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Perioral Rejuvenation and LipAugmentationM. Jafer Ali, MDa, Kevin Ende, MDa,b, Corey S. Maas, MDa,b,*

Perioral facial aging

The process of facial aging generally consists ofintrinsic and extrinsic processes. Intrinsically, themost significant changes occur in the dermis wherethe ground substance, predominantly consisting ofglycosaminoglycans and proteoglycans, decreases.The ratio of type I to type III collagen diminishesand elastic fibers, which maintain the pattern of col-lagen bundles, become thin and fragmented, result-ing in an overall reduction in the total amount ofcollagen. In addition to aging, external processessuch as actinic damage may accelerate this decline.

The decreased laxity of the skin, along with habit-ual repeated contraction of the underlying facialmuscles, result in wrinkles or rhytids. In general,the aging process of the face is a process of atrophy.

The lips are the foundation on which the remain-der of the perioral region is centered. In the modernaesthetic, full lips provide a youthful healthyappearance. A key external anatomic feature of thelips is the Cupid’s bow complex of the upper lip,

formed by two high points of the vermillion joinedat a V-shaped depression centrally. The lower lip hasno such depression. Lying between the cutaneousand red lip is the white roll which refers to theraised line of skin that separates these structures.

Most of the lip bulk is the orbicularis muscle.This muscle is separated from the vermillion andcutaneous portions of the lip with a fascial layer.In the upper lip, the orbicularis muscle fibers de-cussate and insert into the contralateral philtralridge. The lip commissures represent a complex ar-ray of lip elevators and depressors and the buccina-tor muscles.

The aging process of the lips begins with a prolif-erative phase from birth to pubescence, representedby glandular and muscular hypertrophy resulting infull, youthful appearing lips. After puberty, gradualatrophy of the structures occurs that is influencedby the aging process of not only the skin but alsosupporting structures such as the teeth, muscle,and bone. Visually, the aging lip is characterizedby a decrease in vermillion show, blunting of the

F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am 15 (2007) 491–500

a Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco MedicalCenter, 400 Parnassus, Box 0342, San Francisco, CA 94143, USAb The Maas Clinic for Facial Plastic and Aesthetic Surgery, 2400 Clay Street, San Francisco, CA 94115, USA* Corresponding author.E-mail address: [email protected] (C.S. Maas).

- Perioral facial agingSoft tissue augmentation

- Biologically active injectables: Botox- Autologous fat injection- Collagen fillers- Hyaluronic acid fillers

RestylanePerlane

CaptiqueHyalaform and Hyalaform PlusClinical use of hyaluronic acid products

in the perioral region- Calcium hydroxylapatite (Radiesse)

Surgical rejuvenationAblative resurfacing

- References

491

1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2007.08.008facialplastic.theclinics.com


Cupid’s bow, and an attenuated white roll [1]. Therepetitive activity of the circular orbicularis muscleitself can also lead to vertical rhytids of the upperand lower lips. These rhytids have been referred toas smoker’s lines because they are often accentuatedin smokers.

Over time, marionette lines may also form. Mar-ionette lines are characterized by vertical lines at theoral commissures, resulting in an expression of sad-ness. They are the result of muscle hyperactivity; inthis case, the depressor angularis oris muscle. Thedepressor angularis oris muscle finds its origin atthe oblique line of the mandible, lateral and infe-rior to the depressor labii inferioris muscle, wheresome of its fibers also join the platysma muscle.The muscle then fuses with fibers from the risoriusand orbicularis oris muscle at the oral commissures,forming what is called the modiolus. In the agingface, contraction of this muscle over time may causethese vertical rhytids, resulting in a sad expression.Extrinsic factors such as actinic damage and smok-ing may accentuate these lines.

