A New Approach for Lip Filler Injection Using an Inverted... : Plastic and Reconstructive Surgery – Global Open (2022)

Takeaways

Question: Can microcannula be used to reshape the lips and to accentuate the cupid bow and lip tubercles?

Findings: The proposed technique provides satisfactory results in terms of reshaping the lips and providing a safe injection.

Meaning: The three point technique provides a safe and artistic approach for lip filler injections.

INTRODUCTION

Many people consider pouty and flipped lips to be a sign of a youthful and attractive look.1 That is why many techniques have been advocated for lip augmentation, which may be surgical or nonsurgical. Using hyaluronic acid filler to enhance the lip volume is one of the most requested services in our daily facial aesthetic practice.2,3 The term beautification refers to beautifying the lips with respect to the normal lip proportions, which ideally should be 1:1.6. However, this ratio may change in African and Asian patients.4

Attractive lip shapes are in the eye of their beholder: older women seek rejuvenation to treat the signs of aging by achieving a more youthful and hydrated lip.5 Nowadays millennial patients request what is called “Russian lips” (in other words, the tenting technique), where the filler is placed in a vertical struts injection along the whole lip, violating both lip borders (the vermillion line and the wet/dry border) with a possible risk of vascular occlusion and/or filler spread into the skin side of the lip (ergotrid area), creating a plateau appearance (or mustache appearance), as described by Harris.6 This technique aims at achieving a flat profile with an increase in the vermillion height where the ratio is almost 50/50 upper to lower lip. In the latter technique, the filler is placed with a needle.

Several complications associated with lip fillers have been reported by many clinicians, such as ischemia, tissue necrosis, and visual loss.7–9 Detailed knowledge of anatomy, lip zones, rheological properties of the filler, safe injection techniques, and the use of a microcannula10 and/or duplex ultrasound11,12 may minimize the risk of lip filler complications. The technique described here is my innovative modified approach to achieve a lip eversion, increased vermillion height, and redrawing the cupid’s bow to give a pouty appearance with the use of a largely borne cannula, which carries a lower risk of vascular occlusion and complications, especially those associated with the original Russian lip technique.

MATERIALS AND METHODS

The present study included a sample of 10 White women aged 22–29 years who desired to have a lip filler treatment. Both medical and dental history were taken for all patients, as well as the history of any previous injectables and/or COVID-19 vaccine. Written informed consent was obtained for all patients explaining the full details regarding the procedure along with the side effects and possible complications. Full assessments were performed for the mouth at rest and dynamics, any asymmetry, skin quality, lip ratio, and shape. Less than a syringe of hyaluronic acid filler (Belotero Volume, Merz Company) was used for all the patients, and all injections were performed using a microcannula (SoftFil Paris, France).

All patients were anesthetized using Scandonest plain 3% anesthesia (Mepivacaine Hydrochloride 3% without vasoconstrictor). The anesthesia was injected at five points extra orally, two points at 1 cm from the alar base of the nose bilaterally, one point at the subnasale, and two points opposite to the mental foramen bilaterally. This was followed by the application of betadine on the lips and perioral area.

Two vertical lines were drawn from the ala of the nose down to the inferior border of the chin in addition to another line at the midline of both the upper and lower lip, the two vertical lines from the ala outlines, the borders of the injection process where the filler product must be confined within this area, as shown in Supplemental Video 1 (See Video 1 [online], which displays the outline for the injection technique followed by injection of the upper lip.). Three entry points were chosen for the whole injection procedure resembling an inverted triangle or an inverted Mercedes Benz sign, the upper lip was injected through two entry points that were chosen at each Glogau-Klein (GK) point (the ski slope shape of the lip in the profile as you move from the skin above the lip down onto the pink vermillion). The lower lip, on the other hand, was injected through one entry point right at the midline (Fig. 1). Filler injection for the upper lip was performed in the following fashion: a pilot needle was used to create an opening right at the tip of cupid’s bow (GK point) on the right side of the upper lip, as shown in Supplemental Video 2 (See Video 2 [online], which shows the injection technique for the upper lip.). After creating the opening, a softfil microcannula (22 G 50 mm) was used to enter through the opening in a vertical fashion until it reached slightly behind the wet/dry border. The injection was administered in the form of aliquots (0.1 mm) at this area followed by retrograde injection, leaving a microdroplet at the GK point upon exit. The same maneuver was performed many times until achieving the desired pouty appearance in addition to redirecting the cannula from the same entry point to fill in the sides of the lip. The same steps were applied to the left side of the upper lip. Aliquots were mainly placed in the upper lip tubercles.

