volume gradually collapses inward and
contributes to the formation of the fine vertical wrinkles along
the vermilion border. The overall volume of the vermillion lip
may decrease and the upper cutaneous lip elongates laterally,
lending to the downward turn of the oral commissures.17
Benefits of Small Particle Hyaluronic Acid Filler
SP-HAL consists of gel particles that are uniform in both shape
and diameter.12
The rheological properties of SP-HAL, which in-
clude low-density and low viscosity, facilitate the injection of
finer lines compared with traditional hyaluronic acid fillers.18,19
A potential side effect of HA filler that spreads to the upper pap-
illary dermis is the development of a bluish discoloration at the
site (Tyndall effect); however, the rheological properties elastic-
ity, viscosity, hardness, and the ratio of viscosity to elasticity of
SP-HAL promote a controlled flow, making it easy to correctly
place the gel in the reticular dermis.19-21
Optimally, these proper-
ties promote precise placement of filler while potentially using
less filler to achieve the desired outcome.14
This may aid in re-
ducing overcorrection.
Degradation of SP-HAL occurs gradually over time as it is absorbed
by surrounding tissue by a process called isovolumetric degrada-
tion.22
However, during degradation, each molecule continues to
bind water so that similar volume is maintained over time. This
controlled degradation provides a natural-appearing correction in
Lip Metrics
The projection of the lips can be evaluated by extending a line from
the subnasion point, the inside point of the angle between the sep-
tum of the nose and upper lip, to the most anterior mid-point of
the chin (Figure 1a). An ideal projection of the upper lip is 3.5 mm
anterior to the line, and projection of the lower lip should ideally be
2.2 mm anterior to the line (Figure 1a). The height ratio of upper to
lower lip (also known as the “golden ratio”) is generally 1:1.6, and
the distance from the superior edge of the upper lip to the subna-
sion point and from the inferior lower lip to chin is generally 18-20
mm and 36-40 mm, respectively (Figure 1a and b).6,16
Race and eth-
nicity are important considerations while evaluating lip proportion,
although the upper to lower lip ratio is often suggested as 1:1.6, this
is a generality that is suitable for a Caucasian face, while a ratio clos-
er to 1:1 may be more suitable for individuals of African ethnicity.
Lip Anatomy
The edge where the red colored vermillion body meets the sur-
rounding skin is known as the vermillion border (Figure 1b).
This edge also has a slight elevation, known as the white roll.6,15
The vermillion border of the upper lip is defined by a distinctive
curve known as the cupid’s bow, which is another feature that
may range in prominence all according to ethnicity (Figure 1b).
A slight projection located in the center of the upper lip is known
as the tubercle, and the vertical groove extending upward from
the tubercle to the nasal septum is the philtrum.The philtrum is
flanked on both sides by slightly raised philtral columns. At ei-
ther corner of the mouth, where the lower and upper vermillion
lips meet are the oral commissures (Figure 1b).
FIGURE 1. Facial proportions and lip metrics.
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hypodermic needle or by tapered or blunt tip cannula. Among
the contributing authors who use needles, a fine gauge (30 G
x ½”) needle is preferred, and recommend an insertion angle
that is approximate 30 degrees parallel to the length of the lip.24
The injection techniques that use SP-HAL advantageously include
linear threading (retrograde and anterograde), serial puncture
and fanning (Figure 2). Linear threading involves full insertion
of the needle lengthwise into the middle of a wrinkle, fold, or lip
and extrudes filler along an imaginary seam, like a thread. Sever-
al visual cues that help identify adequate needle insertion depth
include a downward dimple in the skin when downward pres-
sure is exerted on the instrument. Alternately, if the grey color of
the needle is visible through the skin, its location is too superfi-
cial for placement of filler and may increase the risk of theTyndall
effect characterized by a blue-gray discoloration.25
A sensory cue
that also help characterize correct needle placement is the rela-
tive resistance felt during extrusion of the filler. For instance, a
sudden reduction in resistance can be indicative that placement
of the needle has shifted into the subcutaneous tissue. It is also
important not to force injection when resistance is encountered,
but to reposition at an alternate point.
