The barcode or periorbicular wrinkles are one of the most difficult areas to treat and many are the treatments physicians can perform; even though it’s not so easy to reach the complete satisfaction of our patients.

Laser treatments are the gold standard in solving these types of wrinkles, but many patients want a faster downtime with no dressing and no medications and overall to achieve a very nice result.

Not invasive treatments like fillers or Botulin toxin or biostimulation or PDO wires are able to give awesome results with no downtime but are completely re-absorbable and their result are not long lasting and they need a lot of months to satisfy patients’ expectations.

The choice of the correct procedure is strictly connected with the quality of wrinkles. We can refer the wrinkles deepness according to the scale of the upper face by Flynn and Carruthers published in 2012, where wrinkles are evaluated from mild to moderate, severe and very severe.

Patients with mild wrinkles, in my personal experience, need only a preventing treatment; effectively the simple use of botulin toxin 2-3 times a year can preserve from the worsening of the bar code and it permits to the skin to completely fulfill wrinkles avoiding their presence at rest. The injection is performed in a subdermal plane with 4 injection dots with 1U for the upper or inferior lip and I generally use a 31G needle 5mm long. The use of 2 PDO wires per side (2,5cm long 30G) is an option in patients scaring botulinum toxin. The firmness of the wire and their fibroblasts’ stimulation reduce the deepness of wrinkles in some months.

The treatment of moderate wrinkles needs more engagement by the patient and by their physicians. The use of botulinum toxin is helpful but should be injected 4 times a year and I usually link it to intradermal injection of biostimulating substances performed every month. PDO wires are useful and I insert 3 of them per side in subdermal layer 3 times a year. HAs with low G’ are another solution. The injection of 0.2cc of HA per side is done in subdermal layer or with a Fan technique (27G cannula) or with 2/3 parallel injections (30G needle).

Severe barcode wrinkles are really a great challenge to correct. Concerning injectable treatment HA is the best substance a physician can perform. The use of 0.3-0.4 cc of HA with a moderate G’ is recommended, a good firmness of the skin is obtained with this treatment and wrinkles are stretched reducing their evidence. The injection of 2 to 4 bolus of 0,1cc of HA under the orbicularis muscle is suggested. Severe wrinkles happen in patient aged 50 to 60 and are often associated with a sagging of lip’s tissue. Lip is elongating and the presence of HA in soft tissue supports a shortening of the lips and an awesome result.

In my opinion when a patient has very severe wrinkles should not be treated with injectable. Fulfilled and frozen lips, obtained with the use of a great amount of HA, are absolutely unrealistic and unnatural. I suggest my colleagues, in these cases, to resist to patients’ will and desire.

We should perform in very severe wrinkles only treatment with resurfacing lasers or non-ablative Radio Frequencies or very aggressive peeling, and the use of injectables should be performed only in a second step as coadjutant treatment to improve the result previously obtained.