There are many physical signs that can give away one’s age. Women know these signs very well and they include such areas as the back of one’s hands, the neck at the sternal notch area, and the mouth. The mouth area is a particularly bothersome area for many women. As a plastic surgeon, the mouth seems to be an area that unfairly ages in women much more than in men. It is actually rare to see deep vertical lip lines in men, even if they have thin lips, until they get quite elderly.

In the November 2009 issue of the Aesthetic Surgery Journal,  a study was reported to investigate the differences between men and women around the mouth area.To determine how bad the wrinkles were, the upper lip of male and female fresh cadavers were analyzed using three-dimensional digital imaging and as well as histologic assessment of full-thickness lip resections in different male and female cadavers. Their results showed that women had more and deeper wrinkles than men. Men had a significantly higher number of sebaceous, sweat glands, and blood vessels in their skin. Somewhat surprisingly, the number of hair follicles did not significantly differ between men and women, although men had a higher number of sweat glands per hair follicle.

This study provides scientific evidence as to why women are more susceptible to the development of mouth and lip wrinkles.The skin around the mouth in women has lesser numbers of skin appendages (hair follicles and oil glands) as well as different connections between the skin and the muscles of the lips.

The key anatomic factor is that with less oil glands, there is less oil production to help keep the skin softer, smoother and better protected. I think the observation that the muscles around the mouth are closer to the skin in women than men is also important. This may allow the muscles to pull the skin in tighter, creating a ‘purse-string effect’ and causing more wrinkles.

Outside of this study, there are likely other contributing factors that accentuate these anatomic findings. One of these is the drop in estrogen in women with aging. This hormonal change causes a decrease in the fat (sebum) secreted by sweat glands. Coincidentally, women on hormone replacement therapy have been reported to have fewer wrinkles than those not taking the hormones. Also, most men perform a daily wrinkle treatment, shaving which is a  form of microdermabrasion. Such superficial skin exfoliation done tens of thousands of time over one’s lifetime will help lessen wrinkling also.

While avoiding smoking and sun exposure and using daily moisturizers are extremely helpful and will reduce the amount of wrinking which will develop, that advice does little for the women who already has significant signs of mouth aging.

Several treatment strategies exist that can help significantly with lip lines and wrinkles. These include injectable fillers, Botox, laser resurfacing, chemical peels, and fat injections. The fundamental concepts of these strategies (with the exception of Botox) is inflation (volume fill or restoration) and smoothing. While everyone does not need all or even most of them, a combination of inflation and smoothing will work better than just one of the concepts. Most commonly, the combination of injectable fillers and laser resurfacing is used. But treatment approaches can differ and I do not always do the same approach for everyone.

The anatomy of lip wrinkles indicates that no matter what is done, none of the treatment approaches actually ‘cures’ the problem. The skin of the lip can not be made permanently thicker and the natural oil production of the skin can not be improved. This indicates that no matter what treatments are done, they will have to be eventually repeated to maintain the improvement.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

Rejuvenation of the upper lip is a commonly requested and performed procedure. There are numerous strategies for treating an aged upper lip and one of the basic approaches is to add volume. Usually through injectable fillers, volume is added to create a more protruding and pouty lip. This is based on the fundamental belief that volume loss is a significant part of lip aging.

I read a recent article that reports that drinking directly from water bottles can cause just as many upper lip wrinkles as smoking. I wouldn’t doubt it as any activity that makes your lips pucker, which activates the orbicularis oris muscle which encircles the mouth, can cause wrinkles to appear on the upper lip. The development of such wrinkles is a function of both the activity and how often it is done. Drinking water these days for some people is about as frequent as a regular smoker who does one or two packs per day.

