One of the most popular treatment areas for dermal fillers is the lips. Why is this? Perhaps it is images from social media influencers, celebrities, and photo filters. Has this changed the societal images of what beauty really is? Or maybe it is because injectables are becoming more popular and mainstream. They are not something that everyone is keeping as a secret. It is normal for people to openly talk about their Botox or filler appointment. Beauty enhancement or youth preservation has become the norm in society.

REALITY VERSUS PHOTO

In addition to lip augmentation being an injectable trend, there are always different lip filler “styles” that many patients request,although it is not as simple as that. One cannot show a picture of what they want their lips to look like because that is unrealistic. The patient should ask themselves, “What are my lip goals?” For example, some people want larger and more voluminous lips, while others want more of a mild plump or hydrated look. Or perhaps one’s top lip has always been very thin, and the goal is to build the top lip. Whatever the goal, a plan can be devised with a professional aesthetic injector.

QUICK FIX

Lips are a popular injectable area because people of all ages are seeking lip augmentation, whether in their 20s and have always wanted plumper lips or in their 60s and wanted to restore their lips back to their previous life when they were younger.Lip filler is a quick go-to. Additionally, while some areas on the face may take multiple syringes, the lips can show a subtle but noticeable difference with just one syringe. Although, those with naturally thin lips will need more than one syringe to attain a full, yet natural pout.

EDUCATIN CLIENTS ON STYLES

Recently, popular lip filler style that has been going around on social media platforms is the full Russian lip. This is a large lip that usually requires more than one syringe of lip filler. Depending on the provider, more filler may be broken up at subsequent appointments or one milliliter to two milliliters of filler at the same appointment.

As a provider, one must educate patients requesting the Russian lip filler style. There is a fine balance because not every individual’s face can accommodate large lips. Depending on facial structure and ethnicity, a larger lip may look natural. For example, typically Caucasians have thinner lips, as well as different lip ratios compared to African Americans or Asians.

RATIOS

While beauty is easily identified, it is has been attempted to quantify for thousands of years. In fact, various lip proportion measurements have been dated back from 300 B.C. The golden ratio, seen with da Vinci, has been used to describe classic proportions of the lips. In youthful Caucasians, the ideal ratio is 1:1.6, describing the vertical height of the upper lip compared to that of the lower lip. Again, this is very individualized as there are Caucasians that naturally have different lip ratios, such as more of a 1:1 ratio or various other ratios.

Other ethnicities tend to have more of a 1:1 ratio naturally. African Americans genetically have a greater lip volume, so a fuller lip may look more natural. While people with lighter skin obviously lose lip volume with age, people of darker skin tend to retain most their volume with aging. This is due to increased melanin that makes them less prone to solar elastosis.

In addition to taking into consideration different lip ratios, another measure to perhaps quantify beauty is the rule of horizontal thirds. Different ethnicities make up different proportions of these facial thirds, which divides the face into three equal parts horizontally. Furthermore, the lower third is also divided into thirds. This extends from the end of the nose to the chin. These represent the upper lip, lower lip, and chin. This rule can be helpful in harmonizing the facial aesthetics of an individual.

CREATING HARMONY

So, no matter what specific trend of lip filler a patient may request, if it is a larger lip they are hoping to achieve, it is important to assess the patient’s natural lip shape, as well as facial features. Some patients may want overly filled lips that can easily look disproportionate. Bigger is not always better. In fact, an overly large lip can make a patient look overdone and age their facial features.

DISPLACED FILLERS & TECHNIQUES TO UTILIZE

Overfilled lips can have a duck-like or Marge Simpson appearance due to filler migration. This is when the lip filler is outside the vermillion boarder. Sometimes this occurs due to the type of filler chosen, the injection technique, patients’ anatomy, or just the muscle of the mouth moving, which eventually can cause the filler to migrate. The orbicularis oris – the muscle around the lips is a sphincter muscle, so with repetitive movement, the filler will sometimes migrate. No matter what the cause, it is important as a provider to point this out to the patient during consultation. The great thing about hyaluronic acid filler is that it can be dissolved with hyaluronidase. Many patients may have built up to their current lip size, so when the discussion of dissolving them comes into play, they can be turned off. But adding filler to this type of lip can make the lip filler look even more displaced.

