Dr. Tapan Patel: We now have Jo here, and we are going to concentrate entirely on her lip treatment indication. When we see her from the front we notice that the upper lip actually has a very nice shape to it, the desired lip shape with a well-defined peak to the Cupid’s bow. We can see that in terms of volume there is more volume towards the central part of the lip, which tails off more at the lateral extent. If we look at the lower aspect, we see there is some degree of asymmetry, and if I place my swab in the middle we will see that there is more show of the lip on the right lower compared to the left lower. To some degree that is due to the fact that she has got a little bit of projection of soft tissue under the lip on this side more than the other side. The second thing to note is animation, so when she pouts there is a fair amount of symmetry but if she smiles we notice that there is excessive gingival display, so she’s got a very big open smile and we are seeing at least 2-3 mm of the gingiva above the canines and incisors. The treatment will be some neurotoxin in the canine fossa, the depressor septi nasi, and the canine fossa on the other side. The purpose of injecting in the canine fossa is to hit the levator labii superioris alaeque nasi in conjunction with the depressor septi nasi. You will notice that there is a big crease there, and this horizontal crease is due to excessive hypertrophy and contraction of the depressor septi nasi, so by treating these muscles together we can get less eversion and excursion of the central portion of the upper lip, which will hopefully give her a more natural smile without showing so much gum in the middle. In terms of the actual lip filler treatment, if I turn her to the side we will see again that the intrinsic shape of the lip is better but she just wants to have a little bit more show of the red. She has pleaded with me that she wants a very natural result, and she would trade a natural subtle result over a fuller and unnatural look, so I don’t want to that aspect of the treatment and accordingly my product of choice here will be Juvederm Volbella. Again, I am going to favour the cannula technique here for the upper lip but I will use a needle in the lower. Any comments from either of you?
Dr. Tijion Esho: I’m interested in why you’re favouring a needle in the lower lip.
Dr. Tapan Patel: I’ll show you more when I do it, but one of the reasons is that I want to work on the asymmetry. Due to the excessive projection of the soft tissue under the lip, you see that the lower part of the lip, the vermillion border, has a fair amount of projection, but then we have this inclination backwards which is almost horizontal. What I want to try and create is a little bit more prominence in the red of the lower lip. In doing that, I suspect I am going to find that easier to do with a needle, especially because of the asymmetry involved.
Dr. Tijion Esho: Actually I don’t know about yourself but what I would do, which I didn’t do in Jasmina, is almost tenting of the lower part of the lip and actually get it to turn out on that side.
Dr. Tom van Eijk: In rotation of the lip you want the rotation to be more dominant.
Dr. Tapan Patel: Absolutely, yes.
Dr. Tapan Patel: I am going to be using my product of choice here, which is Juvederm Volbella. I will use a 27 gauge cannula. My prehole needle is a 25 gauge, and I am going to take a little entry point just on the vermillion border just after the oral commissure. Again, with all of my cannula techniques I am just teasing gently, trying to bypass the various little retinacula. To make it comfortable on the patient, sometimes you can just pinch and the traction you get when you do that allows for easier passage. You can now see that the tip of my cannula is just here at the apex of the Glogau-Klein (GK) point, and I have marked that out in white, because sometimes we can actually lose the anatomy when we are injecting. I will start by injecting a little bolus of product and then lift the cannula as I inject backwards to augment the vermillion border. Now, I’m slightly deeper but still submucosal. If you do get any resistance to the cannula, remember that you can always inject a bit of product, and what the bit of product does is acts like a subcision tool, but instead of using something sharp you are using the gel to overcome tissue resistance. Finally, you can see where I am, just at the medial most tubercle, where I will inject a small amount of product again, and that’s all I want to do on that side. In terms of volumes, I have just used about 0.15 ml. TJ, you use the same product range as me, does it surprise you when we compare that to Juvederm Ultra/Ultra plus/3/4/Smile? It’s called different things in different countries, and we were using quite a lot of product back then so when we’re using something that’s more mouldable, I don’t know about you, but I can sometimes treat an upper lip with less than half a syringe of Volbella. Does the fact that we need less product surprise you?