 
As a general principle, wrinkles form on the face perpendicular to the direction of action of the underlying muscle movement. For example, horizontal forehead wrinkles are the result of ther vertically-oriented and moving frontalis muscle which extends from the brows upward into the scalp. Since the mouth’s main muscle (like the eyes) is a sphincter or encircling muscle which lies parallel (horizontal) to the upper and lower lip (except at the corners), it is no surprise that the lips (particularly the upper) develops vertical wrinkles in some people. The other factor that highly contributes to lip wrinkles is the thickness of your skin and the size of your lips. (which is interrelated) The thicker your skin, the less likely you will ever develop them. Take a look at African-Americans and people of Middle Eastern Descent, you rarely ever see them develop wrinkling of the lips. (and they have larger lips to begin with….as their skin is thicker)

 
Treatment of lip wrinkles is a challenging problem. I tell patients to think of it as improvement as there is no complete cure in most cases. For small and fine lines that are mainly located at the junction of the skin and the lip, an injectable filler can make a nice improvement…if you can accept having slightly to substantially larger lips. (whichever you desire) When the lip wrinkles are deeper and run higher into the upper lip, the concept of skin resurfacing comes into play. Usually this means laser resurfacing and it is just a question of how deep to go and how much recovery does the patient want. Laser resurfacing with lip augmentation with an injectable filler is the most common method by which I treat more significant lip wrinkling issues. This is done in the office under local anesthesia unless the patient is having other facial procedures which requires a trip to the operating room with the use of deeper anesthesia. There is some current debate between the laser techniques of resurfacing or peeling and the use of fractional (fraxel) laser treatments, but there is no hard clinical evidence at this point to say conclusively that fractional laser treatments are better. In the more severe cases, a small amount of Botox to help reduce the amount of muscle movement can also be helpful when done with fillers or laser resurfacing but you must be careful to not use to much lest you make your smile have an unnatural appearance.

 
Other methods of upper lip resurfacing for lip wrinkles is currently being evaluated. One method is to combine laser resurfacing with the use of sandpaper (yes I said sandpaper), known as laserbrasion. With this technique, the laser is only used for the first pass (to remove the very top layer of skin) and the deeper layers are then taken done by fine sandpaper. The concept here is that the use of sandpaper causes less trauma (no heat) and will heal faster without the prolonged redness. And it is just as effective as the laser but safer and with less complications than if one used traditional dermabrasion. The other method is known as percutaneous collagen induction therapy. (PCIT) Known aerating your lawn, a small wheel with fine needles is run over the upper lip, cutting many fine holes into the deeper portions of the skin. As this heals it causes the skin to thicken which helps reduce the amount of visible wrinkling.

 
Upper lip wrinkles in some women are unavoidable and can be very troubling. Injectable lip fillers, laser resurfacing, abd Botox can help but there is no permanent cure. The alternative treatments of fractional laser treatments, laserbrasion, and collagen induction therapy are interesting but it is too early to know if they will offer better results.

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

Upper Lip Lines – A Not So Simple Problem

One of the seemingly ‘simple’ but most difficult cosmetic facial problems that I see in my practice is the woman with upper lip lines. Like dark spots on the hands, these telltale signs of aging are very disturbing for the aging woman. Ironically, I have seen them even in some younger patients, so it is not always a sign of aging! While frequently thought of as being due to smoking or excessive sun exposure (and these certainly are important contributing factors), it is as much due to the native thickness of one’s skin (racial type) as well as how one moves their face with expressions than anything else. These can be easily shown by looking at African-Americans, Hispanics, and people of Middle Eastern or Pacific Rim descent who have much thicker skin (more dermis and elastin fibers), it is very rare to ever seen upper lip lines in these ethnicities. So, in many ways, this is a more significant problem in fair-skinned people of northern European descent, particularly in blondes and redheads.

The two basic treatment approaches are injectable fillers (JuvaDerm or Radiesse) placed directly into the vertical lip lines or laser skin resurfacing. Often I will do both together, at the same time, to get the best result. These are simple office procedures that are done under a local anesthetic to numb the whole upper lip through traditional dental block techniques. Neither of these approaches ‘cures’ the problem, but significant improvements can be obtained. To maintain the result, it is usually necessary to have the treatments twice a year.

An interesting ‘new’ treatment approach is that of medical needling. This is actually an old technique that may be coming back into popularity. Essentially, a roller with many fine needles is run over the upper lip (like aerating your lawn), creating fine tunnels into the deep part of the skin. Topical vitamin C preparations are then applied after so that they may ‘soak’ into the tunnels and stimulate the underside of the skin, causing it to thicken. So rather than burning the top layer of skin off (laser resurfacing) to soften the wrinkles, this approach focuses on stimulating the skin to thicken. It is being called Transdermal Collagen Stimulation therapy. Whether this is better than fillers or laser resurfacing remains to be seen, but I will be able to have a better idea in another year or so after treating and following some patients.

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