Good evening everybody. My name is Gregory Greco, and I'm going to be moderating tonight's session. Welcome to our ASPS Global Partners series. This is one of our webinars, and I just want to go over some of the ground rules for tonight as far as the ability to ask questions and how to go about that. Next slide, please. So, to submit questions, if you look at the bottom of your screen, you'll see that there's a Q&A box. Feel free to type out your questions for tonight, and we're happy with the structure tonight. We're going to have three presenters, and there are going to be 15-minute presentations, and we're going to have the last 15 minutes for Q&A. But please don't worry if you can't get your question answered, because every speaker will have the ability to reach out to you by email. So, in the process of asking your questions, if you'd like to add your email or send us your email, we're happy to have them individually respond as well. Also, tonight's recording will be recorded, so due to that, which is great, you do get to come back and look at this. So, those of you who couldn't join us tonight, we're sorry you couldn't be here with us live, but thank you for looking at the EdNet content. So, just on plasticsurgery.org, you're going to go to ASPS EdNet, and you'll be able to watch this webinar as well as many of our others. So, next slide. So, welcome, and once again, part of our ASPS Global Partners seminar tonight's webinar is going to be Perioral Surgery, Lifting, Filling, Resurfacing, and Combining Techniques. We have three wonderful, talented speakers tonight who are going to be sharing their techniques with you. We have Dr. Bhamangayaran, who's going to be speaking first. Then we have T. Gerald O'Daniel, who will be speaking. He does have a pre-recorded lecture, so once again, very importantly, please type out your questions during his lecture, and we will make sure that Dr. O'Daniel gets your questions and can answer them for you. And lastly, we have Dr. Usha Rajagopal, and I will do an introduction between each lecture to introduce you to our speakers. So, thank you again for joining us tonight. We're going to start with Dr. Ghayaran. Dr. Ghayaran is joining us. He's the founding chair of Plastic Surgery at Case School of Medicine and has published over 300 peer-reviewed journals and six textbooks. He served as the editor-in-chief of Aesthetic Plastic Surgery from 2016 to 2013, and additionally, he has lectured in over 30 countries and has served as a visiting professor in every respected U.S. medical school. Dr. Ghayaran has served in leadership roles in numerous professional organizations in plastic surgery, including the American Board of Plastic Surgery, where he served as a director from 2005 to 2011. He also served as the president of the American Association of Plastic Surgeons, the American Society of Maxillofacial Surgeons, the Aesthetic Surgery Education and Research Foundation, the Rhinoplasty Society, Northeast Ohio Society for Plastic and Reconstructive Surgeons, and the Ohio Valley Society for Plastic and Reconstructive Surgeons. He's received numerous awards for his accomplishments from every prestigious plastic surgery organization. We welcome you, Dr. Ghayaran, and thank you for joining us tonight. Thank you for that kind introduction, and I'm going to share my presentation. Is that good? We got it, yeah. Great. Thank you. These are my disclosures. I received royalty for these four books. In my view, here we oral aging-related changes, under-emphasized and under-corrected, and it is one of the most important aspects of improving the facial appearance for the young or old alike. Changes that can happen in the lip area related to the aging include surface lines, elongation, volume loss, caudal tilt of the oral commissures, and loss of vermilion border. In analysis of the lip area, perioral area, and deciding what I'm going to do, the factors that are common to play include lip length, length, position of the oral commissures, definition of the nostril cell, and definition of vermilion border, amount of incisors show, and lip volume. If I'm going to change the lip length, I'm going to watch the incisors show, and it could be optimal, excessive, inadequate. Each one of these are going to have a different choice in terms of what I'm going to do with the lip. If I have inadequate incisors show long lip, the lip lift obviously is a choice, but it's going to differ depending on what I'm dealing with a patient with well-defined vermilion border or ill-defined vermilion border, and senescent patients obviously are going to have a different approach. If I have a patient who has a well-defined nostril cell, my incision is going to be subnasal, following the contour of the nostrils and the nostril cell. I may extend it laterally, but most of the times I don't. The key factor is to leave at least 12 millimeters between the incision and the top portion of the cubit's bow. Here is an example of such a patient who had a long lip, which was lifted. You can see we are actually seeing the incisors, but we don't see it here, and the incision is hidden right at the base of the nose. I don't want to destroy the nostril cell for this particular patient, and on this mild view you can see elimination of this crease here that is a concern to the patient, and also more acceptable incisors show. If I'm dealing with an ill-defined nostril cell, which includes many of the African Americans, Asians, and Latinos, I'm going to extend the incision inside the nose, and you see these vertical lines to make sure that my alignment was going to be optimal, and I inject area of xylocaine containing 1 in 100,000 epinephrine, and I'm going to make my incision and excise the skin in a segmental fashion using my design, and this is a skin excision mainly. I'm not removing the muscle, but I'm exposing the muscle, and after we complete that, you know, you see the lateral excision, the same patient, and when we complete that, then we're going to achieve hemostasis, then we're going to repair the incisions, and as you can see, a good portion of the incision is going to end up being inside the nose. I could say, actually, the most visible portion of the incision is going to be inside the nose, and then I use 6-0 monoclonal to line up the skin optimally, and again, in a step-by-step fashion, using the corners, landmarks, and this is what we see. Before I use the skin