Update on perioral cosmetic enhancement

Hyperdilute Calcium Hydroxylapatite for the Treatment of Perioral Rhytids: A Pilot Study

Background

The perioral region plays a crucial role in facial aesthetics and is susceptible to age-related changes, such as wrinkles and fine lines due to its dynamic nature. Type I collagen is crucial in providing structural integrity and resilience to the skin. Calcium hydroxylapatite (CaHA-CMC) is a widely used dermal filler whose particles stimulate fibroblastic responses within the skin. When diluted, CaHA-CMC has emerged as a useful treatment for collagen stimulation.

Objectives

The objective of the study is to evaluate the efficacy and safety of hyperdilute CaHA-CMC at a 1:3 ratio, specifically administered in the perioral area, to assess its impact on deep rhytids and overall skin quality.

Methods

Females aged 40 to 70 years with moderate-to-severe wrinkles in the perioral region based on a validated wrinkle scale were injected with hyperdilute CaHA-CMC throughout the perioral region at 2 separate injection intervals (Weeks 1 and 8). This was followed by an injection of hyaluronic acid (CPM-HA22.5) into the perioral region at Week 16. The primary endpoint was a ≥1-point improvement from baseline on the wrinkle grading scale.

Results

Twelve female participants were treated. Investigator and patient ratings based on the 5-point Merz perioral/lip wrinkle grading scale showed at least 1 grade improvement in 83% of the patients with a P-value of .0156. A majority of both investigators and patients rated their lip wrinkles as improved in appearance compared with their baseline.

Conclusions

Hyperdilute CaHa-CMC at a 1:3 dilution may be a safe and effective treatment for improving the depth and overall appearance of perioral rhytids.

Level of Evidence 4

Different Techniques and Quantitative Measurements in Upper lip lift: A Systematic Review

BACKGROUND

The upper lip area is an important component of facial aesthetics, and aging produces an increase in the vertical height of the upper lip. Different upper lip lifting techniques are described in the literature.

OBJECTIVES

This systematic review aimed to assess both invasive and noninvasive upper lip lifting techniques with patient satisfaction, adverse effects, and quantitative measurements of lifting efficiency.

METHODS

This study was conducted per PRISMA guidelines. MEDLINE (via PubMed), EMBASE (OvidSP), and Cochrane Library database were searched from September 14, 2022, to October 12, 2022. Inclusion criteria were reporting on upper lip lift efficiency with quantitative measurements of the lifting degree.

RESULTS

Out of 495 studies through the search strategy, nine articles were included in the systematic review, eight for surgical procedures and one for nonsurgical. Surgical procedures seem to have better longevity than nonsurgical techniques. Reported patient satisfaction for both surgical and nonsurgical treatments was good with no severe complaints. The quantitative measures differ between researches and may be classified into two metrics: anatomy ratio computation using photographic analysis or direct height measurement with a caliper and precise parameters utilizing a three-dimensional method.

CONCLUSION

In general, surgical therapies seem to have a longer-lasting lifting effect on upper lip lifts with an inevitable scar, while nonsurgical techniques are minimally invasive but temporary. There was a lack of consistency in the measurements used to assess lifting efficiency. A consistent quantitative assessment can be beneficial for both clinical decision-making and high-level evidence research.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prospective Evaluation of the Safety and Efficacy of Thermomechanical Fractional Injury for Perioral Rhytides

BACKGROUND

Perioral rhytides can be treated with laser and energy-based devices. More recently, a novel fractional thermomechanical skin rejuvenation system was developed to cause controlled thermal injury through direct heat transfer.

OBJECTIVE

A prospective clinical trial evaluated the safety and efficacy of a thermomechanical fractional injury device (Tixel 2, Novoxel, Netanya, Israel) for perioral rhytides.

MATERIALS AND METHODS

Subjects with moderate-to-severe perioral rhytides were enrolled and underwent 4 monthly treatments.