Threading is usually accomplished in a retrograde manner, so
that filler is being injected as the needle is being withdrawn
(Figure 2a). An anterograde injection is the extrusion of filler
volume with a cosmetic persistence until almost complete deg-
radation of the filler, approximately 6 months on average.14
In a
blinded evaluator assessment of the combined (upper and low-
er) vermillion lip smoothness following correction with SP-HAL,
it was demonstrated that significantly better improvement in lip
smoothness was observed in 133 subjects at weeks 12, 16, 20, and
24 versus baseline compared to no treatment (P< .001).23
The properties of SP-HAL are very suitable for correction of
delicate areas such as the philthral columns and allow for treat-
ment of the vermilion border. One of the benefits of SP-HAL
is the ability to achieve correction of fine line areas such as
perioral wrinkles; characterized by etching, crosshatching, or
perioral lines that extend beyond the vermillion border.
Useful Techniques for Lip and Perioral Enhance-
ment With SP-HAL
Topical anesthetic creams or ointments are often effective ap-
plied 15 to 60 minutes before the procedure.The application of
ice before, during, and after also helps to reduce discomfort.15
The patient should be seated upright to allow normal gravity
for optimal facial evaluation, although subsequent injection
can then be done in a reclined position for patient comfort. Suc-
cessful treatment with lip and perioral fillers involves critical
evaluation of needle insertion points, and may require a variety
of injection techniques. SP-HAL can be administered using a
FIGURE 2. Injection techniques: linear threading, serial puncture, and fanning.
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while advancing the needle into the tissue. Anterograde
threading may be useful while enhancing features such as the
vermilion border (while moving towards the cupid’s bow); as
product flow ahead of the needle’s tip may help to “push” ves-
sels out of the way, minimizing tissue trauma and potential
intravascular injection (Figure 2b).
The serial puncture involving multiple, closely-placed injec-
tions can be made so that the filler can then be merged into a
smooth and continuous line (Figure 2c).6
It is helpful to pull the
skin slightly away and out to give tension and keep the skin taut
while injecting, and care should be taken that no spaces remain
between the injected filler. If minimal gaps are present post-
injection, very gentle massage can promote the blending of
the filler.26
Although serial puncture allows for tight control and
more precise filler placement, and is often used for fine super-
ficial perioral rhytides, the technique’s potential to elicit more
bruising and swelling with increased tissue trauma remains
controversial.26-28
The fanning technique is similar to linear
threading as it involves length-wise insertion of the needle and
extrusion of filler while the needle is withdrawn. However, the
needle is not fully removed as its direction toward a new area is
changed. Filler is injected along a multiple short lines creating
linear deposits in a wheel spoke pattern (Figure 2d).26
Useful Guidelines for Specific Lip Features
Vermillion body
Contributing authors suggest that an initial treatment of the
vermillion body minimizes the potential for overall overcorrec-
tion and will improve a certain degree of the associated radial
rhytides.This collateral benefit to the perioral rhytides has been
observed as a >1-grade improvement in approximately 20% of
subjects receiving only vermillion body injection, which lasted
up to 24 weeks post-injection.14
Injection of the vermillion body
is initiated from the mucosal side of the lip, by inserting the
needle laterally at a 45-degree angle and then directed towards
the center at a 20-degree angle. Retrograde threading of the gel
can then be achieved in a medial to lateral direction (Figure 3a).
Maintaining a gradual rate of injection is important to help the
gel deposit evenly within the space. Stretching the lip slightly
taught will not only help to locate the starting point in the outer
end of the lip, but it will provide a firm surface to inject against
and facilitate a uniform flow of the gel.15
Oral commissures
Injection of filler in the oral commissures is achieved by cu-
taneous insertion and direction of the instrument toward the
commissure, but stopped at least 1 mm before the mucosa
(Figure 3b). Contributing authors recommend an injection vol-
ume of 0.05 to 0.25 mL below the commissure that produces
an upward lift.
