Lip augmentation is a very familiar and popular procedure. By injecting a variety of substances into the lips, they become bigger and more sensual. But not all lip issues can be adequately treated by injectable fillers alone, particularly older lips. Lips as they age often get longer, thinner and turn down at their corners. Adding volume rarely is the best solution. Facelift surgery does little to benefit the mouth area. But unlike the face, the lips can also be lifted. A lip lift can shorten the upper lip and give it more pout through an incision under the nose. The downturned corners can be reversed by a corner of the mouth lift. Volume through injectable fillers can also be done at the same time for additional rejuvenation. This look is consistent with what is portrayed in the sensous lips of models who have a short upper with a pout and a turned-up mouth. Such changes in the older lip can not be done with injections alone.
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 ofcorner 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.
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 withinjectable fillers or fat injections to help fill out the marionette grooves below it.
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 ofnumerous 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.
Like the rest of the face, aging affects the mouth by atrophy and sagging. This is manifest by lips that get thinner, the development of vertical lip wrinkles, corners of the mouth that turn down, and the appearance of marionette lines or folds. These changes collectively can give the mouth an invert U-shape or frowning look, making one look sad or even angry.
Rejuvenation of the mouth area is based on a variety of techniques including volume restoration (injectable fillers), lifting techniques (skin excision and rearrangement) and wrinkle reduction. (skin resurfacing)
2. How do you improve thinning lips?
The most common and simple method for lip augmentation is through the use of synthetically-created injectable fillers. While over a dozen such fillers exist, not all are appropriate for injection into the lips. Those fillers based on hyaluronic-acid (hyaluron, a sugar molecule) produce a natural and soft fuller lip that is very well accepted. Based on their concentration, they may last anywhere from four to eight months between injection treatments.
Fat is another option for lip injection. It is generally done in the operating room when other plastic surgery procedures are being done. While it is the most natural lip filling material, it’s downside is that its survival is not predictable and some resorption does occur.
3. Are there any permanent lip augmentation procedures?
The appearance of a larger lip that is permanent is possible by changing the amount of visible vermilion. (pink part of the lip) This can be done by removing a strip of skin above (upper lip) or below (lower lip) where the vermilion meets the skin. The vermilion is then moved up or below to cover where the skin was removed. This produces a permanent enlargement of the lip…at the price of a fine line scar along the lip line. This procedure is known as a lip or vermilion advancement and can be used on either the upper or the lower lip.
The upper lip vermilion can also be lifted without removing skin directly above the lip line. By removing a strip of skin from beneath the nose, rather than lower at the lip line, the central part of the upper lip can be lifted to show more vermilion. Known as a lip lift, it can only be used on the upper lip (there is no nose on your chin!) and it does not lift the sides of the upper lip which are outside of the nose.
4. Can a facelift help get rid of my mouth frown?
Downturning of the corners of the mouth is a common perioral sign of aging. Although there are some people who have it naturally even when they are young. Contrary to what many people believe, it is not possible to lift the corner of the mouth (commissure) with a pull that comes from the side. (lateral) In addition, the point of pull is far away (by the ear) from the commissure so it would have little effect on it even if it was from the right direction.
5. What is the best way to get my corners of mouth lifted back up?
Changing the orientation of the corner of the mouth to any significant degree requires a procedure that is done directly on it. Known as a corner of the mouth lift (COML), a triangle of skin is removed just above the commissure. Some plastic surgeons remove a triangle, others remove a heart-shape piece of skin. Either way, the corner is moved up to where the skin was removed. This little procedure can make a big difference in where the corner of the mouth is located. The COML is a small but powerful procedure that,if not done carefully, can actually turn the mouth corners up too far creating what is known as ajoker’s smile deformity.
If the corner’s of the mouth is not turned down too severely, the use of injectable fillers can have a mild lifting effect.
6. What can improve the lines that run down from the corners of my mouth?
Vertical grooves or folds develop from the corners of the mouth down to the jawline because of the development of jowling. Loose and sagging skin falls forward toward the mouth and chin where it bunchs up against the more fixed skin of the chin. This creates a mound or fold which gives the appearance that there is a groove or line in front of it. This also makes any downturning of the corner of the mouth look worse.
Injectable fillers can certainly soften the appearance of the marionette lines, although they are only temporary. They can also be improved from the pull of a facelift and such tissue repositioning directly treats the cause of the problem.
In older patients who do not want a facelift or who have had one and have developed recurrent marionette lines due to inelastic skin, one can undergo a direct fold excision. A lenticular-shaped segment of skin is removed directly along the fold. While it does create a fine line scar, it is very effective at reducing its appearance.
7. How do you treat lip wrinkles?
Lip wrinkles develop as a direct result of the underlying action of the orbicularis muscle. When combined with thin skin, the appearance of vertical lip lines is inevitable. Small amounts of Botox can be used to soften the muscle action but too much will affect the way one smiles. Therefore, it is more effective to either try and fill the larger wrinkles directly and/or resurface the lip skin. The best results come from the simultaneous use of both methods. Laser resurfacing is a commonly used method that will soften the depth of most lip wrinkles. Whether fractional laser resurfacing is better than traditional laser methods is a matter of current discussion. Old-style dermabrasion is a time-proven technique for very deep wrinkles that is more effective than laser resurfacing in these more severely wrinkled lips.
