Vermilion: Robert Gordon DDS

Vermilion
D o l l a r L i p s
Robert Gordon DDS

Lip and Perioral Augmentation for the Cosmetic Dentist
D edication
First and foremost, I would like to dedicate this
book to my mother Carol Gordon. The greatest
gift she ever gave me was passion: passion
to pursue whatever I dreamed possible…she
was always supportive and never discouraged
me. I will miss her the most, but I’m sure she
is looking down and guiding me from above.
My children Lance and Sidney who suffered
the endless hours of me reading literature
and researching this book. There were times
they would look at me and ask me something,
knowing my mind was miles away in what they
called “Book Land.” To my father, for always
being there for me. To my staff, patients and
colleagues who put up with my endless and
tireless conversations on and about everything
to do with lips. I also would like to dedicate
this book to those who have chosen to engage
in this new and exciting journey with me. You
all have inspired me with your exuberance,
passion and conviction. It is an honor to be a
part of something that becomes bigger than
oneself everyday.
Vermilion
D o l l a r L i p s
1st Edition
Robert W. Gordon DDS
Vermilion Dollar Publications

Vice Ink Production
© 2007 By Robert Gordon DDS
All Rights reserved. Printed in the USA. No part of this publication

can be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording or any
information storage and retrieval system now known or to be
invented, in any form without prior written authorization from
Vermilion Dollar Publications.

P.O. Box 55006
St. Petersburg, FL 33732-5006
1-877-LIP-FILL (877-547-3455)
http://www.vermiliondollarlips.com
info@vermiliondollarlips.com
ISBN-13 978-0-9797196-0-8
ISBN-10 0-9797196-0-7
Publisher Vermilion Dollar Publications

Editorial Staff Nicole Palmer, Sue Moen,
Chris Jenkins

Photographers Dr. Robert Gordon, John Fisher,
Luca Guarneri
Cover Photo Dr. Robert Gordon (augmented lips)
Cover Model Natalie Delgado
Designer Jerome Frederick
Technical Advisor and Chris Jenkins
Webmaster
With Special Thanks to Kenneth Grundset DDS

J. Mel Hawkins DDS
Ronald Kobernick DDS

Contents
Foreword
introduction
CHAPTER 1: Vermilion Dollar Lips

3
The Art of Augmentation 5
The Science of Augmentation 6
Is Augmentation for You? 7
The Business of Oral-Facial Augmentation 7
Your First Seminar 9
Marketing Your Cosmetic Lip and Perioral Practice 11
FDA Guidelines and Regulations 15
The Psychology of the Lips 15
CHAPTER 2: The Canvas 23

Dr. Gordon’s Lip and Perioral Classification 27
Zones and Segments of the Lips 31
Anatomy 40
Nerves 44
Oral-Facial Aging 49
Vascularity 49
CHAPTER 3: Anesthesia 57
Local Anesthesia for Oral-Facial Augmentation 61
Delivery of Injectable Anesthetic 67
Delivering Local Anesthetic 73
Oral-Facial Anesthesia Techniques 73
CHAPTER 4: The Medium 81

History of Fillers 85
Injectable Fillers 85
FDA Classification and Use of Fillers 86
Common Classification and Use of Fillers 88
Permanent vs. Non-Permanent Fillers 88
CHAPTER 5: The Artist 109
Beautiful Proportions 113
Fashion Trends of Lips: Past and Present 117
Orthodontics 121
Art of the Fill 124
Photographic Documentation 128
CHAPTER
6: INJECTION PROCEDURES AND TECHNIQUES 135
Lips 139
Oral-Facial Skin 148
Technical Considerations 148
Adverse Reactions and Complications 153
CHAPTER
7: Simply Botox 161
Botox (Clostridium Botulinum Toxin) 165
Armament 168
Perioral Injection Techniques for Botox 169
CHAPTER 8: CLINICAL TECHNIQUES – LIP AND PERIORAL,

Botox AND FILLERS 181
Clinical Techniques: Oral-Facial Augmentation 185
Ages 20-30 189
Ages 30-40 199
Ages 40-50 213
Ages 50+ 225
SOME FINAL WORDS 236
REFERENCES 238
INDEX 239
8 Vermilion Dollar Lips
Robert Gordon
Chapter 1 Vermilion Dollar Lips 9
Foreword
Vermilion Dollar Lips® is a discipline that focuses on the observation, plan-
ning, treatment, and reconstruction of the oral-facial area as a whole, so
that the teeth and lips are recreated to complement one another. This spe-
cialized triad of treatment merges the “canvas,” “medium,” and “artist”: the
human body, fillers, and the cosmetic dentist.
There are currently few case studies that focus on the merger of the
oral-facial soft tissue and the dental field. Yet these two areas are in-
separable and must be addressed as a collective discipline in order to
achieve optimal results.
Within these pages, this innovative approach will be explained in detail

in order to provide you a thorough and supportive guide for diagnosing
and creating an appropriate treatment plan to augment your patients’
oral-facial tissue.
Due to the diversity of practitioners who conduct oral-facial augmentation,

there is a noticeable absence of uniform treatment planning, material se-
lection, and application among the various specialists. In the United States
alone, fillers are now being performed by aestheticians, nurses, nurse prac-
titioners, and physician assistants, doctors of osteopathy, medical doctors,
and dentists.
It is my goal to unite the body of practitioners who perform oral-facial

augmentation, to introduce new perspectives that facilitate the
planning and treatment of patients who wish to augment their
lips and perioral areas, to stimulate debate among active
practitioners, and to provide additional research and an
organized body of information in this exciting field.
It has been said that when we are born, we are endowed with the secret of creation. So
that we do not disclose this information, we are touched on our lips to seal these secrets. To
mark this covenant, we are branded with the curvature on our lips from the indentation of
our angel’s touch. This forms Cupid’s bow.
Lips: Why are we so fascinated by them? Without a doubt, our lips are one of the
most sensual and sensitive parts of the human body. Our lips are one of the body’s most
intimate sensory organs. They allow us to connect with our surroundings. Life-sustaining
nutrients pass through our lips during infancy. We rely on our lips to explore and com-
municate. We use them to capture the mist of the tide’s salts as we walk on the early
morning beach. We explore our first love with trembling lips and bite our lips with antici-
pation, awaiting their return.
Through the years, there has always been an intense interest in lip enhancement
through cosmetics, fillers—or even by over-the-counter topical ointments that cause a
reaction to increase the volume of the lips.
Dentists today are becoming more cosmetically savvy because of the social demands
for exquisite lips, delving further into the psychosocial realm of a clearly defined aes-
thetic connection between each individual’s lips and teeth. Dentists are also all too aware
of the psychosocial connection between teeth and aesthetics, and the contemporary
dentist is now confronted with a paradigmatic change in the practice of dentistry which
focuses on lip enhancement. We work with lips and the perioral area every day, rede-
fining smiles through sophisticated treatments in cosmetic dentistry. We anesthetize lips,
retract them, and suture them when patients present with oral-facial trauma.1
During the past few years, I have experienced this revolution in my own practice in
Florida. I have seen firsthand a sequela of botched lip jobs, the limitations of lip disten-
tion from scar tissue, and the masking of normal dentition that resulted from overfilling
the lips. No other medical specialist has as much contact with lips as we do.2,3 Our edu-
cational program trains us intimately with the vascular, nerve, muscle, and skeletal com-
ponents that make up the lips.
We are clearly the experts within this arena, and the lips are the curtains for our
stage.
1
Chapter 1
Vermilion Dollar Lips

crede quod habes, et habes
Believe that you have it, and you do.
The Art of Augmentation
The Science of Augmentation
The Business of Oral-Facial Augmentation
While dermatologic and aesthetic jour- the syringe. Instead, as skilled specialists,
nals deal with substances for implanta- we focus on the flow of the material; ev-
tion, these journals do not, in themselves, ery fill of space and plane is now carefully
hold information regarding the proper scrutinized and measured subjectively, not
goal of lip enhancement. Instead, the analytically. At that moment, we become
answer is found in the dental literature a cosmetic and aesthetic augmenter.
where many articles have addressed the In oral-facial augmentation, the artist
proper height, size and location of the must know:
lips as produced by dental restorations. Medium (Anatomy)
Dr. Arnold Klein, Professor Material (Fillers)
University of California School of Medicine
Department of Dermatology Trends / Artistic License
The scientist, on the other hand, must
The Art of Augmentation know:
Augmentation of the lips has a significant Anatomy
artistic component. Once the dentist is pro- Fillers
ficient in his techniques and materials of Techniques
choice, the application transcends into an In other words, in this arena, the scientist
artist’s creative arena. After learning how and artist must unite. This merger is estab-
to choose the correct material for the right lished upon a solid foundation comprised
application, the art of augmentation takes
over. It is sort of like learning to drive a
car. We don’t think about the mechanics
THE ART OF THE FILL
of the engine combustion, we sit in the car
and it becomes an extension of us.
In dentistry, our “inner scientist” uses
instruments to make observations. We are
trained to use universally accepted meth-
ods to achieve predictable results that can Canvas
be repeated successfully.
The artist, however, works from a
more subjective viewpoint in which there Medium Methods
is a relative means of expression. Within (fillers) (techniques)
this creative spectrum of skill and talent
lies the art and science of the fill. of a full understanding of the human
Becoming an Oral-Facial Augmenter “Artist” body, appropriate fillers, and masterful
techniques. The elements of scientist and
During our first lip and perioral aug-
artist are inseparable in the practice of lip
mentation, the technical expert in us
and perioral augmentation.
constantly looks at the syringe and the
amount of material injected into the lips. Enhancing Beauty
With practice and proficiency, however, Just as every face is different, so is ev-
there soon comes a time when we develop ery set of lips. It can be rather intimidating
an artistic approach. Halfway through the and stressful to try to fulfill each patient’s
lip-fill procedure, we don’t even look at expectations based solely on aesthetics.
Artists face this same dilemma each time technical application implemented. Once
they apply a brush to an empty canvas. you become proficient in augmentation,
As lip augmentation practitioners, our you’ll devote less attention to the scien-
goal is to enhance beauty, not create it. tific aspect of the procedure and will give
The fundamental principle is to augment more consideration to the artistic aspect of
the natural form. Attempting to create a the augmentation.
new shape will only lead to personal frus- When I first started my learning jour-
tration and patient disappointment. ney with lips and perioral augmentation,
Keep in mind that we all interpret there were two distinct camps of thought
beauty uniquely, based on what we ob- and instruction. The first were those who
serve in our reflections in the mirror. taught based on their personal experienc-
When a lip augmentation specialist/artist es; these individuals related most of their
deviates too far from what patients per- professional encounters to their teaching
ceive to be a “natural look,” he or she may perspectives. Their approach emphasized
indeed change their appearance, but these the quantity of patients they treated, often
patients are likely to report that they only noting, “I have done thousands of lips,”
look different, not younger or more rest- or “I have been doing lips for 20 years.”
ed. As you read this book, however, there
It is equally important to keep in mind are new materials awaiting FDA approval
the difficulty of duplicating someone and numerous clinical trials now in prog-
else’s lips. If, for example, a patient pleads ress. Techniques used for placing previous
with you to give her Angelina Jolie’s lips, materials may no longer apply. Conse-
and you try to recreate this universally quently, if our claim to expertise is vali-
recognizable full-lipped smile, you will dated merely by the quantity of patients
undoubtedly fail. After all, only one per- we have treated, we lose our credibility as
son on Earth has Angelina’s lips. oral-facial augmentation experts if we do
not stay current in this ever evolving field
The key to successful lip augmentation of cosmetic dentistry.
is simple: Concentrate on the uniqueness
of each patient’s lips. Focus on how you The second camp was comprised of
can enhance each patient’s form and vol- those individuals who were relatively
ume or lift her commissure.4 new to oral-facial augmentation and
based their treatments on empirical data
The Science of Augmentation from a host of clinicians. Most often than
There is extensive research material not, members of this camp clung to a par-
available on augmentation materials, as ticular “guru” and his/her philosophy and
well as corresponding clinical studies. Yet methodology. Unfortunately, these practi-
there is no formal standard in the edu- tioners had little experience in the field of
cation of lip and perioral augmentation. oral-facial augmentation. Thus, they were
Doctors either learn the science in their destined to suffer the growing pains asso-
residencies during their continuing edu- ciated with the cosmetic field of lip and
cation studies, or simply through trial and perioral augmentation. Their lack of expe-
error. There is a definite learning curve for rience resulted in a range of misfortunes,
perioral augmentation, and this is primar- such as an inability to identify a patient’s
ily based on the materials used and the cosmetic wants or needs, mistreatment, or
unfortunate and transient post-op mor- guide you through your own personal
bidities, such as excessive bruising and journey in learning how to master the art
swelling. of the fill.
On the other hand, the advantage of In time, you will learn how skills and
being among these practitioners was the experience in dentistry gives the oral-fa-
pioneering spirit they possessed. They cial augmenter a competitive edge in the
were able to advance in the new cosmet- evolving practice of cosmetic dentistry.
ic arena because of the exuberant energy There are undoubtedly different ways of
they brought to the art and science of aug- placing fillers and Botox than those that
mentation. have been addressed in this book. In ad-
In truth, success in the field of oral- dition, new materials will likely be intro-
duced after you read this book. However,
facial augmentation lies somewhere be-
tween these two camps. Indeed, there no matter what the method or the mate-
should be a time-honored respect and re- rial utilized, the foundation for “the art of
gard for experience. But the reality is that the fill” will remain the same.
the materials and methods of augmenting
lips and the face are changing every year,
The Business of Oral-
and we need pioneers to pave the way for Facial Augmentation
developing new and innovative treatment
possibilities. Incorporating Fillers and Botox
into your Cosmetic Practice
Is Augmentation for You?
We are fortunate to participate in the
You may decide to incorporate fillers
practice of dentistry today. With the ad-
into your practice and or Botox (botuli-
vent of technologically advanced treat-
num toxin treatment). You may do limited
ments and techniques, we are no longer
procedures on select patients, or you may
confined to just pulling teeth. Today, we
advertise your flourishing oral-facial aug-
are truly in a position to claim the title of
mentation practice on highway billboard
oral-facial experts.
signs. The choice will be yours.
The standard of dental cosmetic work
However, if you do decide to add oral-
is constantly improving. In contemporary
facial augmentation to your dental prac-
practice, we are treating the teeth, mouth,
tice, Vermilion Dollar Lips will guide you
and lips as they relate to the entire face.
through a precise sequence of stages that
We are given opportunities to practice our
together comprise the educational triad
professional skills daily. Because of this,
called “The Art of the Fill.” The book has
we are constantly remodeling and im-
been laid out in a step-by-step format that
proving our treatment methodologies.
will provide you, my fellow dentists, ex-
When considering the addition of oral-
pertise and insights into oral-facial aug-
facial augmentation to your practice, take
mentation from the viewpoint of one of
advantage of your current patient base.
your peers, who has built a successful and
There may be quite a few of your patients
profitable oral-facial augmentation prac-
that have or are undergoing lip augmen-
tice.
tation. Tap into that resource. Ask your
In essence, the Vermilion Dollar Lips’ patients about their filler and Botox expe-
instructional format will introduce and
rience. Was it painful? Did they achieve walls of your practice is especially critical
the results they wanted? If not, why? in aesthetic and cosmetic dentistry, par-
After reading this book, you will ticularly when you begin to practice oral-
see the lip and perioral area in a whole facial augmentation.
new way, and you will most likely be If you do not have a marketing repre-
able to immediately identify those pa- sentative, consider consulting with vari-
tients who have undergone lip or facial ous firms within your community for
augmentation. their expertise on the most wide-reaching
It is also helpful to study your com- and cost-efficient way to promote your
munity; I think you will be surprised at practice and your new oral-facial aug-
the vast number of practitioners—from mentation services. I am certain that they
nurses to physicians—who are augment- will agree that it is imperative to develop
ing lips and injecting Botox. a thorough understanding of the area in
which you will be marketing your prac-
Always consider the unique experience tice.
and training you have as an oral expert
and seize the opportunity to add oral-fa- As dentists, we are isolated in a “bub-
cial augmentation to your practice. ble” of dental professionals, and our
knowledge of advertising and marketing
Internal Marketing is admittedly limited. In order to succeed
In planning treatment for new pain building our practices or introducing
tients, I highly recommend including a new services, we must rely on the exper-
lip and perioral augmentation presenta- tise of local marketing professionals who
tion in your initial evaluation. It is also have a thorough knowledge and extensive
important to educate all of your patients understanding of the wants and needs of
about the advantages of having their lip consumers within the communities they
augmentation performed by you, the cos- serve.
metic dentist. Hang posters and artwork In my own practice, I have found that
that promote lip augmentation aware- hosting local seminars that are targeted to
ness in your office. You may even wish to specific groups has been a very successful
consider offering a free augmentation to means of promoting oral-facial augmen-
patients who have undergone substantial tation services.
dental work.
There is no doubt that women within
The patient’s experience and the num- your community will make up the majori-
ber of referrals he or she ultimately pro- ty of your oral-facial augmentation patient
vides will greatly impact patient reten- base. Research various women’s groups
tion and the success of your oral-facial in your area and approach their program
augmentation practice. After all, most planners about offering their group mem-
lip fillers you will inject are resorbent. As bers a free seminar. This seminar may
professionals, we want every patient’s ex- include a demonstration of an augmen-
perience to be a positive one, so he or she tation procedure. You may even wish to
returns for reaugmentation in 6 months. consider giving a free lip augmentation to
External Marketing one of their members as an added incen-
Promoting your skills outside of the tive to booking a seminar.
Remember: the cosmetic world is

one of discretionary dollars. This
means you will be competing with
other doctors, procedures, and lux-
ury items from which local consum-
ers can choose.
Your First Seminar

Setting up your first seminar can
be a stressful undertaking. I encour-
age you to follow the guidelines I
have provided, customizing and
adapting your own seminars to fit
the needs of the members of your
community.
Before you begin advertising your
seminars, invite a group of your
friends whom you can trust to
be honest and critical to a “dress
rehearsal” of your presentation.
You may even want to film your
presentation for your own self-
evaluation.
The following are some helpful
tips on hosting a seminar that is
both educational and engaging:
Identify your audience and develop
your presentation accordingly.
Involve your audience. In or-
der for your presentation to be a
success, audience participation is a
must. There are various ways to pro-
mote audience involvement. For ex-
ample, I conduct a “Lip Quiz” by
projecting slides of celebrities on
the wall at the opening of the sem-
inar. The initial photographs are
close-up shots of famous mouths
and lips. After asking the audi-
ence to identify who each smile
belongs to, I show a full facial shot
of the celebrity. This is an easy, ef-
fective, and entertaining way to
involve the seminar attendees in your you greater flexibility in circulating

presentation. throughout the room and connecting
Offer a gift. You may wish to consid- with other members and their guests.
er offering a syringe of cross-linked The Advantages of Presenting a Live
hyaluronic acid (HA) treatment as a Demonstration
giveaway or perhaps a free bleaching Including a live demonstration of oral-
that you will perform at your office. facial augmentation techniques during
The gift you give could also be given your seminar gives audience members an
as a prize for a lucky “Lip Quiz par- opportunity to witness firsthand the pain-
ticipant.” less procedure of augmentation, the tech-
Assemble your information in a Pow- niques used to fill certain areas, and the
erPoint presentation, with approxi- effect of pre-op and post-op fills.
mately 40 slides. Be sure to select a patient that needs
Include before and after pictures of limited work so that the results of the
oral-facial augmentation patients in demonstration are immediately visible.
your presentation. Select a patient that needs filler aug-
mentation. With fillers, one sees an imme-
Plan a presentation that is approximately
diate result. Treatment with botulinum
50 minutes in length. Limit your intro-
toxin will take days to produce results.
ductory remarks and PowerPoint presen-
tation to 20 minutes to allow 30 minutes Pick a particular facial area, such as the
to perform a live demonstration. lips, the nasolabial fold, or the commis-
sures. Due to time constraints, you will
Allow ample time for audience ques-
only want to choose one area, as one can-
tions. This is the time to relax and fill
not justifiably do a good job on a patient’s
in any voids in your presentation.
full face in 20 minutes.
Place a reasonable limit to this por-
tion of your presentation, to allow If possible, block the audience’s view
yourself enough time to circulate the as you administer anesthesia to the pa-
room. Keep in mind that you are not a tient. If you elect to do it in full view of all
guest speaker at a dental conference. participants, do your best to obstruct view
You want the audience to become part of the needle and its insertion point by ro-
of your practice, so it is critical to also tating the patient in a direction that allows
allow time to network and connect attendees only to see the deposition of the
with attendees. anesthetic.
Ask a representative of your staff to Try not to linger when administering
attend the seminar with you. While the local anesthetic; the dental-aspirating
you network with attendees, your carpule syringe is rather ominous in ap-
staff member should stay by your pearance. Quick and purposeful move-
side and carry an appointment book ment is always desired in order to ensure
in which he or she can schedule pa- patient comfort.
tients who are interested in pursuing However, you don’t need to hesitate
a personal consult. This will allow you in showing the audience the needle or
to follow up with interested attendees the augmenting syringe. The augmenting
in a definitive way, while allowing
syringe is usually a 30 G ½ inch needle, you do not know the answer to a partic-
which is not very intimidating. ular question. Offer to research the topic
Keep in mind that most of the audience and contact the audience member after
is probably familiar with dental blocks, so the seminar with the appropriate answer.
be sure to refer to them as dental blocks. In the cosmetic industry, there is a great
In fact, using proper terminology through- deal of misinformation and widespread
out your presentation will demonstrate dissemination of “propaganda” that pro-
your expertise and inspire questions from vides little or no service to the public. Al-
attendees who wish to know more about ways limit your opinions to your area of
the procedure. expertise, and when you share them, be
Finally, always leave the audience certain to reveal the sources from which
you acquired your facts and statistics.
wanting more.
Key Things to Remember During Marketing Your Cosmetic Lip

your Presentation/Seminar and Perioral Practice
The decision to hire an external mar-
Take Advantage of Today’s Technology
keting professional or firm to handle the
When I conduct a live demonstration, successful promotion of a cosmetic prac-
I use a video camera feed on the model’s tice is a choice that most practitioners will
lips. The live images are projected onto a eventually face. Many practitioners will
screen in the front of the room to allow be satisfied with the results of internal
the audience to watch the demonstra- marketing, while others will want to im-
tion from their seats, without the need to pact their communities in a more nontra-
crowd around me. ditional and widespread manner.
Know Your Stuff If you decide to hire a marketing agen-
During a live demonstration, you will cy, keep in mind these key points:
have the opportunity to answer ques-
tions and communicate with the audience ake sure the marketing professionals
M
about the different techniques you are em- you hire understand your vision and
ploying. Compared to most professionals, agree to incorporate it in all of their
as a dentist, you are already an authority promotional efforts.
on the oral-facial area. You will be asked Ask the professionals you hire to cre-
some unusual questions, and you must ate a comprehensive 3- to 6-month
be prepared to answer them. Be sure to marketing plan.
respond to each question as directly and
Firmly request a written contract that
completely as possible.
clearly indicates that all the work the
As dental professionals, we are not marketing professional or firm per-
politicians; so when a controversial sub- forms on your behalf is exclusively
ject is broached, it is best to refer to the re- your property and that you have full
sults of recent research studies and allow copyright and access to the work, even
the individual who asked the question(s) if and when you terminate your rela-
to consider your response and form his/ tionship with the firm.
her own opinion.
Remember, marketing professionals
It is also perfectly okay to admit that
are in business to meet your promo- when patients have had cosmetic work
tional needs and should use their ex- that was performed by a practitioner out-
pertise to professionally deliver the side of your practice.
results that you have established for
When the hygienist is trained to inter-
your practice. In essence, they need
rogate the patient subtly and politely by
you more than you need them. Conse-
asking the questions that follow, informa-
quently, any agreement—whether ver-
tion can be gathered without offending
bal or written—should have a clearly
any of the treating doctors:
defined exit strategy available to you
if the marketing firm does not perform Have you ever heard of facial fillers?
as promised. Do you know of the use of Botox in lip
Educating & Training a Competent Staff rejuvenation?
Having competent and educated staff How would you describe the experience?
is critical in all phases of integrating fill- Who performed the procedure? Was
ers into your practice. They will be instru- it a dermatologist, a plastic surgeon, a
mental in motivating your patients to elect nurse, or another medical
oral-facial augmentation and in convey- practitioner?
ing a sense of confidence in patients who Did you experience any pain during
undergo the procedure. the procedure? If so, did the doctor
It is also extremely important to edu- use anesthesia? What type of anesthe-
cate and train your key adjunctive per- sia was used?
sonnel in every aspect of your practice- Were you pleased with the results? If
specific augmentation philosophy. Give not, what would you do differently
them the knowledge and tools they need the next time the procedure was per-
to provide your patients with current informed?
formation on the latest fillers and those Armed with this knowledge, your hygien-
popular in the past. Expose them to your ist can become instrumental in identifying
specialized techniques in lip and face aug- potential oral-facial augmentation candidates
mentation by letting them observe proce- and assisting you in the growth of your filler
dures. Finally, invite members of your practice.
oral-facial augmentation team to join you
in attending continuing education classes Many of your hygienists may already
that focus on fillers and techniques. (Most have been exposed to lip fillers in their
seminars will allow the paying doctor to hygiene recall appointments, especially if
bring a guest or staff members either free they are conducting comprehensive oral/
of charge or at a discounted rate). soft tissue exams. They may feel palpable
lumps or bumps in the patient’s lips and/
Allies Within Your Practice or oral-facial area. Without proper train-
Your hygienist is your best ally when ing, however, they will be unable to iden-
introducing new materials and skills to tify or recognize what they are.
your patients that you as a dentist have
For this reason, it is critical to introduce
acquired and employed. Frequently, a hy-
your hygiene staff to facial fillers, so that
gienist is also privy to information that
as they conduct their exams, they too can
the patient does not readily divulge to the
be aware of currently used fillers and their
dentist. This often holds true most often
impact on the oral-facial area. to other members of your staff can leave
you vulnerable in several ways. So keep
Delegation of Duties
the following in mind:
Fillers and Botox are cosmetic enhance-
ment materials. Due to the fact that they Experience the transformation with
are cosmetic in nature, many medical and your patient. This is absolutely im-
dental professionals are seizing the op- perative. By being present during the
portunities now available in the market- procedure, you have the ability and
place to develop an adjunct to their exist- expertise to pick up on the nuances of
ing practices. their expressions that they may be too
embarrassed to share with the nurse
In many states, nurse practitioners and or other member of your staff who
physician assistants are able to place fill- was responsible for taking their medi-
ers and/or Botox when working under cal information. You will also lose
the guidance or direction of a physician. valuable contact and interaction with
Nevertheless, be aware that delegat- that patient. An oral-facial augmenta-
ing this sensitive part of your practice tion specialist is remiss—and clearly
unprofessional—if he or she merely being performed under your license.

reads a patient’s post-op notes that Ultimately, you are solely responsible
were compiled by a nurse after the for each of your patients.
procedure.
Medical/Legal Issues
If you are not present before, dur- Since the explosion of facial fillers and
ing or after the procedure, you don’t Botox onto the cosmetic market, there
know what information has been has been little public and professional
communicated to the patient in your information on the regulation of the ma-
operating room. I have experienced terial. Because the cosmetic industry is
this firsthand in my own practice. so lucrative, everyone seems to be par-
On several occasions, I have had the ticipating in fillers. Consequently, stories
misfortune of walking into an operat- of unqualified, unlicensed persons plac-
ing room and cringing at what I just ing fillers and Botox flood the headlines
overheard a member of my staff say throughout the nation.
to one of my patients. (One also has
to wonder how much misinformation With the introduction of nonanimal
may have been communicated prior stabilized hyaluronic acid into the filler
to my arrival!) I then have to retract market, the morbidity, pretesting and
any incorrect statements and reassure technical applications have become very
the patient that what he or she just forgiving. Every state, however, is differ-
heard was untrue, which does not re- ent. Therefore, each practitioner should
flect well on either me or my practice. consult their local and state laws of prac-
For the patient, inaccurate commu- tice.
nication can lead to unnecessary ap-
prehension and increased uncertainty
about the outcome of the procedure.
This can easily be avoided by delegat-
ing responsibilities wisely and only to
members of your staff who have been
thoroughly trained in oral-facial aug-
mentation.
You cannot further your skills or
training if you are not personally in-
volved in each step of the augmenting
procedure. By giving anything less
than your full attention to this evolv-
ing division of your practice, you are
performing a disservice, not only to
yourself, but also to your patients.
Simply put, if you cannot or do not
become intimately involved in grow-
ing your oral-facial augmentation
practice, how can you expect to del-
egate and regulate it? It is, after all,
In 2006, the Joint American Society of Provider Qualifications

Plastic Surgeons (ASPS) and the Ameri- The administration of injectable fillers
can Society for Aesthetic Plastic Surgery is considered a medical procedure and,
(ASAPS) Advisory Board published a as such, is subject to the same precautions
position paper on injectable fillers and of any medical procedure. Similarly, the
legal/regulatory issues.5 Fillers must be supervision of non-physician personnel
categorized as a drug or device. A drug is regulated by state and local law. The
is any healthcare product that achieves area of delegated duties and supervision
its primary intended purpose by chemi- guidelines, however, varies greatly from
cal action or by metabolic reaction in state to state.
the body. Conversely, a medical device
Although the dental practitioner is de-
does not achieve its primary intended
fined as an oral-facial expert in the Dental
purpose by chemical action or by meta-
Practice Act, to date, there have been no
bolic reaction. Botulinum toxin Type A
position papers on fillers in the current
(BTX-A), for example, is a drug, while
dental literature nor has any regulatory
artificial skin injectable fillers such as
board been established.
collagen and hyaluronic acid are classi-
fied as devices. Today, there are thousands of dentists
using injectable fillers in conjunction with
FDA Guidelines & Regulations their practices of dentistry today and the
FDA Labeling numbers are increasing. Thus, a position
All too often it seems as though cos- paper and a dental council are needed in
metic materials and drugs are pushed this area of cosmetic practice.
into mainstream practice before ade- Due to the ambiguity of oral-facial fill-
quate long-term testing on their safety ers in the dental field, it is my recommen-
and efficacy are known. These materials dation that dentists practicing oral-facial
are given FDA approval for a specific augmentation should not delegate filling
use and when the material or drug is in to anyone else under their employment or
the hands of the practitioner, other uses supervision.
become evident. An example of this is
Sculptra, which was put on the FDA ap- The Psychology of the Lips
proval fast track for HIV-related facial
What human features express more
lipoatrophy.6 Sculptra is now being used
emotion than the mouth and the eyes, ei-
as cosmetic filler for the face of non-HIV
ther alone or as one entity? Even Darwin
infected patients. Through this type of
developed a theory on the psychological/
phenomenon, the term “off-label” has
emotional relevance of a smile. The Dar-
evolved. FDA-labeled drugs or devices
winian Theory of Antithesis defines the
will state:
smile as the direct opposite of a frown.
1. Approved for a specific use: labeled The high curvature of the smile and the
and approved by the FDA for market- depressed corners of the mouth are con-
ing, which also allows for off-label use). veyed as opposite presentations, possibly
2. Non-approved: not approved by the as a direct action of the nervous system.7
FDA for any purpose and, therefore, in- Yet there is far more in a smile that
eligible for off-label use. transcends all words, all gestures, and
General Guidelines for Use of Filler Devices and drugs

1. Usage of any non-approved implant devices is a violation of the Federal Food, Drug
& Cosmetic (FD&C) Act, which may lead to the invalidation of the practitioner’s profes-
sional liability insurance coverage, as well as criminal penalties and action by regula-
tory agencies.
2. Two circumstances that allow a practitioner access to non-approved drugs and
devices include:
— Use in approved clinical studies, and
— Use in serious, life-threatening emergencies, if the product is under
clinical investigation.
3. When a practitioner uses an FDA-approved drug for off-label, the patient must be
informed of the FDA-approved use, must understand that treatment on any other area
specified is off-label use, and must accept the treatment rationale. For example, Resty-
lane is FDA-approved for nasolabial folds, not lips, but it is commonly used in cosmetic
lip augmentation.
4. It is illegal for a practitioner to commercially advertise any non-approved or off-label
use filler; only FDA-approved uses may be commercially advertised.
5. The position of the American Society of Plastic Surgeons (ASPS) and the American
Society for Aesthetic Plastic Surgery (ASAPS) is that administration of drugs or devices
outside the clinical setting may produce:
— Inadequate patient selection
— Possible peer pressure that leads an individual to consent to treatment
— Providers that are not trained to administer the injectable filler or who are
unqualified to assess or treat complications
— Lack of control over dosage
— Inadequate post-treatment supervision
— The possibility of mixing alcohol and/or street drugs with injectable fillers or
medication used to control post-treatment pain and other side effects.
6. Reimportation of FDA-approved drugs/products is illegal. Currently, only manufactur-
ers are able to reimport their drugs/devices.
7. Counterfeit drugs that are copies of name devices are prohibited.
8. The ASPS and ASAPS’s Joint Code of Ethics states that a member may be subject to
disciplinary action if administration of an injectable or filler is raffled off in a fund-
raiser, contest, or any other promotional event.
The following two Web sites, created by the ASAPS, are a resource where practitioners can find
current information on fillers and other relevant and applicable information: http://www.plasticsurgery.
org and http://www.surgery.org. Unfortunately, the ASAPS does not incorporate the dental profession
into their guidelines. They have published no opinion regarding the injection of fillers in the oral-facial
area within the dental profession.
signs. As dentists, we are accustomed to share your experience with your patients.
making life-changing alterations in the Obviously you have earned their trust;
appearances of our patients through cos- now share your enthusiasm about your
metic enhancements. It is not unusual new specialty. You may be surprised how
to see patients who have had a full set willing your patients will be to enhance
of anterior veneers return to our offices their lips through augmentation proce-
wearing brighter lipstick, a new hairstyle, dures provided by a qualified and trusted
and exuding a higher level of confidence dental practitioner.
and self-esteem. Augmenting the lips is a
Minimizing Patient Anxiety, Maximizing
natural extension of a dentist’s expertise
and should be treated with the same sen- Patient Comfort
sitivity one would use in the discussion of As with any cosmetic practice, the doc-
other appearance-altering treatments. tor will treat a certain percentage of pa-
tients that may present with anxiety-re-
When suggesting lip enhancement to lated manifestations in conjunction with
a patient, try not to critique their current lip augmentation. Dentists are certainly
lip appearance. Instead, concentrate on no strangers to anxiety in the dental chair.
the potential advantages of lip augmen- Approaching a patient’s face with filler
tation and cosmetic dental work. Explain needles during oral-facial augmentation
the knowledge and training a dentist has can elicit a strong anxiety response. Com-
in the oral-facial area and emphasize that prehensive prescreening and complete
dental practitioners have expertise that disclosure of risks and benefits prior to
extends beyond teeth. the procedure, however, can significantly
Attend continuing education classes reduce heightened stress.8 Anxiety disor-
on lips and augmentation treatments and
ders associated with oral-facial augmen- by characteristic behavior that includes

tation may range from a transient bout markedly excessive concern when even
of trepidation to a full-scale case of body the slightest physical anomaly is present.
dysmorphic disorder (BDD). Since the evolution of cosmetic den-
tistry, few articles have been published
Body Dysmorphic Disorder: An Overview
on BDD. In the field of cosmetic surgery,
The Diagnostic and Statistical Manual BDD is prevalent in 6 to 15 percent of pa-
of Mental Disorders (DSM-IV) defines tients who present for cosmetic work.10,11
BDD as a preoccupation with a defect Studies have shown that women and men
in appearance that is either imagined or are equally affected.12 The average age of
slight, which leads to clinically signifi- onset of BDD ranges between 15 and 30
cant distress or impairment in social, oc- years, with most cases occurring when pa-
cupational, or other important areas of tients are in their late twenties.13
functioning. Additionally, the preoccupa-
tion cannot be attributed to another men- The dentist needs to be aware of the
tal disorder, such as dissatisfaction with clinical presentation of patients. How
body shape and size, as in anorexia ner- does one determine if a patient has BDD
vosa.9 In all likelihood, patients suffering tendencies? Obviously, it is not our spe-
from BDD will eventually find their way cialty to diagnose these patients, yet they
to your practice, and you will need to present to us more frequently as a mani-
know how to effectively deal with them. festation of their condition. Patients pre-
senting with BDD usually have dissat-
Generally, the work you will be per- isfaction with specific features of their
forming as a cosmetic dentist is limited to appearance.14,15 BDD patients manifest
the perioral area and dentition. Accord- this specific response in multiple anatom-
ingly, you will draw patients to your prac- ical areas. In fact, 80% of BDD patients
tice that may have had significant cosmet- are dissatisfied with more than one area
ic work done to other areas of their face. of their anatomy, with an average of three
When reviewing their medical history, a to four physical features causing distress
red flag should go up immediately when and exaggerated concern.16
you encounter patients who have had nu-
merous cosmetic procedures in the past, Due to the multiple anatomical areas
as well as patients who have had a sig- with which BDD patients are obsessed,
nificant number of revisions on cosmetic they typically visit a broad spectrum of
work previously performed. Patients who specialists for cosmetic correction, often
complain of long, disappointing histories requesting inappropriate or ineffective
with previous augmentation procedures treatment and medications. This can lead
also need to be assessed and evaluated a significant number of patients to your
carefully to determine if it is at all possible office when you incorporate oral-facial
to fulfill what may be extremely unrealis- fillers into your cosmetic practice.
17
tic expectations. Identifying, Managing and Referring BDD

While there are many types of psycho- Patients
logical disorders that can impact a patient Diagnosing BDD patients is difficult
before, during, and after cosmetic pro- due to the secretive and compulsive nature
cedures, BDD is both the most common of the disorder.18 There are, however, sev-
and most severe condition. BDD is noted eral screening tools available to diagnose
this disorder, such as the Body Dysmor- It is true that refusing to treat a patient
phic Disorder Questionnaire (BDDQ),19 can be problematic. However, if the art of
which was developed for the psychiatric augmentation becomes a passion in your
specialist, but may not be practical for life—like it is in mine—it is imperative to
clinical use. constantly analyze and evaluate your mo-
The dentist should observe and col- tives, goals, and performance. Your skill
lect information on the possible presence level, experience, and innate ability to un-
of BDD during a patient’s initial cosmetic derstand the limitations of materials and
consult for augmentation. The entire office techniques will serve as your compass in
staff should also play a supportive role in making appropriate decisions.
assessing patients. It is not unusual for a Keep in mind that patients that exhibit
patient to express or manifest significant symptoms of BDD or other psychologi-
BDD behavioral indications to support cal disorders can thrust the inexperienced
staff when the dentist is not present. augmenter into situations that may have
It is generally recommended that all legal and emotional ramifications for both
cosmetic augmentation procedures be the patient and the doctor.
avoided on patients whom the dentist Listen to your inner voice, choose wise-
either observes or receives information ly, and perform the art and science of aug-
of any type of psychological disorder. mentation for the benefit of each patient
There is a high likelihood that these pa- and the community.
tients will not benefit from any cosmetic
alteration.20,21

Psychiatric counseling is the initial
treatment of choice for patients with BDD
tendencies or other psychological disor-
ders. These patients should be referred
to a cognitive behavioral therapist before
initiating any cosmetic procedures.
Recommending a psychological evalu-
ation to one of your patients can be quite
tricky. It may be helpful to focus on the im-
pairment and resulting distress that their
concerns cause, as well as its negative im-
pact on the quality of their life. Reassuring
patients that they look fine, attempting to
talk them out of cosmetic treatment, and
discounting their desires usually is inef-
fective in this patient population.12
As a cosmetic augmenter, deciding
which patients you will treat is ultimately
your decision. However, I believe that you
truly master the art and science of the fill
when you are discernibly able to say “no.”
TIPS
Using various facial calipers before and after augmentation can

help guide your treatment planning. When placed near the lips and
photographed, you can enroll your patient into proper lip proportions
and what to expect as a realistic end result.
Chapter 1 Review
STUDY Points
Art of the fill and supporting basis
Relationship between marketing and cosmetic lip and perioral augmentation
Difference between internal and external marketing
Medical/legal responsibilities of injectable fillers and botulinum toxin
Psychological issues with oral-facial cosmetics
STUDY Questions
1) What is the most important step you must complete before launching/developing a
marketing plan?
2) From a medical/legal perspective, how are fillers and botulinum toxin defined and
how are they classified?
3) Who is legally allowed to perform treatment with injectable fillers and/or botulinum
toxin?
4) What does “off-label” mean and how does it pertain to injectable fillers and
botulinum toxin?
5) What is BDD and what implication(s) does it pose within the oral-facial augmentation
arena?
2
Chapter 2
The Canvas
Nemo liber est qui copori servit.
No one is free who is a slave to his body.
Chapter 2 The Canvas 24
Dr. Gordon’s Lip And Perioral Classification

Anatomy
Oral-Facial Aging
Through my own personal journey of learning lip and perioral augmentation, I have been
exposed to many ideas, philosophies, and techniques. Early on, I became frustrated at
the lack of structured teaching in the art and science of oral-facial augmentation.
Due to the diversity of practitioners, the art and science transcends through many
specialties. Dentists, plastic surgeons, dermatologists, nurse practitioners, and
nurses are a few of the licensed individuals practicing oral-facial augmenta-
tion. In addition, there is a significant subculture of individuals performing
augmentations in America that aren’t licensed to perform oral-facial aug-
mentation, yet they continue to practice to this day. Due to this disparity, it
is obvious a uniformed body of practitioners must evolve, and with them,
a common language to usher the art and science of oral-facial augmenta-
tion into the future.
In the new and evolving field of lip and perioral augmentation, we as aug-
menters require a classification system, a language unique to our work, one
in which to communicate and record our efforts for ourselves and the pro-
fessional community of augmenters. When a common language relating to
the architecture of the lips and perioral area (including skeletal, muscular
and soft tissue) is realized, we maximize our potential to become simply
better in this artistic science. The artist must have complete knowledge
of the construction of their canvas and interaction of various mediums
as they are applied; this is essential for the cosmetic augmenter in rela-
tionship to the oral-facial canvas. Having an intimate understanding of
what contributes to the lips and perioral structure is vital in understanding
similarities that make them up and how we can enhance these features, thus
creating our best cosmetic results. It is vital we have a grasp on the process
of aging and how it affects the oral-facial arena. Through this understand-
ing, we are able to reverse the signs of aging. The goal of this chapter is to
address these issues and intertwine then into the science and art of lip and
perioral augmentation.
Oral-facial amount of fill the planes will facilitate. The

two upper lateral planes are cone shaped,
Classification with the apex at the corners of the mouth
and the base abutting the middle plane.
PlaneS of the lips The middle plane of the upper lip is semi-
The lips are formed by five planes. circular and tapers toward the opening of
Three planes form the upper lip, and two the mouth. The lower lip is formed by two
planes form the lower lip. Understanding teardrop shapes that taper toward the cor-
these planes gives the cosmetic augment- ner of the mouth.
er insight into location, direction, and the
SEGMENTS
Vermilion Border (Zone A)
Body (Zone B)
Wet Dry (Zone C)

.618
1
C
B
SEGMENT A
(by plane with body and tail)
Body Tail
Segment
Light
2 3 A
B
C
SEGMENTS B
(lateral view divided by planes) 4
A ZONES
5
Segments (lateral view)
FIGURE 2.1
Planes and Segments of the Lips
Lips are as diverse as the human face. cesses of the face in utero. Incomplete
While no two sets of lips are exactly the union of the medial and lateral nasal pro-
same, all lips have these five structural cesses can lead to cleft lip,22 which has a
planes in common. It is the different com- reported prevalence of 1.00 to 1.82 per
binations of these planes that lead to the 1,000 live births. You can see these planes
unique appearance of each individual’s with the naked eye in patients who suffer
lips. These five planes are created by the from this condition as a result of an iso-
joining of the developmental facial pro- lated defect or hereditary syndromes.
Here are the 5 planes superimposed on

the patient’s lips. Remember these planes
when augmenting and keep them in your
mind’s eye during aesthetic reconstruction or
augmentation of a patient’s lips. For successful
and aesthetically pleasing augmentation,
use these 5 planes as your roadmap.
FIGURE 2.3
As illustrated above, the five planes
of the lips begin to develop in utero.
Incomplete union of the planes leads
to cleft lip and/or palette.
FIGURE 2.2
Static
This is a static representations of the lip and perioral tissue. Notice this patient exhibits incompetent
lips.
Static Vs. Kinetic amine our patients in both a kinetic and

