RHA and smoker’s lines
Visible signs of ageing in the periorbital area can have a significant impact on self confidence. Dr Kieren Bong explains how to treat vertical rhytids with a combination of resilient hyaluronic acid and botulinum toxin
One of the main reasons patients seek non-surgical facial aesthetic correction is to address ageing of the perioral region, specifically the formation of vertical rhytids, commonly known as “smoker’s lines”. Vertical rhytids, which I shall refer to as smoker’s lines in this article, are more prevalent on the upper lips.
Smoker’s lines are small lines that etch the lips and, in some cases, extend vertically from the lips. They are sometimes referred to as “barcodes” or “lipstick lines”, as they are usually first noticed when lipstick starts to ‘bleed’ out of the vermilion border.
The lips and surrounding soft-tissue play a key role in non-verbal communication, through smiling or grimacing, for example. As such, visible signs of ageing in the perioral area can have a significant effect on a person’s self-perception and confidence in interpersonal relationships.
Intrinsic and extrinsic ageing
Successful correction of smoker’s lines necessitates a thorough understanding of the underlying perioral anatomy and detailed knowledge of ageing related changes in the region.
Ageing is a multifactorial process, involving a complex interplay of intrinsic and extrinsic factors. Intrinsic factors consist of genetic components, which play a predominant role in this process, while extrinsic factors include sun exposure, smoking, alcohol intake, stress and depression.
Although smoking does not necessarily cause smoker’s lines, it can predispose a person to develop vertical rhytids and/or accelerate their formation. This is due in part to the repeated pursing of the lips to draw from the cigarette, as well as patho-physiological effects of smoking, such as hypoxia and/or microvascular changes in the skin that adversely affect the integrity of elastin and collagen.
The development of smoker’s lines
As we age, the external white skin (skin between the nose and top lip) lengthens and sags. This is mostly due to decreased skin elasticity, which is a normal part of ageing. Decreasing volume of the facial skeleton is also a typical part of ageing, with this loss of volume seemingly caused by decreased osseous support and atrophy of the soft-tissue. This results in decreased support and projection of the soft-tissue.
In addition, there is a marked decrease in subcutaneous tissue in the perioral region which, along with repetitive bunching of skin and soft-tissue from muscular activity, leads to the formation of smoker’s lines.
We typically treat smoker’s lines with a combination of hyaluronic acid (HA) dermal fillers and botulinum toxin type-A. The choice of treatment depends on the depth of the lines and extent of puckering, with HA providing the most effective non-surgical method for treating smoker’s lines.
Treatment with HA can lead to impressive, natural-looking correction of smoker’s lines, usually requiring only a very small volume of the product to be injected at a precise depth at locations along the lines and lip border. The use of HA presents a non-invasive, cost effective means of treatment with a proven safety record. For best results, I recommend a combination of HA and botulinum toxin type-A.
Botulinum toxin type-A helps to relax the strength of the muscular contracture, thereby relaxing the rhytids, while HA helps to soften any permanent etching that may have occurred. Patients can realistically expect to see improvement in the puckered look, as well as softening of the furrowed lines.
Not only does the combination of HA and botulinum toxin type-A offer superior benefits, this regimen can result in longer-lasting effects. Additional lip enhancement is also worth considering to address contracture of the lips. Adding some bulk to the lips with HA can have a positive effect on the smoker’s lines by further elongating the lip.
Choice of HA fillers
HA fillers are typically formulated for use in static areas of tissue. As the perioral region is a very mobile part of the face, it is essential to choose an HA filler with the correct biochemical specifications to work with dynamic tissue.
Due to their resiliency, I favour the use of Teosyal’s latest range of HA fillers—RHA (resilient hyaluronic acid)—for the perioral region. This range of fillers has been formulated to be able to stretch with movements while resisting compression and other constraints in order to offer results which are both natural and long-lasting.
