Today’s facial surgeons have more options to rejuvenate the periodical area. It is essential to have a thorough understanding of perioral anatomy and perceived signs of aging to implement the proper treatment plan.
The patient and physician need to understand the types of defects that can be improved using non-invasive techniques and those that require a surgical approach. Many products and devices are available to physicians to address these issues and obtain favorable results from dark lips to perioral wrinkles.
In general, changes in skin texture, tone, laxity, or pigmentation are treated with chemical peels, lasers, or energy-based solutions. Dermal fillers, Autologous fat, surgical lip implants, botulinum toxin A, and micro-pigmentation are all adjunctive therapies that may be used to augment or rejuvenate the lips. It can modify Orbicularis oculi muscle function via botulinum toxin (BTX) injections or surgery.
Lips (perioral) Anatomy
Around the mouth and lip anatomy vary in people. Understanding the perioral region’s structural anatomy allows the surgeon to choose the most appropriate and long-lasting treatment, whether that is surgery, soft tissue fillers, fat transfer, skin resurfacing, or a combination of these techniques.
- Each lip consists of a cutaneous portion called a white lip, and a mucosal part is known as the red lip. The cutaneous covering of the white lip is thick, resistant, and very adherent to the underlying muscular plane. The thickness and coloring sometimes differ according to ethnic origin.
- The esthetic upper lip has a “lazy M” configuration at the vermilion–cutaneous junction, commonly referred to as “Cupid’s bow,” which should have two definite anatomical mounds at the highest point of the Cupid’s bow on each side of the midline.
- This junction has a “white roll,” a defining outline resulting from light reflection from this area, and is prominent in youth. The lower lip should have more subtle mounds on either side of the midline.
- The average vertical distance of the upper lip should be 10 mm and of the lower lip 12–14 mm. I should note the length from the columella to the vermilion border of the upper lip. In some patients, this length is excessive and would be ideally shortened with a lip lift.
- I should evaluate the relationship of the lower lip to the upper lip.
- The upper lip width should be one-third to one-half of the corresponding width of the lower lip as measured in the midline.
- The lower lip should have 25% more volume or fullness than the upper lip.
- Finally, the upper lip should protrude by 1 to 2 mm beyond the lower lip.
- The lower lip is more curvilinear and frequently has a similar white roll.
- The lower lip shows fullness in the middle portion.
- Analysis of the lateral view is more straightforward. Likewise, the lower lip should exhibit a steep concavity from the sharp vermilion border to the labio-mental groove.
Position of the mouth commissures located outside or inside a vertical line, which passes through the center of the pupil. With the lips in repose, a minimum of 3 mm of the upper incisors should be visible in the female patient, and 1 to 2 mm is enough in the male patient.
Aesthetically, 2 to 3 mm of the upper incisors may show in repose, but the entire length of the incisors should show while smiling. Conversely, lower incisor shows should be absent, with the lower lip eclipsing them with enough superior positioning.
Lips (perioral) Aging
The perioral skin is smooth in youth, and nasolabial folds are minimal until the third decade. The effects of gravity and actinic damage coupled with the decreased vertical dimension resulting from enamel tooth wear often produce changes in the lips that make them seem to disappear and become thin and flat.
Grinding, wear on the molars, and age-related osteoporotic thinning of the mandible, the distance from the lips to the chin is decreased.
The skin at the commissures begins to sag, and the formation of mandibular-labial folds causes depressions at the corners of the mouth, which are named marionette lines.
The malar fat pads’ descent and the loss of perioral volume and deepening of the nasolabial folds shape the aging midface.
By exerting a constant pull on the upper and lower lips, the orbicularis muscle forms outwardly, radiating perioral lines (lipstick lines or smokers’ lines). Dense vertical perioral rhytids are often associated with the lengthening of the upper cutaneous lip. These vertical lines can result from heredity, photodamage, or excessive use of oral muscles (playing a musical instrument)
Patients are often disturbed by the increased vertical length of the cutaneous lip and the radial upper lip lines that can cause lipstick to bleed upward from the lip and blur the outline of the lip.
