Injecting the lips

Injecting the lips

Foundation Injection techniques for lips & face and protocol

There are 6 main ways to implant filler into the areas of the face which will achieve a variety of results based upon the clients’ needs and/or expectations. Here we outline the technique and the areas of the face each technique can be applied too.

Linear Threading technique for – lips

The needle enters the skin and is kept in a parallel orientation. The product is injected while the needle is withdrawn backwards. This is called a retrograde linear thread. In some instances, you may want to inject the product ahead of the needle. This can be useful because it can push blood vessels out of the way. In this scenario, we call it an anterograde linear thread, and you can see the product is injected ahead of the advancing needle.

Micro Droplet technique – for lips

This method of delivery is similar to serial puncture technique (used in the dermis), however the product is generally distributed via an insulin needle, to ensure only tiny micro drops of dermal filler are superficially injected into the skin, often the vermillion border of the lips, to create subtle yet robust definition – microdroplets are also used in the face for skin boosting cocktails & mesotherapy.

Fanning technique for lips and facial filling

This technique in which we can spread the product over a wider area, called fanning. In a fanning technique, after the needle has passed under the skin, we lay down a linear thread of product as we withdraw the needle. However, instead of removing the needle completely, we simply change the angle of the needle and then create another linear thread of product back towards the entry. We can repeat these threads in a radial pattern. This is what we call the fanning technique. Also used for certain areas of facial filling

Other techniques that are utilized in delivering dermal filler for facial filling are :

Bolus technique for cheeks/ chin A bolus simply means that the needle passes through the skin, usually to a deeper structure, and then we start injecting an amount of product with the needle remaining as still as possible.

Cross hatching or meshing lower facial volume loss. This technique begins by injecting a series of linear threads. We then change the angle of the needle, so that it is 90 degrees from the original, then inject another series of linear threads, which are all perpendicular to the first row.

Shaping lips – the golden rule for lips is:

1:1.6 (upper lip: lower lip) as the lower lip is slightly larger than the upper (about a third)

To give volume to the lips, inject into the body of the lips in the boundary between wet and dry mucosa.

Use a linear threading technique by entering 2-3 mm below the mucosa

Use fanning technique (using two threads) is appropriate for volumising.

WHAT TO TREAT

For anti-ageing / rejuvenation of the lips volume loss in the body & the breakdown of the structure in the vermilion border are the most common complaints, followed by drooping angles (commissures) of the mouth. These two together can give a sad appearance to the smile.

For genetically thin lips, structural augmentation with a deeper-placed filler followed by volume correction with a superficial filler is ideal.

For pure cosmetic enhancement of lips, a superficially placed filler with emphasis on the white roll e.g. the vermillion border and expansion of the vermilion is ideal.

Lips that have good volume can be highlighted by defining them and injecting into the white margins the highlight the vermilion border. Pouts can be created by injecting the filler below the muscle using fanning or linear thread technique.

Typically, the upper lip is treated more often than the lower as the natural anatomy of the lips for most people is that the bottom lip is approx. 20-30 % bigger

The best approach to lip augmentation depends on the nature of the defect and the subject’s aesthetic desires which should be thoroughly discussed & agreed during the consultation process.

Lip augmentation techniques

Injection of the vermillion border :

To restore dermal integrity we select a filler suitable for superficial placement

To enhance the vermillion border place linear threads intradermally along the vermillion border including the Cupid’s Bow area using a 30G 12mm needle

At this point, due to the superficial position of the needle, there no need to aspirate prior to each injection.

The grey shadow of the needle can be seen through the dermis when injection and a temporary tissue blanching of the immediate vermillion border occurs.

This should not be confused with blanching associated with vascular compromise. Regular changing of the needle is essential to have a sharp needle which allows accurate placement within the dermis and avoids unnecessary tissue trauma. Each dermal filler syringe comes with two needles,

Injection of the vermillion (lip body)

Anterior plumping of the lip requires placement between the vermillion border and the wet dry border. Increasing the vertical height of the lip is achieved by placing filler at the wet dry border and eversion can be achieved by placing the filler in the wet border in relation to the

Filler is placed in two or three threads (0.05-0.1m per thread depending on the volumisation required), the length of the lip quadrant before applying gentle pressure with finger and thumb to mould the product into one cohesive sheet.

Injection of perioral wrinkles (smokers lines)

These are caused initially by dynamic muscle movement either from smoking or simply communication, together with age-related loss of dermal integrity.

As the ageing process continues subcutaneous fat atrophy may also be a contributing factor. However, the problem is primarily dermal, and restoring dermal integrity will yield the most natural result. For best results a soft / fine filler is injected extremely superficially directly into the wrinkles using a 30G 12mm needle for a smoothing effect. Very small amounts (o.1-0.2ml) are required for most treatments.

Treating ‘lipstick bleeds’: treat by injecting the vermillion border with a ‘firmer’ filler. This approach can be very effective and usually has the added benefit of everting the lip and defining the Cupid’s bow (Figure 4).

Treatment of the subcutaneous volume loss.

