Starting With Massage, Expert Offers Tips for Filling Lips

PHOENIX — What's the most important aspect of filler technique for the lips?

Massage, Joseph Niamtu III, D.M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

"When you see someone who comes in from another office and they're unhappy and their lip is all lumpy, that's because there was no massage," said Dr. Niamtu, an oral and maxillofacial surgeon at Virginia Commonwealth University, Richmond.

"I keep a little dollop of Vaseline on the back of my glove that I use in massaging the lip," he explained. "I think it's so important to distribute that filler and make it nice and smooth; otherwise it can get pretty lumpy."

Dr. Niamtu presented a wide-ranging set of clinical pearls regarding facial filler injections. "Fillers are really exciting. They're so popular. And in this down economy, as the use of some procedures has gone down, the fillers and Botox [botulinum toxin type A] have gone up. I tell people if you can decorate a cake or caulk your bathtub, you can do fillers," he said.

Among the clinical pearls Dr. Niamtu discussed were how to effectively use miniblocks for optimal pain control, the value of a 0.9-mm fat-injecting cannula, and how to reverse an overaggressive correction:

▸ Control pain. "There's no doubt about it: If you make this a painless experience, you will overcome your competition," he said. As soon as his patients take a seat, a topical anesthetic is applied to the skin and mucosa, followed by ice to enhance the numbness, and then a series of small dental injections that Dr. Niamtu calls "miniblocks."

He said he dislikes conventional nerve blocks because they cause hours of drooling numbness. Instead, he administers a series of 0.2- or 0.3-cc injections of 2% Xylocaine (lidocaine HCl) with 1:100,000 epinephrine through a 32-gauge needle at four or five sites between the cuspids. These submucosal miniblocks are placed just above the sulcus of the upper lip and just below the sulcus of the lower lip. He also anesthetizes the nasolabial folds, injecting 0.2 cc of local anesthetic solution deep in a couple of places.

After a few minutes the perioral area is well anesthetized. Sensation returns within an hour after the procedure.

▸ Use a 0.9-mm fat-injecting canula. A remarkably atraumatic way to get filler into the lip, the fat-injecting canula glides easily through soft tissue.

"This has really changed my practice," Dr. Niamtu said. "You simply anesthetize the lip and make a puncture with an 18-gauge needle. The canula fits right on the filler syringe. You insert it and inject as you withdraw; I tell the patient we're putting air in the tire. Although it looks painful, it is much less traumatic than [multiple] needle sticks. This has really cut down on my postoperative swelling and bruising. I really like this when I'm doing volume."

▸ Get the right depth in lip injections. The target is the potential space between the mucosa and underlying muscle. "If you're in that potential space, you should have very low syringe pressure with very free flow antegrade and retrograde. If you are not in the correct space—in which case you're usually too superficial—you get blanching, increased syringe pressure, and you don't get the nice flow," he continued.

▸ Don't forget the philtrum. The philtrum and philtral columns are the most overlooked areas of the lip, in Dr. Niamtu's view. The philtral columns can be reconstructed with a conical injection from the alar base down to the vermilion border.

▸ Blunt the nasolabial folds. The most common mistake here is undertreatment. It takes two syringes of filler to get a good result in an adult.

"In this economy people don't want to buy two syringes, they want one syringe. I tell them, 'Save your money and come back,'" he said.

For injection of a fold or wrinkle with a hyaluronic acid filler, the improvement should happen right before the operator's eyes; otherwise the needle isn't in the right place.

"Now, if you're using silicone or Sculptra [poly-L-lactic acid], you will have some growth over time. But it's not going to get better tomorrow when you're using the hyaluronic acid fillers. If you don't see that improvement right away, you're probably too deep," he said.

▸ Reverse overcorrection. "Hyaluronidase is a savior. It's so nice to be able to tell patients you can reverse things they don't like," he explained.

Simply reconstitute the hyaluronidase with local anesthetic and inject it into the area of excess filler. It will dissolve hyaluronic acid filler in 24–48 hours and sometimes faster.

▸ Choose the right filler. Twenty years ago the choice was simple. Today there is a confusing array of fillers available, with yet more in the developmental pipeline.

"Now we're effectively bartenders," Dr. Niamtu observed. "Good injectors can do magic with just about anything."

Dr. Niamtu reported having no financial conflicts of interest regarding his presentation.

Using a 0.9-mm fat-injecting canula instead of a needle is less traumatic; the entire lip can be treated with a single puncture. COURTESY DR. JOSEPH NIAMTU III

'Itell people if you can decorate a cake or caulk your bathroom, you can do fillers.' DR. NIAMTU

PHOENIX — What's the most important aspect of filler technique for the lips?

