Asymmetry of the mouth is not rare and consists of differences in the size and shape of the vermilion and/or the corner of the mouth. One side of the upper lip may be smaller than the other side or the corners of the mouth may be at different horizontal levels. Some patients affected by mouth asymmetry have had it since they were born while others have developed it with aging. Certain medical conditions that affect facial nerve function can also create mouth asymmetry with decreased muscular movement on one side.
The most effective method of improvement in mouth asymmetry, not caused by a nerve dysfunction, is a direct one. Moving the location of the vermilion-cutaneous junction through skin excision is the most visually effective technique. Lifting the skin from distant locations is not going to lift the mouth or improve lip symmetry. No form of a facelift or midface lift is going to affect the mouth area. This is well known in facelift where efforts to lift up drooping corners of the mouth is not successful.
Direct excision for improvements in mouth asymmetry are simple variants of the well known procedures of lip or vermilion advancements and corner of the mouth lifts. These direct excisional methods have been around for decades. Their effectiveness at cosmetic enhancements of the lip and mouth area can not be denied but they have never been widely popular due to the risk/concern of scarring.
For upper lip asymmetries a smaller side of the lip can be advance upward by a partial vermilion advancement that only goes as far as the cupid’s bow on that side of the lip. This can be combined with an extension into a corner of the mouth lift to create a complete elevation of the lower or hanging side of the mouth. While fine line scars are always a trade-off, they usually heal well when well executed even in high risk patients with intermediate pigment types. (e.g., Hispanics, Asians)
While not appropriate for everyone with mouth asymmetry, utilization of simple and direct procedures such as vermilion advancements and corner of the mouth lifts can be both effective and have acceptable scar lines.
Background: All areas of the face eventually show the signs of aging. But the mouth area in women is affected more by aging than that seen in men and is affected by sagging, thinning and wrinkling. The once fuller lips of youth give way to thinner lips with less vermilion show and vertical lip lines. The corners of the mouth turn down and jowling develops from the descent of tissues from above. Collectively put together this creates an older and unhappy mouth appearance.
While many plastic surgery procedures exist to treat the aging face, the most recognized ones do not have any influence on the mouth area. A facelift is a great procedure to improve the neck and jowls but does not affect the more central mouth region. Cheek lifts improve midface volume and sagging but will not turn a frown into a smile.
An aging mouth can only be improved by a direct approach and not peripheral pulling or lifting. This requires a series of different small procedures performed directly on the various aging mouth issues. Corner of the mouth lifts, laser resurfacing, lip lifts and advancements, lip volume augmentation and perioral mound liposuction all make up a collection of procedures under the category of perioral rejuvenation.
Case Study: This 57 year-old female wanted to improve the look of her mouth. She felt it looked old and constantly frowned. The corners were turned down and she had moderate jowling and fullness to the side of her mouth. She had excellent lip volume for her age and good skin with very few vertical lip wrinkles.
Under general anesthesia (she was having numerous other facial procedures), she had a corner of the mouth lift combined with perioral mound liposuction. The corner of mouth lift was performed using a small triangular cutout of skin obliquely oriented along the depressed mouth corners. Through a small mucosal incision just inside the corners, a 2mm cannula was used to remove 1.5ccs of fat from each perioral mound area down to the jowls.
These small mouth-related procedures produced a subtle but visible change in the appearance of her mouth giving it a more pleasing and youthful appearance. The smile line was now level and the convexities (bulges) on the side of the mouth were turned into more shapely concavities.
The relatively obscure corner of the mouth lift has been around for over 75 years and, despite its simplicity, is the only procedure that can produce a permanent improvement for downturned mouth corners. It is a very small area of skin excision but it has to be marked out and executed very carefully to avoid visible scarring. Even when done well, there is a 20% to 30% incidence of minor touchups to the scar(s). Perioral mound liposuction is even less well known but less than 2ccs of fat removal can get rid of undesireable fullness and tissue sagging.