This is usually seen in the lower lateral labial fat compartments, immediately below the oral commissures. This can be easily addressed by direct injection into this fat compartment with robust and volumising filler. A 27G needle and inject in a bolus (micro droplet) , aspirating prior to product placement.

Lip filler treatments are commonly requested, and while a single filler approach to simply augment a lip may be suitable for a patient in their early 30s with no significant perioral ageing, the same approach in an older patient with multiple visible ageing facets will result in a poor and unnatural outcome. We must always present a multi-product solution for best aesthetic results.

Treatment of Cupids Bow & Volume Loss

When it comes to the Cupid’s bow, practitioners must determine whether you need to redefine a lip that once had a nice distinct bow or if you need to create one that never existed in the first place. If you inject too much volume into the lip, the Cupid’s bow could become flattened, and this can cause a problem with definition

Be careful not to over-volumise. If you inject too much volume into the lip, the Cupid’s bow could become flattened, and this can cause a problem with definition.

Many younger adults have over-volumised, undefined upper lip shape and it looks unnatural and over-inflated. Similarly, if you overinflate the vermillion border it will result in a ski jump effect and produce the classic ‘duck lips’, which most want to avoid.

For clients who have never had a defined Cupid’s bow, the approach is a bit trickier. This treatment can have varying results, and it may require several treatment sessions before you achieve the most ideal result. Our method would be to inject on the vermillion itself, below the mid portion of the lip. What you might want to create is a tubercle, a volumised effect in the central portion of the lip that lies underneath the philtral groove. If you create volume in here, and consider putting very small amounts of filler in the philtral ridges themselves, that should lift the Cupid’s bow up.

Less is always more. Our recommended approach is to work conservatively & amounts of filler places is usually around 0.1-0.2ml to each area at one time. It’s important that you do this treatment in small incremental steps to build the Cupid’s bow and the philtral columns.

We also advise that practitioners allow the patient to sit with a mirror in their hand and seek their input and feedback after injecting the tiny amounts of product, to determine if they are appreciating the changes.

Aspiration in aesthetics is thought to be an absolute necessity by many practitioners for safety reasons.

What is aspiration?

Aspiration refers to fixing our needle in the position we are about to inject, pulling back on the plunger of the syringe and ensuring no blood has pulled back into the syringe. If there is blood, this would imply that we might be in a blood vessel and hence not safe to inject.

Why is it considered by some to be important?

Intra-arterial injection of filler can block the flow of blood, potentially leading to skin necrosis, ulceration and scarring. Embolisation of filler can even enter the central retinal artery and cause blindness. Anything we can do to minimise this risk could be argued worthwhile!

What might be some of the drawbacks with aspirating?

There may be a false sense of security if the aspiration is negative and then a potential ‘gung-ho’ approach to pushing filler in that very spot – but there are some issues with the accuracy of aspiration. Firstly, even a tiny amount of movement could potentially move your needle out of a safe zone into an artery in the time from completing aspiration to then injecting. Secondly, many argue that the small diameter of the needles means it is very difficult to actually draw up blood, and the force and pressure required may collapse the blood vessel your needle tip might be in …hence a false negative result.

Other issues such as the speed you pull back on the syringe, the viscosity of the filler and whether or not the syringe is properly primed are some of the other issues often argued as reasons that aspirating may not be as reassuring as we think.

We recommend aspiration for all medial depth injection techniques, as will be demonstrated to you in your practical training

The Steps to a perfect dermal injection

Hold the needle correctly, wrist above, using two fingers to stabilise & thumb on the plunger.

This position enables greatest flexibility and means you don’t have to change the position while the needle is in the client’s skin, use your little finger to anchor your position.

Ensure precise injection by lining up the end of the needle with the point on the skin where you want the needle to terminate. Choose your position of entry so the needle tip will reach this point by measuring the length of the needle
Use the correct angle of entry- 45 degrees for deeper lines and volume loss, 30 degrees for superficial creases.
Insert the needle at the chosen angle until around 1/3 of the need has penetrated. Then STOP.
Your needle tip should now be at the correct depth.
Slowly change the angle until your needle is parallel with the surface of the skin. Now when you advance, your depth will be maintained at the correct level. Advance the needle to the desired position, then stop.
Do a depth check. Once you are at the correct depth, check for a flashback by pulling back on the syringe (aspiration) If there is any blood, do not inject and repeat the process.
If no flashback, proceed to inject as per area-specific guides
Withdraw and massage to be smooth, check capillary refill present.

How to do a depth check:

Too shallow: If the skin is blanched without lifting, DO NOT INJECT – you are too superficial, and filler will be visible (Tyndall Effect)

Fine Lines: If you lift the needle and can clearly see the shape of the needle as a defines line (which may blanch -but only on lifting) you are in the right depth for a low viscosity filler to treat a fine line.

Deep lines: If you lift and see non translucent shape of the needle but it’s very defined you are about right for a deeper line or Volume replacement.

Too Deep: If all you see is the skin lifting generally, you are likely deep in subcutaneous fat which is not optimal.