CONSULTATION & COMMUNICATION

For patients seeking a more natural lip augmentation look, hyaluronic acid fillers are great because they draw in moisture. Therefore, they help moisturize the lips. It is especially important to discuss the patients natural lip shape and volume. Many patients will say, “I just want my lips a little plumper.” If you do not ask more questions, the patient may end up with lips that they were not envisioning. When in turn, a few more questions asked by the injector would have given the patient exactly what they had in mind. Question lip ratios and what the patient seeks regarding this. Do they want a fuller top lip? Do they want the top lip to be the same size as the bottom lip? Asymmetries should be pointed out and targeted for correction.

A TRAINED EYE

The aging lip is inevitable. The vermilion body decreases in size, the cutaneous portion of the upper lip starts to elongate, the cupids bow becomes less defined, the development of upper and lower rhytids, and volume loss at the oral commissures cause the corners of the lips to turn down creating a frown appearance. From the age of 25,collagen production decreases by about 1% per year, including the lips. The aging lip can be targeted with hyaluronic fillers. Fuller lips are associated with youth, so when a natural volume is restored in the aging patient, it can add youthfulness. Many patients are pleased and think they immediately look a decade younger.

Is there an ideal lip? The answer is yes, there is an ideal lip shape for each patient based on their natural lip shape, facial features, ethnicity, and sexual identity. Lips are a focus of symmetry of the face. Lips create a state of harmony.They aide in balancing other facial features. Whilst different filler trends and societal ideals will come and go, a trained aesthetic eye will always take into consideration other facial features to balance one’s face and create unity and beauty.

Leigh Reese is a board-certified nurse practitioner and certified nurse injector. She earned her bachelor of science in nursing from Texas Women’s University in 2013 and her master of science in nursing from The University of Texas at Arlington in 2019. Her background in the medical field has been in emergency room medicine and aesthetic medicine. Her goal is to create a natural and youthful appearance for her patients and help devise a plan for their aesthetic journey. She has a passion for continuing education, and her position at SkinRXSpa allows her to attend monthly advanced trainings. 

Many injectors, especially when new to the industry, question which dermal filler is the best filler for the specific targeted area on the face. However, other considerations also come into play when making this decision, such as the client’s anatomy and age. It is important to realize that not all dermal fillers are created equal. The most common type of filler is one comprised of hyaluronic acid.

Leigh Reese is a board-certified nurse practitioner and certified nurse injector. She earned her bachelor of science in nursing from Texas Women’s University in 2013 and her master of science in nursing from The University of Texas at Arlington in 2019. Her background in the medical field has been in emergency room medicine and aesthetic medicine. Her goal is to create a natural and youthful appearance for her patients and help devise a plan for their aesthetic journey. She has a passion for continuing education, and her position at SkinRX Spa allows her to attend monthly advanced trainings.

The trendy vampire facial refers to an aesthetic procedure involving microneedling and platelet-rich plasma. The procedure gained attention in 2013 when Kim Kardashian appeared to struggle through a bloody-looking facial treatment on her reality television show. This example of a vampire facial is hardly the reality that most providers and clients experience. The vampire facial is a staple in aesthetic medicine due to its extraordinary results and minimal downtime. The treatment covers a wide scope of concerns including overall skin rejuvenation, fine lines and wrinkles, large pores, acne scarring, dull skin, lax skin, sun damage, uneven skin tone, and hair loss.

Terri Wojak is a highly sought-after professional with over 20 years of experience in the aesthetic industry. Wojak is the education director of GlycoAla and runs her own education company – Aesthetics Exposed Education. She is a respected authority on skin care in a medical setting, education, and business development on multiple levels. Wojak has built 50 individual courses based on skin care in a medical setting. More than 100 articles by Wojak have appeared in a multitude of industry magazines, and she has published two books, “Aesthetics Exposed: Mastering Skin Care in a Medical Setting & Beyond,” in May 2014, and “Mastering Medical Esthetics,” debuted in 2009. Wojak has trained over 5,000 aestheticians and medical professionals on the importance of incorporating skin care into cosmetic medicine, ultimately helping patients and medical providers alike.