Massage, Joseph Niamtu III, D.M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

"When you see someone who comes in from another office and they're unhappy and their lip is all lumpy, that's because there was no massage," said Dr. Niamtu, an oral and maxillofacial surgeon at Virginia Commonwealth University, Richmond.

"I keep a little dollop of Vaseline on the back of my glove that I use in massaging the lip," he explained. "I think it's so important to distribute that filler and make it nice and smooth; otherwise it can get pretty lumpy."

Dr. Niamtu presented a wide-ranging set of clinical pearls regarding facial filler injections. "Fillers are really exciting. They're so popular. And in this down economy, as the use of some procedures has gone down, the fillers and Botox [botulinum toxin type A] have gone up. I tell people if you can decorate a cake or caulk your bathtub, you can do fillers," he said.

Among the clinical pearls Dr. Niamtu discussed were how to effectively use miniblocks for optimal pain control, the value of a 0.9-mm fat-injecting cannula, and how to reverse an overaggressive correction:

▸ Control pain. "There's no doubt about it: If you make this a painless experience, you will overcome your competition," he said. As soon as his patients take a seat, a topical anesthetic is applied to the skin and mucosa, followed by ice to enhance the numbness, and then a series of small dental injections that Dr. Niamtu calls "miniblocks."

He said he dislikes conventional nerve blocks because they cause hours of drooling numbness. Instead, he administers a series of 0.2- or 0.3-cc injections of 2% Xylocaine (lidocaine HCl) with 1:100,000 epinephrine through a 32-gauge needle at four or five sites between the cuspids. These submucosal miniblocks are placed just above the sulcus of the upper lip and just below the sulcus of the lower lip. He also anesthetizes the nasolabial folds, injecting 0.2 cc of local anesthetic solution deep in a couple of places.

After a few minutes the perioral area is well anesthetized. Sensation returns within an hour after the procedure.

▸ Use a 0.9-mm fat-injecting canula. A remarkably atraumatic way to get filler into the lip, the fat-injecting canula glides easily through soft tissue.

"This has really changed my practice," Dr. Niamtu said. "You simply anesthetize the lip and make a puncture with an 18-gauge needle. The canula fits right on the filler syringe. You insert it and inject as you withdraw; I tell the patient we're putting air in the tire. Although it looks painful, it is much less traumatic than [multiple] needle sticks. This has really cut down on my postoperative swelling and bruising. I really like this when I'm doing volume."

▸ Get the right depth in lip injections. The target is the potential space between the mucosa and underlying muscle. "If you're in that potential space, you should have very low syringe pressure with very free flow antegrade and retrograde. If you are not in the correct space—in which case you're usually too superficial—you get blanching, increased syringe pressure, and you don't get the nice flow," he continued.

▸ Don't forget the philtrum. The philtrum and philtral columns are the most overlooked areas of the lip, in Dr. Niamtu's view. The philtral columns can be reconstructed with a conical injection from the alar base down to the vermilion border.

▸ Blunt the nasolabial folds. The most common mistake here is undertreatment. It takes two syringes of filler to get a good result in an adult.

"In this economy people don't want to buy two syringes, they want one syringe. I tell them, 'Save your money and come back,'" he said.

For injection of a fold or wrinkle with a hyaluronic acid filler, the improvement should happen right before the operator's eyes; otherwise the needle isn't in the right place.

"Now, if you're using silicone or Sculptra [poly-L-lactic acid], you will have some growth over time. But it's not going to get better tomorrow when you're using the hyaluronic acid fillers. If you don't see that improvement right away, you're probably too deep," he said.

▸ Reverse overcorrection. "Hyaluronidase is a savior. It's so nice to be able to tell patients you can reverse things they don't like," he explained.

Simply reconstitute the hyaluronidase with local anesthetic and inject it into the area of excess filler. It will dissolve hyaluronic acid filler in 24–48 hours and sometimes faster.

▸ Choose the right filler. Twenty years ago the choice was simple. Today there is a confusing array of fillers available, with yet more in the developmental pipeline.

"Now we're effectively bartenders," Dr. Niamtu observed. "Good injectors can do magic with just about anything."

Dr. Niamtu reported having no financial conflicts of interest regarding his presentation.

Using a 0.9-mm fat-injecting canula instead of a needle is less traumatic; the entire lip can be treated with a single puncture. COURTESY DR. JOSEPH NIAMTU III

'Itell people if you can decorate a cake or caulk your bathroom, you can do fillers.' DR. NIAMTU

PHOENIX — What's the most important aspect of filler technique for the lips?

