Perioral Rhytides Research Articles

Fractional Carbon Dioxide Laser for Treatment of Microstomia and Rhytids in Systemic Sclerosis Patients.

Systemic sclerosis (SSc) is an autoimmune disorder characterised by skin fibrosis leading to skin tightening and disfigurement. However, there is no definite treatment for SSc and its skin complications. Fractional carbon dioxide laser has been widely used for different cutaneous pathologies. This study aims to evaluate the benefits of CO2 laser resurfacing on microstomia and peri-oral rhytids in systemic sclerosis patients. 33 systemic sclerosis patients were enrolled. Four sessions of CO2 laser treatment were performed at an interval of four weeks. Patients were evaluated monthly. The interincisal distance (IID) measurement was used to evaluate maximal mouth opening capacity, and the mouth handicap in systemic sclerosis (MHISS) scale was used to assess the improvement after treatment. All of the participants were female with a mean age of 47.46 and a standard deviation of 7.11. The mean disease duration was 12.35. The mean total core of the MHISS scale was 25.24, and the mean IID was 48.11 millimetres before the treatment with CO2 laser. The MHISS score decreased, and patient satisfaction increased after treatment. However, observed differences in the results of IID were not statistically significant. In conclusion, it seems that the fractional carbon dioxide laser is effective in the improvement of perioral rhytids, patient satisfaction based on the MHISS score, and mouth disability in SSc patients.

Prospective Evaluation of the Safety and Efficacy of Thermomechanical Fractional Injury for Perioral Rhytides.

Perioral rhytides can be treated with laser and energy-based devices. More recently, a novel fractional thermomechanical skin rejuvenation system was developed to cause controlled thermal injury through direct heat transfer. A prospective clinical trial evaluated the safety and efficacy of a thermomechanical fractional injury device (Tixel 2, Novoxel, Netanya, Israel) for perioral rhytides. Subjects with moderate-to-severe perioral rhytides were enrolled and underwent 4 monthly treatments. Twenty-three subjects were enrolled and completed all study visits. Mean age was 62.5 years, and 100.0% were women. Fitzpatrick Skin Types I-IV were included. For Fitzpatrick Wrinkle Classification System (FWCS), mean baseline score was 6.9. Per investigator, there was a mean 1.9-grade improvement in FWCS at 3-month follow-up ( p < .0001). At 3-month follow-up, 8.7% (n = 2) of subjects had a 3-grade improvement, 69.6% (n = 16) had a 2-grade improvement, and 21.7% (n = 5) had a 1-grade improvement. For physician Global Aesthetics Improvement Scale at 3-month follow-up, 69.6% (n = 16) had 76% to 100% improvement, 13.0% (n = 3) had 51% to 75% improvement, and 17.4% (n = 4) had 26% to 50% improvement. There were no severe adverse events, and subjects experienced minimal pain. A novel device using thermomechanical fractional injury was demonstrated to be safe and effective in the treatment of perioral rhytides.

Incisional Release and Fat Grafting for the Surgical Management of Perioral Fibrosis in Scleroderma: A Technical Report and Institutional Review.

Scleroderma (systemic sclerosis [SSc]) is a rare autoimmune, connective tissue disorder. Perioral fibrosis is a local cutaneous complication, negatively impacting functional capabilities and aesthetic satisfaction. Fat grafting has been postulated to aid in the management of SSc fibrosis thanks to stem cell enrichment. This technique's success has been demonstrated using different graft origin sites and different injection targets. We aim to demonstrate our SSc patients' success using abdominal fat and perioral target. We queried our records for patients with preexisting SSc who underwent incisional release and fat grafting for perioral fibrosis from 2018 to 2021. For perioral release, a semisharp cannula was tunneled under the vermilion border into the vermilion and along the skin. For grafting, cannulas were used to infiltrate the fat with a retrograde filling technique in a radial-fanning manner. Their autoimmune diagnosis, anesthetic risk assessment, systemic disease complications, and degree of presenting symptoms were reviewed along with their postoperative outcomes. From 2018 to 2021, 16 patients diagnosed with SSc were treated with incisional release and fat grafting for the management of perioral fibrosis. Of the SSc patients, 8 presented with limited SSc, and 8 presented with diffuse SSc. The mean patient age was 54.31 years. All SSc patients presented with functional symptoms with the most common concern (n = 9) being "decreased mouth opening." Other common complaints were "difficulty eating" (n = 3) or "difficulty drinking" (n = 2). Some patients (n = 11) also presented with cosmetic concerns with "perioral rhytids" being the most common (n = 6). The mean number of systemic complications, at the time of presentation, was 3.06. The mean anesthetic risk assessment was 2.44. The average amount of fat grafted intraoperatively was 14.89 mL. Two patients with SSc required regrafting. For one patient, this was part of the original treatment plan and for the other due to fat resorption. Patients who followed up reported improved functionality and were pleased aesthetically. Patients with perioral fibrosis due to SSc can benefit from autologous fat grafting. Incisional release in combination with fat grafting can enhance procedure outcomes. This technique provides beneficial functional and aesthetic outcomes. Patients with both diffuse and limited disease are appropriate candidates for this procedure.

