Like the choice of appropriate filling agent, injection techniques vary. Initial patient evaluation should include an overall assessment of the diffuse volume deficit, as well as the individual lines and depressions for a multifaceted treatment approach (Fig. 19.2). In some cases, rejuvenation of the lower face can be accomplished with filling agents alone using a conservative approach and follow-up visits to assess the need for additional treatment. Because of the dynamic nature of the perioral region, fillers often do not last as long as they do in less mobile locations. For this reason, restoration of volume in the lower face is often combined with movement control via botulinum toxin (BoNT). Indeed, combination therapy has been shown by numerous studies to work synergistically, providing optimal and longer lasting clinical benefits than with either modality alone. Some clinicians consider combination therapy the standard for rejuvenation in the lower face.

Figure 19.2 (A) Before and (B) after augmentation of the lower face.

Pearl 2

Neurotoxin and fillers work well together for an outstanding aesthetic effect in the upper, mid- and lower face.

In the only prospective, randomized study of the perioral region to date, Carruthers and colleagues studied HA alone or in combination with BoNT for lip augmentation and the treatment of oral commissures and perioral rhytides. Combination therapy proved better on three patient-reported outcomes: overall satisfaction, perioral / lipstick lines, and total satisfaction. Patients demonstrated satisfaction and improvement in self-perceived age with combination therapy or HA alone, compared with BoNT alone. When investigators rated improvements, combination therapy was superior for all end points, with statistically significant longer durations of effect.

Vertical lip lines

Because vertical lip rhytides, called ‘smoker’s’ or ‘lipstick’ lines, can range from faintly etched multiple lines to deep grooves, treatment techniques will vary. Injections can be placed along the length of the line, slightly perpendicular, or across the lip platform, and any combination of these approaches may be used. Treatment of the entire lip platform may benefit patients with multiple small lines. The platform is filled conservatively, beginning injections laterally above the white roll and using the push-ahead technique, which can decrease the number of injection sites required for correction. Multidirectional injections on the lip platform may be required for widespread correction of perioral rhytides (Fig. 19.3).

Figure 19.3 (A–C) Injection technique for widespread correction of vertical lip lines.

Oral commissures

During the aging process, atrophy of soft tissue and changes to the mandible lead to diminished muscular and cutaneous support of the lateral commissures. As a result, the corners of the mouth begin to turn downward, helped along by gravitational pull and repetitive muscular activity of the DAO and platysma. The negative curve to the lips presents an involuntarily disagreeable facial expression. Correction of the oral commissures requires augmentation to fill the lines and folds and to lift the corners of the mouth. Simultaneous neurotoxin relaxation of the DAO, platysma, and mentalis are also helpful.

A combination of serial puncture and linear threading has been reported in the literature, with the former preferred for deep depressions and lateral lip festoons, and the latter for shallower grooves and less extensive downturns of the mouth. The 30-gauge, 1-inch (2.5 cm) needle is inserted in the mid-dermal level of the modiolus with the patient’s mouth slightly open, while the non-injecting hand holds the skin taut. Slow injection using the ‘push ahead’ technique allows the filler to precede the needle tip through the delicate tissues, reducing injection-related adverse events (Fig. 19.4). In some cases, injections may need to extend into the white roll of the upper lateral lip or higher to elevate the angle of the mouth. Injecting the lateral upper lip and lateral lower lip and extending the filling agent support inferiorly down the melomental fold to the mandibular margin can increase longevity of the result. Cross-hatching may be used in patients requiring extensive correction or to fill the triangular area of the commissures. The needle is inserted approximately 1 cm below the lip, and a linear threading technique is used to inject along the lip and into the marionette lines. As much as 1.5 mL of HA may be used on each side to provide adequate fullness, particularly in older patients. Mouth corners often cannot be adequately addressed without adding extra support to the pre-jowl and perimental areas (see below).

Figure 19.4 The push-ahead technique for augmentation of the oral commissures.

Augmentation in the mouth corners usually does not last as long as in other areas. Concomitant injections of BoNT into the DAO can be used to reduce its downward pull against the zygomatic complex, which elevates the corners of the lips, and to extend the duration of the filling agent by reducing repetitive muscular activity.

Augmentation of the jaw and chin

The chin forms the front of the jaw and is the most prominent element of the lower third of the face in frontal view and in profile. The contour of the chin is determined by the shape and position of the mandible and underlying soft tissues. Bone loss and progressive soft tissue atrophy and descent around the nasolabial folds and marionette lines give rise to the pre-jowl sulcus, perimental hollows, labiomental crease, and ptosis of the chin pad. The redistribution of the overlying skin and subcutaneous tissues leads to a less defined jawline, jowls, and an underprojected or double chin.

Augmentation of the chin can improve its shape and forward protrusion and sharpen the jawline. Typically 0.2–0.4 mL of filler material is injected subdermally into the regions superior and lateral to the mentum (Fig. 19.5). Filling the pre-jowl sulcus – indentations along the jaw directly below the corners of the mouth that interrupt the smooth line of the jaw – smoothes the mandibular border, while augmentation of the perimental hollows and labiomental crease gives additional support to the entire chin complex (Fig. 19.6). The key to correcting the pre-jowl sulcus is the recreation of the inferior border of the mandible, rather than simple volume replacement along the body of the mandible. To correct the pre-jowl sulcus, filler is placed in the deep dermis in the subdermal plane while taking care to avoid the facial artery and vein, which are pre-periosteal. Incremental, slow injection combined with gentle massage can create a smooth correction that blends well with the adjacent chin and jaw contours.