"I love the hyaluronans in lips because they feel really natural to the patient and the patient's significant other," says Jean D. Carruthers, M.D., clinical professor of ophthalmology at the University of British Columbia and Cosmetic Surgery Times editorial adviser.
She says hyaluronic acid (HA) works extremely well in the lips because of its viscosity. Another advantage of HA in the lips is longevity, she says.A study of Restylane (Medicis) in the nasolabial folds found this product lasted six months here; collagen, about four months (Narins RS et al Derm Surg. 2003 Jun;29(6):588-595.). Collagen tends to break down even faster in the lips due to their movement, Dr. Carruthers says.
When injecting Restylane, she says, "I like to see the lip as it is naturally, so we use topical betacaine or ELA-Max (lidocaine, Ferndale Laboratories) to numb the surface of the lip."
Dr. Carruthers also uses a massager held on the opposite side of the lip being injected in about 80 percent of cases to distract patients from any discomfort. Approximately 20 percent of her patients prefer oral blocks with articaine 4 percent with 1/200,000 epinephrine.
Potential complications from Restylane injections include occasional bruising, swelling and gathering of the material into transient lumps, Dr.Carruthers adds. Ensuring that patients avoid aspirin, vitamin E and nonsteroidal anti-inflammatory drugs before the procedure can reduce bruising, she says. If patients are taking such products, she adds, one must inject very slowly and use a lot of ice. Lumping, which she always tells patients to expect, frequently resolves by itself but may also require gentle massage. Other HA products include Hylaform and Captique (both made by Inamed).
"I find Hylaform lasts probably two-thirds as long as Restylane," Dr. Carruthers says. Additionally, she says because Hylaform is made from nongendered chicken combs, this makes some patients pause in light of the H5N1 avian flu threat.
Conversely, she says Captique's manufacturing process relies on laboratory bacteria. Dr. Carruthers adds that Perlane (Q-Med) offers larger particles than Restylane and lasts longer in the lips and perioral region.
Dr. Carruthers says manufacturers will offer a wider array of particle sizes. Additionally, she says Juvederm (HA, Corneal), available in Canada, one day will be marketed stateside. With an increasing array of options, she says, "Layering is going to be the trend."
Among neurotoxins, Botox (botulinum toxin-A, Allergan) remains the only product approved for cosmetic purposes in North America. When using this material to lift the corners of the mouth, Dr. Carruthers says, "If one weakens the depressor anguli oris, one allows the muscles that work against it to have more play."
When performing such injections, she says, "It's important to get the anatomy right, because if one injects too far forward, one can get diffusion into depressor labii," which can create phonation problems that last up to eight months. To avoid this problem, she says she asks patients to tense their jaws because this helps her locate the anterior border of the masseter muscle.
"We suggest injecting just in front of that," she says.
Going forward, Dr. Carruthers predicts that other neurotoxins will become available. Reloxin (Inamed/Ipsen) and Xeomin (Merz Pharma) already are approved in Europe, she notes. In North America, Mentor continues clinical trials of Puretox, Dr. Carruthers adds.