Massage, Joseph Niamtu III, D.M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

"When you see someone who comes in from another office and they're unhappy and their lip is all lumpy, that's because there was no massage," said Dr. Niamtu, an oral and maxillofacial surgeon at Virginia Commonwealth University, Richmond.

"I keep a little dollop of Vaseline on the back of my glove that I use in massaging the lip," he explained. "I think it's so important to distribute that filler and make it nice and smooth; otherwise it can get pretty lumpy."

Dr. Niamtu presented a wide-ranging set of clinical pearls regarding facial filler injections. "Fillers are really exciting. They're so popular. And in this down economy, as the use of some procedures has gone down, the fillers and Botox [botulinum toxin type A] have gone up. I tell people if you can decorate a cake or caulk your bathtub, you can do fillers," he said.

Among the clinical pearls Dr. Niamtu discussed were how to effectively use miniblocks for optimal pain control, the value of a 0.9-mm fat-injecting cannula, and how to reverse an overaggressive correction:

▸ Control pain. "There's no doubt about it: If you make this a painless experience, you will overcome your competition," he said. As soon as his patients take a seat, a topical anesthetic is applied to the skin and mucosa, followed by ice to enhance the numbness, and then a series of small dental injections that Dr. Niamtu calls "miniblocks."

He said he dislikes conventional nerve blocks because they cause hours of drooling numbness. Instead, he administers a series of 0.2- or 0.3-cc injections of 2% Xylocaine (lidocaine HCl) with 1:100,000 epinephrine through a 32-gauge needle at four or five sites between the cuspids. These submucosal miniblocks are placed just above the sulcus of the upper lip and just below the sulcus of the lower lip. He also anesthetizes the nasolabial folds, injecting 0.2 cc of local anesthetic solution deep in a couple of places.

After a few minutes the perioral area is well anesthetized. Sensation returns within an hour after the procedure.

▸ Use a 0.9-mm fat-injecting canula. A remarkably atraumatic way to get filler into the lip, the fat-injecting canula glides easily through soft tissue.

"This has really changed my practice," Dr. Niamtu said. "You simply anesthetize the lip and make a puncture with an 18-gauge needle. The canula fits right on the filler syringe. You insert it and inject as you withdraw; I tell the patient we're putting air in the tire. Although it looks painful, it is much less traumatic than [multiple] needle sticks. This has really cut down on my postoperative swelling and bruising. I really like this when I'm doing volume."

▸ Get the right depth in lip injections. The target is the potential space between the mucosa and underlying muscle. "If you're in that potential space, you should have very low syringe pressure with very free flow antegrade and retrograde. If you are not in the correct space—in which case you're usually too superficial—you get blanching, increased syringe pressure, and you don't get the nice flow," he continued.

▸ Don't forget the philtrum. The philtrum and philtral columns are the most overlooked areas of the lip, in Dr. Niamtu's view. The philtral columns can be reconstructed with a conical injection from the alar base down to the vermilion border.

▸ Blunt the nasolabial folds. The most common mistake here is undertreatment. It takes two syringes of filler to get a good result in an adult.

"In this economy people don't want to buy two syringes, they want one syringe. I tell them, 'Save your money and come back,'" he said.

For injection of a fold or wrinkle with a hyaluronic acid filler, the improvement should happen right before the operator's eyes; otherwise the needle isn't in the right place.

"Now, if you're using silicone or Sculptra [poly-L-lactic acid], you will have some growth over time. But it's not going to get better tomorrow when you're using the hyaluronic acid fillers. If you don't see that improvement right away, you're probably too deep," he said.

▸ Reverse overcorrection. "Hyaluronidase is a savior. It's so nice to be able to tell patients you can reverse things they don't like," he explained.

Simply reconstitute the hyaluronidase with local anesthetic and inject it into the area of excess filler. It will dissolve hyaluronic acid filler in 24–48 hours and sometimes faster.

▸ Choose the right filler. Twenty years ago the choice was simple. Today there is a confusing array of fillers available, with yet more in the developmental pipeline.

"Now we're effectively bartenders," Dr. Niamtu observed. "Good injectors can do magic with just about anything."

Dr. Niamtu reported having no financial conflicts of interest regarding his presentation.

Using a 0.9-mm fat-injecting canula instead of a needle is less traumatic; the entire lip can be treated with a single puncture. COURTESY DR. JOSEPH NIAMTU III

'Itell people if you can decorate a cake or caulk your bathroom, you can do fillers.' DR. NIAMTU