Vertical wrinkles are seen in males from hair follicles in the area. During aging, the lateral portions of the lips recede, resulting in a “rosebud mouth.” The vermilion rolls inside, producing thin and disappointed lips.
The perioral skin is smooth in youth, and nasolabial folds are minimal until the third decade. The effects of gravity and actinic damage coupled with the decreased vertical dimension resulting from enamel tooth wear often produce changes in the lips that make them seem to disappear and become thin and flat. Wear and tear of molars and age-related bony resorption of the mandible, the distance from the lips to the chin is decreased.
The skin at the commissures begins to sag, and the formation of mandibular-labial folds causes depressions at the corners of the mouth, referred to as marionette lines. The malar fat pads’ descent and the loss of perioral volume and deepening of the nasolabial folds shape the aging midface.
By exerting a constant pull on the upper and lower lips, the orbicularis muscle forms outwardly, radiating perioral lines (lipstick lines or smokers’ lines). Dense vertical perioral rhytids are often associated with the lengthening of the upper cutaneous lip.
Patients are often disturbed by the increased vertical length of the cutaneous lip and the radial upper lip lines that can cause lipstick to bleed upward from the lip and blur the outline of the lip. Vertical lines result from heredity, photodamage, or excessive use of the mouth.
Vertical wrinkles are not seen in males from hair follicles in the area. During aging, the lateral portions of the lips recede, resulting in a “rosebud mouth.” The vermilion rolls inside, producing thin and disappointed lips.
The unaesthetic feature around the mouth and the lips may be congenital, present in youth as a genetic characteristic, acquired, and advancing age. Numerous factors: such as facial expression, exposure to the sun, and smoking, can worsen these imperfections. Both the young and the old may acquire an alteration due to accidental or iatrogenic trauma.
Of all the human facial expressions, the smile is the most pleasing and complex in terms of meaning. The smile and its aesthetics depend on teeth, gums, and lips. An attractive smile depends on these three elements’ proper proportion and arrangement.
The upper lip should symmetrically expose up to 3 mm of the gum, and the gum line must follow the contour of the upper lip. I should correct the amount of tooth show changes with age and an inadequate tooth show to rejuvenate the face.
Patients with excessive incisor show are called a “gummy smile.” These patients expose a broad strip of maxillary gingiva above the teeth when smiling. This exposure could be due to excess maxillary length or a short or hypoplastic upper lip. Correction of gummy smile involves lip augmentation, maxillary intrusion osteotomy, or lip lengthening with or without augmentation, depending on the defect.
Another cause of a gummy smile is hyperfunction of the lip elevators, which can be surgically corrected through lip elongation with or without rhinoplasty to repair the anterior nasal spine and depressor septi nasi muscles.
Gum is evident more in dynamic motion. Besides, delayed passive eruption is a developmental problem of the teeth, resulting in excess gum covering the dental crown. Gingivectomy and vestibulopathy can be corrected by a cosmetic dentist or an oral maxillofacial surgeon.
Who Needs Lips and Perioral Rejuvenation?
There are two categories of patients who seek aesthetic improvement around the mouth area, with the lips central to the lower face’s appearance. In the younger patient, lip augmentation, lip shortening, or lip elongation can be done as an isolated procedure to enhance and harmonize the appearance of this area. Dermal fillers, Autologous fat injection, surgical lip implants, BOTOX A, and micro-pigmentation supplement therapies augment or rejuvenate the lips.
There is a definite limit to how much augmentation can be performed on any given lips before the results look unnatural and distorted, i.e., without blunting the edge of the vermilion border or strange fullness above the lips. Asymmetries of the lip associated with smiling can be improved upon but not resolved with lip augmentation.
The prominent nasolabial fold draws attention to the aging around the mouth area that necessitates attention. In the older patient, skin changes (including dynamic and static lines), the tilt of the oral corners, and lip ptosis all play a significant role. Aging also may result in pigmentary changes. Volume loss and gravity can lead to an exaggerated depth of the nasolabial creases or marionette lines.
During aging, the lateral portions of the lips recede, resulting in a “rosebud mouth.” At the same time, the distance between the columella and the vermilion border of the upper lip increases, and the substance of the vermilion rolls inside, producing the thin and disappointing lips that are characteristic of old age—the surrounding skin losses fat, allowing accentuation of fine wrinkles resulting from repetitive mouth muscles—the deepening of the nasolabial fold with aging results from the descendants of malar fat pads.