RESULTS

Twenty-three subjects were enrolled and completed all study visits. Mean age was 62.5 years, and 100.0% were women. Fitzpatrick Skin Types I-IV were included. For Fitzpatrick Wrinkle Classification System (FWCS), mean baseline score was 6.9. Per investigator, there was a mean 1.9-grade improvement in FWCS at 3-month follow-up ( p < .0001). At 3-month follow-up, 8.7% (n = 2) of subjects had a 3-grade improvement, 69.6% (n = 16) had a 2-grade improvement, and 21.7% (n = 5) had a 1-grade improvement. For physician Global Aesthetics Improvement Scale at 3-month follow-up, 69.6% (n = 16) had 76% to 100% improvement, 13.0% (n = 3) had 51% to 75% improvement, and 17.4% (n = 4) had 26% to 50% improvement. There were no severe adverse events, and subjects experienced minimal pain.

CONCLUSION

A novel device using thermomechanical fractional injury was demonstrated to be safe and effective in the treatment of perioral rhytides.

Lip Lift Techniques in Smile Design

The lips are the main aesthetic component of the facial lower third and simultaneously a substantial element for an ideally perceived smile. One of the most accepted and common procedures that is widely used to enhance the shape and contours of the upper lip is the lip lift. With a careful treatment plan and a professional surgery, a lip lift can reliably be used for the reduction of the philtrum height, enlargement of the upper vermilion, improvement of the dental show, restoration of facial aesthetic proportions, and creation of an enchanting smile.

Aging of the Upper Lip: Part I: A Retrospective Analysis of Metric Changes in Soft Tissue on Magnetic Resonance Imaging

BACKGROUND

In scientific literature, numerous theories on the mechanism of facial aging can be found. The debate about facial sagging versus deflation is still ongoing. In this study, the metric changes in perioral soft tissue were demonstrated. These data can contribute to a better understanding of physical changes in the aging perioral area.

METHODS

Upper lip measurements were performed on cranial magnetic resonance images of 200 Caucasian subjects (100 men and 100 women). The study population was aged between 20 to 30 and 65 to 80 years. The upper lip length and soft-tissue thickness were measured on sagittal and parasagittal section. Cross-section surface area of the upper lip was measured in the sagittal section to represent volume. The data were analyzed with a t test and results were considered significant at p < 0.01.

RESULTS

The upper lip in the old age group differed significantly in length (19.24 percent in women and 18.24 percent in men), thickness (up to -40.55 percent in women and -32.74 percent in men), and volume (-20.89 percent in women and -17.40 percent in men). Soft-tissue thickness at the alar nasolabial fold was significantly thinner in the old age group (-25 percent in women and -25.7 percent in men) and showed significantly greater tissue loss than elsewhere in the upper lip (p < 0.001).

CONCLUSIONS

These results suggest that the aging perioral area is affected with a combination of soft-tissue lengthening, thinning, and volume loss. The clinical implications of this study on perioral rejuvenating strategies will be explained in part II.

Lip Lift

The male upper lip has a distinctly longer cutaneous height from the nasal base to the upper vermilion border than its female counterpart. The subnasal indirect lip lift using the bullhorn technique or its modifications allows for shortening of this height to feminize the lower face, creating a more aesthetically pleasing upper lip secondary to increased vermilion height and lip pout. Patient selection is critical, taking into account lip height, vermilion height, alar base width, skin type, upper incisal show, and maxillary height. Precise measurements, controlled excision of the planned resection, and meticulous reapproximation of skin provide an aesthetic result, while minimizing visible scarring.

Upper Eyelid Blepharoplasty With Voltaic Arc Dermabrasion

The aging to the upper eyelid complex includes skin laxity, resulting in rhytids, orbicularis oculi hypertrophy, and pseudohermitian of orbital fat and nowadays a high number of patients seeking cosmetic surgery. Excess and laxity of upper eyelid skin affect more than 90% of women, the impact of these problems on the patient's self-esteem can become important enough to affect quality of life in psychological and sociocultural terms.The aim of the study was to evaluate the clinical efficacy of blepharoplasty with an electrosurgical technology for treatment of skin laxity of upper eyelid, which produced a lid retraction and an elevation of the upper lid without complications.This retrospective evaluation was conducted from October 2008 to July 2015, where 80 patients (56 female and 24 male) were treated for excess and laxity of upper eyelid skin with voltaic arc dermabrasion.The outcome was that all patients displayed some aspects of tissue contraction that stretched the lax skin of the upper eyelids, resulting in cosmetic improvement.In conclusion this technique was predictable and useful to remove the laxity of upper eyelid skin minimal recurrence rates, and acceptable aesthetics.