Social media has quickly become one of the biggest platforms used by aesthetic providers everywhere.  Sites like Instagram showcase their most popular before and after images like a highlight reel. Prospective clients are left in awe of treatments they may never have known existed if it were not for them being posted. One such treatment that has frequented everyone’s newsfeed lately has been the non-surgical rhinoplasty, or termed “liquid nose job.” These images can be so impressive that most clients and some professionals could easily confuse them for a traditional surgical rhinoplasty.

Heather Finks APRN FNP-C is a board-certified nurse practitioner specializing in non-surgical medical aesthetics at OrangeTwist in Fort Worth, Texas. She also founded The Browtini Bar which offers a wide range of “soft” skin care services including aesthetic treatments and cosmetic tattooing. Finks believes in enhancing her patient’s natural beauty and achieves this by using the latest in aesthetic medicine. She has trained under several of the industry’s leading aesthetic providers throughout the country. She believes beauty is more than a “look” or a “trend” but that it is a feeling. Her mission is to give her patients a refreshed and rejuvenated look by enhancing what already makes them beautiful.

As women go through the process of aging and childbirth, they may experience changes in their genitalia. The most common changes that can impact a woman’s quality of life are vaginal laxity, stress urinary incontinence, loss of vaginal lubrication, loss of tone of labia majora, stretching of labia minora, and a decrease in sensation. Although surgical vaginal tightening procedures are not new, historically they have been performed for repairs after obstetrical delivery, rather than for sexual or aesthetic concerns. The number of aesthetic treatments, as well as corrective surgical procedures, are on the rise and these treatments are now becoming more and more common. As women become more comfortable discussing these issues with their physicians, the number of treatments available is increasing.

Dasha Saian Marchese is the co-founder and CEO of Saian Skincare and has over 18 years of experience in the spa industry. In addition to her business/marketing degree, she is a licensed aesthetician, certified nutrition and wellness consultant, official ambassador of the Aesthetics International Association (AIA), and certified family herbalist. Marchese gives lectures and classes internationally and regularly contributes to global trade publications.

Platelet-rich plasmatreatments are the latest injectable-based procedures to be used as a sort of “catch-all” for a seemingly endless slew of aesthetic problems. The combined elements of celebrity endorsement, efficacy doubts, and an increasingly experimental industry have made platelet-rich plasma a hot topic this past year. This procedure has seen an ongoing rise of off-label usage, with some outstanding results, ranging from breast lifts to hair restoration, to vaginal rejuvenation, and more. 

Perhaps one of the most perplexing anomalies impacting the skin is the development and management of acne scars. To the aesthetic professional, they represent a challenge in devising the most appropriate pathway for treatment, as the final outcome of wound healing is variable and often unpredictable. One factor that remains constant is that the development of scars, no matter their source of injury, represents a complex configuration of events leading to their final stage of healing. The most common types of scars encountered in the aesthetic setting are those that are connected with or are a direct result of acne lesions. According to the American Academy of Dermatology Association, acne vulgaris affects up to 50 million Americans annually with many experiencing some degree of scarring.¹ Although there have been numerous theories presented regarding the development of acne scars, and several approaches for treatment, a concise understanding as to acne scarring and repair in all skin types and ethnicities is not fully understood. The socioeconomic impact of acne scarring is globally observed for its influence on self-esteem and potential disfigurement and requires a multi-faceted approach in its management.

The concept of the skin as a factor in Parkinson’s disease is not new, but several factors are just now coming together to force it onto the verge of clinical practice.

A precise diagnosis can be important from two perspectives. It can identify a condition which is treatable. It can also demarcate a contraindication, something that is not treatable. For example, many spa treatments can provoke an inflammatory reaction, so applying them to already inflamed skin is a recipe for disaster.

