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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘perioral rejuvenation’

Case Study: Surgical Rejuvenation of the Aging Mouth

Wednesday, October 16th, 2013


Background: Aging affects all parts of the face and the mouth area is no exception. The changes of the lips and the perioral tissues are classic and include thinning of the lips, downturning of the corners of the mouth and the development of vertical lip lines. These central facial aging changes are unaffected by more peripheral procedures like a facelift. Rather they require a direct approach to their treatment and are not uncommonly done as part of a facelift to provide a more complete facial rejuvenation effect.

While injectable fillers are the mainstay of younger lip and mouth enhancements, the older aging mouth is less responsive to just pure plumping effects. It needs more help with actual mini-lifting prcedures that are designed just for the lips.

Case Study: This 62 year-old female was bothered by the constant frown of her mouth and the thinning of her upper lip. While she had always had a thinner upper lip, it had gotten even thinner as she has gotten older. Her goal was not to have really big lips but an upper lip that matched the size of her lower lip. But what really bothered her was the downturned corners of her mouth. This made he look mad all the time when she really wasn’t.

A lip rejuvenation plan was marked out that included an upper lip (vermilion) advancement, corner of the mouth lifts and fat injections into her marionette lines.

Under local anesthesia which included infraobital nerve blocks and direct local infiltration into the upper lip, a 3mm vermilion lip advancement was initially done with making the cupid’s bow area more accentuated. The tail ends of the vermilion advancements were left open in preparation for the corner of the mouth lifts. Corner of the mouth lifts were done by making an outward line of 7mms from the corners toward the tragus and turning that into a triangle as it curved toward open end of the lip advancement. Finally, fat was harvested from her abdomen from inside her bellybutton, concentrated and then injected from the bottom end of the marionette lines upward, placing 4ccs of fat per side.

There are many options for turning an aging or unhappy mouth area into a more rejuvenated one. While the most common technique that comes to mind are injectable fillers, they usually are inadequate for older lip and mouth area as the exclusive treatment option. To make lips fuller or to change the smile line in older patients requires skin removal and lifting techniques.

Case Highlights:

1) Lip and perioral aging is often accompanied by a combined thinning of the upper lip and downturning of the corners of the mouth.

2) Corner of the mouth lifts combined with an upper lip advancement creates a more complete lip rejuvenation effect.

3) Most perioral rejuvenation procedures can be performed under local anesthesia as an office procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions about Mouth Rejuvenation

Sunday, February 14th, 2010
  1. What happens to the mouth area with aging?

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 a  joker’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. 

Dr. Barry Eppley

Indianapolis, Indiana

Lifting Procedures for the Frowning Mouth (Perioral Plastic Surgery)

Saturday, February 13th, 2010

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.        

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Teeth Whitening for Smile Rejuvenation in Plastic Surgery

Monday, November 30th, 2009

As a plastic surgeon who regularly does procedures to enhance and improve the perioral region of the face, the color of one’s teeth can also make a significant impact on these results. Smiling is an expression that is framed externally by the face and internally by one’s teeth. Full lush lips that move to reveal dungy and yellow teeth is an aesthetic distraction. I encourage my patients to consider teeth whitening as part of their facial rejuvenation process and it is a service that is offered at my spa and office facilities.

Having a dental degree and training, patients frequently ask my advice on dental issues including teeth whitening. Many teeth whitening products are available from the drugstore to a dentist. Strips, trays, toothpastes, mouthwashes, and even light systems are available to improve tooth color. But how effective are they and which is best?

An important concept to understand is why teeth discolor? Time and what you eat are the main causes. As you age, the outer layer of the teeth (enamel) becomes thinner and easier to see through. Like glass, one can see through to the second layer known as the dentin. Since the dentin is naturally darker, our teeth begin to appear less white. In addition, the enamel has tubules which can absorb color from food and drink such as coffee, red wine and tobacco, further contributing to a dull and yellow appearance. To get teeth whiter, one essentially has to get the glass (enamel) cleaner.

