2016 - Surek - Técnica No-Touch para aumentar os lábios

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Lip augmentation has become one of the 
most popular cosmetic procedures in recent 
years. Although it is a seemingly simple tech-
nique, we frequently find inadequate results. We 
must ask ourselves a series of important questions 
before making an aesthetic improvement of the 
lips. In some instances, aesthetic improvement is 
not always equivalent to pure lip augmentation, 
and in certain cases, improving definition or pro-
portions can be equally effective. The focus of the 
injector should be centered toward lip improve-
ment and not necessarily lip enlargement.
Lip enhancement requires addressing the 
lip through its individual components along with 
the relationship of the entire construct (Figs. 1 
through 3). Using the reconstructive concepts 
from several hundred cleft lip, cleft palate, and 
various lip reconstructions that the senior author 
(J.B.) has performed,1 we seek to establish an ana-
tomically based stepwise method to determine the 
aesthetic needs of a patient seeking lip injections. 
Once the patient’s aesthetic needs are established, 
we can determine the proper approach to lip 
enhancement. Patient analysis is multifactorial and 
should assess asymmetries, facial aging, involved 
labial units, and lip proportions.1–30 An additional 
Disclosure: Dr. Beut has been a consultant for 
Q-Med. Dr. Guisantes has been a consultant for 
Merz. The remaining authors have no conflicts of 
interest to disclose.
Copyright © 2016 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000002568
Christopher C. Surek, D.O.
Eva Guisantes, M.D.
Kenna Schnarr, B.S.
Glenn Jelks, M.D.
Javier Beut, M.D.
Kansas City, Kan.; Barcelona and 
Palma de Mallorca, Spain; Kansas City, 
Mo.; and New York, N.Y.
Background: The purpose of this study was to examine the anatomical prin-
ciples of lip structure as they relate to individualized lip enhancement pro-
cedures and to describe a technique that does not violate lip mucosa during 
injection.
Methods: A retrospective analysis of patients undergoing lip enhancement pro-
cedures between 2001 and 2014 was performed. Preprocedural and postproce-
dural photographs were analyzed for lip subunit changes. A stepwise treatment 
algorithm targeting specific anatomical subunits of lip is described.
Results: Four hundred ten patients were treated with a “no-touch” technique 
for lip enhancement. Lip profile is determined by the position of the white 
roll. The white roll is accessed by a 30-gauge needle at a point 5 mm lateral to 
the oral commissure and at the base of the philtral columns. Lip projection 
is established by vermilion formation contributing to the arc of the Cupid’s 
bow. To improve projection, the labial commissure is entered with a 25-gauge 
cannula and tunneled into the submucosal space between the white and red 
rolls. Lip augmentation is a direct reflection of the prominence of the red line 
and can be approached in a perpendicular fashion with a needle or cannula 
descending to the level of the wet-dry junction.
Conclusions: Accurate assessment of the white and red rolls, arc of Cupid’s 
bow, philtrum, and gingival show can guide the injector on the proper en-
hancement that individual patients require. The no-touch technique minimiz-
es mucosal trauma. Tailoring treatment toward lip profile, projection, and/or 
augmentation can yield predictable and reproducible outcomes in this com-
monly performed cosmetic procedure. (Plast. Reconstr. Surg. 138: 603e, 2016.)
From the Department of Plastic Surgery, University of Kan-
sas Medical Center; Plastic Surgery Department, Hospital of 
Terrassa; Department of Anatomy, Kansas City University; 
Plastic and Reconstructive Surgery, New York University; 
and the Instituto Dr. Beut.
Received for publication September 15, 2015; accepted May 
17, 2016.
“No-Touch” Technique for Lip Enhancement
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COSMETIC
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Plastic and Reconstructive Surgery • October 2016
component of lip analysis, which is often under-
stated, is the attractiveness of the patient’s smile.
We feel that standard infiltration techniques 
can lead to prolonged edema and asymmetry. In 
this study, we intend to describe a reproducible 
lip analysis along with an injection procedure that 
does not violate the mucosa barrier, potentially 
minimizing trauma and aesthetic distortion.
PATIENTS AND METHODS
A retrospective review of 410 patients undergo-
ing no-touch lip enhancement with senior author 
Javier Beut from 2001 to 2014 was performed. 