Dr. Tijion Esho: No, because I think it’s how the product spreads in comparison to those previous products. They were still soft, malleable gels, but I find with the Vycross range when you do inject there is a greater diffusion in that tissue plane, and as we’ve shown here you inject superficially, and when you do that you aren’t needing to use as much product to get a good effect.
Dr. Tapan Patel: Absolutely, and I would wonder if you agree that, because it’s a very forgiving gel, we are more confident being superficial?
Dr. Tijion Esho: Oh completely.
Dr. Tapan Patel: With a number of products that I’ve used before I’d always worry a little bit being superficial because you sometimes ended up with just a little grain of product that you couldn’t massage out, so this gives us the confidence to inject more superficially, but knowing that we can still keep the result nice and natural. So we are in this superficial placement, and I have got to my access point, which is at the GK point here, and I am just going to inject that first little strand with a little bolus followed by a linear thread along the vermillion, then another one a little bit further below, and just one more below that. Again, if we are debating the cannula vs needle thing, one thing I always tell my delegates if I’m training is that they both have advantages and disadvantages. To me, a needle gives you precision and the ability to use less product. The cannula is arguably a little bit safer and less traumatic, but you do sacrifice some degree of precision and you do sometimes end up injecting a little bit more product. Tom, I can’t ask you because you only use a cannula once a year.
Dr. Tom van Eijk: No, I think you’re totally right, but of course my main objection to the cannula is that you cannot enter the dermis. Of course, it is safer, absolutely, and my patients are more bruised up in general than people who use cannulas.
Dr. Tijion Esho: I think that you can’t dispute the fact that a cannula will give you less trauma, less bleeding, less bruising, and actually seeing you today, Tapan, using the cannula superficially in this way may increase my usage of cannula in the lip itself.
Dr. Tapan Patel: Well, I’ll charge you royalties of course! Now I’m numbing again, and I typically use this technique for the Cupid’s bow. I want to prevent the product coming into the philtrum itself.
Dr. Tom van Eijk: It looks fantastic immediately!
Dr. Tijion Esho: This is when I wish I’d shown the Midas tool!
Dr. Tapan Patel: Well don’t worry, you’ve been so well behaved, we’ll invite you back! So at this point I think we can see on the upper lip that we are probably about the right level of augmentation. What I now want to work on is her lower lip, especially the side where I feel there is a little less symmetry. I am going to start centrally, and my idea here is that I want to bring out the lower lip a little bit, so I am going to use a cutaneous technique. There are various names attached to this technique, and I first saw it demonstrated and described by a dear friend of mine from Germany, Boris Sommer, so I call it the Sommer technique, like I call tenting the van Eijk technique. What I am doing here is entering just below the vermillion, and I suppose you would call it tenting, but rather than injecting while I withdraw, I’m just compartmentalising the product a little bit more and actually injecting a bolus. I didn’t want to inject as I pulled back otherwise I would have caused excessive projection of the vermillion, and I just wanted to create that little roll from the side here so we get a better continuation from the white soft tissue to the red. Now I’ll just repeat that on the other side. You’ll see that, before injecting, I marked off two white lines, and those white lines are really there to show me what inferior points would correspond with the GK point. I’m not compartmentalising on this side so that I don’t block the camera view.
Dr. Tijion Esho: You can already see that it’s starting to correct.
Dr. Tapan Patel: It’s starting to correct, right? So I’ll use one more just a little further along, and I’m very happy to refer to this as tenting. From a subtle point of view, the approach is exactly the same, and the only delineation I would make is that what I’m not doing is injecting a retrograde thread all the way out, and I can see the advantage of doing that, but that’s probably what I don’t want in this situation, so I am using a micro bolus technique, but the approach, the depth, the superficiality, are all exactly the same, so it’s probably quite easy for someone like me to adopt the tenting now because actually it’s almost how I’ve been treating.
Dr. Tijion Esho: Hopefully, with the people seeing this, what they are going to get is seeing what that technique is truly like, because I think there has been a misconception of how safe that procedure is, and actually it is when it’s done well.
Dr. Tom van Eijk: It can look quite brutal, yes. I’ve noticed it on facebook, some people doing a tenting technique, it can look awful.
