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I would like to introduce our next patient, Hanna, who is currently 30 years old. When I asked her what she was ideally looking to improve, she mentioned that she had three primary concerns. Her first concern was her chin, she described this as a ‘witch’s chin,’ by which she meant she had a little bit of excessive projection, and she felt that the chin was dominant. Her next indication was the under eye hollows, and finally she was seeking to improve the shape and size of her lips. Let’s just have a look at her face shape: when we look at her from the front, we can see that she’s young and attractive, and in line with that she has a very nice dominant cheekbone that you can see leading down. However, she also has a very dominant jaw, which gives off a bit of a square shape in her face. We do know that the ideal face shape for a female is a heart formed by the cheekbones coming down into a delicate chin, or an oval, but in Hanna’s case, the angle of the jaw gives a bit of squaring. We can see that if were able to contour the jawline, we would potentially make her more attractive and give her a more delicate lower face shape.
Lower third assessment
Let’s now look at Hanna’s lower third, from the subnasale to the pegonion. We notice that she has well defined philtral columns and a well defined Cupid’s bow. When we look at the lip, we notice that it has a good shape and definition, but both the upper and the lower lip appear a little bit thin for her face. This is compounded by the fact that she appears to have an excessively long and dominant chin. We can see that the chin has a lot of anterior projection and the mentalis muscle can move this up, creating this labiomental crease. We can see, however, that we can remove the labiomental crease to give a better shape to the chin. If I evert the upper lip, and then both the upper and the lower lip, we can see that it takes away the dominance of the chin and gives her a more attractive perioral region. If I now ask Hanna to smile, we can see if I evert the lip, that she has relatively good occlusion of her teeth, and there is not excessive overbite or underbite.
Moving Hanna to the side, and asking her to smile again, we can see something very interesting. On smile, you will notice that she has these vertical cheek lines, and in her case this is most likely due to the fact that she does have some degree of masseter hypertrophy, as I have pointed out before. Accordingly, the line is formed by the oral commissure pushing against the hypertrophic masseter, creating the vertical creases in the side of her cheek. When I get her to frown, we see minimal DAO activity, but we see a lot of mentalis activity, causing cobblestoning of the chin. This makes her a candidate for treatment in this region with botulinum toxin. If I turn Hanna’s face to the side we notice that she has a nice smooth jawline with a very good shape and definition from the chin to the angle of the jaw. If I get her to contract her neck muscles, we see some platysmal banding, and with minimal contraction the jawline is preserved. When she contracts more heavily, we can see that there is a little bit of blunting on the jawline. In time, she may be candidate for treatment in this region with botulinum toxin to the cervical portion of her platysma. In summary, Hanna, although young, does have treatment indication in the upper third, the midface, the lower third, and possibly in the future, the neck.
Chin and lip assessment
If we look at Hanna from the side, we will notice that she has some degree of excessive anterior projection of her chin. She mentioned to me that she dislikes this intensely and refers to it as her witch’s chin. She does, however, have a beautiful jawline. Accordingly, if we want to improve her profile, we must be careful not to inject her chin anteriorly. Instead, we want to try and create an elongation and reduce the angle from the lip to the chin, i.e. treat her in the labiomental crease. This will also have the effect of supporting the lips. We can see in the profile view that Hanna has relatively thin lips with very little show of the red vermillion. If I turn her back to the front, we can see that the lips are wide but very flat and thin, and she does look better if we can give her some eversion and show of the red lip.
Chin markings and treatment
Although I usually use a cannula when I treat the labiomental crease, in Hanna, because the line is well defined and relatively narrow, I am happier to use a needle. I have marked out the crease, and I will begin by inserting my just slightly before the midline so the tip of my needle will end up in the midline. I am at a subcutaneous depth, and I will now inject a small bolus of 0.05 mls of Juvederm Voluma. After injecting the bolus, I will withdraw in a retrograde linear thread. Once I come out of the skin, I will repeat that action, starting a little bit below so that I end up just at the entry point of my previous needle. Having repeated it for a second time, we can already see that on the treated side the labiomental crease appears to have effaced compared to the untreated side on the left.
