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

aPrivate Practice, Redondo Beach, CAbCosmetic Laser Dermatology, San Diego, CA

cPrivate Practice, Chicago, ILdGalderma 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

The 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

The corrective needs of a patient can range from subtle enhancement 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).

© 2016-Journal of Drugs in Dermatology. All Rights Reserved. This document contains proprietary information, images and marks of Journal of Drugs in Dermatology (JDD). No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD. If you feel you have obtained this copy illegally, please contact JDD immediately at [email protected]

To order reprints or e-prints of JDD articles please contact [email protected]

JO0916

Do Not CopyPenalties Apply

1077

Journal of Drugs in DermatologySeptember 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 MetricsThe 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 AnatomyThe 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.



JO0916


1078



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 the Tyndall 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-HALTopical 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.



JO0916


1079



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 FeaturesVermillion bodyContributing 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 commissuresInjection 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 borderCorrection 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 rhytidesDeeper, 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.



JO0916


1080



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-ationsInjection 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 columnsPlacement 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



JO0916


1081



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.

ACKNOWLEDGMENTSErika 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.

DISCLOSURESGalderma supported the New York 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.

REFERENCES1. http://www.surgery.org/media/statistics. Accessed January 28, 2016. Avail-

able at: http://www.surgery.org/sites/default/files/ASAPS-Stats2015.pdf2. Litner JA, Rotenberg BW, Dennis M, Adamson PA. Impact of cosmetic facial surgery

on satisfaction with appearance and quality of life. Arch Facial Plast Surg. 2008;10:79-83.

complete treatment plan should be broken up into 2 - 3 treat-ment sessions.23 Contributing authors typically do not inject more than 1.0 mL of SP-HAL per injection session, and will wait at least 2 weeks for further touch up treatments.

Injection site reactions, normally of short duration, are com-mon after lip injections as expected after injection with any HA product. In the clinical studies conducted to determine the safety and efficacy of SP-HAL, the most common injection site reactions included swelling, tenderness, bruising, pain, redness, and itching.24 Swelling is among the more distress-ing side effects after any HA filler injection. With SP-HAL it is typically mild in intensity with resolution with 7-10 days.24 The degree of swelling can be minimized by injecting very slowly, avoiding overcorrection and as a rule of thumb, use no more than 1 mL per injection session. In addition, treatment for the management of lip swelling may include oral corticosteroids, antibiotics, antihistamines, NSAIDs, and hyaluronidase to de-grade the SP-HAL.16 Counseling patients about the potential injection site reactions that may occur with these types of pro-cedures may help prepare the patient for what to expect in the post-procedural phase of the experience. In addition, there is some reassurance in the reduced rate of injection site reactions associated with follow-up treatments (after 6 months) in com-parison with initial treatment.24,38

CONCLUSIONThe 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.



JO0916


1082



33. Niamtu J. Filler injection with micro-cannula instead of needles. Dermatol Surg. 2009;35:2005-2008.

34. Hoffmann K for the Juvederm Voluma Study Investigators Group. Volumizing effects of a smooth, highly cohesive, viscous 20-mg/mL hyaluronic acid volu-mizing filler: prospective European study. BMC Dermatol. 2009;9:9.

35. Hexsel D, Soirefmann M, Manoela D, Siega C, et al. Double-blind, random-ized, controlled clinical trial to compare safety and efficacy of a metallic cannula with that of a standard needle for soft tissue augmentation of the nasolabial folds. Dermatol Surg. 2011;38:207-214.

36. Funt D, Pavicic T. Dermal fillers in esthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;6:295-316.

37. Cohen JL, Biesman BS, Dayan SH, DeLorenzi C, Lambors V, Nestor MS, Sadick N, Sykes J. Treatment of hyaluronic acid fillers induced impending necrosis with hyaluronidaseL: Consensus recommendations. Aesthet Surg J. 2015;pii:sv018.

38. CDRH Documents. Food and Drug Administration. United States Govern-ment. Restylane Silk Injectable Gel with 0.3% Lidocaine data sheet. http://www.accessdata.fda.gov/cdrh_docs/pdf4/P040024S072a.pdf. Accessed October 15, 2015.

AUTHOR CORRESPONDENCE

Annie Chiu MD E-mail:................……......................... [email protected]

3. de Aquino MS, Haddad A, Ferreira LM. Assessment of quality of life in pa-tients who underwent minimally invasive cosmetic procedures. Aesthetic Plast Surg. 2013;37:497-503.

4. Rennels JL, Kayl AJ. Differences in Expressivity Based on Attractiveness: Target or Perceiver Effects? J Exp Soc Psychol. 2015;60:163-172.

5. Muñoz-Reyes JA, Iglesias-Julios M, Pita M, Turiegano E. Facial Features: What Women Perceive as Attractive and What Men Consider Attractive. PLoS One. 2015;10:e0132979

6. Klein AW. In search of the perfect lip: 2005. Dermatol Surg. 2005;31:1599-1603.

7. Beer KR. Rejuvenation of the lip with injectables. Skin Therapy Lett. 2007;12:5-7.

8. Cartier H, Trevidic P, Rzany B, Sattler G, et al. Perioral rejuvenation with a range of customized hyaluronic acid fillers: efficacy and safety over six months with a specific focus on the lips. J Drugs Dermatol. 2012;11:s17-26.

