Background:  Aging affects all facial structures, particularly those around sphincters or apertures such as the eye. Changes around the eye are commonly perceived because they are so visible and are part of every human conversation. But just like the eye, the mouth also ages in very characteristic ways. Lines, wrinkles and thinning lips are typical atrophic changes. But falling skin and fat from the side of the face can force down the corners of the mouth, creating a constant frowning or sad expression.

While downturning of the corners of the mouth can occur from the aging process, it can look very severe in those whose mouth corners are more naturally downturned anyway. I have seen very young patients in their twenties and thirties who have a ‘congenital frown’ due to a natural u-shape to their mouth. That will become worse as they age due to the push of the falling nasolabial fold tissues from above.

Treatment options for the downturned mouth can be either non-surgical or surgical. The choice between the two is partially based on the degree of  corner angulation. The use of synthetic injectable fillers can create an immediate effect by pushing up and filling out the corners. It can be effective for moderate degrees of downturn that are less than 45 degrees. In more significant cases with greater than a 45 degree angulation, only a corner of the mouth lift will work based on removing some of the overhanging skin and repositioning the corner of the mouth upward.

Case Study: This 48 year-old women was unhappy with the appearance of her mouth. She was bothered by her constant frowning appearance. People regularly asked if she was sad or unhappy. As a professional, this made her look angry and mad which did not give a beneficial impression.

On examination, the skin overhang of the corners of her mouth measured a 55 degree angulation downward. She had moderate marionette lines that were most deep near her mouth corners. Under local anesthesia a triangular-shaped segment of skin was removed just above the mouth corners, measuring 8mms long, 6mms high and a curved line connecting these two points of the triangle. The skin was removed down to the orbicularis muscle. The most lateral point of the downturned corner of the mouth was brought up and sewn to the middle of the upper line of the excised skin triangle. The skin and the lip vermilion was then sewn together, effectively repositioning the entire corner of the mouth upward to a more horizontal orientation. A small amount (.3cc) of Juvederm was then injected into upper marionette line just under the repositioned corner of the mouth on both sides.

 Dissolveable sutures were used for skin closure so she had no need to come back for suture removal. She sent a picture of her smiling six weeks after surgery, demonstrating the success of the operation both on her mouth and how she now feels about its appearance.  

Case Highlights:

1)      Downturning of the corners of the mouth, skin overhang and the development of marionette lines are common aging changes around the mouth

2)      A corner of the mouth lift removes the skin overhang and levels out the corners of the lips. It can be done under local anesthesia as an office prfocedure.

3)      Corner of the mouth lifts can be supplemented with  injectable fillers or fat injections to help fill out the marionette grooves below it.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

The mouth area is not spared as the rest of the face ages. Most women focus on changes in the neck and jowls as well as around the eyes. And while there are some well known procedures that make great improvements in these facial areas (facelift, blepharoplasty), how to improve the mouth area is not so standard and well known.

The mouth looks older as a result of  numerous anatomic changes. The upper lip will get longer and thinner. The corners of the mouth start to turn downward. From the downturned corners, grooves extend towards the jaw line creating marionette lines. The nasolabial folds or lip-cheek grooves which ‘parenthesize’ the mouth become more pronounced and deeper. Vertical wrinkles develop on both the upper and lower lip running into the pink (vermilion) of the lip, often resulting in lipstick which bleeds into them.

While wrinkle reduction around the mouth can be done with various laser methods and injectable fillers, improvement in that alone is often not enough to make an overall youthful change. Like the rest of the face, the mouth area can benefit from various ‘nips and tucks.’

There are some small but very effective perioral (mouth) procedures that can create some subtle but significant lifting and upturning of the lips. Youthful changes come from having more exposed vermilion and a more even or horizontal smile line. (mouth corner to corner line) These perioral rejuvenation procedures include lifts of the lip, corner of the mouth, and smile lines.

A long upper lip can be shortened with an upper lip lift, often known as a subnasal or bullhorn lip lift. It is done to primarily shorten the aged long lip, but a small amount of increased upper teeth may result when the lips are slightly open. By using a wavy or bullhorn-shaped ellipse of skin under the nose, the central part of the lip is upturned. The key to this procedure is to remove skin only. If one removes any of the deeper muscle, the upper lip will get tight and look unnatural when smiling. There will be a few millimeters or relapse over the first six months after the lift.