As dentists we restore to a tooth-to- static position. This can be accomplished
tooth or a bone-to-bone relationship which by asking the patient to smile and frown.
is both recordable and repeatable. An ex- A simple trick to assist you in establishing
ample of this is “Centric Relation.” Even the relative static position of a patient’s
in the edentulous patient, we can restore lips is to ask him or her to utter the let-
to a certain fixed skeletal relationship.23,24 ter “M.” The position of the lips after this
With the soft tissue of the face, however, consonant is spoken is considered the
we aren’t as fortunate in predicting a re- static position.
peatable relationship. The oral-facial lines Dentists naturally ask patients to smile
and folds change on a consistent basis. in an effort to evaluate the dentition. In
The entire make of the face changes oral-facial augmentation, it is important to
with age, genetics, and environment. The focus your attention on the nasolabial (or
face and, in particular, the lips, can be mental fold) as the patient smiles. If these
viewed in either a static or kinetic state. areas are augmented, it is imperative to
As cosmetic augmenters, understanding consider how augmentation will affect the
the difference between these two states is kinetic fold of the tissue. Augmenting the
essential in planning treatment for our pa- lips in a static position, without viewing
tients. the smile line and incisal appearance, can
lead to overfilling of the lips and produce
During an examination, we must ex- an unpleasant appearance.
In addition the evaluation of perioral der to the lower border of the columella
lines (rhytids) must be evaluated in static nasi of the nose. This zone is wider due to
and kinetic movements for purposes of the philtrum that is, at times, augmented
botulinum toxin therapy; more on this in in this zone. Zone B (ZB) is the area mid-
Chapter 7, “Simply Botox.” point between the inferior border of the

It’s difficult for one to quantify or qual- vermilion border (ZA) and the superior
ify the amount of filler needed when eval- border of Zone C. Zone C (ZC) is the area
uating the relationship between kinetic from the inferior border of Zone B to the
and static tissue. It is in practicing and lower transitional zone (wet/dry line) lip.
perfecting the art of the fill that this mea- Most shaping will be performed in Zone
surement is incorporated into the aug- A and volume will be added in Zone B.
mentation process and becomes easier to Zone C is a label in order to complete the
determine as your experience grows.25,26 mapping of the extra oral presentation of
the lips. Under no circumstances do we
Maxillary Labial augment Zone C. Instead Zone C is used
Zone A (ZA) extends from and includes for marking pathology, injuries, and de-
the superior aspect of the vermilion bor- scribing the relationship of the bottom of
Kinetic
Even as the lip and perioral tissue is stretched around the skeletal and dental anatomy, the
relationship of the ideal proportions still remains. Overfilling the lips may not present as noticeable
in the static position, yet when the patient smiles, the overfill may become more evident as the
filler material is displaced over the dental profile.
Zones and Segments of the Lips
1 2 3
6 5 4
If we analyze the natural planes of the lips and how they are divided, we can divide them into
six segments for lip classification.
the lip to the dentition. Remember, the three parts are divided between the cone
zones curve with the lips in a bow shape and tapered semi-bucket shape of the
and end at the commissure of the lips. philtrum. The lower lips are also segment-
ed into three parts that correspond to the
Mandibular Labial
planes that make up the lip. The lower lip
Zone C extends from the transitional is composed of a teardrop shape that has
zone (wet/dry line) to the border of Zone a ball and a tail. The segments are divided
B. Zone B extends from the middle of the at the ball-and-tail junction.
lip (border of ZB) to the vermilion border
of the lower lip. Zone A extends from— In order to define a constant on which
and includes—the vermilion border and the lips are draped, we use the dentition
the cleft superior to the metal protuber- as a reference point. To assess a patient’s
ance of the chin. segments, you have to have them open
their mouths a little to see the maxillary
Zone A will have fill room, but the ma- dentition. The segments are simply divid-
jority of fill will be performed in Zone B. ed by drawing a line down the lips later-
Zone C is demarcated for completion of ally to the maxillary central incisors (#8,
the classification area. There will be no #9). Upper lip and Lower lip: Segment 1
augmentation in Zone C. Since there is is the area extending from thelateral of
no distinct vermilion border of the lower #8 to the corner of the mouth. Segment
lip like the upper lip, sculpting of Zone 2 is from the lateral of #8 to the lateral of
A on the lower lip will usually never be #9. Segment 3 extends from the distal of
performed. Remember that Zone A of the #9 to the corner of the mouth. Lower lip:
lower lip is a gradual transition from ver- Segment 4 extends from the corner of the
milion tissue of the lips to the keratinized mouth to the line drawn down from the
epithelium of the oral-facial area. lateral of #9. Segment 5 extends from the
Segments of the Lips (Static) line drawn down from the distal lateral of
#9 to the distal lateral of #8. Segment 6 ex-
Lips can be divided into six segments, tends from the line of the distal lateral of
which correspond to the planes that con- #8 to the corner of the mouth.
stitute the lips. The upper lip is segmented
into three parts which correspond to the LARS: Lip Length, Age, Race & Sex
planes that make up the upper lip. The As a cosmetic/aesthetic augmenter, you
Zones of the Lips

Classifying the lips into specific zones enables the cosmetic augmenter to:
— Assess the lips for documentation, whether it is for pre- or post-augmentation
or clinical notes
— Relate proportions in the static and kinetic motions of the lips
— Provide a common language for professional communication
— Facilitate teaching methods and reproduction of augmentation techniques
— Ensure repeatable results or corrective post-treatment
Outer Ring: Nasolabial fold, Mental fold, Marionette Lines, Jowl folds
Inner Ring: Commissure, Lips
Maxillary Lip Maxillary Lip Exposure of Exposure of

Table 2.1 Classification Upper Length Upper Central Lower Central
Maxillary Lip (mm) Incisor Incisor
Length with Relation (mm) (mm)
to Anterior Tooth
Exposure27
Short 10-15 3.92 0.64
Medium 16-20 3.44 0.77
Medium 21-25 2.18 0.98
Long 26-30 1.95 1.95
possess the understanding that there are the beauty our patients possess, not alter
many factors that impact the presentation them to subscribe to intercultural or racial
of the oral-facial area. We can categorize a stereotypes. Nevertheless studies support
majority of these into four factors identi- that there are marked differences between
fied by the acronym “LARS”: lip length, the lips of each race. For example the lips
age, race and sex.28 of African-Americans have a greater inci-
sor inclination and a more protrusive soft
Lip Length tissue profile. A more protrusive profile
The length of the upper lip ranges from is more accepted in the African-American
10 to 36 mm. The longer the upper lip, the population.29-31
less maxillary dentition is visible and the
Sex
more mandibular dentition is shown in
kinetic movement. Usually when we observe an infant, we
are unable to identify whether they are
Age male or female. The influence of sex hor-
As we age, the lips are drawn down mones on the contour of bodies, facial fea-
and out over the skeletal and dental frame- tures, and lips is no different. The male’s
work. The intrinsic and extrinsic effects of face is more rugged and bolder. The fe-
aging are covered in greater detail in the male’s appearance is gentler and rounder.
aging section of this chapter (pg. 49). The subtle differences translate to the lips
Race and face and will be explored further later
A person’s bony structure varies across in the book. Generally males have a lon-
all racial identities. The skeletal/dental ger maxillary lip than females. The aver-
structure is the scaffolding for the oral- age maxillary tooth display is 1.91 mm for
facial region; and with the addition of men and 3.40 mm for women.28
musculature and overlying skin, we see
marked differences in the physical makeup SEGMENTS OF LIPS (KINETIC)
of different races. Facial augmenters must The canine teeth are the cornerstone
realize these differences and appreciate for the arch form in the maxilla and man-
the harmony that lies between the racial dible (Fig. 2). The lip arch form lays itself
spectrum. Our main focus is to enhance over the dental arch form. The lip arch
form presents as a “U,” “V,” or square “Mona Lisa,” is the gold standard in a
shape corresponding to the patient’s den- study of lips. Examine the subject’s facial
tal arch form. The lateral segments (Segs. expression and the line between her lips.
1, 3, 4 & 6) on the upper lip and lower lip Is she smiling? Is she presenting an aloof
become wider and elongated as the lips attitude of superiority, or communicat-
move into a kinetic smile. The central seg- ing a passive state of bliss? We may never
ments flatten and lengthen as the muscles know for certain what her smile conveys
of facial expression contract and pull the about her mood, which is why this work
lips against the dental arch. of art is timeless, captivates our attention,
and inspires us, depending on our per-
THE DYNAMICS OF KINETIC AND sonal perception of her mood.
STATIC MOTION IN THE CLASSIFI- The LBL is dictated predominantly by
CATION SYSTEM the maxillary lip. It is in the mouth’s re-
We augment our patients’ lips in the laxed (static position) where we can best
static position. We assess the lips for aug- evaluate this line. When we augment, we
mentation in both the static and kinetic have a significant impact on the existing
positions. The segments and zones we as- LBL. Consequently, a thorough under-
sign in the static state will translate pro- standing of the different expressions of
portionally to the kinetic state (smiling). the LBL is needed.
In other words, if we overfill Segment 2 in
The expression of this line is in Zone
the static state, this will result in an over-
C in the upper lip. The genetic develop-
fill in Segment 2 in the kinetic state.
ment of an individual establishes the form
Even though we stretch the lips when of the LBL at lip maturity. An inverse LBL
we smile, the proportional relationship of can be viewed as contributing to the aged
the lips will still be present in the same look of the mouth. This is partly because
segment in the kinetic motion. The bor- the inverse smile line corresponds to the
ders for the kinetic segments translate to aging process of the oral facial area, which
the curvature of the arch, which develop is a downward and outward growth and
at the canines. In a full smile, Segments 2 sagging of the oral-facial tissue. Although
and 5 fill the space medial between the ca- an inverse LBL can present as a component
nines of the upper and lower dentition. of an aged smile, it does not completely
imply an aged smile. A lack of fullness in
THE LINE BETWEEN THE LIPS (LBL) the lips presents more of an aged view of
The line between the lips (LBL) pres- the face.
ents in four ways on the human face. Art-
ists use the LBL as an identifying trait on Patients often come in for consultations
all portraits. The line between the lips has because of the loss of volume in their lips.
a definite subconscious effect when we The loss of lip volume contributes more to
perceive a person’s appearance. Because the development of rhytides and deepen-
an artist’s job is to facilitate an emotion ing of lines around the lips. We know that
without overtly exaggerating facial ex- we very seldom augment in Zone C.
pression, this line is very important on Zone C reflects the architecture from Zone
mouth presentation. A. After filling in the volume of the lip
Leonardo da Vinci’s masterpiece, the (Zone B), we then evaluate the architec-
ture of Zone A. If needed we then sculpt
This is a two week post augmentation with NASHA and Collagen fillers. It is imperative to
understand the planes of the lips. The picture above shows the lips from a semi-profile angle.
As the illustration demonstrates the planes of the lips are ever present. The augmenter must be
aware of these planes and fill them in relationship to their natural occurring form.
Lip incompetency is one situa-

tion where cosmetic augmenters
may have an opportunity to add
to Zone C without violating the
dental presentation underneath.
Adding volume in Zone C is
achieved by inserting the needle
into the inferior border of Zone
B and letting a limited amount of
material flow into Zone C.
There is a segment of the
population that has incompe-
tent lips, or lips that separate in
the static position. This can be
attributed to dental and/or skel-
etal malocclusion. The cause of
incompetent lips is usually not
associated with lip deficiency.
Incompetence of the lips is attrib-
uted more to a skeletal malforma-
tion. This phenomenon is related
to excessive interlabial space. At
rest a relatively small amount
of separation between the lips is
normal. The primary measure-
ment of interlabial distance is de-
Leonardo Da Vinci’s Mona Lisa fined by stms and stmi: stomion
Reproduction provided courtesy of 1st-Art-Gallery: www.1st-art-gallery.com
superius and stomion inferius.
Zone A. Zone C will then reciprocate the The measured normal distance
form established by the previous two fill- ranges from lightly touching to a 3-mm
ing orders of Zone B and A. distance between both points.32 Patients
with incompetent lips are excellent candi-
Think of the vermilion border of the dates for augmentation of the lips and or
maxillary lip as a curtain rod that is uni- Botox therapy.
form in both length and width. When we
bend the curtain rod up and down and The jaw rests in a neuromuscular po-
hang the fabric on the rod, the bottom sition creating a freeway space. The free-
edge of the curtain (Zone C) reflects the way space is an approximate 2 mm verti-
shape of the bent rod (Zone A). cal height separation between the upper
Incompetent Lip (Open Lip) and lower teeth. In this position, the mus-
cles of the jaws are at their most relaxed
This presentation of the LBL is open
position. If we are not talking or eating,
when the face is relaxed. There are a myr-
we maintain this position during which
iad of reasons for an incompetent lip, to
the lips are naturally closed or competent.
include VME (vertical maxillary excess),
However, when this inter lip space is ex-
short lip or chronic air way obstruction.
Curtain Illustration
Illustrated below is the idea of how the inferior border of Zone C reflects the architecture
of Zone A, the vermilion border. Therefore, the architecture we establish in Zone A will be
reflected in Zone C. This is an additional reason to avoid filling in Zone C.
Zone
A
Zone
A
C
Four General LBL Presentations

This is the classic presentation of the LBL. The LBL
has a downward swoop at Segment 2’s philtrum
area. In Segments 1 and 3, there is an upward
draw. Segment 2 has a fuller appearance, which
accentuates the “Cupid’s bow” effect of the LBL.
Upward Arch
This lip line has a straight across presentation,
with no discernible upward or downward slope.
Segments 1 and 3 are straight across. Notice the
lack of architecture in Zone C, Segment 2 on the
vermilion border. This lack of curvature reflects
itself in Zone C of the upper lip and the LBL.
Straight Across
This is the inverse relationship to the upward arch.
You can see this downward curve in Segments
1 and 3. The woman pictured here has very
voluptuous lips. Correcting this patient’s lip to
create an upward arch would distort her natural
beauty. We want to augment our patient’s lips
(i.e. enhance their natural beauty), not alter their
appearance.
Downward Arch
This presentation of the LBL is open when the
face is relaxed. There are myriad reasons for an
incompetent lip, to include VME (vertical maxillary
excess), short lip, or chronic airway obstruction.
Lip incompetency is one instance where cosmetic
augmenters may have an opportunity to add to
Zone C without violating the dental presentation
underneath. Adding volume in Zone C is achieved
by inserting the needle into the inferior border of
Zone B and allowing a limited amount of material
to flow into Zone C. Incompetent Lip (open Lip)
cessive and requires the patient to contract tation of the face as we age. With time the
the orbicularis muscle with intention, we constant contraction of the muscles of fa-
classify this as incompetence. This is usu- cial expression take their toll on the facial
ally around 4 mm+. skin, leaving it susceptible to deep kinetic
folds.
Common causes of incompetent lips in-
clude: Artists have always had a keen interest
Soft tissue – Short philtrum, where in the muscles of the face. The thickness of
the space between subnasale (base of the musculature affects the draping of the
the nose) and the superior border of skin which in turn relates to the amount
the vermilion fails to complete a re- and severity of facial folds and wrinkles.
laxed seal of the lips. As a result of the The oral-facial musculature is similar in
amount of interlabial space available, all human beings, yet the variance in their
we are able to augment more liberally composition is significant enough to give
in Zone B, without obscuring needed us our own distinct appearances.
incisal dental length for aesthetic ap- There are also notable differences
pearance. If the patient presents with a in the oral-facial musculature between
full upper lip, other alternative thera- males and females. Females reportedly
peutics may be indicated such as Bo- have higher smile lines than males.33 The
tox therapy (Chpt 7). Denervating the higher draw of the superior lip is attrib-
levator labii superioris alaeque nasi uted to the morphology of a woman’s
(LLSAN) muscle may length the up- levitator muscles.34 Women are also re-
per lip in order for the patient to pres- ported to have a larger muscular capacity
ent with more competent lips. of the zygomatic major and levator labii
Dental – Excessive dental overjet, superioris muscles. Ultrasound studies
35
where the maxillary teeth protrude of the oral-facial muscles, in particular the
over the mandibular jaw, forcing the levator muscles, reveal that women have
lips to separate. thicker zygomaticus major muscles than
men, as well as higher smile lines.36
Skeletal – Relationships attribute to
vertical maxillary excess (VME) with Orbicularis Oris
and without anterior open bite re- This sphincter-like muscle has no true
sulting in down and back rotation of origin or insertion point. Instead it is com-
the mandible and excess lower facial prised of associated muscles interdigi-
height. tating with it as it surrounds the mouth.
The corners of this muscle are made up
of the zygomatic muscle and depressor
Anatomy angular oris, which intersect at the angle
MUSCULATURE of the mouth: those from the zygomatic
major cross the corner of the mouth and
Muscles of Facial Expression terminally engage into the lower lip, and
The muscles of facial expression are those from the depressor angular oris in-
unique in several ways; in particular the tersect and terminally engage into the up-
facial muscles of expression insert directly per lip. Along the path which they run,
into the oral facial skin. This direct inner- these muscles insert into the skin. There
vation contributes to the unique manifes- are also fibers from the levitator muscles
(labii superioris, labii superioris alaeque of this muscle is sneering by contracting

nasi, zygomatic major, and minor) and the the upper lip superiorly. This is the mus-
depressor labii (labii inferioris and menta- cle responsible for the mid portion medial
lis); these intermingle with the transverse to the nasolabial fold. As we mature, this
fibers above. The proper fibers of the lips
are oblique and pass from the undersur-
face of the skin to the mucous membrane,
through the thickness of the lip. The effect
of the orbicularis oris is closure of the lips.
fold deepens and is often regarded as an

undesirable effect of aging.
Levator Labii Superioris Adequate Nasi
The origin of this muscle is the nasal
process of the maxilla and it inserts into
the orbicularis oris medially as well as
the medial nasal ala. This muscle contrib-
The deep fibers of the lips approximate

the lips to the alveolar arch. The superfi-
cial fibers bring the lips together in a purs-
ing form (kissing motion).
Buccinators
Buccinators compress the cheeks so
that during the process of mastication, the
food is kept under the immediate pressure
of the teeth. When the cheeks have been
previously distended with air, the bucci- utes least to lifting the upper lip and the
nator muscles expel the air from between muscular wall medial to effect the naso-
the lips—much like blowing a trumpet, labial fold. Botulinum Toxin treatment in
hence its name (Buccina is the ancestor of this muscle will relieve the lip contrac-
the trumpet.) tion—which is beneficial for patients with
“gummy smiles”—and softens the naso-
Levator Labii Superioris
labial fold.
The origin of this muscle is on the malar
prominence below the infraorbital rim. It
Zygomatic Major
inserts into the orbicularis oris. The effect Origin of the muscle starts at the inferi-
or border of the zygoma and inserts deep-

ly into the orbicularis oris and the modio-
lus at the corner of the mouth. The effect
of the muscle is the smile by elevating the
corner of the mouth superiorly and later-
ally.
Zygomatic Minor
This muscle is medial to both origin and
sue. The effect of this muscle is the pout

look. As the face matures and the dermal
tissue loses subcutaneous thickness, a
cobblestoning effect can take place upon
contraction of this muscle. Many patients
do not realize this pitting effect due to the
fact that when we look in the mirror, we
evaluate ourselves in the static facial posi-
insertion of the zygomatic major. They zy-
gomatic muscle is absent in two-thirds of
cadaver dissections.37 When present this
muscle is plays an adjunctive role to the
zygomatic major.
Depressor Anguli Oris
The origin of this muscle starts at the
inferior border of the mandible anterior to
the masseter muscle. The depressor anguli
oris (DAO) inserts into the modiolus. The
effect of this muscle is frowning. Botox
therapy denervates this muscle causing
the antagonist perioral elevator muscle to
tion or repose.
raise the corners of the mouth.
Depressor Labii Inferioris Nerves
Origin of the DLI is on the inferior bor- The Trigeminal Nerve
der of the mandible medial and superior
This is the fifth cranial nerve that sup-
to the depressor anguli oris. The effect of
plies the majority of sensory innervation
the DLI is lowering of the lower lip.
to the oral-facial area, as well as a minimal
Mentalis amount of motor regulation. The trigemi-
nal is the largest cranial nerve.
The mentalis originates on the mentum
and inserts into the mental dermal tis-
Risorius
The risorius rises in the fascia over
the masseter and passing horizontally
forward—superficial to the platysma—is
inserted into the skin at the angle of the
mouth. It is a narrow bundle of fibers,
broadest at its origin, but varies much in
its size and form. The risorius retracts the
angle of the mouth and produces an un-
pleasant grinning expression.38
Table 2.2 muscles of facial expression

Combo
Perioral Origin/Insert Effect Aging sign Botox Tx Filler Tx Tx
muscles (BTX) (Filler/
BTX)
Not Placed NO
Zygomaticus Inferior zygomatic Elevates corners Minor
major Indicated medial to
arch/modiolus of mouth contributor to
NLF
(corner of mouth) superiorly deepening
and laterally nasolabial fold
(smiling) (NLF)
Medial to same Adjunct to Minor Not Placed
Zygomaticus NO
origins and zygomatic contributor to Indicated medial to
minor
insertions as major (smiling) deepening NLF NLF
zygomatic major
Levator labii Major Rarely Placed

Malar prominence Lifts upper lip YES
superioris contributor to (tendency medial to
below infraorbital (Sneering)
deepening NLF to flatten NLF
rim/medial
orbicularis oris out midface
appearance)
Levator labii BTX TX: Not
Nasal process of Adjunct in lifting Lip lengthens NO
superioris Reduce Indicated
maxilla/medial upper lip
alaeque nasi orbicularis oris (sneering) “gummy
smile”
Obicularis oris Interdigitates with Lip competency Vermilion
Rhytid BTX TX: YES
surrounding muscles Lips pursing Vermilion Sculpting
development
(kissing) (Zone A)
Vol atrophy
Lip Filling
(Zone B)
Depressor Inferior mandibular Downward pull
Drooping of DAO BTX-A Commissure
anguli oris border/modiolus YES
of corners of commisures Lifts corners fill technique
mouth (frown) of mouth
Depressor labii Inferior mandibular Lowers the Contributes to Not Placed
border/inferior NO
Inferioris lower lip deepening of Indicated in fold to
orbicularis oris reduce
the mental fold
severity
Table 2.2 (Cont’ed) MUSCLES OF FACIAL EXPRESSION

Combo
Perioral Origin/Insert Effect Aging Sign Botox Tx Filler Tx Tx
muscles (BTX) (Filler/
BTX)
Mentalis Inferior mandibular Protrudes lip “Cobble- BTX-A Not NO
border/skin of the Compresses stoning” of chin injections Indicated
chin skin of the chin relieve
“cobble-
stoning”
Risorus Platysma, parotid Adjunct to N/A N/A N/A N/A

fascia/modiolus platysma
functions
(grinning)
Buccinator Pterygomandibular Compresses N/A N/A N/A N/A

raphe, alveolar cheek
process of maxilla (blowing)
& mandible/upper
lip and lower lip
Playsma Clavical, 1st ribs, Depressor of Hyperfunctional Lifts corners Commissure YES
acromion/anterior the mandible bands of mouth fill technique
and posterior
mandible
Motor Root This nerve is purely sensory. We will

The motor fibers of the trigeminal nerve be dealing with this nerve and its terminal
supply the masticatory muscles: masseter, innervation when we augment the naso-
temporalis, pterygoideus medialis, and labial line and upper lip. The V2 emerges
pterygoideus lateralis. Motor nerves also out of the cranium through the infraor-
supply the mylohyoid, anterior belly of bital foramen and supplies the mucous
the digastric, tensor tympani and tensor membrane of the nasopharynx, maxillary
veli palatine. sinus, soft palate, tonsil, hard palate, peri-
odontal tissue, and teeth of the maxilla.39
Sensory Root
The three divisions of the trigeminal The maxillary division also innervates
nerve are: ophthalmic division (V1), max- the:
illary division (V2), and the mandibular Middle portion of the face
division (V3). Lower eyelid
Ophthalmic Division (V1) Side of the nose
This division is only sensory and exits Upper lip
the superior orbital fissure. The nerve sup- The Mandibular Division (V3)
plies the nasociliary, frontal, and lacrimal
The V3 is primarily sensory with a
nerves.
minor motor component. The divided
Maxillary Division (V2) branch supplies the lateral pterygoid
FIGURE 2.4
Facial Nerves
Facial nerve (motor nerves), (V7)
Nasolabial (V2), long buccal (V3), and mental nerves (V3)
muscle, masseter muscle, temporal mus- pterygoid and continues on an antero-

cle, auriculotemporal nerve, mylohyoid lateral direction. At the level of the oc-
nerve, inferior alveolar nerve, and incisive clusal plane, it crosses in front of the
branches. anterior border of the ramus and en-
The terminal branches that we will ters the cheek through the buccinator
deal with when we fill the soft tissue of muscle. The long branch does not in-
the oral-facial area include: nervate the lower lip. It provides sen-
Long Buccal Branch—this nerve pass- sory fibers to the skin of the cheek. This
es between the two heads of the lateral area needs to be anesthetized when
doing fills in the corners of the mouth muscle.

and later to the commissure.
Mental Branch—This is the terminal Vascularity
manifestation of the inferior alveo- It is critical to be aware of the vascu-
lar nerve. The mental nerve exits the larity of the perioral region to address the
mandible out of the mental foramen following:
and provides sensory innervation to
Anesthesia: When giving infiltration
the chin and the lower lip.40
around the oral area, it is important to
Facial Nerve (V7) avoid intravascular injection. Knowing the
The facial nerve (V7) exits the skull vascular landmarks and utilizing sound
through the stylomastoid foramen. V7 aspirating techniques will minimize the
passes inferiorly and anteriorly before possibility of this occurrence.
it networks its way through the parotid Bruising: When we inject into or around
gland. highly vascular areas, we exponentially
This nerve supplies the motor move- increase bruising, which leads to unwant-
ment for the muscles of facial expression ed aesthetic outcomes.
(please see the section on musculature). Ischemia: When injecting a solid mate-
The facial nerve consists of five branches: rial like a filler into—or in close proximity
temporal, zygomatic, buccal, mandibular, to—a vascular supply, there exists the po-
and cervical. tential to occlude the vessel.
Temporal The Facial Artery
Innervates anterior and superior auric- The majority of the blood supply to the
ular muscles, the frontalis muscle, and the lips originates from the facial artery (FA).
superior portion the orbicularis muscle. The FA arises from the external carotid ar-
Zygomatic tery. The FA curves around the surface of
Innervates the inferior portion of the the mandible and gives off small muscular
orbicularis oculis muscle, superior por- branches to the masseter and the depres-
tions of the zygomaticus major, levator la- sor anguli oris muscles. The FA then ap-
bii superioris, levator anguli oris, nasalis, proaches the angle of the mandible. The
and orbicularis oris muscles. mean diameter of the FA is 2.6 mm. Usu-
41
ally the FA is located 15.5 mm lateral to

Buccal the angle of the mouth.42,43
Innervates the buccinators and orbicu-
laris oris muscles, the inferior portions of
Upper Lip and Nasolabial Region
zygomaticus major, levator labii superio- The FA supplies the majority of vascu-
ris, levator anguli oris, and nasalis. larity to the upper lip.44 The average exter-
Mandibular nal diameter of the superior labial artery
is 1.6 mm at its site of origin. The supe-
Innervates the depressor anguli oris,
rior labial artery (SLA) branches off the FA
the depressor labii inferioris, and the men-
above the angle of the mouth around 75
talis muscle.
percent of the time and at the angle of the
Cervical mouth 25 percent of the time.
Innervates the platysma, the posterior The FA has three types of major-branch
belly of the digastric, and the stylohyoid distribution:
the middle of the upper lip in the region

Type A — bifurcates into the lateral nasal of the vermilion border. The anastomosis
and superior labial arteries at the angle of is deep to the orbicularis oris, leaving the
the mouth (80-90%) plane between the skin and muscle void
Type B — branches off into the supe- of these major vessels.
45
rior labial and lateral nasal arteries, ter- Lateral Nasal Artery (LNA)
minating as the angular artery (5-10%) The lateral nasal artery (LNA) branch-
Type C — terminates as the angular ar- es from the nasolabial sulcus and runs to-
tery, but the lateral nasal artery branches ward the dorsum of the nose. The mean
off from the superior labial artery (2-5%). external diameter of the LNA is 1.43 mm.
Superior Labial Artery (SLA) Columellar Branches
The superior labial artery (SLA) branch- These are branches that continue off
es off into a superficial and deep ascend- the superficial descending superior labial
ing branch. On average, these branches artery.46
measure 0.3 to 1.1 mm in diameter. The
superficial ascending branch penetrates Lower Lip
the orbicularis oris and appears in the Inferior Labial Artery (ILA)
subcutaneous tissue at the vermilion bor- The inferior labial artery (ILA) is the
der. The deep ascending superior labial artery that supplies the lower lip. The
artery supplies the oral (wet) mucosa. The mean external diameter of the ILA is 1.31
SLA connects with the opposite artery in mm. The ILA branches off the FA at three
Figure 2.5 The Facial Artery

Here are the three variations of the facial artery as it branches off the superior labial artery.
Superior Labial Artery
Zone B
Zone B
Inferior Labial Artery
Depicted here is a cross-section of the upper and lower lips. Notice how deep the superior labial
artery and inferior labial artery are in relationship to the orbicularis oris. The targeted points
for the fillers are superficial to the orbicularis oris. Most vascularity interrupted or bruised will be
accessory branches of the two main arteries depicted here.
Figure 2.6 - The Labial Artery
different areas. Approximately 75% of the tered.

time, the inferior labial artery branches off
The vermilion border is the transition
at the inferior border of the mandible. In
point of the delicate lip tissue and the more
20% of the cases, the ILA branch occurs at
robust facial tissue (epithelium). The term
the commissure of the mouth; and in 5%
“vermilion” means a shade of red, which
of all cases, the branch of the ILA diverges
is imparted on the eye. This is due to the
at the SLA. The SLA then separates into
translucency of the skin that enables the
deep descending and superficial descend-
color of the blood vessels below to show
ing branches. The superficial descending
through. The vermillion border is very
SLA penetrates the orbicularis oris at the
distinct on the upper lip, demarcated by
superior edge of the muscle and presents
Cupid’s bow. The lower lip, however, is
in the subcutaneous tissue and vermilion
made of a smoother transfer of tissue and
border.47 The deep descending branch
is not quite as demarcated.
travels into the submucous tissue and into
the orbicularis muscle.48,49 The philtrum is the indentation above
the superior edge of the vermilion border
Mental Arteries
and below the alar of the nose. This sen-
The vertical and horizontal labiomen- sual facial feature has enjoyed continued
tal arteries (VLA and HLA) are located be- popularity and attention. The philtrum
tween the lower lip and submental region. forms the peaks of the Cupid’s bow of
They are branches of the FA and ILA. the lip. The philtrum starts beneath the
Oral-facial Aging nose and merges to the vermilion border
of the upper lip. The philtrum widens as
Facial skin it lowers to the lip. Although there are no
The Nasolabial line (the smile line) is recognized averages for its length, the im-
the manifestation of excess skin hanging portant point to realize is the symmetry
above a sharp transition line between hav- in the adult that is considered the norm.
ing more fatty deposited tissue above an The length from the base of the subspinal
area where there is less fatty tissue. The and the superior of the upper vermilion
pulling of the musculature associated border should be equal to the commissure
with the smile, in particular the zygomatic height to the subspinal.50
muscle and superior labialis. This trough
deepens as we age. The Effects of Aging
The major dynamics in facial aging
Lips
include gravity, soft tissue maturation,
The skin of the lip makes its transition skeletal remodeling, and muscular facial
from the oral mucosa to the keratinized activity.51 At birth the lips and face are the
skin of the face. Tissue in the mouth is held epitome of fullness. The young child’s
in a unique balance between the need for profile protrudes and the lips are pinched
moisture and the lack of keratinization. between the cheeks.
Studies have shown that the upper lip
is more hydrated than the lower lip. The SKELETAL/DENTAL
lips are among the most vascular organs Throughout our adult life, the oral-
of the human body. This explains why, facial skeletal dimensions continue to
when the body is in a diseased state, the grow. From late teens to the third de-
52,53
appearance of the lips is drastically al- cade of life, there is an average increase
TIPS
light source
Here is an illustration of how light and surface contours interact in the

lip region. The light source is from the upper left, casting a direction
down and diagonal. We can see how Zone A, Segments 1-3 pick up
what is referred to as the height of contour. Zone B, Segments 1-3 are
in the shadow.
Upper Lip:
This is relevant to filling volume in Zone B, Segments 1-3. If Zone B is
overfilled on the upper lip, it will pick up the height of contour and
leave an unaesthetic result, which is often perceived as a “duck lip”
or “bee sting” appearance.
Lower Lip:
The opposite is true in filling the lower lip. The lower lip’s height of
contour is in Zone B, Segments 4-6. We are at liberty to add volume
to the lower lip, accentuating the natural presentation. Adding too
much volume in Zone A, Segments 4-6 will produce a beak effect to
the lips and distract from the natural teardrop shape that constitutes
the lower lip.
in the vertical dimension of our face from tical dimension as the condylar guidance
nasion to menton of 2.7 mm.54 Other stud- and anterior guidance play an important
ies tend to support the idea of anterior associative role.60,61
facial growth well into the fourth decade
of life.55 In addition research has shown SOFT TISSUE
that on average, there is a retroclination Orthodontically the dental profession
of the maxillary incisors in females of 1.44 has associated average angles and lengths
degrees from 22 to 33 years of age.56 The to craniofacial skeletal and soft tissue
skeletal growth direction and inclination landmarks. Orthodontists have tradition-
of the maxillary incisors can account for ally incorporated the soft tissue of the
the progressive loss of lip support and mouth in treatment planning. EH Angle
volume in women. stressed the importance of the oral soft tis-
sue and orthodontics.62 CS Case included
Dentally, as a person ages, the occlusal
the profile presentation of oral soft tissue
surface of the dentition does exhibit wear
into the orthodontic treatment consider-
(approximately 1 mm every 30 years).
ation.63 Both Angle and Case relied upon
Some authors suggest that this is a sig-
more subjective perspectives of the soft
nificant contributor to the loss of verti-
tissue relationship in orthodontics.
cal dimension in the lower portion of the
face.57 Ricketts described the “E plane” (es-
thetic plane) as
As most expe-
the area on the
rienced dentists
face from the tip
would agree, if
of the nose to
there is a substan-
the chin when
tial loss of dental-
viewed from the
vertical height,
profile.64 Within
this is more likely
this area lies the
to be associated
lips; protrusion
with pathogenic
from this plane
occlusal trauma.
is unaesthetic.
These would in-
Burstone pre-
clude primary
sented the idea
tooth trauma A baby’s face is the epitome of fullness. At this age,
that the layman
from malocclu- we see the pucker of youthful, tonus facial tissue.
would be drawn
sion and second-
to the balance
ary occlusal trauma from periodontal or
of the upper lip to the nose in the profile,
supportive tooth structure disease.
this being the nasolabial line angle. The
Clenchers and bruxers are classified relationship of the upper lip to the nose
into two separate categories. Vertical load- from the profile impacts our judgment of
ing during waking hours and eccentric esthetics much more than any other rela-
grinding during sleep, both will wear the tionship within the “E plane.”
vertical dimension of occlusion, thereby
There are certain angle relationships
reducing the facial profile length.58
that are associated with a pleasing profile,
Temporomandibular dysfunctions59
such as the nasolabial angle: 85 to 105 de-
can contribute to the loss of anterior ver-
Age Maxillary Mandibular

Central Incisor Central Incisor
Table 2.3 To 29 3.37 0.51

Aging Tooth
Exposure
30-39 1.58 0.80
40-49 0.95 1.96
50-59 0.46 2.44
60 and above 0.04 2.95

Source: Vig RG, Brundo GC. Kinetics of Anterior Tooth
Display, J Prosthet Dent. 1978;39(5):502.
grees; the distance between the vermilion to the bulk of the lip.
border of the upper lip to the alar of the In the male and female face, the nose
nose: 18-20 mm; and the distance between increases in all dimensions. There is a de-
the vermilion border of the lower lip and crease in the soft tissue at the pogonion, a
inferior border of the mandible: 36 to 40 decrease in the upper lip, and an increase
mm. in the thickness of the lower lip. When the
Steiner’s Angle is the angle viewed facial profile is straightened, the lips be-
from the profile of the lips. This usually come more retrusive in males. The up-
66
related to 30 degrees. G-K (Glogau-Klein) per lip seems to rotate down and back
Point is described as the slight elevation from the base of the nose, which leads to
of the lip from the glabrous skin to the less maxillary incisor exposure at rest and
mucosa of the lips. It is also referred to when smiling. As we age, the tooth ex-
67
as the “ski-jump” point of the upper lip.65 posure at rest decreases in the maxillary
Understanding this angle and reestablish- and increases in the mandibular teeth.
ing this angle can recreate a more youth-
Intrinsic Effects
ful appearance.
There are several key factors that can
Augmentation possibilities: For more be attributed to time’s effect on the skin.
mature patients, successful augmentation For example, fibroblasts, which are re-
will include filling Zone A of the upper sponsible for connective tissue prolifera-
lip and reestablishing the anatomy of the tion, begin to lose their biosynthesis ca-
philtrum and superior vermilion border. pabilities. This gradually decreases the
For younger patients, simply filling in skin’s dermal thickness.68 There is also
Zone B will push up the anatomy in Zone a slow breakdown of the cellular mem-
A to reestablish the angle. This is due to brane due to the oxidative process placed
the tonality of the tissue and anatomy still on the lipid bilayer of the cell membranes
being present, so we are just adding a little and dermal proteins, which has led to the
push for antioxidant creams and associat- overall aging of the skin by trauma from
ed supplements in the cosmetic retail busi- pollutants and damage from ultraviolet
ness.69 The process of DNA repair is also rays.75 Photoaged dermis is hyperplasia
reduced, and the ability to resynthesize of elastic tissue with near complete disor-
collagen and elastin fibers is decreased.70 ganization. Large quantities of thickened,
Some authors believe that this theory of degraded, elastic fibers can be seen under
programmed cellular degradation is due the microscope.76
to our genotype makeup.71 Gravity—it seems that a great deal of
The difference in male and female emphasis is placed on gravity’s contribu-
skin is primarily in the thickness of the tion to the overall drooping of the facial
skin. Skin thickness in a woman reaches skin. Some authorities, however, hold this
its peak in their mid-thirties. Thickness theory with lesser regard. They would ar-
gradually decreases from that time on.72,73 gue that we spend half our lives recum-
A man’s skin in the middle to lower third bent, wondering, why doesn’t our skin sag
of the face is thicker and heavier. The skin to our ears? Our other organs and support
is bearded and is more resistant to wrin- mechanisms do not drop with age. For ex-
kles. Due to this thickness, gravity has an ample, the diaphragm does not sag and
increased pull on the skin and lowers the the kidneys do not stretch and fall into the
overall jaw line as the man ages. lower pelvis. Our leg skin does not sag to
our ankles due to gravity.
If you follow the careers of anchormen
in their younger years, you see them pre- Beginning in the mid to late thirties,
senting with a high smile line and visible changes become apparent throughout
maxillary dentition. Later in their careers, the face. Wrinkles and fine lines appear
you will notice that the lower dentition is around the eyes and mouth. The dermal
more prevalent when they speak. thickness is still relatively intact as in the
earlier years of life, although gravity has
Augmenting the nasolabial line on
weighed the face down. The telltale signs
males requires more filler as the lines are
of aging occur in the upper face first.77 It is
heavier and thicker. It is also more accept-
able for men to present with the matura- commonly believed that the weakest link
tion lines. in the chain of events to cause aging or
drooping of the facial skin is the cohesive
A woman’s skin, however, is thinner ability of the dermis and remodeling of fat
and drapes around the anatomy in a fin- distribution around the face.78
er fashion. This leaves the skin prone to
more wrinkles and folds. Consequently It is important to note that adding filler,
augmenting the facial lines of a woman particularly permanent ones to the cheeks
has a more dramatic result on these lines. or lips in overabundance, can accentu-
Regardless of gender, cigarette smoking ate this effect, increasing the pull effect
clearly has a deleterious effect on the ag- of gravity during the late forties. It is our
ing face. Furthermore, nicotine, a potent goal as cosmetic augmenters to enhance
vasoconstrictor, is known to have an ad- existing facial profiles in a patient’s thir-
ties to forties and not weigh them down.
verse affect on wound healing.74
In our forties to fifties, the dermis tends to
Extrinsic Factors thin out due to hormonal changes and the
Environmental—contributes to the loss of estrogen, which is particularly ap-
parent in women. We see labial rhytides

develop around this time. The constant
constriction of the orbicularis forms “sun-
beam-like” wrinkles around the mouth.
We also may start to develop “marionette
lines” or a “Chinese mustache” at the an-
gles of the mouth descending down to the
inferior border of the mandible. This is the
onset of ptosis that is commonly associat-
ed with the skin.79 Therefore, in the forties
and fifties, we can start to fill and add vol-
ume in the lips and nasolabial areas.
As faces mature through the fifties and
sixties, the jaw line sags and the corners
of the mouth droop down. The lack of
tonus from the musculature and the pull
of gravity draw the overall expression of
the mouth down. The intercommissural
distance increases with age, whereas lip The youthful face is all about volume.
height decreases. As we mature, photo- Oral-facial augmentation with injectable
graphs will reveal that the lower incisors fillers strive to recreate this look by
have become more prevalent when we refilling areas of lost volume.
talk. In photographs of younger people,
on the other hand, the lip line is higher surgical face lift. The surgical face lift is
during conversation and the incisal edge significant surgery where there is a relief
of the maxillary teeth is present.80 of deep muscular structures and the repo-
sitioning of the face in a superior lateral
A youthful face has a full appearance
position. Although this procedure does
to it. The thick skin on the face adhering
relieve sagging and significant folds of the
to the tight musculature of the facial anat-
face, it leaves a flattened appearance.
omy presents with a taut, resilient look.
Traditional face lifts leave the patient with As cosmetic procedures evolve, we are
a flattened out profile, or a pulled effect, constantly trying to correct or inhibit the
which is what has been done surgically. aging process as it occurs (immediately),
Everyone ages differently, either rather than resorting to the need for dra-
through genetics, the environment, and/ matic face lifts. This is not to suggest that
or illness. Restore your patient according face lifts will be eliminated for certain
to how he or she presents, not according segments of the population. However, it
to chronological age. does indicate that the combination of fill-
ers and surgical intervention is destined
Face lift vs. Filler
to become the movement of the future.
There has been an evolution of adjunc-
tive and supportive cosmetic procedures Aging & Maturation of the Lips
with the emergence of the plastic sur- The same principles that impact the
gery culture. Today’s cosmetic society is skin affect the lips. Based on gender, the
looking for alternatives to the traditional maxillary and mandibular lips reach their
TIPS
Prior to initiating the oral-facial augmentation procedure, spend

some time talking with your patient. This gives you, the injector, time
to lift your eyewear loops and see the patient’s entire face. Fill one
side, stop, and evaluate before filling the other side. Take your time
to assess as you go to give the patient a sense of security in your
technical abilities.
maximum fill at different times and at

different ages. The female maxillary lip
reaches its maximum size at around four-
teen years of age, while the mandibular
lip reaches its maximum dimension at
around sixteen years. A male’s maxillary
lip, on the other hand, reaches its maxi-
mum size at around eighteen and for the
mandibular lip, it is shortly thereafter.81-83
Chapter 2 Review
STUDY Points
Constitution of the lips and corresponding shapes
Static vs. kinetic facial movements and their relationship to cosmetic
augmentation
Aging process of the oral-facial area (intrinsic, extrinsic) and implications in lip
and perioral augmentation.
Musculature, vascular and neural involvement in oral-facial augmentation.
STUDY Questions
1) Incomplete union of the lips has a prevalence of what? And the phenomena is an
incomplete union of what two processes?
2) What constituent is used to acquire a patients static lip position for evaluation?
3) Of the three types of lips zones which one is never filled and why?
4) Describe the acronym LARS.
5) Which branch of nerves is most likely to cause facial distortion when anesthetized
and why?
3
Chapter 3
Anesthesia
Haud vir est suus professio vinco primoris dies.
No man is his craft’s master the first day.
Chapter 3 Anesthesia 58
Local Anesthesia for Oral-Facial Augmentation