Two additional signs of aging are seen in the areaof the mentum, including the mentalis crease andpeau d’orange. The mentalis muscle finds its originat the incisor fossa and extends vertically and medi-ally to fuse with the orbicularis oris. Its action is toevert the lower lip. The repetitive action of this mus-cle over time can lead to a transverse rhytid which isknown as a mentalis crease, which gives an expres-sion of doubt. Peau d’orange, the French term mean-ing orange skin, describes a condition of dimplingrhytids on the chin resulting from visible attach-ments of the superficial musculoaponeurotic sys-tem (SMAS) with the mentalis muscle, seenthrough aging thin skin [2].

Finally, one of the more telltale signs of the agingface is the increasingly deep nasolabial folds thatare formed by the malar fat overlying the complexof the orbicularis oris, levator labii superioris, andzygomaticus major muscles. Muscular activity andptosis of skin and the SMAS contribute to their rel-ative severity and depth.

Soft tissue augmentation

Modern soft tissue augmentation dates back to thelate 19th century when Neuber [3] first used autol-ogous fat to correct depressed facial defects in pa-tients who had tuberculous osteitis. In the early1900s, injectable paraffin gained popularity untilforeign body granuloma was found to often bethe result. Refined injectable silicone was intro-duced by Dow Corning in 1962 and initially hailedas an ideal dermal implant, with excellent cosmeticresults and high use potential. However, severecomplications resulting from high-volume injec-tions eventually lead to the U.S. Food and Drug

Administration (FDA) ban of direct liquid siliconeinjections [4].

Recent decades have seen an exponential increasein filler technologies. Injectable bovine collagenwas developed in the 1970s and approved by theFDA in 1981; it has remained the industry criterionstandard. With the emergence of liposuction in thelate 1970s came a resurgence in interest in fat asa convenient source for tissue augmentation. Fur-ther research has lead to a myriad of fillers andbiologically active agents that make up the currentavailable enhancement products, including Botox,collagen, hyaluronic acid (HA) derivatives, and cal-cium hydroxylapatite [4].

Biologically active injectables: Botox

Botulinum toxin A, a protein produced by the bac-terium Clostridium botulinum, is a neurotoxin thatinterferes with muscle contraction by inhibitingthe release of the neurotransmitter acetylcholineat axon terminals. The history of botulinum toxinA, or Botox, is more than 30 years old. It has beenused in the treatment of strabismus, cervical dysto-nia, hemifacial spasm, and, more recently, migraineheadache and hyperhidrosis [4].

In 2002, Allergan earned FDA marketing clear-ance for Botox Cosmetic for treating glabellar rhy-tids, and dermatologists and cosmetic surgeonsalike have since found numerous other applica-tions. In the perioral region, the use of Botox is lim-ited partly because of the potential for paralysisnear the oral cavity and the associated functionalproblems. Nevertheless, depressed corners of themouth are one problem that can be correctedwith Botox through relaxing the depressor angularisoris. This relaxation results in the unopposed actionof the zygomaticus major and minor muscles, lead-ing to favorable elevation of the commissures intoa position that is no longer turned down and sad-appearing [4].

Injection focuses on a position along the jawlineinferior and slightly lateral to the oral commissure.Injecting too medially or aggressively confers therisk for affecting parts of the depressor labii muscle,which may cause a poor aesthetic (asymmetric ele-vation of the lateral lip) and potentially unfavor-able functional outcome. Perioral rhytids may beeffectively improved using conservative doses ofbotulinum toxin; however, best results are achievedusing a combination of Botox (four to five units inupper lip and lower lip, respectively). The injectionsare placed at the vermillion, with emphasis onsymmetry. The authors prefer Cosmoderm 1 forfine-line filling to avoid tracts seen with deeperfillers and the blue-line ‘‘Tindle effect.’’

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Similar principles apply to the correction of thementum. Again, injection of the mentalis muscleshould be directed near its origin at the mentumto prevent inadvertent paralysis of the more superi-orly based depressor labii muscle and unfavorableaesthetic and functional sequelae. This peau d’or-ange appearance is generally treated with five toeight units placed in two or three central injectionsites.