MICROBIOMES

Indeed, science is long overdue to give skin the credit it deserves, both in its true size and significance in human health. In terms of size, skin surface area is accepted to be only 2 meters squared – basically a hide. However, a recent recalculation, expanding skin area to in excess of 25 meters squared, also boosts the developing role accorded to the skin microbiome.²

Only in this century has the gut transitioned from a mere conduit for food into the second brain – an enteric nervous system ranking alongside the central nervous system.³ One major feature is the gut microbiome, a collection of beneficial and harmful bacteria. This is paralleled by the skin microbiome and it appears that both microbiomes communicate, not just with one another, but also with the brain. Another common denominator is a protein, α-synuclein, which is genetically associated with Parkinson’s disease that is present not only in the central nervous system and the enteric nervous system, but also in the skin. This makes Parkinson’s disease one of a number of so-called synucleinopathies. Alpha-synuclein becomes pathogenic when it misfolds and becomes tangled, like dropping a ball of yarn or when playing with a yo-yo goes wrong.

Human skin, with its large surface, harbors a wide variety of microbes, which include bacteria, fungi, viruses, archaea and skin mites. ^2,4-9 Malassezia are a major component of the skin microbiome. They occur as skin commensals, but are also associated with various skin disorders and bloodstream infections.¹⁰

Thus, the working field for an aesthetician has just been expanded by more than tenfold, from a small table to a 20-foot by 14-foot room. The difference derives, mostly, from unfolding follicles. Malassezia yeasts grow in these follicles and produce inflammation. It is also no longer just a hide, it is a living microbiome.

MALASSEZIA YEASTS

Their odd name derives from being named for Louis-Charles Malassez, a 19^th century French scientist who first identified the yeasts in the outer layer of the epidermis of patients with seborrheic dermatitis.¹¹ Seborrheic dermatitis may be defined as excessive secretion of oil by sebaceous glands, with seborrhea of the head, face, and neck. The highest density is found in the sebaceous (oily skin) areas, namely the scalp, face, and upper trunk.

In one of those remarkable examples of serendipity, a Scottish housewife, Joy Milne, has emerged, stunning the scientific community and grabbing headlines in the media by proving that she could smell Parkinson’s disease, even before it had been diagnosed. The smell seems to emanate from fungal infections attributed to the genus malassezia, particularly the scent remaining across the back from a worn T-shirt.

PARKINSON’S DISEASE

The association between the skin and Parkinson’s patients was recognized as early as 1927, when Krestin described a cutaneous manifestation of post-encephalic Parkinsonism as shiny and greasy, with characteristic scarring acne.¹² The condition derived from the rampant flu pandemic of the period. Parkinson’s disease itself does not have a known cause; in medical jargon, it is idiopathic.

It must also be noted that systemic antibiotic treatment of acne (for example, minocycline) changes the composition and diversity of skin microbiota. A similar predicament is seen with the gut. Modern medicine, to date, has been quick to eradicate bacteria via the use of broad-spectrum antibiotics, but has been painfully slow in repopulating desirable bacteria, usually through the use of prebiotics, probiotics, and postbiotics, all of which are heavily promoted in the media.

SPORE HYPOTHESIS

Broxmeyer originated his spore hypothesis that Parkinson’s disease may be due to reactivation of spores, either fungal or bacterial, in the brain – perhaps involving some form of mold.¹³ Berstad updated this, although they chose endospores from an actinomycete as their most likely candidate.¹⁴

THE KEY PATHOGEN

Examples of the malassezia genus are part of normal human flora, however, they are also thought to exacerbate a number of skin conditions such as pityriasis (or tinea) versicolor, malassezia folliculitis, seborrheic dermatitis, atopic dermatitis, and even some life-threatening nosocomial bloodstream infections.¹ Seborrhea may present on the face and scalp and appears as flaking skin with red patches underneath. Seborrhea tends to recur frequently and can be a source of acute embarrassment, an additional stressor that could further worsen the quality of life for the Parkinson’s patient.¹⁵ Malassezia globosa is emerging as the key pathogen in Parkinson’s disease patients with seborrheic dermatitis.

CLINICAL POINT

In order for the professional to make a differential diagnosis, tinea (pityriasis) versicolor, in this case, a number of possibilities need to be excluded such as erythrasma, hypopigmented mycosis fungoides, pityriasis rosea, post-inflammatory hypo- or hyperpigmentation, pityriasis alba, seborrheic dermatitis, and vitiligo.