The key ingredient by which all forms of whiteners work is peroxide. By releasing oxygen, it bubbles away stains in the enamel like wiping a glass window clean. The higher the concentration of peroxide and the longer it can remain in contact with your teeth, the better the result will be. The bleaching action of peroxide solutions can make some teeth temporarily sensitive after treatment as it opens up the tubules down into the sensitive dentin and nerve tissues of the tooth.

For at-home whitening, trays and strips can be effective. These “barrier method” whiteners keep the peroxide solution against the teeth until the solution becomes ineffective. While no single treatment session (usually 30 minutes) produces a dramatic whitening effect, daily use over weeks can improve tooth color up to four or five shades. The highest concentration of peroxide in strips or trays may be up to 9 to 10%. These methods are popular because of their ease of use and low expense. They are not perfect as they are not custom fit. Whitening strips can slip and slide around and may become wrinkled or folded. Disposable trays do not fit everyone well as they are designed for the average-sized mouth.

Paint-on whiteners have become well-marketed and they allow one to apply the peroxide solution to specific teeth or spot areas of teeth. Because there is no barrier for the peroxide, however, it quickly becomes diluted and loses any significant contact time. Some products have a longer application time due to holding agents but they are still inferior to strips and trays. These whitening brushes have gained some popularity because they are portable, not messy, and cause no tooth sensitivity.

Whitening toothpastes can produce a mild brightening effect of maybe a shade over time. They work by mainly by a light abrasive effect. Some do have peroxide action. Again, duration of contact is important and several minutes of brushing per session are needed if any significant effect is to be seen. Some whitening toothpastes also have ingredients that prevent new stains from sticking to teeth. Whitening mouthwashs have more recently become available. While they have good foaming action, they don’t stay in contact with teeth very long. But the combination of a whitening toothpaste and rinse does give teeth several minutes of whitening action every day. At the least, their use may be able to get rid of any stains that are acquired by food and drink on a daily basis.

Professional whitening done at your dentist uses one of three treatment methods. The fabrication of custom bleaching trays for at-home use with differing strengths of peroxide solutions. In-office strong peroxide gels with an applied gum barrier. And light treatments which have accelerated whitening up to 6 or 7 shades in a single session. The light helps intensify the effects of an already high strength peroxide. With such accelerated whitening, tooth sensitivity is common and persistent. However, any dramatic whitening can fade quickly without at-home maintenance (usually a tray, whitening strips or toothpaste). You also have to watch what you eat and drink for a couple of days after, since tooth enamel is very receptive to new color from food or drink for the first 48 hours after a bleaching treatment.

Not everyone can really whiten their teeth significantly. If your front teeth are crowns or veneers, they can not be whitened at all. If your teeth appear more gray than yellow (commonly caused by antibiotics taken as a child), they will not lighten. A simple method to test your whitening potential is to hold up a white piece of paper or 3 x 5 card next to your teeth. If your teeth appear yellowish, they will get whiter. If they appear gray, they will likely not get lighter.

Teeth whitening is an important part of making one’s smile more aesthetically pleasing. It is frequently overlooked in the plastic surgery patient who can get get caught up in lip enlargement, wrinkle reduction, and other methods or perioral rejuvenation. Numerous effective methods of tooth whitening exist. They fundamentally differ based on how long they take to work, how much lightening can be achieved, and their risk of temporary tooth sensitivity.

Dr. Barry Eppley

Indianapolis, Indiana


Lip and Corner Tuckups for the Aging Mouth

Tuesday, October 13th, 2009

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.

Dr. Barry Eppley

Indianapolis, Indiana

Perioral Rejuvenation – Combining Nasolabial Fold Injectable Fillers and Corner of the Mouth Lift

Tuesday, August 4th, 2009

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 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.

Dr. Barry Eppley
Indianapolis, Indiana


Corner of Mouth Lift for Perioral Rejuvenation

Monday, May 18th, 2009

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

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

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.

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