Vermillion border
Correction of the vermilion border can be achieved by using
a retrograde threading technique along the border separating
the red lip from the cutaneous skin (Figure 3c). Serial injections
placed at a third of the height of the cutaneous upper lip is ef-
fective for enhancement of the vermillion border and will also
correct some short perioral rhytides. Avoidance of gel place-
ment above the cutaneous portion of the vermillion border
is important especially while using the threading techniques,
which may otherwise create a sharp and over-defined lip con-
tour resulting in unnatural fullness of the vermillion border and
further elongation of the cutaneous upper lip.
Perioral rhytides
Deeper, static, etched perioral lines are best filled with a fine
gauge needle using a linear threading retrograde injection
placed directly in the line (Figure 3d). Correction of dynamic
lines, which are visualized by having the patient pout, are
FIGURE 3. Needle injection placement: vermillion body, oral commissures, vermillion borders, vertical rhytides, and philtral columns.
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blunt microcannulas as being associated with less pain, less
edema, fewer hematoma, and less redness than regular nee-
dles.31-34
Ideally, without swelling from multiple injections, lip
anatomy is not quickly distorted by swelling, and the volumiz-
ing effect of the filler as it is injected may be easier to observe.
For injection of the vermillion body, one of our contributing au-
thors prefers a retrograde threading technique using a 22 G x
2 ¾” microcannula. An introducer needle, slighter larger than
the cannula (21 G), is used to create an entry port at the lateral
aspect of the oral commissure, where the cannula is then insert-
ed and guided to the same location described for the needle.
Ideally, both the upper and lower vermillion body and the oral
commissures can be accessed from a single lateral entry point
using a microcannula (Figure 4a and b). Without removing the
microcannula, the vermillion border can be similarly injected by
retrograde threading, or by down-sizing microcannula to use at
the same entry point (Figure 4c). Another contributing author
finds the combined use of both instruments also produces opti-
mal results; by using a 27 to 25 G microcannula for the vermillion
body and a needle for the vermillion border and philtral columns.
It should be noted that use of the microcannula is not FDA ap-
proved for SP-HAL, and clinical studies are required to determine
if microcannula use will offer definitive advantages in the injec-
tion of SP-HAL in the lip and perioral region. However, a clinical
trial comparing the safety and efficacy profile of a metallic can-
nula with that of a standard needle for soft tissue augmentation
of the nasolabial folds, has concluded that the cannula is a safe
and useful tool to inject HA fillers in the nasolabial folds.35
Post-injection Techniques and Safety Consider-
ations
Injection site reactions are predominantly mild to moderate
when they occur and typically resolve in fewer than 18 days
(median 10 days) in the lip.24
If a treated area is swollen imme-
diately after injection, an ice pack can be applied to the site for
a brief period, though ice should be used with caution if the
area is still numb due to anesthetic to avoid hypothermal injury.
Following injection, the site may be gently massaged to facili-
tate its conformation with the contour of surrounding tissues. If
overcorrection has occurred, massaging the area between the
fingers or against an underlying area can also aid in modifying
the result. Massage is also useful if blanching of the skin is ob-
served during an injection (overlying skin turning white in color),
at which time, the injection should be immediately stopped and
the area should be massaged until it returns to normal color.36
If there is ever a suspected intravascular injection, immediate
attention should be devoted to resolve it to prevent a potentially
devastating consequence.37
Additional treatment sessions with
SP-HAL may be necessary to achieve the desired correction. It
should be noted that if patients require more than 3.0 mL of
SP-HAL into both lips (total) in a given treatment session, the
then injected in the same manner. Contributing authors rec-
ommend that correction of the very fine lines in the upper
cutaneous lip requires the laying down or fanning of a thin
sheet, which will also improve general texture. In addition,
some deeply etched lines may require the fern technique,
where a thread is placed in line followed by perpendicular
threads placed for support.