1) Aging of the mouth causes a variety of changes including downturning of the corners of the mouth, lip lines, marionette lines and jowling.
2) Perioral rejuvenation includes a variety of procedures including correction of frowning with a corner of the mouth lift.
3) Perioral mound liposuction can help get rid of the sagging fullness to the side of the mouth.
When it comes to treating the aging face, most everyone immediately thinks about a facelift. While a facelift can be a variable concept depending upon how it is done, many patients assume that it is an effective cure for all parts of the face including the mouth. The reality is that lifting the downturned corners of the mouth is almost completely unaffected by a facelift…and trying to do so will likely create a very tight and unnatural facelift result that will leave the patient disappointed.
The reason a facelift can not change the sagging mouth corners is two-fold. First, the point of pull is simply too far away to be effective. The distance between the ear and the corner of the mouth is too distantly separated. Secondly and equally important is that their vectors are completely perpendicular to each other. The sagging corner of the mouth drops vertically, while a facelift pulls tissues laterally. A negligible pull from the wrong vector equals no improvement.
The corner of the mouth lift represents a simple but highly effective method for changing the downturned or sad mouth corner. It works because it attacks the problem directly, affecting its position directly over the problem and in the right vertical or upward direction. Its simplicity is matched by its effectiveness whether done in isolation or as part of a more extensive facial rejuvenation procedure.
In the November 2013 issue of the Archives of Plastic Surgery, an article appeared entitled ‘Descended Mouth Corner: An Ignored But Needed Feature of Facial Rejuvenation’. In this article, the descended mouth corner lift, also known as an anguloplasty, is presented. The authors treated 71 patients using the corner of the mouth lift technique with consistently good results, with just one requiring revision. They conclude that this procedure by itself and in combination with other small operations or even a full face lift can help rejuvenate the aging mouth area.
This is one of the few articles in the medical literature that has written about a mouth lifting procedure that has been around for decades. I would corroborate most everything the article has to say about the corner of the mouth lift with the exception of the number of revisions. Even though it is a very small procedure in surface area, it does create a scar line that goes slightly beyond the vermilion tissue of the mouth corner. While not usually an issue in older patients, some occasional scar touchups may be needed in younger patients with less tolerant skin.
‘Thank you very much for my corner of mouth lift. My mouth has changed now. I came home from United States last week and my friend saw me with my new mouth and she was amazed. She said to me that my mouth is marvelous and is much better now. She was happy and told me that my smile is much improved. A big thank you for the operation on my mouth corners. I am very happy and am feeling much better as my mouth was getting very droopy in the past few years.’
While many plastic surgery operations make big changes in how one’s face looks, few operations that are so small can make such a big difference as the corner of the mouth lift. The mouth that turns down, either from how it naturally developed or from aging due to the descent of surrounding tissues, makes one look sad or even mad. This appearance is usually quite contradictory to how one actually feels but the droopy mouth corners create that impression nonetheless. While Botox and injectable fillers can help push up the downturned mouth corners they offer only temporary fixes…and if not done well the mouth lifting effects can be less than desired. A corner of the mouth lift offers a permanent fix to the sagging mouth corner by removing the skin overhang and changing the position of the mouth corner (commissure) upward. Small scars at the corner of the mouth result from the lift but, if well placed and not overdone, they are not a long-term aesthetic issue. When done as a stand alone procedure, corner of the mouth lifts are done as an office procedure under local anesthesia.
While the corner of the mouth lift seems new, it is really an old procedure that was done long before Botox and injectable fillers were even in development. When there was no other way to change the corner of the mouth but skin excision, the old’ valentine’ corner of mouth lift was done. (the skin excision pattern was shaped like a heart)
Much of one’s facial expression has to do with the mouth or perioral area. While there are over 10,000 different facial expressions, most can be lumped into six major categories. One of these categories of major facial expressions is smiling of which the mouth plays a major role. Everyone knows that an upturned smile line conveys happiness and a downturned frowning one is unhappiness.