Patient age ranged from 18 to 72 years. Preproce-
dure and postprocedure photographs were taken. 
Two frontal view photographs were obtained: the 
first photograph was obtained with the patient in 
repose, and the second was obtained with a Mona 
Lisa smile where attention was placed on not using 
the elevator or depressors of the lip. Right and left 
oblique and profile photographs were also taken.
Patients were analyzed for perioral facial 
symmetry, extent of facial aging, involved labial 
subunits, and individual lip proportions. For 
anthropometric study and evaluation of smile 
attractiveness, the patient’s teeth, gingiva, eth-
nic characteristics, white roll, vermilion, and wet-
dry junction were assessed (Figs. 4 and 5). Using 
established principles, optimal versus excessive 
gingival show was determined (Fig. 6).
The philtral columns, Cupid’s bow, nasolabial 
folds, white roll, vermilion segments, and wet-dry 
junction were marked. Eversion of the lip can 
assist with identification and marking of the red 
roll (Figs. 7 and 8). (See Video, Supplemental 
Digital Content 1, which demonstrates lip mark-
ing, available in the “Related Videos” section of 
the full-text article on PRSJournal.com or, for 
Ovid users, at http://links.lww.com/PRS/B839.) 
Local anesthetic block was performed using a 
combination of injection and topical application. 
Lidocaine hydrochloride 2% with epinephrine 
1:100,000 was used for the injections. Topical 
gel was placed over the vestibular mucosa. Cold 
compress was placed on the lips, and 10 minutes 
was allowed for vasoconstrictor effect. Patient-spe-
cific lip enhancement was performed. Injections 
were placed at the oral commissure and sequen-
tial spots on the vermilion cutaneous junction at 
three locations in the upper lip and two locations 
in the lower lip. The product used was hyaluronic 
acid (Restylane; Galderma, Uppsala, Sweden).
RESULTS
Analysis
In review of patients in this study, we found 
that there are five components to an attractive 
smile. The first component is teeth. The visible 
teeth when the patient smiles should be assessed 
for overall healthy appearance, color, shape/sil-
houette, and position. The second component is 
gingiva. The color, health, and symmetry of the 
gingivae relative to the teeth (especially the inci-
sors) should be evaluated. In the upper lip, we 
prefer the lip line to lie level with the gingival line. 
For the lower lip, we prefer the lip line to lie level 
with the incisal line (Fig. 6). The third component 
is the effect of facial aging in the perioral region. 
Loss of volume in the perioral fat and lip, orbi-
cularis oris action, and thinning of the skin need 
to be documented. The fourth component is the 
patient’s lip appearance relative to theirethnic 
standard. For example, white patients generally 
have thinner lips with longer philtral columns, 
whereas African American patients tend to have 
larger lips and shorter philtral columns. The final 
component to assess is the lip shape itself.
We found that we can best divide the lip into 
three defined areas of potential enhancement 
Fig. 2. The two aesthetic subunits of the lower lip.
Fig. 3. Aesthetic subunits of the upper and lower lips.
Fig. 1. The three aesthetic subunits of the upper lip.
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Volume 138, Number 4 • No-Touch Lip Enhancement
605e
based on the patient’s aesthetic need. The first 
area is the shape and definition of the “white 
roll,” the junction between the skin and dry ver-
milion, which determines lip profile. The second 
area is the vermilion itself between the white and 
red rolls, which determines lip projection. The 
third area is the red roll, which is the invagination 
of the orbicularis oculi muscle and wet mucosa, 
which correlates to lip augmentation (Fig. 9).
Special attention is paid to the patient’s inci-
sor show and gingival line (Fig. 6). Asymmetries in 
these aesthetic measurements are often observed. 
Optimal incisor show leans the injector toward a 
more conservative approach addressing lip pro-
file and projection, but not augmentation. In the 
case of excessive incisor show, mucosal show, and 
negative gingival line, augmentation is an option 
for patients wanting a volumetric approach to cor-
recting excessive incisor show. In patients with 
inadequate incisor show, lip length becomes an 
important factor. Patients with normal lip length 
may benefit from a technique focused on the region 
of lip projection, providing an increased “maxil-
lary soft-tissue” appearance. For those patients with 
Fig. 4. Page 1 of record-keeping sheet for lip analysis and treatment. (Printed with permission © 
Beut&Jelks group.)