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On the other hand, injection of the lower lip was performed in the following manner: a pilot needle was used to create an opening right at the midline of the lower lip at the vermillion border, as shown in Supplemental Video 3 (See Video 3 [online], which shows the injection technique for the lower lip.). Softfil microcannula (22 G 50 mm) was used to enter through this opening, followed by redirecting the cannula to both sides of the lip to volumize the lip in a retrograde injection fashion; aliquots were also placed at the lower lip tubercles.

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(Video) lip fillers " 3 point lips " ( inverted mercedes benz technique ) - Dr. Noury Adel

All injections for the upper and lower lip were performed in a superficial plane as judged by visualization of the shadow of the tip of the cannula through the lip before injection. No injections were performed on either lip border (external and internal), where the internal border is the wet/dry border, and the external border is the vermillion line. For those patients who required definition for the philtrum lines, injections were performed using the same cannula from the same entry point at the upper lip GK point.

RESULTS

Ten patients aged between 22 and 29 years were treated. Of the total patients, 80% reported mild pain at the time of anesthesia injection especially at the subnasale point, with complete comfort after the anesthetic effect started before performing the filler injection. In total, 20% reported comfort through the entire procedure. Some degree of erythema, edema, and bruising was observed in 70% of the patients, which settled down after a couple of days except for the bruising, which lasted up to 1 week in some of the patients. The bruising was only observed at the point of entry at the GK point in the upper lip, where it would be visible on only one side of the lip (the left side or the right side). There were no cases of vascular occlusion or any adverse events as injections were administered with a large-borne softfil cannula and in a safe plane, avoiding the junction of the wet/dry border. There were no cases of filler spread into the ergotrid area, creating a mustache appearance, because no injections were performed at the vermillion border. At the end of the study, 100% of the patients reported a high degree of satisfaction based on a verbal survey and agreed on repeating the whole procedure over again. They also stated that they would recommend the procedure to a friend or relative.

DISCUSSION

Unlike needles, a microcannula provides less risk of vascular occlusion according to anatomical evidence-based research because needles can easily penetrate a blood vessel during injection, where cannulas with blunt ends carry a lower risk.13 However, both small borne cannulas (27 G) and using too much force during the injection may violate a blood vessel with subsequent intraluminal filler placement, causing a vascular occlusion.14

It is of no doubt that using cannulas in lip filler injections provides a degree of safety, as proven in other research.15 However, the conventional technique does not provide much artistry in reshaping the lips; therefore, most clinicians tend to use the needle alone or with a cannula to fulfill this purpose. In my proposed technique, reshaping and defining the cupid’s bow along with accentuating the lip tubercles can be achieved, which offers a degree of artistry.

Moreover, a large number of patients request the Russian lips, where the technique is performed using a needle. The proposed technique could also be a safer alternative due to the use of a large-borne softfil cannula (22 G) with minimal force, in addition to avoiding the junction of the wet/dry border where most of the vessels lie; thus, less risk of vascular occlusion tends to occur. Softfil cannula is different from any other type of cannula in that the internal diameter of the cannula exceeds the outer one; thus the extrusion force is kept to minimal offering a high degree of precision with the injection. In addition to that, the incidence of vessel cannulation is very minimal. In my technique, no injections were performed at the vermillion border, and this eliminates the risk of filler spread, which creates a mustache appearance, as seen in the original Russian technique, which violates the external lip border.6 The zones of injection depend on the need for lip contouring and augmentation, where there are different zones in the lips, as reported by Jacono.16 In this study, all injections were contained within the medial zone of the lip to preserve the natural tapering of the lips as they go on laterally. However, if there is a deficiency in the lateral part of the lips or the patient requests a lateral lip pout, peristomal injections could be applied by extending the injection process beyond the vertical lines drawn from the ala, as proposed in this technique.

CONCLUSIONS

This is a new modified technique for filler injection, unlike the conventional cannula procedure, and this technique may provide a satisfactory result especially for those demanding what is called Russian lips. Further studies with a larger sample size are needed to provide sufficient data about the proposed technique, in addition to considering the use of a cannula with a shorter length than the one used in this technique for better control during the injection procedure.