Traditional face-lift techniques do not sufficiently address the mouth area. With new advancements in cosmetic medicine, non-surgical and minimally invasive procedures have become first-line treatment options. Conventional treatments, topical therapies, mechanical and chemical skin resurfacing techniques, lasers and radiofrequency devices, fillers, fat, and Botox injection.
There are two vital areas to see in looking at the aging mouth. One is the shape of the lips themselves, secondly the volume, and with an aging face, one must note the importance of the support provided to the lower third of the face by dentition and bone structure.
There are several aspects to be considered when rejuvenating the lips, such as redefining the vermillion border, replenishing lost volume, and degree of poutiness. It is difficult to change the size of the lip, and lip augmentation with any material merely enhances the natural lip shape only but not the size of the lips. A physician must focus on restoring the lip end and the building buttresses to restore height to the lower third of the face, correcting the labio-mandibular grooves and oral commissure.
How to Rejuvenate Around the Mouth and Lips?
Today’s facial surgeons have more options to rejuvenate the periodical area. It is essential to have a thorough understanding of perioral anatomy and perceived signs of aging to implement the proper treatment plan. The patient and physician need to understand the types of defects that can be improved using non-invasive techniques and those that require a surgical approach.
Many products and devices are available to physicians to address these issues and obtain favorable results from dark lips to perioral wrinkles. In general, changes in skin texture, tone, laxity, or pigmentation are treated with chemical peels, lasers, or energy-based solutions.
Dermal fillers, Autologous fat, surgical lip implants, botulinum toxin A, and micro-pigmentation are adjunctive therapies. Modification of the orbicularis oculi muscle function is achieved via botulinum toxin (BTX) injections or surgery.
While non-surgical techniques are not a substitute for traditional surgery, the combination of several non-surgical procedures has become a powerful adjunct to or an alternative for open surgery. These cosmetic procedures include:
- Physician skincare products
- Skin Rejuvenation or Skin Resurfacing or Skin Peel
- Laser Skin Rejuvenation or resurfacing or skin peel
- Non-surgical skin tightening and fat reduction
- Photo-rejuvenation or light therapy
- Botox injections
- Filler injections
- Fat Injections
- Microinjections with (vitamins, PRP, and Nano fat)
The signs of chronic photodamage and intrinsic aging are often more apparent on the face and neck than in other locations. Aged skin demonstrates fragmented dermal collagen, fibroblast dysregulation, and a decrease in the production of new collagen. This decrease in collagen is seen clinically as rhytids and laxity. Chronic ultraviolet exposure also causes hyperpigmentation, solar lentigines, telangiectasias, and rough texture.
A basic skin care regimen includes a cleanser, moisturizer, and sunscreen. One of the essential components of any antiaging treatment plan is topical skincare. Creams that contain beneficial ingredients are called cosmeceuticals and are used to improve skin tone, texture, radiance, hyperpigmentation, pore size, fine lines, and wrinkles. Topical retinoic acid (tretinoin) is the gold standard topical treatment for the clinical signs of photodamaged skin.
The daily use of a broad-spectrum sunscreen protects against the damaging effects of UV exposure, which hastens the signs of aging and gives rise to fine wrinkles, changes in texture and tone, and hyper-pigmentation.
Antioxidants—vitamins, certain botanicals—work against free radicals and oxidative stress and have anti-inflammatory properties, reducing redness and producing visible improvements in fine lines, and brightening the skin. Other additives include peptides and growth factors, stimulating neo-collagenases to improve skin texture and laxity.
The optimal treatment approach begins in the MSI office with a tailored program that attends to all the significant issues in your skin layers and continues with the “at-home regimen” to maintain and expand the results. Popular, topical agents that can address the signs of photoaging include tretinoin, a-hydroxy acid, vitamin C, other antioxidants, a-lipoic acid, pentapeptide, and cutaneous growth factors.