Perioral Rejuvenation: A Prospective, Quantitative Dynamic Three-Dimensional Analysis of a Dual Modality Treatment

BACKGROUND

The perioral region is the most dynamic anatomic area of the face and subject to complex and dramatic changes during aging. Successful treatment for perioral rejuvenation has yet to be identified, and prior studies have reported only subjective outcomes.

OBJECTIVES

The purpose of this study was to utilize our validated dynamic 3-dimensional imaging technology to determine whether conservative neuromodulation combined with hyaluronic acid filler volumization can decrease perioral strain and increase volume with significant patient satisfaction.

METHODS

An IRB-approved prospective study of a dual modality treatment for perioral rhytids was performed on females with perioral aging who had not had prior facial treatment within the past year. Eighteen (18) units of Dysport were injected into the upper and lower orbicularis oris and 1 cc of Restylane Silk was injected in volume-depleted perioral regions in each patient. Each patient underwent imaging with digital image correlation (DIC) and completed the FACE-Q survey prior to injection and at 14 days and 90 days postinjection.

RESULTS

Thirty-two female patients were recruited. A significant reduction in perioral strain was observed at both day 14 and day 90. This was concomitant with a significant increase in perioral volume at day 14 that at 90 days was significantly retained in the marionette lines. Further, there was a significant improvement in patient satisfaction with overall facial appearance at day 14 that was maintained at 90 days.

CONCLUSIONS

Conservative neuromodulation and hyaluronic acid filler volumization of the perioral region produces a significant reduction in strain correlating with high patient satisfaction, even at 90 days. This dual modality treatment is effective in rejuvenating the perioral region, and its future optimization will provide greater therapeutic options for this anatomically complex area.

LEVEL OF EVIDENCE 4

Variability of facial movements in relation to sexual dimorphism and age: three-dimensional geometric morphometric study

The aim of this study was to introduce suitable imaging technique and analytical methods for a detailed description of the facial movements in relation to sexual dimorphism and age in adult individuals. Removing of size factor from the analysis, we hypothesised that there will be no significant intersexual difference in facial mobility. We assume facial movements to be more pronounced in the older age category due to increasing the facial surface. We have compared five facial movements - raising eyebrows, closing eyes, pursing of the lips, inflating of the cheeks and smile - in relation to neutral expression of the human face. The material sample comprised three-dimensional facial surface models of healthy adult individuals of the Czech nationality (63 females, 58 males). Methods of geometric morphometry and multivariate statistics were used. Local tissue motion due to facial movements was expressed using colour-coded maps. The movement showing significant intersexual difference was inflating of the cheeks. Ageing in both sexes has significantly influenced the facial mobility on average after 50 years of age. Changes related to senescence have occurred in eye closing, smile and inflating of the cheeks. An enlarged facial surface has been noted in the group of individuals belonging to the older age category, what is probably the result of increased manifestation of skin folds and wrinkles. This is related to the loss of skin elasticity and overall weakening of the underlying muscles, especially in the infraorbital and cheeks area.

Evaluation Effectiveness of the Voltaic Arc Dermabrasion in Perioral Rhytides Eradication

Perioral rhytides affect more than 90% of women, the impact of these problems on the patient's self-esteem can become important enough to affect quality of life in psychological and sociocultural terms. Basic science shows that skin rhytides are related to loss in quantity and function of dermal collagen fibers. An electrosurgical technology was used in this study for treatment of perioral rhytides. The authors treated 34 patients (26 women and 8 men) for perioral rhytides with voltaic arc dermabrasion technique. Patient ages ranged between 30 and 65 years and the majority (90%) of these perioral areas had class II and III wrinkle scores. Voltaic arc dermabrasion was used to remove the keratinized layer for point perioral area. Treatments are minimally painful and in the authors' experience require no anesthesia. No discomfort should be expected once the voltaic arc dermabrasion treatment is concluded. The perioral dermis appears as a pale, erythematous, dull surface. Bleeding is not seen unless excessive abrading occurs with the saline-moistened gauze. No hyperpigmentation, hypopigmentation, erythema, ecchymosis, pain, itching, outbreaks of herpes, infectious processes, and scarring were observed. All patients monitored for fine perioral rhytides showed a reduction in the treated area. Since skin-specific quality of life was significantly improved after "voltaic arc" treatment, this therapy can be recommended for patients with perioral rhytides skin wishing to improve their appearance.