sutures, it's going to be 6-0 fast-absorbing cat cut, and I complete that, and this is what we see, and we're going to see examples of these in a short while. On a patient who has, who's an older patient and has an ill-defined vermilion border, I may make the incision at the vermilion junction, and this actually will give us the scar that is going to be acceptable, and also, it will actually define the vermilion border, that it doesn't exist, and this is removed, and patients who have deep lines, I'm going to undermine the skin slightly to eliminate those lines, and you'll see examples of these, you can see, actually, she has a, this is a portion of makeup, she's creating, actually, a vermilion border, this is a vermilion border that I've created for her, you can see also how we can eliminate the very deep lines, this is a 10-year follow-up on a patient with this kind of, you can see how, again, vermilion border is better defined than before. Yes, the scar can be visible, it will be unlikely, and if the scar is visible, I'm going to treat it with CO2 laser, and we can avoid the asymmetry by paying attention to the details, and it's crucial to understand that many patients have pre-existing asymmetry. For the lip augmentation, I'm going to use fat injection for most patients, but that may not be ideal for somebody who has significant hypoplasia of their lips. On these patients, I'm going to use fat graft, segmental fat combination of fat and dermis graft, and you notice that I'm measuring the stretched lip, which is usually about 10 to 11 centimeters, and then I'm going to deepithelialize this skin, excise it, or we can use the posterior portion of this mass for this purpose. Here's a patient on whom, actually, I removed these Gore-Tex fibers and replaced it with combination of dermis fat graft, and you also see the difference for the shape for the lower lip and upper lip, that it is not actually exactly the same. This is a patient who is undergoing a combination of lip lift with an incision at the vermilion border, and incision, and also lip augmentation. The incision will be in the oral commissure area. I used baby medicine balm to undermine all across bilaterally. Then we're going to use this tendon passer and pass the dermis across, dermis fat across. You see how much extra length there is, but that is going to disappear when I do this. When I do this, I stretch the lip to make sure that the graft is not going to cause undue tightness to the lips, and upper lip, now that we are doing the same thing on the lower lip and stretch it again, then repair the incision. Yes. Recovery on these patients can be a little bit cumbersome, a little bit prolonged, and there could be an uneven graft take, reduced incisor shape. We don't use it on a properly selected patient, and patients really are delighted with this technique, but they need to know that there's going to be a change. Stenosis can be avoided by what I just discussed, and here's an example of such patient who underwent lip augmentation with graft. This is a five-year follow-up on this patient with a smile view. You can see that follow-up again, and here's another patient. You can create really natural-looking lips with this and another patient with the same kind of result, but I also commonly do a combination of lip lift and augmentation. You can see that this patient had a subnasal incision and augmentation because he had significantly inadequate incisor show. And on patients who have oral commissure ptosis, I'm going to resort to my SMAS. I'm going to suspend this SMAS cephalically, then do placation that I call Taylor-Tac technique to suspend the corner of the mouth further cephalically. Yes, I sometimes inject some fat in the designated areas you see, all below the oral commissure to raise the commissure or actually use a fat graft to achieve better results. You can see how those corners can be lifted successfully, and another patient with a similar, a male patient with a combination of lip lift augmentation, facelift, submental lipectomy, and another patient with a similar technique. But again, there are patients like this one that I use fat graft and again, coddle to the oral commissure to lift up that corner, and finally, this patient needs all we have in our mementarium to get good results in the perioral region. In summary, I don't have a single technique that suits everybody, depending on the condition. I'm paying attention to the incisor show and lip length and lip volume. I'm going to make a decision as to what is that is going to suit that patient in a more ideal way. Thank you for your attention, Greg, and again, thank you for the invitation. Thank you, Dr. Gayaran. That was terrific. Our next speaker is Gerald T. O'Daniel, and he is a dual plastic and reconstructive surgeon and facial plastic surgeon in Louisville, Kentucky. He has over three decades of experience performing state-of-the-art aesthetic plastic surgery, and he has a busy private practice that concentrates on facial aesthetic procedures, and he does over 150 facelifts and neck lifts per year. He's the medical director of the O'Daniel Plastic Surgery Studio and the Louisville Surgery Center. In addition, he's a clinical assistant professor at the University of Louisville. He's a member of the ISAPS Educational Committee, Residence Education Committee, and chair of the ISAPS Journal Club, dedicated to teaching and advancing aesthetic surgeons worldwide. He's on the editorial board for Aesthetic Surgery Journal and also Aesthetic Plastic Surgery. He's currently a visiting professor for both ASAPS and ISAPS. Dr. O'Daniel, unfortunately, couldn't join us tonight. We have his videotaped presentation, which we're going to be playing now. Thank you. Hi, I'm Jerry O'Daniel. I'm here to discuss this evening some new concepts using new anatomical findings and anatomical principles for a technique I call perioral gliding. I'm going to share my screen and take us to the beginning slide where we will start talking about these principles for this new concept of perioral gliding surgery. Our typical lip lift is a subnasal approach. However, what we're seeing today is an exaggerated vermilion slope with a short central upper lip. In other words, we reduce the central lip, but we get minimal impact on the lateral lip with minimal shortening, minimal eversion of the vermilion. I'm going to suggest to you that we should have new goals for