Dr. Tijion Esho: We have Jasmina here. Jasmina is typical of many of my patients, normally in the age group of 25-35 and of mixed origin, she’s half Algerian, quarter Argentinian, and quarter English. She has a typical naturally full lip and also that 50:50 ratio we discussed earlier. What she wants to achieve is mostly hydration, and she has had previous treatment before with Volbella. This is my treatment of choice because it has a low viscosity but is also hydrating to the lip, and we don’t need to achieve any volume here, so what we are trying to create is that textural surface for her. Looking at the lip, as I said before, we have got that 50:50 ratio, and she already has a quite defined Cupid’s bow and nice elevation on the Glogau-Klein (GK) points of the lip there. Tom touched upon the outer thirds and that being the marker for many patients. In her aspect, many times she has told me she would like a little bit of a lift here, so we are going to see a mixture of techniques here. We will see what you would call your traditional tenting going across the lips, but just superficially hydrating the lip with Volbella. Also towards the corners here you will probably see some traditional linear threads going across that aspect to open out the aspect of the lip itself.
Dr. Tapan Patel: If you could just explain, in your philosophy, what the difference is between a vertical deposition of product, compared to the traditional horizontal linear thread, what advantage does one technique give you over the other?
Dr. Tijion Esho: I think with the tenting, the vertical technique, you get more vertical lift. If we look at her side profile, she has great projection already, so we are not trying to project the lip any further. For her, she is just looking for that slight lift back on the top and the bottom to maintain that pout.
Dr. Tijion Esho: What I tend to do is I start to get some traction on the lip with my non-injecting hand. I start at the GK point, and I’m injecting superficially, coming down and just drawing back on the lip itself, and I stop when I get back to the vermillion border. I’m injecting just sub-vermillion border and bringing up, so what I tend to do is then tent the lip.
Dr. Tapan Patel: I know that the people watching will always be wondering, so roughly how much product do you think you are injecting in each one of these little threads?
Dr. Tijion Esho: I think in each of these little threads I am probably injecting about 0.05 ml. I see people trying to do this like it’s a race, but you have to take your time and really make sure you’re aligning and repositioning each time you go through.
Dr. Tapan Patel: You talked about the traditional tenting, and I should probably just mention that when you were still in Kindergarten I was starting out in aesthetic medicine, and the very first person who demonstrated, and indeed wrote the article on it is actually Dr. Tom van Eijk here, and he’s beaming with pride as you’re doing it!
Dr. Tijion Esho: I’m very happy, because I’ve actually watched your videos, Dr. van Eijk, so I was aware of you before I came today, hence why I’m very nervous here with you two watching over me right now!
Dr. Tapan Patel: It’s certainly not reflecting in your injection!
Dr. Tijion Esho: If you can see already the comparison between both sides, obviously I know there is edema from the products, but you can already see that there’s slightly more lift on that side compared to the other, and that’s because we’ve injected just superficially then also on the sub-vermillion border and just given that lift.
Dr. Tapan Patel: It’s very clear and obvious, and I think it’s interesting, because when we were discussing earlier about the different demographics or patients we see, I tend not to see the patients who are happy to have good fullness. Most of my patients, even the younger ones, are actually requesting a very natural or minimal enhancement. I think what’s quite clear with this technique here is that it is a very small amount of product, and a very soft product as well.
Dr. Tijion Esho: Yeah, I think that’s important.I’m left-handed, so what I find when in my position when come back across, is I am able to just invert my hand to inject the other side. I feel comfortable that way, but it does depend on how comfortable you feel as an injector, but each time I can feel I am still placing about the same amount of product across the lip.
Dr. Tapan Patel: What is clear to me, as well, is that she’s not even flinching, the patient seems incredibly comfortable, and maybe we can ask her afterwards.
Dr. Tijion Esho: A lot of people talk about this technique being painful, and even sometimes dangerous, but I’d like to point out here that we are very superficial, so people may note that I’m not aspirating at the moment when I’m in the lip, and I think that’s a big topic; when to aspirate or not. I think when you look at this, there’s two deeper things to answer. One is whether aspiration is possible, and we know it is, but we know it’s variable depending on the product in the syringe, the size of the vessel, the pressure in the vessel, and also the time delay – when we are aspirating, how long are we doing it for? Many people do it very quickly, whereas when we look at a lot of the studies it’s 5-10 seconds before we overcome the negative pressure to actually get in the syringe. I don’t know about you two in terms of how you feel about aspiration though.