The lip line at rest is usually seen as a straight horizontal line with the corners of the mouth being level. Whether it is by aging or one’s natural mouth development, some people develop a downturning of the corners of the mouth creating a constant frown and an undesired mouth appearance. While many perceive that a facelift can lift up the corners of the mouth, this is not true as the point of the tissue pull is just too far away. Injectable fillers can create some uplifting of the corners of the mouth but the effect is not sustained and usually only of a minor improvement.
The one proven procedure to uplift or level out a frown is the corner of the mouth lift. This very simple procedure works because it removes tissue directly at the corner of the mouth and changes the position of the lateral commissure. It was described many decades ago and has been called the Valentine Anguloplasty procedure based on the shape of the skin cutout. It works so well that the plastic surgeon must be careful to not overdo it (which is very easy to do) lest the patient is left with a permanent joker’s smile.
A recent internet report out of Asia talks about the growing trend of the ‘mouth corner lift surgery’. They describe a procedure that is identical to the well known corner of the mouth lift. They give it the name ‘Smile Lipt’ because it not only lifts up downturned mouth corners but leaves one with upturned curls for a permanent smile effect. They provided the following before and after pictures to illustrate the effect of the ‘Smile Lipt.’
While some question whether these pictures are for real, they most definitely are. One of the telltale signs of a corner of the mouth lift are small scars on the skin outside of the vermilion or red part of the corner of the mouth. These scars are difficult to hide particularly in thicker Asian skin. Careful inspection of the skin outside of the corners of the mouth in the pictures shows the scars.
Such upturned mouth curls may be a desired fashion trend in Asia, but in America this is exactly the result one wants to avoid from a corner of the mouth lift. They may be cute mouth curls in one part of the world but a undesired joker’s smile in another.
Surgical lip enhancements involve removing select areas of skin to increase the vermilion show of the lips or change the angle of the corner of the mouth. These are precise and measured amounts of skin removal that result in fine line scars either under the nose, along the lip edges or extending out from the corner of the mouth slightly.
The following postoperative instructions for excisional lip enhancement surgery are as follows:
2. There are no dressings applied after lip and corner of mouth surgery. Only antibiotic ointment is used to keep the suture lines soft and supple, whose primary intent is to make suture removal eventually easier.
3. Be aware that your lips will get increasingly swollen over the next few days after surgery. This is normal and not a cause for concern. Lip swelling does not start to go down until three days after surgery and will take a week or two to go away completely. The use of ice packs on the lips is very useful the first day after surgery to control swelling and improve comfort. You may use them as long as you like. Corner of the mouth lifts have little to none of this after surgery issues.
4. The lips and corner of the mouth suture lines may get wet without any danger of increasing the risk of infection. So feel free to wash your face and shave (men) as needed.
5. The incision lines at the base of the nose (subnasal lip lift), lip lines (lip advancement) or corner of the mouth lift will have sutures that need to be removed in a week after surgery. (unless you are an out of town patient). Apply antibiotic ointment to them three times a day to keep them slightly moist. If any blood has accumulated on the suture lines during the first day after surgery, clean it off with a little water or hydrogen peroxide on Q-tips. There is no need, however, to use hydrogen peroxide on clean suture lines. Just apply the antibiotic ointment.
6. Your lips will feel a little tight when you open your mouth widely. That will take several weeks to a month to return to normal. You may stretch open your mouth and lips as much as feels comfortable. You may eat whatever you like. Focus on liquids and soft foods for the first few days after surgery.
7. After sutures are removed and the incision lines healed (several weeks), massaging the lips and stretching them gently will help make them feel softer sooner and regain their normal suppleness again.
8. You may return to any physical activity and work as soon as you would like based on your comfort level with pain and your facial appearance
9. You may drive when you feel comfortable and can react normally and are off pain medication.
10. If any lip redness, tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.
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.
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.
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.
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.