Injection Techniques for Perioral Enhancement (2024)

4.1 Skin rejuvenation injections in the perioral region

The purpose of skin rejuvenation techniques is to reverse cutaneous aging signs including wrinkles. Ablative and exfoliative treatments are commonly used for skin rejuvenation, such as peelings, lasers and microdermabrasion. In contrast to exfoliation or ablation, revitalizing or rejuvenation injections focus on replenishment and nourishment to improve skin aging signs. This concept, unique to the technique of skin rejuvenation mesotherapy or revitalization, focuses on the replacement and nourishment of the vital components of the skin with mostly poly-vitamin solutions and especially non-cross-linked hyaluronic acid [17].

The injectable products used for skin rejuvenation should be sterile, registered for injection within the dermis and suitable for intradermal injections. The ideal product to use should contain ingredients that will replenish the extracellular matrix, reduce oxidation, nourish the fibroblasts and stimulate neocollagenesis. Polycomponent preparations for mesotherapy or intradermal injections are developed to supply the necessary substrates to aging skin that are needed for optimal functioning of the fibroblast [14, 15]. This will typically include free hyaluronic acid, vitamins, minerals, antioxidants, coenzymes and new types of ingredients with scientific evidence of fibroblast stimulation or collagen-boosting properties [14, 15, 16, 17]. There are many new products entering the market for improving skin quality including innovative substances such as peptides, enzymes and exosomes.

Various injection techniques have been recommended, used, or studied to deliver these substances to the dermal fibroblasts and the surrounding extracellular matrix.

Different techniques for delivering skin-replenishing or revitalizing substances include:

• Classic mesotherapy injection techniques—epidermal, dermo-epidermal and dermal techniques

• Intradermal injections with a needle (such as 32G × 4mm needles)

• Intradermal injections with needle devices (such as Nanosoft™)

• Skin needling rollers (dermal rollers)

• Electronic skin needling devices (Demapen®, Mesopen®)

• No-needle injection devices (Figure 3).

To achieve successful results without complications, there are some important rules to follow, which include but are not limited to the following:

• Use a good quality product with scientific evidence of efficacy.

• Use good-quality injection needles or devices.

• Good skills in injection techniques.

• Thorough cleansing and disinfection before injections.

• Do not mix solutions.

• Use only new, unopened vials for injections.

• Check the expiry date of products.

• Be careful of topical anesthesia that may cause skin reactions.

• There are many reports in literature of contact dermatitis to topical anesthesia [18]. These reactions may be further aggravated with multiple needle punctures to the skin barrier as performed by these techniques.

4.2 Botulinum toxin injections in the perioral region

Botulinum toxin injections have been used for various esthetic indications, particularly for the upper face, but also for the middle and lower face and the neck [19].

Several consensus recommendations for the use of botulinum toxin in the lower face have been developed despite this region being off-label indications.

The use of botulinum toxin in the perioral region includes:

• Treatment of perioral wrinkles with small doses in the superficial orbicularis oris muscle.

• Reduction of gummy smile (excessive gingival exposure on smiling) by reducing the activity of the relevant lip elevators.

• Reducing the activity of the depressor anguli oris muscle will give an elevation of the mouth corner.

• Reducing the chin dimpling effect and melomental crease with the relaxation of the mentalis muscle.

The use of botulinum toxin injections in the perioral region requires an in-depth knowledge of the location of the muscles, their depths, their relation to surrounding muscles and their vectors of movement (Figure 4).

When treating perioral wrinkles with botulinum toxin injection, the depth of injection should be superficial and close to the vermillion border of the lip [19, 20, 21]. This will ensure that the deep fibers of the orbicularis oris muscle are not injected, ensuring effective reduction of the perioral wrinkles and mild eversion of the upper lip (Figures 5 and 6).

4.3 Filler injections in the perioral region

The use of fillers for lip rejuvenation and lip enhancement remains a very popular esthetic medical procedure [21]. The most widely used filler material remains hyaluronic acid fillers due to their natural properties, numerous scientific studies and safety aspects, especially since they can be reversed with the enzyme hyaluronidase. Hyaluronic acid fillers are widely used in esthetic medicine for facial rejuvenation and volume enhancement in different body regions and their popular use includes the lips [21, 22].

A frequently misunderstood aspect of beauty is the notion that beautiful lips are synonymous with full lips. While full lips are commonly associated with attractiveness compared to thinner lips, the reality is more complex. Attractive lips encompass more than just their fullness, encompassing factors beyond the absence of perioral wrinkles and the presence of a well-defined Cupid’s bow [23].

In many cases of perioral rejuvenation, augmenting fullness can certainly address and improve specific concerns in the perioral area. However, it may not constitute a comprehensive or suitable treatment strategy for the patient’s unique indications or concerns. Unfortunately, a common issue that arises is not just an excess of fullness but, more frequently, the improper placement of that fullness within the patient’s lips.

The most important step in achieving successful results with lip enhancement is a good proportional evaluation of the lips and the perioral region from a frontal and lateral view, as discussed earlier. The lips themselves also need to be evaluated according to their subunits as known by artists and originating from the embryological development of the lips (Figure 7).

These lip subunits need to be evaluated according to loss of volume or excess volume and this will help guide the treatment plan for lip enhancement.

Further to this, the perioral region needs to be evaluated. Only enhancing the lips and leaving perioral concerns untreated will not result in a satisfactory result (Figure 8).

Perioral lines or wrinkles may reduce the attractiveness of the lips. This may include perioral (barcode or smoker’s lines) (A), nasolabial folds (B) or marionette folds (C) or even an unaesthetic chin profile.

Following the evaluation of the lip subunits and the perioral region, the treatment can be planned according to the aims of treatments for the lips, which may be volumization, contouring, restoration or purely perioral rejuvenation (Figure 9).

Techniques of injection of fillers will depend on the product rheology and the aim of treatments. The lip region remains a highly vascularized and highly dangerous zone for the risk of intravascular injection. The vascular supply of the lips derives from the superior and inferior labial arteries branching from the facial artery [21]. Safe and successful procedures in the perioral region depend on a thorough, comprehensive knowledge of facial anatomy, in particular vascular anatomy. Insufficient familiarity with this aspect can result in significant complications [25].

The use of cannula of 25G or thicker (22 or 23G) reduces the risk of intravascular injection but does not completely eliminate the risk. When using needles, smaller needles and the use of smaller amounts per injection with continuous monitoring of capillary refill are recommended to reduce the risk for intravascular complications [21, 22, 23, 24, 25]. Other complications with fillers in the perioral region could arise due to lack of sterility, incorrect choice of product for the depth, existing localized infection, recent viral infections and other side effects, which are often classified into technique-related or product-related adverse events. All professionals performing these procedures should be familiar with the risks of adverse events, how to avoid or reduce the risks, as well as knowledge of managing such events.

Further to injection techniques, one needs to understand the rheology of the hyaluronic acid (HA) fillers to ensure that the correct product is used for the specific indication. The various factors influencing the viscosity and elasticity such as the length of HA chains, the amount of cross-linking, the molecular weight, G-prime and other factors should be taken into consideration when choosing the product for the indication, the depth of injection and the region of injection (Figures 10–12) [24].

When treating the perioral region, it may also be necessary to balance the profile of the nose, lip and chin region. The evaluation of the frontal and lateral profile measurements is vital to ensure the profile remains balanced and esthetically pleasing (Figure 13).