Delivery of Injectable Anesthetic
Delivering Local Anesthetic
Just ask any dentist and they can testify that one of the most frustrating
parts of practicing dentistry is anesthesia. How many times have we failed
to accomplish anesthesia on our patients (and, of course, nine out of ten
times, it is on the most pain-/anxiety-ridden patient in our practice)? During
the arduous process of administering cartridge after cartridge of anesthetic
in hopes of finally getting our patient numb, our waiting room backs up
and we silently curse the first day we set foot in dental school. Through
my travels, researching this book, and talking to the various specialist
that use dental blocks for oral-facial augmentation, I have come to
one transcendent truth in the oral-facial augmentation community: all
practitioners—irrespective of their specialty—wrestle with the difficult
and oftentimes elusive component of practicing oral-facial anesthesia.
I have always liked to keep two mantras in mind when administering

anesthesia—or any drug for that matter: 1) superior results with
minimal discomfort; and 2) maximum effect with minimal dosage.
This chapter is formulated to lay a sound basis for lip and perioral
anesthesia as applied to cosmetic augmentation of this area. The
following are techniques and suggestions designed to assist all
practitioners from the multitude of specialties optimize their
oral-facial anesthesia.
Local Anesthesia for Oral- Botox and Anesthesia

facial Augmentation Congruent anesthesia with Botox
(BTX) therapy is contraindicated. The use
With the exception of dentists, there of anesthetic has the potential to impede
seems to be reluctance among healthcare the precise location of the targeted anat-
practitioners to use dental blocks in con- omy for BTX cosmetic therapy. Block an-
junction with injectable dermal fillers. esthesia for placement of BTX around the
Since the art of injectable filler overlaps lips and perioral anatomy will leave a cer-
many specialties of healthcare, a sum- tain degree of flaccidity of the oral-facial
mary of practice related to local anesthetic muscles. It is important to understand the
and its application is warranted. result of flaccidity that comes with the ap-
Some clinicians argue against using plication of anesthesia—however signifi-
local anesthetic or dental blocks when cant it may present—does not presume
injecting dermal fillers because they be- the patient will receive distortion of the
lieve that local anesthesia distorts the lips, muscle of facial expression. Yet the limit-
which tends to mask their natural shape. ed loss of any muscular tonus has a large
This would lead to an unaesthetic result impact on botox therapy.
post augmentation. When a practitioner attempts to locate
Another reason commonly cited for the muscle for BTX injection, they will of-
not using blocks or infiltrates during oral-ten have the patient constrict the target-
facial augmentation is that when a pa- ed muscle by pursing their lips or biting
tient has complete anesthesia, the injector down. An example of this is the depressor
is using more force in the application of anguli oris. To precisely locate this mus-
the filler, which can result in lumpiness, cle, we have the patient bite down and we
palpate the inferior border of the mandi-
bruising, and distortion.84 The key is to re-
ble. We locate the DAO by feeling our way
alize that the inability to feel the injection
pressure (G’) is related to the augmenter’s posterior along the mandible until we ar-
lack of expertise and/or training. Calibrat-rive at the anterior border of the masseter.
ing your injection pressure by your pa- Whether the loss of muscle control is per-
tient’s discomfort level, rather than using ceived or actual, anesthesia can encumber
your own tactile and visual perception of our ability to locate the muscles of facial
the flow of the material, is an indicator ofexpression. It is difficult enough at times
improper augmentation. locating specific targeted muscle to den-
ervate. The overlying anatomy of the oral-
It is also important to realize that as a
facial area can be thick and drape more
dentist engaged in the practice of lip and
than expected over supporting structural
perioral augmentation, you have had the
anatomy. Additional variables, such as lo-
basic training to optimize the best of both
cal anesthetic, can complicate treatment.
worlds: complete anesthesia without dis-
tortion and the technical placement of Local Anesthetic Pharmacokinetics
fillers via injection techniques. No other Local anesthetics act on nerve cells by
healthcare practitioner has more didactic, blocking the transmission of electrical en-
clinical, and everyday experience in the doneurium, sending impulses across the
administration of oral-facial anesthesia cell membrane. The transmission of noci-
and hands-on treatment of the oral-facial ceptive (pain) impulses is more sensitive
area. to the action of local anesthetics than the
Here is an example of two stereotypes we face as lip and perioral augmenters…one is obvious,
the other not so much. Clearly, the portrayal of a large needle injecting haphazardly into the
lips is not a flattering portrayal of our profession. Yet, most disturbing to me is the overly large,
nonsymmetrical lips. We have discussed at length the ideal proportion and how it is pleasing to
the eye, yet these lips violate the golden proportion. An equal 1:1 lip ratio is the least appealing
to our eye and this is a perfect example of this. Naturally, writing “a beautiful set of lips” in this
caption would undermine the suggestion of the photo.
transmission of motor impulses. Injectable anesthetic is protein and the anesthetic

local anesthetics consist of amphiphilic with the higher degree of protein binding
molecules, meaning that they dissolve in will remain attached longer.86 For exam-
both aqueous and lipid environments. To ple, bupivacaine is highly protein bound,
achieve this effect, a lipophilic ring struc- which directly correlates with its longev-
ture on one end of the molecule is com- ity during a procedure. Local anesthetics
bined with a hydrophilic secondary or are broken down into various classifica-
tertiary amino group on the other. tions based on the duration of their prod-
Lipid solubility determines potency.85 uct. For the purposes of this book, we will
be dealing with duration as it affects the
The more lipophilic a local anesthetic is,
soft tissue or infiltrate, not profound pul-
the greater the penetration into the nerve
pal anesthesia. The categories are broken
cell membrane, which results in a more ef-
into short duration (< 60 minutes), inter-
ficient blockage of the neural signal.
mediate duration (60 minutes) and long
Anesthetic Classification duration (> 60 minutes).
Local anesthetics are either esters (cocaine,
The pKa (which determines the on-
benzocaine, procaine, tetracaine, chloro-
set of neural blockage) of an anesthetic
procaine) or amides (lidocaine, mepiva-
is the pH at which equal percentages of
caine, bupivacaine, etidocaine, prilocaine),
the drug exist in the ionized and the non-
depending on the type of chemical bond
ionized forms. Local anesthetics are weak
joining the two ends of the molecule. Only
bases and become positively charged in a
amide-type local anesthetics are marketed
negative pH environment. On the other
in dental cartridges. The benefits of these
hand, the nonionized form of the local an-
particular anesthetics include a greater ef-
esthetic penetrates (into) the neural mem-
ficacy obtaining targeted tissue anesthesia
brane. Local anesthetics with a pKa closer
with a lower risk of allergic reactions.
to the physiologic pH produce higher
Anesthetic Characteristics concentrations of the nonionized form,
Protein binding potential determines which increases the speed of onset of that
the duration of the local anesthesia. The particular local anesthetic. Areas of active
idea is that the binding receptor for the infection have a lower tissue pH, which
Table 3.1 Anesthetic Classification
Age Potency Duration PKa pH pH Max Dose

(+ epi) (- epi) (mg/kg)
Lidocaine Short (- epi) 4.5 (- epi)
(Xylocaine) 2 Intermediate (+ epi) 7.9 5.0 - 5.5 6.5 7.0 (+ epi)
Bupivacaine 1.3 (Max dose does
(Marcaine) 4 Long 8.1 3.0 - 4.5 4.5 - 6.0 not exceed 90 mg)
Articaine Intermediate 7.8 4.4 - 5.2 N/A 7.0

Short (- epi)
Mepivacaine 2 Intermediate (+ epi) 7.6 3.0 - 3.5 4.5 6.6
Short (- epi)
Prilocaine 2 Intermediate (+ epi) 7.9 3.0 - 4.0 4.5 6.0
tends to decrease the nonionized form, removed from all local anesthetics circa
thus lengthening the onset time. 1985. If an allergy is encountered with a
local anesthetic, one may use another an-
dental Anesthetics esthetic with the least amount of molecu-
Choosing a Dental Cartridge for Local lar similarity.87 Lidocaine is most similar
Anesthetic to prilocaine and etidocaine, which is no
The standard dental cartridge is the longer available in structure, and mepi-
optimal carrier for anesthetic used in oral- vacaine is most similar to bupivacaine.
facial augmentation. The standard dental Articaine has the most unique molecular
carpule is distributed in a 1.8 mL aqueous structure.
88
solution containing various solutions of There are certain requirements needed

anesthetic. The dental cartridge is com- from the hardware to inject local anesthet-
posed of a cylindrical glass tube, stopper, ic in oral-facial augmentation.
aluminum cap, and a diaphragm. (See fig)
Toxicity
The American Dental Association Council
on Scientific Affairs developed a color- Toxicity, whereby the cardiovascular or
coding system on standard 2 mL dental central nervous system is mainly affected,
carpules. The colors on the carpules are is similar in all local anesthetics. Toxicity
assigned to the various anesthetic compo- to local anesthetics is related to the poten-
sitions used in local anesthetic. cy, total dosage, systemic absorption, pro-
tein binding, metabolism, and excretion.
Adverse Reactions to CNS toxicity ranges from lightheaded-
Anesthetics ness and tongue numbness to excitability,
seizures, and coma at the extreme toxicity
Allergy
levels. The CNS effects are hypothesized
A true allergy to local anesthetics is
to be due to the depression of inhibitory
rare. When an allergic reaction occurs, it is
neurons, leaving the excitatory pathways
usually due to the metabolite para-amin-
unopposed.89
obenzoic acid (PABA) in ester anesthet-
ics and the preservative methylparaben Cardiac toxicity occurs secondary to
(MPB) in amide anesthetics, which was
Dental Anesthetic Products and ManufactureRs

available on the Market
Lidocaine, Mepivacaine:
Darby Dental Supply, 865 Merrick Ave, Westbury, NY 11590
Henry Schein, 135 Duryea Road, Melville, NY 11747
Citanest, Polocaine, Xylocaine:
Dentsply Pharmaceutical, 570 W. College Ave, York, PA 17404
Carbocaine, Marcaine, Zorcaine:
Eastman Kodak, Kodak Dental Products, 343 State St, Rochester, NY 14650-1122
Isocaine, Lignospan, Octocaine, Scandonest, Septocaine-Septodont:
245-C Quigley Blvd, New Castle, DE 19720.
Carpule Colors
Local Anesthetic Solution Color of Cartridge Band
Articaine HCI 4% with epinephrine 1:100,000 Gold
Bupivacaine 0.5% with epinephrine 1:200,000 Blue
Lidocaine HCI 2% Light Blue
Lidocaine HCI 2% with epinephrine 1:50,000 Green
Lidocaine HCI 2% with epinephrine 1:100,000 Red
Mepivacaine HCI 3% Tan
Mepivacaine HCI 2% with levonordefrin 1:20,000 Brown
Prilocaine HCI 4% Black
Prilocaine HCI 4% with epinephrine 1:200,000 Yellow

TIPS
If using cosmetic facial markers, place markings on the face or lips

prior to administering perioral anesthesia. This way, one is ensured
of the accuracy of marked areas, if there is any slight distortion of
the face after oral-facial blocks are applied.
the blockage of the sodium channels in Delivery of Injectable

the cardiac conduction system.90 At high
plasma concentrations, myocardial con- Anesthetics
tractility is depressed. Smooth muscle There are various techniques that can
dilation may cause hypertension. Symp- be used in delivering local anesthetic that
toms of cardiac toxicity include palpita- will optimize a patient’s comfort and re-
tions, cardiac dysrhythmias, hyper- or hy- sults. Warming the anesthetic to 37 C has
potension, and cardiovascular collapse.91 been shown to reduce pain in the injection
Cardiac toxicity is worsened by the use of site.97,98
epinephrine.92 Hypoxia, hypercarbia, and
acidosis are potential risks. The lower the acidity of the local anes-
thetic, the greater degree of pain upon de-
Epinephrine has some distinct advan- position in the tissue. Standard packaged
tages when incorporated into local anes- anesthetics are dispensed in dental car-
thetics. It prolongs the duration of the an- pules that can have an acidic pH of 3-5.5
esthetic by reducing the absorption rate. (to stabilize the epinephrine component),
Epinephrine is a powerful vasoconstrictor which can be painful when injected.99
that provides excellent hemostasis. Its va-
soconstrictive properties lengthen the ef- Tip: Using an anesthetic without epineph-
fect of local anesthesia by decreasing the rine and a pKa close to the physiological
blood flow in the area of administration, pH of the injected site will greatly reduce
which decreases the anesthetic’s metabo- pain upon injection. Remember: using
lism. When proper technique is applied, dental blocks for oral-facial augmentation
oral-facial augmentation requires little requires attaining adequate anesthesia for
hemostasis. In addition, the procedures the comfort of the patient without distort-
are short in duration; therefore, an epi- ing the muscles of facial expression. Us-
nephrine-free local anesthetic should suf- ing a short acting, fast onset anesthetic is
fice for most oral-facial augmentations. It appropriate for most augmenting tech-
is also helpful to use your ASA reference niques. An example of an ideal local is
guide to determine whether or not your lidocaine without epinephrine (see Table
patient is a candidate for epinephrine.93-95 2.1). This particular anesthetic has a pKa
of 6.5 without epinephrine, which will
It should be noted that all local anes- shorten the onset time and be comfortable
thetics are vasodilators. Most vasodilation when injected into the patient (due to its
is confined to the area of injection and is pH).
related to concentration of particular anes-
thetic.96 Due to the vasodilation of local an- A local anesthetic buffered with an
esthetic without epinephrine the potential agent such as sodium bicarbonate neu-
exists for the injected bolus of anesthetic tralizes the acidity of the lidocaine solu-
to spread into adjacent tissue more than tion, whereby making the injection of the
with anesthetic with epinephrine. This material less painful. The dilution rate of
greater spread of anesthetic may result in 1:9 (bicarbonate: lidocaine) ratio is recom-
partially anesthetizing the facial nerves, mended. The disadvantages of using a
100
thereby leading to a greater distortion of buffered solution include the additional

the facial muscle during augmentation. time, material, and expertise of mixing
the solution—since it’s not commercially
available. Furthermore, buffering lido- to the infraorbital foramina without sub-

caine reduces the shelf life of the anesthet- merging the needle to the hub. “Needles
ic to three to four weeks when prepared;101 should not be inserted into tissues to their
and the NaHCO3 disappears within min- hubs unless it is absolutely necessary for
utes. The combination of warming and the success of the injection.”104 The ratio-
buffering the local anesthetic seems to be nale behind this is that if needle breakage
effective for reducing the pain of lidocaine occurs, it would be difficult to retrieve
solutions upon injection.102 the broken segment if the injector has
submerged it to the hub. One may use a
Mechanical injection techniques such
30-gauge or 27-gauge for the mental injec-
as pressure application at the site of injec-
tion. I usually use a 30-gauge needle. It
tion and controlling the speed of injection
is recommended to change needles after
will reduce the discomfort. The use of re-
five to six injections, so it is possible to do
laxation techniques, procedural explana-
all thee blocks using one needle for oral-
tion, an adequate office environment, and
facial augmentations.
staff support will reduce the anxiety of in-
jection procedures. The use and application of local anes-
thetics between dentist and physicians var-
In addition to buffering and warming,
ies in some significant ways. According to
using the appropriate equipment for in-
Scott—who published a study in the 2002
jection will reduce pain of the procedure.
JADA detailing some awareness and use
Using sharp, sterile, disposable needles
of local anesthetic injections techniques—
is paramount. Studies show that patients
the use of buffering agents, warming of
cannot perceive difference in pain upon
injection solution, and vapocoolants re-
injection with needle gauges between 23-,
sulted in a significant difference of the
25-, 27-, and 30-gauge.103
five parameters selected to differentiate
Needle length in oral/ facial augmen- between the specialties. Physicians were
tation applies to only three injections tech- more likely to report use of pH buffering,
niques. A 27-gauge, 32-mm length needle vapocoolants, and procedural explana-
is recommended for the infraorbital injections, while dentists were more likely to
tion technique. The length of the needle report use of warming, pinching or pres-
allows us to deposit the anesthetic close sure application, controlling the speed of
Pre-op picture before injection of Infraorbital infraorbital, long buccal, and mental block vs.
post-op picture after admin of three facial blocks. Markings on the post-op photo indicate areas
anesthetized with blocks.)
injection, relaxation techniques, topical techniques, I am frequently asked why

anesthetics and aspiration.105 professionals outside the practice of den-
tistry experience failure when administer-
Block injection vs. Infiltrate ing block anesthesia. In fact, there are two
Injection of Local Anesthetic primary reasons why a cosmetic augment-
Studies have shown that block anes- er might fail to receive proper anesthesia
thesia is more of a perceived distortion of from a block: limited knowledge or a lack
facial soft tissue, rather than actual clini- of understanding of human anatomy and
cal interference with muscular tonus.106 nerve innervations of the oral-facial area;
Keep in mind that we are anesthetizing and technical error, which is often a result
sensory nerves of V2 and V3. The facial of limited experience in administering lo-
nerve V7 controls the muscles of facial ex- cal anesthesia and/or not placing the lo-
pression. By precise blocking of the nerve cal anesthesia at the right exit point of the
at the exiting foramina, we maximize the nerve.
effect of anesthesia on the targeted facial As a result, the following may occur:
soft tissue, while minimizing the distor-
• Over-injecting the amount of anes-
tion. When we inject infiltrate into the tis-
thesia on a block and receiving distortion
sue of the general area, the muscle tonus
from the percolation of anesthesia into
we want to augment is adversely affected.
surrounding musculature.
Over-administration of anesthesia will
force the fluid to percolate away from the • Injecting an infiltrate anesthetic and,
foramina and affect either the zygomatic, due to lack of knowledge and/or experi-
buccal or mandibular branch of the fa- ence, believing one has achieved anesthe-
cial nerve. This will in turn cause loss of sia.
muscle tonus of the face resulting in a dis- • Placing infraorbital and mental blocks
tortion of its appearance. The facial folds, and still generating nerve pain in the lips.
wrinkles, and architecture will relax and This pain is usually generated from the
we are left with a less than accurate por- buccal nerve that was not anesthetized.
trait of the face and lips. It is critical to keep in mind that as cos-
When we as dental practitioners ap- metic oral-facial augmenters, we are not
ply an anesthetic, the goal is to attain pro- performing dental surgery. Consequently
found anesthesia in the area in which we the amount of anesthesia administered
will be working. There are many times we can be considerably less. To ensure suc-
need to reinject to maintain the appropri- cess, place the blocks at precise foramina
ate level of anesthesia so that the patient points in order to eliminate facial distor-
does not feel any discomfort. Therefore, tion.
we must be keenly aware of the maximum Intraoral vs. Extraoral
amount of injectable anesthesia allowable
per body weight. The amount of anesthe- Injections of Anesthesia
sia needed is considerably less when aug- There is definite evidence of a wide-
menting a patient’s oral-facial area with spread lack of education in the medical
injectable fillers. With the proper tech- community on the proper administration
niques, we can achieve profound anesthe- of dental blocks. This may be due to an
sia with minimal distortion. unspoken, yet apparent “taboo” of explor-
ing a territory that has been traditionally
When I teach oral-facial augmentation
navigated by dentists.
facturer protocol when applying topical

Dentists are typically trained to give anesthetic to ensure maximum tissue an-
anesthetic intraorally and most other esthesia.
healthcare professionals will administer
injectable anesthetic extraorally, due to Topical Antiseptic
their lack of familiarity of the oral cavity. Extraoral—If one is choosing to in-
One of the benefits of using intraoral is ject the local anesthetic extraorally, a
precise block placement due to the rela- topical antiseptic is recommended. Beta-
tive ease of anatomic location. Moreover, dine (povidone-iodine) and merthiolate
injecting intraorally does not need to pen- (thimerosal) are just two of the several
etrate as much anatomy as extraorally, available forms of topical antiseptic. Anti-
leading to a reduced incidence of bruis- septics that contain alcohol may produce
ing, hematomas, and pain. The draw- tissue irritation. Additionally, caution
backs to performing intraoral injections should be taken when using iodine-based
includes learning the various techniques, compounds due to the significant risk of
understanding anatomy of the oral-facial iodine allergies by patients.109
region, and the time needed to develop an Intraoral—Using a topical antisep-
expertise that comes with continued prac- tic intraorally is an accepted practice be-
tice of these blocks. fore injecting local anesthetic intraorally,
Injecting extraorally is advantageous but the majority of dentists do not use
because of the ease of the technique: point topicals.110 Some practitioners will have
and inject. However, the disadvantages of patients rinse their mouths with an oral
this technique are bruising, hematomas, astringent rinse before starting dental
pain, the inability to acquire adequate procedures in order to reduce the bacte-
anesthesia, and unwanted percolation of rial load of the mouth.111
anesthesia to facial nerve, whereby nega-
tively affecting the muscles of facial ex-
pression.
Topical Anesthetic
Extraoral—When dental blocks are
not used, many practitioners use topical
analgesic to reduce injection site discom-
fort. The most popular topical agent is a
5% benzocaine cream that is applied to
the oral-facial area. Clinically the applica-
tions are messy and must be kept out of
the oral cavity. Anesthesia is apparent for
approximately 20 minutes.107
Intraoral—There are a variety of topi-
cal anesthetic compounds available for
use. When a topical anesthetic is applied,
studies show there is a significant reduc-
tion of discomfort in initial needle pene-
tration.108 It is important to follow manu-
Recreating the Canvas
Direction of needle insertion in order to facilitate filling in this plane.

Up until now we have illustrated the natural planes that occur in the lips.
By augmenting them, we are able to reestablish the natural representation of
the lips, thus producing an aesthetically pleasing result.
What if a patient presents with lips where there seems to be a lack
of a natural plane? The above illustration illustrates such a case. This model
has beautiful lips, yet they lack the fullness of the rhomboidal shape or half-
bucket shape in Segment 2 (the middle of the upper lip). In planning our
treatment for a patient presenting with such lips we have two options: 1)
Filling Segment 2 in hopes of creating this plane; and 2) Filling Segments 1
and 3 and then filling Segment 2 in relationship to what the patient previously
presented with.
If you elect option 1 in our treatment plan, be aware you will be
changing the look of the lips that this patient has grown accustomed to. You
will open yourself up to a greater dissatisfaction potential. So complete
communication of this potential is warranted in the initial consultation to the
patient. In addition, one does not know exactly how and where the filling
material will flow. This is primarily due to the fact that the potential plane that
does exist will saturate rather quickly and one will be forcing material into
the plane in hopes of expanding it. The material injected will take the path of
least resistance and may flow into an undesired area.
Points to remember in electing to proceed with option 2 and filling
this plane are: the half-bucket shape does exist in every lip, although in this
particular model, it is not very apparent. Picture in your mind’s eye this shape
and augment bilaterally on both sides of Segment 2 to augment the shape.
It may take several visits to release the tissue to fill the desired plane. A
sequential fill method will work best.
Delivering Local at the site (Although rare occurrences,

they can happen if the wrong tech-
Anesthetic nique or tool is used.)
Armament All syringes use ring plungers for as-
Syringe piration capabilities.
The ideal syringe for the injection of Determine your own comfort level in
local anesthetics has the following charac- deciding the type and amount of anesthet-
teristics: ic to use. In my own oral-facial augmenta-
It is made of metal or similar material tion practice, I use as little as one-quarter
that can be sterilized for reuse. Dispos- of a carpule of anesthetic for my infraor-
able syringes can be more expensive, bital, mental, and buccal blocks. Keep in
yet they offer the optimal compliance mind that like so much in dentistry, the
with sterilization.112 effectiveness of medicine is directly relat-
ed to dose and technical proficiency.
It has a chamber, where standard an-
esthetic carpules can be placed. Oral-facial Anesthesia
It is breech-loading, which means that
the cartridge is loaded in from the Techniques
side. When standard dental blocks are used
It is an aspirating tool. The syringe has before injecting filler agents in the lips,
a plunger/harpoon device in the pis- there are three types that can be used to
ton that enables the syringe to draw deliver complete anesthesia to the lips.
back. This is critical when injecting
into highly vascular areas to avoid in- The Nasolabial and Upper Lip
travascular injection, prevent systemic Generally only one block is required to
overdose, and minimize hematomas achieve complete anesthesia of the nasola-
Outlined on this patient’s face are the lip and perioral innervations of the infraorbital (V2),
long buccal (V3), and the mental (V3) nerves. Precise blocks of these nerves as they exit their
corresponding foramina (circled on the face) will provide anesthesia within the outlined area in
red. The long buccal nerve (V3) does not exit a foramina, so we cannot block the nerve in its true
sense. The long buccal enters the perioral area of augmentation around the area designated
with the circle. Placing an infiltrate amount of anesthesia at this point will anesthetize this nerve
sufficiently to provide anesthesia to the corners of the mouth.
bial fold and upper lip. This injection gives point. With the bevel of the needle placed
profound anesthesia of the mid-facial soft towards the bone and within a 30- to 40-
tissue, including the inferior palpebral, second time period, aspirate and inject a
the lateral nasal, and the superior labial. 0.9 to 1.2 mL carpule by the infraorbital
Procedure: Standard Infraorbital block foramina. Using an anesthetic contain-
ing epinephrine, the minimal amount of
The infraorbital foramen lies 8 to 10
deposited solution is required. With this
mm below the infraorbital rim.113 Place
minimal amount of anesthesia, little or no
your index finger on the inferior orbital
distortion of the lip occurs. Keep the nee-
rim and palpate to locate the infraorbital
dle as close to the periosteum as possible.
notch. Draw an imaginary line vertically
The facial artery runs in this area and, al-
down the face. Inject distal to the premo-
though rare, complications of technique
lar; keep the needle tip 10 mm below the
can cause hematomas. If this occurs, ap-
orbital rim on this plane, and insert a 25-
ply pressure over the foramina for 2 to 3
gauge, long needle superior to the halfway
minutes to reduce hematomas.104
This picture depicts the classic

approach to administering the
infraorbital nerve block as
described in this chapter. The classic
infraorbital nerve block is very
effective in providing profound
anesthesia to the mid-facial soft
tissue. Although its use is excessive
for lip and perioral augmentation, I
have found that using this modified
infraorbital block will produce
adequate anesthesia for lip and
Here is a ring comparison of the

affected areas of anesthesia
when comparing the standard
infraorbital injection and the
Gordon Modified Block (GMB). Standard
As illustrated, the traditional Infraorbital
infraorbital block has a greater Blockd
dispersion area, whereby Infra orbital
anesthetizing facial tissue well
outside the area needed for lip Gordon
and perioral augmentation. The Modified
GMB targets a more constricted Block
area, which includes the nasolabial
fold and upper lip. In addition, the
GMB significantly reduces facial
drooping or distortion by reducing
peripheral anesthesia of the facial
nerve that sometimes occurs with
the traditional infraorbital block.
Gordon Modified Block
Approximate in-
fraorbital foramen
Proposed injection
site for soft tissue
augmentation
Traditional
infraorbital
block
Modified
infraorbital
block
This picture depicts the classic

approach to administering the
infraorbital nerve block as
described in this chapter. The classic
infraorbital nerve block is very
effective in providing profound
anesthesia to the mid-facial soft 15 mm
tissue. Although its use is excessive
for lip and perioral augmentation, I 10 mm
have found that using this modified
infraorbital block will produce
adequate anesthesia for lip and
This picture displays where the mental foramina

lies on the mandible. Orienting your injection
needle between the mandibular premolars will
deposit the bolus of anesthetic approximating
the foramina.
Modified infraorbital block branes anterior to the mental foramen to

By definition this is not a true block the midline of the skin of the lower lip
for we are not directing our anesthetic at and chin. The location of the foramen pre-
the exiting formaina, so I have termed it dominantly lies between the mandibular
a modified infraorbital block. Using the premolars. Studies have shown that the
standard block above may result in dis- foramen is at the apex of the second mo-
siminating of anesethetic into the areas lar 52.8% of the time and between the pre-
where the facial nerve resides. With the molars 32% of the time. The foramen was
modified infraorbital block we move our slightly posterior to the second premolar
target sight medial in respect to the nor- in 14% of studied cases.114 Inject between
maly established landmarks of the tradi- both premolars, being careful to aspirate
tional infraorbital block. The dental land- first. Deposit one-half of a carpule in the
mark for insertion point of the needle is designated areas to achieve the desired ef-
distal to the maxillary canine and mesial fect.
to the first premolar. The infraorbial rim is 2) Long Buccal Nerve Block: Patients can
still a necessary landmark to prevent over- still feel pain in this area when filling the
shooting our targeted area superiorly. commissure or augmenting lateral to the
The advantages of the modified in- corners of the mouth. Feeling remains be-
fraorbital are: cause of the innervation of the long buccal
off of the trigeminal V3 branch. Tradition-
Less later spread of anesthetic, thereby
ally dentists will administer anesthesia
reducing loss of muscle tonus
lateral to the mandibular molars. This is
Reduction in the area of anesthesia, intended to block the accessory innerva-
whereby focusing our effect on our tion to the buccal mucosa for the intend-
targeted areas to be agmented. ed purposes of dental surgery. Attaining
Patient’s perception of profound an- complete anesthesia to the corner of the
esthesia is remarkably reduced. With mouth requires blocking the nerve in dif-
the traditional infraorbital block the ferent locations intra and extraorally.
patient may feel profound numbness
There are several techniques to anes-
over the entire mid-facial area and that
thetize the commissure area. These in-
can be uncomfortable or very unfa-
clude:
miliar to what they have experienced
before with dental blocks. The modi- Type 1: Injecting intraorally superior
fied version reduces lateral spread and and lateral to the retromolar will anes-
the potential negative feelings of total thetize the long buccal before it inner-
mid-face anesthesia. vates the cheek.115 The potential loca-
tion in which we can block the long
Lower
Lip and Commissure buccal is if we follow the nerve’s origin
Due to the cross innervations of the lip farther back into the oral cavity. Lacou-
and perioral tissue the lower lip and com- ture studied the long buccal nerve and
missure may require two injections: the showed that when the mouth is open,
mental nerve block and the long buccal the buccal nerve passes parallel to the
nerve block. occlusal surfaces of the maxillary pos-
terior molars.116 Blocking the nerve lat-
1) Mental Nerve Block: This technique
eral to the molars allows us to place a
anesthetizes the buccal mucous mem-
Type 1 — Buccal infiltrate lateral to the occlussal surfaces of the maxillary molars.
Type 2 — Buccal infiltrate lateral to the commisure of the mouth.

small amount at a location of relatively the mouth can lead to distortion of the
thin mucous membrane for maximum muscular tissue. This is due to the per-
effect. This intraoral application of the colation of the anesthetic to the buccal
block will minimize percolation of an- branch of the facial nerve. The effect
esthesia to the facial nerve, whereby will be an inability to raise the cor-
maintaining muscular tonus. ners of the mouth in a smile and may
Type 2: Placing a small amount of an- cause a drooping of the corners of the
esthetic extraorally or intraorally, 10 mouth.
mm distal lateral to the corner of the
mouth will provide adequate infiltra-
tive anesthesia. Giving anesthesia to
the long buccal nerve at the corner of
Chapter 3 Review
study Points
Role of local anesthetic in oral-facial augmentation; guidelines for usage of local
anesthetic.
Differences between block anesthesia and infiltrate anesthesia as they relate to
oral-facial augmentation.
Types of dental anesthetics; anesthetics ideally suited for lip and perioral
augmentation.
Injection techniques used in oral-facial augmentation: Gordon Modified Block,
mental block, and long buccal infiltrate.
study Questions
1) Under what conditions would the usage of local anesthetic be advised for botulinum
toxin injection cosmetic therapy?
2) What are the two most common reasons cited for not using local anesthetic in
conjunction with lip and perioral augmentation?
3) According to the author, which local anesthetic is ideal for lip and perioral
augmentation and why?
4) What are the advantages of the Gordon Modified Block (GMB) in lip and perioral
augmentation?
5) What are the advantages and disadvantages to block anesthesia and infiltrate
anesthesia as they pertain to lip and perioral augmentation?
4
Chapter 4
The Medium
Naturam primum cognoscere rerum
First, to learn the nature of things.
Chapter 4 The Medium 82
History of Fillers
Common Classification of Fillers
FDA-Approved Fillers
As outlined in the first chapter, the medium is one of the legs of

the tripod that is key in our fulfillment of being a lip and perioral
augmenter. Renaissance artists took great pride in their mediums of
expression. Many cherished their mixtures of paints and pigments
to such an extent that they took their valued, treasured secrets with
them to their graves. In modern times, this is not different. Many
manufacturers guard and protect their material under patents and
proprietary secrets. It is up to us as the applicators, practitioners,
and doctors to maintain the integrity of our professions and apply
temperance in the practice of our craft. Our patients and community
entrust us to protect them, and we must always weigh the benefits in
their favor.
Hopefully, this chapter will facilitate and aid you in your organi-
zation of material and applications and inspire you to continue lit-
erature review and debate, ultimately leading you to provide safe,
satisfactory treatment to your patients.
History of Fillers direct result of Botox, which is a superb

upper-face wrinkle remover and cosmetic
The earliest published medical records enhancer. The need for lower facial reju-
of oral-facial implants date back to 1893, venation soon followed. In the meantime,
when Neuber used autologous fat for tis- independent researchers and companies
sue augmentation.117 Neuber harvested simultaneously were developing safer
free fat-block grafts from patients’ arms and longer lasting filler materials.
and transplanted them into their lips.
Today there is a widespread move-
In the early 1900s, injectable paraffin- ment to add volume to the face rather
and-oil combinations were used for lip than to undergo a face lift. The cost of this
augmentation. However, it soon became treatment is far more affordable and the
evident that there were significant side ef-healing time is significantly reduced. The
fects that resulted from placing these fill-implant material selected should be based
ers, including a high incidence of granulo- on the location of desired augmentation,
mas and material migration.118 permanence of material, and the patient’s
Silicone eventually found its way into desired treatment result.
the fill market in the 1950s.119 Used for
medical purposes, silicones are long poly- Injectable fillers
mers of dimethylsiloxane. They provide There is a wide array of fillers now
a very pleasing aesthetic result, but they available for cosmetic augmentation. In
do have their drawbacks. Silicones have a selecting the proper filler, the augmenter
high abuse rate associated with them, and must select which filler to use in the same
because they are not FDA-approved for manner an artist chooses his or her ma-
cosmetic filling, there has been an aban- terial of expression on a canvas. It is im-
donment of continued development and portant to note that there are no good or
regulation of this substance for cosmetic bad materials, just different fillers that are
purposes in North America. Unfortunate- intended for various applications and ef-
ly this leaves a gap for the administration fects around the face.
of “back-alley” applications, where there
is no control over substance purity or pro- The nasolabial fold, for example, has
fessional responsibility. Hence, there have remarkable features. The fold is deep and
been reports in the news of appalling the malar fat and associated anatomy is
problems with silicone-filler injections. lateral to the fold. This contrasts the me-
dial aspect of the fold significantly, where
Injectable bovine collagen appeared in this area has less bulk and is more tightly
the cosmetic marketplace circa 1977. Bo- laid around the orbicularis oris and levita-
vine collagen has been coined the “gold tor muscles. The filler of choice must be
standard” of fillers. Because this filler resilient enough to be placed in an area
originates from another species, testing is that experiences persistent kinetic move-
required before receiving tissue. Current ment.
advancements have led to materials man-
ufactured from sources without immune The lips, in contrast, are in constant
complications or donor sources. motion. It is paramount that the injected
filler be placed in the natural planes that
Facial fillers manifested themselves constitute the lips. Proper plane place-
strongly on the cosmetic market as an in- ment will stabilize and insure the dura-
tion of the implanted filler and sculpted Off-Label Use

shape. In November 1997, a new provision
Placing different types of fillers in the was added to the Federal Food, Drug and
lips will result in different cosmetic re- Cosmetic (FD&C) Act that allows any
sults. A prime example is hyaluronic acid legally marketed, FDA-approved prod-
(HA). HA placed in the lips will keep its uct to be administered for any condition
injected shape, dependent on the plane within a doctor-patient relationship. This
placement and flow of the material. The is termed as “off-label use” of an FDA-
properties of HA will tend to displace tis- approved product. An example of an off-
sue (Chpt. 5) around the injected site. This label product is AlloDerm, which was
effect can be exploited to sculpt and shape FDA-approved for extraoral grafts. In the
the lips. field of dentistry, some clinicians use it for
periodontal surgery and oral-surgery ap-
The Ideal Filler plications.
An ideal filler meets the following cri- Caution should be exercised when us-
teria: ing fillers for off-label usage. In the cos-
It is safe to use and allows ease of metic industry, the companies marketing
placement without trauma, scarring or the various fillers may lead the practitioner
irrefutable damage to the host tissue to believe that a material is indicated for
or immune system. something other than its FDA-approved
It is technically able to be retrieved, usage.
dissolved or reformed to shape a par- If you choose to use a product under
ticular area to achieve the desired ef- an “off-label” usage you should observe
fect. It is also easy to handle and sim- the following guidelines:
ple to both learn and incorporate into Have a complete understanding of the
the clinical practice. product you intend to use, including
It lasts long enough to satisfy the im- the history of the product, FDA-ap-
mediate cosmetic correction or desire, proved usage, current mainstream us-
yet does not maintain its duration or age, and possible future side effects or
migrate to the extent that it would af- complications that may be associated
fect the dynamics of the facial presen- with the product.
tation in a negative manner as it ma- Consult with the patient on the above
tures. information before engaging in the
It is pleasing in form, texture, and treatment.
touch Govern yourself accordingly. You
It is cost effective for all patients. are dealing with patients who may
tempt you to go beyond your comfort
FDA Classification and Use of boundaries. Temperance in your own
Fillers exuberance will foster your continued
The Food and Drug Administration growth in the art of facial filling.
(FDA) has determined that collagen is a
Class III.A device and injected particles
are a Class III.B device. They are regarded
as implants into the human body.
TIPS
1 .618
Above is an example of the ideal proportion and how it is pleasing

to the eye. The photo on the left arranges the water flasks and the
shot glass in an ideally proportionate way. The photo on the right
demonstrates how the movement of the shot glass in the middle
rearranges the composition of the same items, and dramatically
affects the presentation. The photo on the right is not as pleasing
visually as the left, which is arranged in an ideal proportion.
Common Classification of clude: large amount of source material

Fillers and Use available, long history of use with little
adverse reactions, and if side effects
Today, dermal fillers are being clas-
occur, they are usually short-lived.
sified into several groups depending on
The disadvantages of this group are
source and/or desired outcome. Generally
possible immune response to trans-
the classification systems are based on: 1)
planted material.
source 2) duration of implant in tissue 3)
mechanism of action, and 4) intended use. Alloplastic material is an inert foreign
This chapter follows this format in explor- body (synthetic) used for implantation
ing the various augmentation materials. into tissues. Radiesse is an example of
an alloplastic material. Benefits of allo-
Dermal fillers categorized by source plastic materials include lower cost of
include: filler material, consistency in formula-
Autograft is the process of moving tis- tion of filler, longevity of material in
sue from one place to another in the implantation site and a limited sensi-
body. Examples of an autogenously tivity. The drawbacks of using allo-
conducted graft are lipotransfers, plastic material are that the techniques
which consists of taking fat from one of application are very sensitive and
part of the body and injecting it into the permanency of material and ex-
the patient’s oral-facial area. Advan- traction of material usually requires
tages of auto grafts are no promotion surgical intervention with possible
of an immune response, excellent in- scarring and disfigurement.
corporation into targeted site, and su-
perior esthetics and feel for patient. Permanent vs. NonPermanent
Disadvantages include the need for Fillers
adequate harvesting tissue and trauma Due to the recent influx of so many
from the harvested site. fillers and the lack of long-term studies,
Allograft is tissue harvested from the there are three categories of filler classifi-
same species and implanted into the cation that have evolved. These categories
patient’s lips. Examples of allografts are assigned in relationship to their per-
are CosmoDerm/CosmoPlast. Advan- manence and biodegradability. The three
tages of an allograft are species com- categories are temporary biodegradable,
patibility. Disadvantages are that strict semi-permanent biodegradable and per-
screening protocol standards must be manent nondegradable.120
continually developed and monitored. Temporary Biodegradable Fillers
Social and psychological concerns of
Temporary biodegradable fillers last
transplanting tissue from an unknown
from 3-8 months. Included in this catego-
donor are also a consideration.
ry of fillers are collagen (human, bovine
Xenograft is a transplant from another and porcine) and Hyaluronic Acid (avian
species. Crosslinked hyaluronic acid and bacterial).
(HA) products such as Restylane, and
Semi-Permanent Fillers
Juvederm are bacterial derived and
Zyplast and Zyderm, which are har- This category of fillers usually last one
vested from cows, are examples of xe- to two years and includes fillers that in-
nografts. The benefit of xenografts incorporate material to provide a scaffold-
ing effect and/or are designed to elicit an Fashion Trend Changes: as previously
induction of collagen to augment an in- discussed, facial cosmetics are ever
jected area. Nevertheless, the initial filler changing. What was “in” five years
is supposed to disappear after two years ago is “out” today.
and the patient’s own collagen replaces Host Immune Response: as we ma-
the previous filler. Semi-permanent fill- ture, we develop an entire library of
ers usually consist of CaHa (Calcium antigens that have the potential to cre-
Hydroxylapatite), DEAE (Sephadex par- ate an immunologic response to a ma-
ticles), Dextran, PLLA (Polylactic acid), terial or materials that previously did
PVA (Polyvinyl alcohol), Chitosan, HEMA not affect our bodies.122
(Hydroxyethyl methacrylate), human fi-
Facial Aging: due to the intrinsic and
broblasts (cultured) and autologous fat.121
extrinsic effects of aging, permanent
Permanent Fillers fillers that were placed in what was
As the name describes this filler re- considered an ideal position 10 years
mains in the tissue permanently. This cate- ago may migrate to an area that is no
gory of fillers includes PMMA (polymeth- longer considered an ideal location.
ylmethacrylate), PAAG (polyacrylamide Technical Error: the reality is that there
Gel) and silicone. is a learning curve associated with all
The Inherent Drawback of Permanent filling agents on the market today;
Fillers some are more forgiving than others.
No matter where you are on the learn-
The idea of undergoing a cosmetic
ing curve or how much injection ex-
procedure that utilizes permanent filler
perience you have, the possibility for
that eliminates the need to maintain and/
suboptimal technical placement exists.
or reconstitute the site of implantation is
With temporary fillers that only last
especially appealing to many patients. By
four to six months, the technical error
definition, permanent filler lasts forever.
will subside and no longer be evident
The advantages of such an implant may
within a short period of time. This is
seem to be cost effective and convenient,
one of the obvious benefits of utilizing
but let’s examine the following ramifica-
temporary fillers.123
tions that also exist:
Technological Advances: with ever- Histology of Injectable Fillers
evolving advances in science, the per- Histologically, fillers are classified into
manent placement of any substance for two groups according to their histological
cosmetic reasons would not be advis- reaction in the surrounding tissue: Volu-
able. Potential risks that patients may mateurs, which offer little cellular invasion
be willing to assume now may not be of surrounding tissue; and Stimulateurs
necessary in the near future as new which have a strong cellular reaction in
treatments and technologies evolve. and around the adjacent tissue where they
Patients should not be encouraged are placed.124 It is important to realize that
to consent to any device, material or all injectable fillers elicit a normal inflam-
procedure that presents possible long- matory response.125 Host defense mecha-
term and/or negative side effects that nisms react differently to the various filler
may exist with the use of permanent materials, but all substances—resorbable
fillers. or nonresorbable—appear to be clinically
and histologically safe. Inevitably it is the Microspheres below the size of 15 microns
host’s defense mechanism that dictates are phagocytosed and can be transported
the success of the placed mechanism. to the lymph system. Microspheres larger
than 15 microns, with a smooth surface,
It has been published that granulomas
occur in patients at a rate of 0.01 to 1.0% are encapsulated with129fibrous tissue and
based on the chemical composition, shape are not phagocytosed. Studies show mi-
and surface structure of the particles.126,127 crospheres of a diameter of 100 µm pro-
The main complications for fillers are the mote only about 56% connective tissue;
occurrence of granulomas and hypersen- microspheres of a diameter of 40 µm pro-
sitivity at the injection site.128 All fillers mote about 78% connective tissue. This
run the risk of eliciting these responses, fibrous network then becomes the perma-
but most research on current fillers cat- nent filler.
egorize these as small occurrences. Gener- In the United States there are no FDA-
ally every material elicits its own unique labeled injectable fillers for the true body
resorptive response on its host. Ideally of the lips (Zone B). Why is there a con-
with resorbable fillers, the process of sensus among most doctors for particular
breaking down and excreting the material lip fillers and what are the common ideals
will leave no trace of the initial substance, of these fillers for the lips? By far the most
not affect any other body physiology, and commonly used fillers for the body of the
will leave no negative immune memory lips (Zone B) are crosslinked HA prod-
for the initial material or crossover thera- ucts.
peutic materials.
In the United States, all crosslinked HA
Microspheres are agents placed into products approved by the FDA are indi-
fillers to retard desorption and/or stimu- cated for correction of moderate to severe
late encapsulation to maintain volume. facial wrinkles and folds, including naso-
Five Filler Classifications and their