Autologous fat injection

Neuber’s initial attempt at using autologous fat asfiller was found to be unpredictable at best. Spo-radic attempts over the next several decades didnot show fat to be a particularly reliable filler; thatis, until the 1970s when liposuction was popular-ized and large amounts of adipose tissue were avail-able. The technique of microlipoinjection was thenpopularized. Microlipoinjection involved using thetumescent technique for fat harvest from the legs,buttocks, hips, or abdomen then purifying the fatcells from serosanguineous debris. A large-boreneedle was then used to inject fat into the subcuta-neous areas that needed enhanced volume. Over-correction of 30% to 50% was advised because ofthe anticipated reabsorption; multiple injectionswere often required to obtain a desirable result [4].

Lipocytic dermal augmentation was introducedin 1989 and involves the harvest, lysis, and purifica-tion of injectable fibrous tissue from oily residue,which is discarded. This filtrate has been shown tohave similar longevity to collagen fillers such as zy-plast. Slight overcorrection with anticipation of re-absorption is recommended [4].

Biopsies of injected tissues suggest that the mech-anism of action of this kind of filler is in stimulatingan inflammatory response that is later replaced withfibrotic tissue. No adipocytes were found in biopsysamples [4].

In the perioral region, fat injection may be bene-ficial for correcting nasolabial and melolabial foldsand lips. However, its limited longevity and irregu-lar surface contours have restricted its use in thesemobile areas.

Collagen fillers

The role of soft tissue fillers is to restore facial vol-ume. Collagen has been used for more than 2 de-cades and was one of the first fillers used in theaesthetic setting. Initial laboratory research effortsin the late 1950s led to the discovery that minormolecular modifications of collagen moleculescould decrease their antigenicity, paving the wayfor clinical use. This development ultimately led

to the first FDA-approved collagen filler in 1981:Zyderm [5].

The current FDA-approved bovine collagen deriv-atives are Zyderm I, Zyderm II, and Zyplast. ZydermI is a 3.5% bovine collagen with 0.3% lidocaine. Ithas been used to treat superficial skin lines. In theperioral region, Zyderm I is commonly used forlines around the upper lip. Zyderm II is similar,but has a higher collagen concentration at 6.5%,making it thicker.

Zyplast is similar to Zyderm I, but has the addi-tional feature of a 0.0075% glutaraldehyde additivethat cross-links the collagen fibers, making it lessaccessible to breakdown by collagenase. Zyplast,like Zyderm II, is often used in deeper lines suchas the nasolabial fold and vermillion border ofthe lip to emphasize the white roll. The require-ment for skin testing has reduced the market shareof these products, especially with the advent ofCosmoderm and HA fillers.

Alternatives to the bovine collagen fillers weredeveloped more recently that use bioengineeredhuman collagen. These fillers are known as Cosmo-Derm I, CosmoDerm II, and CosmoPlast andmirror their bovine counterparts in composition.CosmoDerm I is a 3.5% collagen mixture, Cosmo-Derm II is a 6.5% solution, and CosmoPlast hasthe glutaraldehyde additive that allows the cross-linking seen with Zyplast. All of these productsalso contain 0.3% lidocaine. The major advantageto these products over their bovine counterparts isthat, because of their human origin, allergy testingis not necessary for patients before injection [6].

Collagen is often applied using a layering-typetechnique in conjunction with other products. Be-cause collagen products are typically premixedwith lidocaine, a topical anesthetic is usually suffi-cient for anesthesia. If other products are used inconjunction with the collagen product, using thecollagen/lidocaine mixture first for anesthesia iswise. The collagen and lidocaine may also help de-crease bruising.