Philtral columns
Placement of filler in the philtrum helps project the lip forward
and enhances the median region of the lips, and can also help
to soften the upper lip rhytides. The columns appear as an in-
verted “V”, which narrows as it approaches the nostril sills and
columella.22
An injection of SP-HAL into each philtrum column
is achieved by insertion of the needle at the G-K point (Figure
1b) and guided toward the nasal septum. While using a slow
retrograde technique a small uniform thread of product is de-
posited, and by pinching the skin with the non-dominant hand
during the injection, lateral splaying can be prevented (Figure
3e). Contributing authors find that the small particle size and
rheological properties of SP-HAL, along with a slow pressure
on the plunger, helps prevents lateral splaying in the philtrum
columns. At the end of the retrograde thread, a small amount
of gel can also be deposited to produce a lift to the cupids bow
and help shorten the appearance of an elongated upper cutane-
ous lip.To re-create a cupid’s bow using a needle, the tip of the
needle is placed at the inferior point of the philtrum column and
while using a retrograde injection, a thin thread of gel can be
deposited to create an antero-posterior strut that will support
the projection of the central upper lip.16
Considerations for Use of a Microcannula
Use of the microcannula for injection of the lips and perioral
features may be less common than the traditional hypodermic
needle. However, at least one contributing author who now
uses microcannulas exclusively for the lips does so because his
patients experience less swelling and bruising than with needle
injections and patients also report less discomfort. For clini-
cians interested in incorporating the microcannula into their
treatment of the lip and perioral region, blunt tip microcannu-
las (ranging in size from 30 G X 1” up to 22 G x 2¾”) have been
found to be entirely comparable with the ease of filler place-
ment provided by a traditional needle.
The advantage provided by the microcannula is access to mul-
tiple lip areas through a single entry point by simply redirecting
the microcannula without needing to remove it.29
The use of a
microcannula reduces the number of needle punctures through
the epidermis, and because of their blunt tip they can be navi-
gated through the dermis with less potential trauma to vessels
or nerves, and theoretically, a larger gauge microcannula would
further minimize the potential risk of vessel cannulization and
ischemic injury.29,30
Numerous studies support the advantage of
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techniques to use with each feature is important foundational
information. Likewise, the choice of the injection instrument
and the filler material is equally important because it facilitates
the success of the injection techniques used. The rheological
properties and smaller particle size of SP-HAL make it an excep-
tionally well-suited filler for the correction of lip shape, volume
and fine perioral rhytides, where the adage “less is more” may
be the best facilitator of a natural-looking outcome.
ACKNOWLEDGMENTS
Erika von Grote, PhD, Dan McGill, and Ron Gottschalk, MD,
(Gottschalk Consulting, LLC) provided professional writing as-
sistance in preparation of this manuscript, which was funded
by Galderma Laboratories, L.P.
DISCLOSURES
Galderma supported the NewYork consensus meeting and the
creation of these recommendations.The content of the publica-
tion reflects the experts’ independent opinions and experiences.
The participants have disclosed financial relationships with the
following companies:
Dr. Chiu has received support for speaking, consulting, and
training for Galderma. Dr. Fabi has received support for
research, speaking and consulting from Galderma, Merz, Aller-
gan, and Valeant. Dr. Dayan has received support for research,
speaking, and consulting from Galderma. Dr. Nogueira is an
employee of Galderma Laboratories, L.P.
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Contributing authors typically do not inject
more than 1.0 mL of SP-HAL per injection session, and will wait
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CONCLUSION
The importance of the lip in overall facial aesthetics has an im-
pact on positive self-image and self-confidence. Correction of
fine perioral rhytides and volume deficiencies can be technically
challenging, and the corrective needs of each patient may vary.
To achieve a desirable outcome, a thorough understanding of
the relevant anatomical features and the appropriate injection
FIGURE 4. Microcannula injection placement: vermillion body, oral commissures, and vermillion borders.
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AUTHOR CORRESPONDENCE
Annie Chiu MD
E-mail:................……......................... Drchiu@thederminstitute.com
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