Histological Responses
Autologous Fat
Quick to resorb, unpredictable stability, with no long-term study on transplanted cell
longevity.
Natural Filler Substances (collagen, hyaluronic acid)
Slow absorption with minimal histological reactions.
Fluid Filler Substances (silicone, acrylamides)
Dislocate larger volumes through muscle movement and gravity with little fibrosis.
Particulate Materials (PMA gravel and PMA microspheres)
Powdered material microspheres (2-50 microns) packed to induce minimal foreign body
reaction. Pure fillers that absorb more slowly.
Microspheres (non-resorbable, PMMA) (Artecoll, Radiesse)
Designed to stimulate encapsulation and scaffolds of permanent or temporary connec-
tive tissue formation; considered “Living Implants.”
labial fold and marionette lines. All other ican Association of Tissue Banks (AATB),
uses are considered off-label usage.130-133 where FDA standards are implemented.
The use of crosslinked HA products for All of the materials presented in the book
Zone B of the lips is considered an off-la- are regulated under such standards. If,
bel application. The most popular cross- however, the practitioner goes outside of
linked HA products used are Restylane, North America for harvested material, be
Juvederm, Captique and Hylaform deriv- aware of the potential medical/legal rami-
atives. These are all resorbable materials fications that may arise.
with tissue duration of approximately 3 to
As a side note, autologous and allo-
6 months.134
genic products are not approved by the
One of the esthetic advantages of using FDA. This is due to the fact that because
crosslinked HA fillers in the lips is their they are derived from human tissue, these
ability to add volume without distortion products are not required to undergo
of the vermilion border. When the filler is FDA-approval processes. Consequently
injected into the right plane, the vermil- patients should be educated about the
ion border may be lifted to reestablish the filler material, source and safety protocols
nasolabial line angle. Other fillers tend to of their donor materials prior to their oral-
obscure this relationship. An example is facial augmentation procedures.135
silicone which, when placed in the upper In addition to the filling component
lip, tends to migrate into the tissue. The of allografts, transplanting processed hu-
gel dissipates into millions of micro-drop-man tissue from one person to another is
lets126 that blur the vermilion border by theorized to initiate fibro-induction and
infiltrating above and below its demarca- or fibro-conduction. This phenomenon
tion line.65 As discussed in Chapter 2 (seeis called inductive interaction,136 which is
“Anatomy” section, p. 40), there is no clear
where the connective tissue affects the
demarcation line in the lower lip. There surrounding tissue cells. Epithelial cells
is a slow, gradual transition between have the genetic potential to differentiate
the red vermilion tissues to the stratifiedinto keratinized or nonkeratinized forms.
squamous tissue of the face. Silicone fill Fibro-induction is a process that causes
would be more suitable here. Some fillers, inductive interaction. Fibro-conduction
such as CosmoPlast, have been approved provides the scaffold for the connective
for rhytids around the lips and the vermil-cells to proliferate. The dental specialty of
ion border (Zone A), but not for the true oral surgery uses a substantial amount of
vermilion tissue of the lips (Zones B and allografts (ie, AlloDerm: see section below
C). for more detail.) as an alternative for lip
Off-label Lip Fillers augmentation137 and in periodontics, there
are constant ongoing studies on the idea
Human Collagen Allograft & Human Col-
of fibro-induction with respect to gingival
lagen (Allograft, Semi-Permanent) grafts.
Using these materials has some dis- Current periodontics therapy includes
tinct advantages, but some precautions using cadaver tissue from a tissue bank to
may need to be taken. The tissue acquired graft intraorally for gingival recession and
must be subjected to a donor-screening defects. Manufactured by LifeCell Corp,
process of viral deactivation. The materi- AlloDerm is a tissue graft prepared from
als also need to be regulated by the Amer-
cadaver-donated skin.
AlloDerm: Allograft (LifeCell Corp) The freeze-drying phase of the tissue
preparation removes all viable cells from
AlloDerm is a human-derived graft
the donor tissue. The resultant graft is an
material that is surgically placed into the
acellular matrix of type IV and VII colla-
host dermas or overlying grafts for larger
gen, laminin and elastin.138
areas like burn victims. The donor mate-
rial comes in a variety of shapes, depend- Cymetra: Allograft (LifeCell Corp)
ing on usage. For the lips, 3.0 x 7.0 cm This is an acellular, freeze-dried der-
Table 4.1
Types of Off-Label Material Potency Duration Indications
Lip Fillers
Cross-linked HA Allopast Face, rhytids
Restylane 4-6 months Off-label lips
Perlane 6-8 months
Touch 4-6 months
Captique 4-5 months
Juvederm 6 months
CosmoPlast Allograft 4-5 months Face, rhytids

CosmoDerm Off-label lips
Zyderm/ Xenograft 4-5 months Face, rhytids
Zyplast Off-label lips
Cymetra Allograft 1-2 years Face, rhytids
Off-label lips
graft segments are available. Trimming mal graft. The injectable filler is made
the graft is required prior to its placement from processing human tissue acquired
in the lips via incision sites in the corners from cadavers screened by the American
of the mouth. Association of Tissue Banks (AATB). The
The tissue graft is from an allograft graft tissue is separated from its epidermis
source, so the source of origin must be and the dermal cells. This tissue is then
screened for Hepatitis B antigens (HBsAg), processed to remove major histocompati-
Hepatitis C, HIV types 1 and 2, syphilis bility complex (MHC). These antigens are
(RPR or VDRL), and T-lymphotropic vi- removed to prevent immune responses in
rus (HTLV) type 1 and 2 antibodies. Addi- the recipients. The remnant tissue is colla-
tional steps for purifying the donor tissue gen types IV and VII, lamina, and elastin
of viruses include incubating the tissue in residue.
solutions for viral inactivation. Cymetra is a particulate form of this
matrix processed by nitrogen freezing has been halted due to pending FDA ap-
(cryofracture). The micro-particles are proval. This filler is currently unavailable
dried and placed in a 5-cc syringe for rein the US.
frigerant storage. The average particulate CosmoDerm & CosmoPlast: Allograft
size of the powder is 123 µm and the range (Allergan Aesthetics)
of powdered particles range from 59 µm to
593 µm. Seventy-seven percent of the par- These are the only FDA-approved
human collagens that are commercially
ticulates are under 52 µm, which subject
them to phagocytosis by the host scaven- available. The collagen is derived from
ger cells.139 This is delivered in a powder human neonatal foreskin cells. Through a
sophisticated tissue-engineering process,
form to be reconstituted for injection with
the resulting implant material is filtered
saline, lidocaine for injection. The recon-
for bacterial and viral components. Due
stitution of the powder-to-liquid ratio can
to the original source of tissue, no allergy
deliver volumes up to 330/mL. Indications
testing is required as is mandated for xe-
are for lips, nasolabial folds and rhytids.
nografts.
The longevity of this substance is longer
than other interdermal collagen.140 CosmoDerm is 35 mg/mLmL of solu-
bilized collagen. This filler is most effec-
With Cymetra and AlloDerm (a non-
tive when placed in superficial dermis.
water-based graft material), it is specu-
Although only a few studies have been
lated that there is epithelial induction at
conducted on this substance, it clearly
the site of implantation, thus stimulating
shows long-term potential.
growth or replacement of graft with host
connective tissue. This theory is one pos- CosmoPlast has 35 mg/mL of solubi-
sible explanation for its longevity.23,141 lized collagen cross-linked with glutaral-
Autologous Fat dehyde. This filler’s preferred placement
is in the deeper dermis. The practitioner
Autologous cellular therapy is a pro-
must be aware that there is the potential
cess where a patient’s own cells are ex-
for a negative reaction to occur in patients
tracted, cultured, and expanded expo-
with glutaraldehyde sensitivity. The idea
nentially for reintroduction to the patient
is to transplant a scaffold matrix for the
for the treatment of specific cosmetic and
conduction/induction of fibrocytes to pro-
medical applications.
duce a collagen fill by the patient’s own
Isalogen (Isalogen Corp; Exton PA) cells.142
This filler consists of autologous fibro- Both of these fillers have a low viscos-
blasts. In this process, a 3-mm punch biop- ity and, therefore, an exceptional flow. Be-
sy of skin is acquired from the patient. It cause of the ease of flow, these filler prod-
is sent to the receiving lab and processed. ucts have the potential to be massaged
The processing lab then returns the culti- into the superficial dermis.143 These ma-
vated cells in a vial containing 20 million terials come hydrated in 0.3% lidocaine.
cells. The solution is then injected into the The advantage is the ease of use and the
epidermis to augment the tissue. The treat- ability to use a 30- or 32-gauge needle.
ment is repeated every two to four weeks Several leading authorities now pos-
for three sessions. The transplanted cells tulate that these two filler products will
are placed to produce fibroinduction (col- eventually replace Zyplast and Zyderm
lagenisis). Production of this substance
(due to their bovine constitution) and due HA was discovered in 1934 by Karl and
to the inherent benign immune response John Palmer, scientists at Columbia Uni-
potential.144 versity, New York. Isolating the substance
from a cow’s eye, they named it after “hy-
When either of these filler products is
alos,” the Greek word for glass and the
placed in the lips, patients should be in-
uronic sugar found in the substance. HA’s
structed not to pucker for a day. Due to
incorporation into medicine has been very
the low viscosity of the filler, it has a ten-
impressive.147
dency to migrate away from the original
deposited area within the first day. The human body contains approxi-
Hyaluronic Acid (HA): Xenograft mately 15 grams of HA. Our bodies pro-
duce and house HA in our vitreous hu-
HA is a naturally occurring gly-
mor, synovial fluid, umbilical cord, and
cosaminoglycan biopolymer composed of
connective tissue, where the highest con-
linked alternating residues of the monosac-
centration is found—especially in the skin.
charides D-glucuronic acid and N-acetyl-
Its role is to add volume by binding to wa-
D-glycosamine, and produced by various
ter and mediate cell growth.148 Hyaluronic
cell types within the cell membrane.145,146
acid is highly hydrophilic (water-loving)
Through continued research and de- and tends to form extended molecular
velopment, it is now extensively used in formations that occupy a tremendous
ophthalmic surgery and as an ingredient volume relative to its injected mass. One
in over-the-counter cosmetics. It can also gram of HA has the potential to bind to 3
be used in drug delivery, orthopedics, L of water.
cardiovascular aids, and wound healing. HA is a nonprotein molecule, which
Figure 4.1 HYALURONIC ACID

HA is a naturally occurring glycosaminoglycan biopolymer composed of linked alternating
residues of the monosaccharides D-glucuronic acid and N-acetyl-D-glycosamine.
virtually eliminates a cell-mediated ad- chemical and molecular properties in all

verse reaction and the potential for im- mammalian species, making this material
munogenic hypersensitivity. The prod- a promising filler.151 The main disadvan-
uct is naturally integrated into the tissue, tage to Hylan is its short half-life, one to
allowing important nutritive agents to two days, in all connective tissue in the
pass freely through the implant and cells human body. The natural state of this
to pass between fragments of the gel. To filler does not have sufficient resistance to
stabilize, or avoid early breakdown, HA break down for use in soft tissue augmen-
needs to be cross-linked with a neighbor tation procedures.152
molecule.
Hylan B implants are produced by us-
As we age, the concentration of HA in ing sulfonyl-bis-ethyl cross-links between
the dermis decreases. Because of the re- hydroxyl groups of the polysaccharide
duction of HA, there is a decrease in the chains. This cross-linkage adds to its lon-
amount of water retained by the dermis, gevity and stability.153 Numerous studies
leaving the skin thinner and more prone were performed with hylan “B” (hyla-
to wrinkles.149 HA is marketed and inform) and the studies show that there is
corporated into many over-the-counter substantial evidence that Hylaform is a
cosmetics as a hydrophilic medium, yet safe and effective material for soft tissue
because of HA’s high molecular weight it augmentation.154 Hylaform comes in three
will not penetrate the dermis of the skin. forms: Hylaform, Hylaform Plus (larger
Due to its affinity to attract moisture and particle size, lower dermis) and Hylaform
hold its form, it is a very efficient filler. Fine Line (smaller particle size, upper der-
Most adverse reactions to HA are associ- mis).
ated with its injection, and are a result of Hylaform Plus: Allergan (xenograft)
delayed hypersensitivity reactions.150
It is derived from the same source as
HA is derived from animal and bacte- Hylaform (avian combs). The bond is the
rial sources, which makes it a xenograft same divinyl sulfone cross-linkage, ap-
source material. The difference from the proximately 20% by composition of ma-
two sources is predominantly the length terial. The particle size is larger with this
of the final processed chain. The molecu- product: around 750 µm. It is dispensed
lar weight of the bacterial source is 1.0 in a 5.5 mg/mL volume of Hylan B.
to 2.0 DA. At this weight, there are 4 to Cross-Linked Hyaluronic Acid (Restylane/
7 thousand repeating units (monomers).
Perlane – Medicis, Inc.) (Juvederm,
The molecular weight of the animal-based
Captique - Allergan)
HA is 4 to 6 M DA, composed of 10 to 15
thousand repeating units (monomers). Cross-linked HA is very biocompat-
ible with a 0.06% adverse reaction to treat-
Hylaform: Xenograft (Allergan)
ment, in which the major reaction is hy-
This substance is derived from rooster persensitivity, occurring in 1 out of every
combs. The gel particle size is 500 µm. It 5,000 patients.150 Most hypersensitivity re-
is dispensed in a concentration of 5.5 mg/ actions are theorized to be caused by injec-
mL of Hylan B gel. Due to its xenograft tion technique and the speed of injection,
nature and originating source of rooster rather than authentic immune reactions.156
combs, hylaform has been studied for 10 There have been very isolated occurrenc-
years.150 Hyaluronic acid has the same es of foreign body reactions.157 However,
TIPS
Massaging of injected filler around an injected site works

particularly well for the commisure area. After injecting a
Hyaluronic Acid filler one can manually displace it into the
surrounding tissue. Be advised that over massaging of injected
filler can completely displace its presence thereby eliminating
its intended purpose.
leading authorities have argued that these a process in which the individual chains
reactions were most likely due to a pro- of hyaluronic acid are chemically bound
tein contaminate of the treatment, rather together. The resultant material is a gel
than the hyaluronic acid itself.158 Current product in which its viscosity is depen-
processing of crosslinked HA has signifi- dent on the amount of cross-linkage. The
cantly decreased these contaminants. degree of this process is calculated by the
Crosslinked HA products have a very percentage of HA that undergoes cross-
good clinical reliability in both a 3-month linking. For example, Juvederm has a de-
study, with an effective improvement of gree of cross-linking of 6-8% degrees and
96.4% using the 5-grade Global Aesthet- Restylane has a degree of cross-linking of
ic Improvement Scale,159 and a 6-month less than 5%.
study with Juvederm. The filling effect of Uncross-Linked HA
cross-linked HA (Restylane) was notably Almost all cross-linked HA products
longer in the areas less affected by anima- have a certain percentage of uncross-
tion. Due to the activity and vascularity of linked HA in the composition of the filler.
the lips, there is usually a 6-month, 50% The uncrossed HA adds to lower the G’
satisfaction rate for results.160 Compara- and aids in the flowability of the material.
tive studies show crosslinked HA to pro- Uncrossed-linked HA is absorbed within
duce a longer lasting cosmetic result than a couple of days and does not contribute
bovine collagen. The frequency, intensity, to the overall persistency of the filler.
and duration of local injection-site reac- Gel Hardness (G’)
tions were similar for the two products.124
Restylane composition is set to balance to This characteristic of gel formulation
normal tissue pressure. When the tissue is relevant to the amount of force required
pressure is raised due to swelling or low- to initiate the flow of the HA filler out of
ered from dehydration, the cross-linked the syringe. Factors to consider when ana-
HA swells and shrinks in relation.161 lyzing elements that affect G’ are:
The higher the cross-linkage of HA,
Formulation of Cross-Linked the higher the G’
HA Products The higher the concentration of HA,
The cross-linked HA gel formulation the higher the G’
is characterized by the total HA concen- The larger the size of the gel particle,
tration, concentration of cross-linked HA, the higher the G’
concentration of uncross-linked HA, and How the cross-linked HA is sized
gel mass sizing. These properties influence
Amount of uncross-linked HA
the handling properties of the particular
crosslinked HA filler. The handling prop- The G’ for Juvederm is around 190 Pa
erties influence the texture, persistence, a and the G’ for Restylane is around 400
and injection pressure needed (G’). Pa, at 1.6 H2.
Cross-Linking TIP: the lower the G’ the more tactile feel
Unbound HA forms a liquid made the augmenter has of the material. The ad-
of highly hydrated individual polymers vantage of an increased tactile perception
(chains) that are metabolized in the body is superior feel of the material flow and
within 24-48 hours. Cross-linking refers to resistance mounting in a plane when it be-
comes saturated. This advantage greatly of the filler in the dermis and anatomical
reduces the complication of overfill. sites leads to superior results and a maxi-
Hydrostatic Equilibrium mizing of the materials.
HA has a great affinity to water. The Crosslinked HA from Medicis Aes-
amount of HA in an injectable form will thetics is available in three forms:
affect the augmentation site. For example, 1. Restylane: 1 x 105 HA particles of N250
Captique is dispensed in a solution close µm size in HA fluid, or 100,000 gel beads/
to hydrostatic equilibrium, which is 5.5 mL. This translates into 20 mg/mL. Used
mg/1mL water. When injected into the for medium-sized lines.
dermis it will not want to attract addition- 2. Perlane: 8 x 103 gel particles/mL of ap-
al water to bind to itself. Your fill with this proximately 500 µm in diameter or 8,000
material will remain stable: what you fill gel beads/mL. Used for deep wrinkles,
is what you get. Juvederm and Restylane folds and scars, offers longer lasting re-
are dispensed in 24- and 20-mg/1 mL, results for lip enhancement or enlargement.
spectively. At this ration, these fillers will
3. Fine Lines: 2 x 105 gel particles/mL of
want to attract and bind to water in the
20-30 µm in diameter or 200,000 gel beads/
dermis. After augmentation the filler will
mL. Used for superficial facial lines.
have the propensity to slightly increase in
volume. At six months post-treatment, a higher
proportion of patients showed a greater
Restylane (Medicis)
than or equal to 1-grade improvement in
Restylane, a nonanimal stabilized the Wrinkle Severity Rating Scale (WSRS)
hyaluronic acid, is a cross-linked, carbo- score with Restylane/Perlane (75%) than
hydrate-based molecule that comes in a with Hylaform (38%).164 Restylane/Per-
concentration of (20 mg/mL).162 Restylane lane was considered superior in 64% of
is obtained from the culture of nonpatho- patients, whereas Hylaform was superior
genic bacteria (S. equi or ) through a pro- in 8% of patients. Due to the viscosity of
prietary process (Medicis). The bacteria Perlane, a 27-gauge needle is recommend-
are unicellular organisms without chloro- ed.
phyll secretion, thus a nonplant organism.
The bacteria belong to the class Monera. It FDA-Approved Fillers
is a pure class of HA because the bacteria Captique (Allergan)
are without a nucleus and live on sugar
Captique passed FDA approval for
and plant amino acids.163 The stabilizing
filling in corners of the mouth, nasolabial
process for cross-linkage uses 1.4-butandi-
fold, and lips. This is a cross-linked, non-
ol diglycidylether Bonds.
animal hyaluronic acid gel. The cross-
Restylane claims to cross link the man- linkage is via a divinyl sulfone bond. Gel
ufactured HA at 1-3% of the whole sub- particle size is 500 µm. This is dispensed
stance. Nevertheless, stabilization of the in 5.5 mg/mL HA gel.
filler is the most important contributor to Juvederm (Allergan)
its longevity, an aspect that must be clear-
Juvederm is a cross-linked HA product
ly defined. When using filler, the goal is to
that was FDA approved in 2006. Juvederm
maximize the correction duration, not to
is cross-linked by 1,4-butanediol diglyci-
maximize the time that the filling material
dyl ether in a phosphate buffered solution
remains in the tissue. Correct placement
of 6.5-7.3 pH. Juvederm’s unique proper- Initial research on collagen started

ty is the softness of the filler as compared with Gross and Kirk at Harvard Medical
to other hyaluronic acids. Three types of School on extracted fresh calf skin in 1958.
Juvederm are available: Juvederm 18 for Under the right conditions, a solid gel was
fine lines, Juvederm 24 (Juvederm Ultra) produced from the calf skin specimen.167
for the forehead and cheeks, and Juved- Through years of continued research, the
erm 30 (Juvederm Ultra Plus)for the lips bovine collagen was purified and refined,
and nasolabial folds. Juvederm Ultra and until Zyderm collagen was developed by
Ultra Plus are available in the US. Juved- Collagen Corp and tested by 728 physi-
erm has not been made available in the US cians in the Zyderm Clinical Verification
at this time. Program. Sam Stegman and Ted Tromov-
ich (dermatologists) and a California co-
Juvederm sets itself apart by its pro-
prietary method of manufacturing HA. operative study group managed a study
The Hylacross™ technique has two com- on corrections of facial scars and depres-
ponents. One is the crosslinkage tech- sion in 5,109 patients. In 1981, Zyderm
nique, which consists of 90% crosslinked collagen received the stamp of approval
by the FDA for soft tissue augmentation.
HA/1mL syringe and 10% unlinked HA.
This was the first substance the FDA ap-
The cross-linked HA in a 24 mg/mL sy-
ringe would be 21.6 mg/mL. Another proved for soft tissue augmentation.
way this substance sets itself apart is its This study started the surge of mod-
advanced sizing technique that reduces ern-day collagen corrections, later evolv-
the G’ (G’ at 1.6 Hz) (170-200 Pa), which ing into cosmetic facial fills.168,169 To date,
increases the tactile feel of the material more than 1.3 million individuals have
when injected. received injectable collagen treatments.143
This bovine collagen-based filler is har-
Cross-Linked HA Degradation vested from the hides of specially bred
A significant advantage of nonanimal cows sequestered since the initial produc-
stabilized hyaluronic acid is its prolonged tion began in the 1970s. Zyderm collagen
resident time in the tissue. Cross-linked is available in three preparations: Zyderm
HA is slowly broken down after injection. 1, which is the original material, it is com-
There is no trace of the original implant posed of 3.5% bovine collagen by weight
material in the site of implantation after (35 mg/mL); Zyderm 2, which is 6.5% bo-
host resorption. Finally the degraded hy- vine collagen by weight (65 mg/mL); and
aluronic acid is transferred from the der- Zyplast, a glutaraldehyde bovine colla-
mis and degraded in the liver to carbon gen, which is a manufactured cross-linked
dioxide and water.165,166 bovine collagen. The glutaraldehyde pro-
duces covalently bonded, cross-linked
Bovine Collagen (Xenograft)
bridges between approximately 10% of
There are pure bovine collagen fillers
the available lysine sites on the bovine
on the market, such as Zyplast and Zy-
collagen molecules.170
derm. Likewise, there are combinations
of bovine collagen and other alloplastic Zyplast lasts four to six months before
sources, such as Artecoll and ArteFill. clinical corrections diminish.171
Zyplast is
injected in a phosphate-buffered, physi-
Zyplast and Zyderm (Inamed) (Resorbable ological saline solution containing 0.3%
Filler) lidocaine for reduced injection pain. Hy-
persensitivity is a risk because of the xeno- is administered. The patient is asked to

graphic nature of these fillers.172 Testing is return within 48-72 hours to evaluate for
required with the use of these xenographs. possible reaction.174 A positive reaction is
The testing procedure recommended by defined as swelling, palpable induration,
the manufacturer is that four weeks prior or persistent or evanescent tenderness,
to the procedure, a Collagen Test Implant as well as intermittent or persistent ery-
is administered intradermally into the in- thema and any redness that persists or oc-
ner forearm to determine if a patient has curs six hours or longer after the test was
a sensitivity to the implants. The reported performed. Allergy testing is also recom-
incidence of allergic response to Zyplast mended to retest individuals who have
ranges from 3-10%.173 This material has previously undergone collagen therapy,
been noted as the “gold standard” in der- more than one year earlier.175
mal fillers.
Fillers for Facial Augmentation
Allergy Testing Protocols
(Not for Lips)
Proper skin testing is of the utmost
importance with xenographic injectable ArteFill (Artes Medical; San Diego, CA)
fillers, such as Zyplast and Zycore. Any (Alloplast/Xenograph)
person with a history of sensitivity to li- It is a permanent, injectable cosmetic
docaine, prior bovine collagen or any ana- filler composed of polymethylmethacry-
phylactic history is not a candidate for cos- late (PMMA). Microspheres (20% by vol-
metic bovine injections. Skin-test syringes ume) between 30-50 microns in diameter
are manufactured to test for allergies to are suspended in a solution of 3.5% bo-
all forms of injectable collagen. The pro- vine collagen, 80% by volume. Dentistry
cess of testing is a tuberculin-like test on uses PMMA quite often in fabrication of
the inner forearm. A spot penetration into prosthetic devices. Additionally, PMMA
the dermis of 0.1 cc of Zyderm collagen has long been known as bone cement and
Material Source Duration Indications
ArteFill, Artecoll Alloplast/Xenograph Semi-permanent Face;

Lips contraindicated
Radiesse Alloplast Semi-permanent Face;
Lipotransfer Autograft Semi-permanent Face, Rhytids
Isolagen Autograft Semi-permanent Face;

Table 4.2
Fillers Recommended for Nasolabial Folds
(Artecoll, ArteFill, Radiesse, Lipotransfer, Autologen)
has been used in cosmetic surgery with a diameter, 20% by volume, that are sus-
very good safety record. PMMA micro- pended in a bovine collagen solution with
spheres are biologically inert and nonde- a volume of 80%, and 0.3% lidocaine to
gradable. The treatment results are per- alleviate discomfort during injection. Col-
manent, therefore technical errors as well lagen is the vehicle with which the per-
as incorrect injections will last.176 manent PMMA spheres are injected into
Following the subdermal injection of the skin. As the Artecoll is a collagen that
ArteFill, the collagen suspension liquid is is absorbed, it is replaced by the person’s
reabsorbed by the body within one to three own collagen as the microspheres act as a
months leaving the PMMA microspheres stimulus for new collagen formation.
in place. The microspheres stimulate the Since bovine collagen is used, the stan-
body to lay down a layer of connective tis- dard protocol for preinjection testing is
sue, which encapsulates the microspheres. required. This process is permanent and
This process will be completed within two is essentially completed approximately
to four months after the injection. This three to six months after the area is in-
layer of connective tissue combines with jected. It is used for wrinkles, such as the
the microspheres to produce a long-last- smile lines, frown lines and lip lines, as
ing correction. Duration is quoted by the well as for acne scarring. It usually takes
manufacturer as 10 years.177 This is a pro- two to three treatments to complete this
cess where the implant carrier is actually procedure. Because Artecoll is a perma-
replaced by the body’s own tissue. The re- nent filler—unlike Restylane, Hylaform,
sulting induction of connective tissue cre- Juvederm, and the collagen products—
ates a living implant. The injected size of complications can occur. If placed in the
the PMMA microspheres must be isolated wrong plane, the material is very unfor-
spheres and range between 30-42 µm. This giving. Deposition into muscle may cause
is the ideal size that escapes phagocytosis. nodule development.180 Artecoll has been
The microspheres also have to be small associated with granulomas and nodules
enough to pass through a 27-gauge needle around the lips.181 Since this is a new mate-
without too much back pressure.178 rial, no long-term studies have been done
Since ArteFill is a permanent filler and and migration of any permanent filler is
tissue migrates with aging, there are con- possible as the face ages. This material is
cerns about its placement. In addition, not FDA approved for lip enhancement.
there are long-term studies on the justi- The differences between ArteFill and
fication of placing a hard substance like Artecoll are primarily due to the technolo-
polymethylmethacrylate microspheres gy used to fabricate the microspheres and
into soft tissue.179 the resultant PMMAs. ArteFill has a very
Artecoll (Rofil Medical International) smooth surface, attributable to its PMMA
(Alloplast/Xenograph) microspheres, which reduces the associ-
ated granulomas.
This product is formulated and marketed
for distribution in Europe and the world, Techniques for PMMA Placement
but it isn’t distributed in Japan and the PMMA fillers are more technique sen-
United States. Artecoll is a product which sitive than collagen or hyaluronic acid,
combines bovine collagen with PMMA which requires a bit of patience to become
microspheres between 30-42 microns in proficient in its use. Most clinicians rec-
ommend a “tunneling technique,” where Calcium hydroxylapatite has been used

the needle is moved back and forth when in many forms for the last 15 years in re-
injecting material into the dermis. Artecoll constructive surgery, orthopedic surgery,
should be implanted deep intradermally and dentistry.185 Radiesse is marketed as
only into the reticular dermis, just above a subcutaneous or deep tissue filler. The
the junction between dermis and subcu- mechanism of action in Radiesse is pri-
taneous tissue.182 Significantly more pres- mary through the product being encapsu-
sure is required to fill with Artecoll since lated by surrounding tissue and then be-
the viscosity of Artecoll is three times ing replaced by the body’s own collagen
higher than Zyplast.183 Due to its viscos- (collagenisis).186 The remaining calcium
ity, a 27-gauge needle will be needed. A hydroxyapatite particles are broken down
tunneling effect is most effective for de- by an enzymatic process into calcium and
positing into the dermis. phosphate until complete phagocytosis is
Other PMMA Fillers achieved. Because of the calcium hydrox-
ylapatite granules, it is proposed that this
Aphrodite Gold (European Medical
material will last longer; however, concern
contract Manufacturer; Nijmegen, The
over particle migration and ossification
Netherlands) is the former Artecoll in a
exist. Results of calcium hydroxylapatite
new package, distributed outside Europe
show clinical improvement with minimal
and the United States. Metacrill (Nutri-
side effects.187 In the skin, especially in the
cel Laboratorios; Rio de Janeiro, Brazil)
lip, Radiesse does not “remain soft” but
is polymethylmethacrylate microspheres
exhibits a clear hardening of the implant,
1-80 µm in diameter. Bioplasty (Dr. Almir
which resolves over time. Therefore, it is
Nacul; Porto Alegre, Brazil) is similar to
not recommended for lip augmentation.
Metacrill, as is Precise (Clinica Estetica;
Tijuana, Mexico). SPECIAL NOTE: If reaugmenting lips
Calcium Hydroxylapatite Microspheres previously injected with Radiesse, the
augmenter must be aware of the follow-
Radiesse, formally known as Radiance, ing:
Radiance FN (calcium hydroxylapatite) After the degradation of the filler ma-
(BioForm Medical, Inc., San Mateo, Calif.), trix of Radiesse, the calcium particles
is a semi-permanent filler. It is composed may remain. Injecting a different type
of 55.7% calcium hydroxylapatite (CaHA): of filler into the lips may bring the cal-
25- to 45-µm microspheres suspended in cium particles to the surface of the mu-
36.6% water for injection USP, 6.4% Glyc- cosal again, making them visible.
erin USP, and 1.3% sodium Carboxymeth-
ylcellulose.184 The implant compound hy- This material is very technique sensi-
droxylapatite has already received FDA tive. Radiesse must be injected deep
approval for laryngeal augmentation, soft intramuscularly or deep glandular
tissue marketing and filling/augmenta- into the lip mucosal; otherwise the ma-
tion of dental intraosseous defects and terial will be visible and/or palpable.
oral/maxillofacial defects. It has also been Therefore, Radiesse is contraindicated
for
used as a transurethral bulking agent for augmentation.
stress related urinary incontinence. The
use of Radiesse for facial aesthetics is “off Lipotransfer
label.” Modern fat transplantations began
in the late 1700s, ultimately leading Complications associated with the use
to the liposuction movement spear- of silicone include foreign body type
headed by Fischer and Fischer.188 In siliconomas lasting over 10 years and
1986, during the American Society for immune related complications.193,194
Dermatologic Surgery, Pierre Fournier Medical grade silicone is sterile, apy-
presented the micro lipoinjection tech- rogenic, clear, colorless and can have
nique with 13-gauge needles for fat viscosity ranges from 350 to 1,000 cen-
transplantation.189 Lipotransfer is most tistokes (cs). Water has a viscosity of
successful when 100 cs. Mineral oil
viable fat cells has a viscosity of
are transferred 350 cs.
to areas already
As you can
occupied by fat
imagine, injecting
cells. The results
a silicone with the
of autogenous
viscosity of 5,000
fat injections
requires great force
are mixed with
and special injec-
the transplanta-
tion syringes. In
tion, yielding
North America, sil-
results of near
icone was cleared
to total resorp-
for use during post-
tion in several
operative retinal
years.190,191
tamponade during
Other Patient presents 7 months post-injection of vitreo-retinal sur-
Radiesse in lips by a plastic surgeon. Notice gery. In Europe,
Synthetic nodules in Segment 4 and 5. Patient reports select silicones are
Filler feeling nodules generally around lingual of allowed for lip
Materials labia. and facial filling.
Alloplast Silicone particles
Silicone (Silikon have an irregular
surface and cannot be phagocytosed,
1000s, Alcon Lab Inc, Ft. Worth TS,)
but may eventually form foreign
(Adatosil 5000, Bausch and Lomb,
body granulomas due to “frustrated
Rochester NY) (PMS-350) macrophages.”195 Silicone is not an ap-
A purified polydimethylsiloxane, sili- proved filler for the lips in the US for a
cone is a highly purified, long chain variety of reasons. In some states, it is
trimethylsiloxy-terminated polydim- against the law to possess silicone with
ethylsiloxane silicone oil. Silicones the intent to inject into human skin.196
are synthetics and do not occur in the
body naturally. The earliest recorded Due to the controversial efficacy of
silicone usage was published in the silicone in the human body, it is only
1950s.192 Silicones in general give a approved for ophthalmic treatment.
great aesthetic result; nevertheless, More important is the regard to per-
some serious medical complications manent fillers in the cosmetic augmen-
have occurred with their use and abuse. tation community, whereas placement
of a long-term filler is not conducive facial fat loss by replacing lost volume.
with comprehensive cosmetic en- Sculptra provides an increase in skin
hancement. The dynamics of the lips thickness, helping to create a more natu-
change with age, as do the trends that ral facial appearance in those with facial
may have influenced the original aug- lipoatrophy.199 Sculptra is contraindicated
mentation.197 for lip augmentations. It has shown great
Additional Silicone Fillers198 results in treating facial lipoatrophy with
HIV patients. However, long-term studies
• Silikon (Alcon Laboratories; Fort
still need to be
Worth, TX), approved by the FDA for
concluded.
retinal reattachment since 1998. It has a
viscosity of 1,000 cs. Polytetrafluoroethylene (e-PTFE) (Gortex),
• SilSkin (Richard-James De-
velopment Corp; Peabody,
MA), not approved by the FDA.
It has a viscosity of 1,000 cs.
• PMS (Vikomed; Germany),
it has a viscosity of 350 cs.
Sculptra (Dermik, Berwyn, Pa.)
This product is a polylac-
This particular patient presented to my

office with an asymmetrical augmentation
of her lips. Her lips had been augmented
with silicone. After 3 years, notice
that the material is unforgiving. This
deformation has a significant impact on
the patient, and it stains the community
of professionals who pride themselves on
the science.
tic acid (PLLA). PLLA is a biodegradable (Softform, Ultrasoft, Ultrasoft-RC, Tissue

synthesized from corn materials which Technologies, San Francisco CA)
has been used in surgical sutures (Vicryl, Gortex has been used in millions of
Dextran) for years in surgery. The mech- vascular surgeries since 1970. The pore
anism of action is to stimulate a foreign size of the particular Gortex graft being
body reaction (neocollagenesis). Due to used influences how the implant is inte-
the nature of collagen induction from this grated into the adjacent tissue. The great-
product there is a significantly higher risk er the porosity in the material, the more
of granulomas. This is an injectable prod- surface area is available for nearby tissue
uct that restores and corrects the signs of incorporation, which results in a more
stable, natural feeling implant. Reduced are discreet, single, well-defined locations
porosity associated with the graft dimin- and do not grow. A true granuloma ap-
ishes tissue incorporation. This leads to pears late, usually after 6 to 24 months.
more of an encapsulation of the graft, Granulomas manifest themselves at all
which increases the potential for tissue injected sites around the same time, they
migration.201,202 Various forms of e-PTFE grow fast and respond well to intralesion-
are available, such as Soft, Ultrasoft (Tis- al steroid therapy. Foreign body granulo-
sue Technologies), and Advanta (Atrium mas have been reported in the literature
Medical). with all fillers at a rate of 0.01-1.0%.203
Immune Responses to Dermal Hyperplastic granulation tissue is
Implants composed of multinucleated giant cells.
Granulomas These giant cells are derived from mac-
As augmenters we need to differenti- rophages.
ate between lumps or nodules and granu- All implants undergo an inflamma-
loma. Lumps present immediately within tory response which integrates, isolates
the first four weeks. Lumps and nodules or rejects the implant or a combination of
This patient formed a granuloma in her right lateral nasolabial fold. Notice the inden-
tation from scarring from surgical removal and associated reduction in volume due to
concurrent steroid therapy.
Points to ponder on Using Filler Agents
Get informed on the particular filler you intend to use. Include testing, success/failure
rates of the particular material.
Get safety data for material. Suggested material may not be cleared for lip augmenta-
tion. Check your peer-reviewed journals and documents. Look beyond the scope of den-
tal journals and national publications.
Don’t jump on the bandwagon. When you start practicing lip augmentation, lots of mar-
keters will be showing up. Use your professional compos to guide your purchases. Some-
times it takes years for negative side effects of materials to occur.
Research the CDRH database (http://www.fda.gov/cdrh/databases.htmL) for device
indications.
Use discretion when using a device for OFF-LABEL indications.
Off-label use: In the United States, FDA regulations permit physicians to prescribe ap-
proved medications for other than their intended indications. This practice is known as
off-label use. Great care should be taken using such devices and procedures, espe-cially
in the cosmetic arena.
Report adverse reactions and product problems to the FDA MedWatch system (http://
www.fda.gov/medwatch).
Report treatment successes to colleagues, study groups and professional journals.
Attend continuing medical education courses on fillers and subscribe to various journals
with emphasis on lip augmentation.
these. The skin is one of our first line or- macromolecules, bacteria, and tissue
ganisms against environmental attack. We cells.204,205 The importance of sterile, pure,
have developed an evolutionary system conspicuously regulated filling material
of defense that has to be respected when is paramount in reducing host reactions.
injecting substances into the dermis. The Good injector experience in needle place-
majority of the immune system is based ment and injection technique will greatly
on T cells and a class of lymphocytes con- reduce the potential for granuloma forma-
sisting of functionally and phenotypically tion. The term pathergy seems to be cited
distinct groups that mount a response. for a significant amount of studies relative

to long-term formation of granulomas.
There are many theories that attribute
Pathergy Theory is defined as an exag-
to the granuloma formation and the in-
gerated, altered, uncontrolled response to
termediate steps postulated are greatly
nonspecific stimuli, a process that proba-
related to the constitution of the implant
bly involves memory T cell activation and
used and/or delivery mechanism. Never-
is operant in the multiplicity of pathologic
theless, as soon as the implant is in place,
process.206
there is a “race for the surface” between
TIPS
Tactilely feeling filler material is an important process during any

augmentation. I stop several times during an augmentation appointment
to feel where I have placed filling material. This is particularly
advantageous in the nasolabial fold, commissure and marionette lines.
The advantages to intermittent breaks during injection are:
Allows augmenter to manually locate area filled and distribution
of filler.
Gives perspective into how the patient may be feeling the material
in their dermis.
Is the first step prior to manually massaging filler into the tissue if
one has overfilled in a particular area or wishes to redistribute filler
in the plane manually.
Treatment for Granulomas of surrounding tissue rate associated with

Intralesional corticosteroids and mi- it. This steroid atrophy can be leveled out
nocycline are traditionally used. Blanch- with hyaluronic acid or collagen until nor-
ing injections form a 10 mg/mL Kenalog mal recovery occurs. Another approach is
ampule into the inflammation, and in- to inject intralesional normal saline from
tralesional injections form a 40 mg/mL 5-20 mL per session.207 Lastly surgical
Kenalog ampule in the granuloma. Both incision of hard and well-defined granu-
pathologic conditions require as much of lomas may be indicated. This is usually
the triamcinolone as possible to be inject- performed after intralesional therapy is
ed. Steroid therapy has a 20-30% atrophy performed.
Chapter 4 Review
study Points
History of injectable fillers
Properties of fillers: what constitutes an ideal filler, FDA classification of fillers.
Five histological responses to fillers according to their classification
“Off-label fillers,” “label-usage filling,” and the various products that these
applications affect
Formulation of cross-linked hyaluronic acid
Relevant immune responses to dermal fillers and complications
study Questions
1) What are the four inherent drawbacks of permanent fillers?

2) What is the main role of microspheres in dermal fillers?
3) What are the advantages to using cross-linked hyaluronic acid?
4) Filling in Zone B of the lips is considered an “off-label” or “labeled” usage? Is
Zone A of the lips considered “off-label” or not?
5) What are the properties of cross-linked hyaluronic acid that are affected in the
formulation process?
6) What is the incidence of foreign body granulomas in relationship to injectable
hyaluronic acid?
7) Define pathergy.
5
Chapter 5
The Artist
Omnia mutantur nos et mutamur in illis
All things change, and we change with them.
Chapter 5 The Artist 110
Beautiful Proportions
Orthodontics
Art of the Fill
After lecturing, I often field many questions from the participating

audience. The questions I receive usually focus on the technical
aspect of augmentation. Yet when the dust of “post-lecture
classroom style” questions settles, I am intrigued at some of the
straggling, one-to-one questions I receive. One persistent question
I address time and again goes a little something like: “now that
I know how….why?” What are the fashions trends of lips? What
are my guidelines? What are the varieties of lips and how do I
augment a patient’s lips when I have so little knowledge of the
fashion of lips?
To me these questions are the most revealing areas of interest

pertaining to the specialty practice of lip and perioral
augmentation. They set the tone for the impact of lip and
perioral augmentations in the practice of dentistry and oral-
facial cosmetics. You see until recently it was the fashion industry
that dictated fashion trends of the lips. They do this in a very
similar way clothing designers introduce new fashions. This is
done through marketing and product development. With the
advent of cosmetic injectable enhancement of the lips we (the
practitioners) are significantly altering the traditional way of
marketing fashion. We as professional doctors are held to an
entirely different standard of care, for they are our patients first
and consumer last. We must base our techniques and treatments
on science and proven repeatable and predictable methods and
lesser on trends. The good news is the science and studies are
there, we need nothing more than to arm ourselves with them for
the benefit of our patients and profession.
I wrote this chapter with those questions in mind. There are

sources from scientific literature and anecdotal evidence I have
summarized on my own personal journey through lip and perioral
augmentation.
Beautiful Proportions
Facial Symmetry (Divine Proportion)
The space between the slit of the mouth and the base of the nose is one-seventh of the face…the space from
the mouth to below the chin will be a quarter part of the face, and similar to the width of the mouth…
1
1.618
1
1.618
As illustrated, the lip can be divided up in the divine proportions accordingly.

