Performance of hyaluronic acid filler in the anatomization of thin lips: case reportABSTRACT
The goal of this study is to describe the effect of hyaluronic acid filler on thin lips, evaluating the distribution of the material and its relationship with tissue vascularization, as well as the effectiveness of structuring tissue shape and volume through the immediate clinical results achieved. In addition, this study observes the longevity of the results for a period of 10 months after performing this intervention on the lips. Methodology: A healthy 40-year-old Caucasian woman, complaining of thin lips and who had never undergone clinical or surgical procedures on her lips, participated in this study. An analysis of the lip vascularization and distribution of the filler material in the tissues was carried out using ultrasound images. The adequacy of volume, contour, lip hydration and patient satisfaction were also analyzed. Results: To achieve the desired lip profile, 3 ml of filler material was used throughout 4 sessions. Botulinum toxin therapy was applied to control the depressant muscle forces of the angle of the mouth, the orbicularis oris muscle, and the tip of the nose. A small amount of filler material was used at the tip of the nose to harmonize the facial profile. Conclusions: Thin lips required larger volumes of filler material, which was considered safe and effective if the vascularization is monitored to decide on the best insertion plan for the filler material. A combination with complementary therapies, such as the use of botulinum toxin, may be recommended for the effectiveness of the contour and shape of this lip pattern.
Indexing terms
Aesthetics; Dentistry; Hyaluronic acid
RESUMO
O objetivo deste estudo é descrever o efeito de um preenchedor de ácido hialurônico em lábios finos, avaliando a distribuição do material e sua relação com a vascularização tecidual bem como a efetividade da estruturação da forma e volume tecidual através dos resultados imediatos e sua longevidade após o período de 10 meses. Participou deste estudo uma mulher caucasiana, 40 anos de idade, com queixa de lábios finos, que nunca havia feito qualquer procedimento clínico ou cirúrgico nos lábios e sem qualquer alteração sistêmica. Foi realizado análise da vascularização labial e distribuição do material preenchedor nos tecidos através de imagens de ultrassom. Também foram analisados a adequação do volume, contorno, hidratação dos lábios e satisfação da paciente. Para se atingir o perfil labial desejado utilizou-se 3 ml do material preenchedor ao longo de 4 sessões. Terapia com toxina botulínica foi associada para o controle das forças musculares depressoras do ângulo da boca, orbicular bucal e ponta do nariz. Uma pequena quantidade de material preenchedor foi usada na ponta do nariz para a harmonia do perfil facial. Lábios finos exigem maiores volumes de material preenchedor considerados seguros e efetivos desde que se monitore a vascularização para a decisão do melhor plano de inserção do material preenchedor. A conjugação com terapias complementares como uso da toxina botulínicas pode ser indicada para a efetividade do contorno e forma deste padrão labial.
Termos de indexação
Estética; Odontologia; Ácido hialurônico
INTRODUCTION
The lips, located in the lower third of the face, are part of the aesthetics of the face and participate in the transmission of emotions, personal expressions, and self-esteem of the patient. The shape and position of the lips are fundamental factors in having a pleasant smile. With the approval of the use of hyaluronic acid for tissue filling and the influence of social media, there has been an exponential increase in the demand for lip filling procedures in both young and old patients [1,2]. In contemporary conception, younger patients prefer larger, lower lips, while older patients prefer smaller lips, mirroring the natural progression of volume loss with age [1].
Perfectha Deep and Perfectha Derm are sterile hyaluronic acid gels of non-animal origin with formulas recommended to fill deep depressions in the skin and facial lines, increase lip volume, redefine the contours of the nose, correct nasolabial folds and lip corners, and cause moderate projections of the chin and moderate increases in the cheeks. Perfectha Deep and Perfectha Derm are produced by Sinclair, which is headquartered in London (subsidiary of Huadong Medicine Ltd.) and are officially approved by the MHRA in the UK, Anvisa in Brazil, and the FDA in the USA. These filler materials can achieve full distribution in the tissues and provide flexibility and support for the maintenance of natural movements and the dynamics of expression.