REFERENCES

1.Wollina U, Goldman A. Lip enhancement and mouth corner lift with fillers and botulinum toxin A. Dermatol Ther. 2020;33:e14231.

  • Cited Here

2.Nikolis A, Bertucci V, Solish N, et al. An objective, quantitative assessment of flexible hyaluronic acid fillers in lip and perioral enhancement. Dermatol Surg. 2021;47:e168–e173.

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3.Votto SS, Read-Fuller A, Reddy L. Lip augmentation. Oral Maxillofac Surg Clin North Am. 2021;33:185–195.

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(Video) I Got Lip Filler Injections For The First Time | Macro Beauty | Refinery29

4.Heidekrueger PI, Juran S, Szpalski C, et al. The current preferred female lip ratio. J Craniomaxillofac Surg. 2017;45:655–660.

5.Wollina U. Perioral rejuvenation: Restoration of attractiveness in aging females by minimally invasive procedures. Clin Interv Aging. 2013;8:1149–1155.

6.Harris S. The Harris classification of filler spread. Prime Journal. 2020

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7.Gupta A, Miller PJ. Management of lip complications. Facial Plast Surg Clin North Am. 2019;27:565–570.

(Video) Lip filler using softfil cannula , inverted mercedes benz technique (3 point lips) - Dr. Noury Adel

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8.Haneke E. Managing complications of fillers: Rare and not-so-rare. J Cutan Aesthet Surg. 2015;8:198–210.

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9.San Miguel Moragas J, Reddy RR, Hernández Alfaro F, et al. Systematic review of “filling” procedures for lip augmentation regarding types of material, outcomes and complications. J Craniomaxillofac Surg. 2015;43:883–906.

10.Blandford AD, Hwang CJ, Young J, et al. Microanatomical location of hyaluronic acid gel following injection of the upper lip vermillion border: comparison of needle and microcannula injection technique. Ophthalmic Plast Reconstr Surg. 2018;34:296–299.

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11.Mlosek RK, Słoboda K, Malinowska S. High frequency ultrasound imaging as a “potential” way of evaluation modality in side effects of lip augmentation—case report. J Cosmet Laser Ther. 2019;21:203–205.

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(Video) Inverted Mercedes Benz lip filler Technique using microcannula ( 3 point lips ) - Dr. Noury Adel

12.Urdiales-Gálvez F, De Cabo-Francés FM, Bové I. Ultrasound patterns of different dermal filler materials used in aesthetics. J Cosmet Dermatol. 2021;20:1541–1548.

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13.Fulton J, Caperton C, Weinkle S, et al. Filler injections with the blunt-tip microcannula. J Drugs Dermatol. 2012;11:1098–1103.

14.Pavicic T, Webb KL, Frank K, et al. Arterial wall penetration forces in needles versus cannulas. Plast Reconstr Surg. 2019;143:504e–512e.

15.Chopra R, Graivier M, Fabi S, et al. A multi-center, open-label, prospective study of cannula injection of small-particle hyaluronic acid plus lidocaine (SPHAL) for lip augmentation. J Drugs Dermatol. 2018;17:10–16.

16.Jacono AA. A new classification of lip zones to customize injectable lip augmentation. Arch Facial Plast Surg. 2008;10:25–9.

(Video) Dr Sebagh Lip Technique with Hyaluronic Acid
Copyright © 2021 The Author. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.

FAQs

What is the newest lip filler? ›

Say hello to Restylane Kysse, the newest FDA approved filler for the lips. This filler enhances lip volume and adds definition to lip contours to create soft, natural-looking lips.

What is the Ashton lip technique? ›

The Ashton Technique has an M shape up top and the more aggressively you pull the top up, the more of a keyhole pout you create. While Russian Lips also have an M shape up top, they, however, have a more defined keyhole. This is created by pulling up as much as possible on the top lip.

What is Glogau Klein point? ›

The portion of the upper lip border that forms a double curve is called the Cupid's bow, named after the ancient Roman god of love. The peaks of the bow, named the Glogau-Klein points, coincide with the philtral columns, the raised vertical ridges that connect the bottom of the nose to the upper lip.

