Lip lines - understanding the beauty of normal lips
There are four major types of lip lines that bother us when they appear! Before we look at these lines, it is important to bear in mind the normal (and beautiful!) shape of ideal lips and the mouth! A careful study of youthful lips allows the particular plastic surgeon to know the surface anatomy that is so vital to recreating lip structure after trauma, tumours or for aesthetic purposes. I have analysed the lips below in detail not found in standard plastic surgery text books.
Proportions of beauty: short distance from upper lip to nose, upturning upper lip margin, a full upper and lower lip, smooth skin around the lips, no downward turns to corners of mouth. Lip piercing draws attention to the lip beauty!
This nicely illustrates that the lips are NOT full all the way to the outer corners. The central fullness decreases as one moves laterally (racial variability should be studied, though!). The central fullness of the upper lip is supposed to be subtly bilobed with the appearance of "puppet-on-a-string" lifting by the commanding philtral columns. A nice groove (sub-labial hollow) below the lower lip casts a beckoning shadow giving the lips a three-dimensional structure. The subtle grooves on the lips themselves allow expansion and contraction without obvious demarcations. The skin around the lips is not sullied by any corrugations
Prominent philtral columns embracing the pronounced cupid's bow and inter-columnar groove, proportioned fullness of lips, hollow below the fullness of the lower lip and nice neutral corners of the lips with an elegant upward tilt. Distance between nose and upper lip is half the distance between lower lip and chin. Fullness of lips should be "age-appropriate"!
"I have fillers done to my lips because they give me confidence and I think they are my best feature. Dr. Patel always talks me out of over-filling them and I am glad he does as I work in medicine and would not like patients to think I look funny. Although I like fuller lips, he shapes them beautifully and no-one realizes I get fillers to make my beautiful lips look even better. I know it is shallow of me because I look after cancer patients but many of my patients pass comments on my "beautiful lips" and I enjoy talking to them about things other than cancer" L. Restori 29 Yrs Old with Gorgeous Lips in London- London, England
Lip lines - applying knowledge of surface & three-dimensional anatomy to reconstruction after trauma and cancer
Understanding the surface anatomy described above, the relationships between the wet and dry zones of the lips, the vermillion border, the gradual but defined decrease in fullness of the normal lip as one gets to the lateral edges and the importance of preserving and recreating the lip mound (I call it "the earthworm that sits on the lip's edge" giving it the prominence and beauty of a normal lip) allows the cosmetic and reconstructive surgeon to use his cosmetic understanding and respect for proportions to be applied to reconstructive cases.
Loss of the lower lip involved the wet part of the lip, the dry part of the lip, part of the "earthworm mound", orbicularis oris muscle and skin. Reconstruction demands that attention is paid to each of these to give not only a good cosmetic outcome but also a functionally useful lip!
"My husband actually asked me the other day when I was going to see Dr. Patel as he loves my lips after I have filler done by Dr. Patel. It is always invisible to everyone and I don't know how but he makes those two vertical lines for me and what he calls the cupid's bow to give me a hollow between the lines which makes my lips look much younger. I have fine lines on my lips which look much better after the filler and I like having my lips fuller again. I would like them fuller still but he tells me to be conservative "don't spoil a perfectly good result" is what he told me and so I am sticking with just one vial of restylane filler for my lips!" Mary S 49 Yrs Old with Lips in Park City, Utah
Understanding the four types of "lines" that afflict lips over time
1. Vertical lip lines
Vertical lip lines are variously called "smoker's lines", "straw lines", "marionette lines" (which is an incorrect use of the descriptor "marionette"), "whistle lines" and just plain "old lady lines".
Interestingly these occur much less impressively in chaps: whether hormones have anything to do with them is unknown. Those men that do get them are generally smokers. Genetics has an important role, as is lifestyle (smoking, sun damage, etc). Although over decades these lines become deeper, the first lines are often seen in the third decade in non-smokers (and white Caucasians) and in even in the second decade in smokers.
The lines are much less common in people with darker skin: melanin protection has some part to play.
These photographs were taken 50 years apart. They demonstrate the changes that occur in the structure of facial tissues, the collagen, the skin health, the effects of sun damage and the effects of genetics with vertical lip lines and other facial rhytids
These lines are seen in a non-smoker and in a lady only in her 30's. Genetics and lifestyle may have a part to play in these in people this young. Lines always seem to appear earlier on the upper lip where they also tend to be deeper. This may be to do with the fact that there is more movement of the upper lip.
2. Downward turning lines at the corners of lips
The downward turn of the corners of lips leads to a "sad" look. Hence these are called "sadness lines", "Marionette lines" - which points to the continuation of the downward turn of the corners of the mouth into the mento-labial folds, "Cruella lines", and more recently, "handmaiden lines".
As one develops laxity of the lower face, and, in particular jowls, these corners of the lips turn further downwards. The depressor angularis oris muscle also, over time, seems to dynamically pull the corners of the lips downwards.
Downturning corners of lips seem to affect all races, but the depth of the lines are less deep in races with more pigment.