Cosmetic Treatment Using Botulinum Toxin in the Oral and Maxillofacial Area: A Narrative Review of Esthetic Techniques.

Botulinum toxin (BoNT) is an anaerobic rod-shaped-neurotoxin produced by Clostridium botulinum, that has both therapeutic and lethal applications. BoNT injection is the most popular cosmetic procedure worldwide with various applications. Patients with dynamic wrinkles in areas such as the glabella, forehead, peri-orbital lines, nasal rhytides, and perioral rhytides are indicated. Excessive contraction of muscles or hyperactivity of specific muscles such as bulky masseters, cobble stone chins, gummy smiles, asymmetric smiles, and depressed mouth corners can achieve esthetic results by targeting the precise muscles. Patients with hypertrophic submandibular glands and parotid glands can also benefit esthetically. There are several FDA-approved BoNTs (obabotuli-numtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, letibotulinumtoxinA, prabotulinumtox-inA, daxibotulinumtoxinA, rimbotulinumtoxinB) and novel BoNTs on the market. This paper is a narrative review of the consensus statements of expert practitioners and various literature on the injection points and techniques, highlighting both the Asian and Caucasian population separately. This paper can serve as a practical illustrative guide and reference for optimal, safe injection areas and effective doses for application of BoNT in the face and oral and maxillofacial area. The history of BoNT indications, contraindications, and complications, and the merits of ultrasonography (US)-assisted injections are also discussed.

Patient Comfort, Safety, and Effectiveness of Resilient Hyaluronic Acid Fillers Formulated With Different Local Anesthetics.

Maximizing patient comfort during hyaluronic acid gel injection is a common concern that is usually addressed by selecting fillers with lidocaine. Two randomized, double-blinded, split-face trials aimed to demonstrate noninferiority of specific hyaluronic acid fillers incorporating mepivacaine (RHA-M) versus their lidocaine controls, at providing pain relief. Thirty subjects per trial received injections of RHA R -M versus RHA R , and RHA4-M versus RHA4, respectively, in the perioral rhytids (PR) and nasolabial folds (NLF). Pain was assessed on a visual analog scale; aesthetic effectiveness was evaluated with validated scales, and safety was monitored based on common treatment responses (CTRs) and adverse events (AEs). RHA-M fillers proved as effective as their lidocaine counterparts at reducing pain (noninferior, p < .0002 and p < .0001). Bilateral wrinkle improvement was measured both in the PR (-1.5 ± 0.6 points on each side) and in the NLF (-1.8 ± 0.6 and -1.9 ± 0.5 points) trials at one month, with virtually identical responder rates (≥96.7%). Common treatment responses and AEs were similar between treated sides, and none was clinically significant. Resilient hyaluronic acid fillers with either mepivacaine or lidocaine are equally effective at reducing pain during treatment and equally performant and safe for correction of dynamic facial wrinkles and folds.