the ideal perioral aesthetics. Those which diminish the exaggerated medial to lateral vermilion slope, as well as lift the commissures to a level midline with the central oral aperture. In addition, I think we need to be paying close attention to not only the relationship of the upper lip length, but also the relationship of the lower lip and the surrounding face. So the key structures we're going to discuss include the piriform ligament, the aponeurosa, also called the levator aponeurosa in our new publication coming out, and the perioral musculature. We're going to describe tonight a specialized upper lip levator aponeurosa, which is a dense non-stretching fibro fatty layer of the upper lip that has a dense central nasal attachment that prevents central descent. There's perinasal levator muscle insertion for elevator of the lip, and there's a loose attachment to the ubicularis below the levator insertion, allowing the multifunctions of the mouth. There's insertion of this levator aponeurosa into the vermilion-containous edges, which elevate the lip margins. We get ptosis of the lateral lip secondary to a lateral aponeurotic musculoskeletal support, as we're going to describe. So what we're looking at here is dissections by Leonard Minelli, where the skin is being elevated. You can see beneath the skin the soft tissue. As we lift the skin off the upper lip, it's quite thin and difficult to detach from this more gray structure, which is the levator aponeurosa. As we raise layer two and three, which is the musculature and fascia, you can now see the upper lip. Layer two in the upper lip is this levator aponeurosa. The levator musculature has an insertion along the infrared rim and goes into this aponeurosa, as you can see right here. There's a dense central nasal attachment of this levator aponeurosa. This shows you the perioral musculature. This is the LLSAN and the LLS originating from the infrared rim and the medial-orbital rim. You can see there is the aponeurosa in yellow. As you can see in this picture, there's a dense nasal attachment. This central gray material does not stretch. There's insertion above and below of the levator musculature. You can see the mucosa and the muscle stretches quite easily. The levators and zygomaticus minor insert into the nasal labial crease, which then allow the depth of the crease and the fold is above this. As you can see, there is the crease. On the underside, we can appreciate the insertion of the LLSAN, the LLS, as well as the zygomaticus minor. And this is what makes up the superior and middle component of the nasolabial crease. The aponeurosa and the nasolabial crease and fold, as you can see, have insertions right here, the musculature. Medially, you have this dense fibro fatty tissue. It's quite gray. As we go more lateral, you're going to see it's more yellowish, more fibro fatty, all the way to the level of the commissure. And this fat overlies the zygomaticus major, the depressor anguli oris, the ubicularis oris, the levator superior oris, and the depressor labia inferior oris. So this is going to be superior to the musculature. Now, the reason this is important in non-surgical means is when people are getting filler into their nasolabial fold, it impacts the elevation of the upper lip. So the levator function is hampered by injections of filler into the nasolabial fold, which diminishes the ability of the lip to elevate. Now, there's a glide plane beneath the saponeurosa overlying the ubicularis musculature, which you can see the ubicularis there. There's the artery. And if we look from a surgical standpoint with the light on, there is the plane, and it very easily separates. So this plane is important for more reasons than just a surgical plane. As you can see, there's the levator aponeurosa inserts in the vermilion. As we lift the aponeurosa up, there's a glide plane of that space between the ubicularis and the levator aponeurosa. This layer allows migration of filler. So when people are getting fillers into the vermilion component of their lip, the sphincter function of the ubicularis forces the fillers superiorly, and this is what gives people that monkey lip look. It also causes ptosis of the upper lip, pushing the outer aspect down. You can see on puckering, the filler becomes much more noticeable as it becomes bulging over top of the ubicularis muscle between the levator aponeurosa. So this levator aponeurosa, we've named this because of the similarities to the upper eyelid. As you can see, there is the upward movement of the upper eyelid with the contraction of the levator musculature. Similarly, this attachment of the levator aponeurosa to the levator musculature causes elevation. So there's the muscle contraction exerted through the aponeurosa to the edge of the lip. You can see simulated with the lifting the aponeurosa. You can see in the clinical picture on this side, the snarl, the edges of the lip come up with the aponeurosa. So what I'm proposing is there a concentric descent away from the midline. And the reason there's a concentric descent away from the midface is because of lack of attachments. You can see the attachments to the medial labial fat are gonna be up in the zygomatic arch as well as the nasal base. So this lack of fixation allows this to rotate in a direction away from the midface. So if this is actually the case, what you see is the corner of the mouth goes down, the distance from the eyelid to the lip gets longer. So if in fact, this is what's happening and you're getting this rotation, it only makes sense that correction will be rotation back to the midface of the commissure. And this shows you elevation of this levator aponeurosa pulling it to the piriform ligament. And as you see, we hold this to the mucosa. It lifts the commissure by lifting the aponeurosa up and down. So based on this concept, we've developed this technique to enhance the upper lip and correct lateral ptosis of the lip, facilitate jowl correction, restore lower third facial proportions. I use a design that starts with a minimal height of 12 millimeters. I'll go as much as 15 millimeters in the midline to avoid exaggerated vermilion descent. And then I will increase one millimeter every five millimeters on this grid, it's graduated. And you wanna avoid the incision going beyond the nasal labial alar groove. You can also do an isolated corner lift through this isolated incision to lift the corner. So