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Plastic and Reconstructive Surgery • October 2016
poor incisor show and excessive lip length, a lip-
shortening procedure may be the best option. In 
our practice, young patients undergo a lip lift with 
an incision at the nasal base, whereas older patients 
with perioral rhytides will receive a lip lift with an 
incision located within the vermilion border.
Technique
No-Touch Infiltration Technique
The plunger on the filler is marked on the 
opposite side to the beveled opening on the 
needle23,24 (Figs. 10 and 11). The no-touch tech-
nique refers to the concept that the mucosa is 
never violated during infiltration. In all three 
facets of this method, the needle or cannula 
is inserted on the outside of the white line. 
Each technique can be performed with either 
a 29-gauge diameter/12-mm length needle or a 
25-gauge diameter/40-mm length blunt cannula.
Lip Profile
Correct display of the white roll tenses the 
upper lip. The needle or cannula is marked on 
Fig. 5. Page 2 of record-keeping sheet for lip analysis and treatment. (Printed with permission © 
Beut&Jelks group.)
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Volume 138, Number 4 • No-Touch Lip Enhancement
607e
the opposite side of the beveled opening and 
inserted 5 mm lateral from the oral commissure. 
Retrograde infiltration is performed beneath the 
white roll, working progressively toward the mid-
line in three segments (Fig. 10). Lower lip white 
roll infiltration lifts the oral commissure and is 
performed in two segments (Fig. 11). Lastly, the 
philtral columns are infiltrated from the base of 
the column vectored toward the nose or from the 
base of the nose vectoring toward the Cupid’s 
bow. (See Video, Supplemental Digital Content 2, 
which demonstrates lip profile, available in the 
“Related Videos” section of the full-text article on 
PRSJournal.com or, for Ovid users, at http://links.
lww.com/PRS/B840.) If a cannula is chosen for use 
for white roll profile, a needle is still used for the 
Cupid’s bow profile-plasty.
Lip Projection
Cannula Technique: The oral commissure is the 
port of entry (Fig. 12). A passage is initially made 
with a 21-gauge needle. Then, a 25-gauge cannula 
is gently passed in a rotary motion into the sub-
mucosal space, between the white and red rolls 
(Fig. 13). Sequential boluses in a retrograde fash-
ion are placed starting cephalically and working 
caudally as required for symmetry. Slow injection 
and careful observation is required. (See Video, 
Supplemental Digital Content 3, which demon-
strates lip projection, available in the “Related 
Videos” section of the full-text article on PRSJour-
nal.com or, for Ovid users, at http://links.lww.com/
PRS/B841.)
Fig. 6. Illustration of gingival line and incisor line.
Fig. 7. Photograph of patient with marking of lip aesthetic sub-
units. The philtral columns, Cupid’s bow, nasolabial fold, white 
roll, vermilion segments, and wet-dry junction are marked.
Fig. 8. Photograph of patient demonstrating upper lip eversion 
to assist with identification and marking of the red roll.
Video 1. Supplemental Digital Content 1, which demonstrates 
lip marking, is available in the “Related Videos” section of the 
full-text article on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/B839.
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http://links.lww.com/PRS/B841
http://links.lww.com/PRS/B841
http://links.lww.com/PRS/B839
http://links.lww.com/PRS/B839
Rud Varela
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Plastic and Reconstructive Surgery • October 2016
Needle Technique: The injector positions himself 
or herself behind the patient. The needle is passed 
into the skin directly outside the vermilion, passing 
under the white roll, without puncturing the labial 
mucosa directly. Boluses are deposited throughout 
the three segments of the upper lip. The expansion 
of the vermilion is perceived with the index finger. 
Each hemilip is compared for symmetry. Needle 
technique is a good option for precise touchup 
after cannula treatment (see Video, Supplemental 
Digital Content 3, http://links.lww.com/PRS/B841).