However, for treatment to be successful, multiple variables must be considered aside from the rheological properties of the filler materials and the plane of insertion into the tissue. The length, thickness, and shape of the lips can be the result of variations in the skin and muscle layer. Lip characteristics are also associated with age, breathing patterns, tooth positioning, and phenotypic and functional characteristics of the facial muscles in each patient [1]. Thin lips may be due to individual or physiological characteristics, or the results of systemic changes or surgical interventions [1]. The application of lip fillers for thin lips is considered challenging in clinical practice due to the interaction of multiple muscular, functional, vascular, and genetic factors in the effectiveness of increasing the volume and shape of the lips [1]. Studies with a critical analysis of clinical cases are still scarce in the literature.
The goal of this study is to describe the effect of hyaluronic acid filler on thin lips, evaluating the distribution of the material and its relationship with tissue vascularization, as well as the effectiveness of structuring tissue shape and volume through the immediate clinical results achieved. In addition, this study observes the longevity of the results for a period of 10 months after performing this intervention on the lips.
CASE REPORT
The participant in this study was a healthy 40-year-old Caucasian woman who was complaining of thin lips and had never undergone any clinical or surgical procedures on her lips; she wanted fuller lips and a more attractive appearance, according to Brazilian standards.
For guidance on achieving the patient’s desired appearance, the FACE-Q SFAOS instrument for assessing patient satisfaction with treatment, which is validated in Brazil, was used [3]. This instrument was developed and validated for facial aesthetic procedures and consists of ten items that assess the current perception of facial appearance in regard to symmetry, harmony, proportion, vitality, and self-perception of appearance [3]. There are four possible responses regarding the appearance of the face as a result of the facial aesthetic procedure: very dissatisfied, somewhat dissatisfied, satisfied, and very satisfied. Assigning scores from zero to three consecutively for the answer options, a score from zero to thirty for patient satisfaction is obtained, with the higher the score, the greater the satisfaction.
In all sessions, photographs were taken for records using a personal camera with front and profile photos at 45-degree angles; the photos were taken in artificial light and had a light background. Assessments of lip texture and color were made using a 3-fold magnification of digital photographs.
To define the satisfactory profile of the lips, the Carruthers 5-point photo numeric scale [4] was used. This scale was developed and validated to objectively quantify the filling of the upper and lower lips separately. The scale evaluates the position and three-dimensional relationship of the lips to the patient’s nose, teeth and perioral structures at rest, during speech, and when making facial expressions. The scale is based on Steiner’s line, which is a line drawn from the tip of the nose to the most prominent point on the chin (Pogonion cephalometric point - PG). The scale ratings are zero for very thin, one for thin, two for moderately full, three for full, and four for sufficiently full lips, where the lower lip touches the Steiner line and the upper lip is very close to this line.
To control variables that could trigger allergies or symptoms of hypersensitivity, the patient did not use any cosmetic product contraindicated for the face and not authorized by the Brazilian National Health Surveillance Agency (ANVISA) during treatment.
The patient signed the free and informed consent form for the publication of the clinical case, as established by the resolution of the National Health Council of Brazil (CNS 466/12). This study was approved by the Research Ethics Committee (decision number 6.181.906).
The patient had a straight profile with more than one-third of her upper anterior teeth exposed when smiling. However, from the patient’s mimicry, we observed that the depressor muscles of the angle of the mouth and mentalis exerted greater depressor pressure, giving an appearance of a sad smile (figure 1). Thus, to complement the lip filling treatment, it was recommended to paralyze the depressor muscles of the buccal angles with two units of botulinum toxin A (Botox-Allergan) and three injections on the left and right side of the midline in the mentalis muscle with two units of the same botulinum toxin at each point. This application was carried out seven days before the first lip procedure.
Initial lips with muscle depressant action, with demarcation of the filling path and an ultrasound image of the vascularization located in the deep tissue plane.
From the initial ultrasound image, the labial artery was seen in a deep plane between the submucosa and intramuscular layers, thus favoring the treatment area (figure 1).