Dr. Tapan Patel: Tom, are you an aspirator?
Dr. Tom van Eijk: Not very much, when I do some injections at the nasal alar, where the angularis is, I tend to aspirate there, and what we call the Gong point on the zygoma. I don’t aspirate in the lip though.
Dr. Tijion Esho: What about yourself, Tapan?
Dr. Tapan Patel: I’m a big champion of aspirating, but I don’t aspirate in the lips. When we are using needles in the lip there’s a lot of individual punctures that we’re doing, and precision is important. I think you said it very elegantly yourself, Dr. Esho, your placement is superficial, we’re under the mucosa and in this region this is not where we find either the superior or inferior labial arteries. Of course, there are branches and tributaries that do supply but I don’t think in that scenario with such small vessels that the aspiration is such a valuable commodity.
Dr. Tijion Esho: I think it comes to the point where you were talking about, actually the different factors you look at for vascular occlusion, are the pallor, the texture, the patient’s reaction to pain, etc. I think there are a number of other factors that we need to take into account, not just aspiration itself, that will tell you if something is going wrong. Relying upon that as a tool on its own is incorrect, but using it as part of your arsenal is the correct thing to do.
Dr. Tapan Patel: For sure.
Dr. Tom van Eijk: I think the chance of blocking anything with that moving needle is slimmer than if you put it in one bolus.
Dr. Tapan Patel: So just talk us through what you’re doing now, you’ve gone from the vertical to the more traditional horizontal liner threads.
Dr. Tijion Esho: Exactly, the reason why I’ve done that in Jasmina’s lip is because she’s already got a low lip, she already has that projection there, so for me to add that I think it would give it an undesirable finish. What I’ve just done is because now we are particularly focussed on the definition of the border here, I have chosen a retrograde linear thread. For me, that would be it, I wouldn’t do any more on there. The key thing when we are doing lips is to know what’s too much and what’s too little. Sometimes we can almost go into robot mode and think we have to fill aspect after aspect, when actually each patient is different so you may only need to touch up certain areas. For Jasmina, she has a full body and now she has a good lift on the upper part and a nice border definition to the lip with no volume, and that will settle in two weeks time to see.
Dr. Tapan Patel: I think there’s a couple of learning points here.I’m going to ask you a very facetious question. You’ve got about 0.4 ml left in the syringe, where do you think is the best place for that to go?
Dr. Tijion Esho: For me, the job is done so it would go in the bin.
Dr. Tapan Patel: Absolutely.
Dr. Tijion Esho: I think you find sometimes, and I think you will get it, patients will notice that there’s some left and ask for it to be injected somewhere else, but you don’t treat for the sake of using leftover product, you treat for an intention. In this case, we have treated the intention and it has been achieved so the rest is disposable.
Dr. Tapan Patel: Thank you very much.
Dr. Tijion Esho: As you can see, this is the end result now and I’m very pleased. We’ve used traditional tenting across the upper part of the lip and within the sub-vermillion border, which has given it a nice vertical lift and definition. Also on the bottom we have used linear threading across, which has been done well so we have not dipped the lip too low as we would have done if we had done traditional tenting across this side as well.
Dr. Tapan Patel: Absolutely, and I’ve got to tell you that when you first showed me your model selection, because this is not the demographic of patient that I normally treat, I was concerned that maybe before the lips were already oversized, but in fact following the treatment you’ve very nicely restored some balance here. The lips look beautifully defined, and they are obviously very full. She has a very beautiful face so she can carry these lips off excellently, but what I’m dying to find out is from the guru of the tenting technique. Dr. van Eijk, what did you think, how did our boy do?
Dr. Tom van Eijk: I couldn’t be more proud, it’s a really good job! It looks very natural, enhanced but natural, really good!
Dr. Tijion Esho: Thank you very much.
Dr. Tapan Patel: Well done.