Lip Augmentation
Cannula Technique: The oral commissure is 
the port of entry. A passage is initially made with a 
21-gauge needle. Then, a 25-gauge cannula is gen-
tly passed in a rotary motion into the submucosal 
space, inferior and deep to the red roll. Sequential 
boluses are placed starting cephalically and working 
caudally as required for symmetry. (See Video, Sup-
plemental Digital Content 4, which demonstrates 
lip augmentation, available in the “Related Videos” 
section of the full-text article on PRSJournal.com or, 
for Ovid users, at http://links.lww.com/PRS/B842.)
Needle Technique: The injector positions him-
self or herself behind the patient. The needle is 
Fig. 9. Photograph demonstrating the location of lip enhancement 
of lip profile, lip projection, and lip augmentation.
Fig. 10. Demonstration of performing upper lip profile tech-
nique for enhancement of the white roll. Note the purple mark-
ing on the needle hub, which represents the nonbeveled side of 
the needle. Retrograde infiltration is performed in segments to 
address each hemilip subunit and Cupid’s bow.
Fig. 11. Demonstration of performing lower lip profile tech-
nique for enhancement of the white roll. Note the purple mark-
ing on the needlehub, which represents the nonbeveled side 
of the needle.
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Volume 138, Number 4 • No-Touch Lip Enhancement
609e
passed into the skin directly outside the vermilion 
passing under the white roll, without puncturing 
the labial mucosa directly. The vector is focused 
deep and perpendicular to the red roll. Boluses 
are placed beneath the wet vermilion. The expan-
sion of the red roll and wet mucosa is perceived 
with the index finger. Each hemilip is compared 
for symmetry. Needle technique is a good option 
for precise touchup after cannula treatment. Pre-
procedure and postprocedure photographs are 
shown in Figures 14 through 16.
DISCUSSION
Improvement of facial aesthetics requires a 
good working knowledge of the lip and perioral 
anatomy. The inspiration for this subunit approach 
to lip rejuvenation stems from fundamentals seen 
in cleft lip and palate repair. These operations 
present surgeons with a complex surgical puzzle, 
where one must rebuild all structures that are clin-
ically absent but anatomically present. The evolu-
tion of lip reconstruction techniques has allowed 
us to work within these reconstructive parameters 
and apply them to technical aesthetics for improv-
ing the appearance of a normal lip.
Most lip injections are typically performed with 
a linear threading or serial puncture technique 
proceeding from medial to lateral, often without 
a clear understanding of the underlying anatomy. 
Along the lip body, the targeted level for filler 
Fig. 12. Demonstration of entry point of cannula-based 
enhancement of upper lip projection.
Video 2. Supplemental Digital Content 2, which demonstrates 
lip profile, is available in the “Related Videos” section of the full-
text article on PRSJournal.com or, for Ovid users, at http://links.
lww.com/PRS/B840.
Fig. 13. The technique for cannula-based enhancement of lip 
projection begins by gentle rotary advancement of the cannula 
within the submucosal space, between the white and red rolls. 
Retrograde injections are performed to desired volumization of 
the dry vermilion.
Video 3. Supplemental Digital Content 3, which demonstrates 
lip projection, is available in the “Related Videos” section of the 
full-text article on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/B841.
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Plastic and Reconstructive Surgery • October 2016
placement is within the submucosa just above the 
orbicularis oris muscle. Traditional techniques tar-
geting increased red vermilion definition describe 
inserting the needle directly into the mucosa. 
However, we feel this mucosal trauma may lead 
to aesthetic distortion during the procedure or, 
more importantly, prolonged edema and ecchy-
mosis following the procedure. These unwanted 
adverse events can be dissatisfying for the patient 
and a source of frustration for the injector. Many 
younger patients benefit from volume enhance-
ment along the philtral columns, which helps to 
further outline and define the lips. This usually 
involves mid-dermis filler injection within the base 
of each column. In older patients, lip enhance-
ment involves the same considerations as above.
This no-touch technique is applicable to any 
brand of hyaluronic acid filler. The authors do 
not carry an industry bias; however, the patients in 
this series were treated with Restylane (Restylane, 
Perlane, and Vital; Q-Med AB, Uppsala, Sweden). 
