- Volume 13, Issue 2
Behind a syringe, a decision made
Dr Elghblawi Ebtisam
(MBBCH, MScRes, ADD-Dip. Derm, DRH, PGDip dermatoscope)
Dermatology OP Clinic, Private practice
Published author in a field related to dermatology
Tripoli (+21) 91 320 1315
Received: January 2019; Accepted: February 2019; Published:
April 1, 2019
Citation: Ebtisam Elfgblawi. Behind a syringe, a decision
made. Middle East Journal of Nursing 2019; 13(2): 35-38.
The lips and the eyes boost facial beauty, and with
the lip as the focal center of the lower face, both
have been highlighted since ancient times. The face
depicts a sculpture and a voluptuous lip is often portrayed
as a symbol of youth, associated with sex appeal and
romance. A young lady in her mid thirties presented
with asymmetrical upper lips with a vertical scar on
the left side.
Lip contouring with defining
and a fractional laser were proposed and the gained
results were aesthetically appealing and pleasing.
Lip augmentation is a common
aesthetic treatment, well tolerated and it combines
a medical treatment with an element of artistry and
the results are visible immediately after the procedure.
Key words: Fractional laser, hyaluronic acid
(HA), lip repair, surgical lip, augmentation, cosmetic,
Injection technique, needles.
The lip region is an extremely important area when it comes
to facial aesthetic enhancement. Both eyes and lips are considered
to be the two most beautiful
sections of both genders faces.
The lady was born with a cleft lip,
and sought a non-invasive correction. She had no other complaints.
Cleft lip is a congenital anomaly that mandates correction
at a younger age. Cleft lip can be isolated or part of multiple
The patient presented seeking an
aesthetic correction for her upper lip scar post multiple
cleft lip surgical corrections. On examination, the left side
was nearly abolished with no cupid and no philtrum, but a
visible linear scar extended from the left upper vermilion
to the left nasal ala (figure 1-a). Also she has asymmetry
at columella and that should be sorted by the ENT practitioner
surgically and is not within the scope of this paper.
The first proposal was fractional
laser to mitigate and improve the vertical scar tissue texture,
and then followed after a month by a temporary filler injection
to attenuate it.
She signed informed consent for the filler and serial photography
to assess the changes and discussed the best option for the
patients specific goals for treatment corrections.
Lip augmentation is practiced with
increasing frequency by cosmetic practitioners using a variety
of different filling substances. In this case, Stylage M was
proposed and injected on the left affected side.
The upper lip starts from the bottom of the nose to the nasolabial
folds laterally and to the free edge of the vermilion border
inferiorly. The lower lip extends from the superior free vermilion
edge, to the oral commissures laterally, and to the mandible
inferiorly. Around the vermilion, a fine pale line of skin
emphasizes the color difference between the vermilion and
normal skin. Along the upper vermilion, two paramedian vertical
columns of tissue outline the Cupids bow and two raised
perpendicular lines of issue form a midline depression called
the philtrum dimple1.
Lips reach their peak fullness at
14 years and become plumper and blossom with fullness. And
they appear redder as capillaries appear through the translucent
lip tissues. The ideal proportion for lips is a 40/60% ratio
between the upper and lower lip.
To minimize the upper lip scar and repair the upper lip left
Procedure and treatment strategy
The best approach to lip augmentation depends on the nature
of the defect and the subjects aesthetic desires. However
for pure cosmetic enhancement of lips, the injection technique
adopted was superficially placed filler with emphasis on the
white roll (vermilion border) and expansion of the vermilion
is ideal. This will redefine the vermilion border and give
the frame for the final result.
The injection was carried out and
administered in retrograde linear fashion with a small injection
volume gently and slowly with a 30-gauge needle that packed
with the HA, aiming to achieve a 100% correction of the lip
line and contour with no over-correction and to achieve the
most natural-looking lips. This was then massaged for optimal
Topical anesthesia was administered
before the injection with eutectic mixture of lidocaine and
prilocaine (EMLA 5%).
The patient had increased lip volume on the left side, with
lip line definition, and improved Cupids bow areas (Figures
1-b). The total volume augment was measured as an increased
volume of 1 cc.
Two modalities of fraxal lasers were
employed; namely, 1- Co2 fractional laser and 2-Asclepion
MultiPulse laser. The first laser was Co2 fractional laser
with the scan mode setting for a surgical scar, and then after
a month, the second fractional laser followed by applying
the Asclepion MultiPulse laser. This was done due to logistical
issues. The ascelepion employed setting was as by the manufactures
instruction (traumatic scar fractional treatment, hexagonal
scanner, 25 W, dwell time 1700 Microsec and a pitch of 700).
A satisfying esthetically pleasing result was instantly examined
as the lip contour with lip definition was constructed on
the left side, and the patient was content with the results
achieved and examined. The ladys
upper lip symmetry was restored and had achieved an augmented
technique had improved the patients body image, self-esteem,
self perception, and boosted her confidence and her quality
of life. The image can be appreciated for that change. There
was no localized lip swelling post the injection procedure
as the patient came for a follow up.
One should always bear in mind that the less is more
principle is the key, and should comprehend that the application
of llers is both an art and a science and it is critical after
all. Poor technique can result in dissatisfaction and complications.
acid (HA) dermal llers have been used extensively in recent
years for facial soft tissue augmentation including lip augmentation
due to their longevity and low immunogenic potential. Some
HA is believed to be strongly hydrophilic, where it attracts
and binds water and thus incurs swelling. HA is stabilized
through the cross-linkage which makes it more resistant to
enzymatic degradation, thus increasing its life span within
tissues. Moreover, it stimulates collagen synthesis (2).
