Hema Sundaram, MD, FAAD Disclosures

Editor's note: In this case, one product line of hyaluronic acid (HA) fillers is used. There have been no head-to-head clinical trials comparing HA fillers, and the use of particular products in this case should be viewed as a clinical choice and not as a representation of product attributes that have been demonstrated in clinical trials or as an endorsement of particular products by Medscape. This case discusses off-label uses of HA fillers.
Case Presentation
A 36-year-old black scientist presented complaining of a drooping mouth and lines around her mouth, which she felt made her look older. She wished to improve the shape of her lips and diminish the lines around them without significant lip enlargement. She also requested improvement of her skin hyperpigmentation and skin texture, which had worsened insidiously over several years. She reported that she spent much of her time in Africa, where she was exposed to strong sunlight. She had smoked about 5 cigarettes a day for more than 10 years.
The patient had Fitzpatrick skin type V (Figure 1). There was asymmetry and mild-to-moderate loss in maximal height and projection of the upper and lower vermilion lips. Although the vermilion borders were moderately well defined, the Cupid's bow was mildly atrophied and there was decreased eversion of the vermilion borders, which was most apparent laterally where there was some loss of the white roll. In the immediate perioral frame, skin elasticity was good but there was moderate loss of volume. There was minimal ptosis of the lateral oral commissures. Her philtral base was slightly widened and the definition of the philtral columns was mildly diminished. The distance from the philtral base to the columella was increased and there was a slight labiomental groove. Examination of the peripheral perioral frame showed good skin elasticity with moderate volume loss, manifested by nasolabial folding and an incipient prejowl sulcus on both sides. Chin projection was slightly less than optimal for this patient's facial contours.

Figure 1. Before treatment.
Treatment
After topical anesthesia, the patient was treated by injection of about 0.4 cc of a large-particle nonanimal stabilized hyaluronic acid (NASHA) filler (Perlane; Medicis; Scottsdale, Arizona) just above the wet line of the vermilion upper lip and the right aspect of the vermilion lower lip, using serial anterograde vertical puncture through a 27G needle, followed by gentle massage. This author usually avoids injecting a bolus of filler directly into the vermilion tubercle; instead, injection on either side of the midpoint of the vermilion upper lip enhances its projection and produces a more appealing contour.
To evert the lips and enhance the white roll, a small-particle NASHA filler (Restylane; Medicis) was injected by anterograde serial threading through a 30G needle just above and just below the upper and lower vermilion borders -- a technique that this author prefers for NASHA fillers. Injecting a NASHA filler directly into the vermilion border, as one would do with a collagen filler, may blur the angle between the vermilion border and the adjacent skin and compromise the white roll.
In the immediate perioral frame, the mouth angles were lifted by injection of the small-particle NASHA filler via anterograde serial threading through a 32G needle. Each philtral column was enhanced by injection of the same filler through a 30G needle, using a medial approach and a retrograde threading technique while grasping the column between the thumb and forefinger of the nondominant hand. This technique simultaneously prevents misplacement of the filler and allows molding at the time of injection. The amount of filler injected was gradually increased as the needle moved down from the philtral column's junction with the columella towards the vermilion border. The overall effect of this injection pattern was to slightly reduce the distance between the philtral base and the columella. The large-particle NASHA filler was injected into the cutaneous lower lip through a 27G needle using anterograde serial puncture and serial threading followed by gentle massage, and the small-particle NASHA filler was injected by serial threading through a 30G needle into the labiomental groove.
In the peripheral perioral frame, the nasolabial folds were filled with the large-particle NASHA filler through a 27G needle using an anterograde cross-hatching technique, followed by the small-particle NASHA filler injected through a 32G needle via serial threading over the large-particle filler to fill fine nasolabial rhytides. The prejowl sulci and inferior aspect of the chin were injected supraperiosteally with the large-particle NASHA filler through a 27G needle using serial threading technique followed by gentle massage. The large-particle NASHA filler was injected by serial puncture through a 27G needle into the inframedial and supramedial midface. A total of 3 cc of large-particle and 1 cc of small-particle NASHA filler were injected.
The small-particle filler placed in the fine nasolabial rhytides was injected into the mid to upper dermis; all other NASHA filler injections in this patient were placed deeper, ranging from the mid to deep dermis to the subcutaneous tissue and supraperiosteally. All injections were stopped before withdrawing the needle to avoid producing the Tyndall effect -- blue discoloration due to placement of NASHA filler too superficially.
This patient was also treated on the same day with a multiple-step, modified Jessner's chemical peel including salicylic and lactic acids, resorcinol, and retinoic acid (Vitalize peel; SkinMedica; Carlsbad, California) for improvement of skin texture and hyperpigmentation. All steps of the peel except for the final one were performed prior to NASHA injection. The final step -- application of retinoic acid -- was performed after NASHA injection.
At follow-up 1 week later, before the patient returned to Africa, she described herself as "delighted" with her results. She reported that strangers had stopped her while she was shopping in a mall 4 days after her treatment, to compliment her on the beauty of her lips (Figures 2-4). This patient has subsequently had NASHA filler injections to the periorbital region and to the earlobes.