How is Russian lip technique done? ›

The Russian lip technique uses smaller volumes of a dermal filler, placed in more parts of the lips. Instead of injecting into the lips a larger volume of a dermal filler and then massaging and spreading it out, the Russian technique injects more areas of the lips with a lesser volume of product.

What is the most natural looking lip filler? ›

What Lip Fillers Ensure the Natural-Looking Volume and Shape?
  • #1. Juvederm Volbella;
  • #2. Juvederm Ultra XC;
  • #3. Restylane Silk;
  • #4. Restylane Kysse;
  • #5. Radiesse;
  • #6. Bellafill;
  • #7. Belotero Lips Contour;
  • #8. Belotero Lips Shape.

What type of lip filler is best? ›

Juvederm Volbella XC won the 2020 NewBeauty award for the best filler for plumper lips. Volbella XC was designed to add subtle volume to the lips and to smooth vertical lip lines (perioral lines) around the lips. With Juvederm Volbella XC, results last for up to a year.

What are Russian lips? ›

The term “Russian lips” refers to a technique that raises the pink of the top lip higher, whilst the bottom lip drops lower giving a deep 'V' shaped curve toward the chin. This technique tends to lift the lip rather than add volume, giving a flatter appearance from the side. This shape gives a “Russian doll” aesthetic.

What is Russian doll lip filler technique? ›

The process involves placing tiny droplets of filler, injected vertically into the lip, compared to lines of filler underneath the border. This technique widens, lifts, and opens the lip body without any compromise of projection.

What's the difference with Russian lips? ›

The Difference

Unlike traditional lip filler, an injector using the Russian Lip technique injects the product vertically starting at the base of the lip and drawing the product outward toward the lip border. Rather than starting from the lip border and working inward, the injector works the product from the inside out.

What makes lip injections look fake? ›

When the upper lip is equal to or begins to exceed the volume of the lower, the augmentation starts to look fake. Once that ratio is breached, the result degrades rapidly, even with minor volume additions.

What are keyhole lips? ›

One of the injection techniques that patients are looking for is the “Keyhole Lip”. This is where the lips are filled with a small gap in the center of the lips where the top and bottom lip meet that looks like a “keyhole”. This look is also referred to as “the keyhole technique” or “keyhole pout.”

What is a heart shaped lips? ›

Heart-shaped lips typically have a pronounced cupid's bow up top, with a sharper bottom lip. Now, the exact definition might vary from person to person (some may have a stark point at the bottom; others may have a softer edge), but the key here is that V-shaped cupid's bow.

Which lip filler lasts longest? ›

Juvederm and Restylane fillers last longer than other fillers. Juvederm and Restylane are currently the longest-lasting and most durable dermal fillers on the market. Juvederm and Restylane are families of hyaluronic acid fillers with numerous possible formulations.

Do the Kardashians have lip fillers? ›

"A little bit of Botox," Kardashian said while reportedly pointing to her forehead. "But I've chilled, actually." Kardashian said she has no cosmetic filler in her face, and she has "never filled" her lips or cheeks.

Do lips swell more with Russian technique? ›

As there are several injection points with the Russian lip technique, you may find that you have slightly more initial swelling and some bruising after this procedure. This treatment may cause more discomfort than a normal lip filler treatment due to the multiple injection points your injector needs to use.

What happens to your face after years of fillers? ›

As well as stretching of the skin, excessive use of fillers can result in longer term damage including wrinkling of the lip and disturbance of the attachment of the facial fat pads and some degree of irregularity and ageing of the skin, he explains.

Which filler makes you look younger? ›

Fillers like Juvéderm, Restylane®, and Belotero Balance® can help transform the eye area for a younger, rejuvenated look. Cheek volume is another popular area that clients want to target with fillers. With age, the cheeks can become hollow in appearance or look flat due to a decrease in collagen production.

How can you tell if someone has lip fillers? ›

How to tell if someone has had lip filler injections? - YouTube

What lip fillers do Kardashians use? ›

There are a plethora of fillers on the market that are perfect for restoring volume loss, it just depends on how much volume or plump you want to add. Kylie prefers Juvederm, a brand of filler that's owned by Allergan. While there are different types of Juvederm fillers, Kylie's team goes for Juvederm Ultra Plus.

Which lip filler lasts the longest 2021? ›

While the lifespan of dermal fillers can vary considerably between patients, depending on the product, your lifestyle and unique metabolism, Juvederm is the longest-lasting temporary lip filler with results visible for up to a year. Restylane comes in at a close second, with results lasting between 6-10 months.