Central Lip Lift as Aesthetic and Physiognomic Plastic Surgery: The Effect on Lower Facial Profile

BACKGROUND

A central lip lift was introduced to Westerners in 1980s. However, no studies have been conducted on the facial aesthetic and physiognomic perspectives of a central lip lift in the Asian population.

OBJECTIVES

The authors presented the central lip lift as aesthetic and physiognomic treatment in Asians and explained its effect on lower facial profile.

METHODS

A retrospective chart review was performed in 202 cases of asians. The authors analyzed patient age, cause of long philtrum, purpose of the treatment, and postoperative satisfaction. The authors then performed an anthropometric assessment and a photographic analysis.

RESULTS

The vertical disproportion of the lower face was improved after the treatment, and there was significant shortening of the philtrum length (P < .001) and an increase in a visible upper vermilion (P < .001). In Westerners, a long philtrum was mainly caused by the aging process. Aging patients (range, 40-59 years) underwent the central lip lift for upper lip rejuvenation. In contrast, in Asia, a long philtrum was primarily caused by bone retraction after an orthognathic surgery or orthodontic procedure. Young patients (range, 20-39 years old) underwent the central lip lift to correct a relatively lengthened philtrum after 2-jaw surgery. Furthermore, about half of the patients (52.0%) underwent the central lip lift for facial physiognomic improvement.

CONCLUSIONS

In today's multiracial society, plastic surgeons planning a central lip lift in Asian patients should consider both aesthetic and physiognomic perspectives. Regardless of the aesthetic outcome, the surgeon should strive to maximize patient satisfaction.

LEVEL OF EVIDENCE

4 Therapeutic.

IncobotulinumtoxinA in aesthetics: Russian multidisciplinary expert consensus recommendations

BACKGROUND

Although there are various international consensus recommendations on the use of botulinum neurotoxin type A (BoNT/A) in facial aesthetics, there are no global or Russian guidelines on the optimal dose of incobotulinumtoxinA, free from complexing proteins, within specific aesthetic indications. This article reports the outcomes of two expert consensus meetings, conducted to review and analyze efficacy and tolerability data for incobotulinumtoxinA in various facial aesthetic indications and to give expert consensus recommendations to ensure best clinical practice among Russian clinicians.

METHODS

Thirteen dermatology and/or plastic surgery experts attended meetings held in Paris, France (November 2013), and Moscow, Russia (March 2014). The expert group reviewed and analyzed the existing evidence, consensus recommendations, and Russian experts' extensive practical experience of incobotulinumtoxinA in aesthetics to reach consensus on optimal doses, potential dose adjustments, and injection sites of incobotulinumtoxinA for facial aesthetics.

RESULTS

All experts developed guidance on the optimal doses for incobotulinumtoxinA treatment of different regions of the upper and lower face. The expert panel agreed that there are no differences in the efficacy and duration of the effect between the four BoNT/As that are commercially available for facial aesthetic indications in Russia and that, when administered correctly, all BoNT/As can achieve optimal results. Experts also agreed that nonresponse to BoNT/A can be caused by neutralizing antibodies.

CONCLUSION

On the basis of the scientific and clinical evidence available for incobotulinumtoxinA, coupled with the extensive clinical experience of the consensus group, experts recommended the optimal doses of incobotulinumtoxinA effective for treatment of wrinkles of the upper and lower face to achieve the expected aesthetic outcome. These first Russian guidelines on the optimal use of incobotulinumtoxinA for augmentation of glabellar lines, periorbital wrinkles, forehead lines, bunny lines, perioral wrinkles, depressor anguli oris, mentalis, masseters and platysmal bands, and performing the Nefertiti lift, are presented here.