Stylage vivacy is a French product and it comes in a wide
range of products including stylage S, stylage M, stylage
L, stylage XL, stylage XXL, stylage special lips, and stylage
Each of the stylage products was
designed to meet the needs of their indication and to allow
the best tissue integration, by keeping the same ideal concentration
of HA (20 -24 mg/ml) with varying the degree of cross-linking
and the gel calibration. Also mannital was added as an antioxidant.
There has been an actual immediate
volume augmentation with lip definition which the lady appreciated
immediately. Sequential photography had been taken on the
follow up to track the changes and possibly for a touch-up
injection which can be used as well to trace up the persistence
of volume and of augmentation over a time period in the future.
However in this lady no touch-up was received. The lady returned
to her social engagements on the same day. There is an artistic
and aesthetic significance of the injection to accomplish
an appropriate satisfying result.
Regarding the degree of cross-linking
and gel calibration, both parameters play an important role
in the efficacy and tolerability prole of HA ller with its
longevity and stability (2). Larger-sized gel pieces can generate
enhanced volume (3).
The lady is well informed and aware that the HA is a temporary
treatment and might last 6 to 12 months and she will require
retreatment to maintain the achieved enhancement. She is a
displaced lady from the East of Libya and due to the war zone;
she never came back for any further follow ups despite the
It has been documented that different
HA fillers show various degrees of immediate swelling which
is undesirable by many patients and which is usually a subjective
phenomena (4). In this case the product was well-tolerated
and there were no documented side effects, no pain, no redness,
no pruritus, no bruise, no haematoma, no nodule and no swelling.
This can be attributed to the hydroscopic nature of some hyaluronic
acid filler brands such the Juvéderm and some have
claimed as well, Restylane for such features (3). However
from my own practice, observation and experience, Restylane
was safe and no side effects like swelling were noticed in
my injected cases.
There is a fractional lling technique which can be employed,
whereby injections of relatively smaller amounts of ller product
until the desired level of ller correction are reached (3).
Volume restoration can be achieved naturally and progressively
over a period of time through fractional lling as opposed
to large volume correction in the one sitting which is well
received and tolerated by some patients who demand a lip augmentation
(5). However some favour the large volume instant corrections
at one go. On the other hand, some advocated fractional filling
would prolong ller longevity but this is debated debate and
remains speculative (4). All of which has neither clinical
basis nor clinical relevance, just imperative from experience
as an experts experience.For patients who have undergone
numerous corrective surgeries, this approach is a novel and
less invasive method to recuperate their cosmetic concerns.
The only possible disadvantages are the swelling and bruises
which could happen within the
next few days, however in this case such a thing does not
happen due to the technique adopted.
In this case the level of subjective
appreciation of the achieved aesthetic improvement was actually
high and bearing in consideration the achieved natural lip
look and feel which would mean that HA can be the most efficient
and safest solution for such cases with no down time (6).
In this paper I reported a satisfactory,
a harmonious, an attractive, and a successful handling with
injected temporary HA in a young lady with one side Lip Asymmetry
after multiple surgical corrections of her cleft lip.
Lips are considered to be a sensual attractive sign of a face.
It is understandable that a person can feel self-conscious
if a feature of the face is out of proportion and disfigured.
My lady was an aesthetically sensitive
person and disliked her lip appearance. I presented hereby
a case of surgical lip deformity that was corrected with Fractional
laser with HA fillers injection. She was feeling much happier
and less embarrassed, less bothered and less self conscious
about her lip appearance.
After all, simple measures can have
a huge satisfying impact on patients. Scientific innovations
and advances in aesthetic can easily be explored and incorporated
to make little changes with great impact and outcomes.
To conclude, searching the existing
literature only yielded two different case reports by Schweiger
et al 2008 and Stolic et al. 2015. To the best of my knowledge,
such a case has never been reported in the Libyan dermatological
literature. Therefore, this is the first reported case from
Libya to be added to the existing literature that has been
corrected by the use of injectable HA.
The artful and judicious application
of dermal fillers to this lady lip was appreciated. In fact,
the lady was happy about the achieved and accomplished results
and I hope her corrected lips will be sustaining the best
results for a longer period.
Consent, for the publication of this
case report and any additional related information, was taken
from the patient involved in the study.
1. Schweiger ES, Riddle CC, Tonkovic-Capin V, Aires DJ. (2008).
Successful treatment with injected hyaluronic acid in a patient
with lip asymmetry after surgical correction of cleft lip.
Dermatol Surg. 34(5):717-9. 3.
2. Luthra A. Shaping Lips with Fillers. (2015). J Cutan Aesthet
Surg. 8(3): 139142.
3. Rzany B, Bayerl C, Bodokh I, Boineau D, Dirschka T, Queille-Roussel
C, Sebastian M, Sommer B, Poncet M, Guennoun M, and Podda
M. (2011). Efcacy and safety of a new hyaluronic acid dermal
ller in the treatment of moderate nasolabial folds: 6-month
interim results of a randomized, evaluator-blinded, intra-individual
comparison study. Journal of Cosmetic and Laser Therapy. 13:
4. Lowe P & Low N. 3D Photography and lip filler: A novel
assay. (2007). Journal of Cosmetic and Laser Therapy. 9: 237240
5. Adrian C Lim. The potpourri approach to hyaluronic acid
ller injections. (2010). Australasian Journal of Dermatology.
6. Stolic D, Jankovic M, Draskovic M, Georgiev S, Stolic M.
The Surgical Lips Deformity Corrected with Hyaluronic Fillers:
A Case Report. (2015). Open Access Maced J Med Sci. 3(3):423-5.