The lips consist of complex anatomy that includes more than simply the red portion of the lips. Each anatomic area of the lip ages and may benefit from interventions targeted to those changes. The following information is adapted from a presentation I have given to other medical professionals. Seek a fellowship-trained facial plastic surgeon if you have questions or concerns about your face or neck.
Peri-Oral Rejuvenation: An Explainer
Dr. Jeffrey Harmon
Youthful Peri-Oral Anatomy
The upper red lip has a well-defined “M” shaped border – called the vermillion border – with the peaks of the “M” called the cupid’s bows. The bottom lip is larger and more rounded than the upper lip with an ideal ration of size between the upper and lower lip at approximately 1:1.6, which is also known as the “Golden Ratio.” When most individuals refer to the lips, they are referring to the red lips as described above. However, this does not encompass the entire lip anatomy.
The skin between the red upper lip, the base of the nose, and the nasolabial folds and the skin between the red lower lip, chin, and marionette lines (pre-jowl sulci) are also components of the peri-oral region. The nasolabial folds of the upper lip and the pre-jowl sulci of the lower lip are created by ligaments extending from the bone to the skin that hold up fat pads sitting above them. These fat pads droop down and to the center of our face as we age, leading to more prominent nasolabial folds and pre-jowl sulci.
Age-Related Changes to the Peri-Oral Region
The aging process occurs in three dimensions. First, the skin develops wrinkles (rhytids) and age spots. The depth and number of rhytids depends on several factors, including genetics and environmental factors such as smoking history, alcohol use history, and sun exposure. Overall, soft tissue and bone shrink, and soft tissue thins and droops. Probably the most noticeable change that occurs is a lengthening of the upper lip, which can eliminate the naturally youthful upper tooth (central incisor) show when the lips are relaxed and imparting a simian appearance to the lip. This effect becomes exaggerated when too much filler is placed in the lips for many years. The upper and lower red lips also shrink and lose definition, which can result in a loss of naturally youthful lip pout. The corners of the mouth, called the oral commissure, droop due to thinning of tissue. Finally, as described previously, superficial fat pads in the cheeks and along the jawline fall to the center of the face, leading to an accentuation of the nasolabial folds and pre-jowl sulci, which leads to marionette lines.
Deep Plane Facelift Surgery is the Best Method to Address Deepened Nasolabial Folds and Marionette Lines
Deep plane facelift surgery and, specifically, the extended deep plane facelift, is the gold-standard in facelift techniques. Deep plane facelift surgery is the only facelift technique that can naturally address the anatomic changes that lead to a deepening of the nasolabial folds and marionette lines.
As discussed in a previous post, deep plane facelift surgery is distinguished from other facelift approaches by the fact that a composite skin and deep tissue – composed of muscle and the fascial layer called the SMAS – flap is lifted in the middle of the face and the ligamentous attachments in the cheeks and the jawline are released for a comprehensive, tension-free lift of not only the jowls but also the cheeks. This is what allows the nasolabial folds, marionette lines, and drooping oral commissures to be treated.
The extended deep plane facelift advances deep plane surgery by extending the deep plane approach into the lateral neck, which allows the jawline to be better contoured all the way to the back corner of the jawline and the central neck to be more effectively tightened.
Hyaluronic acid filler such as Restylane© and Juvederm© products are commonly used in the nasolabial folds and marionette lines to “blunt” their appearance. These products are also used around the corners of the mouth to provide a “lift.” While this non-surgical treatment can be appropriate in certain circumstances, the problem is they do not address the actual changes that occur with age, i.e. weakened ligaments, drooping fat, and loose muscle and skin. Attempts to eliminate the nasolabial folds and marionette lines with hyaluronic acid filler or other fillers including fat can overinflate the face and make patients look distorted by eliminating subtle transition points between the cheeks and lips.
Skin Resurfacing and Nano-Fat Can Treat Peri-Oral Wrinkles
Wrinkles around the mouth are treated primarily by resurfacing procedures, which fall under three categories: laser resurfacing, chemical peels, and mechanical resurfacing. All three approaches remove the top layers of the skin in a controlled fashion. The healing process after treatment results in the deposition of collagen in a more organized fashion that better reflects a youthful skin composition.
