Case Study: Lips in Skin of Colour Patients

Case Study: Treating Lips in Skin of Colour Patients

Aesthetic nurse Lucy Williams discusses her method for treating skin of colour lips

The golden ratio is considered an important concept for treating the face in medical aesthetics, and in terms of lip treatments it refers to where the lower lip should be 1.6 times thicker than the upper lip.1 While this is true for the Caucasian face, it does not apply to all ethnic groups.1 Certain skin colours, in particular black skin patients, genetically have greater lip volume as they age. This is due to increased melanin in darker skinned patients, which helps protect the skin against ultraviolet radiation and cause the skin to be protected throughout the patient’s lifetime, shielding the skin against damage to the DNA2 and ultimately resulting in patients of racial origin having a greater lip fullness.3 Skin of colour is also less prone to solar elastosis, a degenerative condition of elastic tissue in the dermis due to prolonged sun exposure, which causes the skin to become thicker (also known as photoageing).3 It is normally found in patients with fair complexions, negatively affecting the production of collagen and elastin.2 Due to this, skin of colour patients rarely develop radial rhytids (fine lines and minor creases) in their lips and vermilion border, resulting in more volume within the lip regardless of ageing.4 Therefore, in the case of black or mixed-race patients, the ratio of their lips should typically be 1:1 rather than 1:1.6.1 As such, when treating skin of colour patients, practitioners should ensure that they are able to assess and treat the face differently. In terms of lip filler treatments for ageing skin of colour patients, they may seek to restore the youthful fullness of their lips. In this case it is more common that the injectable product is placed only in the upper lip, as the lower lip usually maintains its volume.5 It is also found that decreased lip volume and perioral lip lines are also more pronounced in Caucasian skin, likely due to a combination of muscle action and the deleterious effects of UV exposure on lighter skin.6 So, it may be more likely that perioral lines are less likely to be a concern for patients with darker skin.

Case study

Consultation and assessment A 30-year-old skin of colour (mixed race white and black Caribbean) female patient presented to my clinic with concerns of a general lack of definition to the lips and a lack of volume in the top lip, which she felt had worsened with age. A thorough understanding and assessment process will result in a better understanding of the aesthetics of the lips and consequently a more successful treatment plan and outcome. As such, I spent around 45 minutes undertaking a full consultation which included a full facial approach and gave the patient all the information about the treatment, so that fully informed consent could be given. It is also important to fully understand the patient, who they are, and their motivations for treatment to help manage patient expectations and give them a good treatment outcome. The patient had no relevant medical history and had never had any aesthetic treatments before. To add to this assessment, mental health, social and economic factors were also undertaken. My assessment determined that my patient was a previous smoker, exercised regularly, ate healthy and had no sun damage concerns. Undertaking a full medical consultation enables us to give an understanding of the patient’s reason for treatment and for us to develop a safe treatment plan. Lips are three dimensional and it’s important to assess the profile as well as the front view. There are three basic types of facial profile. A straight profile, also known as the straightjawed or orthognathic, is where the nose, lips and chin are almost inline; a convex profile, also known as the retrognathic profile, has a retruding chin, long nose and prominent mouth; and a concave profile, also known as the prognathic profile, is characterised by a bold lower jaw and chin.7 The angle of convexity of 8-16° indicates a straight profile, while an increased or decreased angle is an indication for convex or concave profile.8 As such, I identified that my patient had a

As the patient wanted natural looking lips with volume and definition, the correct product selection was key

Before After

Figure 1: Patient before and after treatment using 1ml of Restylane Kysse

straight profile, which gave an indication of how much volume I could add to the upper and lower lips to keep the profile straight and the results natural. From the assessment I also noted that the patient had a slight natural asymmetry to her top lip in which her right top lip had more height and her bottom right top lip had slightly more volume than the left. It is important to point out asymmetries to patients so expectations can be managed, and they do not have unrealistic outcomes. There are limitations to dermal fillers especially when treating asymmetrical areas.10