Here is an example of the

reverse relationship of lips.
Even though the model’s lips
are symmetrical from a frontal
view, the photographer shot
the photo perspective from an
inferior view. What makes the
picture pleasing is the inverse
relationship of the lower lip
being slightly smaller than
the upper lip: the 1-1.618 or
“golden proportion.”
vine proportion.” Artists of

the Renaissance constantly
sought to replicate its val-
ue. There seems to be an
arrangement of space that
people find pleasing. This
arrangement is pleasing to
This passage was included in Leon- look at, exist in, and create by.
ardo da Vinci’s notes on facial symmetry
The divine proportion is a compilation
written 800 years ago. The divine propor-
of positive and negative spaces. It’s the
tion has many different names, including
silence between the notes. It is an asym-
“the golden section,” “the golden mean,”
metrical balance that balances our eyes.
and the “golden ratio.” The divine pro-
The divine proportion implies an innate
portion is represented by the mathemati-
beauty we, as human beings, find pleas-
cal symbol of phi, which was named
ing. This type of beauty is not subjective,
after the Greek sculptor, Phidias (Phi=
but transcends all our learned or condi-
1.6180339887…), which was introduced
tioned bigotry, which we are subjected
by the ancient Greeks around 500 BC. The
to on a conscious and unconscious basis.
divine number is the reciprocal of Δ[(Δ5-
Divine proportion has a definite mathe-
1)/2].
matical relationship, which is simply 1 to
This proportional relationship is evi- 1.618 or 1 to 0.618. If we use a calibrator,
dent in architectural work like the Par- we can measure out select cuts of the hu-
thenon in Athens and with the building man anatomy which fall into this arrange-
of the great pyramids. In the 1500s, the ment. The face falls into this relationship
renaissance brought about further ex- as illustrated.
ploration of its numeric value. Da Vinci
Facial symmetry has a significant role
used these proportions when painting
in the overall appeal of the human face.
“The Last Supper,” and he illustrated for
Some studies suggest that symmetrical at-
a dissertation by Luca Pacioli, titled “De
tractive faces from both sexes are reported
Devina Proportione,”208 which means “di-
to present a greater emotional and psy-
chological health.209-211 The introduction ofchological hook: the asymmetry grabs our
the divine proportion was introduced in eyes and attention and we are pulled in
dentistry by Lombardi in 1973.212,213 These our attempt to comprehend the imbal-
studies related the age-old formula to the ance. This inverse proportion of the lips
anterior display of the maxillary denti- is okay and can look very pleasing, if the
tion. divine proportions are kept. The trick is in
not allowing the reversal of the relation-
The Divine Proportion and Lips ship of the lips to overly exaggerate the
How does the divine proportion apply upper lip. The lip reversal captures our
to lips? If we look at the lips, we see this attention, the subconscious relates the in-
relationship as normal and pleasing to the version, it registers okay with us, and we
eye. When we disrupt this proportional move on. All of this is done in a matter of
arrangement, the lips look unsettling, seconds and during that time the lips are
even unnatural. The arrangement of the the center of our attention. Because the di-
lips according to the divine proportion al- vine proportion is kept, our subconscious
lows the eye to flow from focus point to makes sense of it and we accept it. Artists
focus point. play with these variations all the time, as
does Mother Nature. Remember these re-
Currently there are trends to fill lips
lationships hold true to them.
so that the superior lip has more volume
than the lower lip, a trend you may see As cosmetic dentists placing fillers, we
in some “Hollywood” lips. This is a psy- want to incorporate ideal proportions to
This is a computerized replication of the face. Both sides are mirrored to comprise a
perfectly symmetrical face. Although this is not an unattractive face, symmetry is not the
first thing we’re attracted to. It’s the averageness that is culturally biased.
enhance our patient’s natural beauty, not Actress Gloria Swanson’s Cupid’s bow
disrupt it.214-217 set the trend in the 1920s. The look was
Beauty and Society heart-shaped, dark red, and matte lips.
1930s women’s lips evolved into curved
What is the relationship between
lips with a satin finish. In the 1940s, the
beauty and society? No doubt there is cer-
lips were curved more deeply and a dark-
tainly a population among us obsessed
er ruby color of lip shade was applied.
with beauty, yet even the most non ob-
The 1950s ushered in a very soft feminine
sessed person will wake up and comb and
shape with satin sheen. The 1960s set the
style their hair before going off to work.
trend with lips that were poutier with a
Researchers show us that we see attrac-
fuller look. The 1970s focused on clearly
tive people conveying social skills, social
drawn lip lines, orange gold, and high
adaptability, and absence of shyness and
gloss. Lips of the 1980s were very earthy,
anxiety.218 In the American culture, we
metallic and frosty. In the 1990s lips were
see early conditioning towards the rela-
hot red glossy, had a matte satin finish,
tionship between beauty and ugliness.
and a deep outline. Today women’s lips
In children’s books we see the bad witch
have a natural and vital quality. They suit
and evil giant are ugly and the good witch
their faces while improving overall looks.
and virtuous prince attractive. The media
Excess volume is out. Well-defined lines
portrays attractive people in successful
are in. Just a small amount of filler is often
positions. It has also been shown that the
all
facial proportions consistently judged to that is needed.
be attractive are those proportions near All around the world, women adorn
the mean of the population, within their their lips. Some cultures augment their
racial group.219,220 lips beyond our traditional ideals. Yet
The idea is that an average face is there is no doubt that celebrities and their
thought of as occupying a central location Hollywood makeovers have had an im-
in a multidimensional face space, whose pact on American culture. One orthodon-
dimensions correspond to the character- tic study confirmed that the lips of Cau-
istics people use to mentally represent casian fashion models were considered
faces.221,222 Even though “averageness” is more aesthetically pleasing than those of
not the sole discriminate factor for attrac- nonmodel Caucasians.228
tiveness, it appears to have a significant Historically most women have en-
impact unto which gender selection is hanced their lips with various cosmetic
based or perceived.223,224 The symmetrical products and procedures in an effort to at-
face is also associated with an attractive tain a more youthful appearance with the
face.225 Bilateral blending of the symmetri- application of permanent and nonperma-
cal proportions of the face have a pleasing nent color agents. It wasn’t until currently
effect on the viewer.226 Symmetry is inde- that scientific means have led us to the
pendent of attractiveness or averageness age where we can manipulate the form of
in the overall face.227 Symmetry adds to the lips without significant surgery and
the overall pleasing effect of a face. cost. According to the 2005 statistics on
the American Society for Aesthetic Plas-
Fashion Trends of Lips: tic Surgery’s Web site, women had nearly
Historic and Present
10.7 million cosmetic procedures in 2004, enhancement and rejuvenation tradition-

an increase of 8% from 2003 to 2004.229 ally held for women.
Perception of Beauty The society for Aesthetic Plastic Sur-
gery reports that men had 1.2 million cos-
Women
metic procedures in 2004 (10% of total), an
There is a consensus within the sci- increase of 8% from 2003 to 2004.229 Unlike
entific community on broad features of a females, men have different goals when
woman’s face that are attractive to men. they request lip or facial corrections. The
There are neonatal or nondominant quali- ideal is not as important to them. Typical-
ties that are implanted in our psyche. ly they are seeking a more rejuvenated or
Having a large forehead, large, wide-set rested look.
eyes, a small nose, and thick lips are all
Ideal Lips
neonatal qualities. These characteristics
stimulate the nurturing side in us. These Omnia mutantur nos et mutamur in illis:
are facial qualities that infants possess, “All things change, and we change with
and it is hypothesized that as humans, them”…this Latin quote applies mostly
we react receptively to them.230 Men re- to lips and trends in cosmetics. Here is
spond to a combination of these neonatal “the rub,” as Shakespeare would say. Al-
expressions, as well as mature, expressive though we refer to the “ideal lips” in lit-
features that include higher, wider cheek- erature and art, there’s no documented
bones. Expressive facial features add to standard. Clinicians are supposed to rec-
the perceived attractiveness, which would reate this ideal, but there is no guideline.
include a wider smile, higher eyebrows, Of the hundreds of journals, magazines,
and larger pupils. The expression of these and photos I have researched, I have yet
ideals on the female face promotes a sense to come across the perfect lips. Dental and
of availability to mate.231 medical literature has ambiguous and var-
ied data on what constitutes perfect lips.
Men
Understanding there are no ideal lips, we
A female’s perception of attractiveness cannot deny that our lips portray certain
leans more toward mature features. These perceived emotions to others.
would include a wide jaw, strong chins,
and thin lips.232 The most attractive males What constitutes the ideal set of lips?
had a combination of neonatal qualities The answer is based on cultural upbring-
mixed in the facial expression.233 Men are ing, public awareness, and personal pref-
increasingly turning to lip and facial aug- erence. Ideal lips seem to have symmetry
mentation to reestablish a more youth- associated with them. The natural rela-
ful, vital appearance. The term “metro- tionship between upper and lower lip is
sexual,” coined in 1994, is an urban male a 1:3 ratio. There is symmetry in common
with a strong aesthetic sense who spends with all pleasing lips, which can be attrib-
a great deal of time and money on his ap- uted to the divine proportion, as I will dis-
pearance and lifestyle. There are many cuss in greater depth later.
connotations to the word, some narcissis- When we look at a person’s face, we
tic and some flattering; nonetheless, this focus on two things, eyes and mouth.234,65
term exemplifies the movement of men Even though we may look at the eyes
into the cosmetic arena and the increasing first, it is the mouth that impacts our first
popularity of men partaking in cosmetic
PresenCe
Mood
The first area of the face we notice is the eyes for presence, then the oral-facial is recognized
second. Yet, the oral-facial is the most descriptive of the two on first impression.
impression of an individual the most.235 Studies show there is a perceived dif-

When the lips are full and well-defined, ference in judging a person’s attractive-
they impart a sense of youth, health, and ness, when those persons being looked at
attractiveness. Thin, frail lips project fra- are in a static or kinetic state of facial ex-
gility and senility.236 pression.226 As oral-facial augmenters, we
Studies show that a face with a greater must understand the concept of kinetic
vermilion-to-skin ratio in both upper and and static beauty and how they relate to
lower lip always ranks higher in aesthetic one another. The face can be viewed in a
preference.237 The layperson will select a static or kinetic state. A subconscious rec-
medium, full upper lip in complement ognition of a face as attractive in a kinetic
to a slightly fuller lower lip.238 There are position does not always correlate with a
strong academic studies to complement pleasing recognition of the same face in a
the general perceived advertised ideal static position.
240-242
that fuller lips are more pleasing to the During our examination, we must ex-
layperson’s eye.239 Findings in these stud- amine our patients in a kinetic and stat-
ies also concluded that the dentists polled ic position. Have the patient smile and
seemed to pick the same relationship as frown; dentists naturally have patients
the lay public as far as medium upper smile to evaluate the dentition. Now draw
lip volume and lower lip volume in the your attention to the nasolabial or mental
vermilion-to-skin ratio. Plastic surgeons fold during the smile or the frown. Ask
had a tendency towards overall fuller lips. yourself the question: if I augment these
Studies also show that dentists incorpo- areas now, will it affect the kinetic fold
rate the dentition more into evaluating the of the tissue? Augmenting the lips in a
mouth presentation, whereas the general static position, without viewing the smile
public was less impacted by the dental line and incisal appearance, can lead to
variable in contrast to the lips. Fuller lips overfilling of the lips which leaves an un-
are associated with a significantly higher pleasant post-augmentation appearance.
degree of sexual attractiveness and femi- It’s difficult for this author to quantify
ninity, but they are also associated with or qualify the amount of filler to be used
perceived feelings of friendliness, intelli- when evaluating the relationship between
gence, success, and honesty. Thinner lips kinetic and static tissue. It is in “the art of
portray aggressiveness, unattractiveness, the fill” that you as the augmenter (artist)
and masculinity.239 will develop a sense of the amount of filler
When augmenting the lips we are at needed to achieve a cosmetic correction
liberty to shape the upper lip more and and this skill243,244will develop as your experi-
add volume to the lower lip. This may ence grows.
be due to the natural presentation of the Projection
upper lip and the philtrum and defining pro•jec•tion
structures that surround it. Although cur- 1. The act of projecting or the condition of
rent trends seem to regard the upper lip being projected.
as fuller in volume, this may be attributed 2. The attribution of one’s own attitudes,
to the increase of prosthetic implants and feelings, or suppositions to others.
fillers.
In art school, models sit in the middle
Kinetic vs. Static of the room and students with sketch
pads and pens surround them. As the stu- Aesthetic Vs. Cosmetic
dents draw, the instructor walks around Aesthetic signifies “natural,” a quality
them and guides their pen, but does not that comes from within. It can be defined
influence their style. Work is placed on as the science of beauty that is applied in
the wall and critiqued at the end of a sit- nature and in art. Cosmetic refers to sub-
ting. One event stands out and most any stances and procedures that are used to
observer can see this when guided to look enhance or correct defects in the face, skin,
for it. Without knowing who sketched and hair. Cosmetics are the preparations
which portrait, nine times out of 10, we to change the appearance or enhance the
can identify who drew it. Simply put, look beauty of the face, skin or hair. The prac-
for details of the artist’s face in their sub- tice of lip augmentation is truly a combi-
ject’s portrait. This projection is more dif- nation of both these terms. Aesthetic and
ficult to detect in the advanced artist, yet cosmetic are separate distinct definitions,
there are still telltale signs of them in their yet they are inseparable.
work. Nevertheless, students with long
noses project longer noses on their por- Orthodontics
traits. A thinner artist’s portrait will have
Up until now we have discussed the
more sculpted facial appearances. The les-
subjective part of beauty: how do we
son is that we see beauty in relationship to
translate these proportions into a scien-
ourselves. When doing portrait work, the
tific method (a true method reflecting ac-
professional artist has trained himself to
curacy, precision, and reproducibility)?
separate himself from this bias.
In addition to the method of obtaining
In the actual business of painting information, we have to be able to statisti-
portraits, clients are greatly offended if cally analyze the information by ways of
the artist fails to represent their family’s standard deviations and means. No other
broad chins or distinctive noses. In keep- medical specialty deals in such analysis
ing with that idea, when augmenting in detail from birth to adult as the dental
your patient’s lips, do not project your vi- field. In particular, the orthodontic special-
sion of what is good looking onto them. ists have pioneered advances in quantify-
Two results will come from that scenario. ing and qualifying oral-facial parameters.
One, their look will be changed opening Indeed the dental/skeletal relationship
the opportunity for them to be displeased affects the lips and associated soft tissue.
with the results. Two, you will have an When we do our soft tissue assessment
entire town filled with your lips; and as for augmentation, it is important to real-
the filler in your patient’s lips shrink, so ize that there are a significant number of
will your patient base. Cosmetic dentists cases where lip asymmetry needs to be
definitely perceive facial aesthetics dif- orthodontically corrected and not aug-
ferently than the layperson.245 Not only mented with fillers to reestablish lip sym-
do we need to be cognitive of our natural metry.248
inclination to project our discrimination,
With the advent of orthodontic, cra-
but we have been conditioned profession-
nial/facial measurements, most of the fa-
ally as to what is the standard acceptable
cial research has been done using lateral
aesthetics.246,247 The answer is between the
cephalometry.249 Lateral cephalometry is a
two extremes and that is the balance the
great tool for establishing and projecting
artist in us weighs with every patient.
Illustrated above are the landmark points of the lips from a side profile
future oral-facial growth, but it has its lim- cial proportions into the mean of a popu-
itations. Lateral cephalometry simplifies a lation. The drawback to anthropometric
3-dimensional structure to a 2-dimension- studies is that it is time consuming when
al radiograph. Soft tissue and structures it comes to implementing the measure-
out of the mid-sagittal plane are subject ments. In addition, we must be cognizant
to increased errors of magnification and of the genotypical expression of the sam-
identification.250 If we take a cephalogram ple population from where the data was
from the posterior to anterior view, in gathered and how that relates to the pa-
combination with lateral cephalometry, tient we are currently analyzing. With the
we produce a 3-dimensional view of the advent of computer technology, we are
skeletal structure yet no reliable soft tis- able to scan 3-dimensional studies of the
sue replication.251 face and project soft tissue growth into a
more predictable, speedy outcome.253
Anthropometry is a 3-dimensional
measurement of the face. It is a statistical Orthodontically we have identified
base of measurements carried out dur- landmark points of soft tissue on the face.
ing 1967-1984, with 2,500 people as the These points are helpful in gathering in-
information source.252 One hundred sixty- formation on a patient to assess treatment
seven indices involving cranial and facial planning of possible soft tissue augmenta-
measurements are incorporated into this tion or muscular denervation (Botox). For
body of information. This means of mea- purposes of this book, we will limit these
surement enables us to group distinct fa- dental/alveolar points to the lips and pe-
rioral tissue. A complete orthodontic we have historical and cultural views of

workup is not indicated for lip and perio- perceived attractiveness. In addition we
ral augmentation, although a practitioner are aware of the psychological implica-
should be familiar with basic guidelines tions of perceived attractiveness. It is the
to help the patient in their treatment plan-
composition of these ideas, data, and per-
ning. spectives that lead us to the fulfillment and
The classic points of reference for cat- understanding of beauty from an oral-fa-
egorizing lip proportions are: cial augmenter’s viewpoint. Through the
• vermilion understanding of these ideals, we are lead
• subnasale (Sn) to their implementation. This is known as
• labrale superius (LS) the Art of the Fill.
• labrale inferius (LI)
• stomion superius (stms)
Art of the fill
• stomion inferius (stmi) Vermilion Dollar Lips®
• commissures As a dentist we have the ability to in-
• interlabial gap clude a complete cosmetic oral-facial soft
• gnathion (Gn) tissue exam in conjunction to our dental
• pogonion (Pg) exam. One of the benefits of coming to
Note: The Gordon classification is an ad- a dentist for oral-facial augmentation is
junct to these previously established land- our ability to give a complete diagnosis
marks. It develops a more detailed map- on the soft tissue presentation. Just as the
ping of the lips for the purposes of lip dentist looks at the radiograph and then
augmentation. clinically at the tooth, we can look at the
dental, skeletal form then the soft tissue
PROFILE LIP POSITION overlying these structures. This part of
MEASUREMENTS the chapter will guide you on how to ap-
This is evaluated by drawing a line proach the diagnosis, treatment planning,
from the subnasale (Sn) to the soft tissue and augmenting therapy. It is our goal to
pogonion (Pg). The amount of lip protru- achieve the maximum oral-facial cosmetic
sion or retrusion is measured from the potential for all your patients.
line perpendicular to this Sn-Pg line. It is Pre-Treatment Consultation
normal for the upper lip to be slightly pro- Due to the subjective results of cos-
trusive in comparison to the lower lip on metic procedures, it is important to evalu-
this plane. The average adult’s upper lip ate several points. Document all current
is 3.5 mm anterior to the Sn-Pg line and facial features via a recordable reference
the lower lip is 2.2 mm anterior to this chart. This documentation will give you
line.254 The vertical lip length is defined and your patients a baseline to start and
by measuring the upper lip from the Sn to a reference to refer to for post-treatment
the stomion superius (stms) and the lower results. During a pre-treatment consulta-
lip is measured from the stomion inferius tion, you should:
(stmi) to the gnathion (Gn).
Assess patient’s expectations. The
We have established a statistical data term “full correction” is applied in
base of parameters for the skeletal, dental plastic surgery. The definition is better
and soft tissue of the oral-facial area and described as “optimal correction tri-
Common Common Sugical Perioperative

Name and Uses Cautuion Recommendations
Dose (Marketing)
1 Chondroitin (400- Osteoarthritis Perioperative Discontinue 2-

800mg BID) bleeding 3 weeks before
augmentation
2 Ephedra Energy, weight loss, Hypertensive, cardiac D/C 1 day before

(2.7-3.0 g QD) asthma instability with augmentation
anesthetics
3 Echinacea Infections, ulcers, Potentiate D/C 2-3 weeks

(2.7-3.0 g QD) arthritis, prevention of barbiturate and before augmentation
bruising halothane toxicity,
allergic reaction,
immunosuppression
4 Glucosamine Osteoarthritis Hypoglycemia D/C 2-3 weeks

(1500 mg QD) before augmentation
5 Ginkgo biloba Cognition (dementia), Postoperative D/C 1.5 days before

(120-240 mg QD) vascular disease, sedation, augmentation
tinnitus, asthma, colds, perioperative
anti-inflammatory bleeding
6 Goldenseal Laxative, anti- Volume depletion, D/C 2-3 weeks

(125-500 mg BID) inflammatory, infection postoperative before augmentation
sedation,
photosensitization
7 Milk thistle Hepatoprotective, Volume depletion D/C 2-3 weeks

(100-300 mg TID) anti-inflammatory (choleretic activity) before augmentation
8 Ginseng Antioxidant, energy, Perioperative D/C 1 week before

(0.5-2.0 g QD root) lowers blood glucose bleeding; avoid augmentation
(200-600 mg QD use in children and
extract) pregnant women
9 Kava Anxiolytic, muscle Postoperative D/C 1 day before

(2.7-3.0 g QD) relaxant sedation augmentation
10 Garlic (600-900 mg Infection, hypertension, Perioperative D/C 1 week before

QD) (8 mg QD oil)(4g hypercholesterolemia, bleeding augmentation
QD cloves) cancer prevention
Adapted from Heller J. et al.
TABLE 5.1 Top Ten List of Medicinal Herbs/Supplements

FACIAL ANALYSIS Checklist

Before adding volume, one must analyze the lip. Here are some of the questions one
must ask of their patients:
Male or Female?
Age?
Is there any dental reconstruction treatment planned in the future and, in particular,
anterior aesthetic reconstruction? If so then IDEALLY, the dental work must be
completed first. Remember the teeth are the framework for the lips and our limits of
fill are dictated in part by the borders of our teeth.
Look at the appearance of tissue for any signs of trauma, and/or congenital
aberrations.
Thin lips may require multiple visits; analyze the lips, palpate them. Are they thin,
fibrotic, senile (thin) lips that may have atrophied over time or are they congenitally
thin? The resultant fill will be a result of the quality of lips.
Is the philtrum well defined?
Is there the desired form of the Cupid’s bow?
When the patient is in the neuromuscular rest position, is the mouth open or closed?
When the patient smiles, is their dentition showing and if so, how much?
Is the commissure of the mouth depressed or angulated down?
Are there rhytids and facial lines?
Kinetic motion: how do the lips look in motion? A patient’s lips may look thin when in
a static position; but when they talk, the relative thickness of the lips may flatten out
over the curvature of the dentition, giving way to a fuller look in kinetic movement.
Mental lines: are there any lines above the mentalis (usually in men) that can be
augmented to relieve their severity?
Nasolabial folds: the facial line that extends from the alar of the nose to the corners
of the mouth. As we age, this crease deepens and is a telltale sign of age.
View the patient form profile. Is the patient a class 2 skeletal, where adding volume
may produce a duck-like appearance to the lips? As a dentist, we are acutely aware
of the oral-facial, skeletal/dentition and how the lips relate to them. We are in the
unique position to offer a patient different treatment options to correct their soft
tissue appearance. A patient may benefit from orthognathic surgery, orthodontic
treatment or simple anterior dental reconstruction. These treatment modalities may
offer a patient a more pleasing aesthetic result.
ad,” which includes the patient’s de- Work on your timeframe. All too of-
sires, ideal proportions, and the doctor ten, patients want lip enhancement
(material propensity and technical ex- two days before a wedding or they are
pertise). Explain to your patients this leaving on vacation for two weeks the
triad and what results can be expect- next day. These patient-dictated time-
ed. Educate your patient on treatment tables have the potential to put you
processes and outcome possibilities into a bind, especially if post-operative
for their augmentation. It is important complications arise. Some sequelae
that all patients have realistic expecta- of events that can occur are a longer-
tions for their augmentation. Lips may than-normal swelling or bruising. No
be refined and volume added, but the matter how much you warn your pa-
overall presentation should not be tient, you will be to blame.
changed. (see “The Psychology of the Take a thorough history of your pa-
Lips,” Chapter 1, pg. 15) tient’s lips, including accidents, dis-
Do NOT combine a dental restorative ease, and prior augmentations. There
appointment with an oral-facial aug- may be scar tissue deep in the lip that
mentation. This is a critical mistake the may present itself in a clefting fashion
beginner augmenter will make. My upon fill.
worst facial fills were done in conjunc- Also take a history of over the counter
tion with a dental appointment. Rea- medication and herbal meds that may
sons not to combine appointments: influence treatments.
When we augment a patient’s oral- Perform a thorough dental exam. Doc-
facial area, we are in a more cre- tors augmenting patients with dental/
ative mode of working than when alveolar abscesses have reported a
we are restoring teeth or surgically higher incidence of asymmetric swell-
manipulating the mouth. Altering ing post injections. Inform your patient
attention from oral-facial augmen- that there is a possibility that there will
tation and dental restorations di- be more post-op swelling due to den-
verts one’s attention away from the tal/periodontal infections orally.
freer artistic mode of operation one There are two ways to present finan-
needs to be in when augmenting a cial estimates to your patients. You
patient’s lips or face. may give an estimate based on cost per
We tend to use more dental anes- vial and number of vials estimated for
thesia to achieve a full, pain-free, total correction. Or you may present
dental appointment. This is more a fee for total correction, letting your
than is necessary for soft tissue patient know there will be an addi-
augmentation and it has a greater tional fee if more correction is wanted.
propensity to spread and distort Whatever you decide, Do Not Bargain
the musculature tonus of the mus- with patients. In dentistry, when we
cle of facial expression. may give “deals” to patients, it usu-
The post-operative sequelae of a ally comes out of our time in the profit
dental appointment can be painful margin. This is a material and a defi-
at times; this can translate into an nite measurable amount is needed for
unpleasant augmentation experi- a complete correction. We fill for effect,
ence for the patient. not amount of material
I have some patients hold a mirror ity to produce instant photos to show our
and evaluate intermittently between patients; thus, we should already be us-
injections. NOTE: make sure you ing photos for documentation of dental
choose your patients wisely for this work.
technique. Not all patients are able to There are many kinds of cameras on
be as active in this type of treatment. the market today. The body and lens for
A significant number of patients will intraoral photography needs to be outfit-
have an aversion to the needles and ted with additional flashes and lenses.256
the slight amount of blood that comes
Soft tissue photography of the oral-facial
with injecting into the vascular area of
area requires less equipment. Most cam-
the lips.
eras sold to the average consumer are
Discontinue aspirin two weeks before calibrated for portrait photos. You can
treatment. purchase a high-grade pixel camera at a
24-48 hrs before treatment, avoid a relatively inexpensive price.
diet high in sodium, sugar, caffeine,
Try to make taking photos of your pa-
alcohol, and spicy foods.
tient a habit. Once again, if you delegate
Avoid any chemical peels, laser treat- this task, you cannot rely on your assis-
ments or cosmetic treatments one to tant to capture all the angles you may see
two weeks prior to treatment. from your trained eye. In addition, when
you as the dentist are the one taking the
Photographic Documentation
photos, it conveys a personal touch to the
Pre-fill documentation is a must for a entire cosmetic process, which conveys
complete lip augmentation treatment, and confidence and commitment to the pa-
with the advent of digital photography, tient.
shots can be taken and compared pre- and
post-treatment to illustrate the desired re- Most pictures of the face can be done on
sult to the patient. This process enlight- autofocus. Setting the camera for ‘portrait’
ens patients on actual changes, because mode is required. Aiming the autofocus
all too often patients fail to see how much on the patient’s lower eyelid will usually
fill was achieved until they compare the encompass the tip of the nose to the ear in
results to the preoperative photos.255 Once the depth of field,257 that being the area in
you have begun your treatment, you can’t which the image is in focus. Using a dark,
matte finish material for your backdrop is
turn back; therefore, dentally/legally, it is
prudent to have documentation. More- essential. This will absorb aberrant flash
over, you will want to have a catalog of rays and eliminate background noise,
your success and the ability to share your such as office furniture, office equipment,
difficult cases with others for everyone’s and other objects that may distract from
benefit. the subject. In addition, use of the same
backdrop will ensure consistency in pa-
Be sure to have your patient remove tient imaging pre- and post-operative.
all makeup and do all photos before anes- Photographing the nasolabial fold and
thetic is applied. Make sure your camera fine lines of the face can be challenging.
is capable of realizing facial blemishes, Too much flash or direct lighting will
scars, and facial color. With the advent of blend in the lines you marked for correc-
digital photography, we have the capabil- tion. I shoot most of my facial pictures
40-60 cm away from the patient’s eyes. I want to capture the lines, wrinkles, and
use a zoom lens to acquire a closer shot folds in our pictures that are ordinarily
so I don’t blanch out the facial lines ear- unwanted in conventional photography.
marked for correction. Remember, we If a patient complains of a wrinkle or fold
Full head shot with kinetic smile.
Soft tissue in static position.

that comes out in certain photos or light- Measurement Tools For

ing, try to recreate the lighting for them by
using a separate handheld or dental light. Aesthetic Quantification
And Qualification
Profile shot in static position.
Semi-profile shot of oral-facial and kinetic.

It’s hard to develop a nonsubjective

The Global Aesthetic
gauge for cosmetic results. A multitude Improvement Scale258
of factors play a part in our perspective 1 Very much improved: optimal cos-
as discussed previously in this chapter. I metic result for the implant in this
have provided five assessment scales be- patient.
low that have been published in various
studies as a baseline classification. You can 2 Much improved: marked improve-
choose to incorporate or modify them for ment in appearance from the ini-
your pre-op and post-op augmentations. tial condition, but not completely
The idea is to have a consistent, repeat- optimal for this patient. A touch-up
able form where you can gauge progress would slightly improve the result.
3 Improved: obvious improvement.
The Wrinkle Severity
Rating Scale
1 Absent: no visible fold; continuous The Wrinkle
skin lines Improvement Scale
2 Mild: shallow but visible fold with 0 No Improvement
a slight indentation; minor facial
feature; implant is expected to 1 Mild Improvement
produce a slight improvement 2 Moderate Improvement
3 Moderate: moderately deep folds; 3 Significant Improvement
clear facial feature visible at normal
As you can see this scale is rather subjective
appearance but not when stretched;
in nature.
excellent correction is expected from
injectable implant.
4 Severe: very long and deep folds;
prominent facial feature; less than
Rated Numeric
2 mm visible fold when stretched; Kinetic LIne Scale259
significant improvement is expected 0 No Wrinkles
from injectable implant.
1 Wrinkles not present at rest, fine
5 Extreme: extremely deep and
long folds, detrimental to facial 2 Wrinkles not present at rest, deep
appearance; 2- to 4-mm visible lines with facial expression
V-shaped fold when stretched; 3 Fine wrinkles present at rest, deep-
unlikely to have satisfactory er lines with facial expression
correction with injectable implant
4 Deep wrinkles at rest, deep furrows
alone.
with facial expression.
The WSRS is a photograph-based outcome This scale shows statistically significant inter
instrument that is designed specifically for observer reliability for rating hyperkinetic
quantifying facial folds. lines.260
in your patient augmentation.
Rubin Smile Classification Armament for Injectable

The Rubin classification generalizes Fillers
the smile into three categories. The cat- Syringes
egories are rather broad, but for a quick Injectable syringes for fillers and in-
analysis, it will suffice in pre-augmenta- jectable syringes for anesthetic are quite
tion records.261 similar. The injectable syringe is com-
Mona Lisa smile: dominated by the zy- posed of a body, plunger, thumb presser
gomatic major, which is characterized by and needle.
sharply elevated corners of the mouth.
The syringe is held in the same man-
Canine smile: dominated at the levator
ner as local anesthetic syringe. Due to the
labii superioris, which manifests itself by
viscosity of the fillers (or G’), aspiration
strong raising of the medial portion of the
of the material is ineffective. The various
upper lip.
injectable fillers are packaged without the
Full denture smile: where there is a needle being attached. The operator must
simultaneous contraction of all upper lip attach the needle. Care must be taken to
elevators and lower lip depressors.
Here is a picture of the standard injecting syringes for cross-linked hyaluronic acid. Notice
that the syringes have no aspirating rings. This is due to the inability to aspirate because
of the low viscosity of the materials. The marketed syringes can be distributed in volumes
of .2 mL to 1 mL.
screw in the needle tightly. If the needle

is not secured tightly, one will express a
significant amount of material out and it
will be wasted.
Needles
Syringe needles must be appropriate
for the filler. Usually injection needles are
packaged with the fillers. After multiple
injections—particularly in the more heav-
ily keratinized epithelium of the nasola-
bial fold or vermilion border—the needle
tends to dull or bard. Using several nee-
dles when augmenting the lips can reduce
bruising and ease your patient’s comfort.
Needle Gauge
A larger gauge may assist in flow and
application of filler. Needle gauges range
from 27-32. Each gauge and length has its
advantages with different fillers. The use
of a 27 gauge allows for easy flow and less
dulling of needles. The use of a 32 gauge
has been proposed by some for rhytids
fills and cross-hatching techniques. Be- These are the 3 types of needle gauges
cause of the viscosity of some fillers, nee-
one may apply to a standard filler syringes.
dle selection is significant. The smaller
Green is the 32 Gauge, Tan is the 30 gauge
the gauge (ie, the larger the diameter),
the easier the expression of the filler will and brown is the 27 gauge.
be; however, more pain (if no anesthetic
used) and bruising are associated with the
injection site. Conversely, the longer the
needle, the more back pressure required
to fill. The advantage to this is that less
puncture sites are required due to needle
length; one can fan around in the dermis
and have a greater area available for de-
posit of filler.
Chapter 5 Review
study Points
Divine proportion and its relationship to lips, face, and augmentation.
Comprehend neonatal, averageness, symmetry, and male vs. female perception
of beauty.
Orthodontics and relevance to lip and perioral augmentation.
Incorporating photography into your practice of oral-facial augmentation
study Questions
1) What is the calibrated golden proportion number?
2) Which is most appealing to the onlooker: the averageness of a face or the more
symmetrical face?
3) What are neonatal qualities of the face and how do they affect our perception
of beauty?
4) What is the average upper and lower lip projection related to Sn-PG line?
5) What is anthropometry and what is its inherent drawback in the context of
statistical analysis?
6) Is it best to combine conventional dental appointments with lip and perioral
augmentation?
6
Chapter 6
Injection Techniques
and Procedures
Ventis secundis
Go with the flow
Chapter 6 Injection Techniques and Procedures 136
Lips
Oral-Facial Skin
Technical Considerations
Now that we have reviewed the Canvas (anatomy) and the

Medium (injectable fillers), we are now completing the third
leg of the triad: the artist. The third leg of the triad is com-
prised of two separate yet equally dependent parts. Part 1 is
composed of the artist’s internal and external understanding
and vision of beauty which was discussed in Chapter 5. Part
two are the technical skills the artist uses in application of their
vision and the application of their art. In this following chapter,
my goal is to lay the groundwork pertaining to the techniques
of lips and perioral augmentation.
As you grow and develop your augmentation practice, you

will inevitably incorporate pieces of philosophy and tech-
niques from many practitioners—as well as you should. The
techniques I have included are sound treatment options and
delivery methods. I have put my personal touches on these
techniques and they have yielded safe, predictable, and out-
standing results consistently. These will be your building blocks
for you to initiate and develop a successful and long lasting lip
and perioral augmentation practice.
“Men are wise in proportion, not to their experience, but to their capacity
for experience.”
George Bernard Shaw
Lips
There are three potential places fillers can

go when we are injecting filling material into
the lips for augmentation.
Natural Plane
This is the plane that naturally exists in the
patient’s dermis. The junction of the dermal
layer that the needle is placed in is right be-
low the vermilion epithelium. This plane will re-
lieve itself laterally to host the fillers as pres-
sure is applied. The resistance in this layer to
separation differs from skin type. The more
keratinized the tissue, the more resistance and
vice versa. The lips have very little resistance
in the dermal plane. The fill can be easily
distorted by expressing too much pressure in
the fill. The distortion comes from the material
flowing into undesired zones of placement.
Acquired Plane
This plane has been established by a pre-
vious fill of a material that has occupied the
space for a time. This plane may divert your
filling material away from your planned aug-
mented areas.
Path of Needle Insertion
This plane is created by the needle as it
was injected into the dermis. If we apply very
little pressure and withdraw the filler as we
express the material, we will fill this space.
INJECTION
TECHNIQUES FOR THE LIPS tion site is needed in Segment 3 of the
When augmenting the lips, our goal upper lip is due to the change in angle
is to maximize the cosmetic result with that may present as the Cupid’s bow arch
the least amount of material and with the form bows down. This plane in Segment
minimal amount of trauma to tissue dur- 3 orients itself downward and anteriorly.
ing the process. Some patients may not need this addition-
al injection point because the flow of the
Plan Ahead filler material will extend into Segment 2.
Remember to plan for the minimal Segment 5 of the lower lip does not redi-
amount of injection points to achieve ef- rect its plane so dramatically. Segment 5
fect. Before we lay a needle to the lips or is more of a union of two planes coming
to the oral-facial area, we must have en- together. Usually an injection site in Seg-
visioned in our minds the final cosmetic ment 4 and 6 will adequately direct mate-
outcome and the processes we have to go rial into Segment 5.
through to attain the desired result. Plan
Lower Lip
out in your mind how many injection
points you will use, the direction of needle Initial injection starts in the corner
and amount you will deposit, and envi- of the mouth. Place needle to hub, inject
sion the plan in the lips you want to fill. slowly and monitor flow. On the lower
lip, a maximum of three points of injec-
Start with reestablishing volume. Ini- tion will be needed. Since the lower lip
tial volume fill should be done in Zone B. has only two planes contralateral to each
It is important to inject in the middle of other, the material tends to flow easier.
Zone B to allow the flow of the material
to go superior, inferior and anterior, and INJECT SLOWLY
posterior. This is a three-dimensional pro- There are three reasons to inject slowly.
cess of adding volume to the lips. Start at
1) Potentiating the plane requires reliev-
the corners of the lips and work inwards
ing connective tissue of the vermilion to
in order to provide scaffolding for the me-
house the filler. This should be done slowly
dially placed filler. A minimum of two
to maximize natural potential. Fillers will
injection points are needed for this tech-
take the path of least resistance. When the
nique for upper and lower lip. If you are
filler has filled the plane, it will distort the
not able to achieve the desired flow, more
natural plane, resulting in an unaesthetic
injection points may be needed, usually a
result. Injecting filler too fast can obscure
total of four on the upper lip and three on
visually and tactilely the natural terminal
the lower.
fill of the plane.
Upper Lip
2) Post op swelling—hastily injecting will
Initial injection starts in the corner of
initiate an overexuberant inflammation
the mouth. Place the needle to the hub. In-
response. This will obscure your present
ject slowly and watch flow. If you aren’t
filler process as well as lead to significant
getting a satisfactory flow, then more in-
postoperative pain, bruising, and swell-
jection sites are needed to properly fill the
ing.
lips. You may need to inject in six sites
within segments 1, 2 and 3. 3) Edema race—as we inject the filler,
we are displacing the natural tissue and
The reason why an additional injec-
fluid to compensate for the filler. Pushing
Here is a general guide

for mapping out injection
points for the upper and
lower lip. Remember to
start at the outermost
injection point first and
inject your fill sequence
medially.
Filling in segment 5 of
the lower lip should
be injected as the
illustration at left shows.
Enter on both sides of
the segment to ensure
proper flow and form of
the plane.
Segment 2 should be
augmented by injecting
bilaterally and the
direction of the needle
downwards and medial.
this will insure proper
potentiating the plane.
TIPS
Reducing a prominent jowl line indentation can be effectively

accomplished with dermal fillers. The intra oral mental block will
provide substantial enough anesthesia for this augmentation technique.
A sound diffential diagnosis is warranted for this procedure. Although
one may relieve the prominence of the jowl indentation, other cosmetic
treatments may be a better long term alternative, such as conventional
face lifts. Yet initial filler therapy is a great introductory relief of this
age defining oral-facial manifestation.
the filler in the lips too quickly can lead material and tacitly feel the material satu-
the augmenter into a false perception of rate the plane when injecting.
where the filler is or how much one has
One needs to visually see
the flow of the material and its
saturation of the plane. Here is
an example of a lip where the
plane is saturated. We now pull
the needle out and reinsert in
another plane to continue aug-
mentation.
Vermilion Border
Filling
(Zone A)
The goal of augmenting in
Zone A is to accentuate or cre-
Depicted here is an example of plane saturation. ate anatomy. Zone A incorpo-
Notice the blanching of the lips medial to the needle. rates the transition from the
vermilion tissue of the lips to
At this point, one needs to remove needle and reinsert
the stratified squamous tissue
into another plane if additional fill is planned. of the oral-facial. Due to the
transition in the keratinization
saturated the plane. This is due partly to of the tissue, there will be a great reduc-
the edema of the tissue that projects tight- tion in the flow of filler in this transitional
ness in the lip. Pushing the filler slowly zone. Because of the buttressing effect of
into the lips gives the tissue time to allow a the thicker keratinized tissue of the oral/
certain amount of hydrostatic equilibrium facial area, we need to watch the flow of
in the lip. Slowly injecting filler facilitates filler at the vermilion border, for it has a
better assessment of the fill and the ability tendency to flow to the path of least re-
to place more filler in the plane. sistance. The path of least resistance will
be towards Zone B and if we have already
Determining Plane Saturation
added to Zone B, this can lead to overfill-
We determine plane saturation by vi- ing of the lips. When filling the vermil-
sual and tactile perception. We determine ion border, we will fill by potentiating
this by watching the material flow into the the space made by the needle. We inject,
tissue or zones of the lips, and by feeling withdraw, and inject at a constant pres-
the back pressure of the filler as we insure and recoil of the needle. Our goal is
ject into the plane or zone of the targeted to place a uniform tubular fill of material
area. The skill of tacitly feeling the injec- in the vermilion border.
tion pressure (G’) is still developing in the
beginning augmenter, so they may need Philtrum Filling
to rely on visually observing plane satu- The purpose of augmenting in the
ration. Ultimately it is the goal of the aug- philtrum is to accentuate existing anato-
menter to both visually see the flow the my or create anatomy in the patient. The
philtrum is composed of stratified

squamous epithelium. The filler
will not flow as well in the phil-
trum area as it does in the lips.
The technique used is deposit and
withdrawal. We will be depositing
way of the insertion point. Slowly inject
the filler as we withdraw the needle.
contents in a superior-to-inferior direc-
Indications: Where there is a signifi- tion under even, constant pressure. Apply
cant lack of anatomy in Zone A and aug- to both sides evenly. Remember that the
menting Zone B of the lip would produce philtrum is slightly wider at the bottom,
a flattened look or “beak effect.” then superior by the nose.
If anatomy is overfilled, lips will look Perioral Lines (Rhytids)
too “worked.” To achieve definition, we
These lines around the mouth have
are able to insert the needle into the tip
been described as hyperkinetic lines,
of the Cupids’ bow along the philtrum
smokers’ lines or bleeder lines. There are
line. Before injecting, gently lift the nee-
many contributing factors to the develop-
dle length to assure path of injection. This
ment of these lines. If they occur in pa-
should line up evenly and to the height of
tients around the ages of 30-40, they are
contour of the philtrum line angle. This
usually associated with chronic contrac-
particular injection potentiates the space
tion of the orbicularis oris muscle. These
by the needle diameter. This means that
patients usually have incompetent lips
there is no plane for the material to flow
and as the patient compensates through
extensively into like the lips. The plane or
their lifetime to close their lips to complete
space is made by the needle and we inject
a lip seal, these perioral lines develop. In
the filler as we pull our needle back the
addition, the normal compe-

tent lip may develop rhytids.
With the effects of aging, loss
of lip volume and redistribu-
tion of fat rhytids develop. A
rhytid extends perpendicular
from the vermilion border of
the lip in an outward, fanning
fashion. When stretching the
vermilion tissue of the lip, one
may observe a softer, less cal-
loused tissue deep in the fissure
of the rhytid. The color may be
lighter deep in the rhytid due to un-
derexposure to the ultraviolet rays of
the light.
The majority of rhytids will be pres-
ent on the upper lip. These lines can
usually be eliminated by augmenting
the volume of the lips first in Zone B. If
after filling Zone B there are still some
rhytids present, one may fill
them by utilizing some fairly
simple techniques.
Approach the lines inferior-
ly with the needle insertion
point at the vermilion bor-
der. Insert the needle under-
neath the rhytid along its full
path. We have now potenti-
ated the plane underneath
the rhytid. Express the filler
as you withdraw the needle.
On the lower lip, it is usually
not necessary to eliminate
rhytids. Filling in Zone B usually
eliminates most of the rhytids
due to the amount of filler the
lower lip can accept without
looking distorted. If there are re-
maining rhytids in the lower lip
after Zone B fill, then they need
to be filled in a similar fashion as
with the upper lip.
We should always strive for minimal injection points to optimize cosmetic results. One
technique is to inject lateral to the commissure and utilize the same injection point fill
superior and then inferior to commissure. Remember to place more filler inferior to corner
of mouth to give a slight rise to the commissure.
Corners of the Mouth advantage of the single site injection tech-
Filling of the commissure of the mouth nique is less trauma of site, because only
is desired for two reasons: 1) to add ad- one area is injected into. Another benefit of
ditional support for the lips, and 2) to re- this technique is the ability to take advan-
verse the effects of aging that causes the tage of the natural plane that exists in that
corners of mouth turn down. This down- patient for filling, whereby we augment
ward turn of the commissure is a result of the patient’s natural anatomical presenta-
the overall movement of the facial tissue tion. The disadvantage is when we cannot
in the outward and downward direction attain the flow of filler in a uniform way or
during aging. With certain filling tech- we are not able to potentiate the space for
niques, we are able to lift the corners of our basis to fill the lips.
the mouth to reverse this sign of a droop- The second is to inject lateral to the
ing commissure. commissure and direct the needle supe-
Sometimes it is necessary to fill the rior and inferior to establish fill, while uti-
corners of the mouth for additional scaf- lizing one injection point. The key to this
folding in order to add volume to the lips. technique is to inject slightly more filler
Failing to fill the corners of the mouth if below the angle of the commissure, than
needed and continuing on to the lips may we do above the commissure. This will
produce a beaking effect of the lips. There lend the corners of the mouth to lift slight-
are two techniques for this augmentation ly.
fill: single injection point and flow and se- Multiple injection points
rial injection points and flow. Three injections may be needed to es-
Single injection techniques tablish the corner of the mouth. You can
With this technique, we inject lateral try and enter the dermis in one point and
to the commissure and watch the material inject filler into the plane, slowly with-
flow superior and inferior to the lips. The draw and reinsert the needle into the oth-
er plane. The advantages of this technique
are that we can direct the flow of the ma- of the flow is greater in the keratinized,
terial more precisely. The disadvantage is stratified squamous epithelium tissue of
more injection sites and intradermal nee- the face. When placing fillers into the na-
dle trauma is required. solabial or mental fold, we achieve a bet-
Lifting the corners of the mouth ter effect by layering the material or cross-
hatching. For example, in areas like the
Lifting the corners of the mouth can be
apex of the nasolabial fold (puriform), one
accomplished with all of the above men-
may be able to place a pearl and receive
tioned techniques. The key is to place a
a limited amount of flow of the material.
little more filler in the inferior plane of the
Crosshatching the filler over the nasolabi-
lower commissure. Filling in the commis-
al fold will be a process of potentiating the
sure will naturally lift the corners of the
plane by the needle. Since we are placing
mouth; however, we want to add a little
fine lines over the nasolabial fold and the
more to the inferior plane to ensure the
dermis is thicker here, the potential for
lift.
filler to flow is rather limited. We create a
space for the filler by displacing tissue by
Oral-facial skin the diameter of the needle we are using
The same three potential spaces exist for our augmentation.
for the oral-facial skin, although resistance
Illustrated on the left is a pearl-drop form of filler placment. On the right is the crosshatching
technique that one can implement of filler placement medial to the nasolabial fold. In
addition, when filler is applied to the mental fold, it must be placed superior to the crease
with supplementary cross-hatching over it.
Pearl Placement by the needle. In the crosshatching tech-

In the apex of the nasolabial fold (pu- nique, we will be depositing the filler as
riform), one can place a teardrop form of we remove the needle, so several injection
filler. Filler material will flow well at the will be needed.
apex of the nasolabial fold. This is due to MENTAL FOLD
the nature of the attached epithelium at
We will place the fill medial to the
the junction of the nasolabial fold and the
fold, which is located superior to the men-
alar angle of the nose. This epithelium is a
tal fold. Depending on the severity of the
supple tissue and easily filled. Be careful
arch of the fold, you may have to make
not to overextend the fill here, for it will
two separate injection points lateral to the
leave a bubble effect.
distal extent of the mental fold and fill
Crosshatching one-half of the arch at a time. This area is
Layering the filler over the pearl drop comprised of a very thick dermis. Most
form in the puriform allows us to ap- (if not all) filling in the mental fold will
ply more filler to the area and facilitate a be done by potentiating the space by the
smoother appearing fill. This is due to the needle of the filler.
ability to taper the filler out into the face After the initial inner fold fill, we want
more and not being limited by the ana- to crosshatch over the fill diagonal to the
tomical constraints of the puriform recess. arch of the mental fold.
In addition by layering we are creating a
scaffolding of filler across the nasolabial Technical Considerations
fold which reduces the propensity for the
There are several factors to consider
invagination of the kinetic fold. The results
with injection fillers, such as:
of cross-hatching are a more pleasing fill
in the static as well as kinetic movement Magnification—using loupes or some
of the nasolabial fold. other magnification device when injecting
will help you visualize the plane of place-
NASOLABIAL FOLD ment and flow of material.
We always place the filler medial to the Speed of Injection—Inject slowly, inject
nasolabial fold. If we placed the filler on or slowly, inject slowly. This will allow ma-
lateral to the fold, we would increase the terial to flow and the practitioner to visu-
depth of the fold. The filler will not flow alize where it is going. Fillers will take the
to a great extent in this area of the face. In path of least resistance. When the filler
this case we are filling in the space poten- has filled the plane and cannot flow lat-
tiated by the needle. erally, it will inflate. This is immediately

Another technique is to continue a visual as an isolated localized lump form-
troth of filler medial to the nasolabial fold ing. At this point, you must stop and rein-
all the way down to the corners of the sert to another area. If the filler materials
mouth if needed. Crosshatching the naso- go into an unwanted space, stop. Evaluate
labial fold after placing a line of filler me- and place in another area. The reasons for
dial to the fold will smooth out the fold this abrupt flow stoppage is multifaceted
during static and kinetic positions. Unlike (see “Potentiating the Plane,” Chapter 6,
the puriform recess the potential plane pg.141). In addition, there could be a his-
for this technique will be created more so tory of trauma in that particular area of
the lip where scar tissue (not visual) has the clinician and their ability to move into
made the tissue more adherent between the realm of artistry in their fill technique.
the dermis. Moreover, going slowly will The point is to let the initial compression
greatly reduce swelling. of the body fill subside until you can bet-
Time Allotment for Injection—schedule ter assess the lips and add definition to
enough time to fill, especially in the begin- the newly filled lips. Swelling is different
ning. Rushing your fills will create nega- between materials and patients, although
tive results including: bruising, clumping two days generally will suffice for sub-
of material, and wrong placement in the stantial swelling to diminish.
dermis. Lip/Face Swelling During
Selecting Layer for Injection Site—which Augmentation—tissue distortion during
layer should you inject into? With fillers facial augmentation occurs from two po-
in general, it seems that the deeper one in- tential sources:
jects into the dermis, the less definition is 1) Distortion from improperly placed
present, the more bulking of the existing anesthesia, usually when an inexperi-
look is achieved, and the shorter the sub- enced practitioner uses infiltrate anesthe-
stance lasts before it is resorbed. Deeper sia around the lips. In addition to acquir-
fills require more material. The more su- ing only infiltrate anesthesia, the fluid
perficial one layers, the more definition is from the anesthesia distorts the lips
present and the longer the substance lasts. 2) Initial swelling of lip post injections.
Regardless of the filler used, when the ap- Initial swelling after injections differs be-
propriate plane is located, the material tween patients, although it usually hap-
will flow easier and more uniform instead pens within a couple of seconds. The sec-
of being clumped into muscular structures ond can lead to uneven, asymmetric fills.
or connective tissue. This is a tactile sense Stop the procedure if distortions are lead-
that will develop over time, with repeated ing to inability to perceive fill. Sculpt an-
deposition of the filler. other day. Some fillers, like cross-linked
Sequential Fill Technique—a different HA products, offer you a week before it is
paradigm of filling procedure, whereby no longer manipulative and it is attached
we expand the lips over sequential vis- via hydro bonds to connective tissue. Pa-
its by filling the body of the lips with a tients are very amenable to sequential fill-
highly cross-linked filler, then finishing ing if the doctor explains the rationale for
the treatment sequence with contours in it.
the vermilion border.262 Remember, the Combination Fill Technique—because
changes of aging have occurred over time; our skin is a mixture of different vis-
therefore, reestablishing fullness and/or coelastisity and anisotropic properties
definition of the lips may require multiple (combination skin), combining different
visits. In my personal experience sequen- material at different sites in different lo-
tial filling can be accomplished in as little cations can optimize the filler’s effect and
as two office visits. Or for the more ad- longevity.262 An example of combination
vanced case the entire process may take technique would be placing a cross-linked
up to 6 months to potentiate a space in HA filler in Zone B of the lips and inject-
the lips in order for them to be adequately ing CosmoPlast into Zone A. Cross-linked
filled. However, this depends solely on HA filler displaces and adds volume to
the lips well, although they tend to be stiff entation.

and present an unnatural appearance to Massaging of the Material—massaging
the vermilion border. CosmoPlast is more in the injection site may be necessary af-
subtle when injected and leaves a more ter injection to achieve desired effect. Be
pleasing appearance and feel to the ver- aware this is usually painful and patients
milion border. should be blocked to perform this.
Stretching the Lip—potentiates the plane • NOTE: When we massage our filler,
to the flowability of most fillers. Wipe off it is usually because the flow we attained
all topical anesthetic and makeup thor- was not satisfactory. The lips have gone
oughly so you can stretch the tissue suf- through life with the patient suffering
ficiently to inject in the proper plane. cuts, burns, and bruises. Upon original ob-
servation of the lips, these manifestations
Material Expression—when injecting, be
may not present. When we inject and fill
careful to terminate expressing the ma-
the lips, we may bring these aberrations to
terial before the pullout. If one prolongs
the surface. Massaging may give the filler
expression all the way up to and beyond
a false sense of evening out the defect by
withdrawal of needle, a papule of material
inducing immediate swelling. It suffices
will remain under the epidermis leaving a
to say the only perfect, fillable lips we ever
raised appearance at the injection site.
possess are given to us at birth.
Bevel Orientation—the needle bevel can
Filler Material—will almost always be
be placed up or down. If the practitioner
palpable to the touch. You should explain
is in the correct plane, the material will
this to your patient. The fill should not be
flow just fine without regard to bevel ori-
visible.
TIPS
During the augmentation process the patient must be set in an upright

position. The reason for this is mainly due to soft tissue positioning.
If the patient is laid in a supine position the lips and perioral tissue
will displace laterally. Also, the targeted line and fold will dissipate,
leaving an obscured representation of the patient’s normal facial
presentation.
Acne scars: Not contraindicated.