Laser resurfacing devices include CO2 and Erb:YAG lasers. Resurfacing lasers target water molecules (H2O) in the skin, heating the tissue to a controlled depth. Most resurfacing lasers used today are fractional, which means the laser energy reaches the skin in organized columns with untreated skin in between. Fractional lasers heal faster and are less likely to result in complications than non-fractional lasers.
Chemical peels are a diverse group of chemical mixtures (e.g., TCA peels, Hetter peels) which are applied to the skin for resurfacing. The depth of the peel is dependent on the mixture’s active ingredients and their relative concentration as well as the number of passes used.
Mechanical resurfacing, otherwise known as dermabrasion, involves the use of a hand piece with a spinning tip that is often diamond coated and which effectively serves as a sander for the skin. The tips come in many shapes and sizes for use on different areas of the face. The rate of spin and number of passes also contribute to the depth of the resurfacing procedure.
A complementary approach to resurfacing procedures on the mouth wrinkles involves the use of nano-fat. Nano-fat is harvested from the patient’s own body fat in the stomach, flank, or thighs just like fat augmentation procedures. The difference between nano-fat and the fat used to augment the face is that it is processed to be a thin liquid. Nano-fat is injected superficially into the wrinkles prior to the resurfacing procedure. The purpose of placing nano-fat in these wrinkles is primarily to improve healing after the resurfacing procedure and secondarily to soften the deeper wrinkles that may not be treated completely with the resurfacing procedure.
The Lip Lift Can Treat Lip Lengthening and Thinning
The lip lift procedure is the best approach to treat the lengthening of the upper lip skin as well as the loss of definition and projection of the red upper lip. Providers often try to address these changes with hyaluronic acid filler to poor effect. In fact, adding large volumes of filler to the upper lip can stretch the upper lip. Adding large volumes of filler to the upper lip can also over project the upper lip, leading to a “duck-lipped” appearance.
The lip lift, which is also known as the sub nasal or bullhorn lip lift, involves the excision of skin and fat in a gullwing or bullhorn pattern at the base of the nose. This incision then hides in the creased of the base of the nose. This procedure can accomplish three things. First, it increases the height and improves the definition of the red lip. Second, it balances the length of the upper lip skin with the red lip height. Third, it improves the pout of the red lip.
The lip lift is a complementary procedure to cosmetic dentistry procedures, because the lip lift can restore some of the youthful central tooth show that occurs when the lips are relaxed apart.
Some providers perform lip flip procedures using botulinum toxin to the muscle surrounding the mouth, called the orbicularis oris. This procedure is not recommended, because it is generally not effective and can cause problems with speaking and drinking through straws for weeks-to-months after the procedure.
Multiple Techniques Can Re-Volumize the Lips
Some patients with deflated lips can benefit from procedures that restore their volume. In fact, many patients who undergo a lip lift also undergo lip volumizing procedures.
Temporary options for lip volumizing include hyaluronic acid filler.
Permanent options for lip volumizing include fat and SMAS, which is the strong fascia that lies over the fat and deep muscles of the face. The fat is removed from the stomach, flank, or thighs, processed, and injected using blunt-tipped cannulas into the upper and lower lips. SMAS is removed from immediately in front of the ear during the extended deep plane facelift procedure and inserted into the upper and lower lips through incisions hidden at the corners of the mouth.
The patient above is an excellent example of how multiple procedures work simultaneously to rejuvenate the peri-oral region. This patient underwent a lip lift, fractional CO2 laser resurfacing with nano-fat grafting of the wrinkles around the mouth, and lip enhancement with hyaluronic acid filler to balance the bottom lip with the top lip.
Trust Your Face to a Facial Plastic Surgeon
It is important to seek a fellowship-trained specialist in plastic surgery of the face and neck when you have concerns about your face or neck.
Request a Consultation
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This blog post is for educational purposes only and does not constitute direct medical advice. It is essential that you have a consultation with a qualified medical provider prior to considering any treatment. This will allow you the opportunity to discuss any potential benefits, risks, and alternatives to the treatment.