 Rather than done under the nose, lip advancements are done lower at the actual border of the upper lip. It creates a different and more complete upper lip lift because it effects the entire horizontal width of the upper lip. Lip advancement achieves improved exposure of the vermilion and eliminates the bottom end of the vertical lip lines. A small strip of skin abobe the lip line is removed to make the whole upper lip look bigger as well as shortens upper lip length.

The corner of the mouth lift is the ‘cutest’ of the perioral procedures because it removes such a small amount of skin to achieve its effect. Its intent is to elevate the down turned corners of the mouth so that the smile line (lips at rest) becomes more horizontal. This makes one’s mouth appearance more perky. This is done by removing a small triangle or heart-shaped piece of skin above each corner which changes the location and angulation of the sides of the mouth.

Beyond the corners of the mouth, folds of skin may drape downward. This loose skin can be improved somewhat by a facelift but some patients may not want to invest that much effort for improvement. These “parachute” folds of skin can be removed, placing a fine line scar in the lower end of the cheek-lip groove. It also creates a small amount of  lifting of the corners of the mouth as well.

One of the great benefits to these procedures is that they can be done in an office setting under local anesthesia. This keeps the cost down compared to more extensive surgery. They can be combined with injectable procedures such as Botox and fillers as well as laser and light skin treatments. They are a great compliment to be done with a facelift, either before or after.

Nips and tucks of the mouth area will result  in some small scars as a trade-off for their rejuvenating effects. Minor scar revision and touch-ups may occasionally be needed as the margin of error or forgiveness of any scar abnormality is quite small in the very visible mouth area.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

A frowning look is not associated with the perception of happiness nor youth. A frown is primarily a result of the angulation of the corners of the mouth. The mouth corner is where the upper and lower lips meet and should be at the same horizontal position  as the lip line. (the line where the upper and lower lips meet from one side to the other) For some people, they have a natural downturn of the corners. Most downturned mouth corners, however, are the result of aging. As the skin and deeper tissues above the relatively static lips fall, the corners of the mouth are often forced downward.

When the corners of the mouth droop down, the lip line gets a gentle convex arc This convex arc often turns into a vertical gutter at the sides of the chin. These are known as marionette lines which are likewise caused by the descending jowls folding over the fixed chin tissues. Downturning of the mouth corners and marionette lines usually go together for most aging patients.

No type of face lifting procedure will move the corners back up to a horizontal position. Whether the pull comes from the direction of the ears (facelift) or from the direction of the corners of the eyes (midface lift), the corners of the mouth will be relatively unaffected.

The best method to change the orientation of the corners of the mouth is directly. By removing a simple modified triangle of skin, the corner angle is moved upward. This simple procedure, known as the corner of the mouth lift (COML), is very powerful at changing the lip line. It does result in a small incision line that goes horizontally outward from the corner, but this almost always heals well with minimal scar. The key to the COML is not to remove too large of a triangle of skin as this can cause the mouth corners to turn up or out too far, resulting in a joker’s smile deformity.

The COML can be easily done in the office under local anesthesia. In my Indianapolis plastic surgery practice, I often combine it with the use of injectable fillers to lessen the marionette lines inferiorly, the nasolabial folds superiorly, or with simultaneous lip enlargement. It is also not uncommon to perform it with other major surgeries such as facelifts. The COML is a little ‘nip and tuck’ that is a valuable part of the numerous procedures that can be done for perioral rejuvenation.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

As the face ages, so does the mouth area as well. Many perioral changes take place that go beyond the development of wrinkles and vertical lip lines. The upper lip may get longer, the corners of the mouth may droop, and both upper and lower lips get thinner and lose any poutiness. Three distinct grooves also develop including the nasolabial lines (oblique lip-cheek grooves), marionette lines (vertical chin-facial groove) and the horizontal labiomental groove below the lower lip.

Collectively, any number of these mouth area changes create an older aging lower face and often creates a sad, angry, or unhappy look. While skin resurfacing methods, such as chemical peels or laser treatments, are a part of perioral rejuvenation strategies, they do not make enough of an appearance difference to be used a stand alone treatment. As is well known, no form of a facelift or necklift procedure provides any improvement to the aging mouth.