we remove full thickness of skin down to this levator aponeurosa, which is this yellowish layer here. Laterally, you see the insertions of the musculature. We develop a glide plane between the uvicularis and the levator aponeurosa, separating it from the soft tissue. This shows you a video leaving a three millimeter limb, which I'll use to attach to the piriform ligament. I will make an incision with the cautery. The first sonometer is quite densely attached with the levator aponeurosa and the uvicularis are very dense. And that explains why there's an absence of wrinkle going all the way to the nasal base. You can see the labial artery quite superficially. Once you get a sonometer below the alar base, this glide plane enters very easily and separates. Separates like butter, as Ozan Sozar says. So once we've got it separated, we then want to mark the area that's been separated for the net application for securing the lip in a more superior direction. The arrows are marking the vector of movement. So the piriform ligament is used to suspend the skin and the aponeurotic composite. We use this fixation for precise elevation of the lip. It prevents alar distortion. You can see the suture is placed through the piriform ligament. It doesn't move the face. I then pass it through the levator aponeurosa. And when I close this, you can see there's no tension on the base of the nose at all. Which then gives us a tension-free closure with a 7-0 nylon. We then apply the hemostatic net. This allows us to hold the skin in a new position over the musculature. It also secures eversion of the vermilion and elevates the corner of the mouth. This shows you the hook elevating it. In this particular instance, I'm using a horizontal suture. Typically, I will most commonly use a vertical, but you can also use horizontal. The key is to evert the vermilion edges, rotating the vermilion out. And we do multiple rows until we have completely closed the dead space. This is elevating the commissure, taking it all the way to the alar base. You can see we can also use an isolated nasal base where there's a very limited skin excision. The amount of skin release really depends on how much ptosis there is. You can see this dissection is going beyond the labial mandibular fold and separating this glide plane. Medial to this fold, there's dense attachments of the skin to the underlying depressor labia inferioris. And lateral, you have a glide plane that is over the melolabial fat. This allows us to actually connect our dissection plane from the base of the nose to the neck to get optimal elevation and rotation of the lip. You can see in this circumstance where there's minimal, if any, skin excision, there's diminishment in the upper lip length, increase in the distance from commissure to lower jaw. The recovery is actually not so terrible. You can see 48 hours, the surgical net is going to come off. At six days, the sutures are coming out. She had concomitant fat injections at the same time, can be done safely. 10 days post-op and 14 days post-op. You see her one year post-op. You can see the enhancement of the lip. You can see the improvement in the soft tissue at the commissure, the distance of the lip from the commissure to ALA, from commissure to jawline as compared to 18 years of age. This is a 26-month recovery showing the improvement. She's 76 years old, that's 78 years old. And then four years, nearly four years post-op at 80 years of age with no makeup on. We can do this with an isolated corner lip as shown here. We're trying to get eversion of the vermilion and improvement in the exaggerated vermilion fold, excision of skin down to the aponeurosis, the amount of skin for undermining. This is undermined with the scissors. We then elevate it to the piriform ligament, apply the hook to evert the edges, apply the surgical net. You can see on the table, quite unusual looking. You see her the morning after surgery and you see her one year after surgery. What you're seeing is the appearance of a shortened central upper lip, but in fact, what it is, is improvement of the exaggerated vermilion fold. And there's also eversion of the vermilion. The more ptosis you have, the more elevation you do. We go through an isolated approach with this person with a very stressed upper lip and nose relationship. We did not cross the vermilion. Only through this limited corner lip, you can see the net application. This was published a couple of years ago showing this result in a commentary on isolated corner lips. We can continue this dissection. We have significant descent from the midline to also lift the jowl to rotate it back to the midline. So we, once again, are going to use that isolated approach with a very limited nasal approach, extensive application of the surgical net after release and rotation to the midline, showing improvement nine months post-op with a smile, nine months post-op compared to 18 years of age with full smile. We can get these extremely difficult cases. This lady had three previous lip operations, including fat grafting, previous facelifts, eyelid surgery, neck lift, and elsewhere. You can see the severe ptosis of the corner on the operating room table. This is subcutaneous undermining, rotating back to the nasal base, deep plane undermining with customized inset of the vectors of the facelift. And you see what I have done is a dual plane, subcutaneous and deep plane to rotate the lip one direction and the face in another direction. You can see the recovery. This is 70 years of age, the morning after surgery, day three, day 10, four months, and then seven months. And you can see the restoration of the scars. You see the improvement in the face. This is 71 years of age, that's 28 years of age. This is 25 years of age. There she is at seven months post-op, and you can see the marked improvement at the corner of the mouth in an extremely complicated revisional surgeries. So in conclusion, all the previously described lip lift surgeries have had certain disadvantages and certain shortcomings. The perioral gliding techniques allow customization of the entire lip shape. It allows access to the lower face so that you can concentrically assist in the management of very heavy jowls. The specialized levator aponeurosa is a new anatomical insight that describes a dense non-stretching fibrofatty tissue with a dense nasal attachment with paranasal insertions with loose attachments