As mentioned, aging changes around the mouth take different forms and at different rates. These changes vary according to age, race, sex, history of smoking, degree of sun damage, type of skin and
familial hereditary characteristics.
The youthful mouth has the following characteristics:
The distance from the nose to the upper lid margin is short, about one half of the distance between the lower lip and the chin.
Smooth upper and lower lips with no vertical lines
Pronounced cupid’s bow and vertical philtral columns and and an inter-column depression
Distinct white roll
Good lip volume with a balance whereby the lower lip is roughly twice as full as the upper lip
Gentle nasolabial folds with a smooth transition from the perioral region to the cheeks
Lack of Marionette lines with horizontal or slightly upward slant to the lateral commisures
Pronounced chin with no ptosis of the chin fat pad
Smooth chin with no visible pores
No visible quivering of the mentalis muscle
A smooth jawline with a lack of jowls or pronounced depressions
The overall changes that may be seen are summarized in the following drawing:
Elongated upper lip
Lip vertical lines
Loss of cupid’s bow and vertical columns
Loss of white roll
Loss of lip volume and loss of balance
Nasolabial folds
Melolabial folds (Marionette lines)
Witch’s chin
Large pores chin
Quivering chin!
Jowls
Pre-jowl sulcus or hollow
Treatment of the elongated upper lip
As we age, the distance between the nose and the upper lip elongates. When significant, this distance can be narrowed using a “bull-horn” technique where radiofrequency instruments are used to give an almost invisible scar. Tissue removed can be de-epithelialized and used to augment the upper and/or lower lip as well.
Treatment of the short upper lip
If the upper lip is too short, there is an appearance of “teeth-show”. In such cases, the frenulum which is too short is lengthened with multipls Z-plasties.
Treatment of the large lower lip
Macrocheily is an excessively enlarged lip: it is seen in a number of conditions. These large lips are reduced with an anatomically planned resection of a longitudinal wedge of mucous membrane deep inside the lower lip so that the subsequent scar is well hidden.
Treatment of vertical lip lines
Various methods can be used to improve vertical lip lines including microdermabrasion, dermabrasion, and chemical peels.
vertical lip lines and lip volumes are always addressed when performing facelifts and necklifts.
The eyelids and lips are unique in that there are muscles which have no deep attachment to the periosteum but only attachments to the cutaneous structures. This results in vertical lines around the lips and crows’feet around the eyes. The vertical upper and lower lip lines are variously called “lemon wrinkles”, “smokers’ lines”, and “bleed lines”.
Lip lines can be treated using several techniques, each chosen with the patient’s skin type, age and pigmentation in mind. Dermabrasion, chemical peels, radiofrequency peels, laser peels and other methods are available to treat these.
Treatment of loss of cupid’s bow and vertical columns
the innovative plastic surgeon should have a plethora of techniques to choose from. This is a rather clever technique that allows us to get an excellent elevation of the cupid’s bow and also the creation of philtral columns.
Suture and incision techniques now allow us to obtain subtle but impressive elevation of the cupid’s bow and some accentuation of the philtral columns. These are minimally invasive techniques which yield a reliable outcome. This particular technique is called philtropexy.
Treatment of the “frowny mouth”
A frowny mouth is the term used to describe the down-turning corners of the mouth or lip commissures. This downward turn gives the face a sad, pessimistic facial expression. Even with well-performed facelifts, this downward angulation of the lip commissures can be difficult to correct. Using “Optimistic suture” that were designed by Dr. Panfilov, we have had excellent results. This correction may be performed at the same time as a facelift or in isolation.
the “frowny mouth can be improved using rather innovative techniques. Here, besides a facelift and necklift, “optimistic sutures” have been used to improve the position of the angles of the mouth.
Improvement in the peri-oral region with a facelift and necklift and also “optimistic sutures”.
Treatment of loss of white roll
There is a clear reflection of lips just above the pink edge of the lips called the vermillion border. This “white roll” is lost with age, as we lose the definition between the upper lip and the vermillion border. Together with this loss of the white roll, we also lose the vertical columns called the philtral collumns. In youthful lips and mouths, these philtral columns are separated by a hollow, the inter-philtral groove, which gives the upper lip and the area between the nose and the upper lip structure. Caucasian races lose these structures (the white roll, the philtral columns, the inter-philtral groove) earlier than other races. Even without surgery, with the proper use of fillers of various kinds, one can recreate these youthful anatomical landmarks as seen here.
Recreating the white roll, the philtral columns and the inter-philtral groove giving a more youthful mouth.
In younger faces, a more aggressive creation of the white roll, the philtral columns and the inter-philtral groove gives an even more youthful result. This is combined with creating a balanced filling of the upper and lower lips.
Treatment of loss of lip volume and balance
The balance of the upper and lower lips has to be remembered but differences between countries should also be considered. For example, in Brazil, the upper and lower lips are balanced equally. In most of northern Europe, the creation of the cupid’s bow with philtral columns and a larger lower lip is considered more attractive.
