Lip filling with microcannulas

Received on: 10/06/2011
Approved on: 08/09/2011

This study was carried out at Clínica
Dermatológica Dr. André Vieira Braz - Rio de
Janeiro (RJ), Brazil.

Conflicts of interests: The author is a consult-
ant and speaker at Allergan Cosmetics
Financial support: None

Abstract

This paper describes a lip filling technique that administers hyaluronic acid using microcannulas. This technique considerably reduces the number of punctures compared to the conventional method, which uses needles. In addition, the microcannula’s blunt tip reduces the risks of intravascular injection of the substance and of disrupting key structures such as vessels and nerves. The results obtained by the authors confirm the less frequent occurrence of adverse effects and a high degree of physician and patient satisfaction.

Keywords: HIALURONIC ACID, LIP, REJUVENATION

INTRODUCTION

Despite their wide use in other medical specialties, such as ophthalmology, there are few reports on the use of microcannu- las to inject filling material in dermatology1.2 Aging causes the lips to become narrower and lose their volume and contour, however hyaluronic acid injections help re-establish those char- acteristics. 3,4

METHODS

Patients with aesthetic complaints about their lips (such as deficiency in contour definition, volume and projection) were included in the study. Patients with a history of allergy to the filler product, those with collagen disorders and pregnant women were excluded. The treatments were carried out at a private practice between October 2010 and May 2011.

APPLICATION TECHNIQUE

If the needles and cannulas used has a small gauge , there is no need for an anesthetic point to introduce the microcan- nula into the skin. Punctures are made in the skin 25 mm from the apex of the cupid''''''''s bow on the upper lip with a 26G ½ nee- dle, as shown in Figure 1. After inserting the 30G calibre 25-mm long microcannula (Magic Needles ®, Needle Concept, Paris, France), the practitioner will feel a resistance caused by the der- mis'''''''' fibrotic fibers. Continuing the injection past that point indicates that the subdermic plane, where the filling should be placed, has been reached. We used 24-mg/ml hyaluronic acid with added lidocaine (Juvéderm Ultra®, Allergan inc, Irvine, California, USA) for the implant.

This technique uses only one micropuncture for the intro- duction of the microcannula, allowing the treatment of three different features of the lips with different results: contour defi- nition, projection and increase in lip volume.

To improve the upper lip''''''''s contour, the microcannula is introduced between the skin and the vermilion of the lip. Next, the linear retro-injection of the product is carried out starting from the apex of the cupid''''''''s bow (on the side being treated) towards the corner of the mouth (Figure 2).

To improve the projection of the lips, the microcannula, which is still in the subdermic plane, is moved towards the lip''''''''s mucus membrane. The product is then retro-injected or inject- ed all at once (Figure 3).

To increase the lips'''''''' volume, the microcannula is directed towards the oral mucus membrane and inject the product all at once (Figure 4).

To treat the lower lip''''''''s contour, a 26G ½ needle enters 10 mm from each corner of the mouth and the same technique used for the upper lip is carried out. For treating the shape of the middle of the lower lip, a micropuncture is made 25 mm from the first orifice, and the hyaluronic acid is retro-injected (Figure 5).

When the objective is to treat the corners of the mouth, the filling of the contour of the lower lip is carried out by retro- injection with a microcannula so as to form the 25-mm base of an inverted triangle. Next, three vertical support pillars are formed by retro-injecting hyaluronic acid from the same entry micropuncture, located 7 mm from the horizontal base, with a 30G needle, as shown in Figure 6.

Using the same micropuncture made in the corner of the lip, it is possible to treat perioral wrinkles by directing the 30G microcannula upwards to those wrinkles to carry out the retro- injection (Figure 7).

RESULTS

Patients aged 18-71 (n = 55, 47 women and 8 men) were treated. The patients reported a high degree of satisfaction (Figure 8). We observed minimal edema and erythema com- pared to conventional procedures that use needles when reshap- ing the lips. Mild edema, without erythema, was noticed in the treatment of the lip and oral mucus membrane areas. There was no bleeding and, consequently, no ecchymose. No edema or erythema was observed in the treated lips in the six hours fol- lowing the procedure.

DISCUSSION

The lips are centrally located in the lower third of the face and are capable of expressing emotion, sensuality and vitality. 3 In this technique to treat the lips, the author''''''''s classification, which divides the lips into three different anatomical areas, was employed. A different result will be obtained in each of those areas after the filling:

- Lip contour: it is enhanced when the product is retro- injected linearly from the central to the lateral area of the lips.

- Lip mucous membrane: the projection of the lips is obtained when this area is injected.

>- Oral mucous membrane: when filling that region using the bolus technique, the volume of the lips is increased because the local dental arch pushes the filled area to the front. 4

The skin of the lips can be described as thick and juxta- posed to the muscular layer, with its thin and delicate red zone comprised of transition epithelium between the skin and the mucous membrane. The lateral region of the lips'''''''' subcutaneous layer affects the adhesion of the skin and mucus membrane to the muscles. 5

The superior and inferior labial arteries (branches of the facial artery) are responsible for irrigating the lips. Facial arter- ies are extremely tortuous; needle-based or intravascular injec- tion techniques frequently perforate them, producing a greater risk of hematomas and ecchymoses. 6 Injections with sharp and short (7 mm) needles require several punctures for the fillings to be carried out, 7 which causes a higher release of histamine and increases the risk of edema, erythema and hematomas, in addi- tion to causing more pain.

Microcannulas are very safe due to their flexibility and blunt tip, which does not hurt vessels or nerves, and is more comfortable for patients. Although the procedure is not com- pletely without complications, the use of microcannulas avoids the lesion of important structures and accidents that can be caused by intravenous injection, considerably decreasing the amount of bruising. 8

CONCLUSION

If procedures are carried out carefully and delicately, it is safe to work in deep, subdermic planes with microcannulas, which reduce the risks to the patient.

References

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3 . Rohrich RJ, Ghavami A, Crosby MA. The roles of hyaluronic acid fillers: scientific and thecnical considerations. Plast Reconstr Surg. 2007; 120(Suppl 6):41S-54S.

4 . Braz AV. Update no tratamento com ácido hialurônico. In: Kede MPV, Sabatovich O, editores. Dermatologia Estética. São Paulo: Ateneu; 2009. p. 646-61.

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8 . Nácul AM. Contour of the lower third of the face using an intramusculary injectable implant. Aesthetic Plast Surg. 2005;29(4):222-9.