of the levator aponeurosa that search in the vermilion edges and elevates the lip while letting ptosis occur due to the lack of aponeurotic musculoskeletal support. So thank you for your attention. I will be available for questions. Thank you, Dr. O'Daniel. Dr. O'Daniel may be joining us for the Q&A. We're not sure yet, unfortunately he has a prior commitment. Next, I'd like to introduce Dr. Usha Rajagopal. She's a board-certified plastic surgeon and the medical director of the San Francisco Plastic Surgery and Laser Center. She specializes in cosmetic surgery of the face, breast, and body, and her practice is a premier center for cosmetic dermatology, medical skincare, and laser treatments. For the past decade, Dr. Rajagopal has been invited to present at national conferences and has served as a trainer for advanced injectable and surgical techniques. She's recently published articles on non-surgical rhinoplasty and thread lifts for the face, and in the latest volumes of advances in cosmetic surgery. She's appeared in Glamour, WMAG Magazine, New York Post, Forbes, Huffington Post, New Beauty, and Harper's Bazaar. Welcome, Dr. Rajagopal. Thanks for joining us. Thank you, Dr. Greco. Can you see me? We can see you. I don't see any slides yet. You don't see, okay. And we can hear you, obviously. Yes, okay. Just a reminder, if you have questions for Dr. O'Daniel, please provide your email just in case he can't join us. So feel free to write your questions down with the provided email. Thank you. Okay, how about now? Yes, we can see everything. Okay, perfect. Okay. So today I'm gonna shift gears a bit, and we're gonna be talking, especially my first half of my presentation is gonna be non-surgical perioral rejuvenation, really focusing on lip filling using neurotoxins. And then the latter half of my discussion is gonna be a little bit about combining techniques with outpatient surgical techniques. So these are my relationships. I'm gonna be mentioning some products that I use and that I prefer. And if you have further questions, you can email me. I can talk to you about that in more detail. Okay. Again, like we talked about, first I'm gonna be talking mostly about fillers, how we do fillers, how I decide on what filler to use, and then combining that with neurotoxin. Second, we're gonna be talking about, we call it lip rehab because nowadays we have a lot of patients coming in with overfilled lips that look horrendous. They've decided that it looks bad also. And so we've started dissolving and then refilling really judiciously. And then other than aesthetic lip augmentation, I do lip injections, non-surgical techniques, really more in a reconstructive manner. And I have a couple of patients that way. And then lastly, we're gonna be talking about combination techniques. So really for anything, even if it comes to a simple lip filler, they need to have realistic expectations. They need to understand that these are temporary in nature, especially if you're talking about hyaluronic acid fillers or some of the other fillers in the market right now, unless we're doing laser, dermabrasion, et cetera. There's a little bit of downtime involved. There is, everyone gets swollen. There'll be some, you know, certainly bruising. It really takes, I tell people, it takes three to four weeks to look the best. So you will not look good the very next day. And it really does take a while to settle. A couple of things, I am gonna talk briefly, have some pictures on fat transfer. One of the things just to keep in mind is that it's still a little bit unpredictable. You cannot be, you cannot guarantee how a lip is gonna look or how the upper lip right tits are gonna look. If you've done fat transfer, you gotta let them know that there's a little bit of unpredictability and they may need to get another treatment done. With any of these, obviously you don't want them on any sort of blood thinners and even certainly with over-the-counter things like non-steroidals, fish oil, et cetera. We want no active infections in that area. One of the things we always do, so even for a regular lip filler, one of the first questions we ask them is cold sores. We treat them prophylactically before we do any sort of filler. And again, to just go over briefly, anatomy of the face. So the major pertinent anatomy for the lip area is once the facial artery comes off the mandibular border, it really separates into the branches, into the superior inferior labial artery that you need to be taken care of. And that is generally, it's deep. It's in the intramuscular deep layer. So if you stay pretty superficial with your lip filler, you're safe. And if we do anything in the chin area, you have to really be cognizant of the mental artery too. So those are the three main arteries that you need to be wary of when you do any sort of injectables. And treatment, again, you've probably seen this slide. It talks about danger areas. I know the lip isn't marked, but I've seen where patients refer from elsewhere who've had vascular injury to the labial artery when someone really does not pay any attention injecting lip fillers. And again, protocol for any patients, any filler. So this is the protocol we use for fillers throughout the face. I inject fillers other than the lip, the chin, nose, glabella, eyelids, et cetera. So the informed consent is quite in detail. So things it includes are certainly tissue necrosis, and I do have blindness in there as a rare risk. We take photographs, obviously. This is done, this is our routine, obviously. So topical numbing initially. I do have the mice. So this is something I do differently is once we numb for 10, 15 minutes, I have them ice the area for a few minutes because I do believe that the vasoconstriction can help with initial reducing bruising and obviously us inadvertently getting into a blood vessel. And for the lip area, I generally just use a needle. I don't use a cannula. Again, this is again for all fillers. We have an emergency protocol in place. All injectors are familiar with this. And we kind of go over this once every three times a year. We have tons of hyaluronidase because that is an enzyme that reverses any hyaluronic acid. We have lots of that. Other things we also have are aspirin, nitro paste. If you think you're inadvertently in have a vascular compromise, they get prophylaxis of antibiotic along with other treatments. So Pronox to help dilate any