Collagen is often used to enhance the lips. Injec-tions are typically given in the vertical vermillionborder and the white roll. The white roll is an acces-sible place to inject because it is essentially a poten-tial space. After adequate local anesthesia is applied,injection is performed with a 30-gauge needle. Thespace is entered laterally and injection is performedslowly. Because of the potential space medially, theneedle does not need to be advanced initially. Slowinjection allows the collagen to flow mediallythrough the potential space. Occasionally, particu-larly in patients who have actinic damage or scar-ring, a disruption of this ‘‘natural tunnel’’ mayoccur. In these cases, the needle is removed and re-inserted in the white roll just medial to the area in

Perioral Rejuvenation and Lip Augmentation 493


which resistance was encountered. Injections aretypically performed in this manner in four quad-rants, approaching laterally in the upper and lowerlip. If the lip is to be further treated with otherfillers, such as HA, the collagen can be used as a sup-porting framework. After the collagen injection,some of the vertical lines at the commissures, ormarionette lines, may in fact dissipate because ofthe increased volume at the lip borders. These linesmay be further treated with a combination of Botoxand a collagen filler such as CosmoDerm [6].

Injection of the nasolabial fold can actually beconsidered correction of two separate issues. Thedepth of the fold itself is caused by volume loss,whereas the overlying skin creases are rhytidsfrom the muscular contractions of smiling. Volumeis best corrected with a cross-linked collagen filleror alternative. The improvement in volume, how-ever, does not help to dissipate the rhytids; theseshould be addressed separately. For these types ofsuperficial rhytids, CosmoDerm can again be usedand injected directly into the area [6].

Hyaluronic acid fillers

First isolated more than 70 years ago, HA is a highlyhydrophilic glycosaminoglycan polymer that is nat-urally occurring. Common sources for HA purifica-tion include rooster combs, umbilical cord, vitreoushumor, tendons, skin, and bacterial cultures. An av-erage-sized human is composed of approximately15 g of HA, which is found mostly in the extracellu-lar matrix of connective tissue and serves as theground substance of dermis, fascia, and other tis-sues. An estimated one third of the human body’sHA is turned over daily. The naturally occurringmolecule is easily broken down by the enzyme hy-aluronidase. Therefore, chemical modificationthrough cross-linking these molecules is necessaryto produce an effective filler. Cross-linking providesincreased surface area and, therefore, decreased sur-face area for degradation to take place [4].

The hydrophilic nature of HA is the key to its clin-ical usefulness; 1 g of HA can bind 6 L of water. Thisfeature allows for its unique ability to maintain thehydration of the intracellular matrix in which cellsare organized and thereby maintain tissue volumeand support for surrounding tissues. HA is alsounique because it is not species- or tissue-specific,giving it essentially no antigenic specificity. There-fore, it has a very low risk for allergic response inclinical use. The HA products currently availablevary in the source through which they are purifiedand, more importantly, the size of the molecules.This property, in particular, gives each product itsunique characteristics. HA products have been

characterized as the ‘‘cement’’ that hold the collagen‘‘bricks’’ together [7,8].

Restylane

Restylane was introduced in 1996 as the first non-animal stabilized HA. Restylane is derived fromthe fermentation of Streptococcus species. Themolecules are cross-linked by the addition of 1,4-butanediol diglycidyl ether. Restylane has an HAconcentration of 20 mg/mL with a particle size of400 mm, making it somewhat more viscous thansome of its animal-derived counterparts. In 2003,it was approved by the FDA for correction of mod-erate to severe facial wrinkles and folds [7].

No skin tests are required before using Restylane,and a commercially available hyaluronidase may beused to dissolve the HA if necessary. Adverse out-comes have been reported in approximately 5% ofpatients, including bruising, swelling, bumpiness,asymmetry, and erythema. Restylane is typicallyinjected with a 30-gauge needle that is distributedin prepackaged form [7].

Perlane

Perlane is essentially identical to Restylane in itscomposition and manufacture. The major differ-ence between the products is that, although Resty-lane contains an average of 100,000 gel beads permilliliter, Perlane contains only 8000 because it isthicker material. As a result, Perlane has a signifi-cantly decreased surface area and, therefore, is lessdisposed to breakdown by hyaluronidase. This fea-ture may account for the anecdotal reports ofincreased longevity of this product, although thishas not been confirmed [7].