As the aging mouth presents the conceptual issues of a thinning and downturned problem, appropriate treatments should be those that create thickening and uplifting solutions. One must, therefore, look at combining direct surgical approaches (e.g., lip lifts and advancements) with injectable fillers.

While there are a variety of differing combinations of these surgical and non-surgical mouth procedures, one of my favorite is the use of injectable fillers for the nasolabial folds and a corner of the  mouth lift. This combination is particularly effective because both treatments affect the same line of perioral aging. And both can be performed fairly quickly under local anesthesia in the office with no significant downtime.

The use of injectable fillers is a common and very effective method for most deepening nasolabial fold areas. They are not effective when the folds are so deep that they are inverted however. But for shallow and moderate depths folds, injectable fillers will provide a nice softening with an instantaneous result. There are numerous filler options and all will work. I prefer those that last the longest such as Juvaderm, Perlane, Evolence, Radiesse, or Sculptra. Injection under an infraorbital local anesthetic nerve block makes the injection painless.

The corner of the mouth lift is done to turn up the corners of the mouth. This small procedure is quite powerful as it alters the sad mouth appearance. By removing a small  triangle of overhanging or downturned skin above each mouth corner, the mouth line becomes level. This does result in a fine line white scar that lies along the upper lip border and extends slightly beyond the mouth corner. This does result in a scar but it is only visible on very close inspection. The little scar is red for a while but will fade to a white color over time. Tiny little dissolveable sutures are used and make-up can be applied immediately.

The combination of nasolabial fold augmentation with injectable fillers and a corner of the mouth lift helps address collateral areas of around the mouth aging. In my Indianapolis plastic surgery practice, this is done as an in-office procedure that takes about an hour under local anesthesia. These changes are effective and easy to go through with no recovery. Some corner of mouth lifts may require a touch-up but they are very long-lasting. Injectable fillers are not permanent and  will need to be repeated in about a year.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Even after a facelift many patients are left with mouths that do not look happy or younger. This is because a facelift does not really affect the mouth area (contrary to popular perception) and the presence of  marionette lines. Marionette lines (sometimes called puppet folds) are those folds of skin that run down from the corners of the mouth to the jaw line.  These skin folds are only marginally improved by a facelift. Marionette lines make the corners of the mouth turn down, creating an upside down U-shape to the lower face.This shape to the mouth makes one look unhappy and not as young looking as one may feel inside. In my Indianapolis plastic surgery practice, I am often told by patients that people often ask them what is wrong or why are they mad.

Mouth lifts can very nicely correct this problem. Mouth lifts, or more broadly known as perioral rejuvenation, is a combination of lip procedures that can lift up and rejuvenate the mouth area. This is done by changing the position of the corner of the  mouth to a more horizontal  or level position. This can be combined with  injectable fillers to also make the lips temporarily bigger or with lip (vermilion) advancements to achieve a permanent fuller lip.

It is very common to do mouth lifts at the same time of a facelift to get a central and lateral facial rejuvenation. However, they can also be performed as a stand alone procedure in an office setting under local anesthesia. The mouth lift procedure involves removing a small triangle of skin just above the corner of the mouth, making the area around the mouth smoother, tighter and more happy looking. The scars are hidden along the red part of the lip with a small portion of it going away from the corner of the mouth at an angle. The scars are very hard to see afterwards. A mouth lift not only makes one look a few years younger but also has a natural non-operated look to it. (if not overdone)

When done as part of a facelift, other mouth rejuvenating procedures can be done as well. This could include laser resurfacing for vertical lip wrinkles. While complete elimination of these wrinkles rarely occur, significant reduction can be obtained. Fat injections to the lips  ( as opposed to temporary synthetic fillers) can  provide some amount of permanent lip enhancement.  The harvest, preparation, and injection of fat into the lips is done exclusively in an operating room setting.   

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Angular cheilitis is a chronic inflammation of the corners of the mouth which makes them cracked and painful. This condition can last for days to months, often cycling between almost gone only to come back as severe as ever. It makes opening the mouth painful as that pulls on the inflamed corners. In many cases, this is caused by a fungal infection which can be resolved by a combination antifungal and steroid cream.