I can now repeat the same technique on Hanna’s left side. To reiterate, I will enter with the needle slightly away from the midline, entering into the subcutaneous, and injecting a bolus of approximately 0.05 mls of product, and then continue to inject as we withdraw in a retrograde linear thread. The second entry point will be determined in such a way that we can end up just at the beginning of our previous injection. Having withdrawn, we can now massage the product to look at the result.
Lips marking and treatment – complication
We are treating Hanna’s lip with a cannula. We want to get an eversion, and ideally place the product posterior in the lip. This is, unfortunately, exactly where the superior and inferior labial arteries are found. I am using a 25 gauge, 38 mm cannula, with Juvederm Volbella. After placing the prehole just lateral to the oral commissure, I will then find a posterior plane for my cannula. You will notice that it slides in relatively easily, and now I am at the apex of her lip just below the Cupid’s bow. I am at the junction of the wet-dry border and I can inject the product. I will use approximately 0.2 mls in linear retrograde threads. Having treated the upper lip on the right side, I will now move on to treating the left side. I use the same technique, using a needle for the prehole. We remove the needle and then can introduce the cannula, held like a pen, to facilitate passage. As it goes through, it is not unusual to feel a popping sensation as it passes through the fascia. We need to manipulate the cannula and enter the posterior, or deep, plane of the lip, and we can see that it passes easily up to the region of the Cupid’s bow. Very carefully, we will then inject the same amount of product as on the right side, and we can do this in two passes. You can use your non-injecting hand to stabilise the lip and as we inject using the cannula it is often possible to see the result as we withdraw. In this case, we can see a nice and subtle eversion of the lip as the cannula is withdrawn.
While I was doing this treatment, at this stage, I noticed that there was an unusual appearance to Hanna’s upper lip. In the region of the white lip above the treated area on the left side, I noticed what appeared to look like a bruise. However, when I examined this carefully, I noticed that there was a very reduced capillary refill time. I could not exclude a vascular occlusion even though she experienced no pain, and I didn’t see any obvious flash or whitening of the area. Accordingly, I had to assume that there may have been a vascular occlusion and we decided to treat Hanna using the High Dose Pulsed Hyaluronidase Protocol. You can see a separate video on how to use this. In real terms, this meant that we stopped injecting and applied vigorous massage. We had already made up some Hyalase and I proceeded to inject 500 units in the region of her lip. We then administer hot packs and we repeated the Hyalase 3 more times at 1 hour intervals. We took some footage on an iPhone camera of the area of her lip so that we could monitor the capillary refill. She made a good recovery and I will now show you some footage so you can see what the tissue looked like, both on the day of the treatment and over the next few days.
This is Hanna approximately an hour after treatment, when some hyalase has already been administered. You can see that there is an area of erythema but some reduced capillary refill in her upper lip and tip of the nose. It is difficult to know at this point whether the capillary refill is sluggish because of bruising. The following day, we can see more obvious bruising, and the capillary refill is slightly better but still sluggish compared to surrounding tissue. When we look at her at 4 days, we now see that the capillary refill is almost normal and there is just the remnants of some bruising in her upper lip. Finally, at a week, we can see that the capillary refill is completely normal and the bruising has all but disappeared.
Treatment outcome at 6 weeks
We have Hanna here at 6 weeks following some Botulinum toxin and some dermal filler treatment. The first thing to notice is a significantly improved facial shape. We can see due to the masseter Botox treatment that she has now a more feminine, oval, or heart-shaped face. This is due to a diminution in the projection of the angle of the jaw when we treated the masseter. We can see that when she frowns, she has practically no activity of the procerus or corrugator. When she raises her brow, there is some movement but the lines are diminished. This is the perfect ideal for frontalis treatment, because we preserve movement but we reduce the lines. If you look at her brow shape, you will also notice that the tails of the brow have lifted and are more aesthetically pleasing. When we look at the chin, we notice that it is now soft and there is no longer the cobblestone appearance she had pre-treatment. If we turn Hanna to the side we will notice that the chin is still slightly projected anteriorly, but considerably less so than pre-treatment. If we turn her to the other side and she smiles, we will notice that the little line she had in her cheek was also reduced substantially following treatment to her masseter. Also notice the significant improvement to the under eye area after treatment.