Medically based skincare products target three cellular components that contribute to aged skin: keratinocytes, melanocytes, and fibroblasts. The goals of the topical regimen are to reverse sun damage, slow the aging process by increasing collagen, elastin, and glycosaminoglycans (GAGs), and minimize oxidative damage.
In aesthetic practice, the use of cosmeceuticals in combination with cosmetic procedures is a new treatment ideal for skin rejuvenation. Pre-treatment with cosmeceuticals can prime the skin for procedures, and post-treatment can reduce complications. Instituting the correct routine will slow the progression of aging and work toward reversing the extrinsic and intrinsic aging changes.
After formulating your medicine, the second step is to increase the penetration of cosmeceutical to achieve faster and better results. We utilize available technology at MSI to overcome the skin barrier and enhance our medicine delivery.
The path starts from skin steaming, facial masks, microdermabrasion, superficial peels, laser-assisted drug delivery, fractional radiofrequency microneedles, and the latest technology, “no needle mesotherapy” or electroporation. Electroporation induces temporary pores and electrically uses bipolar radiofrequency in the skin to allow the passage of drugs (antiaging, whitening, and antiacne) painlessly without needles.
Skin Rejuvenation Peel
MSI Skin rejuvenation peel is a comprehensive antiaging, antiacne, and scar treatment program that uses state of the art in aesthetic medicine. It is tailored precisely to your skin condition, needs, and expectation. It includes steam, masks, exfoliation, comedones extraction, cosmeceuticals, PRP, chemical peels, LED, IPL, laser, ultrasound, and radiofrequency.
In addition, we apply new techniques to enhance skin penetration of cosmeceutical ingredients, such as whitening, vitamins, antiacne, antiaging dermal roller, derma pen, and no needles mesotherapy (electroporation), microdermabrasion, fractional laser, and radiofrequency.
Skin Rejuvenation Laser Peel
Unlike chemical peels and dermabrasion, laser skin resurfacing (LSR) with the CO2 laser generates heat, which results in immediate tightening because of the shrinkage of collagen, which forcefully shortens the collagen fibers by 30%.
The laser continuously stimulates healthy new collagen and elastic fibers in the skin for six months after resurfacing. Collagen fibers’ shortening translates clinically into smoothing out superficial irregularities, including wrinkles, acne scars, nevi, epidermal growths, and even tumors, as well as a tightening effect that improves the skin’s overall appearance. Therefore, any wrinkles or scars will continue to improve.
Light Skin treatment or photo-rejuvenation encompasses many procedures using light or laser-based technology to reverse the effects of photoaging. Non-ablative photo-rejuvenation refers to the controlled use of thermal energy to carry out skin rejuvenation without disturbing the overlying epidermis and with minimal to no downtime.
Currently employed non-ablative modalities include primarily intense pulsed light (IPL), visible wavelengths including 585nm pulsed dye laser (PDL), and 532 nm green light (KTP laser). Different infrared wavelengths with water as the target are used for dermal remodeling collagen.
The primary mechanism of action is thermal injury, either by heating the dermis to stimulate fibroblast proliferation or by heating blood vessels for photocoagulation. The newest way to deliver these wavelengths is by fractionating the dose.
The non-thermal mechanism, which represents a fundamental change in thinking, is the theory of photo-modulation. This novel approach to photoaging uses non-thermal light treatments to regulate the activity of cells and not invoke thermal wound healing mechanisms. Two types of photo rejuvenation are available: the Intense-Pulsed Light (IPL) and the Light-Emitting Diode (LED) treatments.
Fractional Radiofrequency (FRF) Skin Rejuvenation
Fractional radiofrequency (FRF) delivers heat energy creating zones of heat-affected skin adjacent to unaffected areas. FRF improves acne scars and large facial pores, wrinkles, and facial laxity reduction. The treated areas result in thermal damage of collagen fibers, stimulating wound healing, dermal remodeling, new collagen, elastin, and hyaluronic acid formation.
The unaffected areas serve as cell reservoirs that promote and accelerate wound healing. The most common sequence effects are erythema and edema, which are transient (a few days). You may use a topical anesthetic cream before the treatment to minimize pain.
