Age Grouping to Optimize Augmentation Success

SUBGROUPS WITHIN THE AGE GROUPS
Understanding the various patient-presenting groups is vital in lip and perioral augmentation. This article generally divides the patients into 4 age groups. The 4 age groups present different augmentation needs to attain a successful, aesthetic result. Yet within these 4 age groups are 3 subgroups, which include: (1) patients with no previous lip augmentation treatments, (2) patients with prior lip augmentation with positive results, and (3) patients with prior lip augmentation with negative results.

One must also understand the natural lip planes that exist in a lip (Table 3). There are 3 potential places fillers can go when we are injecting filling material into the lips for augmentation.

Natural Plane: This is the plane that naturally exists in the patient’s dermis. The junction of the dermal layer that the needle is placed in is right below the vermilion epithelium. This plane will relieve itself laterally to host the fillers as pressure is applied. The resistance to separation in this layer differs by skin type. The more keratinized the tissue, the more resistance, and vice versa. The lips have very little resistance in the dermal plane. The fill can be easily distorted by expressing too much pressure in the fill. The distortion comes from the material flowing into undesired zones of placement.

Acquired Plane: This plane has been established by a previous fill of a material that has occupied the space for a time. This plane may divert your filling material away from your planned augmented areas.

Path of Needle Insertion: This plane is created by the needle as it is injected into the dermis. If we apply very little pressure and withdraw the filler as we express the material, we will fill this space.

(Further in-depth description and planes augmentation can be found in the textbook, Vermilion Dollar Lips, by Dr. Robert Gordon.)

Patients With No Prior Lip Augmentation
Patients with no prior lip augmentation present physiologically with some distinct challenges. The tissue for implantation has had no previous fill, so the potentiated space is reliant more on the natural space or planes. When we are augmenting “virgin” lips with filler material, the filler has the propensity to glump or become bumpy in the lips. This is due to the tight tonicity of the vermilion tissue, and this pressure can lead to an uneven flow. This is particularly true of highly viscous materials such as cross-linked hyaluronic acid. An important point to remember is not to force more material into the lips at the time of occurrence. Instead there are several options available to remedy when an uneven flow of materials occurs:
Wait until the one-week post-op to smooth out the filling material.
Add additional filler material after one-week initial augmentation.
After waiting one week for reaugmentation, this allows the tissue that was previously taut to loosen up, via the natural pressure of the existing filler. We are also in a better situation to evaluate the fill without the natural swelling that comes from the trauma of filling a needle injection.

Patients With Prior Lip Augmentations: Positive Aesthetic Results
When we refer to a positive aesthetic result, we are categorizing the patient by effect resulting from:
Lip augmentation fulfilling the patient’s cosmetic desires
The augmentation presents with a natural pleasing appearance
The prior lip augmentation has had no traumatic effect on patient’s lip and/or perioral tissue that may encumber sequential augmentations.
This subgroup of patients is the most “user friendly.” By this, I mean these patients have had previous experience in lip augmentation, which leads them to be more receptive to treatment modalities. They are usually less anxious during treatment and they are more patient in the postaugmentation phase. The planes in the lips of these patients have been filled, and there is a memory of plane saturation that responds well to a refill. That is why it is so important to fill your initial lip patients as well as possible and to abide by the natural planes of the lips. This focus will allow easier more pleasing sequential fills.

Patients With Prior Lip Augmentations: Negative Aesthetic Results
This is the most challenging of all subgroups. A bad lip augmentation will not only present unpleasantly; it has the potential to affect sequential fills on that patient, even when a resorbable material is used. An overzealous fill or improper lip plane placement will distend and relieve a space within the lips. When the augmenter readministers filler into the lips after resorption of a previously placed filler, the plane may still exist. The sequential augmentation will follow the path of least resistance and has the propensity to flow into the plane. The only solution when one encounters such a case is to slow down the injection process. Observe the flow carefully, and when the filling material deviates from the natural planes of the lips, STOP—Evaluate—and Relocate. Relocate the needle into an area of the lip that will allow the flow of the material to augment the natural plane. Logic dictates that one will have to inject in several more additional sites around the lips to facilitate the even distribution of the natural planes. My own clinical experience dictates that it only takes a couple of reaugmentations to resolve most bad augmentations.

Remember that when augmenting the lips, the material will want to fill the natural planes. The kinetic movements and static positions are conducive to the natural planes. Following these planes will allow for a more aesthetic, durable, and repeatable augmentation.

SUMMARY
This article has described the different age groups that present for noninvasive injectable lip and perioral augmentation, as well as the breakdown of 3 subgroups that present within the 4 general age groups. With the fundamental understanding of these presenting groups and subgroups, the practicing augmenter will be able to better treatment plan and educate the patient on realistic and optimal aesthetic outcomes.