One of the fastest-growing industries in the world is facial aesthetics. Yes, beauty might be in the eye of the beholder, but beholders tend to agree. While beauty may be skin deep, its effects run far deeper.
A long-standing cliché advocates to not judge a book by its cover, but people do judge books by their covers, as well as people by their appearances, especially by their physical attractiveness.
In 1985, Dr Gordon Patzer published the Physical Attractiveness Phenomena, in which he defined these as “the collective realities of physical attractiveness”, which tend to be complex, powerful and pervasive, discomforting and unfair, and despite different notions of physical attractiveness, transcend culture, time and geography. Dr Patzer states that the “components of the face do not contribute equally to the evaluation of physical attractiveness”. There is a hierarchy in that some components are of greater importance. There are five dominant factors, of which all are facial components, and these components in order of priority are the teeth, smile, lips, eyes and nose. The focus of this article will be the lips, including the modification, rejuvenation and correction of symmetry and so much more using the Fotona family of lasers.
A natural approach for lip rejuvenation
As the world population continues to age and our concern with aesthetic appearance increases, more and more clinicians and practitioners are looking for options to offer their patients a natural approach to improving their appearance. When it comes to the lips, age- related changes include loss of volume, perioral wrinkles and fading into the face. When developing a strategy for lip rejuvenation, it is important to understand the anatomy and mechanisms of tissue breakdown. After the age of 25, we lose 1.5% of our collagen synthesis per year. This decrease in collagen production is compounded by an increase in degradation. Matrix metalloproteinases, such as collagenase, are induced by ultraviolet (UV) exposure and factors such as smoking and dietary toxins and are capable of degrading extracellular matrix components. Histologically, this is characterised by irregular and disorganised collagen fibres. These collagen bundles are also more highly cross-linked than is seen in more youthful skin. The ratio of collagen types also changes, having a predominance to Type III collagen with less elasticity. The most dramatic loss of collagen is in the upper third of the der-mis, presumably related to the depth of UV penetration into the skin.1 The lips are significantly more susceptible because of the thin epithelial layer and should be protected.
The traditional indications for using lasers in facial aesthetics include advancing age-related and lifestyle- related loss of facial volume, reduction in elasticity and skin or lip dryness, all of which are caused by loss of collagen. Today, many patients are benefiting from the use of laser therapy to maintain a youthful appearance and prevent facial ageing by stimulating collagen and maintaining collagen formation. Use of lasers in aesthetics includes both ablative (tissue removal) and non-ablative types. In the 2000s, Fotona released the SMOOTH mode protocol, a non-ablative Er:YAG fractional laser pulse modality that results in much shorter recovery times. Fotona’s proprietary SMOOTH mode pulse modality creates no bleeding and allows for precisely controlled deposition of heat into the tissue. The optical/thermal energy is delivered in a unique sub-second-long pulse sequence, which prevents heat build-up on the surface, but achieves homogeneous heating by thermal diffusion down into the lamina propria level of the tissue. The lamina propria layer is where the fibroblasts are the densest and where, through generation of new collagen, collagen and elastin are formed.
Fotona’s LipLase procedure was created to address the rapid increase in demand for restored and or plumper lips. LipLase fulfils this need with minimal downtime, anaesthetics and postoperative discomfort. The result is fuller, smoother lips, collagen synthesis stimulation and remodelling. The patient will see an immediate response, the plumpness increasing as the treatment continues. Of utmost importance is to monitor the tis-sue response to avoid overtreatment.
LipLase goes through three phases, starting with the inflammatory stage, where a series of vascular, cellular and biochemical events occur and water increases in the lips, resulting in an immediate plump as a response to the tissue heat-shock. The extent of lip plumping will be slightly more than the resulting long-term result, so a slight over-plump is suggested. The second phase is a light surface peeling, resulting in the exposure of fresh, younger-appearing tissue. The third phase is the phase in which new collagen is formed.