Perioral Rejuvenation in Aesthetics: Review and Debate

Perioral rhytides are a common reason for presentation to the cosmetic dermatologist. Various treatment options exist, and it can be challenging to determine the optimal technique to use in a given patient encounter. We herein provide a review article highlighting various treatment options in the correction of perioral rhytides, focusing on the roles of neurotoxin, filler, microneedling (with and without radiofrequency), fractional resurfacing (nonablative and ablative), and fully ablative lasers, with a brief mention of deep chemical peels. For each modality, we review the evidence behind the specific technique, its advantages and disadvantages, post-procedural effects, expected downtime, as well as the onset and duration of desired effects. Despite longstanding debate regarding the "best" modality to use, we instead propose that the best approach is a combination approach which takes into account he patient's treatment goals while staying consistent with the expected amount of downtime. Importantly, we share clinical pearls based on the senior authors direct patient experience as Director of Laser and Cosmetic Dermatology at University of California, San Diego (UCSD).

Efficacy and Safety of a New Resilient Hyaluronic Acid Filler in the Correction of Moderate-to-Severe Dynamic Perioral Rhytides: A 52-Week Prospective, Multicenter, Controlled, Randomized, Evaluator-Blinded Study.

The perioral region is highly mobile and subject to multifactorial changes during aging. Resilient Hyaluronic Acid Redensity (RHAR), an RHA filler, was developed with the aim of optimizing outcomes in dynamic facial areas. This randomized, blinded, multicenter clinical study aimed to demonstrate superiority of RHAR over no-treatment control for correction of moderate-to-severe dynamic perioral rhytides. Blinded live evaluator assessments of efficacy included improvement in perioral rhytides severity using a proprietary scale (Perioral Rhytids Severity Rating Scale [PR-SRS]) and the Global Aesthetic Improvement Scale. Subjects self-assessed their results with FACE-Q, a validated patient-reported outcome measure, and satisfaction scales. Safety was monitored throughout the study based on common treatment responses (CTRs) and adverse events (AEs). The primary efficacy end point was achieved, with the treatment group showing statistically significant superiority over the control group at Week 8 (80.7% vs 7.8% responder rate by PR-SRS, p < .0001). Most patients (66%) were still responders at Week 52 (study completion). Most AEs were CTRs after perioral injection of a dermal filler, and none was a clinically significant treatment-related AE. Resilient Hyaluronic Acid Redensity is effective and safe for the correction of dynamic perioral rhytides in all Fitzpatrick phototypes, with marked durability.

Role of botulinum toxin A in improving facial erythema and skin quality

Botulinum toxin A (BTX-A) injections have become the most popular noninvasive cosmetic procedures performed worldwide. With growing interest, investigators continue to uncover an expanding array of aesthetic indications for BTX-A. Botulinum toxin A has been used off-label in the management of masseter hypertrophy for facial slimming, platysmal bands, nasal 'bunny' lines, perioral rhytides, gummy smile and scars, to name a few. Interestingly, the injection of multiple microdroplets of dilute BTX-A into the dermis, sometimes referred to as 'microbotox', has been investigated as a tool for facial rejuvenation. A handful of prospective studies and case series have demonstrated the benefit of BTX-A in the treatment of facial erythema and improving skin texture. The aim of this review is to summarize and appraise currently available data on the role of BTX-A in treating facial erythema and skin quality, with a special focus on potential pathophysiologic mechanisms.

A Randomized, Controlled, Evaluator-Blinded, Multi-Center Study of Hyaluronic Acid Filler Effectiveness and Safety in Lip Fullness Augmentation.

HARK was recently approved in the US for lip augmentation and correction of upper perioral rhytids. To demonstrate noninferiority of HARK versus a control (HAJV) in lip fullness augmentation at Week 8 after last injection (blinded evaluation). Secondary objectives were to evaluate the effectiveness and safety of HARK in lip fullness augmentation and correction of upper perioral rhytids. Treatment with HARK or control (randomized 2:1) was administered on Day 1 in this 48-week, evaluator-blinded study with optional touch-up at Week 4. Primary endpoint was change from baseline to Week 8 in lip fullness. Secondary endpoints included lip fullness, wrinkle severity, aesthetic improvement, subject satisfaction, adverse events, and local tolerability (subject diary entries). The primary objective was met; HARK was noninferior to control in lip fullness augmentation at Week 8. Lip fullness and wrinkle severity improvement persisted at Week 48, and was accompanied by high aesthetic improvement and subject satisfaction scores. The mean volume of HARK injected was approximately 20% lower than control. Treatment-related adverse events and local tolerability symptoms were predominantly mild and transient. HARK was noninferior to control in lip fullness augmentation at Week 8, well-tolerated, and effective throughout this 48-week study.