One can see the downward turning lips becoming the marionette lines from the corner of the lips to the jawline. When pronounced, they give an especially sad or grumpy look to one's face. Besides descent of tissues and the downward traction by jowls, dermal changes and tissue volume changes all have a part to play in the formation of these grooves
3. Horizontal mental crease
This is less common as a cosmetic concern than the first two types of lines described. As can be sen in the photos below, there is generally a gentle depression between the lower lip and the chin. In youth, it is rarely deep, but does deepen with time. At what level it becomes cosmetically objectionable is undefined. In my experience, some people are bothered by it more than others. A number of tissue release and augmentation with fillers or fat may be used to improve the deep crease, as seen in some of the results shown further below.
The mental crease is a normal crease, albeit a gentle depression rather than a deep gouge! In some people, this groove becomes deeper and can accentuate any age-related changes that may afflict the chin. It also divides the mental region into two, which is unnatural to the mind's eye. This crease does not appear to have anything to do with smoking or environmental factors and is almost completely dependent upon one's genes!
4. Subnasal crease
This is the least common of the lines around the lips that is seen and needing attention. However, when it is present, it becomes accentuated when one smiles and gives a rather pronounced look to the perioral region. Those people who have it, know about it and do not like it!!
This supra-labial, sub-nasal crease does not have a given name and deserves one! As can be seen, it becomes more pronounced with a smile: the wider the smile, the worse the crease looks! A combination of subcutaneous tissue release, filler or fat and laser helps to reduce this nicely.
Improvement in the mental crease gives a better looking lower lip and chin. Also improved are the vertical upper and lower lip lines, the downward turn to the corners of the lips and the marionette lines. We generally address as many of the four different lines that occur around the mouth to give a congruous and pleasing result
Before-and-after photographs of the four types of lip lines
As is understandably obvious, lines generally do not occur in isolation: one often sees the vertical lines together with one or more of the other lines. Treatment is therefore focused on the particular anatomical and physiological changes to achieve the best results.
Some lip lines may be treated in isolation with lasers with or without fillers. More often, a combination of tissue manipulation, augmentation, laser use, tissue repositioning and repair of surrounding tissues (jowls, folds, grooves, volume deficiency, volume excess, etc) is used to give the best possible results.
Here we see improvement in the vertical lip lines, the corners of the lips, the chin changes, an improvement in the mental groove and a generalized thickening of the peri-oral tissues surrounding the lips giving a much more robust and youthful look to the mouth and lips
The sub-mental crease has been shallowed, giving the chin a more youthful look. The corners of the lips and the marionette lines have been addressed as have the vertical lines on the upper lip. Lip shaping with appropriate fillers can now be performed to give more projection without looking like "overfilled lips".
Combination management of lips
In this patient, three of the four types of lines were addressed. However, to make lips and the perioral region look more attractive, attention must be paid to the tissues surrounding lips and the mouth, viz. the jowls, the jawline, the nasolabial folds and also any lower facial deformities.
In this case, a lower cervico-facial rhytidectomy (facelift) allowed us to improve the jowls, achieve elevation of the descended cheek fat pads, augmentation of the jawline and the lips with fat and the use of lasers to the perioral pores and rhytids. This rejuvenates the whole region. it is a mistake to try to improve just one single change that may affect the lips: results are then incongruous.
Lip augmentation can be undertaken after the cosmetic reconstructive surgery is complete, giving a nice chape and age-appropriate fullness to the lips.
Here, the marionette lines, the downward turning lips, the lateral lip grooves, the few lip lines and the proportions of the lips have been addressed. With age, one loses the normal proportions of lips: paying attention to recreating these proportions pays dividends!
Isolated vertical lip lines
If you are an active smoker, treatment of the lips with lasers can be undertaken, but your healing will be slower, there is a greater risk of infection and the risk of scarring is also increased. These are just facts that you ned to know. If you have completely stopped smoking, these risks reduce over time!
In many cases, these lines are seen in non-smokers. Certainly, in the modern world, second-hand smoke does have a part to play in the development of some of these changes. Genetics, sun exposure and lifestyle also have a bearing on the speed with which these appear and progress.
In the absence of other surrounding changes (jowls, labio-mental lines, neck laxity, etc), isolated treatment of the lips can give very gratifying results as seen here.
Vertical lip lines, even in non-smokers, can appear in the third decade. Whilst there is no way of preventing them, treatment with a combination of appropriate lasers, fillers and/or fat grafts gives very nice results.
Whereas it is impossible to completely eliminate the horizontal crease that some people develop between the nose and the upper lip, a nice improvement may be obtained with appropriate attention to anatomy, physiology and tissue healing in response to surgery and lasers!
Horizontal line sub-nasal/supr-labial!
With great care and attention to surrounding surface anatomical contours and changes
Examples of lips, lips, lips.....
"I had a excellent eye lift done by Dr. Patel. He knows what he is doing and is very pleasant. Dr.Patel was easy to get an appointment and he works with you. The office staff was very pleasant and made you feel calm." D. Gull Highly recommended for eye lift surgery - Salt Lake City, UT