Age-related changes around the mouth, known as perioral aging, are a very common concern for many women. Like the rest of the face, the mouth area deflates and sags with aging. One of the most effects of aging is that the upper lip sags, particularly at the corners, causing the mouth to sag. As the mouth corners turn down, the loose skin and tissue to the side of the mouth falls forward creating what is known as a marionette fold. The combination of both of these effects can create an inverted U-shape to the mouth, making it look aged as well as sad.
When considering rejuvenation methods, the mouth is like an island. It’s location is far away from the pull of any traditional method of skin lifting such as the lateral pull of a traditional facelift or the superior pull of a midface lift. While both of these procedures do provide some improvement to the sides of the mouth and marionettes folds, it is not as significant as most people think. Early recurrence is common because of the stretched out and thin skin that most b elderly have.
There are several changes that can help improve the appearance of the aging mouth. These would include fuller lips, a more horizontal orientation of the mouth corners (commissures), and softening or elimination of the marionette folds. Injectable fillers are a common method used for perioral rejuvenation. While they can make the lips more full and soften deep vertical lip lines, they will not improve the frowning or downturned look to the mouth.
Lifting of the mouth is best done by removing selected areas of skin. The most common mouth lifting procedure done is a corner of the mouth lift. (COML) By removing small triangles or heart-shaped segments of skin just above the commissures, the corners can be immediately and simply repositioned. Whether done in conjunction with a facelift in the operating room or as an isolated procedure done in the office under local anesthesia, it is very effective and leaves very discrete scars that I have not seen to be of any significant concerns. One important consideration when doing the procedure is to not let the length of the scar that trails away from the commissure get too long.
While the COML is directed to improvement of the orientation of the commissure, it will not help the appearance of the marionette folds. That requires a separate procedure which is less commonly done. Most patients will do well with injectable fillers in the marionette lines but older patients do not respond very effectively with this treatment method. When the marionette folds are significant, a method of skin removal known as a lentiform excision or marionette fold excision (MFE) can be used. This is a modified ellipse of skin removal that starts above the corner of the mouth along the upper lip line and extends inferiorly into the marionette line crease. How far down the excision pattern goes is determined by how severe the marionette fold is.
Marionette fold excision initially seems aggressive and there is justifiable concern about the scar. But in the elderly patient with thin and inelastic skin, the scar can be quite thin and heal inconspicuously. This is well known in elderly patients in extensive experience from facial skin cancer excision and closure. It can be performed after unsuccessful improvement or early recurrence after a facelift or done at the same time as a facelift. The length of the resultant marionette line scar will depend on how severe the fold is and whether it is done in conjunction with a facelift.
Rejuvenation of the aged and frowning mouth may benefit from excisional procedures. While one should usually try injectable fillers first, the age of the patient and the severity of the downturning may allow one to skip right to excision. COML and MFE, while creating some scar, can make improvements that are not achievable otherwise.
One of the telltale and most bothersome signs for women as they age is the development of an aging or “old mouth”. Besides the lines and wrinkles that form in the surrounding skin, other anatomic changes occur that change its overall appearance. The upper lip begins to get longer and thinner. The drooping skin from above the lips forces the corners of the mouth to turn downward. As the corners turn downward, furrows extend from the corner of the mouth downward, known as marionette lines. The lower lip sags and the horizontal groove beneath it (labiomental sulcus) becomes more pronounced. The nasolabial folds or lip-cheek grooves, which bracket the mouth from above, become deeper.
Skin resurfacing methods, such as lasers and chemical peels, are useful to decrease wrinkling around the mouth area. But they often only improve just a part of the problem. Injectable fillers add a good method of rejuvenation because they replace lost volume and help provide a small lift to some areas of the mouth. When combined with skin resurfacing, some nice changes in the aging mouth can be seen.
In some cases, the mouth or perioral area requires some surgical manipulation to get that more youthful look.There is a set of small but very effective mouth procedures that are more effective at lifting and upturning than any injectable filler alone. The goal here is to have fuller lips with a more even or horizontal smile line. These perioral rejuvenation procedures include lifts of the lip, corner of the mouth, and smile lines.
The simplest lift is that of the upper lip. It is performed to shorten the long lip of aging, allowing the upper teeth to show slightly 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. Lip advancements, however, are more widely used as they affect the entire upper lip. Lip advancement achieves exposure of more of the pink mucosa (vermilion) and removes some of the vertical lip lines that run directly into the lips. A small strip of skin outside the lip line is removed to make the lips look bigger
There is really only one way to lift the downturned mouth corners. The corner of the mouth lift is performed 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 of skin above each corner which changes the location and angulation of the sides of the mouth.
Just beyond the corner of the mouth can lie folds of skin which hang down. While it is tempting to think that this loose skin can be improved by a facelift, it usually is not. These “parachute” folds of skin can be improved by direct excision of loose skin and fat in the lower portion of the nasolabial fold. This excision of skin places a small scar along the lower end of the nasolabial fold. It can also help with some minor lifting of the corners of the mouth as well.
Any direct excision of skin in the mouth area do result in scars. Patients have to be willing to accept that trade-off for the benefit of mouth rejuvenation effects. While most of these scars heal well and very indiscriminately, some may need revision or smoothing out later. In my Indianapolis plastic surgery experience, these small revision rates are most commonly needed for corner of the mouth lifts and about 10% to 15% of patients may benefit by them.
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 positionas 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.
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 themouth 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 prominent 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, 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.
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 themouth to a more horizontalor level position. This can be combined withinjectable 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.
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 is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.