As a second example, consider malassezia (pityrosporum) folliculitis an acneiform eruption consisting of chronic pruritic follicular papules and pustules on the upper trunk, neck, and upper arms. The differential diagnosis includes acne vulgaris, bacterial folliculitis, and eosinophilic folliculitis.

PREVALENCE

Seborrheic dermatitis is a common chronic inflammatory skin disorder affecting up to three percent of the general population. However, research at the University of Belgrade in Serbia by Dr. Valentina Arsic Arsenijevic has confirmed that it is far more frequent among those with Parkinson’s disease, reaching a prevalence as high as 59 percent.¹ This twentyfold increase is intriguing and has led to seborrheic dermatitis being confirmed as a possible precursor to Parkinson’s disease.¹⁶ Professor Caroline Tanner of the University of California San Francisco has endorsed seborrheic dermatitis as a premotor feature of PD, which could serve as an early disease marker of PD.¹⁷

TREATMENTS

As numerous skin disorders, including melanoma, affect patients with Parkinson’s disease, awareness and correct treatments are important to improve and even save patients’ lives. Skin care professionals should re-emphasize the importance of sun protection, including limiting exposure and using high-factor sun blocking agents for them.¹⁸

Appropriate antifungal treatment, such as ketoconazole, can be useful for Parkinson’s disease patients by reducing malassezia growth and enzyme production.¹⁷ Also, when using oral ketoconazole, it is important for the patient to exercise to the point of sweating one hour after taking the medication, as it is delivered to the skin surface through sweat.

Anti-inflammatory agents in the form of topical steroids or topical calcineurin inhibitors can also be used in treatment, thus improving the patient’s well-being and quality of life.¹⁸

TESTING

It has now become possible to select the treatment by testing its effectiveness in-vitro. In microbiology, the minimum inhibitory concentration is the lowest concentration of a chemical which prevents visible growth of a bacterium. Some malassezia species showed high minimum inhibitory concentration values for ketoconazole. The lowest minimum inhibitory concentrations were found for the azoles (itraconazole, posaconazole, and voriconazole). All malassezia species were resistant to echinocandins and griseofulvin.¹⁹

Thus, a simple skin sample can not only save a lot of time, in the precise selection of an effective drug regimen, neurodegenerative disorders, such as Parkinson’s disease, may shortly be diagnosed through investigation of the skin.¹⁸

This is also a reminder to not always jump to heavy duty drugs. Perhaps a shampoo will be effective. While seborrheic dermatitis is treatable with topical ointments and creams, dandruff shampoos (coal tar or selenium-based) are often effective if it is in the scalp or over the eyebrows and forehead; it is advised not to overuse them; their use should be restricted to no more than twice weekly.²⁰

These are exciting times for those in the field of skin. It is no longer simply the outer layer we inhabit and decorate to present to the world but a vital component of our entire being.

References

1 Arsenijevic, V.S.A., D. Milobratovic, A.M. Barac, B. Vekic, J. Marinkovic, and V.S. Kostic. “A laboratory-based study on patients with Parkinson’s disease and seborrheic dermatitis: the presence and density of Malassezia yeasts, their different species and enzymes production.” BMC dermatology 14 (2014): 5.

2 Gallo, R.L. “Human skin is the largest epithelial surface for interaction with microbes.” Journal of Investigative Dermatology 137 (2017): 1,213–1,214.

3 Gershon, M.D. The Second Brain. Harper Collins, New York: 1998.

4 Findley, K., J. Oh, J. Yang, S. Conlan, C. Deming, J.A. Meyer, D. Schoenfeld, E. Nomicos, M. Park, H. Kong, et al. “Topographic diversity of fungal and bacterial communities in human skin.” Nature 498 (2013): 367–70.

5 Meyers, J.M. and K. Munger. “The viral etiology of skin cancer.” Journal of Investigative Dermatology 134 (2014): 29–32.

6 Hannigan, G.D., J.S. Meisel, A.S. Tyldsley, Q. Zheng, B.P. Hodkinson, A.J. Sanmiguel, S. Minot, F. Bushman, and E. Grice. “The human skin double-stranded DNA virome: topographical and temporal diversity, genetic enrichment, and dynamic associations with the host microbiome.” mBio 6 (2015): 01578–01515.

