An alternative approach to vertical lip lines

Dr. Dover

Dermatologist Jeffrey S. Dover, M.D., frequently deals with the challenge of treating vertical lip lines at his Chestnut Hill, Mass., practice. He says traditional treatment options using neurotoxins or filler injections are far from optimal.

“Upper lip lines - vertical lip lines - are very difficult to treat, and when you survey most women it’s near the top of their hit parade of things they dislike the most,” Dr. Dover says.

But there is an approach, which he and his practice colleagues refined, that uses laser-assisted delivery of topical poly-l-lactic acid (PLLA) to treat upper lip rhytides. Dr. Dover was senior author on a paper published July 2019 in Dermatologic Surgery  suggesting laser-assisted delivery of PLLA is a safe and might be effective for treating the pesky lines.¹ He tells Dermatology Times his practice has since done nearly 100 cases using the approach, and he is a believer.

Current Treatment Options

Dr. Dover says clinicians most commonly use either neuromodulators or fillers to treat upper lip lines.

Using neuromodulators tends to be the simplest and least expensive of today’s options and aims to gently weaken the patient’s pucker and the approach is used because it addresses one of the root causes of the lip lines.

But getting good outcomes can be tricky.

“If you use too high a dose, the patient won’t be able to speak or drink from a straw or even out of a glass,” Dr. Dover says. “A very low dose works, but it takes months to see improvement. We believe that if it’s done on a somewhat regular basis, every three or four months, you can stop the natural progression, and slowly but surely the lines start to soften.”

Another option is to gently fill the upper lip lines with a soft hyaluronic acid (HA) filler. Dr. Dover’s favorites for the task are Volbella (Juvederm, Allergan), Restylane Silk (Galderma) or Belotero (Merz).

“Fillers work, but it’s painful. It often causes swelling and bruising and it doesn’t last that long,” he says. “It works well in conjunction with neuromodulators and when lip lines are fine, but it’s doing nothing to actually reverse the cause. That’s why we started to look at other potential ways to improve these lines and to improve photoaging around the mouth.”

The OMAR Approach

In a study published June 2014 in Dermatologic Surgery dermatologist researchers showed they could treat atrophic scars by using fractional ablative laser resurfacing by making thousands of little holes in the skin and applying PLLA, to where the liquid filler entered the holes.2

“This was one of the earliest studies in the field now called laser-assisted drug delivery,” Dr. Dover says.

Dr. Dover, along with Omer Ibrahim, M.D., the practice fellow, and Kenneth A. Arndt, M.D., a partner at SkinCare Physicians where Dr. Dover practices, secured funding from the ASDS for a study using laser-assisted drug delivery on vertical lip lines through the Fredric S. Brandt MD Innovations in Aesthetics grant. The researchers studied 10 women who received fractional ablative laser-assisted topical PLLA (Sculptra, Galderma) delivery to treat their vertical lip lines. Patients had three bimonthly treatments of low-density fractional carbon dioxide laser followed by topical application of PLLA suspension, according to the Dermatologic Surgery abstract.

“We treated just the upper lip. We only used topical anesthesia. The procedure was very well tolerated and there was no pain after the procedure. Healing time was on average five to six days. There was redness, a bit of swelling and light crusting. Simple wound care started the day after with gentle cleansing and Aquaphor Healing Ointment,” Dr. Dover says. “We saw on average 49% improvement of the lip lines on digital photographic analysis. Patients thought it looked better, and equally importantly, we measured the number of lines, the depth and the appearance of them and could quantify the improvement.”

Dr. Dover says that since doing the study he and practice colleagues have treated almost 100 patients using the approach. They’ve treated not just upper lip lines, but also lower lip lines and have started to extend treatment to lines on the cheeks and around the eyes, and occasionally to the entire face.

“So far, we’ve seen improvement in 100% of patients,” Dr. Dover says. “We are just analyzing the data, but for the most part all patients are pleased with the improvement and there have been no long-term side effects.”

Dr. Dover says he and colleagues have not seen any nodules from the Sculptra that can be seen when the product is injected and don’t think they will because of the technique they’re using, he says.

“When we treat the upper lip, 2000 tiny laser ‘holes’ are produced, and a small amount of Sculptra is applied to the lip, and it fills the holes uniformly with tiny amounts of product, unlike the clumps of product which end up in the skin when the product is injected,” he says.

The procedure, which the doctors have since nicknamed OMAR, for “optimized mechanical ablative rejuvenation,” isn’t a perfect solution, but Dr. Dover favors it over other options for the treatment of vertical lip lines.

“You’re not going to get rid of the deep etched lines. But for mild to moderate vertical lines on the upper lip or for that matter around the face, we think it’s a lovely new addition to our options for treatment,” he says. “We recommend doing it in conjunction with Botox [Allergan] or Dysport [Galderma] to optimize the outcome.”

Disclosures:

Dr. Dover receives research support from and has consulting agreements with Lumenis and Solta (Bausch).

References:

1. Ibrahim O, Ionta S, Depina J, Petrell K, Arndt KA, Dover JS. Safety of Laser-Assisted Delivery of Topical Poly-L-Lactic Acid in the Treatment of Upper Lip Rhytides: A Prospective, Rater-Blinded Study. Dermatol Surg. 2019;45(7):968-974.
2. Rkein A, Ozog D, Waibel JS. Treatment of atrophic scars with fractionated CO2 laser facilitating delivery of topically applied poly-L-lactic acid. Dermatol Surg. 2014;40(6):624-31.