Figure 2. Before treatment (left) and 1 week after treatment (right) with small- and large-particle NASHA fillers and modified Jessner's chemical peel with retinoic acid.

Figure 3. Before treatment (left) and 1 week after treatment (right) with small- and large-particle NASHA fillers and modified Jessner's chemical peel with retinoic acid.

Figure 4. Before treatment (left) and 1 week after treatment (right) with small- and large-particle NASHA fillers and modified Jessner's chemical peel with retinoic acid.
Discussion
When rejuvenating the mouth and perioral region, this author first evaluates the symmetry, shape, and projection of the lips. She then evaluates skin elasticity and the extent and pattern of volume loss in the perioral region, which she divides into immediate and peripheral perioral frames.[1] The immediate perioral frame encompasses the region that is adjacent to and encircles the vermilion lips, comprising the cutaneous upper lip including the philtrum, the angles of the mouth, and the cutaneous lower lip extending to the level of the labiomental crease. This author considers the peripheral perioral frame to encompass all areas in which injection of fillers can produce perioral lifting. By this definition, the peripheral perioral frame extends from the zone lateral to the angle of the mouth across the inferior midface and lower face to the preauricular region and mandibular angle and also includes the portion of the supramedial midface that lies just above the alar-facial groove. This division of the perioral frame into immediate and peripheral zones allows accurate assessment of the degree and pattern of volume loss in the lower face.
This case illustrates the value of volume replacement to the lips and perioral frames, even in patients whose lips are inherently full. Injection of the appropriate fillers using the appropriate techniques significantly lifted and recontoured this patient's mouth without overfilling her lips. Volume restoration to the immediate perioral frame achieved local lifting of the mouth, while volume restoration to the peripheral perioral frame provided more global lifting of the mouth and lower face.
It is important for the injector to appreciate that evaluation of the lips and perioral frame in patients of color differs from evaluation in white patients in several respects. A full understanding of these differences is vital in order to formulate a successful treatment strategy. At any given age, the lips and perioral frames tend to appear less wrinkled in a patient of color than in a white patient, and thus the patient may be perceived as looking less old. This is because skin of color tends to retain good skin elasticity; aging is characterized more by volume loss, resulting in skin folds such as those present before treatment in this patient's nasolabial region. This pattern of aging has given rise to the aphorism that skin of color ages by folding rather than by wrinkling.
It is essential to recognize and correct signs of volume loss in patients of color, such as asymmetry of the vermilion lips, loss of vermilion border eversion (which may be focal rather than global), and lengthening of the distance between the philtral base and the columella. It is equally essential to listen to patients' concerns, which generally center on what has happened to their faces as they have aged; these changes from the baseline of youth serve as an invaluable aid for the clinician in assessing the individual aging process. In contrast, a clinical approach that overfocuses on detection of lip thinning and skin wrinkling is not relevant to skin of color; this approach may lead to underdiagnosis and undertreatment of volume loss and consequent patient dissatisfaction.
An additional challenge when treating many patients of color is to achieve their objectives of lip lifting, shaping, and defining without adding appreciable fullness, which they may consider undesirable if their lips are already full. The treatment paradigm for this patient illustrates how 2 NASHA fillers can be combined to rejuvenate the lips and perioral frames. Volume restoration lifted the lips and the perioral frames together -- a vivid demonstration of the symbiotic relationship between these 2 structures and the synergistic results that can be obtained through revolumizing both in tandem. When the appropriate NASHA fillers are selected and injected with the appropriate techniques into the perioral region, the resultant secondary lifting and recontouring of the lips obviates the need for large-volume filler injection into the lips themselves.
This author considers NASHA fillers to be ideal for volume replacement in patients of color. Slow, steady anterograde injection of free-flowing NASHA fillers minimizes tissue trauma and consequent inflammation,[2] decreasing the risk for postinflammatory hyperpigmentation, a complication to which skin of color is particularly prone. The injection strategy for this patient was to inject the fillers as deeply as possible -- no higher than the mid-dermis -- to avoid upper dermal inflammation and thus to further reduce postinflammatory hyperpigmentation. In this regard, it is particularly advantageous that the large-particle NASHA filler that was used can be injected subcutaneously or supraperiosteally where appropriate, such as in the chin and prejowl regions. Where superficial placement of the small-particle NASHA was required (into the fine nasolabial rhytides), it was accomplished by injection through a needle with the smallest possible diameter (32G), again to avoid upper dermal inflammation. Anecdotally, this author has observed greater longevity of the NASHA fillers used in this case in many patients of color, compared with white patients. This may be due to intrinsic differences in the dermal structure of skin of color and in the de novo collagenesis that manifests after injection of these fillers.
This author finds that a 2-layer approach, using deeply injected large-particle NASHA to volumize and lift the lips and more superficially injected small-particle NASHA for lip shaping, gives a soft feel immediately after injection and allows for precise results and excellent contour stability, usually with little or no post-procedural swelling. It is often stated in the lay press that augmented lips are characterized by the absence of the fine vertical lines that are naturally present on untreated lips. These lip lines can be preserved by the 2-layer approach described for this patient. At reevaluation of this patient 7 months and 9 days after her treatment, she still had good retention of volume and lift to her lips and perioral frames (Figure 5).