In accordance with the characteristics of the patient’s lips, it was estimated that three ml would be needed to fill the lip area. This volume was gradually inserted throughout three sessions, evaluating the flow of the product and the patient’s perception of the appearance and positioning of the lips. In the first session, the Perfectha Deep filler (Sinclair) was applied using a 25 g cannula according to the technique by Adel [5], and following a demarcation indicated in figure 1. On the upper lip, two vertical lines were drawn on the walls of the philtrum. Intraoral anesthesia of the mental and anterior superior alveolar nerves was applied with local anesthetic (3% Mepivacaine Hydrochloride without vasoconstrictor), with the socket needle being inserted into the highest red line of the lips where it meets the philtrum. After creating the opening, a SoftFil microcannulas (25 g 50 mm) was used to vertically enter through the opening until reaching just below the wet/dry border [5]. A bolus of 0.1 ml was injected in the vermilion of the lips in the direction that follows the walls of the philtrum. Additionally, 0.2 ml of filler was injected in a retro injection that runs perpendicular to the midline of the upper lip, and 0.05 ml was injected on both sides in a line parallel to the philtrum on (figure 1). A 0.1 ml bolus was injected in the lower lip and re-injections were made in a line perpendicular to the midline, using 0.05 ml on each side. The three lip filling sessions followed the same technique [5], and the interval between sessions was 30 days. In the second filling session, the patient had very stiff lips with little volume gain and eversion. Therefore, in this session a filler with greater elasticity, Perfectha Derm, was used. Additionally, the technique was complemented by injecting one unit of botulinum toxin into the upper lip at two superficial points on the vermilion line where the skin begins, with the goal of promoting eversion of the upper lip. The points were 1.0 cm and 1.5 cm distal to the Cupid’s bow in the mediolateral direction.
Thirty days after the second injection of filler material the patient’s upper lip remained everted, although it still required a greater volume according to Carruthers’ photo numeric scale [4]. Another one ml of Perfectha Deep (Sinclair) was then used. In this session, however, the patient complained of being unable to make a sucking movement due to the botulinum toxin in her lips. During clinical examination, the
Hyaluronic acid used to plump thin lips patient was able to blow and make a kissing movement. When asked to suck on a straw, the sucking function was observed. The patient did not make the grasping movement with the tongue against the palate, and instead only used her lips to suck liquids. She was taught to perform the milking movement with her tongue and thus regained her sucking function.
The satisfactory profile of the lips was observed in the third lip filling session, totaling three ml of filling material, and presenting a score of four on Carruthers’ photo numeric scale (figure 2). Clinically, better hydration and texture of the lips were observed with a significant reduction of cracks in the lips (figure 2). The lip circulation, which was assessed with a Doppler ultrasound before and after completing the lip filling, did not suffer any interference (figure 3).
The assessment of the impact of the procedure on the patient’s well-being was positive, however, with a score of 27 (on a scale of 0-30). Upon completion of the research questionnaire, a small dissatisfaction with her profile image was reported. Through anamnesis it was determined that the complaint was due to a small depression on the tip of the nose (figure 2). Therefore, the tip of the nose was slightly filled with 0.05 ml of Perfectha Fill (figure 2). During the patient’s longitudinal follow-up period of 10 months, there were no reports of itching, irritation, or changes in the shape or function of the lips. The lip filler remained satisfactory with a score of four on Carruthers’ scale, which can be considered quite satisfactory in the patient’s perspective when considering the complete treatment and 10-month follow-up (figure 4).
DISCUSSION
Thin, flat lips do not have the flexibility or tissue area that allows for the insertion of large volumes of filler material. Therefore, structuring must be a constructive process over multiple sessions, respecting the individuality of each case, and it is essential to observe the patient’s individual anatomical characteristics. There is no difference in the effectiveness and safety of lip filling when comparing surgical techniques and the use of hyaluronic acid-based filler materials [6]. However, congenital and autoimmune complications, trauma, and iatrogenic lip enlargement can interfere with the effectiveness and safety of hyaluronic acid fillers [1,7]. The patient in this study had a deeper labial artery path, allowing for a greater amount of filler material to be injected into the tissues. The literature reveals anatomical variations in the path of the superior and inferior labial arteries; the majority (78.1%) of these arteries are in the submucosa, followed by smaller proportions in the intramuscular (17.5%) and subcutaneous (2.1%) planes [8]. One must also consider the anatomical variations and modiolus plexus, in addition to the subalar and septal branches sometimes present in the perioral region in close relation with the upper lip [9,10].