Pre-treatment As the patient wanted natural looking lips with volume and definition, the correct product selection was key. I decided to use the Restylane OBT range, which contains soft gels with varied degrees of cross-linking and a high flexibility to provide natural looking effects.11 With my patient wanting volume and definition I decided that Restylane Kysse was the perfect choice to give my patient her desired outcome, as this filler is specifically formulated to enhance, define, or augment the lip body and border.11 Before any treatment is carried out, I always recommend that the patient has a coolingoff period to take in all of the information so they can make a fully informed decision. I recommend a cooling-off period of two weeks as recommended by the General Medical Council (GMC).12,13 Pre-treatment instructions were given including no alcohol, anti-inflammatory and antiplatelet agents for one week prior to treatment, unless medically necessary, to reduce the risk of vascular injury such as swelling and bruising post-treatment. 14,15

Treatment Before any treatment, I always take pretreatment photographs to document the results. The patient’s makeup was then removed from the lower third of the face using Clinisept+ Prep & Procedure. I find this a great method of cleansing the skin before any aesthetic treatment as it employs an oxidising method of action, which is not only more effective in removing microbial contamination but is also gentle on the skin. EMLA cream was then applied to the lip area, and we waited for approximately 15 minutes for the area to numb, after which I once again cleaned the lower third of the face with Clinisept+. The patient’s asymmetries were marked out with a white pencil and documented, and the patient was laid down to a flat 180-degree angle to begin the treatment. As the asymmetries were already identified, I corrected these asymmetries first before adding volume. In my experience it is much easier to fix asymmetries first and add definition with a needle, rather than a cannula. I used a 30 gauge needle to inject 0.1ml into the submucosal of the left side of the Cupid’s bow, using a tenting technique to adjust the asymmetry. I then added 0.1ml to the lower left side lip body to correct the asymmetry on the bottom lip. I sat the patient up to a 90-degree angle to check that the asymmetries were corrected, which they were, and once I was satisfied that this had been addressed the patient was laid back to add definition and restore lost volume. Again, I used a tenting technique for the top lip, starting at the Cupid’s bow continuing along to the oral commissures. The tenting technique provided definition to the lip border, and I then added a small amount of volume to the main body of the lip. To do this I used a linear threading technique to the three small tubercles on the upper lip and two on the lower lip, which gave the shape of the lips its individuality, something that should be preserved during augmentation. Following the treatment, the area was cleaned with Clinisept+ Aftercare and a lip ice pack was applied for approximately five minutes, which I find can help prevent erythema and oedema. Post-procedure photographs were also taken, and I documented in the patient’s notes how much product had been injected and to what area of the lip. It is important to document the treatments performed for patient follow-up appointments to ensure continuity, and in case any complications arise such as skin necrosis.

Results Immediately after the treatment there was minor swelling and no obvious bruising, and the patient was advised that this would rectify itself within 48 hours, with the lips taking up to two weeks to fully settle. It is vitally important that all patients are given relevant aftercare advice to reduce the risks of side effects and complications, for example no makeup should be applied to the area, no heat exposure, no exercise, no alcohol, and no smoking for 24 hours following the procedure.14 The patient was extremely happy with the results and by correcting the asymmetries, adding definition, and increasing volume, she was more confident in her appearance. She was advised that the results would last approximately up to 12 months,16,17 and then a follow-up appointment will be needed.

Treating all ethnicities effectively Ultimately as a medical aesthetic practitioner, I find it is important to consider the goals, anatomy, and ethnic background of each individual before performing lip augmentation. As always, a full facial and holistic approach should be undertaken prior to treatments, and whilst ethnicity plays an important part, a patient will not be treated based on this aspect alone.

Lucy Williams is the founder and director of Aurielle Aesthetics, Wiltshire. She has more than 10 years’ experience as a nurse and more than three years’ experience as an aesthetic injector. Williams is registered with the ACE Group World and has extensive training and expertise within aesthetics, having recently completed the Lee Walker Aesthetics Academy. Qual: RGN, DIP Nursing

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