Patients who don’t like the vertical lines that form above the lips when they pucker up may benefit from botulinum toxin injections.
"Many patients look at themselves in the morning and they’re not concerned about lip volume, but they’re concerned about these radiating lines that go around their mouth. We call this the ‘bar code,’ " Dr. Joel L. Cohen said.
Dr. Joel L. Cohen
These patients may complain of radiating lines when the mouth is animated, of lipstick bleeding out from the lips, or of a hollowed look around the mouth. The injection of botulinum toxin into the orbicularis oris muscles can "soften" the columns that appear when the mouth moves, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery in Las Vegas.
He and his associates compared two doses of onabotulinumtoxinA (Botox) to treat the bar code in a recent study of 60 patients. To make the comparison, the investigators first developed three photographic scales for classifying aesthetic features of the perioral area; they presented the scales in a poster at the 2011 meeting of the American Society for Dermatologic Surgery. The scale used in this study assigns a severity grade of none, mild, moderate, or severe vertical lip-line attributes when the lips are at maximum contraction.
All patients had moderate or severe vertical perioral lines at maximum lip contraction before being randomized to receive either 7.5 U or 12 U of Botox in a blinded fashion. Results were assessed for 53 patients at 4 weeks and for 51 patients at 12 weeks. In the 7.5-U group, moderate or severe perioral lines were seen in 15 of 28 patients who had 4 weeks of follow-up (54%) and in 21 of 25 patients who had 12 weeks of follow-up (84%). In the 12-U group, 9 of 25 patients with 4 weeks of follow-up had moderate to severe perioral lines (36%), as did 11 of 26 patients with 12 weeks of follow-up (42%).
Results in either group tended to dissipate by 12-16 weeks of follow-up. As expected, the rate and duration of adverse events were higher in the group that got 12 U of Botox.
"It really convinced us that low-dose botulinum toxin – in this case, it was Botox at 7.5 U – can have a durable response for about 12-16 weeks," said Dr. Cohen, who practices dermatology and dermatologic surgery in Englewood and Lone Tree, Colo.
The safety assessment included 59 patients who had at least one follow-up visit or reported an adverse event. Treatment-related adverse events were seen in 13 of 30 patients in the 7.5-U group (43%) and 18 of 29 patients in the 12-U group (62%). The treatment-related adverse events tended to resolve faster in the 7.5-U group, he said. Five patients in the 12-U group who had mild or moderate adverse events required follow-up, compared with no patients in the 7.5-U group.
In regular daily clinical practice, Dr. Cohen tends to use a total of 6-10 U around the mouth, treating both the upper- and lower-lip regions because patients say they feel "a little bit funny" if only the upper lip area is treated. He injects using BD Medical’s 31-gauge, short-hub needle, inserting it about a third of the way into the skin to stay superficial, he said.
In addition to affecting perioral lines, the injections produce what appears to be a pseudoaugmentation of the upper lip in some patients, although he is unable to predict which patients will have that reaction. "I don’t think we have a great understanding of that," he said.
When they get informed consent for Botox injections to treat vertical lip lines, dermatologists should warn patients that the treatment may affect their ability to whistle, drink from a straw, purse their lips, or enunciate the letters "P" and "B," he said. Dr. Cohen avoids this treatment in patients for whom these effects may be important, such as singers, woodwind instrument players, broadcast journalists, and scuba divers.
Some dermatologists have shied away from using onabotulinumtoxinA in the lower face after having had unsatisfactory experiences in some cases. "Understanding the anatomy is absolutely critical to success," Dr. Cohen said. "I hope that with this type of precise [anatomical] knowledge, people will give lower-face [onabotulinumtoxinA] another try."
The use of onabotulinumtoxinA in the lower face, in combination with fillers or with laser- or light-based treatments, "may be very, very helpful," he added. Botox alone would not be the primary treatment, for example, in a patient who has significant vertical lines above the upper lip when the mouth is at rest.