In some cases of angular cheilitis, however, there is an anatomic reason why the corners of the mouth are chronically inflamed or predisposed to chronic wetness and subsequent infection. This is best illustrated in those who wear full dentures where age and ill-fitting dentures can cause the mouth to over close resulting in small folds of skin forming in the corners of the mouth. This can also occur in those with teeth where aging (facial sagging) or their natural anatomy create the same situation with the upper lip edges turning down or falling over the corner of the mouth. This anatomical change disrupts the natural dam effect of the mouth corners. Now a natural spillway (crease or fold) is created which makes these folds chronically moist with saliva providing the ideal conditions for angular cheilitis to form.

In these patients with overhanging folds at the corners of the mouth that will not respond to any method of conservative therapy, a small plastic surgery procedure may be effective. The overhanging fold of skin can be removed and lifted through a corner of the mouth lift. By removing a small triangle of skin along the overhanging skin (or the actual hanging skin can be removed), the corner of the mouth is turned up and the downturned crease improved. Injectable fillers or fat grafts can also be placed at the same time to plump up the corner and the remaining downward crease. These changes should eliminate or decrease the salivary spillway so it occurs less or not at all. This simple procedure can be easily performed in the office under local anesthesia. I have done this a few times in refractory cases of angular cheilitis and it has worked well. One also gets the cosmetic benefit of getting rid of a downturned mouth or smile line.

The corner of the mouth lift is a procedure of last resort for angular cheilitis. It is not for every case and one’s anatomy has to be just right and proven to not respond well to topical treatments.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

As plastic surgery has worked its way into the mainstream of American society, it is no surprise that procedures are being done today that were not imaginable a mere ten years ago. And I am not referring here to surgery wonders of technology and scientific advancement (although that exists also), I am talking about what patients desire to have done. This is a reflection and commentary on contemporary American culture, not necessarily how far the science of plastic surgery has come.

 
As I talk with friends and colleagues about some of the plastic surgery procedures that I do today, I have come to realize that some of them may be considered ‘unusual’ . Certainly, some of them are different than traditional perceptions of plastic surgery. Many are relatively minor procedures that can be performed in the office and probably reflect the trend toward treating smaller concerns. They are the opposite of bariatric plastic surgery, for example, where a new subspecialty of plastic surgery has developed to treat the sequelae of gastric bypass and massive weight loss patients. The emergence of larger plastic surgeries and big procedures doesn’t occur very often but every few decades. But the emergence of more minor plastic surgery procedures occurs much more frequently. Here is a list of my unusual plastic surgery procedures that have emerged and become popular in the past decade.

 
Buttock Implants/Fat Injections - The appeal of a larger, more rounded buttocks is certainly a body image of recent note. Whether done by transferring fat from one body part to another or by an implant placed through an incision near the tailbone, the desire for buttock enhancement could not have been envisioned ten or twenty years ago. There is actually a great number of patients who would like buttock reduction but no single good procedure exists for that problem.

 
Labial Reduction - Whether due to discomfort from rubbing on clothes or during inetrcourse or simply to ‘look better’, reducing the size of a woman’s labia is now a common procedure. One would never have thought that such a concealed part of the anatomy would create a demand for treatment. A very simple and effective procedure, labial reduction restores the outer appearance of the vagina to a more youthful appearance.

 
Earlobe Reduction/Enhancement - As woman age and with the lifelong use of ear rings, the ear lobes will frequently get longer. The size of the ar lobe can easily8 be reduced in the office and it is a procedure that I often do at the same time of a facelift. Aging may also make one’s earlobes get quite thin and almost shriveled in appearance in very thin females. Injectable fillers, such as Juvaderm or Radiesse, can give an immediate rejuvenation effect to the earlobes that may last as long as a year.

 
Eyebrow/Eyelash Transplants - The science of hair transplantation has evolved to the point that single hair (follicle) transplants are now routinuely done in scalp hair restoration. It is quite logical that single follicular transplantation be applied to very small areas such as the eyebrow and even the eye lashes. The alternatives of permanent makeup, colored pencils, and false eyelashes made opting for actual hair tranplants a difficult decision. But some few patients do.

 
Umbilioplasty - While every full tummy tuck patient gets a new bellybutton (umbilicus), some non-tummy tuck patients want one also. Most commonly, it is to change an outie to an inne belly button.