In an innovative approach, Prof Moawad offers his patients FRF to make tiny holes into the skin to overcome the stratum corneum to enhance PRP or nano-fat penetration. The results are double, and you will enjoy both the rejuvenating effect of the FRF resurfacing system and the regenerative effect of growth factors and stem cells.
Microneedling and Microinjection Skin Rejuvenation
The basis of micro-needling (MN) relies on physical injury. It has been proposed that the trauma generated by needle penetration in the skin induces dermis regeneration. This results in the deposition of collagen by fibroblasts.
The technique of micro-needling has been well-exploited to increase the penetration of drugs across the skin barrier, including macromolecular biopharmaceuticals and drugs such as minoxidil, tretinoin, and L-ascorbic acid, vitamins, and hyaluronic acid (Meso-lift), platelets rich plasma (PRP), and nano-fat (vampire face-lift) and even botulinum toxin microinjection (meso-botox) into the deep layer of skin and subcutaneous tissue.
Mouth and Lips Botox Injection
Botox has been used less often for indications in the lower face. The depressor anguli Oris (DAO) is a vital muscle that influences how others see us. Constant hyperactivity might lead to deep furrows or Melo-mental folds drawing down the corners of the mouth, leading to an overall sad, slightly depressed impression and has traditionally been treated with soft-tissue augmentation alone. In addition, platysmal bands can increase this downward effect.
Botox can be used to weaken this muscle, elevating the mouth corners or returning them to a neutral position. We inject 3 to 5U at the jaw level but at its posterior margin, close to the anterior margin of the master, which will significantly weaken, rather than paralyze, the muscle to upturn the corners of the mouth. The combination of soft-tissue augmentation and BOTOX injected into the DAO will lengthen the duration of the augmentation and prevent the repeated molding and contortion of the soft-tissue augmenting agent.
The lips and the around the mouth region have an essential role in the aesthetic balance of the face. The mouth muscles act in concert to achieve the extraordinarily complex movements that control facial expressions, eating, and speech. The lips are central to the appearance of the lower face. During aging, the lateral portions of the lips recede, resulting in a “rosebud mouth.”
At the same time, the distance between the columella and the vermilion border of the upper lip increases, and the substance of the vermilion rolls inside, producing the thin and disappointing lips that are characteristic of old age.
The orbicularis Oris (OR) is the sphincter muscle that encircles the mouth, lying between the skin and mucous membranes of the lips, causing the lips to close and pucker. Dense vertical around the mouth, wrinkles are often associated with the lengthening of the upper cutaneous lip during aging.
These vertical lines are labeled as “smokers” lines but can also result from heredity, photodamage, playing a musical instrument that requires embouchure, or even whistling. Patients are often disturbed by the increased vertical length of the cutaneous lip and the radial upper lip lines that can cause lipstick to bleed upward from the lip and blur the outline of the lip. Vertical lines of the upper lip are a secure sign of aging. Even when using an injectable filler, some of these lines might remain.
Treating the upper and lower lip is to reduce these unsightly wrinkles. BOTOX Injection points should be made at the vermilion border, parallel to the lips, and at least 1.5 cm away from the corners of the mouth. Appropriate patients must be chosen carefully, as those who play wind instruments or professional singers/speakers are not ideal candidates.
The total dose should be distributed in four to six points, four at the upper lip and two at the lower lip. Low doses and superficial injections are preferred to avoid functional impairment of the lips. The patient is asked to pucker, and the areas of muscle contraction next to the lines are marked.
Small doses (1–2U per lip quadrant) are usually enough to weaken the (OR) without causing a paresis that could interfere with elocution and suction, primarily when combined with a soft tissue augmenting agent. BOTOX injections must achieve the desired cosmetic result with the smallest dose without functional discomfort.
Surgical or traumatic lesion of the (OR) or the risorius muscle can result in the mouth being pulled off-center by the free action of the partner muscles on the customarily innervated side. BOTOX chemo denervation of the risorius at once lateral to the corner of the mouth on the customs innervated side will reenter the mouth when the face is in repose.
Moreover, some individuals have congenital or unilateral weakness of the (DAO) muscle, resulting in an inability to depress the corner of one side of the mouth. In this case, BOTOX treatment of the partner muscle also restores functional and aesthetic balance.