Restylane is a transparent gel composed of hyal-
uronic acid isolated from a species of Streptococcus 
and chemically cross-linked with 1,4-butanediol 
diglycidyl ether.4,5 Because it is a nonanimal 
source of hyaluronic acid, there is minimal risk of 
Fig. 14. (Above) Preprocedure anteroposterior photograph dem-
onstrating flattening of the philtral columns, widening of the 
Cupid’s bow, blunting of the white roll, and diminished lip vol-
ume. (Below) Postprocedure anteroposterior photograph follow-
ing enhancement of lip profile, projection, and augmentation.
Fig. 15. (Above) Preprocedure anteroposterior photograph of a 
smiling patient demonstrating excessive gingival show of the 
upper alveolus. (Below) Postprocedure anteroposterior photo-
graph of a smiling patient following enhancement of lip profile, 
projection, and augmentation.
Video 4. Supplemental Digital Content 4, which demonstrates 
lip augmentation, is available in the “Related Videos” section 
of the full-text article on PRSJournal.com or, for Ovid users, at 
http://links.lww.com/PRS/B842.
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Volume 138, Number 4 • No-Touch Lip Enhancement
611e
an allergic reaction, and skin testing before injec-
tion is unnecessary.
Potential adverse reactions are minimal and 
are mainly injection-related and self-resolving.6 
Common issues on injection include pain, swell-
ing, erythema, discoloration, tenderness, and 
temporary palpable nodules at the injection site 
that typically resolve within 1 week.
Friedman et al.10 reviewed data acquired from 
Q-Med Esthetics of adverse events of 306,000 
patients that were treated with nonanimal stabi-
lized hyaluronic acid gel (Restylane, Perlane, and 
Restylane Fine Lines) between 1999 and 2000 
from physicians in Europe, Canada, Australia, 
South America, and Asia. In 1999, there were 
222 adverse events reported from approximately 
144,000 patients, corresponding to one of every 
650 patients. The major adverse reaction to inject-
able hyaluronic acid was localized to hypersensi-
tivity reactions, occurring in approximately one in 
every 1400 patients. In 2000, an estimated 262,000 
patients were treated with Restylane. One hun-
dred forty-four adverse events were reported, cor-
responding to one in every 1800 patients treated. 
The most significant adverse event was again local-
ized hypersensitivity, occurring in one in every 
5000 patients treated. The reduction in adverse 
events and hypersensitivity reactions between 
1999 and 2000 was attributed in improvement in 
purification of bacterial fermentation.7
Guidelines on the most effective application 
and use of Restylane were reported in 2006 based 
on the consensus of a large group of experienced 
injectors across the aesthetic specialties.4,5 The 
majority (65 percent) of consensus panel members 
used an anesthetic combination of an infraorbital 
block with a commissure block. Most panel mem-
bers administer infraorbital blocks intraorally 
using approximately 1.0 ml of anesthesia. Among 
70 percent of panel members, 1.0 ml is the typi-
cal volume of Restylane injected, although the 
amount was adjusted depending on the patient. 
First, the cutaneous-vermilion border was injected 
to create distinct borders and contours. Then, the 
lip vermilion segments were injected to add full-
ness and proportion to the upper and lower lips.
Accurate identification of the red and white 
rolls, the arc of the Cupid’s bow, the philtrum, 
and dental exposure give the injector a frame-
work for constructing a precise and symmetric 
lip enhancement. This approach facilitates indi-
vidualized treatment of the patient’s needs with-
out following templates of lip type. We divide 
the technique into three parts: profile, projec-
tion, and lip augmentation. Not all patients will 
need all three steps of the infiltration technique; 
they may require onlyprofiling, only projection, 
or just an increase in the lip height through 
augmentation. It is very important to identify 
what the patient does and does not require, to 
achieve natural results. In some cases, the lip 
enhancement treatment includes maxillofacial 
surgery and not infiltration with fillers. This is 
analogous to situations where certain patients 
present requesting a chin augmentation or rhi-
noplasty, but once the surgeon evaluates them 
it becomes apparent that orthognathic surgery 
is indicated.
A strong command of the vascular anatomy of 
the lip is the first step toward a safe and effective 
Fig. 16. (Left) Preprocedure oblique photograph showing patient disproportion of the upper 
lip volume compared with the lower lip. (Right) Postprocedure oblique photograph following 
enhancement of lip profile, projection, and augmentation.