Filler Amount—the amount of filler used Prior permanents fillers: Even with
is sometimes more important to the pa- a complete patient history of oral-facial
tient’s pocketbook than its effect. Keep fillers, one can’t account for the aug-
an eye on the amount of filler material menter’s placement skill and/or choice
placed. With experience, you will be able of fillers that were used. Explain the vari-
to assess the amount of filler needed and ous complications that may occur if lips
cost of augmentation more precisely. were previously filled with nonconven-
tional materials or treatment modalities.
Adverse Reactions and Arterial embolism: This author’s re-
Complications search revealed one documented case of
Arterial embolism on a patient after Re-
Reported adverse reactions are less
stylane was placed. (Schanz S, Schippert
than 2%, and usually include erythema,
W, Ulmer A, et al. Arterial embolization
ecchymosis, and acne. Friedman et al. re-
caused by injection of hyaluronic acid
ported that in 2000, an estimated 262,000
(Restylane). Br J Dermatol. 2002;146:928-
patients were treated with Restylane. Of
929.) The filler was placed in the glabel-
those, 144 (0.06%) were reported as having
lar region where the dorsal nasal artery
adverse events.
was affected. This is a very remote occur-
Normal Adverse Reactions rence and may have to do with technical
placement error.
Acneiform eruptions, lumps, asym-
metry, over and under corrections, needle Systemic Adverse Reactions
marks, bruising, erythema and pain.
Recurrent herpes: HSV-1 poses a
Anatomic complication in oral-facial augmenta-
Skin thickness: Dermal thickness un- tion. HSV-1 serum antibodies can be
der 0.4 mm thick, like the eyelids, is usu- found in up to 90% of Americans who
ally a contraindication for all fillers. This have been tested.22 Approximately 30-
situation usually presents around the eyes 40% of patients exposed to HSV will de-
and cheeks with fine lines. Laser resurfac- velop recurrent infections.263 Recurrent
ing or chemical peel is the treatment of HSV infections have been associated
choice in these areas. with exposure to sunlight, stress, fa-
tigue, menstruation, and oral-facial trau-
Scar tissue: There may not be any vis-
ma.264 It is recommended to postpone
ible scarring or lumping in the area you
oral-facial augmentation with patients
intend to augment. The filler you’re plac-
who have a current outbreak of herpes
ing can cause enough pressure to distort
lesion on and around the tissue to be
or bring previous scars to light. This puts
augmented. In addition, patients with a
the new augmenter in a precarious situ-
significant history of recurrent herpetic
ation. No matter how you explain to the
outbreaks should be premedicated with
patient afterwards what happened, you
antiherpetic medications. Some various
run the risk of losing the patient’s confi-
premedication protocols include:
dence. Explaining to patients beforehand
about possible filler reactions can allevi- Valacyclovir 500 mg Q12 starting two
ate this situation. days before treatment and continu-
ing three days after.265 rary filler: There are no contraindica-

Acyclovir (400 mg) 14 caps, two cap- tions for placing a temporary filler over
sules QD, starting one day before antici- a permanent. In many other countries,
pated augmentation.26 where the restrictions for permanent fill-
ers are much less severe, temporary fill-
Autoimmune Disease: Prior lawsuits ers are placed over permanent fillers (eg,
have come against augmenters relating to silicone) without any documented nega-
a relationship between collagen and poly- tive reactions. Although outside the US,
myositis and dermatomyositis in some pa- physician and/or patients reporting ad-
tients. The FDA examined the relationship verse reactions are not as thorough as in
and decided in 1995 “a casual relationship the US
between collagen injections and PM/DM or
other connective tissue diseases listed has Blanching of skin after filling:
not been established.” This ruling by defi- Superficial placement of filler: The
nition would include systemic lupus, which gray of the needle should never be seen
is an autoimmune disease characterized by during augmentation. Blanching is nor-
anti-DNA antibodies. mal for treatment of superficial scars

Rheumatoid Disease, Scleroderma: and will disappear within 5-10 min.
Not a contraindication for dermal fillers if Smoothing the filler is recommended.
wound healing is normal. This should be done with a finger, in
order for the patient to feel the amount
Diabetes: Not a contraindication for fillers. of pressure being applied. The pressure
Immunodepressed patients: Generally should be firm and a down and outward
wound healing is not delayed with these motion applied to blanched area. Super-
patients. Immunosuppressive therapy ficial placement of filler in the lips may
needs to be tenfold higher in concentra- produce nodules.
tion to affect the fibroblasts in the healing Tyndall Effect: On occasion, I get a
process. Fillers are not contraindicated for call from a patient and they explain they
these patients in general, yet good commu- have a nodule that has formed on their
nication with the attending physician pre- lip post augmentation, and it has a bluish
scribing the protocol is recommended. color in appearance. This is termed the
Combination permanent and tempo- Tyndall effect. The Tyndall effect is an
optical effect of light that passes through
a clear substance and is refracted back
through the surface of a thin membrane.
A bluish tint will appear to the nodule.
The Tyndall effect is caused by:
Too superficial placement of filler in
the dermis
Placing filler in an area where the
dermis is too thin (usually at or be-
low 0.4 mm)
When the plane of injection is satu-
rated, the filler material will try to
Tyndall Effect
escape the plane on the path of least the vermilion plane—that is if segments
resistance. This path may be directed of the filler were placed too deep into the
towards the superficial epidermis, cre- musculature—lumping of material can oc-
ating the Tyndall effect. cur. These lumps can be resolved through
I explain the color phenomenon to the manual manipulation, post-filling is of
patient and that due to the swelling that voids between lumps or drainage. Preven-
occurs with some patients during the aug- tion is all in the art of placement. Injecting
mentation process, areas where this effect in the correct plane and not too deep will
may occur may not be immediately vis- significantly reduce this occurrence.
ible. When the swelling subsides is when Nodules present in the lips when the
this phenomenon may present itself visu- augmented plane is saturated and the fill-
ally. If the nodule is still present, I either er looks for the path of least resistance. If
massage the material into the deeper der- the path of least resistance is towards the
mis or lance the nodule and milk the filler vermilion epithelium, nodules will begin
out. Either of these techniques usually to appear. STOP, ASSESS and REINJECT
takes care of this undesirable effect. IN ANOTHER PLANE.
Here is example of when a plane becomes Underfill of the lips/voids in lips:
saturated and nodules may start to ex- When filling in the lips from the lateral
press superficially at the vermilion tissue. segments towards the midline, the filler
Overfill of the lips: Overfilling the lips material will usually only flow a couple
results in: millimeters in front of the needle bevel.
The filling material will create a hydrody-
Beaking of lips namic force of fluids building up medial
Lumps to the outer edge of the injected material.
Nodules This phenomenon may create resistance
and a false sense of saturation of the plane
Beaking of the lips is caused by overly
targeted to be filled. Injecting slowly will
augmenting a patients lips, thereby dis-
let the hydrostatic pressure of the inter-
torting their natural presentation. Follow-
stitial fluid subside a little before pushing
ing the ideal proportions and guidelines
more filler in the plane. Voids or under-
set out in earlier chapters will prevent this
filled areas can occur in the injected plane
occurrence.
if one rushes the fill and perceives the
Lumps in the lips are largely due to plane is filled when it is not. Clinically the
improper placement of the filler into the plane will look filled due to the pressure
targeted plane. If the augmenter does not of the fluid that can build up in the un-
adhere to the proper plane placement or augmented plane. After the swelling sub-
if the filler is placed too deep and into the sides, the result will be a “crater effect”
muscularity, the muscular contraction of just medial to the terminal end of fill. If
the orbicularis oris during the first week this occurs a touch-up fill is required.
of implantation will squeeze and distort
Causes of underfilled voids:
the filler. During the initial week of filler
placement, it resides in the lips as a paste, Rapid injection of filler g pressure
not fully incorporated into adjacent tis- buildup in plane
sue. If the filler is not uniformly placed in Traumatic needle injection g swelling
Improper plane placement of needle, filling practitioners were polled about

which may traumatize deeper ana- their touch-up visits, the results were as
tomical structures g bleeding follows:
Techniques to prevent underfill or voids: Fifty-six percent of the group routinely
Inject slowly recommended touch-ups
Proper injection plane placement Forty-four percent of the group sel-
dom or never recommend touch-ups
Palpate the lips during injection of
filler. Manual palpation will help the When touch-ups were prescribed:
augmenter assess where the material Sixty percent recommend waiting less
is dispersed in the intended plane. than one week
Post injection tissue asymmetry: Ten percent suggested waiting one to
Swelling begins within minutes of injec- 2 weeks
tion of fillers. Due to the vascularity of the Thirty-three percent recommend wait-
lips, this occurs rapidly and dramatically. ing more than 2 weeks
The swelling can last days in some cases. It is interesting to note that in the
It is advised to wait one week for evalu- group of facial-filling practitioners who
ation of asymmetrical presentation of the infrequently did touch-ups, all empha-
augmentation site. sized the importance of utilizing proper
Patient Instructions technique during the first visit.267
Following the augmentation proce- Post-Augmentation
dure, patients should be given specific
instructions on post-op care. Advise your Corrections
patients to: Despite our best efforts, there are times
Avoid taking contraindicated analge- that undesirable results are achieved.
sics, such as acetaminophen or aspirin, Typically these unwanted results are vis-
as directed. ible 3 to 7 days after the initial augmenta-
Apply an ice compress lightly around tion. Post-augmentation corrections may
the tissue of the lips before, during, be needed to remedy lumpiness, overfills
and after augmentation. (Most prac- or overall asymmetry.
titioners apply ice for 15 minutes fol- Resterilization or Recapping Syringe
lowing the augmentation). There are a significant number of aug-
Avoid engaging in any strenuous ac- menters that routinely recap previously
tivity immediately for 24 hours fol- used cross-linked HA syringes. The ratio-
lowing the procedure. nale behind recapping is to save the pa-
Avoid manipulation of tissues (In oth- tient money and/or the ability to reuse a
er words, don’t touch the augmented previously injected syringe on a patient
areas). for a follow-up visit. A pilot study was re-
cently published focusing on the incidence
Restrict alcohol consumption for 24
of bacterial contamination on non-animal
hours.
stabilized hyaluronic acid stored after
Touch-Up Techniques initial injections.268 After use of a specific
When a group of well-known, facial- sterile sequence, nonanimal stabilized hy-
aluronic acid from 30 previously used sy- mentation patients to avoid:

ringes was stored at room temperature for Cosmetic tattooing
2 to 9 months. No bacteria were cultured Microdermabrasion
from any of the samples. Bhatia reported
similar results in their study.269 Additional cosmetic procedures, such
as chemical peels, laser treatments or
Panel members from the Consen- Retin A applications.
sus Recommendations for Cross-Linked
HA 2006267 were asked how they usually Follow-Up Visits
handle unused cross-linked HA. Forty- According to the Health Insurance Por-
four percent of the members discard the tability and Accountability Act (HIPAA)
unused product, and 13% store it for lat- of 1996, patients in the United States
er use in the same patient. Thirty-eight should sign a release giving medical pro-
percent of the panel used the remaining viders permission to use their medical
product in another area of the face during information and/or pass it from one pro-
the same office visit. Reuse of previously vider of care to another. After oral-facial
injected Restylane is discouraged. augmentation procedures, follow-ups ap-
Post-Augmentation Care pointments should be handled carefully.
Most patients want their cosmetic work
The following tips should be shared handled discreetly. Simply calling up
with the patient following their oral-facial patients after their augmentation proce-
augmentation procedure: dures is unacceptable. The doctor should
Hydration is instrumental in maintain- ask the patient for his or her permission
ing healthy lips. Some fillers, such as to make a follow-up telephone call. Af-
cross-linked HA, are maintained with ter all, you performed the cosmetic work,
hydration. Insufficient hydration will and you have an honest desire to not only
diminish the outcome of the augmen- see the outcome of the procedure, but to
tation. provide continued care to your patients.
Protective barriers, such as lip balm This doesn’t mean the doctor has to call
and/or lipstick, will assist in maintain- personally, yet if he paves the way by ask-
ing lip moisture. Patients should also ing permission, the follow-up call is not
be advised to choose a lipstick that an intrusion, but a welcome expectation.
provides sun block protection. Dam-
age to the lips can be avoided by ap- Techniques for Post-
plying a lip sunblock with SPF-15. Augmentation Correction
Dentists should dispense lip protector Palpable Redistribution of Filler (mas-
and hydrators to oral-facial augmenta- saging fill)—this technique can be ef-
tion patients in the same manner that fectively used with certain fillers, most
toothbrushes are given to dental pa- notably cross-linked HA. According to
tients. Matarasso’s poll of leading facial aug-
Regular maintenance of facial-filling menters with Restylane, most panel mem-
procedures is required. These proce- bers (60%) massage Restylane during and
dures can be held in conjunction with after treatment. The majority of practitio-
dental hygiene recalls. Schedule these ners do not recommend patients self-mas-
appointments accordingly. sage. Restylane can be massaged up to
It is also wise to advise oral-facial aug- two weeks after injection. The substance
This patient presented with an overfill of cross-linked HA. Insertion of a 27-gauge needle
into thickest part of the filler and withdrawal of the needle will allow draining of excess
filler. This technique works particularly well with cross-linked HA.
of Restylane will not be disrupted or de- Treatment of Visible and Nonvisible Scars
natured via manual manipulation.270 Without a doubt, treatment of nonvis-
ible scars is the most challenging and frus-
Aspiration—to correct small areas of
trating experience in cosmetic augmenta-
undesired overfills, as well as larger areas
tion. These scars or adhesions develop
in which there is an asymmetric fill, insert
from trauma and pathology suffered by
a 27 gauge needle into the middle of the
the lips or oral-facial area. The lips seem
nodule to extract the desired amount of
to hide these scars until the moment of fill-
filler out to reduce overfilled area.
ing, when the adhesions become visible.271
Incision—if an unpleasant nodule Filling areas that have scar tissue can ex-
that needs to be eliminated appears, take acerbate the depressed or cleft appear-
a small scalpel with a 15-c blade and make ance. As a general rule, the patient should
an incision at the center of the nodule to al- be consulted on the additional complexity
low material to express out. Although the of correcting such affected areas. Small in-
lips are very resilient, we should strive not durations or clefts can be treated by using
to make incisions. This is not the standard some simple techniques, which include:
protocol for treating these nodules, unless Subcision—this is a process of using
other methods have proven unsuccessful. a needle to undermine a subcuticular ad-
TIPS
Positioning is paramount in visualizing landmarks for injecting

anesthesia for soft tissue. Here the injector is located behind the
patient in order to visualize the landmarks for the mental block. In
addition, the injector is able to distract the patient by jiggling the
lips during the injection process.
For the infraorbital injection, one may lay the patient in a more
supine position for better visualization of the intraoral landmarks.
hesion.272 This technique involves using a with a history of keloid scarring; and seque-
disposable 1”, 22 to 27 G, hypodermic B-D lae, such as infection, altered physical con-
needle. These are tribeveled needles that sistency of treated site whereas the relieved
facilitate puncture of the skin. Inserting the area may produce a firmer area to the touch,
needle below the adhesion, the bevel is ori- yet still have an overall improved appear-
ented upward on insertion. The entry point ance, discoloration or hyperpigmentation,
acts like a pivot point, and the needle is ma- suboptimal response, excess response, and
neuvered underneath, cutting the adhering keloid scarring.
fibers.273 The surface skin is minimally af- Sequential Filling—through sequential fill-
fected, and the release of this tissue alone ing, the pressure from the filling material will
potentiates the elevation of the skin without gradually release the adhesions. In time, this
directly introducing filler. The subcision will produce a more aesthetic appearance.
technique also promotes an inflammatory
reaction, which promotes the formation of
renewed connective tissue to fill in bound-
down scar tissue.274 Contraindications for
subcision are: active inflammation; patients
Chapter 6 Review
STUDY Points
Three potential places filler can be injected into
Lip injection points and techniques
Plane saturation
Cross-hatching techniques with respect to oral-facial filling
Adverse reactions and complications
STUDY Questions
1) Of the three potential spaces where fillers can be injected, which one can be the
most frustrating for lip and perioral augmenters and why?
2) When augmenting the lips, we want to first establish or reestablish what? Once
established, what is the second goal of augmentation? How do these techniques
relate to the zones of the lips and perioral arena?
3) What are ways we can identify plane saturation and what is involved technically
when we have acquired plane saturation?
4) What is the Tyndall effect?
5) List three possible post-op corrections for injectable fillers.
7
Chapter 7
Simply Botox
Uti, non abuti.
To use, not abuse.
Chapter 7 Simply Botox 162
Botox (Clostridium Botulinum Toxin)

Armament
Perioral Injection Techniques for Botox
Over the past 30 years, the field of minimally invasive soft tissue augmentation has un-
dergone a vast explosion and at no time has the list of injectable agents been greater than
what it is today. With the recent FDA approval of several injectable fillers and many more
on the horizon, the timing of this book could not be better. While many injectables have left
their mark on the field of aesthetics, none have been more significant than the approval of
botulinum neurotoxin Type A for cosmetic indications—which today is the most common cos-
metic procedure in the United States. Soft tissue augmentation is no longer the sole territory
of the plastic surgeon and cosmetic dermatologist. Instead, aesthetic surgery has become a
fixture in multiple areas of practice. One of the most recent specialties is cosmetic dentistry,
and it is in the dental literature that I made my initial observations on restoring the lower
third of the face, as it is through the process of aging that we lose bony support and dental
structural support. It is essential to reconstruct the structures of the lower face in order to
achieve an aesthetically pleasing, natural and superior result.
Optimal outcome should reflect careful observation and subtle correction. Most patients
do not want to have a “done” or “frozen” look and frequently, less is more. Minimally inva-
sive soft tissue augmentation is both art and science. It is paramount that the practitioner—
regardless of their specialty—has a thorough understanding of the procedures and tech-
niques involved with soft tissue augmentation, as well as current knowledge of the medical/
dental literature. In what follows, Dr. Robert Gordon has written a thought out, heavily
referenced, authoritative text on the evolution and current use of botulinum neurotoxin Type
A in cosmetic dentistry. Furthermore, Dr. Gordon lays out in a clear and concise fashion the
art and technique of injection. Vermilion Dollar Lips should serve as the reference guide for
cosmetic dentists who are practicing or considering soft tissue augmentation in their practice.
What we did yesterday is not of importance today. We are only as good as what we have
done today. We must all strive to be the best at what we do and the chapter that follows
will enable serious-minded cosmetic dentists to achieve this standard of practice.
Arnold W. Klein, MD
Professor of Medicine and Dermatology
David Geffen School of Medicine,
University of California at Los Angeles, CA
About Dr. Arnold W. Klein

Few people have made as profound an impact on facial cosmetics as Dr. Arnold W. Klein. In
short, Dr. Klein revolutionized facial cosmetic rejuvenation. He has published over 100 pa-
pers and books. He is an editor at the Archives of Dermatology and Cosmetic Dermatology
and the Journal of Dermatologic Surgery—and he sits on the advisory boards of countless
others. He lectures extensively on soft tissue augmentation and Botox, both domestically
and internationally. Dr. Klein is recognized as a world-renowned dermatologist who has
pioneered numerous minimally invasive procedures.
Botulinum Neurotoxin peutic value for BTX-A. Soon after, Dr.

Shantz developed the first batch of what
(clostridium botulinum is commonly known today as “Botox”
toxin) in 1979. Dr. Shantz formulated a 150 mg
Botulinum neurotoxin has developed batch labeled 11-79, which served as the
significantly in perioral facial aesthetics source of all BTX-A used in humans in
and the combination of fillers and Botox the USA until 1997. The FDA-approved
will usher in a new era of cosmetic rejuve- BTX-A source is currently produced by
nation in the oral-facial region.275 It is vital Allergan (Irvine, CA).276 Today this neuro-
that we as dentists understand the poten- toxin has been attenuated and processed
tial of botulinum neurotoxin as a mono- for countless medical and cosmetic thera-
theraputic device in oral-facial cosmetics, pies.
as well as its new evolving combinational TYPES OF BOTULINUM
application it is used in.
NEUROTOXIN
Botulinum neurotoxin is regarded as
There are eight serotypes of botulinum
the facial cosmetic therapy that has ushered
neurotoxin: A, B, C1, C2 and D-G. Type A
in the evolution of oral-facial fillers. Perio-
is the most potent and commonly used in
ral Botox cosmetic therapy is increasing as
clinical practice.277 Currently two available
art and science. The adjunctive therapy of
forms of Botox are in use in North America:
injectable fillers and perioral Botox opti-
botulinum toxin Type A (BTX-A; Botox9)
mizes the cosmetic potential of oral-facial
A and botulinum toxin Type B (BTX-B,
augmentation. Traditional monotherapy
MYOBLOC). Although not as popular,
limits creative alternatives in restoring lip
botulinum Type B is reported to be more
and facial presentations. This chapter’s
stable on a long-term basis, requires less
goal is to expose the cosmetic dentist to
preparation before use, and has a different
botulinum neurotoxin and current appli-
antigen specificity. The antigen specificity
cations, including its history, mechanism,
allows Type B to be used when there is a
current perioral cosmetics therapies and
tolerance that develops to Type A.278,279
techniques.
MECHANISM OF ACTION
HISTORY
The molecule of clostridium botu-
The history of botulinum neurotoxin
linum toxin consists of 150 kD dichain
started in 1895, when 34 members of a
polypeptides composed of heavy and
music club in Elezelles, Belgium, fell ill
light chains linked by disulfide bonds.
and three of them died after eating a meal
Both compounds of Botulinum form neu-
of raw salted ham. Professor E. Ermen-
rotoxin-protein complexes (900 and 700
gem isolated the cause of the outbreak
kD complexes).280 After injection into the
and named the bacteria Clostridium botu-
muscle, the molecule’s heavy chain binds
linum. The neurotoxin produced by this
to the motor nerve terminal. This process
bacteria is one of the most deadly on the
takes a couple of hours so we instruct pa-
planet.
tients not to disturb the injection site for
Medical use of botulinum began in the three hours or the potential for the move-
1950s by Dr. Vernon Brooks. Around the ment of the toxin is possible, possibly par-
1970s, Dr. Alan Scott revealed the thera- alyzing a muscle not desired. The toxin is
then internalized via receptor-mediated store functional muscle activity takes 3 to

endocytosis when the plasma membrane 6 months.279
of the nerve invaginates around the tox-
Dilution volumes vary for desired ef-
in receptor-complex. A vesicle inside the fect. Dilutions are generally based on the
nerve terminal is formed. The neurotoxin
spread of the toxin. Higher doses or less
molecule is then released into the cyto-
diluted solutions (50-100 U/mL) localize
plasm and the light and heavy chains are
the effect of the paralysis more with many
cleaved. experienced clinicians. Lower doses or
With Botox-A, the light chain cleaves more diluted solutions (5-10 U/mL) fan
a 25 kD synaptosomal-associated protein out the paralysis more and clinicians may
(SNAP-25). The SNAP-25 protein is vital use this to affect the platysma more. A
to the successful attaching and releasing norm for dilution is 100 U/mL.
of acetylcholine from vesicles at the nerve
ending. With Botox-B the light chain IMMUNOGENICITY
cleaves the vesicle-associated membrane The development of antibodies is a
protein (VAMP). The nerve recovers by concern for the use of Botulinum tox-
sprouting finger-like projections. What in.283 When Botulinum toxin resistance
role these projections play is still under has been reported, it has been less than
investigation, for they disappear soon af- 5%.284 Factors that potentially contribute
ter the effects of the botulinum wears off. to botulinum resistance include: dose and
The process of the Botulinum molecule frequency of treatment intervals.285 Pa-
binding and interfering with nerve trans- tients treated with high doses (300 units
mission takes six to 36 hours after initial of Botox or higher) at frequent intervals
injection.281,282 The duration of effect to re- seem the most likely to develop antibod-
Contraindications to Botulinum neurotoxin

Patients with peripheral motor neuropathic diseases or neuromuscular functional
disorders like myasthenia gravis.
Co-administration with aminoglycoside, cholinesterase inhibitors, succinylcholine,
curare-like depolarizing blockers, magnesium sulfate, quinidine, calcium
channel blockers, lincosamides, polymyxins, or other agents that interfere with
neuromuscular transmission, which may potentiate the effect of botulinum toxin
Type A.
Patient with hypersensitivities to product ingredients.
Active inflammatory skin diseases (psoriasis, contact dermatitis, eczema) at the
time of proposed injections.
Pregnancy (pregnancy category C).
Breastfeeding mothers, for it is not determined if the toxin is excreted in humans
or what the effects are on a developing infant.
ies. Patients treated with Botulinum toxin aspirin and how it is used routinely for
typically ranging from 25-75 units at in- anticoagulant therapy and heart disease.
tervals of several months are not likely to Countless numbers of patients have ben-
develop resistance.276 It is recommended efited from the off-label use of aspirin.
to limit the total amount of toxin to less
A general rule is Botulinum toxin Type
than 100 U per session and avoid booster
A (BTX-A) for the upper face and fillers for
injections for a minimum of 3 months.286
the lower face. With the advancing science
ADVERSE REACTIONS of lip and perioral augmentation, there are
exceptions. There are new areas and tech-
Botulinum toxin Type A (BTX-A) has
niques developing for the mid- and lower
a long history of safe use. If any adverse
face region.290 In addition, there have been
reactions occur, they are usually mild and
some good results from therapies with pa-
transient.287 One long-term retrospective
tients exhibiting “gummy smiles,”291 oral
study pertaining to the safety of botuli-
rhytids, and mentalis. Not only can Bo-
num toxin explored the various outcomes
tox remove excessive perioral rhytids, the
of 50 patients receiving facial injection.
same technique can be applied to facilitate
The most significant adverse reactions as-
eversion of the lips.
sociated with botulinum toxin were ptosis
of the eyelids, various asymmetrical cos- Botulinum toxin therapy in the mid
metic results, bruising, pain in injection face presents with a trade off: although
site, and functional alterations. These ad- patients do receive great cosmetic results,
verse reactions can be overcome by care- there are some significant adverse effects
ful selection of injections sites and appli- to be aware of when the proper technique
cation techniques.288 is not applied. Most all of these negative
side effects will resolve within a couple of
PRE-TREATMENT PRECAUTIONS months; nevertheless, your patients will
To reduce ecchymosis, the patient be quite unsatisfied with their experience
should refrain from aspirin, aspirin-con- and applicator. Injecting in the muscle of
taining products, and nonsteroidal agents the lower face requires a great deal more
for seven days before Botox treatment.289 accuracy as compared to the upper face.
Consult with your patient over-the-coun- The muscles of the upper face are fewer
ter drugs they may be taking that might in number and are anatomically easier to
affect their post-injection bruising. identify than the lower face. This is par-
tially because the muscles of the upper
CURRENT USAGE face lie over more pronounced body land-
Most of the usage of Botox is for “off- marks as opposed to the lower face mus-
label” therapy. In April 2002, Botox was cles suspending and encompassing the
approved for cosmetic use limited to the mandible.292 If there is an unwanted migra-
glabellar (frowning areas between the tion of the Botox, paralysis of muscles at-
eyes) for patients 65 and younger. Up until tending speech and lip competency can be
this time all cosmetic usage was off-label affected. This reinforces the psychological
therapy. The fact that the entire process of aspect of the face. Botox in the mid- and
FDA approval takes a significant amount lower face has the propensity to change
of time may delay appropriate therapy the look if not applied correctly in the spe-
with a new drug. One example of this is cific area targeted in the goal to enhance
the existing facial features. Many patients cular activity, which weakens the muscle.
are upset by the appearance of their treat- This block works on striated muscle and
ment if their facial features or natural ex- eccrine glands. Botulinum Type A weak-
pression are significantly changed. ens the overactive underlying muscle con-
Over treatment of the perioral area can traction. This action produces a flattening
produce: of the facial skin and an improved cos-
metic appearance.294
Difficulty in pursing lips
Speech impairments: the inabil-
ity to pronounce “b” and “p”
Loss of lip competency, which
can affect eating, brushing, and
drinking
Diminished proprioception
Botulinum toxin Type A (BTX-A)
therapy on nasolabial lines (mari-
onette lines) and on the mentalis is
also being accepted into mainstream
oral-facial cosmetic therapy. We all
manifest different tissue expression,
particularly when we are talking.
There is a population group that
exhibits strong contraction of the
mentalis, whereas botulinum toxin Botulinum toxin is traditionally injected with insulin
is being used to treat these mental syringes. Here are two such examples: the top
indentations (or “cobblestoning”) syringe is a 1 CC tuberculin syringes with a 32-
below the lower lip due to the hy- gauge needle attached. The bottom syringe is
perkinetic contraction of the menta- an ultrafine syringe: 3/10 CC, 8-milimeter, 31-
lis muscle.293 Here botulinum toxin gauge needle.
is placed superficially and not deep.
When the botulinum is placed too
deep, lip and speech competency is af-
fected. Success relies on technical exper- Armament
tise and anatomical precision. Botulinum
toxin type therapy for select patients with RECONSTITUTION AND HANDLING
chronic TMD appears to be beneficial. This Botox Type A (Allergan Inc.; Irvine,
is an off-label use and patients undergo- CA) is supplied in a vial containing 100 U
ing this therapy usually have exhausted a of vacuum-dried neurotoxin complex. The
conventional therapy. In addition, recommended reconstitution is 2.5 mL of
one can lift up the corners of the mouth 0.9% nonpreserved saline to final concen-
by injecting botulinum toxin into depres- tration of 4.0 U/0.1 mL.295 Preserved saline
sor angular oris. can be used to reconstitute a Botox vial.
Botulinum toxin Type A (BTX-A) works The advantage to using preserved saline
on the peripheral blockade of neuromus- is diminished pain upon injection of Bo-
tox, up to 54% with 0.09% preserved ben- served saline maintains its efficacy up to
zyl alcohol. The results of a study showed four to six weeks before use, when stored
that 100% of the patients injected with pre- at 4°C.303,304 Recent studies suggest that
served isotonic saline reported less pain there is no significant difference in Botox
than when injected with nonpreserved stored in a refrigerator rather than a freez-
isotonic saline (P < .001).296 er.305
A study of clinicians and their dilution PATIENT ASSESSMENT
ratio yielded the result that the most used
As discussed previously, we need to
dilution ratio was 2.5-3.0 mL per vial.297
have a plan before initiating Botox treat-
A dose-dilution study was performed in
ment. Ultimately the end result will be
which a total dose of 30 U was reconstitut-
perioral shaping of the tissue by means
ed with 1, 3, 5 or 10 mL and no differences
of select paralyzing of the muscles associ-
between efficacy or safety were observed
ated with animating the undesired perio-
in treating glabellar rhytids.298 Reconstitu-
ral presentation. Most wrinkling is associ-
tion ratios for the perioral region need to
ated with excessive muscular contraction
be considerably less. The main objective in
or a combination of both.
dilution ratio of the Botox is to allow effec-
tive control of the administering dose.299 Gender Selection
In addition, due to the dense musculature There is a distinct difference in the
of the orbicularis oris, injecting larger vol- amount of units given for select therapy
ume units cause unnecessary pain. The between the genders. In general, males
usual reconstitution ratio for the perioral require more units per injection site to ac-
region is 1.0 mL to 2.5 mL nonpreserved complish the same cosmetic result. This is
saline per vial of 100 U of Botox. This di- due to the increased muscular mass males
lution ratio gives a dispersion area of 1 to experience in the oral-facial area.287
1.5 cm, so this is the minimum spacing
of injections.300 There seems to be anec- Perioral Injection
dotal and published reports that relate the Techniques for Botox
greater the volume, the shorter the dura-
tion of the effect.301 PERIORAL INJECTIONS
There has been some debate over han- There are ultimately three goals in pe-
dling of reconstituted Botox, in particular rioral Botox injections: 1) removal of ki-
the shaking or agitating of the solution netic rhytids 2) increase in lip surface area,
after its reconstitution with saline. Recentand 3) establishing a desired eversion of
studies show that reconstituted Botox agi- the lip. Botox treatment of oral rhytids is
tated to allow bubble formation was just the most common new area for which pa-
as effective in therapy as Botox handled tients request treatment.306 Botox has been
extremely gently.302 proven to reduce the perioral lines around
the lips. Injecting adjacent to the fine lines
SHELF LIFE around the mouth results in a smoother
Prescribing information included in appearance of the lips and an eversion of
botulinum Type A suggest that reconsti- the vermilion border of the lips.307,308 It is
tuted Botox should be used within four important to understand that the perioral
hours. Clinical studies indicate that a re- lines around the mouth have both a static
constituted Botox solution with nonpre- and dynamic relationship, which is differ-
Additional Considerations for Patient Assessment

Assess facial expression at rest and during animation
Evaluate the range of motion of involved muscles
Palpate muscles during repose and contraction
Assess brow position. In women, be sure to consider whether the brows have
been plucked or tattooed
Evaluate any asymmetries
Exercise caution in patients who have undergone surgery that can alter the
underlying anatomy
Begin with recommended starting doses and add more units or additional sites
if necessary at a 2-week evaluation
Do not completely paralyze the muscles
Consider patient expectations as well as cultural viewpoints in planning the
overall effect
Assess the need for treatment with other modalities, such as soft-tissue
augmentation, dental, orthognathic or surgical intervention
Modified from Consensus Recommend Plastic and Reconstr Surg.
ent than the lines and folds of the upper the rhytids do not correspond or deepen
face. The upper face line and folds mani- when the patient purses their lips, these
fest themselves in the kinetic motion pre- lines are a manifestation of loss of lip vol-
dominantly. ume and would be better suited for filler
therapy. More injection sites are required
The first step is to analyze the oral
rhytids to distinguish between dynamic for the upper lip in contrast to the lower
rhytids acquired from muscular contrac- lip, for the upper lip is where the majority
tion of the underlying orbicularis muscle of rhytids manifest in patients.
and static rhytids from the aging process Eversion of the vermilion border of the
of the skin. lips can be acquired by precise injection
This is done by having the patient con- of Botox in the perioral area (Zone A). By
tract the lips in a pursing movement and weakening the superficial orbicularis oris,
observing the rhytids. If the rhytids deep- there is an eversion of the G-K line angle
and a corresponding increase in surface
en and coincide with the contraction of the
mouth, then they are most likely due to area of the lips proper (Zone B).
the hyperkinetic action of the orbicularis Dilution and Dosage
and can be treated with Botox therapy. If The consensus of dosage ranges from
approximately 5-6 U
around the vermilion bor-
der with 1-2 U per injection
point. The injection points
are at or just above the ver-
milion border (Zone A).309
Technique
Introducing Botox cos-
metic therapy around the dental explorer will suffice.
mouth to your patients can be intimidat-
Start with drawing a line down from
ing. Improper techniques or dosage can
the lateral corners of the nose through
lead to partial paralysis, lip incompetence
the upper lip. Inject within the bor-
or an unaesthetic result. By following the
ders of this line and you will receive
guidelines outlined in this chapter, you
desired lip eversion and/or increased
can achieve maximum effect of perioral
surface area of vermilion (Zone B). In-
rhytid removal or lip eversion without
ject lateral to these border lines and
distorting lips competency or function.
you have a greater chance of effecting
Due to the robustness of the orbicularis
lip competency.
oris this treatment usually lasts six to eight
weeks. Measure your planned injection points
out so they are symmetrical and mark
Material needed: an eyeliner (prefer- them. In general, the injection point
ably cheap) and a measuring ruler or a
Pictured above is the horizontal line drawn in the middle of the chin. We inject below the
horizon of this line. This ensures we do not compromise lip competency.
of losing the tonus to the Cupid’s bow,

Alternatives for perioral others disagree. In my experience, if you
rhytid removal have a very toned Cupid’s bow, 1 U inject-
Chemical peel ed midpoint will facilitate a fuller eversion
of the lip.
Laser resurfacing
Combination Therapy
Filler injections
When deciding to do a combination
technique of Botox and fillers around the
should be kept symmetrical and su-
mouth, you have to set up the sequence
perficial.
of treatment modalities and desired effect
Spread the vermilion border with your for them individually and in combination
fingers so the tissue is taut. This will (See Table 7.1, pg. 178). Botox treatment
reduce pain upon needle insertion should be done first. Think of Botox treat-
and stabilize the lip. You will not lose ment periorally the same way as an art-
your reference point since it is already ist prepares the canvas for his medium.
marked with the eyeliner. The canvas has to be framed, stretched,
Insert and inject 1 U at the vermilion and primed for the artist to work on. Bo-
border. tox treatment will create more of a surface
Inject superficial rather than deep. area of the lips (Zone B). Botox will not
Some authors recommend not inject- add volume to the lips, only fillers will do
ing in Segment 2 of the upper lip for fear this. The results from the Botox take a cou-
ple of weeks to manifest. When the results perioral therapy, one may find there is no
of the perioral Botox therapy are present, need for additional augmentation-like fill-
then one can add volume and sculpt the ers. There are times that I am surprised at
mouth with fillers. the post-injection results of perioral botu-
Sequence of Botox and Filler Therapy linum toxin therapy where the lips and
perioral tissue have smoothed out, which
Botox Botox Figure 7.1