Microlipofilling of facial structures with autologous fat grafts can be used for different parts of the face, including the upper and lower lips. Variable amounts of properly treated fat are injected into the upper and lower lips. There is always postoperative swelling which can make the augmentation look excessive, but this invariably settles to a level where one wishes more had been done! There is a variable degree of absorption of the transplanted fat, but as I always tell my patients, the 50 – 60% that survives is forever (almost)!
Other options of augmenting lips include fillers which are presented and discussed elsewhere. We also use the SMAS we remove during facelift surgery to augment parts of the face, including lips as needed.
Other options of lip augmentation include the use of orbicularis muscle removed from eyelids, temporalis fascia or other fascia or muscle, depending upon what other surgery may be performed. Fascial and muscle graft
absorption is about 50%.
results immediately after fat grafting.
fat grafts to lips for volume
Fat grafts to upper and lower lips showing a nice improvement in the volume of the lips
Use of SMAS tissue during a facelift to augment the lips
Results of fat grafting four months after the procedure.
Treatment of Nasolabial folds
the nasolabial and the melolabial folds can be filled with the appropriate filler to give a pleasing improvement in the depth of the folds. This is not in any way a lifting procedure and is not a substitute for a good facelift.
Nasolabial folds are the folds one develops between the nose and the mouth. These folds deepen with age and make the midface look older, casting a shadow below the cheek. There are several approaches to improving nasolabial folds. Non-surgical approaches include the use of fillers which may be performed in clinic and will give results that
last up to 9 months.
Treatment of melolabial folds
surgical reduction of the depressor angularis oris muscle may be used, but botox can achieve the same result, albeit on a more temporary basis.
Surgical markings for angular lift and weakening of the depressor angularis oris muscle.
improvement in the melolabial folds and the angle of the mouth using the lifting surgical technique together with surgical weakening of the depressor angulari soris and fat augmentation of the mesolabial folds.
Melolabial folds are the folds between the corners of the mouth to the jawline: these give us what we call “frowny faces” with the downturning of the corners of the mouth. This area is treated using three techniques. Botox can be injected in the depressor angularis oris muscle which allows the depressor of the corner of the mouth to relax, hence giving us a “happier” look. A similar result can also be obtained by surgically weakening the depressor angularis oris and elevating the angles of the mouth with proper plastic surgery techniques:
Fillers can be used in the melolabial folds and along the jawline to improve the shadows cast by the deep
melolabial folds and the area in front of the jowl.
Improvement immediately after using fillers in the melolabial folds and in the pre-jowl sulcus.
Treatment of the witch’s chin
A number of different techniques are used to address the “witch’s chin”. Nice reduction in the witch’s chin can be achieved giving the mouth, lower face, jawline and neck a more congruous look.
The witch’s chin is the description used for the droop in the chin that occurs with age. In the lateral view, it shows as a “dropped chin”, with the inferior edge of the chin extending below the neck line, giving the so-called witch’s chin. We always address this when we perform facelifts and necklifts to improve the profile view of the face and neck:
All of the aging changes that affect the perioral region are addressed in the above patient with improvement in the nasolabial folds, the melolabial folds, the pores, the vertical lip lines, the loss of lip volume, the jawline, the jowls and the pre-jowl sulcus.
Treatment of Chin pores
The skin around the mouth and chin ages much more than the skin on the rest of the face because it is made up of thicker, more sebaceous skin and also because of the constant wear-and-tear that this area undergoes. Indeed, changes like a deep crease just below the lower lip, pores on the chin, quivering of the chin muscles (the mentalis muscles), vertical lip lines, nasolabial folds, melolabial folds, jowls, and lengthening of the upper lip all conspire to give us an older look. In plastic surgery, when we perform facelifts and necklifts, we address each of these changes to give the rest of the face a nice balanced result. Some of these changes can be addressed with fillers, botox and lasers.
Treatment of the quivering chin
As we age, the mentalis muscle often develops a quiver which gives us depressions on the chin. This change can be nicely managed with the use of botox injections. If there are any depressions, fillers or fat grafts improve the changes without resorting to the use of chin implants, which are reserved for the genuinely recessed chin (hypoplastic chin).
Treatment of jowls
The best treatment for jowls is a properly performed facelift and necklift. This allows the creation of a strong jawline, the reduction of jowls and the recreation of a youthful face and neck. Isolated liposuction of the jowls does not give reliable or effective results.
Treatment of pre-jowl sulcus
no surgery was performed. Cleverly injected fillers can give an immediate result with a more youthful face and a stronger and straighter jawline.
On occasion, when a patient does not desire to undergo surgery, the hollow in front of the jowl can be partially filled with a filler which gives a straighter jawline. Although the results are not as good as seen with a well-performed facelift and necklift, they are still excellent. In particular, when photographs are taken, these pre-jowl hollows (sulci) cast a shadow which makes people remark “I don’t like my photos to be taken”. Improving this jawline
makes photographs much more pleasing!