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612e
Plastic and Reconstructive Surgery • October 2016
lip volumization.17–19 The no-touch technique of 
infiltration allows injectors to mold the lip without 
puncturing the mucosa, which reduces edema, 
ecchymosis, postoperative discomfort, and the 
“bee-stung” effect. In our hands, this has allowed 
greater precision, product life, and control of the 
infiltration. Edema and ecchymosis of the mucosa 
can quickly alter lip shape, distorting injector 
assessment during the procedure. Trauma to the 
mucosa can cause inflammation and thus the 
absorption of the filler may be quicker. This tech-
nique may also reduce the risk of contamination 
and infection by oral flora, as the skin is less con-
taminated than the oral mucosa. This technique 
is a stepwise algorithm based on anatomical prin-
ciples that has the ability to produce predict-
able results with a low margin for error. We must 
inform the patient of all the asymmetries before 
treatment because patients are often not aware of 
these asymmetries until after an aesthetic treat-
ment. We do not recommend permanent mate-
rials because of the risk of short- and long-term 
complications.
CONCLUSIONS
Accurate assessment of the white and red 
rolls, arc of Cupid’s bow, philtrum, and gingi-
val show can guide the injector on the level of 
enhancement each individual patient requires. 
Submucosal placement is critical for long-lasting 
results. The use of a no-touch technique facili-
tates proper enhancement without traumatiz-
ing the mucosa, potentially decreasing edema 
and postoperative bruising. Tailoring techniques 
toward lip profile, projection, and/or augmen-
tation can yield more precise, predictable, and 
reproducible outcomes in this commonly per-
formed cosmetic procedure. The ultimate goal 
is to achieve more natural results and improved 
patient satisfaction.
Christopher C. Surek, D.O.
Department of Plastic Surgery
University of Kansas Medical Center
3901 Rainbow Boulevard, Mailstop 3015
Kansas City, Kan. 66160
csurek@kumc.edu
ACkNOwLEDgMENTS
The authors would like to extend a special thanks to 
Marina Guisantes from petiteguisantita.com for medical 
illustrations. They also extend special thanks to Galderma 
Spain for product support for part of the study, along with 
the Asociación Española de Cirugía Estética Plástica and 
the Instituto Anatomico Universidad de Valencia.
REfERENCES
 1. Beut FJ. Cleft Lip & Palate Manual. Cirujanos Plastikos Mundi: 
CPM First East Indian International Cleft Surgery Workshop; 
Bathalapali, India; CPM & Smile Train.
 2. Caruthers A, Caruthers J. Nonanimal based hyaluronic acid 
fillers: Scientific and technical considerations. Plast Reconstr 
Surg. 2007;120:33S–40S.
 3. Jansen DA, Graivier MH. Evaluation of a calcium hydroxyap-
atite-based implant (Radiesse) for facial soft-tissue augmen-
tation. Plast Reconstr Surg. 2006;118:22S–30S. 
 4. Carruthers J, Matarasso S, Jewell M. Consensus recom-
mendations for soft-tissue augmentation with nonanimal 
stabilized hyaluronic acid (Restylane). Plast Reconstr Surg. 
2006;117(Suppl):3S–34S; discussion 35S–43S. 
 5. Fagien S, Fitzgerald R, Matarasso A. Introduction to 
“soft-tissue fillers and neuromodulators: International 
and multidisciplinary perspectives”. Plast Reconstr Surg. 
2015;136(Suppl):9S–10S.
 6. Medicis Aesthetics, Inc. Restylane injectable gel (nonani-
mal stabilized hyaluronic acid; NASHA) (package Insert). 
Scottsdale, Ariz: Medicis Aesthetics; 2008.
 7. Baumann L. Replacing dermal constituents lost through aging 
with dermal fillers. Semin Cutan Med Surg. 2004;23:160–166.
 8. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectable 
hyaluronic acid gel for soft tissue augmentation: A clinical 
and histological study. Dermatol Surg. 1998;24:1317–1325.
 9. Matarasso SL. Injectable collagens: Lost but not forgotten. 
Review of products, indications, and injection techniques. 
Plast Reconstr Surg. 2007;120:17S–26S.