9. Bosniak S, Cantisano-Zikha M, Giavas IP. Nonanimal stabilized hyaluronic acid for lip augmentation and facial rhytid ablation. Arch Facial Plast Surg. 2004;6:379-83.

10. Klein AW. The efficacy of hyaluronic acid in the restoration of soft tissue volume of the lips and lower 1/3 of the face: the evolution of the injection technique. J Cosmet Dermatol Sci App. 2011;1:147-152.

11. Jacono AA. A new classification of lip zones to customize injectable lip aug-mentation. Arch Facial Plast Surg. 2008;10:25-29.

12. Glogau RG, Bank D, Brandt F, Cox SE, et al. A randomized, evaluator-blinded, controlled study of the effectiveness and safety of small-gel-particle hyal-uronic acid for lip augmentation. Dermatol Surg. 2012;38:1180-1192.

13. U.S. Food and Drug Administration. Restylane silk injectable gel. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=p040024s072. Accessed January 28, 2016.

14. Beer K, Glogau RG, Dover JS, Shamban A, et al. A randomized, evaluator-blinded, controlled study of effectiveness and safety of small particle hyal-uronic acid plus lidocaine for lip augmentation and perioral rhytides. Derma-tol Surg. 2015;41:S127-S136.

15. Klein AW, Ayers BW. Lip Augmentation Posted: 07/31/2008. Medscape Dermatology. Posted July 31, 2008. http://www.medscape.org/viewarti-cle/578228_print. Accessed October 14, 2015.

16. Sarnoff DS, Gotkin RH. Six Steps to the “Perfect” Lip. J Drugs Dermatol. 2012;11:1081-1088.

17. Penna V, Stark GB, Voigt M, Mehlhorn A, et al. Classification of the Ag-ing Lips: A Foundation for an Integrated Approach to Perioral Rejuvenation. Aesthetic Plast Surg. 2015;39:1-7.

18. Maas CS, Bapna S. Pins and needles: minimally invasive office techniques for facial rejuvenation. Facial Plast Surg. 2009;25:260-269.

19. Sundaram H, Cassuto D. Biophysical characteristics of hyaluronic soft-tis-sue fillers and their relevance to esthetic applications. Plast Reconstr Surg. 2013;132:5S-21S.

20. Micheels P, Besse S, Flynn TC, Sarazin D, et al. Superficial dermal injection of hyaluronic acid soft tissue fillers: comparative ultrasound study. Dermatol Surg. 2012;38:1162-1169.

21. Pierre S, Liew S, Bernardin A. Basics of dermal filler rheology. Dermatol Surg. 2015;41 Suppl 1:S120-126.

22. Dayan SH, Bassichis BA. Facial dermal fillers: selection of appropriate prod-ucts and techniques. Aesthetic Surg J. 2008;3:335-34.

23. Bank, D, Chopra R, Nogueira A, Mashburn J. Independent photographic evaluation of small particle hyaluronic acid gel plus lidocaine (SPHAL) on lip smoothness when performing lip augmentation. Poster pres., American Academy of Dermatology, Washington, DC; 2016.

24. Restylane Silk® (Hyaluronic Acid). Instructions for Use. Galderma, Uppsala, Sweden

25. Hirsch RJ, Narurkar V, Carruthers J. Management of injected hyaluronic acid induced Tyndall effects. Lasers Surg Med. 2006;38:202-204.

26. Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Re-stylane) in facial cosmetic surgery: review and technical considerations. Plast Reconstr Surg. 2007;120:41S-54S.

27. Smith SR, Lin X, Shamban A. Small gel particle hyaluronic acid injection tech-nique for lip augmentation. J Drugs Dermatol. 2013;12:764-769.

28. Bertucci V, Lynde CB. Current Concepts in the Use of Small-Particle Hyal-uronic Acid. Plast Reconstr Surg. 2015;136(5 Suppl):132S-138S.

29. Mukamal LV, Braz AV. Lip filling with microcannulas. Surg Cosmet Dermatol. 2011;3:257-260.

30. Cassuto D. Blunt-tipped microcannulas for filler injection: an ethical duty? J Drugs Dermatol. 2012;11:s42.

31. Fulton J, Caperton C, Weinkle S, Dewandre L. Filler injections with the blunt-tip microcannula. J Drugs Dermatol. 2012;11:1098-1103.

32. Zeichner JA, Cohen JL. Use of blunt tipped cannulas for soft tissue fillers. J Drugs Dermatol. 2012;11:70-72.



JO0916


Chiu_2016_Lip Injection Techniques Using Small-Particle Hyaluronic Acid Dermal Filler

Documents

Transcript of Chiu_2016_Lip Injection Techniques Using Small-Particle Hyaluronic Acid Dermal Filler