Dr. Tapan Patel: Here, I am just going to put one linear thread just to marry up superficially, and that’s just here. From a building point of view I talk about putting pillars down and then putting a joist over the top, so my little boluses are giving me that anterior projection and then that little thread at the end is giving the support over the lot of them. At this point I am going to give her a very gentle massage and then we will sit her up and see, but I suspect there might be the need for just a little touch up, with a very small amount of filler on her upper right, but I am very happy with her upper left. One point I will make about the Vaseline that we use is that we make sure it is clean and uncontaminated, and obviously with the needle marks that we make there is the possibility for a focus of injection, so it’s important to make sure that not only is our technique as clean as possible, but also we’re not using anything contaminated to put on afterwards. We see that we’ve maintained the shape of the upper lip, she’s ever so slightly fuller on the left upper, so I’ve added a drop more to the right to even that up. We can now see, especially if I turn her to the side, we can now see that the lip is better everted, there’s better show of the red on this side compared to the other side, and we can see that the balance of the upper and lower are more in keeping with the aesthetic ideal. If I get her to smile, we notice that just the filler itself is reducing the amount of gingival display, so some of this will be Lidocaine, but of course if she’s got full excursion of the smile then you will notice that we can overcome the Lidocaine and we can see that we will benefit from just a small dose of Botox for treating a gummy smile. We’re going to use three points of injection to treat the muscle that’s causing excessive gingival display, often known as a gummy smile, and I am going to start by targeting the lower fibres of the levator labii superioris alaeque nasi in the canine fossa. This is a deep injection of two units, and I will do the same on the other side. These do sting, and you can see that Jo is finding it a little uncomfortable. Finally, we are going to target the depressor septi nasi, and we are going to make it a bit more comfortable for her with a little pre-numbing with some ice.
Dr. Tom van Eijk: I inject that last one from the inside just to make it more comfortable.
Dr. Tapan Patel: That’s interesting, the only thing I would worry about is sterility when going inside the mouth, so I think I’ll stick to the outside.
Dr. Tapan Patel: Hopefully, what we can appreciate now in this oblique profile is a nice harmony of projection, show of the red vermillion, eversion of the previously excessively everted lower lateral left lip, and a balance of proportion that is in keeping with the rest of her face. If I turn her to the front now we can still see that she appears to be slightly more fuller on this side, and now that I have adjusted for the product I have felt and palpated and I suspect there might just be a small degree of haemotoma or swelling there so I don’t want to overcompensate today, I would rather just keep it as it is and if this side doesn’t settle then I can always add a little bit of product on a future occasion. Anything to add?
Dr. Tijion Esho: No, but I think what you just said at the end is so important, about noting what is product and what is haemotoma and swelling, because sometimes when a patient then looks in the mirror they may tell you that it looks wonky, when actually it isn’t. If you’re able to tell them that and follow up your patient, which many people don’t, you can then correct these things at the second stage.
Dr. Tom van Eijk: I totally agree, like you say people will look in the mirror and say they need a bit more on one side, but ideally I’d ask them to wait for 2-3 weeks and then decide what they think.
Dr. Tapan Patel: I think it’s also important because we take such careful consideration of the amount of product we inject that we know we couldn’t have got such a wide degree of asymmetry from 0.05 ml of product so clearly something else is going on, like submucosal haemotoma, or just a bit of excess swelling, so that’s why I’m very happy to wait and then review in 3 weeks.
Dr. Tijion Esho: I think it’s important for the injectors watching this to have that confidence to do so.
Dr. Tapan Patel: Absolutely, now we’re just going to show Jo the mirror and let’s see what she thinks. Do you like it?
Patient: It’s great!
Dr. Tapan Patel: Is that in keeping with the level of augmentation that you wanted?
Patient: Yes, absolutely!
Dr. Tapan Patel: One of the tricky things that I find with patients who request minimal or subtle results is that the balance between getting it natural enough to be natural but impactful enough to see a result is a fine line, isn’t it? Thank you very much Jo.
Dr. Tapan Patel: I had a chance to review Jo a week after her treatment just to see the impact of the botulinum toxin on her smile. You can notice that following the treatment she has a considerably better and aesthetically more pleasing smile with almost no display of the gum.