April 2019 - Volume 13, Issue 2

Behind a syringe, a decision made



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Dermatologist

Corresponding author:
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
Libya
Email: ebtisamya@yahoo.com

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. DOI: 10.5742MEJN.2019.9363

Abstract


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.

Introduction
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 syndromes (1).

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.

Anatomy
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 Cupid’s 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.

Objective
To minimize the upper lip scar and repair the upper lip left side.

Procedure and treatment strategy
The best approach to lip augmentation depends on the nature of the defect and the subject’s 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 placement.

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 Cupid’s 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 manufacture’s instruction (traumatic scar fractional treatment, hexagonal scanner, 25 W, dwell time 1700 Microsec and a pitch of 700).

Results


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 lady’s upper lip symmetry was restored and had achieved an augmented volume.

This technique had improved the patient’s 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.

Discussion
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.

Hyaluronic 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 Hydro.

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 calls.

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 expert’s 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.

Conclusion
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.

References
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): 139–142.
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: 107–112.
4. Lowe P & Low N. 3D Photography and lip filler: A novel assay. (2007). Journal of Cosmetic and Laser Therapy. 9: 237–240
5. Adrian C Lim. The potpourri approach to hyaluronic acid ller injections. (2010). Australasian Journal of Dermatology. 51, 76–78.
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.

 



 





 



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