Expectations and treatment planning
Most of our aesthetic patients have a specific idea of what they want, and because of this, the most successful aesthetic consultations have involved handing the patient a large hand mirror and asking him or her what makes him or her unhappy about his or her facial features. Once the patient has expressed this desire, we review his or her concerns and reconnect the patient with realistic expectations. We use the Merz lip grading protocol to establish the starting point for treatment (Fig. 1) and then we provide the patient with a colour copy of the various lip shape diagrams (Fig. 2) as a point of discussion. Patients desire volume and symmetry or sometimes correction in specific areas and shape change.
Thorough photographic documentation is essential both for treatment planning and for medico-legal documentation of the existing condition before the treatment is started. We also include postoperative photographs at each appointment and then again at the follow-up appointment, 21 days after the last treatment of a series. Knowledge of photography is important in aesthetics, as a cell phone camera is not adequate for facial aesthetics owing to wide-angle distortion. We try to have the photographs up on a large monitor (greater than life-size) during the consultation, as magnified images greatly help the patient scrutinise the images during the discussion.
The hardware necessary to provide this procedure is from the Fotona family of lasers (Dynamis/Spectro family, TimeWalker Fotona4D, LightWalker), employing the proprietary Er:YAG SMOOTH mode pulse modality. There are no other lasers on the market that can re-produce this effect in the same way. These lasers have two different wavelengths built in: Nd:YAG, which is ab-sorbed in pigment and haemoglobin as its main chromophores, and Er:YAG, which has a high absorption in water as its primary chromophore. These two wave-lengths are some of the most researched wavelengths in laser aesthetics. For the LipLase procedure, the handpieces required are the PS03X, PS03 or FS01 (for the Dynamis/Spectro family of aesthetic lasers) or the PS04 (for the LightWalker dental laser). These hand-pieces are patterned or fractional and produce an array of deep microscopic thermal injuries that stimulate more repair and new collagen formation.
The LipLase protocol is initially a restorative treatment that ramps up over the course of treatments. LipLase involves primarily treating the mucosal aspect of the lips intra-orally first to obtain good lip support, then moving out to the dry part of the lip up to and including the ver-million border (Fig. 3). The necessary energy settings are different for the wet and the dry parts of the lip. Patient sensitivity will increase dramatically on the dry part of the lip if it is allowed to desiccate or the plume control evacuation too close. Rehydration with warm saline or water is very important. Using chilled solutions will defeat the focus of the treatment (deep thermal effect).
The handpiece of choice must be kept at a 90° angle with the tissue to enable optimal thermal energy penetration. The mucosal aspect is treated from right to left, with six SMOOTH mode pulses per spot, keeping the hand steady to drive the heat into the tissue (usually no overlap is needed). This is then repeated a total of six times. On the dry part of the lip, the protocol and energy settings drop, and two to four SMOOTH mode bursts per spot and two to four passes are used, based on the patient’s desired volume. The commissures should not be treated. Once a plump has been achieved, we can evaluate the shape and any deficits. Pharmaceutical-grade vitamin E oil or coconut oil should be applied immediately after treatment, but no pigmented lipstick or lip gloss for four days. Lip products of a sufficient Sun Protection Factor should be used afterwards to prevent UV damage. The treatments are on a 21-day cycle, as that is biologically what is needed for the thermal injury and repair cycle.
Clinical experience has shown that patients in their twenties to forties plump faster, but tend to need maintenance after three to four months. In contrast, patients in their fifties to eighties take more time to plump, but the plump will last for more than six months. Maintenance schedules are an important preconsent discussion for treatment, as they are an additional expense. Typical re-treatment is every three to four months to maintain the plump without significant loss and usually involves one treatment. Patients who go over six months may require more than one treatment, as this requires restoration of the plump as opposed to maintenance thereof. Typical results are shown in Figures 4 and 5.
In conclusion, we have found the LipLase procedure to be an effective aesthetic, restorative and corrective procedure. If done correctly and with adequate training, it is a safe procedure for both male and female patients.