7 Horz, H.P. “Archaeal lineages within the human microbiome: absent, rare or elusive?” Life 5 (2015): 1333–45.

8 Moissl-Eichinger, C., A.J. Probst, G. Birarda, A. Auerbach, K. Koskinen, P. Wolf, and H. Holman. “Human age and skin physiology shape diversity and abundance of Archaea on skin.” Scientific Reports 7 (2017): 4039.

9 Grice, E.A. and J.A. Segre. “The Human Microbiome: Our Second Genome.” Annual Review of Genomics and Human Genetics (2012).

10 Theelen, B., C. Cafarchia, G. Gaitanis, I.D. Bassukas, T. Boekhout, and T.L. Dawson Jr. “Malassezia ecology, pathophysiology, and treatment.” Medical Mycology 1, no. 56 (2018): 10-25.

11 Levin, N.A. “Beyond Spaghetti and Meatballs: Skin Diseases Associated With the Malassezia Yeasts.” Dermatology Nursing 21, no. 1 (2009). 

12 Krestin, D. “The seborrheic facies as a manifestation of post-encephalitic Parkinsonism and allied disorders.” Quarterly Journal of Medicine 21 (1927): 177–186.

13 Broxmeyer, L. “Parkinson’s: another look.” Medical Hypotheses 59, no. 4 (2002): 373-7.

14 Berstad, K. and J.E.R. Berstad. “Parkinson’s disease; the hibernating spore hypothesis. Medical Hypotheses 104 (2017): 48-53.

15 Colcher, A. and T. Simuni. “Parkinson’s Disease and Parkinsonian syndromes: clinical manifestations of Parkinson’s disease.” Medical Clinics of North America 83, no. 2 (1999):327-347.

16 Koller, W. “Does a long preclinical period occur in Parkinson’s disease?” Geriatrics 46, no. 1 (1991): 8-15.

17 Tanner, C.M., K. Albers, S. Goldman S, F. R. Fross, A. Leimpeter, J. Klingman, and S. Van Den Eeden. “Seborrheic dermatitis and risk of future Parkinson’s disease (PD).” Neurology 78, no. 1 (2012).

18 Ravn, A.H., J.P. Thyssen, and A. Egeberg. “Skin disorders in Parkinson's disease: potential biomarkers and risk factors.” Clinical, Cosmetic and Investigational Dermatology 10 (2017): 87-92.

19 Leong, C., A. Buttafuoco, M. Glatz, and P.P. Bosshard. “Antifungal susceptibility testing of Malassezias pp. With an optimized colorimetric broth microdilution method.” Journal of Clinical Microbiology 55, no. 1 (2017): 883–93.

20 Olanow, C.W. and W.C. Koller. “An algorithm (decision tree) for the management of Parkinson’s disease: treatment guidelines.” Neurology 30, no. 3 (1998): 1-57.

The author, David Ponsonby, M.Ed., is a health educator specializing in sports medicine for the last five decades. His late father developed Parkinson’s disease, which added a new interest area, although sports concussions are now being viewed from the perspective of long-term neurological disorders, notably dementia and possibly Parkinsonism. This email address is being protected from spambots. You need JavaScript enabled to view it.

The skin periodically encounters a variety of incursions and, within its extraordinary capacity for surveillance, is able to initiate its defense systems at a moment’s notice to fight infection and initiate healing. The intricate relationship that the skin has with the body represents a complex network of communication via the entire integumentary structure: nervous system (neurons for sensory function), immune system (healing response and defenses), circulatory system (surface capillaries and oxygenation), and the digestive system. The digestive system has both the ability and capacity to provide sustenance and, as such, represents the threshold of the skin’s potential to initiate nutrition-transcription factors for healing.

As most aestheticians will confirm, typically, people with skin disorders don’t always seek the help of an aesthetician. However, because of the explosion in professional skin care technology, this trend is shifting. More and more people are beginning to understand the helpful role the aesthetician plays in the treatment and management of skin disorders, including physicians. As most disorders are treated by a physician, adding the services of the aesthetician is the best case scenario for the patient and/or client.