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Perioral rejuvenation is a central point in our aesthetic practices,” says Joel L. Cohen, MD. Demand for treatment is high, but there is often a disconnect between what the patient thinks they want and the dermatologist’s approach for optimal outcomes.

“Patients think about bigger lips,” Dr. Cohen says. This leads them into the office seeking filler injections into the lips. In reality, he insists, “We really need to think about combination therapy.” The best approach will include fillers, but not limited to the lips. Additionally, devices play an important role.

Dr. Cohen says that to make the lips appear more pronounced, he injects fillers in the cheek, “to roll back and soften the nasolabial folds.” Increasingly, the approach to injecting reduces the amount of filler in the nasolabial folds, “but still building up the oral commissure.”


Get more. Watch Dr. Joel L. Cohen, Director of AboutSkin Dermatology and DermSurgery in Englewood and Lone Tree, CO, discuss perioral rejuvenation at Cosmetic Surgery Forum 2015 in Las Vegas.

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In his practice, Dr. Cohen says, “Resurfacing has made a significant resurgence.” This helps reduce lines and wrinkles around the lips. Ablative approaches offer the most significant improvement. “If you can get people to do downtime of 10 days or two weeks, then the fully ablative modalities, such as fully ablative erbium, can work really well.”

Increasingly, Dr. Cohen says, he is employing neuromodulators before fillers and devices. “Predosing with neuromodulator beforehand leads to less mechanical action, less contraction, and less imprinting of those lines around the lips,” he observes.

A recent study has provided good evidence for the combined use of neuromodulators and fillers in order to prolong the filler effect. According to a study published in the January issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS), longevity of hyaluronic acid-based dermal fillers is affected not only by the properties of the HA fillers, but also by forces applied to them—including contraction of neighboring muscles. For a more objective demonstration of this approach, researchers designed a study in rabbits in which a small amount of HA filler was injected under the skin in front of each ear. This area was chosen because it corresponds to the forehead region in humans—a common area for dermal filler treatment.


Speakers from Cosmetic Surgery Forum 2015 share pearls and talk about their favorite moments from the meeting in Las Vegas last December.

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On one side, HA filler alone was used. On the other side, HA filler was combined with BoNT-A to paralyze the muscle in that area. After three months, MRI scans were performed to compare the amount of filler remaining on the two sides.

The follow-up scans confirmed that BoNT-A slowed degradation of the injected filler. At three months, chemodenervation with BoNT-A decreased the degradation rate of the HA fillers by 42 percent. At the same time, the remaining volume of HA filler was 50 percent greater on the side where BoNT-A was used.

Dr. Cohen also notes thatthere is research to suggest that neuromodulation may affect specific cytokines and chemokines. “This is happening through a biologic pathway, as well,” he says.

As with any cosmetic intervention, perioral rejuvenation should be accompanied by good skincare. Topial retinoids, including in advance of lip procedures, help to resurface the area and reduce wrinkles. “Post-procedure, growth factor products may be synergistic with healing. Preparation of the skin is important and support for recovery are really very important for these procedures.”

Combinations Rule the Day

The best approach to lip augmentation takes a holistic view of the face and employs multiple synergistic modalities, according to Dr. Cohen. As he says, “We’ve really had a lot of new developments and a lot of new data on combinations to give our patients better results, in particular around the mouth—as well as around the eyes.” n

Cosmetic Surgery Forum will be held November 30-December 3 in Las Vegas. For more information, visit

Another Perspective

CSF Faculty Member Hema Sundaram, MD recently spoke to Modern Aesthetics® magazine about lip rejuvenation. Here’s what she had to say. Read more at

“The important thing to realize for natural-looking lip augmentation—especially for patients beyond their early 30s or so who’ve lost some facial volume due to aging is that it’s at least as much about restoring lip support as injecting the lips themselves. Often the lip support is the important part, because loss of this support is the cause of thinning lips, and injecting instead into the lips themselves can produce that notorious, unnatural-looking “duck lip” effect due to addressing the effects of what is seen rather than the cause.

In my teaching, I define immediate and peripheral perioral frames to which volume should be restored for most effective lip rejuvenation. The peripheral perioral frame extends as far out as the skin just in front of the ears, and down to the base of the chin. For lip injection, the aim is for the lips to be soft and the filler completely undetectable. I like Belotero Balance® for its scientific properties (low elasticity or G’ and low viscosity) that make it soft and easily spreadable. It doesn’t tend to swell too much after injection. For immediate lip support just below, above, and around the lips, I like Belotero Balance® or Restylane® Silk injected as a superficial thin sheet parallel to the red border of the lips, just below the skin. This is good also for the “bar code” also known as the vertical lip lines that are sometimes called “smoker’s lines.” For surrounding lip support, I like Juvederm® Ultra Plus, Restylane® or Restylane® Lyft, Radiesse® or Juvederm® Voluma, injected deeply into the fat layer below the skin. The choice of filler depends on the quality of the patient’s skin and on the desired amount of ‘lift’ or tissue re-volumization. I avoid very firm products in thinner skin as they may cause lumps and bumps.”

Hema Sundaram, MD | Dermatologist | Fairfax, VA and Rockville, MD

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