Classification of the Aging Lips: A Foundation for an Integrated Approach to Perioral Rejuvenation

BACKGROUND

Although perioral aging is highly individual with several distinct processes taking part simultaneously, there is scarce systematic information which helps to indicate the right rejuvenation approach among the multitude of proposed procedures. Existing data about perioral aging has not yet been transformed into a consistent therapeutic concept. The intention of this study was to provide a simple, yet reproducible classification and to offer appropriate rejuvenation approaches.

METHODS

To identify reliable and constant landmarks of the ongoing process of perioral aging, 462 perioral photo documentations were morphometrically analyzed. Based upon the identified landmarks a two-dimensional classification was developed. The classification was validated by three plastic surgeons. Inter- and intra-rater reliability was calculated using Cohen's kappa coefficient.

RESULTS

Perioral aging can be broken down into changes of the lip shape and changes of the lip surface. Both processes can be classified into three stages each: Lip shape according to the shape in profile view, the lip length in relation to the frontal incisors, and the degree of vermilion inversion. Lip surface according to the presence and degree of radial wrinkles and the visibility of the structural elements Cupid's bow, philtrum, and white roll. Inter-observer reliability was rated very good (kappa values between 0.819 and 0.963) and perfect for intra-observer reliability (1.0).

CONCLUSION

A better understanding of perioral aging leads to a simple classification for the aging lips. Using the classification helps to tailor an appropriate treatment to the individual patient and aids to achieve a natural rejuvenation result.

Five-year Experience with Perma Facial Implant

SUMMARY

Augmentation cheiloplasty is becoming an increasingly popular aesthetic procedure despite current methodologies having met with disappointment among surgeons and patients. The goal of this study was to examine the benefits and drawbacks of 1 device in particular-Perma Facial Implant (PFI). The senior authors (P.R. and S.W.H.) performed 832 consecutive PFI lip augmentations with excellent results based on photographic documentation, patient satisfaction surveys, unbiased surgeon ratings, and low complication rates. In addition to augmenting thin lips, PFIs hide excess dentition and improve vermilion rhytids and pout. Contrary to alternatives, they are both permanent and reversible. However, they do not level out asymmetries or benefit razor-thin lips without prior lifting or mucosal advancement.

The labial aging process: a surface analysis-based three-dimensional evaluation

BACKGROUND

With increasing age, the smile becomes elongated and less appealing. Currently, several methods are proposed for analysis of lip morphology including lateral cephalograms, profile and frontal photographs, video images, and three-dimensional systems. Despite several descriptions of morphologic and histologic age-related changes in the literature, no scientific well-supported model of the labial aging process is reported.

METHODS

For this study, 33 healthy volunteers were selected and divided into two groups according to age: a youthful group (ages 21-34 years) and an aged group (ages 45-65 years). Their dental and labial stone casts were obtained, digitized, and virtually reproduced using a computerized electromechanical digitizer and applying nonuniform rational B-spline geometry. To obtain a synthetic parameter describing local surface deformation, average curvature and curvature variability indexes were computed and compared.

RESULTS

No significant age- or sex-related differences in the average curvature were detected. In contrast, the curvature variability was significantly greater in the young than in the aged subjects.

CONCLUSIONS

The labial arch surface remains macroscopically constant between the third and the sixth decades of life, but with local modifications that influence the standard deviation of its curvature. A high standard deviation described the protruding labial appearance of the young subjects, whereas a reduced one described the flat lips of the aged subjects.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A succinct review of botulinum toxin in dermatology; update of cosmetic and noncosmetic use

Botulinum toxin A has a wide variety of clinical applications in medical and dermatologic sciences. Nowadays, researchers introduce some other indications for botulinum toxin in cosmetic and especially noncosmetic aspects of dermatology such as medical rhinoplasty, hypertrophic scar, chemical brow lift, supraciliary wrinkles, pompholix, eccrine angiomatosis, Hailey-Hailey, dermatochalasis, lichen simplex, nosthalgia parestetica, and granulosis rubra nasi. In this general overview of the use of botulinum toxin in dermatology, an extensive literature search was carried out to updates of all dermatology-oriented experiments and clinical trials on the mentioned aspect of botulinum toxin.