Sequence of
Combination
Therapy for
1-Week Surface Area G-K Line the Lip
Evaluation Angle
Sculpt Sculpt
2nd Add Volume Vermilion Vermilion
Treatment (Zone B) (Zone A) (Zone A)
My typical sequence for preparing a

leads to a very aesthetically pleasing re-
patient for Botox and filler therapy is as
sult.
follows: Botox appointment first, post-op
visit, and evaluation one week later. At Elevating The Corners Of The Mouth
the 2nd week post-op visit, I add fillers. Part of the aging process can lead to the
over development of the depressor angu-
There are three main reasons for this:
lar oris (DAO). This muscle can cause the
1. In allowing the Botox to shape the lips
downward droop of the mouth with time.
for accurate assessment and placement of
Injecting Botox into the bottom of this fan-
fillers, you may find you do not need as
shaped muscle will relieve the contractile
much filler as initially suspected for treat-
effect of this muscle and create a subtle lift
ment.
in the corners of the mouth. This is in part
2. If we inject filler around the lips immedi- because the antagonistic levator muscles
ately after placement of Botox, we run the maintain their tonus adding to the lift of
risk of displacing the Botox injection fluid the corners of the mouth. It is suggested
to other anatomical areas. Remember, it that the DAO doesn’t work alone in this
takes 3 hours for the injected botulinum effect and that the platysma muscle has an
to acquire a stable location in the muscle adjunctive effect in depressing commis-
tissue. The flow of filler has the potential sures of the mouth. When we inject into
to displace the Botox one has carefully in- the targeted DAO, the platysma in that
jected in precise locations. area also receives denervation because the
3. Following a 1-week assessment post- platysma overlays itself upon this mus-
cle.
This is a representation of a straight line drawn from the puriform recess to the inferior
border of the mandible. At the bottom of this line is the injection point for Botox injection.
This point is midpoint in the fan-shaped DAO. This targeted area reduces complication of
oral competency inherent in the improper placement of perioral Botox injections.
dible where the fan-shaped DAO muscle
Technique is the widest. The dose of 2-4 units may be
The DAO is fan-shaped and controls administered depending on the age, sex,
the frowning of the corners of the mouth. and muscle tonus of the patient.
Ask the patient to bite down and palpate COMBINATION THERAPY:
the masseter muscle on the inferior man-
dible. Just anterior to the masseter lies COMMISSURE
the posterior border of the DAO. Target The combination of Botox and fillers to
the posterior inferior border of the DAO; raise the commissures of the mouth is su-
this will keep you clear of the depressor perb. The sequence is less important, Bo-
angular oris muscle that can cause lip in- tox therapy and filler therapy can be ap-
competency if injected into. By drawing plied simultaneously. Remember: for the
an imaginary line from the corner of the lips, BTX therapy purpose is to increase
nose to the mandible, you arrive at the the surface area for filling. With the cor-
base of the depressor angular oris muscle. ners of the mouth, we aren’t so dependent
One can use a cosmetic pencil, ruler or on the resultant BTX result to evaluate for
any other straight-lined device to estab- commissure lift.
lish this line. When we establish the line, Mentalis
we inject lateral to it. The injection point Botox injection can be very effective in
will be located by the angle of the man-
TIPS
Dilution
r
Diamete
1ml
2 ml
4 ml
Saline raser
Pencil E
Dime
Quarter
Relative
r
Diamete
The concept of Botox dilution can be confusing for the beginner.
It helps to think of 100 units of Botox like the shot glass pictured
above. The red water represents 100 units. If we pour the shot
glass into the small glass container and another equal shot glass
into the large container, we have diluted the Botox into a larger
and smaller medium. Now each container holds 100 units of Botox.
If we draw 1 syringe cc out of the large container or 1 cc syringe
out of the small container, we are injecting the same amount of
Botox per unit.
The medium, in this case water, is only relevant to the dispersal
of the Botox in the tissue. In the clinical setting, a dilution of 100
units of Botox with 4mL saline will affect a quarter-sized diameter
from the center point of injection. A dilution of 1 mL of saline will
affect a pencil eraser.
reducing the cobblestone appearance of a cosmetic pencil before injecting.

the chin. The dimpled appearance of the
Assess the degree of contraction first
chin results from the aging process de-
and err on the lighter side of injecting
scribed in Chapter 2, which includes loss
units used. If the desired effect is not real-
of subcutaneous fat and long-term con-
ized after the two-week, post-injection pe-
traction of the mentalis muscle. The ma-
riod, re-administer a couple more units in
jority of patients fail to see the significance
the same location. Before injecting, pinch
of their pebbly chin, due to the fact that
the chin to facilitate deep placement into
most people view themselves in the static
the mentalis of the Botox. Remember, the
form (repose) in the mirror.
platysma runs superficially over the men-
Technique talis and we want to penetrate deep to this
One or two injection points are neces- muscle to the mentalis. Usual duration of
sary for the weakening of this muscle. Re- this treatment is three to four months.
member, we want to weaken the mentalis,
not paralyze it. Muscles to watch out for Combination Therapy: Mental
around the mentalis include the orbicular- Fold
is oris and depressor labii. Overtreatment Combining Botox and filler to relieve
of this area can lead to lip incompetency the mental fold will extend the duration
and associated side effects. of the filler. Filler placed in the mental fold
First, establish if there is clefting in the has the tendency to wash out quicker due
chin. This will determine if one or two in- to the fact that the duration is less there
jections will be required. If there is a cleft, than in other anatomical spots. This is due
two injections will be performed bilateral to the strength of the mentalis and associ-
to the cleft in symmetrical points to ated perioral muscles. Injecting Botox into
one another. If no clefting is the mentalis will weaken the
present, then one injection constricting muscle, where-
site should suffice. by reliving the severity
of the fold and subse-
Injection points quent filling will last
will be no higher longer.
Patients exhibiting an
than midpoint to inverse LBL may not be Reducing Gummy
the center of the candidates for denerva-
mentalis. Any Smile Or Nasola-
tion of the LLSAN. Botox
higher than this es- for these patients may bial Therapy
tablished horizon exaggerate their inverse The above two
LBL in an unacceptable therapies are inter-
line may affect lip way.
competency. Start changeable because
out with one injec- the technique to ac-
tion point inferior to quire the effect is the
the horizon. If two injec- same. The targeted mus-
tion points are to be used, cle of denervation is the le-
make sure they are symmetri- vator labii superioris alaeque
cally placed at or below the midpoint nasi (LLSAN). This area of the face
horizon. Inject 2-6 units on females and is significant in facial presentation. If one
2-8 units on males. Mark your points with inadvertently affects other areas of facial
Injection point for LLSAN

denervation.
Targeted areas for

perioral injections. The
blue circle demarked at
the tip of Cupid’s bow
may flatten out the cupids
bow if injected with
Botulinum toxin. Reserve
this injection point for
patients with severe
perioral rhytids of overly
exagerated Cupid’s bow
architecture.
Gummy Smile Perioral Mentalis Depressor

(Nasolabial) Angular Oris
Target Muscle levator labii superioris Orbicularis Oris Mentalis Depressor an-
alaeque nasi (LLSAN) gular oris (DAO)
Upper lip 4 max 1 point /

Injection Points 1 point / bilaterally 1+2
Lower lip 3 max bilaterally
Units/Injection 1 unit 4-10 U dis- 2-6 (female) 1 - 3 units /

Point tributed evenly 2-8 (male) bilaterally
(symmetrically)
Below mid- Inferior man-

Location piriform aperture At vermilion of dibular border/
point horizon of
the lip posterior border
mentalis
of DAO
Depth of Superficial Superficial Superficial Deep Muscular

Needle Muscular Muscular
Table 7.1 Injection points

expression, the patients “look” can be dra- this depression can help you visualize the
matically affected. Botox is largely unpre- spot of injection.
dictable for these areas of treatments, re- The targeted muscle is the levitator la-
sulting in author published success rates bii (LLSAN). Keep the injection point me-
of 64%.310 When an overuse of mid-facial dial in orientation. Lateral to the levitator
Botox therapy occurs, the patient’s main labii are the zygomatic minor and major.
complaints are that they don’t look like If the Botox spreads to these muscles, the
themselves and/or they have some loss of facial expression will be affected more
lip control.311 A result of denervating the dramatically. Keep the injection point su-
LLSAN muscle is the desired lip length- perior to the orbicularis muscle in order
ening, which in itself is a sign of aging. to keep lip competency. Inject 1 unit bi-
As a result of this potential problem, pa- laterally for effect. I use a 1 mL dilution
tient selection is critical. Patients who will to keep the area of dissolution with in a
benefit the most are those with a “gummy pencil eraser diameter.
appearance” to their smile. The nasolabial
fold is best treated with filler agents. Duration
Technique
Combination Botox and Fillers
Place your patients in a recumbent Advantages of combination therapy
position. View the kinetics of the smile as included:
well as the static view. Mark on the pa- Superior aesthetic result
tient’s face with a cosmetic pencil the tar- Less material used to attain result (ie,
geted injection points. Mark lateral to the filler to augment)
nasolabial fold and just inferior to the na-
Increased treatment options to achieve
sial columna. This area is called the piri-
desired outcome(s)
form aperture and placing your finger in
Longer lasting results
TIPS 1
1
Here is a case of mine from the beginning of my lip augmentation

days. In this particular case, I made several pinnacle mistakes.
1) Violation of the ideal lip proportion of 1:1.618. We can see

after augmentation that this patient presents with a 1:1 lip ratio.
This is most unpleasing to the eye aesthetically.
2) Overfilling the lips in volume, upper and lower leading to a
“duck lip” presentation.
3) Failure to adhere in filling the natural planes of the lips. This led
to an overall distortion of the lips and a blending of the planes into
one uniform shape.
Fortunately, the choice of filler for this case was a cross-linked HA.
The advantages to using cross-linked HA for the beginner is the
resorbability of the material. We certainly don’t plan for failure
in our cases, yet these are the trials of passage we must face.
Thereby it is important to encompass materials that are forgiving
in our armament, when we begin on our path of lip and perioral
augmentation.
Chapter 7 Review
study Points
History of Botulinum neurotoxin
Botulinum neurotoxin mechanism of action
Contraindication(s) to Botulinum neurotoxin
Adverse reactions to Botulinum neurotoxin
Lip and perioral injection techniques with Botulinum toxin
study Questions
1) How many serotypes are there of botulinum neurotoxin?
2) Which forms of Botulinum neurotoxin are most prevalent in North America?
3) If one is to treat a patient with Botulinum toxin and filler therapy periorally, what
is the ideal sequence of treatment?
4) What two results can be expected from lip botulinum toxin treatment?
5) True or False. Generally with male and females the same amount of botulinum
toxin is sufficient.
6) Which dilution will have a longer duration of effect when injected into the same
muscle and amount: A) dilution of 4 mL saline to 100 U of Botox or B) dilution of
1 mL saline to 100U Botox ?
8
Chapter 8
Clinical Techniques:
Lip and Perioral,
Botox and Fillers
Docendo discimus.
We learn by teaching.
Chapter 8 Clinical Techniques: Lip and Perioral, Botox and Fillers 182
Clinical Techniques: Oral-Facial Augmentation

Ages 20-30
Ages 30-40
Ages 40-50
Ages 50+
Less is More
If a picture is worth a thousand words, this chapter is
priceless. The art of lip and perioral augmentation is so
hard to convey in mere words. The art of augmentation is
best learned in an apprentice-like atmosphere. An artist
must progress through the “rites of passage,” mentored
and guided by instructors who in all reality are only one
step ahead of their students on the same journey. The
lip and perioral community has yet to reach a consensus
on a uniform and cohesive educational curriculum. Thus,
the beginning augmenters are subject to suffering the
trial and error method of learning and, unfortunately,
so are their patients.
When reviewing the following cases, examine the
photographs closely. Realize the angle of attack;
observe the needle in its plane of injection and watch
the flow of the material. Keep in mind there are many
ways to hold a paintbrush; likewise, there are various
ways to inject and augment the lips and perioral area.
Establishing a consecutive sequence of steps is critical
in oral-facial augmentation. To achieve optimal results,
it is highly recommended that oral-facial fillers first be
placed in the outer ring first before addressing the lips
in the inner ring.
The order of fill will be outermost first, which
encompasses the nasolabial fold, mandibular jaw line,
and mental protuberance. The inner ring encompasses
the zones of the lips. In addition, we fill the lips from the
outside in with our planed injection points.
Clinical Techniques:
Oral-Facial
Augmentation
Outer Ring: Nasolabial fold, Mental fold, Marionette Lines, Jowl folds
Inner Ring: Commissure, Lips
COMMISSURE
Step 1: augment the com-
missure of the mouth first if
needed. If we do not follow the
outer ring to inner ring order,
we can potentially overfill or
create a beak effect to the lips.
Fill the lips first and if there is
significant commissure drop,
we can add to the beak effect of
the augmented lips.
LIPS
Step 1: fill from the corners
of the lips inward. Failure to fill
outwards inwards on the lips
potentiates lip beaking, over-
fills, and asymmetry.
Step 2: We will always start
by filling in volume first (Zone
B). This means that we will fill
in Zone B first. By filling in Zone B, we

will allow the lips to reestablish vol-
ume. In addition, we can resolve a sig-
nificant amount of rhytids that have
developed from loss of volume in the
lips. If there is still a significant amount
of tonicity in the lips, the natural anat-
omy will reestablish itself around the
vermilion border and philtrum col-
umns. If we were to fill in Zone A first,
we may overstate the anatomy in this
area when we add volume to Zone B.
Step 3: Define anatomy if needed

2nd (Zone A). Never Fill Zone C; for
anatomical and pathologic classifica-
tion only.
Needle Size
One of the most often asked ques-
tions I receive when I lecture is: what
needle size do you use when injecting
fillers? The majority of the augmenting
community will use needle sizes from
Table 8.1
Gauge Flow Sculpt Correction Select Needle Sizes
27-30 gauge. I will often switch between
27 Gauge Yes No No 30 gauge and 32 gauge needles during
my augmentations. Generally, if I want
30 Gauge Yes No 50 / 50 to observe the flow of the material, I will
use a larger diameter or smaller gauge
32 Gauge No No Yes needle. If I am potentiating the plane by
the needle or sculpting tissue, I will use
a 32 gauge needle.
A When correcting previous fills, I will use

a 32 gauge the majority of the time, al-
though if the defect needs significant
material, I may use a 30 and 32 gauge in-
terchangeably. For example; when plac-
ing a pearl drop cross-linked HA in the
puriform recess of the nasolabial fold, I
will use the 30 gauge needle that comes
B with the syringe. When I use the cross-
layering technique over the pearl drop
and fold, I will use the 32 gauge needle.
Upper Lip
Picture 8.1
A) 32 Gauge
C B) 30 Gauge
C) 27 Gauge
Age Lips Commissure Nasolabial Philtrum

Marionette Lines Fold Mental Fold
20-30 Zone B frequently Rarely Rarely Rarely
Zone A rarely
30 - 40 Zone B frequently Less frequently Less frequently Less frequently
Zone A less frequently
40 - 50 Zone B and A frequently More frequently Frequently Frequently
in conjunction
with lips for
support
50+ Zone B and A Frequently in More More
more frequently conjunction with frequently frequently
lips for support
Table 8.2
Relationship Between Augmentation Areas and Age
Ages 20
30
thru
This patient group usually has very robust oral-facial

features. Very seldom will you need to perform any
augmentation in the nasolabial lines or rhytids in this age
group. Instead, you will be more likely to add volume to the
lips. Plan for the minimal amount of injection points per lip on
these patients. Usually two to four injection points per lip will
suffice. This population group will most likely consist primarily
of females. In youthful lips, the material will flow easily, which
potentiates the augmenter to err on overfilling the lips.
KEY POINTS TO REMEMBER

Greater overfill potential in this age group. Less is more when filling the lips
Plan to augment isolated planes to achieve natural appearance (ie, Segment 2,
Zone B of the upper lip). Will present an overall full upper lip
Due to this young age group, a differential diagnosis is warranted. A complete
oral-facial evaluation may be needed to evaluate if the patient will benefit from
dental, orthodontic or orthognathic treatment to achieve the desired cosmetic re-
sult of oral-facial soft tissue
Zone B is where most of the material plement the presentation of tissue at this
will be added. Start from the lateral seg- age.
ments (1, 3, 4 and 6) and fill inwards. Put Lower Lip
the needle into the hub and fill slowly
Zone B is where most of the material
(Picture 8.2). Zone A and C fills are not
will be added, utilizing a slow filling tech-
needed for this age group. Most patients
nique. In youthful lips, the material will
in this age group want volume, and that is
flow well. Maintain constant pressure; ob-
all they need. The connective tissue, mus-
serve the flow of filler as it saturates the
cle tonus, dental, and skeletal support is
targeted plane of the lip.
intact. Filling and defining anatomy in the
philtrum and vermilion border will give
a “worked on” look and would not com-
Picture 8.2
Injection technique for filling and shaping segment 2 zone B.
Case Presentation (Select

Volumizing) Outer Ring: None, Remarkable
Inner Ring
History
Zone B: volume segments 2
This patient presents with the desire
to increase the volume in her upper lip. Zone A: N/A
This patient is an amateur model and is Treatment
Picture 8.3
Post-augmentation of this patient’s lips reveal a harmonic lip relationship as evidenced
by the ideal proportion caliber.
Restylane was placed in Segment 2,
periodically contracted to perform photo Zone B in the upper lip on this patient.
shoots for commercial products. It has Two small pearl drops were placed in
been suggested to her that some minor the upper lip on this patient. This slight
facial augmentation would increase her augmentation may not be visible to the
photo desirability for advertisement lay- average person, although this patient was
outs. very pleased (as were her photographers).
Cosmetic Diagnosis This patient is in a profession where de-
Evaluation of this patient showed near- tails may keep them working or not. I was
perfect proportions, although the upper more than happy to serve her career ad-
lip presents slightly disproportionate to vancement…it’s that simple.
the lower lip.
Note these segments. Although I didn’t fill a lot

A consideration of cost comes into play of cross-linked HA into Segments 1 and 3,
when we plan treatment of patients in this the filling of Segment 2 supports the drap-
group. After all, a syringe of cross-linked ing of the lips as they taper outwards.
HA can be very costly and for this type of This technique is particularly effective
augmentation, only a quarter of a syringe for cross-linked HA products, where they
is usually used. I use a 0.4 mL touch-up displace and support adjacent tissue.
syringe distributed by Restylane. These On a personal note: this patient has
syringes are designated for post-augmen- undergone two photo shoots within the
tation corrections of asymmetry or areas week of initial injection (Picture 8.4) and
of under fill. she and the photographers were very
Result pleased. Such a minimal amount of fill
One week post-clinical evaluation re- makes a big difference in some of these
veals a fuller upper lip. Segments 1-3 have cases.
increased in volume and we have reac-
quired the natural planes associated with
Picture 8.4
One-week post-augmentation evaluation.
Case Presentation (Gummy component of the maxillary smile, in par-

Smile) ticular the lift of the upper lip by the leva-
tor labii superioris alaeque nasi (LLSAN).
History Augmenting the lips to correct the prob-
The patient illustrated here is a 29- lem in hopes of covering more gingiva is
year-old female. Her chief complaint is contraindicated: it would increase lip vol-
that when she smiles she displays too ume, yet since our patient has a relatively
much gingiva. Patient presented with a ideal upper to lower lip proportion, we
normal health history without any con- run the risk of overfilling the lips. This is
traindications to Botox or filler therapy. a classic mistake the beginner augmenter
Cosmetic Diagnosis will make in efforts to correct this cosmet-
ic
Upon evaluation of her facial propor- presentation.
tions, we see that her lips are in ideal pro- Differential diagnostic treatment op-
portion. The lips are full, vital, and she tions would include: periodontal surgery
presents with a slightly upward curved to remove excess gingiva, which was re-
LBL. Upon brief skeletal/soft tissue exam, jected for the potential increase in tooth
we find that this patient’s anterior skel- length, whereby producing an unaesthet-
etal relationship is within normal limits, ic result. Orthodontic/orthognathic treat-
without exhibiting an overly exaggerated ment was considered overtreatment on
maxillary relationship. The clinical find- the basis of time, post-operative healing,
ings draw more attention to the soft tissue and expense.
Picture 8.5
Notice high smile line produced by a heavy contraction of the LLSAN muscle.
Picture 8.6
Pre-augmentation evaluation demonstrates ideal proportions of lips.
Picture 8.7
Pre-augmentation ideal proportion evaluation reveals ideal relation of dentition to Sn to Me.
Picture 8.8
Demonstrated here are the injection point landmarks for denervating the LLSAN. Notice
injection is directed towards the most medial part of the puriform recess.
Outer Ring: nonremarkable tential treatment. There are other thera-

Inner Ring: excessive gingival display pies that can possibly produce a better
cosmetic result, such as orthodontics, oral,
Therapy: Botox therapy at a dilution of 1
periodontal surgery, and cosmetic dental
mL of non-preserved saline to 100U of Bo-
restorations. The adverse effects of this
tox (Allergan).
treatment are significant and can last for
Treatment several months. We must also be diligent
Botox therapy in this case will dener- in the differential diagnosis in this area,
vate the LLSAN and release the pull of the for when using a large dilution ratio (3
upper lip, thus draping the anterior max- mL or greater), the diameter of the inject-
illary more inferiorly and providing more ed Botox will be much greater, leading to
gingival coverage. The first step is locat- a wider dispersion of the effect. The larger
ing the LLSN in the puriform located at the dispersion, the greater the potential
the superior aspect of the nasolabial fold. that other perioral muscles may be affect-
Inject medial to the nasolabial fold. ed. This may lead to increased flaccidity of
Potential Adverse Effects and Complications the lips where the patient appears to have
Bell’s palsy syndrome. Stay above the zy-
Botox therapy for the LLSAN is not
gomatic arch and lateral to the nasolabial
indicated for everyone that presents with
fold, in order to keep distance from the
a “gummy smile.” In fact, it is the most
zygomatic muscle, which is the primary
technique sensitive and requires a great
muscle of lip elevation.
deal of differential diagnosis before po-
Result overly denervate these muscles in hopes

Two weeks post-injection reveals a gen- of achieving this effect. I usually keep my
tle relieving of the upper lip. We see that dosage at 1 U in the puriform.
the inferior border of Zone C lies across This patient can feel a difference in
the cervical margin of the maxillary denti- the post-treatments results. Her ability to
tion. You may also realize a slight relaxing lift her upper lip is not compromised, yet
of the nasolabial fold and flattening of its normal muscle contraction of the LLAN
presence. In some cases, this is an example muscle does not pull her lip superiorly to
of where Botox can be used to lessen the such an extent as to display such a “gum-
nasolabial fold. Care must be taken not to my smile” anymore. She is very pleased.
Picture 8.9
Post BTX-A treatment. We have successfully brought down the high smile line, where
Zone C of the upper lip drapes over the gingival line.
Ages 30
40
thru
This patient age group will make up the bulk of your lip
augmentation practice. They are by far the most discerning
in their opinions about their lips. In addition, they are heavily
influenced by the media and peers pertaining to current
fashions and trends in lip augmentation. They aren’t too shy
to sit in your chair and demand Angelina lips, yet they have
the potential to build your practice immensely if treated
appropriately. The majority of this group of patients will still
have a significant tone to their oral-facial tissue; thus, adding
volume will reestablish their natural anatomy.
A four – six point per lip injection technique with this patient
group is recommended. Remember to start in the corners of
the mouth first and work your way inwards. Some additional
sculpting of anatomy may be needed in Zone A with the older
segment of this age group, but it will usually be limited to the
vermilion border of the upper lip. We do not want the lips to
look overworked. Less is always better: one can always add
more filler in subsequent follow-up appointments.

Differential diagnosis for dental and lip augmentation in congruent therapy. Patients
can receive fantastic results from anterior dental reconstruction and lip augmentation
If nasolabial fold or any other outer ring augmentations are planned, do them first
If the commissures need lifting, fill first then augment the lips
We start laterally and move our injection points medial
Start in Zone B then Zone A
Stay away from Zone C. Filling this zone is not needed and can easily obscure
the anterior dentition, violating the natural presentation of the teeth. In addition,
when filler is placed in Zone C, the potential to violate the wet/dry line exists and
the patient will feel the filler with their tongue due to the thin mucous membrane
of the oral cavity
Plan for the minimal injection points. Eight total injection points in the body of the
lips (Zone B) were planned: four in the upper lip and four in the lower.
facial trauma. I decided to include in her

Case Presentation dental treatment planning additional lip
and perioral soft tissue cosmetic alterna-
Patient history
tives. The patient voiced a desire to al-
The patient presented originally for ways have “more lips” and was thinking
anterior cosmetic dental work due to oral-
Picture 8.10
Pre-augmentation evaluation reveals less than ideal proportions of the lips. The upper
lip presents with the opportunity to add additional volume.
Picture 8.11
Proportional evaluation of the patient’s smile reveals a pleasing relationship that falls
within the calibers relationship.
about having silicone injected into her material technique of filler products to
lips. After a brief consultation, I assured include collagen (CosmoPlast) and cross-
her we could increase the volume in her linked HA (JuvédermTM). CosmoPlast was
lips while preserving and enhancing her treatment planned for Zone A (vermilion
lip’s natural anatomical form. borders). We want to augment Zone A
Cosmetic Diagnosis with a subtle, soft, filler (eg, CosmoPlast).
This is due to the youthful tonus texture
The patient has had no prior lip or pe-
of a younger patient’s Zone A. Our objec-
rioral augmentation. Her lips fit into ideal
tive is to accent or recreate a slight G-K
proportions, although they were lacking
line angle. For more mature lips, it may
in volume compared to the rest of the face.
be necessary to use a stiffer filler material
Her smile line and lower facial proportion
like cross-linked HA in Zone A in order to
are within ideal proportions.
create this effect. Remember: cross-linked
Outer Ring: nonremarkable HA products will displace the tissue that
Inner Ring: lack of lip volume it is injected into more so than collagen-
Zone B: add volume to Segments 1 – 6 based fillers like CosmoPlast.
Zone A: sculpt vermilion border segments First injection point starts in the corner
1,2,3 of the mouth: Segment 1, Zone B.
Treatment Objective After insertion of the needle, we visu-
Lip augmentation using a combination alize our plane by tenting out the needle.
We want the material to potentiate the
space slightly in front of the needle and

then saturate the natural plane as we
slowly remove the needle while express-
ing the filler. The second insertion point
will be medially placed in Segment 1.
Picture 8.12
Picture 8.13
Zone B (Picture 8.12, 8.13).

This picture illustrates Segment 1 imme-
diately after augmentation (Picture 8.14).
Picture 8.14
After finishing Zone B fills, the patient’s multiple injection points are needed to
vermilion border (Zone A) was filled with fill in the border (Picture 8.15, 8.16). Re-
CosmoPlast, a collagen filler. This particu- member to always work your way from
lar collagen filler has a shorter needle and the outer ring in or from the corners of
Picture 8.15
Picture 8.16
the mouth inward. When injecting into line to be augmented (Picture 8.17, 8.18).
the vermilion directly, we potentiate the After augmentation of the upper lip Zones
plane by the needle. The direction of the B and A in that order, we proceed to the
needle must be in line with the vermilion lower lip.
Picture 8.17
Picture 8.18
The sequence of injecting is important. der I fill in Zone A on the upper lip first
My general rules are before proceeding to the lower lip. The
• Fill in Zone B first reason for this is that if we move to the
• If I am to augment the vermilion bor- lower lip and finish Zone B for both upper
and lower lip, the vermilion may distort
Picture 8.19
Picture 8.20
from swelling, which may alter the per- inwards (Picture 8.19, 8.20, 8.21). Again,
ception of fill in Zone A of the upper lip make note of the slightest amount of
• Fill Zone B of the lower lip. The lower blanching on the lower lip (Picture 8.22).
lip will require only four injection points. When this occurs:
Start at the corner of the mouth and work
Picture 8.21
Picture 8.22
Stop, withdraw, and reacquire another mediately after augmentation at times.

plane to inject. They are great for building your augmen-
Any further injection of material will tation library and you can show potential
cause distortion, excessive swelling, and lip patients what to expect immediately
after augmentation (Picture 8.23).
bruising of the lips.
Result
I like to take post-injection photos im-
Picture 8.23
Patient presented for photography semi profile angle (Picture 8.25).

two weeks post augmentation. You can If we examine Zone A on this patient,
see this patient has significantly fuller lips we are still able to distinguish between
(Picture 8.24). In addition, a more acutely the demarcation line form of the vermil-
recreated G-K line angle is visible from a ion and surrounding perioral skin. With
Picture 8.24
Picture 8.25
injectables such as silicone, we lose thisimagine if we did not separate the planes
demarcation due to the migration of the in our injection technique. What if we
filler into the surrounding perioral skin.laid a consistent semilunar shape of filler
With cross-linked HA and collagen fillers,in the maxillary lip from Segments 1-3?
we displace the surrounding tissue more, The result would be an obscuring of the
lip planes, whereby a loss of the natural
leaving the integrity of the lip line angles.
shape of the lip. As augmenters, we have
At this position (Picture 8.26), we can
to constantly monitor the “wants” of our
see the planes of the lips clearly. Just
patients.
Picture 8.26
Ages 40
50
thru
Patients in this age group will begin to exhibit deeper nasolabial

lines and rhytids. Using the correct technique, one is able to
decrease the severity of these folds and lines substantially.

Perform a complete cosmetic history; patients with prior augmentation require slow
potentiating of the planes to be filled. If the augmenter is overzealous, the filler
may be displaced into previously filled planes. The filling of this prior potentiated
space may leave an unwanted esthetic result
Introduce this patient age group to combination therapies such as Botox/filler
augmentations
Nasolabial Folds
No facial structure hints at aging more The severity of the nasolabial fold de-
than the nasolabial fold. As we mature, pends on:
the crease from the lateral edges of the Genetics, and the thickness of the facial
nostrils to the lower edge of the commis- dermal tissue. Thick facial skin gener-
sure deepens. ates deeper folds and less accessory
Picture 8.27
Illustrated here is the planned injection point for deposition of filler in the puriform recess. Ideal
placement should be in a teardrop shape.
Picture 8.28
If additional filling is required, crosshatching of filler should be layered in the following man-
ner.
wrinkles while thin facial skin leads to the fold in static situations and some-
shallower nasolabial folds and more what in kinetic movement and works
accessory facial wrinkles. With men, best with thin skin.
we see deeper, more distinct nasola- Perform lateral cross lines perpendicu-
bial fold due to the thicker facial skin lar to the fold; pinch the fold periodi-
men have. cally to see fill. This particular method
Gravity. Thicker facial skin tends to will reduce nasolabial fold in static
draw the nasolabial fold down in a mode as well as in kinetic. More vol-
vertical direction on the face. ume of filler is required for this meth-
Thicker facial skin usually requires od. Several passes may be required.
more filler by volume to correct, although Combination Fill Technique—this
the correction is more forgiving that is technique is particularly effective for
less visible if the filler is placed incorrect- deep nasolabial folds. Start by filling
ly. Filling the fold in can be executed us- in the nasolabial line with the filler and
ing one of four techniques as described in crosshatching underneath the filler
Chapter 6: you just applied to the fold. This lifts
Inject a pearl form in the apex of the the filler just applied to the fold and
triangle that forms the nasolabial fold provides a surface area for the kinetic
and the lateral nasal.
Perform a line fill on the inside of the
nasolabial fold. This technique reduces
reduction of the fold. mentation. Her chief complaint was the

loss of volume in her lips and the devel-
Case Presentation (BTX-A Lips) opment of lines around her upper lip.
(Filler Lips) Cosmetic Diagnosis
History Select BTX-A therapy around the lips
This patient was interested in lip aug- to establish increased surface area of lips
Picture 8.29
Picture 8.30
and subsequent filler therapy to fill lost Dilution: 1 mL of unpreserved saline

volume. During the lips and perioral eval- was used to reconstitute 100 U of Botox.
uation, have the patient purse their lips
Filler: cross-linked HA filler (Resty-
and relax them. If the rhytids correspond lane) planned for Zone B volume fill.
in the kinetic as well as static positions of Rhytid fill with cross-linked HA if needed
the mouth, then this patient is a good can- after revolumizing the lips and Botox
didate for BTX-A perioral therapy. (Pic-
ture 8.29, 8.30) This particular patient ex- (Pic 8.31 Use an eyeliner pencil to draw
hibits deepening of the rhytids in kinetic the facial landmark borders. The eye liner
pursing of the lips. is easily cleaned off and will not smear
when working on the face.)
In addition to relieving the kinetic
rhytids, this patient needs more surface Treatment
area of the lip (Zone B) exposed on the BTX; Dilutions 1 mL nonpreserved sa-
upper compared to the lower. At the 1 line to 100 U Botox.
mL/100 U Botox dilution ratio, the area There are two objectives for BTX-A ther-
of effect will be the diameter of a pencil apy in relationship to the lips on this pa-
eraser. This diameter will denervate the tient. One is to reduce the rhytids around
vermilion area alone. the lips and two, to create more surface
area for subsequent lip augmentation.
Outer Ring: nonremarkable
Inner Ring Before injecting Botox in the lips, it is
best to mark the desired injection loca-
Zone B: volume segments 1,2,3,4,5,6
tions. As a rule, I do not inject Botox lat-
Zone A: fill rhytids segment 1,2,3 eral to the ala of the nose. Keeping the
Therapy injections within the ala borders greatly
Botox reduces the potential for lip incompeten-
Picture 8.31
cy (Picture 8.31). I then mark my planned upper lip than lower lip, which is usually
points of injection around the vermilion the case.
border. This particular case, I opted for Facial Markings: You may notice the asym-
two injections in the lower lip and four metry in this patient’s face (Picture 8.33).
injections on the upper lip. (Picture 8.32) This asymmetry becomes more evident
There are significantly more rhytids in the when we mark our landmarks on the face.
Picture 8.32
Picture 8.33
The injection points around the vermilion Procedure: Inject 1 U into the superfi-
are asymmetrical, which are in appropri- cial orbicularis oris muscle and 6 injection
ate relationship to the face. This is the ad- sites on the vermilion border. The lips are
vantage of facial marking before any BTX, one of the most sensitive areas of the face.
particularly perioral. Facial marking en- Injection technique is particularly impor-
sures we keep the integrity of the patient’s tant, since anesthesia is contraindicated
face appearance and that we do not alter with Botox. Placing an ice pack on the lips
their appearance, we enhance it. before injections can relieve some of the
Picture 8.34
pain upon injection. (Picture 8.34) jecting into Zone B, Segment 1 (Picture 8.35).
Lay your needle over the proposed plane of
Filler
injection. Inject your needle into the plane
Juvéderm was selected as the cross-linked and tent the lip out over the needle to reas-
HA filler to be placed in this patient, one week sure plane placement (Picture 8.36). Slowly
after initial BTX-A therapy. We begin with in- inject to saturate the plane. Remember the
Picture 8.35
Picture 8.36
cone shape of this plane and taper your filler jection is tented over the lip. Notice after
as you exit the tail of the cone. augmenting Segment 1, Zone B alone, the
The second injection point is in the rise in the vermilion border and establish-
medial part of Segment 1. The tip of the ment of the G-K line angle (Picture 8.38).
needle will reach into Segment 2. This is At this point, we can move to the contral-
demonstrated in Picture 8.37 as the in- ateral side and augment Segments 2, Zone
Picture 8.37
Picture 8.38
B or move to the lower lip and augment 8.39).

Segment 6, Zone B. I elected to move to Place the needle over Segment 6, Zone
Segment 6, Zone B and—after adding vol- B to approximate plane and inject. Re-
ume here—to evaluate the lips with one member the form of this plane is teardrop
side augmented and the other not (Picture
Picture 8.39
shape with the head of the tear in Segment Patient presented two weeks post-aug-
5 and the tail in Segment 6. Notice on the mentation. Her lips are full and natural in
final injection the blanching of the lip. appearance. I have eliminated her perio-
Again, this indicates plane saturation… ral rhytids through a combination Botox
stop at this point. and filler lip therapy. Due to the inherent
Results tonicity of her lips, filling in the planes
Picture 8.40
Ages 50+
Typically the oral-facial skin in this patient group is thin and
fibrotic tissue. The lips are thin and indurated, which is a result
of loss of volume. In addition, there may also be a lack of
anatomy in areas such as the vermilion borders. The maturity
of the skin (intrinsic and extrinsic), as well as skeletal and
dental changes, are contributing factors within this age group
that will prompt Zone A fills.
has created a slightly upward LBL with- patient about the potential of this occur-
out having to augment the corners of the rence. With time, the epithelium will ma-
mouth. ture or weather itself comparable to the
Lips adjacent tissue.
Upper Lip: Fill in volume first (Zone Cupid’s Bow
B) as described in previous fills. Augment If the patient has no Cupid’s arch, we
Zone A as needed for sculpting the ver- can establish one with fillers. Even with
milion borders. the age group of 50+, we first inject into
Lower Lip: Zone B fill for volume. Zone B to fill the mass of the lips, and then
Augmenting Zone A on the lower lip can if the anatomy is not realized, we begin to
be technique sensitive. The lower lip has a fill in the anatomy of Zone A. Sometimes
natural roll as it transitions from the ver- you may be surprised at the realization of
milion color to the facial epithelium. There the Cupid’s arch after filling Zone B, even
are no clear demarcations of borders like in this age group. If the bow is not real-
that of the upper lip. Injecting filler into ized, then filling Zone B will reduce the
the transitional zone of the lower lip can potential of overstating Zone A anatomy.
leave an unnatural appearance. Combination technique: In order to
Rhytids realize or recapture the natural appear-
There are three ways of using fill- ance of the border, a combination of filler
ers and BTX-A to reduce and eliminate may be used. Cross-linked HA products
rhytids around the mouth: 1) Volumizing displace tissue and when injected into
the lips in Zone B will distend the vermil- the vermilion border, the material tends
ion border and reduce rhytids, 2) Filling in to distend the border and leave an un-
the rhytid line directly with an augment- natural hardened appearance and feel.
ing product like collagen, or cross-linked Fillers such as CosmoPlast recapture the
HA, and 3) Botox therapy around the ver- anatomy with a more subtle presentation,
milion border; this is more effective for ki- whereby leaving a natural feel. One can
netic rhytids. expect superb results from the combina-
tion technique.
Rhytids present on patients in this age
group can be challenging to eliminate. Procedure: Begin injection in the red
When a patient presents with significant area of the transitional color zone. Set
rhytids at this age group, from either your needle more superficially in the
static or kinetic, the deep invagination of dermis and on an even plane. Tent your
skin around the lips has been developing needle out to reaffirm path of placement
for a long time. Sometimes it is difficult and verify planar depth. Inject slowly and
to distinguish between kinetic and static with constant pressure and finish at the
rhytids. Filling the rhytid may bring the medial point. Attempt to place the filler
deeper covered epithelium to the surface, in a manner that only one congruent line
which may not be the same color or tex- lays on the vermilion border.
ture due to many years of being protected Layering is not a very effective tech-
from ultraviolet rays and normal dermal nique on this anatomical structure. Very
abrasion. Always distend the vermilion little material is necessary to achieve this
border before augmenting to examine the effect. The space for the flow of the filling
tissue of the rhytid and consult with the
material is potentiated
by the needle. We in-
sert the needle to pro-
duce our path for filler
then we inject the filler
when we withdraw
the needle.
When working
with patients in this
age group, it is also es-
sential to be clear on
the dynamics of the
patient’s smile. Look
beyond the lips to the
supporting dental
structure.
Commissure Picture 8.41
Augmenting the Here I am demostrating Zone A filling in the vermilion border.
corners of the mouth Notice the direction of placement: I follow the natural contour of
on this patient cre- the vermilion border as I inject. Several injections are needed
ates a fuller corner of around the vermilion border when performing this technique.
the mouth. The result
of the fullness is that the corners of the lips will lift upwards.
Most injections will need to be directly be-
low the epidermis and
superior to the deep
anatomy, because the
corner of the mouth is a
vital insertion point for
many of the muscles of
facial expression. The
filler material will al-
most naturally flow
towards the lip due to
the firmness of the un-
derlying anatomy.
Two filler techniques
are available for turn-
ing up the corners of
the mouth. First, pull
Picture 8.42 the corner of the mouth
Here I am augmenting the commissure of the lips. I enter lateral up and lateral. Start in-
to the commissure and stretch the tissue as I inject. This technique jection point around
allows me to better visualize the flow of material. 10 mm lateral to the
corner of the mouth.
Inject a linear amount in the above lateral has been debating over more significant
corner and then a little greater than equal cosmetic procedures such as a face lift,
amount in the lower lip. Second, start in- but she feels she’s not ready for them yet.
jection 10 mm lateral to corner of mouth, The patient had a history of Botox in the
directly medial. The flow of material will forehead region and wanted her lips and
express itself above and below the corner perioral area evaluated for cosmetic treat-
of mouth. ment. As you can see, from (Picture 8.43,
Marionette Lines 8.44) the patient’s lower proportion is not
ideal. Nose to incisal edge, this patient is
Marionette lines are just a continuance
close to ideal. From incisal edge to chin,
of the fall of the commissural corners of
there is a defiant elongation in appear-
the mouth. Approach this area similar to
ance. In addition, the patient manifests
the nasolabial folds. Inject a buttressing
with significant jowl folds. These two
amount medial to the fold and then layer
presentations of the lower face support
over the fold. Injecting in layers across the
the excessive drooping of the lower facial
lines will add sufficient resistance to the
dermis. Obviously a conventional face
kinetic fold of the marionette line.
lift would correct this more dramatically,
Nasolabial Fold but this patient isn’t quite ready for this
The nasolabial folds are one of those therapy yet. Filler and Botox therapy are a
anatomical structures that display the tell- gateway into this realm for some of these
tale signs of aging. They also require a sig- patients. They are able to appreciate small
nificant amount of filler to correct (usually improvements and later may very well
a 1 mL syringe). When the nasolabial folds undergo more substantial plastic surgery.
are augmented, they can reverse the signs Cosmetic Diagnosis
of aging tremendously. There are several
Outer ring
techniques that can be implemented, de-
pending on the depth of the fold. For light This patient has fairly thick oral-facial
folds a simple pearl drop placed in the pu- dermal skin, with the combination effects
of aging and environment. This is reflect-
riform recess will tent out the facial tissue.
For moderate to severe folds a combina- ed in the marionette and sagging jowl
tion technique is optimal for cosmetic cor- lines. There will be a significant number of
rection. cases where the augmenter can use a com-
bination of Botox and filler therapy. This
The first step on both techniques is particular patient is one such case. Dener-
similar with a pearl placement. In the com- vation of the DAO will lift the corners of
bination technique, one overlays thread- the mouth. Augmenting the patient’s jowl
like filling over the pearl drop form and fold will lesion the degree of indentation.
descending fold.
Nasolabial fold: fill cross-linked HA
Case Presentation (Botox Marionette lines: fill with combination of
LLSAN)(Fill Nasolabial, lips, BTX
commissure) Mental lines: N/A
History Jowl fold: limited fill
This patient presented with interest in Inner ring
rejuvenating her facial appearance. She
Zone B: volumize segment 1, 2,3,4,5 and augmentation

6 BTX, Dilution: 1 U of Botox at 1 mL dilu-
Zone A: Sculpt segments 1, 2,3,4,5 and 6 tion per 100 U bottle.
Therapy Filler: Juvéderm for zone B and Cosmo-
Combination Botox and Filler Plast for Zone A.
Picture 8.43
Picture 8.44
Treatment best. I continue to palpate the region with

Botox—objective: to raise corners of my thumb up to final injection of Botox
mouth. Therapy to lift up on the corners of (Picture 8.45). I injected 1 unit bilaterally
the mouth was selected. The patient’s face into the DAO. Since this was the patient’s
was marked. It is important to palpate the first exposure to perioral BTX, I decided
DAO’s posterior border. With this patient, to use only 1 unit. If desired results aren’t
we see significant facial drooping and if realized with this dose, I can always add
we would simply use a straight edge and an additional unit at the 1- to 2-weeks
soft tissue landmarks to locate the direc- post-op.
tion and origination of the DAO, we can Filler
be misled. A combination of palpation and It was decided to place filler in the
straight edge location of landmark serves nasolabial fold, commissures, marionette
Picture 8.45
lines, and lips. As stated in the Botox rience, the low level of BTX-A placed in
chapter, I usually wait one to two weeks the DAO will not significantly distort the
after the BTX-A treatment to initiate filler filler placement in the commissures and
treatment. I do make exceptions for areas marionette lines.
in the outer ring more often. In my expe- Commissure Lift
Picture 8.46
Picture 8.47
I chose to lift the commissures on this filled for demonstration purposes, but it is to-
patient with placement of cross-linked HA. I tally appropriate for the beginner/novice aug-
selected a single injection technique in filling menter to mark intended areas of augmenta-
the area I previously marked with a cosmetic tion on the face. On this patient, through one
pencil. I marked the area on the patient to be injection point I injected lateral and inferior
Picture 8.48
Picture 8.49
to the corner of the mouth (Picture 8.46, 8.47). ing index finger. This stabilizes the lip and
This technique is referred to as fanning. I allows a nontraumatic precise injection
mark quite frequently on patients, in par- into the targeted plane. Insert needle and
ticular when I am doing combination filler inject filler as you draw the needle out.
and BTX-A therapy. To increase the but- Philtrum
tressing effect of the filler, I will lay down
I also sculpted the philtrum with Cos-
layers over previously placed filler (Pic-
moPlast. The philtrum anatomy was pres-
ture 8.48) and continue them down along
ent, so collagen was the filler of choice to
the marionette lines (Picture 8.49)
accent its form. We potentiate this plane
The objective of this technique pertain- by the needle. Insert the needle to the hub.
ing to this patient is to provide a buttress Tent the dermis out a little to reconfirm
of filler at and below the commissure in plane placement. Inject the filler material
order to displace the tissue upward. This as you withdraw the needle. Cross-linked
will in turn raise the corners of the mouth. HA products can be used here to establish
Placing filler above the horizon of the LBL a philtrum.
will direct the commissure’s angle down.
Mark your area of intent and fill this area. Zone B
Multiple injection directions are used to The objective of Zone B fills is to add
layer and saturate this plane at and just volume. For this technique, I selected Ju-
immediately below the commissure. The véderm, which is a cross-linked HA prod-
filler agent of choice must have substan- uct. We start at the corners of the mouth
tial tissue displacement properties. Cross- and work inwards. Remember the natural
linked HA products have this quality and plane of the lips and taper the fill in Seg-
are my choice for this treatment tech- ments 1, 3, 4 and 6.
nique. Result
Zone A Two weeks post-augmentation, we
CosmoPlast was placed in the ver- evaluated this patient. Photographs show
milion border for the purpose of sculpt- an increase in lip volume and decrease in
ing existing anatomy. Collagen is usually rhytid presentation. We have a bilateral
my selected material for Zone A because elevation of the corners of the mouth. The
of its softness, malleability, and cosmetic marionette line has been smoothed out as
presentation. Collagen in the vermilion well and a less pronounced mental fold.
border has a natural, subtle presentation The nasolabial folds have also been re-
without looking too worked or sculpted. I lieved.
use cross-linked HA product when I wish The total syringes used on this patient
to create architecture in Zone A that has were 3 cross-linked HA syringes, 1 col-
disappeared completely. lagen syringe and 2 units of Botox treat-
We potentiate the plane by the needle ment. We have achieved some significant
on the vermilion border. Place your nee-
dle over the anticipated plane. Hold the
corner of the mouth with your noninject-
results, yet one may question the amount cosmetics. Patients are able to see an im-
of money invested in this particular ther- mediate positive cosmetic result, which in
apy that will disappear around 6 months. turn potentially leads them down the path
Fillers and conjunctive Botox therapy are of more substantial corrective cosmetic
an ideal introductory therapy for facial work on their face such as traditional face
lifts. When they finish permanent facial
revisions, the addition of supplemental
filler and Botox therapy is often needed to
maintain their new look.
Picture 8.50
Chapter 8 Review
Points
Points
Importance of outer ring towards inner ring augmentation.
Direct fill augmentation from commissure toward midline of lips.
Treatment planning, outcomes, and cosmetic therapy for varying age groups
Importance of needle placement and plane augmentation.
Observance of combination of botulinum toxin cosmetic therapy and cosmetic filler
augmentation therapy.
SoME FINAL WORDS. .