16510 A randomized, controlled, evaluator-blinded, multicenter study to evaluate the effectiveness and safety of HArk versus a control in the augmentation of soft tissue fullness of the lip

Purpose: To evaluate the effectiveness and safety of a new hyaluronic acid product, HArk, in lip augmentation and correction of upper perioral rhytids. The primary objective was to demonstrate non-inferiority of HArk versus a control (HAjvob) in lip augmentation 8 weeks after last injection (blinded evaluation). Design: In this 48-week, randomized, controlled, evaluator-blinded multicenter study (NCT03320824), treatment with HArk or control (randomized 2:1) was administered on day 1, with optional touch-up offered 4 weeks after initial injection.

A Randomized, Blinded, Prospective Clinical Study Comparing Small-Particle Versus Cohesive Polydensified Matrix Hyaluronic Acid Fillers for the Treatment of Perioral Rhytids.

Perioral rhytids are a bothersome sign of aging for many patients. Although multiple treatments exist, choosing an optimal modality may be difficult considering that rhytids in this region are fine and the anatomy dynamic. The authors sought to compare the efficacy and safety as well as patient satisfaction of a small-particle hyaluronic acid filler with 0.3% lidocaine (SP-HAL, Restylane Silk) and cohesive polydensified matrix hyaluronic acid filler (CPM-HA, Belotero Balance) in reducing superficial perioral rhytids. The study was double-blinded, and 48 patients with moderate to severe superficial perioral rhytids were enrolled. Patients were randomized to receive either CPM-HA in the left perioral region and SPHAL in the right or vice versa. Rhytid severity was measured by patients utilizing a linear analog scale, and by investigators utilizing a validated 5-point scale, for 180 days following treatment. Both SP-HAL and CPM-HA achieved a reduction in rhytid severity, and neither treatment group returned to baseline after 180 days. Investigator-reported scores for rhytid severity were significantly better for SP-HAL than CPM-HA and remained so at 180 days (P < .05). SP-HAL also proved significantly better for reducing rhytids according to patient scores, although this difference occurred between 120 and 180 days only. Adverse events included rash and mild acne for CPM-HA, and SP-HAL was associated with 1 postinflammatory nodule and 2 occurrences of Tyndall effect. Although both SP-HAL and CPM-HA are effective at reducing perioral rhytid severity and have similar safety profiles, SP-HAL possesses a longer duration of effect.

Long-Term Assessment of Perioral Rhytide Correction with Erbium: YAG Laser Resurfacing.

Use of nonsurgical skin rejuvenation has grown over the past two decades. This has led to an increase in ablative and nonablative resurfacing devices. Moderate to heavy perioral rhytides require an ablative laser to maximize results. Traditionally, this was performed with carbon dioxide lasers; however, more recently, erbium lasers have been used to target heavy rhytides. The purpose of this study was to assess long-term correction of perioral rhytides with the use of the senior author's (A.J.B.) erbium laser resurfacing technique. A retrospective review of all patients who underwent perioral erbium laser resurfacing performed by the senior author from 2009 to 2016 with a minimum of 6-month follow-up was performed. Ten blinded nonphysicians and 10 blinded plastic surgeons evaluated the imaging based on a previously established standardized grading sheet, with gradation improvement from 1 to 8. The absolute and percentage improvement were evaluated, along with complications. Forty-five patients met inclusion criteria, with an average follow-up of 13 months. A statistically significant score improvement of 2.2 gradations was seen, in addition to a significant improvement (from 56 percent to 66 percent). Both the surgeon and nonphysician groups showed improvement, with no differences between the two groups. There were no cases of hypopigmentation at the 6-month postoperative visit. Erbium laser resurfacing is a powerful and safe tool for correcting perioral rhytides. It is effective in isolation or with other facial rejuvenation procedures. Erbium laser resurfacing is a useful adjunct in facial rejuvenation that can deliver exceptional results with few complications when performed within the proper guidelines. Therapeutic, IV.

Assessment of the Impact of Perioral Rejuvenation With Hyaluronic Acid Filler on Projected First Impressions and Mood Perceptions.