In this clinical case, exaggerated muscle strength was observed, which interfered with the harmonious positioning of the commissure and lower lip. The literature reveals an association between lip sealing forces and the perioral muscles [11], and the interaction of functions between facial muscles [12]. As a complementary therapy, botulinum toxin was used to relieve tension in the mentalis, depressor anguli, and perioral muscles. In this latter region, the botulinum toxin helps to enlarge the upper lip and shorten the philtrum. A botulinum toxin injection, applied with caution, may be an option for lip enhancement [13].
Furthermore, lip filling was favorable in this situation this clinical case due to the patient’s good vertical dimension of occlusion, as well as the size, shape, insertion, alignment, and color of the teeth, factors which contribute to the beauty and attractiveness of the smile associated with the lips [14-16]. In this clinical case, it is important to note the presence of functions that directly interfered with the positioning of the lips and the sucking movement.
Patient satisfaction is directly related to the effectiveness of the treatment. In this case, the level of satisfaction with the result of the lip was negatively affected by the slight lack of projection at the tip of the nose. This was corrected with a filler, favoring a point of light at the tip of the nose. The overall harmony of the face cannot be determined by a single feature [15].
Anatomical characteristics of the labial muscles can interfere with the distribution of the filler material, requiring the professional to make adaptations [17]. The rheological properties of the materials must be known and respected; however, the manufacturers themselves emphasize that the rheological properties of the gels describe the physical responses to forces applied in vitro, so they should not be individually translated into clinical performance. Considering that the first filling session with the denser material (Perfectha Deep) did not result in a natural appearance of the lip contour, we opted for a product with greater elasticity for the second filling session (Perfectha Derm) to allow for better manipulation and distribution of the material in the lips.
Considering the insertion of fillers composed of hyaluronic acid for the correct tissue distribution of the material, several techniques have been described and shown to be safe and effective [5]. The technique used with this patient is in accordance with the procedures considered safe for lip filling and requires fewer entry points [5].
The effects of lip fillers are not just in the contour of the lips. Greater hydration was observed, resulting in a more vibrant color and reduced cracks in the lip epithelium. These results are similar to those described in the literature [18].
The properties of hyaluronic acid fillers indicate the degree of tissue distribution and crosslinking. However, this case report evaluates and highlights the importance of observing factors such as the anatomy of the vascularization of the lips and perioral region, in addition to the interaction of facial muscle forces, and perioral and labial areas of the patient that can interfere with the behavior and duration of lip fillers. Moreover, this case also highlights the effect of functional sucking habits that interfered with the medium- and long-term results of the positioning of the lips, which is in accordance with the literature [12]. The interrelationship of the factors described highlights the need to observe multiple variables in the filling and contouring procedure for thin, flat lips. Such factors may interfere with the result and duration of treatment. For this reason, the clinical results in this case were monitored for 10 months.
A limitation of this research is the design of the study, considering there was only one participant in the sample group and, as this is a clinical case without a control group, it is not possible to generalize the results for all patients. Emotional state and gender identity have a direct impact on the patient’s expectations and should be investigated [14]. However, case studies are important in the evaluation and management of different clinical characteristics and for the construction of a treatment protocol. This study also evaluated the longitudinal monitoring of reconstructing thin and flat lip shapes and contours, which can be considered challenging in clinical practice.
CONCLUSION
Lip filler materials were effective and stable for reconstructing and shaping the lip volume in this specific clinical case. For the success of different types of treatment, it is essential to evaluate muscular and oral functions. Ultrasounds are essential for the safety of procedures through the diagnosis of anatomical variations in circulation and muscles and contribute to the effectiveness of the treatment plan. Mimicry and functional habits interfere with muscle strength, and the effectiveness of lip fillers and can be controlled with the adjuvant use of botulinum toxin.
How to cite this article
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Fernandes MLMF, Souza MOM, Carvalho PHR, Thebit MM, Fonseca AHA. Performance of hyaluronic acid filler in the anatomization of thin lips: case report. RGO, Rev Gaúch Odontol. 2024;72:e20240037. http://dx.doi.org/10.1590/1981-86372024004020240014
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Assistant editor: Luciana Butini Oliveira
