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

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

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

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

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

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

Case Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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