blood vessels. So we have that in the office that we use for other things. So we could use that. And really, if you've noticed tissue compromise from vascular injury, other than reversing it, something that really helps that tissue heal is hyperbaric oxygen. The Timalol is more for eye. The last two are really related more to the eye. But really the most important out of all this, you need to be able to identify if you're in a vessel and you need a lot of hyaluronidase to reverse it right away. So those are basically the two most important takeaways here. So we're gonna talk about a bunch of lip fillers. So a lot of times, so this is what it looks like. On the left side, you have this young woman. So a lot of these lip filler patients are gonna be young females. We'll show you a couple of males, but young females. So this patient population, so you have a young woman, she comes in for lip filler. So you see what it looks like right after. So a lot of times in social media, you'll see the lip right after, obviously really full. And in fact, in a day two, it may get even worse. So the third picture is how someone would look three months post. So that's what a one syringe of, this filler here, that's what it looks like. And she actually wanted more fullness, so that's her right after the second injection. And again, this tells you between the far left side and the slide adjacent to it, you see what happens with one syringe. So that's what one syringe of filler looks like. And again, this is when she had a second treatment, but it kind of gives you an idea of how full. It's nice to have these pictures to show patients so they have realistic expectations of what one syringe of filler will do. And again, more pictures of patients with what happens immediately after versus several months down the line. And this is again before and several months down the line, same thing before. And also we have pictures of patients who have different kind of fillers. Some patients really want very full lips, then we'll use a certain filler that has a higher G prime, higher viscosity. And then there are some patients who just want a very, very subtle look, then we'll choose a different kind of filler. And so with her, we've used a filler that is more subtle. And I call this more of a lip gloss effect. So just mild fullness, little more hydration, but not very full. And again, these are patients who've had fillers before and after. A lot of patients do like, and it's also really important to find out what they're looking for. Are they looking for just fullness? Are they looking for that smoothness? There's some fillers that end up being more hydrophilic. They'll give you that smoothness of the lips. If you look at her lips, you'll see how smooth and shiny they are. That's a personal preference. So if someone likes that, you have a choice. The various fillers in the market and can choose specifically a filler that'll tend to do that a little bit more. And again, this is what you can achieve with one syringe of filler. And this is, again, if you look at the rightmost picture, that's her pre-op, that's her after one session, after a couple of months, and then that's her after two sessions after a few months. So that's what you can go to as you can gradually increase their lips to what they desire. Again, so this patient has several things long. If you look at her, she's a little older. She's got a little bit of hair, but if you look at her, she's a little older. She's got that increase in upper lip height. She's got the lip variability, a pink of the upper lip doesn't show. So we did a couple of things for her. I actually injected some AHA product in the body of the upper lip. So when you look at her after the quarter view, you'll see how it appears shorter because the body of the upper lip is fuller and then I injected a little bit within her lip. So that's something you can do to rejuvenate. You can actually kind of produce youth and shortening of the body of the upper lip by creating a little more curvature by adding filler. So this is done, this filler is actually injected. When it's injected in the body of the lip, we're actually going quite deep. So intramuscular, behind the muscle, et cetera. Again, lip fillers are great for men also, but this is a smaller portion of our population when it comes to men who want some lip fillers. So he just wanted a little bit of fullness upper and lower lip. So this is considered a very difficult lip. So these are called M-shaped lips. So if you look at it, you'll see how her, the central lip, very, very full. And then you'll see that little arch that looks like an M. So a little difficult to treat and you need to kind of know why they're coming in and really address that correctly. Otherwise you can actually exacerbate and make it worse if you're just randomly filling the lip. And again, before and after with the M-shaped lip. So this is, we call lip rehab. These are patients who've been overfilled. They come in and they're like, I don't want this. I want all my lip filler dissolved. So this sometimes takes a lot. I read a study that talked about, this is a thicker filler. It's called Voluma. That's one of the higher density fillers to completely dissolve one CC of Voluma, you need approximately 10 CCs of hyaluronidase. So you can see how that ratio. So it depends on how thick your filler is. The thinner the filler, the less hyaluronidase. But if you start going for the very high G prime fillers, you're gonna need to use a lot of hyaluronidase. So for someone like this who needs a lip rehab, we usually do them in stages. We'll inject them, see them back in two weeks and then re-inject. And then have them wait two weeks to refill if we need to. So this patient did have it refilled. So she had the left picture is where she's full and it's not very happy. That's after dissolving. And the picture on the right is after we have refilled it. And again, same thing, a woman who's had overfilled lips and she wants, what they don't like is the mustache above the actual pink of the lip due to migration of the filler. And so this is her before, after dissolving. And she just, this is what she posted on her social media page, what she shows and what she looked like when you dissolved it and what she looks like afterwards. They love showing off their lips after any sort of correction. And again, so this is what I said. So this, you can use HE fillers