RHA is available in four grades, each of which is dedicated to the different dynamic areas of the face. The grades differ in HA concentration and the percentage of crosslink. RHA is unique because for the first time, the long HA chains are preserved during the manufacturing process. This, coupled with the preservation of the intrinsic and dynamic bonds which only exist between long HA chains, affords this filler dynamic properties best suited for mobile areas of the face.
For the perioral area, I recommend using RHA grade 1, which contains 15mg/ml of partially crossed linked HA (rate of 1.9%). This formulation is ideal for treating fine lines and wrinkles where the HA filler needs to flow freely, be subtle, soft and smooth. The unique formulation of RHA and the preservation of long chains also mean that the product integrates very well into the soft-tissue. Results can last up to one year.
Two injection techniques are useful when treating smoker’s lines: retrograde linear threading and serial punctures. Both techniques are carried out with the use of a hypodermic needle, with the target injection depth in the superficial dermis.
Some practitioners believe it virtually impossible to inject precisely in the dermis due to the girth of the needle being thicker than the dermal layer. While this may be true if one uses a 30G needle, the unique formulation of RHA1 allows it to glide through the lumen of a 32G needle without any difficulty. As such, a 32G needle is my preferred choice of instrument for treating smoker’s lines with RHA1.
The retrograde linear threading technique can be carried out either pointing the tip of the needle caudally or cephalically. In the case of a cephalic approach, the needle should be inserted at the junction of the rhytid and the lip, oriented along the course of the rhytid. Using the thumb and second finger of the non-dominant hand, guide the needle into place and apply gentle pressure to inject the product.
I prefer the serial puncture technique because it affords superior accuracy. Again, precise injection into the superficial dermis is the key to success. Following the injection, firm pressure should be applied to smooth out the filler and ensure that it softens. This helps to avoid overcorrecting the smoker’s lines, which is a common mistake that results in a series of bumps replacing the rhytids.
Adverse events are not common with the use of HA to correct smoker’s lines. In my experience, when adverse events do occur they are typically a result of inappropriate product choice, poor technique or a combination of the two.
Lumpiness or surface irregularity can occur with any HA filler, although it is more prevalent with high viscosity HA fillers. The risk can be minimised with the use of non-particulated HA fillers of low viscosity and appropriate technique to avoid overcorrection.
I have found that transient side effects such as injection site inflammation, including erythema and discomfort, typically resolve within one or two days. ‘Tyndall effect’ may occur with too superficial a placement of HA and is more commonly observed when particulated HA fillers are used in this region. This presents as a bluish hue just beneath the skin and can be corrected very easily with the injection of hyaluronidase.
Infection is possible with any injection, but the risk is low and can be minimised through judicious use of antiseptic prior to the treatment and observing a strict protocol for infection control.
Cutaneous necrosis is a rare but clinically significant complication. This may present as vascular interruption at the treatment site with subsequent localised tissue necrosis.
Bacteria-derived HA fillers are generally considered non-immunogenic, although there is a theoretical risk of hypersensitivity against any impurities that remain after the purification of HA. Patients who have previously experienced an immune response to HA should not be considered candidates for this type of treatment.
Treating smoker’s lines with HA fillers can be technically challenging, but the unique formulation of Teosyal’s latest range of HA fillers, RHA, has made treatment of the perioral area much easier. Teoxane’s patented method of preserving the long HA chains during the manufacturing process gives RHA unique properties that make it a superior product for this dynamic area of the face.
Dr Kieren Bong is a Cosmetic Doctor, trained in both medicine and surgery. He is the clinical director of the Essence Medical Cosmetic Clinic in Scotland, and combines his creative talents with his scientific, medical aptitude to provide excellent natural and refined aesthetic results for his patients. Internationally, Dr Bong has an outstanding reputation as a leading lecturer, trainer and expert in aesthetic medicine, having carried out training master classes and workshops in over 25 countries. Dr Bong is the pioneer of the ‘Two-Point Eye Lift’ and ‘3D Ultimate Lift’ techniques for effective peri-orbital rejuvenation and advanced facial contouring and sculpting with dermal fillers.