Small-particle hyaluronic acid filler is approved for lip augmentation and correction of perioral rhytides. Treatment with this product may improve facial aesthetics, projected first impression, and self-perception of mood. To determine the effect of perioral rejuvenation with hyaluronic acid on patient perception of mood and projected first impression. Seventeen subjects underwent perioral rejuvenation treatment with small-particle hyaluronic acid filler. Each subject underwent photography and completed 2 surveys measuring self-perception of mood before treatment and after achieving an optimal cosmetic result. Aesthetic improvement with treatment was assessed using the Global Aesthetic Improvement Scale and the Oral Commissure Severity and Perioral Line Severity scales. Seventeen hundred blinded evaluators rated pre-treatment and post-treatment photographs of the subjects using a First Impressions Questionnaire. Perioral filler treatment significantly improved pre-treatment and post-treatment scores for happiness within the Happiness Measures Scale. This treatment was found to significantly improve projected first impression across all categories. Small-particle hyaluronic acid filler treatment for perioral rejuvenation is an effective method for improving physical appearance as well as first impressions. Larger studies are necessary to verify whether perioral rejuvenation with hyaluronic acid offers enhanced self-perception of mood.

Segmental phenol–Croton oil chemical peels for treatment of periorbital or perioral rhytides

Rejuvenation of deep rhytides of the perioral and periorbital areas often requires ablative laser devices, which can be cost prohibitive and might not deliver definitive results.

Sex Differences in Perioral Rhytides—Does Facial Hair Play a Role?

Sex Differences in Perioral Rhytides—Does Facial Hair Play a Role?

Evaluation Effectiveness of the Voltaic Arc Dermabrasion in Perioral Rhytides Eradication.

Perioral rhytides affect more than 90% of women, the impact of these problems on the patient's self-esteem can become important enough to affect quality of life in psychological and sociocultural terms. Basic science shows that skin rhytides are related to loss in quantity and function of dermal collagen fibers. An electrosurgical technology was used in this study for treatment of perioral rhytides. The authors treated 34 patients (26 women and 8 men) for perioral rhytides with voltaic arc dermabrasion technique. Patient ages ranged between 30 and 65 years and the majority (90%) of these perioral areas had class II and III wrinkle scores. Voltaic arc dermabrasion was used to remove the keratinized layer for point perioral area. Treatments are minimally painful and in the authors' experience require no anesthesia. No discomfort should be expected once the voltaic arc dermabrasion treatment is concluded. The perioral dermis appears as a pale, erythematous, dull surface. Bleeding is not seen unless excessive abrading occurs with the saline-moistened gauze. No hyperpigmentation, hypopigmentation, erythema, ecchymosis, pain, itching, outbreaks of herpes, infectious processes, and scarring were observed. All patients monitored for fine perioral rhytides showed a reduction in the treated area. Since skin-specific quality of life was significantly improved after "voltaic arc" treatment, this therapy can be recommended for patients with perioral rhytides skin wishing to improve their appearance.

Current Concepts in the Use of Small-Particle Hyaluronic Acid.

Soft-tissue augmentation with hyaluronic acid (HA) fillers has become one of the most popular cosmetic procedures performed. HA fillers represent safe and commonly used fillers. Several different HA fillers are available. The differences lie in the manufacturing process, allowing for tailored uses. A small-particle HA with lidocaine (SP-HAL; Restylane Silk; Galderma, Uppsala, Sweden) was approved by the US Food and Drug Administration in June 2014 but has been available for many years in Canada as Restylane Fine Lines and in Europe as Restylane Vital. Relevant articles were reviewed relating to the composition, effectiveness, and safety of SP-HAL. We also discuss the author's extensive clinical experience in the use of this product in Canada. SP-HAL has demonstrated proven benefits for lip fullness, augmentation, and treatment of perioral rhytides. Although off-label in the United States, SP-HAL is also well suited for the treatment of superficial fine lines, including periorbital, forehead, marionette, and smile lines. In addition, it has also been used in the tear trough region. A novel application for SP-HAL includes use as a skinbooster with intradermal micropuncture. In this technique, small aliquots of product are injected so as to gradually rejuvenate the skin in areas such as the face and hands. Side effects of SP-HAL were generally transient and mild. The most common side effects were swelling, tenderness, bruising, pain, and redness. SP-HAL is an effective and safe HA filler with varied clinical uses.