I am often asked (during lectures, conversations and patient consultations) how I would enhance
a set of lips. More often than not, I respond by sharing what I wouldn’t do…which made me
realize that there are a significant number of instances in which I will do nothing. This may sound
strange, but have you ever attended a lecture where the presenter showed a list of cases and
his treatment plan was to do nothing? Remember, it is your right to refuse to perform an elective
cosmetic treatment. If you question your patient’s motives, or if you do not have a clear endpoint
in mind (where you will be at the conclusion of treatment with your patient), stop. Reevaluate
and communicate this to the patient.
Cosmetic lip and perioral augmentation is just that: cosmetic. Patients can live their whole lives
with thin and wrinkled lips. When we augment, our goal is to improve or reestablish the patient’s
natural look. Nothing draws more attention or criticism than a botched lip job. Poorly done lip
and perioral augmentations cast a dark shadow over our specialty and culture, and mars your
good name as the practitioner. Most importantly, let us not forget that the patients we treat with
haste, ill-preparedness and self indulgence will suffer the most from public scrutiny.
There were several instances where I have had some prominent personalities in my chair want-
ing work done. And despite the fact that it would have been a great ego boost and/or po-
tential referral source, I refused to perform cosmetic treatment for that patient. Sure, there are
times that I heard that they went to another practitioner and had work done, but the point is that
I in all good consciousness could not see what I could do to improve their lips. And that
is the crux of this field. Only in performing great lip augmentations and holding
oneself to a standard will you be ensured a long, successful practice.
I hope this book inspires you to learn, grow, and develop a lip/cosmetic
practice of your own. It is a passion of mine that has given me great
joy and it is my sincerest hope you will find similar rewards.
crede quod habes, et habes

Believe that you have it, and you do.
I am often asked (during lectures, conversations and patient consultations)

how I would enhance a set of lips. More often than not, I respond by
sharing what I wouldn’t do…which made me realize that there are a
significant number of instances in which I will do nothing. This may sound
strange, but have you ever attended a lecture where the presenter
showed a list of cases and his treatment plan was to do nothing?
Remember, it is your right to refuse to perform an elective cosmetic
treatment. If you question your patient’s motives, or if you do not have a
clear endpoint in mind (where you will be at conclusion of treatment with
your patient), stop. Reevaluate and communicate this to the patient.
Cosmetic lip and perioral augmentation is just that: cosmetic. Patients
can live their whole lives with thin and wrinkled lips. When we augment,
our goal is to improve or reestablish the patient’s natural look. Nothing
draws more attention or criticism than a botched lip job. Poorly done lip
and perioral augmentations cast a dark shadow over our specialty and
culture, and mars your good name as the practitioner. Most importantly,
let us not forget that the patients we treat with haste, ill-preparedness
Robert Gordon
and self indulgence will suffer the most from public scrutiny.
There were several instances where I have had some prominent
personalities in my chair wanting work done. And despite the fact that
i t would have been a great ego boost and/or potential referral
source, I refused to perform cosmetic treatment for that patient.
Sure, there are times that I heard that they went to another
practitioner and had work done, but the point is that I in
all good consciousness could not see what I could do to
improve their lips. And that is the crux
of this field. Only in performing great
lip augmentations and holding
oneself to a standard will you be
ensured a long, successful practice.
I hope this book inspires you to
learn, grow, and develop a lip/
c o s m e t i c practice of your
own. It is a passion of mine
that has given me great joy and
it is my sincerest hope you will
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injections with botulinum toxin Type
Index
A tooth exposure (Table 2.3), 52
adatosil, 103 face lift vs filler, 54
administration techniques facial skin, 49
for anesthesia, 66-70, 73-80, 159 lips, 49
for filler placement, 148, 149, 155, 197, nasolabial line, 49, 51-54
202-204, 205-208, 216, 221-223, oral-facial, 49, 51
227-229, 231-234 allergy, 64, 93, 100
adverse reactions, 88, 95, 106, 153, 154, skin-test for collagen, 100
167, 248, 256 testing protocols, 100
normal, 88, 95, 153 allies within your practice, 12
acne, 153 AlloDerm, 86, 91-93, 246, 247, 249
ecchymosis, 153 allograft, 88, 91-93
erythema, 100, 153 alloplastic material, 88
systemic American Association of Tissue Banks
autoimmune disease, 154 (AATB), 91, 92
diabetes, 154 American Dental Association Council on
immunosuppressed patients, 125, Scientific Affairs, 64
154 American Society for Dermatologic
recurrent herpes, 153 Surgery, 103
rheumatoid disease, scleroderma, American Society for Aesthetic Plastic
154 Surgery (ASAPS), 15, 16, 117, 239, 252
Tyndall effect, 154 Joint Code of Ethics, 16
post-augmentation corrections, 156, 157 legal/regulatory issues, 15
techniques for post-augmentation American Society of Plastic Surgeons
corrections, 157, 158, 160 (ASPS), 15, 16, 239
aesthetics amphiphilic molecules, 63
cosmetic dentistry, 8, 28, 34, 40, 50-52, anaphylactic history, 100
61, 72, 85, 93, 97, 98, 102, 103, anatomy, 5, 18, 30, 40-43, 52-54, 61, 69,
117, 118, 120, 121, 126, 141, 160, 70, 85, 91, 114, 137, 144, 145, 170,
164, 165, 171, 173, 178, 179, 195 187, 191, 199, 225, 227, 228, 234,
practitioners, 2, 6, 121 241, 245, 254
quantification and qualification, 131 arteries, 46-49
age. See LARS, 34, 56 lower lip, 49
aging upper lip and nasolabial region, 46,
and maturation of the lips, 49, 53, 47
effects, 34, 49, 51-53 musculature, 40
extrinsic, 34, 53, 54, 89, 225 buccinators, 41
environmental, 53 depressor anguli oris, 42
gravity, 53 depressor labii Inferioris, 42
intrinsic, 34, 52, 53, 89, 225 levator labii superioris, 41
skeletal/dental, 51 levator labii superioris alaeque,
soft tissue, 51 nasi, 41
Index 258
mentalis, 42 Artecoll, 90, 99-102, 249

orbicularis oris, 42 arteries
risorius, 42 facial artery (FA), 46, 47, 74,
zygomatic major, 42 inferior labial artery (ILA), 48, 49
zygomatic minor, 42 horizontal labiomental artery (HLA), 49
nerves, 44 lateral nasal artery (LNA), 47
facial nerve, 45, 45 superior labial artery (SLA), 47-49
trigeminal nerve, 44 columellar branches, 47
skeletal/dental, 51 vertical labiomental artery (VLA), 49
soft tissue, 51, 52 ArteFill, 99-101, 249
vascularity, 46 arterial embolism , 153
anesthesia artist
administration techniques, 46, 66-70 art of augmentation, 5, 6, 19, 25, 35,
adverse reactions to, 64 183
allergy, 64 beautiful proportions, 113, 114
toxicity, 64, 67 becoming an oral-facial augmenter, 5
armament, 73 enhancing beauty, 5, 6
Botox and, 61 injection techniques and procedures for
oral-facial augmentation, 61, 64, 67 filler placement, 43, 44, 85, 140-153
lower lip and commissure, 78 inner placements, 5, 140, 148
buccal nerve block, 78, 79 asymmetry, 116, 121, 153, 156, 186, 193,
mental nerve block, 78 219, 251, 253
nasolabial and upper lip, 73, 74, 78 audience, 9-11, 111
anesthetic augmentation
block injection vs infiltrate injection, 69 art of, 5, 19
classification, 63 business of oral-facial, 7-19
characteristics, 63 advantages of presenting a live
intraoral vs extraoral injections, 69 demonstration, 10, 11
pharmacokinetics, 61 external marketing, 8
pKa, 63, 67 internal marketing, 8
topical, 70 lip, 6-8, 16, 17, 85, 91, 102, 104, 106,
Angle EH, 51 121, 124, 128, 179, 199, 201, 202,
antiseptic, topical, 70 217, 218, 237, 243, 246, 248, 249,
antithesis, Darwinian theory of, 15 materials, 6, 88
anthropometry, 123, 252, 253 methods, 5, 7, 112, 158
anxiety disorders, 17, 18 oral-facial, 5-8, 10, 12-15, 17, 22,
anxiety-related manifestations, 17 25, 55, 56, 59, 61, 64, 67-69, 73,
Aphrodite Gold, 102 80, 91, 100, 118, 124, 127, 134,
armament, 150, 153, 157, 165, 184, 185,192
anesthesia, 73 perioral, 5, 6, 8, 25, 56, 61, 75, 76,
injectable fillers, 132 80, 112, 124, 134, 137, 167,
art of augmentation, 5, 19, 183 137, 167, 179, 184, 202, 237
learning curve, 6, 89 combination therapy, 173

science of, 6, 7, 19 technique, 174
techniques, 10, 32, 69 mentalis
augmenter, 5, 7, 19, 25, 27, 29, 32, 34, 36, combination therapy, 174
37, 39, 53, 61, 62, 69, 83, 85, 97, 102, technique, 176
105, 107, 120, 124, 127 reducing gummy smile
autograft, 88, 100 combination therapy, 176
autologous technique, 178
cellular therapy, 249 mechanism of action, 165
fat. See also lipotransfer, 85, 89, 90, perioral injection techniques, 169-
93, 247 172
fibroblast, 93 combination therapy, 172-
authority, 11 174
averageness, 116, 117 dilution and dosage, 170,
171
B technique, 171
bacteria, 70, 88, 93, 95, 98, 106, 156, pre-treatment precautions, 167
157, 165, 245, 254 reconstitution and handling, 168
beauty shelf life, 169
enhancing, 5 gender selection, 169
perception of, 118 patient assessment, 169
beautiful proportions, 113 types, 165
facial symmetry, 113, 114 botulinum toxin type A, 15, 165-168
divine proportion and lips, 113, 114 botulinum toxin type B, 165
beauty and society, 117 bovine collagen, 85, 97, 99-101, 248
becoming an oral-facial Brooks V, 165
augmenter “artist,” 5 buttressing effect, 144, 229, 233
bioplasty, 102
blanching of skin after filling, 144, 154, 223 C
Body Dysmorphic Disorder (BDD) Patients, 18 calcium hydroxyapatite microspheres. See
identifying, managing and referring, 18 also Radiesse, 89, 90, 102
questionnaire (BDDQ), 18 canvas
Botox facial aging, 49
additional considerations, 170 oral-facial anatomy, 40, 52, 53, 54
adverse reactions, 167 oral-facial classification, 27-40
armament, 168, 169 planes of the lips, 27, 28, 31, 32
combination therapy, 172-178 Captique. See also NASHA, xenograft, 91,
contraindications, 166, 195 92, 95, 98, 246
cosmetic therapy, 165, 168, 171 Carbocaine, 64
current usage, 167 carpule, 10, 64, 65, 67, 73, 74, 78
history, 165 Case CS, 51
immunogenicity, 166, 167 case presentation
and fillers in your cosmetic practice, 7, 8 cosmetic diagnosis, 192, 195, 202, 217,
injection techniques, 169-178 229
elevating the corners of the mouth history, 192, 195, 201, 217, 229
Index 260
potential adverse effects and communication, inaccurate, 14

complications, 197 consensus recommendations for
result, 193, 198, 210, 223, 224, 234 NASHA 2006, 157, 254
therapy, 197, 218, 221, 224, 227, 229, corners of the mouth, 15, 27, 42, 46, 54,
230, 233, 234, 235 74, 78, 80, 92, 98, 126, 132, 147
treatment multiple injection, 147
centric relationship, 192, 193, 195, 197, single injection, 147
198 copyright, 11
cephalometry, lateral, 121, 123 cosmetic
Chinese mustache. See also marionette lines, allies within your practice, 12
54 dentistry, 6-8, 18, 164
Citanest, 64 enhancement materials, 14
classification system, dynamics of kinetic and field, 6
static motion, 26, 35 incorporating fillers and Botox, 7
cleft lip, 28 industry, 11, 14, 86
clinical studies, approved, 16 market, 14, 85
clinical techniques minimizing anxiety, maximizing
oral-facial augmentation, 185 comfort, 17
outer ring, 186, 192, 197, 201, 202, practice, 7, 11, 15, 17, 18, 237
206, 218, 229, 231 procedure, 18, 19, 54, 89, 117, 118,
nasolabial fold, 185, 188, 197, 201, 124, 157, 164, 229, 243, 254
215, 216, 229, 231, 234, cosmetic diagnosis
246, 248 CosmoDerm. See also allograft, 192, 195,
mental fold, 188, 234 202, 217, 229
marionette lines, 188, 228, 229, CosmoPlast. See also allograft, 88, 92, 93,
231, 233, 234 247
jowl folds, 185, 229 counterfeit drugs, 16
inner ring, 186, 192, 197, 202, 218, crosshatching, 148, 149, 216
229 cross-linkage, for HA production, 97, 99
commissure, 186, 188, 201, 215, cross-linking, 97
228, 229, 231, 232, 234 Cupid’s bow. See also philtrum, 2, 39, 49,
lips, 186 117, 126, 141, 172, 177, 227
clostridium botulinum. See also Botox, 165, Cymetra, 92, 93, 246
255
Code of Ethics, ASPS and ASAPS’s Joint, 16 D
cognitive behavioral therapist, 19 Da Vinci, 35, 37, 114
collagen, 15, 36, 53, 85, 88-93, 97, 99-101 delegation of duties, 13
collagenisis, 93, 102 demonstration. See also seminar
columella nasi, 30 advantages of presenting a live, 10
combination therapy, 172-174, 176, 178 tips to remember during your, 11
commissure, 6, 10, 32, 33, 43, 44, 46, 49, dental practice, 7
78, 124, 126, 147, 148, 173, 174, 185, allies within your practice, 12
186, 188, 201, 215, 228, 229, 231, Dental Practice Act, 15
232, 234 dentistry, 5-8, 15, 18, 59, 69, 73, 86,
common fillers, 88 101, 102, 111, 116, 127, 163, 242-
245, 252 153, 156-158, 160, 164, 165, 167-

lip and perioral augmentation, 5, 6, 8, 170, 176, 178, 185, 189, 191-193,
11, 61, 111, 137 195, 199, 201, 202, 215, 216, 218-
practitioners, 6-8, 11, 12, 14-17, 25, 61, 220, 225, 227-230, 234, 235, 239-
69, 70, 86, 91, 93, 111, 124, 146, 243, 246-256
149-151, 156, 157, 163, 237 aging, 49, 89
dental blocks, 11, 59, 61, 67, 69, 70, 73, 78 analysis, 126, 132
dentist, 1, 5, 7, 8, 11, 12, 15, 17-19, 25, symmetry, 49, 113, 114, 117, 118, 134,
29, 51, 59, 61, 68, 70, 78, 116, 120, 251-253
121, 124, 126, 128, 157, 163, 165 nerve, 2, 44-46, 56, 67, 69, 70, 74, 75,
dentition, 2, 18, 29, 32, 34, 35, 51, 53, 116, 76, 78, 80, 165, 166, 241, 244
120, 126, 196, 198, 201 buccal, 45, 46, 69, 78, 80
dermal fillers by source, 92 cervical, 46
allograft, 88, 91-93 mandibular, 44-46, 69
alloplast, 92, 100, 101 temporal, 44
autograft, 88 zygomatic, 46, 69
xenograft, 88, 92-95, 99 fashion trends of lips, 112 , 117
divine proportion and lips, 113, 114, 116, FDA (Food & Drug Administration), 6, 16, 66,
118, 134, 251 85, 86, 90, 91, 93, 98, 99, 101, 102,
dynamics of kinetic and static motion in the 104, 106, 108, 154, 164, 165, 167,
classification system, 35 239, 249
guidelines & regulations, following, 16
E off-label drugs or devices, 15, 16, 22,
educating & training a competent staff, 12 86, 91, 92, 106, 108, 167, 168
Ermengem, E, 165 MedWatch system, 105
emergencies, 16 FD&C (Federal Food, Drug &
endocytosis. See also Botox, 166 Cosmetic Act), 16, 86
enhancing beauty, 6, 34, 39, 117, 121 fibroblast, 52, 89, 93
environmental effects of aging, 53 fibro-conduction, 91
epinephrine. See also toxicity, 65, 67, 74 fibro-induction, 91, 93
ethics, ASPS and ASAPS’s Joint Code of, 16 filler, 2, 5, 7, 8, 10, 12-18, 22, 30, 36, 43,
evaluation of patient, 8, 156, 170, 173, 44, 46, 48, 53, 54, 61, 59, 73, 85, 86,
191-193, 195, 196, 201, 202, 217 88, 89-108, 116, 117, 120, 121, 132,
eversion of lips, 167, 169-172 133, 137, 139, 141, 143-151, 153-
expertise, 6-8, 11-13, 17, 61, 67, 70, 127, 158, 164, 165, 167, 170, 174, 176,
168 178-180, 184, 187, 191, 195, 199,
201, 202, 203, 205, 211, 215-218,
220, 221, 224, 227-229, 231, 233-
F 236, 239, 242, 245, 246, 247, 249,
face lift, defined, 54, 56 250, 254
facial, 2, 5-18, 21, 22, 25, 27-29, 32, 34, armament for injectable, 132, 133
35, 40, 42-47, 49, 51-56, 59, 61, 64, syringe, 132
66-70, 73-76, 78, 80, 85, 86, 88, 89, needle, 133
91, 98-100, 102-104, 112-114, 117- needle gauge, 133
121, 123, 124, 126, 127, 129-131, classification, 86, 88-90, 108
134, 141, 143, 144, 148, 150, 152,
Index 262
source, 88, 92, 99, 100 Fischer A, 103, 249

duration of implant in tissue, 63, 100, flaccidity, from anesthesia, 61, 197
101 follow-up visits
temporary biodegradable, formulation, 88, 97, 108
88 cross-linking, 10, 92, 93, 95, 97, 98, 99,
semi-permanent, 88, 89, 91, 108, 132, 150, 156-158, 179, 188,
100, 102 193, 202, 211, 218, 220, 227, 229,
permanent, 53, 89, 90, 100, 232, 234, 246, 248, 254
101, 104, 108, 153, uncross-linked, 97
154 Fournier PF, 103, 249
mechanism of action, 88, 102, 104, freeway space, 40
180 frustrated macrophages, 103
stimulateurs, 89
volumateurs, 89 G
intended use, 88 gauge, 68, 74, 93, 98, 101-103, 131-133,
combination therapy, 172, 173, 176, 158, 168, 188, 244,
178 gel hardness (G’ @ 1.6 Hz), 61, 97-99,
devices, 15, 16, 106 132, 144
drugs, 15, 16, 167 genotypic expression, 123
facial augmentation, 5-8, 10, 12-14, 15, G-K (Glogau-Klein) point, 52, 170, 173,
17, 22, 25, 29, 54-56, 59, 61, 64, 202, 210, 222
67-69, 73, 80, 91, 100, 118, 124, glycosaminoglycan biopolymer, 94
127, 134, 150, 153, 157, 165, 184, Global Aesthetic Improvement Scale, 97,
185, 192 131
FDA classification and use of, 86, 108 glutaraldehyde, 93, 99, 248
histology, 90, 246 Gordon classification, 75, 80, 124
history, 85, 86, 88, 108 Gordon Modified Block, 75, 80
ideal, 86, 108 gortex, 104, 105
injectable dermal, 61 granuloma, 85, 90, 101-106, 108, 245-248
injection techniques, 61, 68, 80, 139-160 pathergy theory, 106, 108
combination with Botox, 165, 169, treatment, 108
172-174, 176, 178, 180, 215, 216, gravity effect on aging, 49, 51
224, 229 Gross J, 99, 248
elevating the corners of the mouth, guidelines & regulations, following
15, 42-44, 132, 173, 174, 234 labeling, 15
reducing gummy smile, 43, 176, 195, general guidelines for use of filler
197, 198 devices, 16
reducing oral rhytids, 167, 171, 172, gummy smiles, 42, 43, 167, 176, 178, 195,
224 197, 198
nasolabial folds, recommended for, 16,
93, 100
off-label use, 15, 16, 86, 91, 106 H
permanent vs nonpermanent, 88 histology, 246
PMMA, 89, 90, 100, 101, 102, 249 stimulateurs, 89
synthetic materials, 89, 90 volumateurs, 89
five filler classifications, responses, 90
history of fillers, 85 oral-facial skin, 148, 149

HIV, 15, 92, 104, 239, 250 pearl placement, 149
infected patients, 15 crosshatching, 149
related facial lipoatrophy, 15 nasolabial fold, 149
human collagen, 91, 93 mental fold, 149
hyalos, 94 technical considerations, 149-151
hyaluronic acid (HA). See also NASHA, injector, 55, 61, 68, 106, 159
xenograft, 10, 14, 15, 86, 88, 90, 94- intralesional corticosteroids. See also
99, 102, 108, 132, 153, 156, 157, granuloma, 108
242, 247, 248, 254 isalogen, 93, 100
hydrostatic equilibrium, 98, 144
hygienist, 12 J
Hylaform. See also NASHA, xenograft, 91, Juvéderm. See also NASHA, xenograft, 88,
95, 98, 101, 246-248 91, 92, 95, 97-99, 101, 202, 220, 229,
hylan. See also NASHA, xenograft, 95, 246, 234
247
hypersensitivity reactions, 90, 95, 100
K
kinetic, 29, 30, 35, 40, 52, 85, 120, 129,
I 130, 131, 149, 169, 178, 227, 229,
immune reactions, 97 240, 242,
responses to dermal implants. See also motion, 32, 35, 169
granuloma, 85, 90, 101-106, 108, movements, 30, 34, 56, 85, 126, 149,
245-248 216
incompetent lip, 29, 37, 39, 40, 145 position, 35, 120, 149, 218
causes, 40 smile, 35, 129
dental, 40 state, 29, 35, 120
skeletal, 40 Kirk D, 99, 248
soft tissue, 40
inductive interaction, 91
injection, L
block injection vs infiltrate, 69 LARS, 34, 56
delivery of injectable anesthetics, 67-70 lip length, 34
perioral injection techniques, 169-178 age, 34
injection techniques and procedures, 139- race, 34
160 sex, 34
adverse reactions and complications, LBL (line between the lips), 35, 37, 39
153, 154 presentations, 37, 39
injection techniques for the lips, 141 downward arch, 39
lower lip, 141 incompetent lip (open lip), 39
upper lip, 141 common causes
inject slowly, 141 dental
philtrum filling, 144, 145 skeletal
vermilion border filling, 144 soft tissue
perioral lines (rhytids), 145, 146 straight across, 39
corners of the mouth, 147, 148 upward arch, 39
Index 264
learning 73
curve, 6, 89 techniques, 61, 67, 68, 73, 74, 78, 80,
journey, 6 nasolabial and upper lip, 73
legal/regulatory issues, 15, 16, 239 modified infraorbital nerve block, 75,
Leonardo da Vinci, 35, 37 76, 78
lidocaine, 63, 67, 68, 93, 100, 101, 244, lower lip and commissure, 78, 80
245 mental nerve block, 78
lip long buccal nerve block, 78
augmentation, 6-8, 16, 17, 85, 91, 102, Lombardi RE, 116, 251
104, 106, 121, 124, 128, 179, 199, lower lip, 27, 32, 34, 35, 41-44, 46, 48, 49,
201, 217, 218, 237, 243, 50, 52, 78, 91, 114, 116, 118, 120,
cleft lip, 28 124, 132, 134, 141, 142, 146, 168,
commissure and lower, 78-80 170, 178, 191, 192, 195, 207-209,
divine proportion and, 113, 114, 116, 219, 222, 227, 228, 241
118, 251
fashion trends, 113, 117 M
Gordon classification, 124 marcaine, 63, 64
ideal, 118, 179 marionette lines, 33, 54, 91, 107, 168, 185,
incompetent, 29, 37, 39, 40, 145 229, 231, 233, 234
LARS: length, age, race, sex, 34, 56 marketing, 8, 11, 12, 15, 22, 86, 102, 113,
line between (LBL), 35, 37, 39 125
nasolabial and upper, 46, 47 external, 8, 11,
philtrum, 32, 49, 191, 234 internal, 8, 11, 22
planes, 27, 28, 31, 32, 36, 72, 85, 141, your cosmetic lip and perioral practice,
179, 191, 193, 211, 215, 224 11, 12
profile position measurement, 124 maxillary, 32, 34, 35, 37, 39, 40, 44, 51,
projection, 121, 133 52, 78-80, 116, 195, 197, 198, 211,
psychology of the, 15, 17-19 243, 245,
quiz, 9, 10 central incisors, 32, 34, 52, 54, 56
scars, 98, 99, 128, 153, 154, 154, 158 dentition, 32, 34, 35, 51, 53, 116, 120,
segments, 27, 28, 31, 32, 35, 39, 50, 126, 198, 201,
72, 141, 155, 191-193, 202, 211 division (V2), 44
218, 222, 229, 234 labial, 30
static or kinetic state, 29, 35, 120 lip length, 34
vermilion border, 27, 30, 32, 37-39, 47, maximizing patient comfort, 17, 18
49, 52, 91, 133, 144, 146, 150, medical/legal issues, 22, 91, 165
151, 169-172, 187, 191, 199, 202, medium, the, 81-108
205, 207, 218, 220, 222, 225, 227, Botox, 85
234 categorized by source, dermal, 88
lipoatrophy. See also Sculptra, 15, 104, 239, common fillers, 88
250, FDA classification and use of fillers, 86
lipotransfer, 88, 100, history of fillers, 85
local anesthetics. See also anesthetics, 61, 63, ideal filler, 86
64, 67, 68, 73, 243, 244 off-label use, 91
armament for delivering, syringe, 67, 68, measurement tools
profile lip position products. See also xenograft, 16, 64, 88,
aesthetic quantification and qualification 90, 91, 93, 94, 97, 101, 108, 117,
Global Aesthetic Improvement 150, 167, 192, 193, 202, 227, 234
Scale, 97, 131 nasolabial line (the smile line), 44, 49, 51,
Rated Numeric Kinetic Line Scale, 53, 91, 168, 189, 213, 216
131 nasolabial or mental fold, 10, 16, 29, 33,
Rubin Smile Classification, 131 41- 43, 75, 85, 91, 93, 98-100, 105,
Wrinkle Severity Rating Scale, 98, 107, 120, 128, 133, 148-150, 176,
131 178, 184, 185, 188, 197, 198, 201,
Wrinkle Improvement Scale, 131 215, 216, 229, 231, 234, 246, 248,
mepivacaine, 63, 64 253, 256
Metacrill, 102 needle gauges. See also gauges, 68, 133,
metrosexual, 118, nerves, 44-46, 67, 69, 74, 241
microspheres, 90, 100-102, 108, 249 facial nerve, 45, 46, 67
minimizing patient anxiety, 17, 18 trigeminal nerve, 44
minocycline. See also Granuloma, 108 ophthalmic division (V1), 44
Mona Lisa, 35, 37, 132 maxillary division (V2), 44
muscles of facial expression, 35, 40, 43, 44, mandibular division (V3), 45
46, 61, 67, 69, 70, 228, 256 motor root, 44
musculature, 34, 40, 46, 49, 54, 69, 127, sensory root, 44
155, 169, 241 neocollagenesis, 104
buccinators, 41, 44, 46 Neuber F, 85, 245
depressor anguli oris, 42, 43, 46, 61,
173, 174, 178, 229-231 O
depressor labii inferioris, 41, 42, 46 octocaine, 64
levator labii superioris, 40, 41, 43, 46, off-label, 15, 16, 86, 106, 108, 167,
132, 176, 178, 195 lip fillers, 92
levator labii superioris alaeque nasi, 40, use, 86, 91, 106, 168
43, 176, 178, 195 oral-facial, 2, 5-8, 10-18, 22, 25, 54-56,
mentalis, 41, 42, 46, 126, 167, 168, 59, 61, 64, 66, 80, 112, 113, 123, 126,
176, 178 130, 134, 143, 153, 160, 165, 184,
orbicularis oris, 41-43, 46-49, 85, 145, 185, 189, 191, 199, 225, 229,
155, 169-171, 176, 220 aging 49, 89
risorius, 43, 44 facial skin, 40, 53, 148, 168, 215,
zygomatic major, 40-43, 46, 132, 178 216, 225
zygomatic minor, 42, 178 lips, 34, 35, 41, 49
the effects of, 34, 49, 89, 146, 147,
N 229,
NASHA (non-animal stabilized hyaluronic skeletal/dental, 51
acid), 98, 99, 157 soft tissue, 51, 52
degradation, 99 anatomy, 15, 18, 30, 40, 52-54, 61, 69,
formulation, 97 70, 85, 91, 114, 137, 144, 145,
cross-linking, 10, 92, 95, 97-99, 108 170, 187, 191, 199, 225, 227, 228,
uncross-linking, 97 234, 239, 241, 245, 254
hydrostatic equilibrium, 98, 144 arteries, 46-48, 49, 74, 153, 241,
Index 266
245 mental fold, 149

musculature, 34, 40, 46, 49, 54, 69, trauma, 2, 51, 53, 86, 88, 126, 141,
127, 155, 169, 241 147, 148, 150, 153, 158, 201,
nerves, 2, 44-46, 56, 61, 63, 67, 69, orthodontics, 51, 121-124
70, 74-76, 78, 80, 166, 241, overfill of the lips, 2, 30, 29, 35, 98, 120,
244 144, 145, 155, 189, 195,
skeletal/dental, 34
soft tissue, 12, 25, 29, 34, 40, 45, P
49, 51, 52, 63, 69, 74-76, Pacioli, Luca, 114
95, 99, 101, 102, 121, 123, Palmer, Karl and John, 94
124, 126-129, 151, 159, Pathergy Theory, 106, 108
164, 170, 191, 195, 201, Patient
230, 239, 240, 243, 246- assessment, 169, 170, 243,
250, 254 BDD, identifying, managing and
vascularity, 46, 48, 97, 156 referring 18,19
augmentation, 5-8, 10, 12-15, 17, 22, interaction with, 13
25, 55, 56, 59, 61, 64, 67-69, 73, minimizing anxiety, maximizing comfort,
80, 91, 100, 118, 124, 127, 134, 17
150, 153, 157, 165, 184, 185,192 perception of beauty, 118-121
clinical techniques, 184-236 periodontics, 91
perioral, 5, 6, 8, 11, 18, 22, 25, 29, perioral,
30, 42, augmentation, 5, 6, 8, 22, 25, 56, 61,
classification, 27-40 75, 76, 80, 112, 124, 134, 137,
planes of the lips, 27, 167, 179, 184, 202, 237
Gordon lip and perioral learning curve, 6, 89
classification, 75, 80, lip and, 5, 6, 8, 11, 22, 25, 29, 30,
124 56, 59, 61, 62, 74-76, 78,
inner ring, 33 80, 83, 112, 124, 134, 137,
outer ring, 33 160, 167, 179, 180, 184,
static vs kinetic lips, 29, 30 201, 237
segments of lips (kinetic), 35 Botox cosmetic therapy, 165
dynamics of kinetic and static injection techniques for Botox, 169-
motion in the classification 178
system, 35 rhytid removal, 171, 172
line between the lips (LBL), chemical peel, 172
35, 37 filler injections, 172
segments of lips (static), 32 laser resurfacing, 172
zones and segments of the lips, 31 permanent fillers, inherent drawback, 89
zones of the lips, 27-33 fashion trend changes, 89
maxillary labial, 30 host immune response, 89
mandibular labial, 32 facial aging, 89
skin, 148, 149 technical error, 89
pearl placement, 149 technological advances, 89
crosshatching, 149 Phidias, 114
nasolabial fold, 149 philtrum, 30, 32, 39, 40, 49, 52, 120, 126,
144, 145, 187, 188, 191, 234 ptosis, 54, 167

photoaged dermis, 53
photographic documentation, 128-130 Q
pharmacokinetics, 61 qualifications, provider, 15
pKa, 63, 67
planes of the lips, 28, 31, 36, 179, 211
PMMA (polymethylmethacrylate), 89, 100- R
102, race. See also LARS, 34
microspheres, 90, 100 Radiesse. See also Alloplastic, 88, 90, 100,
techniques for PMMA placement, 102 102, 103
PMS, 103, 104 Rated Numeric Kinetic Line Scale, 131
points to ponder on using filler agents, 106 re-importation, 16
Polocaine, 64 recurrent herpes, 153
post-augmentation care, 157 resterilization or recapping syringe, 156
post-treatment supervision, 16 Restylane. See also NASHA, xenograft, 16,
Polytetrafluoroethylene (e-PTFE), 104, 105, 88, 91, 92, 95, 97, 98, 153
250 retrusion, 124
practitioner, 6-8, 11-17, 25, 59, 61, 69, 70, rheumatoid disease, scleroderma, 154
83, 86, 91, 93, 112, 124, 137, 149- rhytids, 30, 92, 100, 126, 133, 145, 146,
151, 156, 157, 164, 237, 244 167, 169, 170, 186, 187, 189, 213,
pretreatment, 124, 167 217-219, 224, 227
consultation, 124, 125 Ricketts RM, 51, 242, 251
precautions, 15, 91, 167 Rubin Smile Classification, 132
precise, 7, 61, 69, 70, 74, 102, 170, 173, canine smile, 132
234, full denture smile, 132
presentation, lip and perioral Mona Lisa smile, 132
augmentation, 8
procedures, 5-15, 17, 18, 67-70, 74, 89, S
91, 95, 100, 101, 106, 117, 121, 124, scandonest, 64
143, 150, 156, 157, 164, 220, 227, scales
229, 241, 245, 250, 254, 256 Global Aesthetic Improvement Scale, 97,
delivering anesthetic, 73 131
profile lip position measurement, 124 Rated Numeric Kinetic Line Scale, 131
projection, 120, 121 Wrinkle Improvement Scale, 131
proportion. See also Gordon classification, Wrinkle Severity Rating Scale, 98, 131
21, 30, 32, 62, 87, 98, 113, 114, 116, scars, treatment of visible and nonvisible,
117, 121, 123, 124, 127, 134, 137, 158, 160
155, 179, 192, 195, 196, 201, 202, sequential filling, 150, 160
229, 251 subcision, 158, 160
divine, 113, 114, 116, 118, 134 tissue, 2, 12, 153
points of reference for lip, 124 science of augmentation, 6, 7
protrusion, 51, 124, scientist, inner, 5
provider qualifications, 15 Scott A, 165,
psychological disorders, 18, 19 Sculptra, 15, 104, 239
psychology of the lips, 15 segments of the lips, 27, 28, 31
Index 268
seminar. See also demonstration. See also Stegman SJ, 99, 248
presentation, 8-12, Steiner’s Angle, 52
external marketing, 8 steroid therapy, 105, 108
lip and perioral augmentation, 11 studies, approved clinical, 16
sensitivity, 17, 88, 90, 93, 95, 100, 244 supervision, 15
Septocaine-Septodont, 64 post-treatment, 15, 16
sex. See also LARS, 34 non-physician personnel, 15
Shantz, Dr. 165 symmetry, 49, 113, 114, 116-118, 134,
silicone, 85, 89-91, 103, 104, 154, 202, 251, 252, 253
245, 250 synthetic filler materials, 103
silikon, 103, 104 systemic adverse reactions, 153-156
Silskin, 104 syringe, 5, 10, 11, 73, 93, 97, 99, 100, 103,
skeletal, 2, 25, 29, 30, 34, 37, 40, 49, 51, 132, 133, 144, 156, 157, 168, 175,
121, 123, 124, 126, 191, 195, 225, 188, 193, 229, 234, 254
239, 243
ski-jump, 52 T
skin test, 100 Tables
skin thickness, 53, 104, 153 2.1 maxillary lip length, 34
smile, 2, 6, 9, 15, 29, 30, 35, 40, 42, 43, 2.2 muscles of facial expression, 43, 44
49, 53, 80, 101, 118, 120, 126, 129, 2.3 aging tooth exposure, 52
132, 167, 176, 178, 195, 197, 198, 3.1 anesthetic classification (dental), 63
202, 228, 240, 241, 253, 254 4.1 types of off-label lip fillers, 92
Darwinian Theory of Antithesis, 15 4.2 fillers recommended for nasolabial
Rubin Classification, 132 folds, 100
Society for Aesthetic Plastic Surgery, 15, 16, 5.1 top ten list of medicinal herbs, 125
117, 118, 252 7.1 injection points, 178
soft tissue, 12, 25, 29, 34, 40, 45, 49, 51, 8.1 select needle sizes, 188
52, 63, 69, 74-76, 95, 99, 101, 102, 8.2 relationship between augmentation
121, 123, 124, 126-129, 152, 159, and age, 188
164, 170, 191, 195, 201, 230, 239, technical considerations with injection fillers,
240, 243, 246-250, 254 149-151, 153
softform, 104 bevel orientation, 151
squamous epithelium. See also philtrum, 145, combination fill technique, 150
148 filler amount, 151
staff, 10, 12-14, 19, 68 filler material, 153
delegation of duties, 13 lip/face swelling during augmentation,
educating & training a competent, 12 150
hygienist, 12 magnification, 149
static, 29, 30, 32, 35, 37, 56, 120, 126, massaging of the material, 151
129, 130, 149, 169, 170, 176, 178, material expression, 151
216, 218, 227, 252 selecting layer for injection site, 150
motion, 32 speed of injection, 149
position, 29, 30, 35, 37, 56, 120, 126, sequential fill technique, 150
129, 130, 149, 218 stretching the lip, 151
state, 14, 15, 29, 35, 49, 95, 120 time allotment for injection, 150
Techniques, 135-153, 161-169 Tips

clinical, oral-facial augmentation combination therapy, 172-178
inner ring, 192, 197, 201, 218 delivery of injectable anesthetic, 67
commissure, 186 gel hardness (G’ @ 1.6 Hz), 97
lips, 186 topical anesthetic, 70, 151
outer ring, 192, 197, 201, 218 topical antiseptic, 70
jowl folds extraoral, 32, 69-70, 78, 80, 86
marionette lines, 168, 185, intraoral, 69-70, 78, 80, 92, 128, 159
228 toxicity, 64, 67, 125
mental fold, 149 training a competent Staff, 12
nasolabial fold, 149 trigeminal nerve, 44
corners of the mouth, 147 mandibular division (V3), 44-45
multiple injections, 147 long buccal branch, 46
single injection, 147 mental branch, 46
cross-linkage, for HA production, 95 maxillary division (V2), 44
injections for the lips, 141 motor root, 44
lower lip, 141 ophthalmic division (V1), 44, 94, 103
philtrum filling, 144 sensory root, 44
perioral lines (rhytids), 30, 145 Tromovich TA, 99
upper lip, 141 Tyndall effect, 154, 155, 169
vermilion border filling (Zone A), 144
injection techniques with Botox, 169 U
combination with fillers, 172 Ultrasoft, 104, 105
elevating the corners of the mouth, underfill of the lips/voids in lips, 155
173 upper lip and nasolabial region, 27, 32, 34-
reducing gummy smile, 176 35, 39-44, 47, 49-52, 72-75, 91, 114,
reducing oral rhytids, 167, 169, 170, 116, 120, 124, 132, 141, 146, 170-
177, 224 172, 178, 191-193, 197-199, 201,
oral-facial anesthesia, 59, 61-70, 73 206-208, 217, 219, 227
perioral injection for Botox, 169
establishing a desired eversion of the
lip, 169 V
increase in lip surface area, 169 Vermilion Dollar Lips
removal of kinetic rhytides, 169 art of the fill, 5, 7, 22, 30, 110, 120,
PMMA placement, 102 124
post-augmentation correction, 157 border, 27, 30, 32, 35, 37-40, 42-44,
aspiration, 158 46-47, 49, 52, 54, 61, 91, 126,
incision, 158 133, 144, 146, 150-151, 169-172,
palpable redistribution of filler, 157 174, 178, 187, 191, 198-199, 202,
resterilization or recapping syringe, 156 205, 207, 218-220, 222, 225, 227,
subcision, 158, 160 230, 234
touch-up, 131, 155, 156, 193 business of oral-facial augmentation, 7
technology, take advantage of today’s, instructional format, 7
11 medical/legal issues, 14
temporomandibular dysfunctions, 51 perioral augmentation, 1, 5-6, 8, 22,
25, 56, 61, 75-76, 80, 112, 134,
Index 270
137, 167, 179, 184, 202, 237, 238

philtrum, 30, 32, 39, 40, 49, 52, 120,
126, 144-145, 187-188, 191, 234
psychological issues, 22
sequential filling, 150, 160
subcision, 158, 160
visible and nonvisible scars treatment, 158,
160
W
Wrinkle Improvement Scale, 131
Wrinkle Severity Rating Scale, 98, 131
X
xenograft, 88, 92, 93, 94. 95, 99
Xylocaine, 63, 64
Z
zones of the lips, 32, 144
mandibular labial, 32
maxillary labial, 30
Zyderm. See also xenograft, 88, 92, 93, 99
100
Zyplast. See also xenograft, 88, 92, 93, 99,
100, 102

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Vermilion

Robert Gordon DDS

Robert W. Gordon DDS

Vermilion Dollar Publications

© 2007 By Robert Gordon DDS

All Rights reserved. Printed in the USA. No part of this publication

Vermilion Dollar Publications

Publisher Vermilion Dollar Publications

With Special Thanks to Kenneth Grundset DDS

CHAPTER 1: Vermilion Dollar Lips

CHAPTER 2: The Canvas 23

CHAPTER 4: The Medium 81

CHAPTER 8: CLINICAL TECHNIQUES – LIP AND PERIORAL,

SOME FINAL WORDS 236

Within these pages, this innovative approach will be explained in detail

Due to the diversity of practitioners who conduct oral-facial augmentation,

It is my goal to unite the body of practitioners who perform oral-facial

Vermilion Dollar Lips

Remember: the cosmetic world is

Your First Seminar

involve the seminar attendees in your you greater flexibility in circulating

Key Things to Remember During Marketing Your Cosmetic Lip

unprofessional—if he or she merely being performed under your license.

In 2006, the Joint American Society of Provider Qualifications

General Guidelines for Use of Filler Devices and drugs

ders associated with oral-facial augmen- by characteristic behavior that includes

tic expectations. Identifying, Managing and Referring BDD

Using various facial calipers before and after augmentation can

Dr. Gordon’s Lip And Perioral Classification

Oral-facial amount of fill the planes will facilitate. The

Wet Dry (Zone C)

Here are the 5 planes superimposed on

Static Vs. Kinetic amine our patients in both a kinetic and

Zones and Segments of the Lips

Zones of the Lips

Maxillary Lip Maxillary Lip Exposure of Exposure of

Medium 16-20 3.44 0.77

Medium 21-25 2.18 0.98

Long 26-30 1.95 1.95

Lip incompetency is one situa-

Four General LBL Presentations

(labii superioris, labii superioris alaeque of this muscle is sneering by contracting

fold deepens and is often regarded as an

The deep fibers of the lips approximate

or border of the zygoma and inserts deep-

sue. The effect of this muscle is the pout

Table 2.2 muscles of facial expression

Levator labii Major Rarely Placed

Table 2.2 (Cont’ed) MUSCLES OF FACIAL EXPRESSION

Risorus Platysma, parotid Adjunct to N/A N/A N/A N/A

Buccinator Pterygomandibular Compresses N/A N/A N/A N/A

Motor Root This nerve is purely sensory. We will

muscle, masseter muscle, temporal mus- pterygoid and continues on an antero-

doing fills in the corners of the mouth muscle.

ally the FA is located 15.5 mm lateral to

the middle of the upper lip in the region

Figure 2.5 The Facial Artery

Superior Labial Artery

Inferior Labial Artery

different areas. Approximately 75% of the tered.

Here is an illustration of how light and surface contours interact in the

Age Maxillary Mandibular

Table 2.3 To 29 3.37 0.51