What is the difference between lip injections and lip fillers? ›

Lip injections are the procedures done to help plump the lips. Lip fillers are the product that is used to inject into the lip to do the plumping.

What is the best 2021 lip filler? ›

Juvéderm Ultra is one of the most popular Hyaluronic Acid fillers in the industry, considered to be the gold standard of lip filler. It creates gorgeous volume and structure in the lips, while also maintaining a soft and natural feeling.

Which lip filler lasts the longest 2021? ›

While the lifespan of dermal fillers can vary considerably between patients, depending on the product, your lifestyle and unique metabolism, Juvederm is the longest-lasting temporary lip filler with results visible for up to a year. Restylane comes in at a close second, with results lasting between 6-10 months.

Which lip fillers last the longest? ›

Juvederm and Restylane fillers last longer than other fillers. Juvederm and Restylane are currently the longest-lasting and most durable dermal fillers on the market. Juvederm and Restylane are families of hyaluronic acid fillers with numerous possible formulations.

What kind of lip fillers do the Kardashians use? ›

There are a plethora of fillers on the market that are perfect for restoring volume loss, it just depends on how much volume or plump you want to add. Kylie prefers Juvederm, a brand of filler that's owned by Allergan. While there are different types of Juvederm fillers, Kylie's team goes for Juvederm Ultra Plus.

What is the best filler for upper lip wrinkles? ›

One of the most common choices for minimizing the appearance of vertical lip lines is an hyaluronic acid (HA) filler, like Juvederm or Restylane. Hyaluronic acid is a natural part of your skin's connective tissue.

How much should I tip for lip fillers? ›

Tipping standards in the cosmetic and beauty industry are subjective. A general tipping etiquette is anywhere from 10% to 20%, but this standard is by no means universal.

What is the thickest lip filler? ›

Voluma contains the thickest, strongest gel—ideal for deep injection into the cheek area to get a nice lift and volume boost. Volbella contains the thinnest, most spreadable gel—perfect to fill fine lip lines or even smooth the delicate area under the eyes.

Why does Juvederm not last in my lips? ›

Answer: Lip Filler Not Lasting

In smokers the fillers don't tend to last as long either. You can either try adding more filler, or switching to a bulkier filler such as Juvederm Ultra Plus or Voluma. Make sure you are seeing an experienced injector.

Can your body reject lip filler? ›

While side effects are extremely rare, there is a small change of having an allergic reacting to the hyaluronic acid fillers. Since this is natural component of your body, the chances are rare. Bruising and temporary swelling may happen in the days immediately after filler.

Why did my lip filler go away so fast? ›

Your metabolism determines how long your lip filler will last. The same bodily mechanism that regulates how quickly you metabolize calories determines how fast your filler will break down. In short: if you have a fast metabolism, your lip filler will likely break down more quickly.

What happens to your lips when you stop getting fillers? ›

Botox lip injections work by relaxing the muscles in the upper lip area so they'll curl upward to achieve a plump look. When the treatment is stopped, the effects of Botox fade away and the muscles return to their normal state which can lose your pout and cause lip wrinkles and fine lines to slowly reappear.

What is Russian lips filler? ›

Unlike traditional lip filler, an injector employing the Russian Lip technique injects the product vertically starting at the base of the lip and drawing the product outward toward the lip border. Rather than starting from the lip border and working inward, the injector works the product from the inside out.

Do lips go back to normal after fillers? ›

Lip fillers are temporary

The experts at Body+Beauty Lab can let you know how long to expect results to last during your initial treatment. When the treatment is dissolved, patients will notice their lips return to their normal appearance.

What procedure did Kylie Jenner have on her lips? ›

Kylie Jenner revealed she first got lip fillers after feeling insecure about her lips as a teen. According to the makeup mogul, a comment from one of her first kisses led her to get fillers.

Do lip fillers go saggy? ›

There is a very common misconception that dermal fillers can make skin sag, however we can safely say that this is FALSE. People assume that once they have been fully absorbed by your body you will be left with loose, hanging skin leaving you looking even older than you did previously.

Is there a difference between lip injections and lip fillers? ›

Lip injections are the procedures done to help plump the lips. Lip fillers are the product that is used to inject into the lip to do the plumping.

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