to really help more than just the aesthetic part. So him, again, aesthetic, but if you look at this gentleman and not focus on his nose, I injected his nose. If you look at the upper lip, do you see how it's retreated? So the maxilla is retreated. And that is him after one cc of a dense filler. And you'll see how his upper lip now is more in balance. And his whole face is more now in really more harmony than pre-op. So that can be done. Literally, this is a 10 minute procedure. And these fillers, since they're more dense, they will last a year and a half to two years. And again, she also has, if you look at this young woman, she has a retreated, again, upper lip. It's more than just the vermilion border, the entire body of the lip. And so she obviously has some hypoplasia of her maxilla. So adding filler. So she had filler added to the body of her upper lip. And that, again, really balanced out her upper and lower lip. So there are a lot of things you can do with these fillers. And this young patient, obviously cleft lip palate, she's exhausted all surgical procedures done and she still wanted a little more improvement. So I injected not just her lip, a little bit of a nasal cell and a little bit of her nose, but certainly today we're talking about lips. So these patients, I would be really careful about taking on, especially initially, there's a lot of scar tissue. The anatomy will be completely, it's scary. You don't know where the vessels are. They could be entrapped in scar. So I would take these kinds of patients on very, very carefully. And so now we're going to be talking a little bit different. This is more for a gummy smile. So I prefer, and I'm going to show you a video. So for gummy smile, I prefer injecting the obicularis compared to injecting the nasolabial fold laterally, where you're kind of injecting part of the zygomaticus. So when I do this, it gives a more gentle, easy correction to these. So with her, she's had this kind of treatment done. So she had approximately three units of neuromodulator applied to the upper lip. So she had a total of six units applied to her upper lip. And so this is what she looks like before and after. What I prefer this to injecting along the nasolabial fold, because that actually affects your smile. So you will have a restricted smile here. Her smile appears normally, just that her lip doesn't move as much. And so I prefer this technique. And so we're going to be talking about some combination treatments. And these are all, again, non-surgical combination treatments. So obviously I showed you young women, but you can certainly extend this to older patients and use different fillers in different areas. So this patient, you'll notice that she's got a lot of perioral right tits. She's got a marionette line. She's got a little jowling, et cetera. So for her, we did a combination of filler for the perioral lines, a little bit of Botox, both for her upper lip lines. I usually like to do Botox along the DAO, about two to three units per side, and then some filler along her jawline. So you can get a nice, if you look at her pre-jowl sulcus and the jowls, all that in a post is kind of smoothed out by adding filler. And again, here you're going to have high density fillers along the jawline, going all the way from the gonial angle a little bit, all the way to the chin. And so in this area, I tend to use a cannula when I do this, but you can also do this using a needle and the syringe that comes, the needle that comes with the syringe. But you can get this kind of treatment without surgery. So her downtime would be primarily related to some bruising because these kind of treatments where you do a lot of fine injections in perioral area, I expect that she'll be bruised and she's a redhead, so she'll be bruised. So you kind of have to let them know ahead of time. So here we're, I'm talking primarily more about dermabrasion that I sometimes do isolate as a standalone office procedure, works very well, or I certainly combine with other procedures. So you can see in the upper left, she's got those fine right tits. She can move her mouth. She's got fine right tits. And then this is a post where you notice that she can still move. Her orbicularis is moving, but then overall the right tits are much improved. I do like, I still do like doing dermabrasion, works very well. So this patient only had some laser resurfacing just to give you an idea. So I think generally I would have you use procedures that work well in your hands. So I would say if chemical peels work well, really get to be a master of that. Same thing with lasers. I have a CO2 laser. I know how to work it well. So you want to become an expert in what you have and try to master what you have before you either try new techniques or buy more machines. And again, so in her, it was a combination along with other procedures. If you just focus on her perioral area, I did a lip lift along with some CO2 to rejuvenate her skin. And she also had a little fat transfer to her lip done. So it's kind of combination of several things to give you that rejuvenated look. And again, this patient had a combination of a CO2 laser along with fat transfer. And again, it kind of rejuvenates the entire lip area. And when I do my fat transfer, I'm not doing nano fat. I'm just doing micro fat transfer here. Again, this is a combination of a lip lift, fat transfer. So in her, I did a 30% TCA peel and not a laser. So you can combine these kinds of procedures easily together. So this patient has had a fat transfer to her nasolabial fold, to her lip area, along with CO2. And this patient has only had, she had fat transfer with the facelift and nothing else. So she, in her, I would say her fat transfer was good. She had enough take off the fat and you can see a nice before and after, but I'll show you another patient where she didn't do that well. That's gonna come up in a few slides down. So her again, so she had a younger patient, lip lift, fat transfer, both to her lips and her nasolabial fold. So this patient had fat transfer to the lips, didn't actually take very well. So then she just, we went back to a lip filler on the right side. Thank you. Thank you so much, Dr. Rajagopal. And this, we have some time for a couple of questions tonight. I, there's a few in the Q&A. I'm gonna start for Dr. Gajaran. Do you have a ratio to determine how much skin to excise for the seal incision of the