 10. Friedman PM, Mafong EA, Kauvar AN, Geronemus RG. Safety 
data of injectable nonanimal stabilized hyaluronic acid gel 
for soft tissue augmentation. Dermatol Surg. 2002;28:491–494.
 11. Fagien S, Klein AW. A brief overview and history of tem-
porary fillers: Evolution, advantages, and limitations. Plast 
Reconstr Surg. 2007;120(Suppl):8S–16S.
 12. Fagien S. Facial soft tissue augmentation with autolo-
gous injectable collagen. In: Putterman AM, ed. Cosmetic 
Oculoplastic Surgery: Eyelid, Forehead, and Facial Techniques. 3rd 
ed. Philadelphia: Saunders; 1998:367–375.
 13. Henly DR, Barrett DM, Weiland TL, O’Connor MK, Malizia 
AA, Wein AJ. Particulate silicone for use in periurethral 
injections: Local tissue effects and search for migration. J 
Urol. 1995;153:2039–2043. 
 14. Dewan PA, Hoebeke PE, Hall H, Chow CW, Edwards GA, 
Terlet J. Migration of particulate silicone after ureteric injec-
tion of silicone. BJU Int. 2000;85:557.
 15. Dolwick MF, Aufdemorte TB. Silicone-induced foreign body 
reaction and lymphadenopathy after temporomandibular joint 
arthroplasty. Oral Surg Oral Med Oral Pathol. 1985;59:449–452.
 16. Hatanaka S, Oneda S, Okazaki K, et al. Induction of malig-
nant fibrous histiocytoma in female Fisher rats by implanta-
tion of cyanoacrylate, zirconia, polyvinyl chloride or silicone. 
In Vivo 1993;7:111–115.
 17. Lee SH, Gil YC, Choi YJ, Tansatit T, Kim HJ, Hu KS. 
Topographic anatomy of the superior labial artery for der-
mal filler injection. Plast Reconstr Surg. 2015;135:445–450.
 18. Tansatit T, Apinuntrum P,Phetudom T. A typical pattern of 
the labial arteries with implication for lip augmentation with 
injectable fillers. Aesthetic Plast Surg. 2014;38:1038–1089.
 19. Nakajima H, Imanishi N, Aiso S. Facial artery in the upper lip 
and nose: Anatomy and a clinical application. Plast Reconstr 
Surg. 2002;109:855–861; discussion 862.
 20. Matsson L, Goldberg P. Gingival inflammation at deciduous 
and permanent teeth: An intra-individual comparison. J Clin 
Periodontol. 1986;13:740–742.
Maria Clara Rosa Muniz - eubiomariaclara@gmail.com - IP: 179.174.208.130
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613e
 21. The Burton Goldbery Group. Alternative Medicine: The Definitive 
Guide. Tiburon, Calif: Future Medicine Publishing; 1995.
 22. Goldberg PV, Higgijnbottom FL Wilson TG. Periodontal 
considerations in restorative and implant therapy. Periodontal 
2000 2001;25:100–109.
 23. Lip enhancement, the no touch technique. Presented at: 
Beut Jelks Symposium; 2010.
 24. Beut J. The no touch technique, master class. Presented 
at: International Master Course on Aging Skin; Palma De 
Mallorca; 2008.
 25. The no touch technique for lip enhancement. Presented at: 
Vallex Symposium; 2011.
 26. Hilinski JM, Cohen SR. Volumetric use of injectable 
fillers in the face. In: Amsterdam: Elsevier Health; 2007:1–17.
 27. Fledman J. Secondary repair of the burned upper lip. Perspect 
Plast Surg. 1987;1:31–67.
 28. Rohrich RJ, Pessa JE. The anatomy and clinical impli-
cations of perioral submuscular fat. Plast Reconstr Surg. 
2009;124:266–271.
 29. Flowers R. Blepharoplasty and peri-orbital surgery. Clin Plast 
Surg. 1993.
 30. Rumyantsev E, Beut J, Dyachencko Y. What’s new in lip injec-
tion. Plast Aesthet Med. 2012;80–90.
Maria Clara Rosa Muniz - eubiomariaclara@gmail.com - IP: 179.174.208.130