Because of its increased size, a 27-gauge needle isrequired for injection, which may cause increasedpatient discomfort. It is designed for correctingdeeper cutaneous depressions and folds and for fa-cial contouring. It may also be used in lip augmen-tation in conjunction with Restylane, which may bemore appropriate for vermillion borders to providedefinition [7].

Captique

Captique is another bacterial biofermented HAproduct that was approved in 2004 by the FDAfor correction of moderate to severe wrinkle aroundthe nose and mouth. It has an intermediate concen-tration between Restylane and Hyalaform, makingit a more flexible product to use [7].

Hyalaform and Hyalaform Plus

Hyalaform and Hyalaform Plus are HA productspurified from rooster combs then cross-linkedchemically by divinyl sulfone. Both are clear gelsand, like other HA products, have essentially no

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antigenicity. They have been used with favorable re-sults to correct facial wrinkles, folds, and grooves,and as lip volumizer, and are stable up to 4 months.

Hyalaform Plus is similar to Hyalaform except fora larger particle size requiring a 27-gauge needle forinjection [7].

Clinical use of hyaluronic acid productsin the perioral region

With the multiple filler products available, it ishelpful to have a sense of which product shouldbe used in which situation. For example, Hyalaformand Captique may be used for natural-appearingcorrection of nasolabial folds or to increase lip vol-ume filling, but are generally not recommended be-cause of their short duration of effect. Less viscouscollagen agents, such as Zyplast or Cosmoderm,may be more appropriate for the superficial dermis.Layering of superficial and deep fillers may yield thebest result. Furthermore, unlike collagen injectionsthat lose volume over just a few weeks, HA productsare hygroscopic and may increase correction 10% to15% after injection [7].

Nasolabial foldsIf using only HA products for correcting nasolabialfolds, a combination of deep injections of Perlaneand superficial layering with Restylane may be

adequate. Deep furrows can also be treated withHyalaform Plus or Captique. Alternatively, Hyala-form layered with superficial Captique or Captiquealone are alternatives [7].

In any case, serial puncture or linear threadingtechniques can be used. It is important to stretchand compress skin to visualize fold, and to injectmedial to the fold to avoid further cheek ptosis.The needle should be beveled up and injected dur-ing withdrawal to decrease the risk for intravascularinjection.

LipsWhen injecting the lips with HA fillers, physiciansmust consider the three injectable components:(1) vermillion border or white roll, (2) wet–dryjunction of the red lip, and (3) dental arcade thatprovides volume throughout the mucosa to the su-perior lip. As a rule of thumb, the upper lip shouldbe approximately 75% to 80% the volume of thelower lip and the central lower lip should protrudeslightly beyond the upper lip.

Restylane or various collagen products can be in-jected into the vermillion border to emphasize con-tour of lip and white roll. Various HA products,such as Perlane, may be used for the mucosa ofthe lips. It is injected into the submucosa to defineshape and restore lost volume of lip mucosa.

Fig. 1. Preoperative view (left). Postoperative view 13 months after subnasal lip lift (right). The red:white lip ratiohas been improved. The vertical red lip height is increased, and the vermillion border is undisturbed.



Patients should be forewarned that all HA productsmay result in nodule formation. Lip injections canalso be painful and perioral nerve block shouldbe strongly considered before treatment.

Marionette lines and vertical rhytidsAlthough some physicians use HA products such asRestylane and Perlane for vertical lip rhytids, the au-thors prefer to avoid the risks by using CosmoDermor some combination therapy using Botox. Mario-nette lines may also be corrected with HA productsthrough serial puncture. The corner of the mouthshould be elevated during injection to raise saggingtissue. Filling these lines involves injecting an HAproduct into the rhytid and medial triangle fromthe lateral lower lip skin and vermillion to the mod-iolus. Care should be taken not to inject too super-ficially, which may result in persistent beading.Most side effects are minor and transient, includingpain and mild bruising. If the material is injectedintravascularly, tissue necrosis may occur [7].

HA products may also be used in numerous othercorrective applications in the perioral region, in-cluding the mentalis crease, and for depressed scars.