lip lift? And I'm just gonna read them all because it's, and then, cause all related. Please describe the closure of the milky skin and describe the closure of the million border lift. And then Dr. Gajaran, have you had any effect? Have you seen any effect on lip length and incisors show with rhinoplasty specifically with rotation of the tip cephalically? You're muted, Dr. Gajaran. There are three good questions. Number one, for the vermilion border repair, I use 6-0 monocryl and 6-0 plain CAD-CUT. The ratio, mostly when we do it at the sub-nasal level is more like 65, 67%, meaning if I want to increase the incisor show, let's say three millimeters, I'm going to have to go with like four millimeters excision. And in terms of the role of the rhinoplasty in the lip, the answer is if yes, particularly if you use a collimolestrate and suspend the medial cura from the collimolestrate, you're going to increase the incisor show. Actually, we just had this month an article in the aesthetic surgery journal, two back-to-back articles about the role of rhinoplasty in the lip position that I recommend that whoever asked this question to read that. But specifically, you have to really suspend the medial cura and you can see discernible change in the incisor show. Essentially, you're doing a lip lift with the tip rotation and mainly gaining more projection to the tip. Thank you, Dr. Gayaran. There is another question for you. I just want to ask Dr. Rajagopal just a question as well. You mentioned hyperbaric oxygen in your practice. I don't know if it's something that you specifically use or just something obviously as a recommendation for an intravascular injection. And if it is something you use, is this something that you recommend as a facility or do you have actually hyperbaric oxygen? You know, they do have portable chambers now for the offices for lots of different reasons. So can you just comment on that? Yeah, so I don't have one in the office and we have places in San Francisco that we would pay a patient to go to if that happened. Having said that, I'm actually gonna be purchasing a hyperbaric oxygen chamber and I've done a lot of research on that. And I think there is value. It really does improve, you know, improve tissue survival if you do have injury. And I know in, I haven't seen as much, but in Southern California, it has become so commonplace that patients are having, going in to get hyperbaric oxygen after any procedure. So for us, it's pretty much any procedure. It can be a facelift. It can be a breast reduction, tummy tuck. It's starting to become a routine for anyone and anything in plastic surgery. Great, thank you. I have one more question for you. So you mentioned the MLIP and, you know, you kind of showed pictures of that, that transverse non-existent lip. You know, so just maybe just a couple of just tips for our audience about, you know, what filler are you actually choosing for that? Because getting that vermilion to show and trying to build that up, you know, especially Dr. O'Daniel kind of spoke about the glide planes and the possibility of building up that superior, you know, lip border where you get that chimpanzee look, you know, so how do you avoid that and how do you choose your filler? Yeah, so obviously there's tissue deficit in that area. You have the thickened filtral part of the lip and then laterally hardly any lip. So you kind of have to stretch it out with your filler. So we end up a lot of times using two, so I'm gonna name a couple of fillers that I would like to use. So one would be something called Restylane Kiss that is one of our most popular fillers to increase vermilion show. And then the way it's injected is we do it in what's called a picket fence. So basically going individual little pricks. It does hurt a little bit, but individual pricks that will give you generally more lip show. And then in addition to that, when you want to give more volume in that volume deficit area, I'll usually use another filler that again has a little more density and that will, and this I go transversely. So we're going cross hatching. So we're going to picket fence and then we go cross hatching. So this one, I would use like a medium thickness filler like a Velour. So I've mentioned two companies of Juvederm Velour and Restylane Kiss. That combination would give that kind of lip. That's great. I think it's very helpful for people to hear. So, and last we have time for one more question from the audience for Dr. Gayaran. How often is removal of the skin in the lower lip done in your practice? I actually have done it once and I wouldn't do it again. And I think that the lower lip has a tremendous capacity to form a scar, visible scar tissues unlike the upper lip. But while I have the opportunity, let me mention something that I mentioned and Jerry is actually focused on. And that is being careful about lifting the center of the lip beyond what is ideal. Most patients who have a longer lip have sort of ptosis of the central portions that they are ideal candidates for a sub nasal lip. But there are patients that I have said no to them because if I raise the center portion of the lip and I agree that with lateral excision, even without the dissection, we're going to raise the corner of the mouth as much to some degree. But even you saw on Dr. O'Donnell's cases, they were not, the corners didn't lift proportionally to the center portion. So we need to be careful not to create a rapid lip deformity, meaning the central rising too much. I'm seeing too much of that coming across patients who have had a lip lift and not paying attention to the balance between the corner of the mouth and the central portion, meaning cubits full. Thank you, Dr. Gajaran. I want to thank our panelists tonight. This has been incredibly informative. Thank you for sharing your experience with us this evening. Thank you for everybody who joined us this evening. And once again, plasticsurgery.org is the ASPS website. You can go to EdNet. This will be available to everybody who is an ASPS member, either a national member or an international member. So once again, thank you for your time and thank you for sharing your expertise with us. And thank you for joining us this evening, everybody. Have a great night.

perioral surgery

lip lifts

Dr. Ghayaran

Dr. O'Daniel

Dr. Rajagopal

lip aesthetics

neurotoxins

dermal fillers

perioral rejuvenation

facial aesthetics