 
Nipple Reduction/Nipple Enlargement - I have seen it both ways. The concern of large nipples is that they can be very visible through clothes…and at all times. Reducing the size of the nipple is a simple procedure and some women may lose a little sensation. Most recently, I have started to some men that want their nipples reduced also! Conversely, nipple enlargement or enhancement is about changing an inverted nippled (which is turned inward) to one that has some outward projection. While not quite as predictable (long-term result) as nipple reduction, the nipple can be released and brought more outward.

 
Corner of Mouth Lift - The downturning of the corners of one’s mouth with age gives a sad or angry appearance. A simple procedure in which a small amount of skin is removed and the corners lifted up and the mouth line leveled gives a nice and subtle improvement. Such a procedure is a simple office operation or is often done as part of a facelift. This is actually an old procedure that has now been ‘reinvented’ or rediscovered.

One wonders what this list will be in another ten years!

Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Many female patients today seek rejuvenation procedures which involve making the mouth area look better or less aged. As women age, some will lose lip volume, develop upper and lower lip wrinkles, and have the corners of the mouth draw down. This often creates a sad, mad, or unhappy appearance to the lip area. Most commonly, lip injections with hyaluronic fillers such as Juvaderm, Restylane, or Perlane are done to enhance the size of the lips, help fill out some of the fine wrinkles which are around the pink part of the lips, and raise up the mouth corners to some degree. While these forms of injectable treatments are effective and non-invasive, they are not permanent.

 
The corner of the mouth lift is a surgical option that has lasting effects. It is an old procedure that has been around for many decades. The corner of the mouth lift should be more popular than it is given that it is a minor procedure that can be performed alone in the office or as part of many other facial rejuvenation procedures. By taking a small triangle of skin from just above the drooping mouth corner, the downhanging mouth corner can be turned up quickly and easily. It is a very powerful procedure for such a small removal of skin and one must be careful not to overdo it by raising the corner of the mouth too far up and having too long of a scar. It does create a very small scar at the corner of the mouth but it is nearly indetectable if done right.

 
The key to a good corner of the mouth lift result is making the mouth corner level, and not more, and keeping the scar small that does not wander far from the corner of the mouth. Many facelift patients mistakenly think that the facelift will pull up the corner which is a misunderstanding. That is why some facelift patients with ‘frowns’ needs a concurrent corner of the mouth lift procedure.

 
I have found this procedure to be well accepted and most patients are surprised when I mention it as they have never heard of it. As an in-office procedure, it works well with lip injections and lip lifts and advancements. The frown that runs down into the ‘marionette lines’ will usually need filling of the deeper marionette line with injectable synthetic fillers, fat grafts, or a soft gore-tex implant, depending upon whether the procedure is done in the office or the operating room. For those patients with chronic irritation due to salivary overflow (a condition known as angular cheilitis), a corner of the mouth may even be curative as it rearranges the angulation of the ’spout’ and creating a more competent lip dam effect.

Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Mouth Lifts – Turn Up That Smile Line!

While lip concerns can range from lips that are too thin to those with too many wrinkles, the ‘frowning smile’ is a different issue. In this lip problem, it is the corners of the mouth that are downturned, creating a sad or unhappy expression when one is not smiling. Some patients have this naturally, others develop it from aging to the weight of the falling cheek tissues onto the corner of the mouth. Eiher way, it is not an infrequent concern that I hear expressed from many patients.

The good news is….there are two simple methods for improvement of this problem…and both can be done in the office. The easiest treatment is to simply place any of the injectable fillers into the mouth corners, (e.g., Restylane, Juvaderm, or Radiesse) , making less deep the natural crease that exists there as well as creating a subtle lifting effect. While easy and instantaneous, the result is not permanent and will last only as long as the filler persists. (months) I prefer in some cases a corner of the mouth lift, it can be more effective than fillers and is more permanent. In this office procedure under local anesthesia, a very small triangle of skin is removed from just above the corner of the mouth and the corner lifted into a new position. While it does create a very small scar, I have not found it to be a problem in any of my patients. The key is a subtle lift and not to overdo it. The creation of a permanent smile or the ‘Joker’ look is not natural. I have found this procedure, combined with the use of injectable fillers in other areas of the lip, provides a nice more youthful look to the mouth area.

Dr Barry Eppley
www.eppleyplasticsurgery.com
www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical center, Avon, Indiana
Indianapolis