Calcium hydroxylapatite (Radiesse)

Radiesse is currently approved by the FDA for thecorrection of moderate to severe facial wrinkles

Fig. 2. Lip lift: intraoperative view. A bullhorn- or sea-gull-shaped excision was performed on one third ofthe cutaneous upper lip. This pattern closely resem-bles the vermillion lip border.

Fig. 3. Intraoperative view of lip lift procedure (right). Elevation has been performed over the orbicularis muscle.Excised portion of cutaneous upper lip (left).

Ali et al496


and folds and for HIV-associated lipoatrophy. It iscomposed of a suspension of calcium hydroxylapa-tite (CaHA) in sodium carboxymethylcellulose,glycerin, and water. The CaHA microspheres areidentical in chemical composition to those foundin bone and teeth. It is biocompatible and degradednaturally by the body’s immune system by phagocy-tosis [9].

Radiesse is supplied in ready-to-use 1.3-mL and0.3-mL syringes and a 27-gauge needle. A nice fea-ture of this product is that it has a long 3-yearshelf-life if the package remains unopened. It doesnot require refrigeration [9].

After Radiesse is injected into human tissues,the carrier component degrades within 6 months.However, the CaHA microspheres remain and serveas a scaffolding for collagen deposition. Therefore,Radiesse is considered a long-term correction [9].

Injection of Radiesse is performed in the immedi-ate subdermis. If injected more superficially, theproduct may be visible and result in nodularity ofthe skin. Deeper injections require more productfor the desired effect and may increase inadvertentinjection intravascularly.

Correction is performed by first obtainingadequate anesthesia. Regional blocks and topicalanesthetic are preferable to injection to limit theamount of distortion in the treated area. Injectionis performed using a fanning technique in a cross-hatch pattern during withdrawal of the syringe.Overcorrection is not necessary with this product,with the final result proportionate to postinjectionresults. Immediately after injection, Radiesse is mal-leable for a short period in which it can be moldedand sculpted as necessary.

In the injection of nasolabial folds, typically 0.6to 1.0 mL are required per side. The injection is per-formed in a fanning motion axially while slowly

increasing the angle. Injection is subdermal only.Residual superficial lines must be addressed withother fillers, such as intradermal Radiesse.

Oral commissures can be addressed successfullywith Radiesse. A similar axial fanning motion isused in these wrinkles. A cross-hatched patterncan be used just below the level of the vermillionto restore volume and lift the commissures. Mario-nette lines are more challenging to address withRadiesse alone and typically require more of a com-bination approach using an intradermal filler formore superficial lines.

Surgical rejuvenation

Injectable fillers are often inappropriately used inisolation to increase the vertical height of the ver-million. Providers must understand that volumeenhancement not only increases the vertical heightof the lip vermillion but also increases lip volumecircumferentially. Attempts to significantly increasevertical lip height with fillers alone project the lipproportionally in the anterior plan and result inthe now often seen ‘‘duck lip.’’

Fig. 4. Subnasal lip lift: immediate postoperativeview. The single layer suture line falls within thealar grooves bilaterally and along the nasal sill.

Fig. 5. Deep perioral rhytids (top). Postprocedureview 8 months after perioral chemical resurfacingwith Baker’s phenol solution (bottom).



Fig. 6. Mild perioral rhytids (left). Postprocedure view 8 months after perioral chemical resurfacing with Litton’ssolution (right).

Fig. 7. Deep perioral rhytids (left). Postprocedure view 7 months after perioral chemical resurfacing with phenol(right).

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Surgical options are available for improving thered:white lip ratio with or without the use of inject-able fillers. Among these are direct vermillion ad-vancement, V-Y advancement, and the subnasallip lift.

Direct vermillion advancement has been widelyused and reported. The procedure improves verticallip height but attenuates the lip roll and results ina typically white scar along the red:white lip border.The authors do not use this procedure in cosmeticpatients. The V-Y advancement procedure uses bilat-eral intraoral incisions. Some authors have reportedsuccess with this procedure; however, in the au-thors’ experience, results are unpredictable.

