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The face develops many visible signs of aging. But none are more problematic or pesky than that of upper lip lines or vertical rhytids. Such lip lines are very bothersome to women as they not only suggest an older lip but also cause problems with lipstick, often bleeding into the lower end of the vertical line. By far, vertical lip lines occur most commonly in Caucasian women of Northern European descent. They are very rarely ever seen in women that have more skin pigment, thicker skin and fuller lips.

While upper lip lines are often perceived as being caused by those smoke (and this certainly is a contributing factor), but many other factors contribute as well. The most significant, as previously mentioned, is light skin pigment and a genetically thin upper lip. This means that the upper lip has thin skin thickness and less subcutaneous fat which offers little buffer from the motion of the underlying circumferential orbicularis oris muscle. (facial wrinkles develop perpendicular to the action of the underlying muscle movement)

The treatment of upper lip lines is challenging because the source of the problem, movement of the mouth, is something that can not be changed after surgery. One can adopt a new diet to protect a liposuction result or avoid the sun and do numerous topical therapies to preserve other facial surgery changes, but one can not change the thickness of the upper lip or stop eating, drinking or smiling after lip line treatments.

The fundamental treatment of upper lip lines has historically been laser resurfacing. Using deeper laser treatments, the objective is to bring down the entire epithelial thickness of the skin and cause some collagen thickening as well. Much like sanding an irregular surface, significant reduction in lip lines can be achieved by total ablative laser treatments. But it can thin out the skin, cause pigment loss and can not usually be done more than once if the initial laser depth was deep. Thus enters the concept of fractional laser resurfacing where the risks of skin thinning and color loss is minimized. By cutting deep laser holes in just a fraction of the skin surface (22% or less), better collagen production and skin tightening is achieved. When combined with an initial very superficial ablative laser pass (< than 50 microns), significant and sustained lip line reduction can be achieved.

Other lip skin resurfacing methods are available including the dermaroller and old-style dermabrasion. For very deep lip lines, dermabrasion provides the most aggressive method of ‘sanding’ that actually produces the best results. But it is a highly technique sensitive method of resurfacing and is prone to a higher risk of hypertrophic scarring and severe skin thinning. The dermaroller is very much like a poor man’s fractional laser that punches small holes in the skin but its ability to induce collagen production is not as powerful and multiple treatments are needed to approximate even one laser resurfacing.

The other approach to lip lines is to add volume by injectable fillers. Most patients think this means trying to directly inject the vertical lip lines, and this can be done for the very deepest ones, but it really means augmenting the size of the upper lip vermilion. This will  increase the size of the upper lip which directly plumps out the lower end of the vertical lines as they join into the pink part of the lip. For those women that do not mind some increase in their lip size this is an essential step in a lip line reduction strategy. Whether one should use any of the available hyaluronic acid-based fillers (e.g., Restylane, Juvederm) or consider some autologous fat is a matter of discussion with each patient. There is also the option of a lip lift or lip advancement which provides a permanent change in the vertical size of the lip vermilion and cuts out some lower lip lines as well. (lip advancement only)

The best upper lip line reduction therapies incorporate a combination of skin resurfacing and volume addition. If done in the office, fractional laser (22%, 100 microns) with Juvederm upper lip injections is my preferred technique done under topical anesthesia. If done in the operating room, as part of a facelift for example, then I would do a more ablative laser treatment (two passes) with fat injections into the upper lip. Either way the patient needs to be aware that lighter maintenance fractional laser treatments will be needed in the future.

The key word to use in the treatment of vertical lip lines is reduction, few patients will achieve complete elimination of them in a single treatment.

Dr. Barry Eppley

Indianapolis, Indiana

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