A randomized, evaluator-blinded, controlled study of effectiveness and safety of small particle hyaluronic acid plus lidocaine for lip augmentation and perioral rhytides.

To compare the safety and effectiveness of small particle hyaluronic acid plus lidocaine (SPHAL) versus no treatment for lip augmentation and perioral rhytides. Adults scoring 1 (very thin) to 2 (thin) on the Medicis Lip Fullness Scale (MLFS) for upper and lower lips were randomized (3:1) to SPHAL or no treatment. Treatment success was an MLFS increase ≥1 point at Week 8. Secondary end points (MLFS score, independent photographic review, Global Aesthetic Improvement Scale, Wrinkle Assessment Scale for Upper Lip Lines) and safety were assessed throughout. Statistically significantly more patients were treatment successes with SPHAL (upper lip [80.2% vs 11.9%], lower lip [84.2% vs 18.4%], and upper and lower lips combined [76.1% vs 11.6%]), compared with no treatment (p <.001, all outcomes). Patients treated for both lip augmentation and perioral rhytides were rated as having an aesthetically meaningful improvement in perioral rhytides (p <.001). Most common treatment-emergent adverse events (AEs) included lip bruising, swelling, and pain and were mostly mild and transient in nature, without anticipated device AEs. Small particle hyaluronic acid plus lidocaine was effective and well tolerated and significantly more effective when both lips and perioral rhytides were treated, with improvement evident up to 6 months after treatment.

Outcomes Assessment of Combination Face Lift and Perioral Phenol–Croton Oil Peel

Face-lift surgery when combined with perioral phenol-croton oil peel is an underappreciated tool for face rejuvenation. The procedure results in significant central face skin tightening and wrinkle reduction. A retrospective review of 47 consecutive patients who underwent simultaneous face lift and perioral peel was performed. The objective measures used to evaluate the change in appearance of the patients included (1) a validated patient satisfaction questionnaire, (2) an evaluation of apparent age, and (3) an evaluation of perioral wrinkles by independent reviewers using a validated model. The assessment of apparent age was performed as follows: preoperative and postoperative photographs were shown randomly to six reviewers, who were asked to estimate the patient's age. The apparent age was compared with the patient's actual age, and the reduction in apparent age was calculated. Improvement in perioral rhytides was evaluated by using the Glogau classification system (range, 1 to 4). Survey results documented overall patient satisfaction, which was rated as 6.5 on a scale of 1 to 7 (with higher scores indicating greater satisfaction). Patients' postoperative apparent age estimate was 8.2 years younger than their real age (p=0.0002). The Glogau classification system score demonstrated a mean reduction of 1.15 (3.3 preoperatively as compared with 2.15 postoperatively, p<0.0001). Outcomes measurements, including patient satisfaction, objective evaluation of wrinkle improvement, and significant reduction in apparent age, document the power of this technique. Therapeutic, IV.

Systematic Review of Clinical Trials of Small- and Large-Gel-Particle Hyaluronic Acid Injectable Fillers for Aesthetic Soft Tissue Augmentation

Hyaluronic acid (HA) is the most frequently injected filler for soft tissue augmentation in the United States. To systematically review published evidence for aesthetic use of small- and large-gel-particle HA. Clinical data on anatomic area, level of evidence, patient population, trial design, endpoints, efficacy, and safety were extracted from PubMed. Fifty-three primary clinical reports were analyzed. The highest-quality efficacy evidence was for the nasolabial folds (NLFs), with 10 randomized, blind, split-face, comparative trials. Several randomized, blind trials supported treatment of the glabella, lips, and hands. Lower-level evidence (from studies with nonrandomized, open-label, or retrospective designs) was recorded for the nasojugal folds (tear troughs), upper eyelids, nose, infraorbital hollows, oral commissures, marionette lines, perioral rhytides, temples, and cheeks. Common adverse events (AEs) across anatomic areas were pain, bruising, swelling, and redness. Serious AEs were uncommon (8 events in 8 patients of 4,605 total patients) and were considered to be unrelated (7 events) or probably unrelated (1 event) to treatment. The efficacy and safety of small- and large-gel-particle HA are well established for NLFs; evidence for the glabella, lips, and hands is more limited. Preliminary reports in other anatomic regions suggest efficacy without major complications.