Originally published in Aesthetic Medicine Magazine, this article by Nurse Julie Brackenbury explores the use of botulinum toxin (BoTxA) for subtle lip enhancement.
The Lip Epidemic
It is not uncommon knowledge that lip augmentation is now part of the regular beauty routine for millions of women (slowly increasingly and arguably, men). Most aesthetic practitioners would agree lip augmentation is the biggest facial fashion accessory of this decade, and one that symbolises sensuality, sexuality and youth.
However, there was a time BoTxA applied in the perioral area was deemed as controversial treatment, but we now see indications for BoTxA constantly evolving and in safe hands, it can be administered in many areas of the face and neck.
Social Media
In the past, only celebrities have battled constant scrutiny about their appearance. Nowadays, it is popular for most to have a public image, whether it be on Facebook, Instagram, or Twitter. Diller et al (2011) suggested that for some women, the phenomena of using a public image on social media can create a compulsive obsession with looking perfect, and describes this as “beauty dysmorphia.”
Other experts strongly believe that social media is the main contributory factor for the growing rise in cosmetic procedures, and consequently advises that aesthetic practitioners need to be aware of these drivers and the challenges. Importantly, it is not just females who are feeling the pressure; Hobza et al (2007) and Barker (2009) have suggested a strong relationship between social media and male self-esteem.
Confusion Within the Public Domain
Many are not aware of the different modes of action between dermal filler and BoTxA. Most people speak of “injectables” as non-surgical options for facial enhancement, but many misunderstand that there are different types of injectables, and that different materials serve different functions.
In the author’s opinion, there are a number of reasons for this: mixed messages via the mass media, lack of education, and incorrect information from family and friends. In addition, those who are perceived to have gone “overboard” with aesthetic treatments can sometimes cause controversy and confusion within their peer groups. All of these reasons can be a challenge to the aesthetic practitioner.
Application
The cupid’s bow is a facial feature where the double curve of a human upper lip is said to resemble the bow of Cupid, the Roman god of erotic love. The peaks of the bow coincide with the philtral columns, giving a prominent bow appearance to the lip, whilst the orbicularis oris actions cause pursing of the lips and, over time, result in etched-in lines around the mouth, which can also be treated with small doses of BoTxA.
The application of BoTxA in the oral region has been described by several authors. This results from diminishing the hollowing appearance within the vertical muscular bands, offering a “pseudo-augmentation.” Consequently, treatment can result in a widening of the philtrum column as well as slight eversion of the vermillion itself.
A series of injections of one to two units of BoTxA (Botox®) across the upper and lower lips can enhance the treatment of vertical rhytids. The effect of decreasing the pursing actions creates a slight eversion of the lips, resulting in lips that appear to have been augmented. Alternatively, if your patient doesn’t have a specific cosmetic concern about their lip rhytides, BoTxA can be used as a stand-alone treatment to subtly enhance the cupid’s bow.
Importantly, patients will have many questions for aesthetic practitioners from the common misconception that BoTxA should not be used in the lower face. This application is an off-label treatment and by law, doctors, dentists, and non-medical independent prescribers (i.e. nurses and pharmacists) are permitted to use or advise using a licensed medicine for indications, in doses and by routes of administration outside of the licensed recommendations.
It is important to note that the responsibility for the consequences of the above actions lies with the prescriber. The prescription of a drug requires the prescriber, in light of the evidence, to balance the potential good and harm that might ensue.
Patient Selection
Patient selection is key and the best results, in the author’s opinion, have been seen in those with fuller and more youthful lips. For patients who rely on lip contraction for their occupation (for example, scuba divers or wind instrument players), this treatment should probably be avoided.
In addition, patients with a very thin or atrophic upper lip, or a long columella-to-vermillion distance, should not be injected. Some believe that these patients may experience an even thinner-lipped appearance because of the slight lengthening of the lip. Managing expectation is absolutely key in non-surgical aesthetic medicine and must be reflected in the consent form.
Technique
Consultation, consent, photography, topical anaesthesia is performed, and the lips are wiped with alcohol. The main goal is to accentuate the white roll and cupid’s bow area to provide definition, especially in the “lazy M” region.
To treat this muscle, a single injection of three to five units of BoTxA is used, based upon the estimated muscle mass of the individual. By using a 31-gauge short-needle insulin syringe, the needle hub is inserted perpendicular, approximately halfway into the skin at each tip of the cupid’s bow, by way of an isolated serial puncture technique and bolus administration.
The overall procedure takes approximately 20 minutes of clinical time to perform, but can be less depending on the practitioner’s experience.
Adverse Events
There does not exist a cosmetic procedure that is complication-free, and many of the problems aesthetic practitioners face are consistent with a learning curve, thus becoming less common with experience. As mentioned above, patient selection is a skill that comes from knowledge, skill, and time.
An in-depth consultation, informed consent, and management of expectation can help improve communications when problems arise. In the author’s opinion, the number one rule for BoTxA is the same for dermal fillers and for all cosmetic procedures: take a conservative approach. Over-treatment or correction is challenging and stressful for both the patient and practitioner, whereas under-treating can provide comfort, confidence, trust, and less stress.
Side effects include: overcorrection, undercorrection, allergic reaction, bruising, swelling, unmet patient expectations, asymmetry, and oral pursing problems.
One of the side effects that patients notice immediately after treatment is that their lips look instantly “plumped”. The reason for this is a combination of the numbing agent used, as well as the mild swelling caused as a result of the injection. In some cases, this can provide an actual idea of what the result will look like once the effect of BoTxA starts to take place.
Length of Duration and Follow Up
From the author’s experience, the effects can last up to eight weeks and this reflects in the studies. Toxin duration at this location is typically seven to ten weeks—shorter than that seen in other regions, but still on par with other highly dynamic areas such as nasalis lines. A follow-up visit is recommended at two weeks following treatment to assure patient satisfaction, efficacy, and symmetry.
Conclusion
Our understanding and knowledge about the toxin has grown tremendously since it became available, which has led to an expansion of its use and indications and, although generally safe, effective, and well-tolerated, BoTxA at this location is best reserved for patients with a history of successful results in the upper face.
BoTxA is a minimally invasive way to provide substantial cosmetic improvement to the signs of ageing around the lips and can provide an adjunct to lip augmentation. Of course, for real lip volume improvement, fillers are better advised. On the other hand, some patients “worry” about fillers, so to offer an alternative seems a reasonable option.
Overall, successful injection technique requires a thorough understanding of the facial anatomy and interactions between the muscles. Aesthetic practitioners should be aware of the secondary compensation mechanisms that may occur when trying to paralyse or diminish the activity of a certain muscle or group of muscles.
Reproduced with permission from Aesthetic Medicine Magazine, October 2016.