Figure 5. Before treatment (left), 1 week after treatment (middle), and 7.5 months after treatment (right) with small- and large-particle NASHA fillers and modified Jessner's chemical peel with retinoic acid.
Besides the greater longevity of the NASHA fillers injected with these techniques compared with previously available fillers, such as bovine and human collagen, another advantage is that the NASHA fillers provide not only contouring but also volume restoration. As this author has discussed elsewhere,[3] selection of injection techniques depends on the NASHA filler that is used. Optimal injection techniques for the NASHA fillers used in this case -- including recommended implantation depth -- may differ from those recommended for other HA fillers.
The modified Jessner's chemical peel with retinoic acid that was used for this patient is a very useful adjunct to filler injections, and it can be adapted for a diverse range of skin types. It can be performed on the same day as NASHA filler injections, as with this patient, or during a separate treatment session. This chemical peel provides more efficacious exfoliation than glycolic acid or conventional Jessner's peeling and is safer and more predictable than trichloroacetic acid peeling. In general, 1 to 4 of these modified Jessner's chemical peels significantly improve hyperpigmentation and changes in skin texture, which tend to be earlier signs of aging in skin of color than frank wrinkling.
There is a relatively small margin of error with lip enhancement; half a milliliter too much filler or misplacement of filler a mere millimeter from its desired location in the lips can transform an aesthetically delightful result into a laughingstock. Volume replacement to the perioral frame must also be performed with a high degree of precision. Hyaluronic acid fillers have the advantage in that they are correctable through the injection of hyaluronidase to enzymatically digest undesired filler or through simple extrusion of filler that has been placed too superficially.[2]