The subnasal lip lift, which is the authors’ strongpreference, provides predictable increase in the ver-tical height of the red lip, preserves the delicateanatomy at the lip border, and improves the red:-white lip ratio in a predictable fashion (Fig. 1).

The procedure may be performed under local an-esthesia. The marked incision begins at the alarcrease and traverses the vestibule of the nose withinthe nasal sill following the subcolumellar–lip bor-der bilaterally. With proper judgment, one thirdto one half of the lip skin is excised in this bullhornshape (Figs. 2 and 3). The wounds are closed withsimple interrupted 5 or 6-0 nylon or Prolene su-tures. One or two subcutaneous sutures may be

used to reduce tension. No muscle is excised andhemostasis should be meticulous (Fig. 4).

In the authors’ experience, this procedure is suit-able for all age ranges, but patients must accepttransient scar redness and upper dental show fora period of weeks during recovery.

Ablative resurfacing

Ablative resurfacing is defined as wounding the skinto levels of the dermis. The tools available to do thisinclude peeling agents, dermabrasion, and variouslaser treatments. During the healing process, thedermis produces smoother, firmer, rejuvenatedskin.

Several peeling agents are available and their useis largely dictated by the depth of penetration de-sired. For example, 88% phenol alone may beused for medium-depth resurfacing, and is themain ingredient of Baker-Gordon peeling solution.Alternatively, Jessner’s solution in combinationwith 35% trichloroacetic acid creates a maximum-depth peel while maintaining a good safety profile.Treatment of the perioral area with peel solutionsrequires special attention to the transition area be-tween the facial skin and the lip, which is often in-adequately peeled. Treatment of this area isfacilitated by stretching out the vermillion borders

Fig. 8. Moderate perioral rhytids (left). Postprocedure view 1 month after perioral chemical resurfacing withphenol (right).



and flattening them to provide even distributionover vertical rhytids along the lip (Figs. 5–8) [9].

Dermabrasion is another ablative resurfacingtechnique, which mechanically removes the epider-mis and dermis, usually with a diamond-poweredfraise. It is ideally performed in the operatingroom because of exposure. During the procedure,one must remember that entering the subcutaneousplane must always be avoided [9].

More recently, laser technology has allowed abla-tive resurfacing to be performed in a more controlledfashion. The carbon dioxide laser is most commonlyused. Protective eyewear and fire precautions mustbe strictly adhered to when using this modality.Lasers use thermal energy to dermabrade the skin,and therefore cautery is an added benefit [9].

References

[1] Maloney BP. Aesthetic surgery of the lip. In:Papel ID, editor. Facial plastic and reconstructive

surgery. 2nd edition. New York: Thieme MedicalPublishers; 2002. p. 344–52.

[2] Loos BM, Maas CS. Relevant anatomy for botuli-num toxin facial rejuvenation. Facial Plast SurgClin North Am 2003;11(4):439–44.

[3] Neuber F. Fat translation. Chir Kongr VerhandlDsch Gesellch Chir 1893;20:66–8.

[4] Monhian N, Ahn MS, Maas CS. Injectable andimplantable materials for facial wrinkles. In:Ira D. Papel, editor. Facial plastic and reconstruc-tive surgery. 2nd edition. New York: Thieme Med-ical Publishers; 2002. p. 247–61.

[5] Klein A. Filling substances: collagen. In:Narins R, editor. Cosmetic surgery: an interdisci-plinary approach. New York: Marcel Dekker;2001. p. 193–210.

[6] Rostan E. Collagen fillers. Facial Plast Surg ClinNorth Am 2007;15(1):55–62.

[7] Monheit GD. Hyaluronic acid filler. Facial PlastSurg Clin North Am 2007;15(1):77–84.

[8] Ahn MS. Calcium hydroxylapatite: Radiesse. FacialPlast Surg Clin North Am 2007;15(1):85–90.

[9] Roy D. Ablative facial resurfacing. Dermatol Clin2005;23:549–59.

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