Softening of the mental crease can be achieved by injecting the mentalis, just anterior to the point of the chin. We insert 3 to 5U into each side of the midline under the button’s position, just anterior to the bony mentum, rather than injecting centrally. Care is taken not to insert at the level of the mental crease since this will also weaken the lower lip depressors and (OR) and cause serious adverse effects that can persist for six months or more, depending on the dose. Again, as in the mouth area, weakening, rather than paralysis, is the aim of treatment.
The dimpled appearance of the chin is the result of the actions of the mentalis muscle coupled with the loss of collagen and subcutaneous fat in the chin. Treatment with Botox can be used to restore a smooth appearance of the chin. This technique has also been used to correct abnormal contraction following chin implant or genioplasty with mental dysfunction following surgery. I may need deeper placement with a higher dose.
A usual number of BOTOX injection points is 1–2 points (start with one mid-line or two regular, lateral injections) and 2–8 units for a total starting dose. I should avoid the lip depressor muscle because lip incompetence can usually result in two injection points at the prominence of the chin resulting in a cosmetically correct outcome.
To prevent mouth asymmetry or lower lip ptosis, I should do the injections close to the mandibular bone. The contraction of mentalis m. It can also promote lower lip projection. Thus, when the dimpled chin and drooping mouth corners are treated together, lower doses per point are recommended to prevent the overtreatment of this condition.
BOTOX INJECTION AND GUMMY SMILE
Of all the human facial expressions, the smile is the most pleasing and complex in terms of meaning. Although it has long been the motive for artistic and philosophical debates, the smile, from an anatomic and physiologic standpoint, is the result of the exposure of the teeth and gums during the contraction of the muscle groups in the middle and lower thirds of the face. The smile itself and its aesthetics are influenced by three components: teeth, gums, and lips.
An attractive smile depends on these three elements’ proper proportion and arrangement. The upper lip should symmetrically expose up to 3 mm of the gum, and the gum line must follow the contour of the upper lip. The exposure of more than 3 mm of the gum during the smile is known as a gingival or gummy smile (GS).
GS is an aesthetic disorder, and therefore, various correction methods are proposed, including gingivoplasty, orthodontic treatment, orthodontic surgery, and bone resection. They are overly complex procedures involving moderate to severe morbidity, prohibitive cost, and considerable time. They are becoming less often recommended.
By contrast, the use of BOTOX (BT) is a simple, fast, and effective method for the aesthetic correction of GS. The use of BT for the treatment of GS can be considered remedial (when the cause of GS is exclusively muscular), adjuvant (when there is an association of reasons and an indication of additional treatments such as lip augmentation or orthodontic devices), or palliative (when definitive surgical treatment is recommended).
After applying BOTOT to fix GS, the adverse events most reported are ptosis or stretching of the upper lip (“joker-like” smile), asymmetric smile, and difficulty smiling or chewing. Case choice, BOTOX, may be an effective treatment alternative for patients with excessive gingival display caused by hyperactive lip elevator muscles. For this purpose, a dose of 2.5 units of BOTOX should be injected at two sites per side (four locations) in “Yonsei point” as an appropriate injection point for BOTOX.
BOTOX INJECTION And MOUTH FROWN
It is important to remember that the effect of BOTOX on one muscle often has an impact—positive or negative—on another. An excellent example of this is the “mouth frown,” the permanent downward angulation of the lateral corners of the mouth, which is caused by the action of the DAO and the upward motion of the mentalis. We have found that attempts to weaken the DAO or mentalis alone, while proper in some individuals, are ineffective or associated with unacceptable side effects in others.
BOTOX INJECTION AND Asymmetric Smile
Injections of Botox are a simple, non-invasive, and safe way to correct asymmetric smiles. The number of points and total doses are defined individually according to the muscle involved. The results become clear in less than five days, and the effects last from 4 to 5 months after the first treatment. In following procedures, it is recommended to reduce the doses, and the results usually last longer.
BOTOX INJECTION AND FACIAL ASYMMETRY
Asymmetries may be caused by bone elements or soft tissue or originate from neurological or muscular causes. The two latter categories can be classified into hyper-functional (e.g., Hemifacial spasm) or hypofunctional (e.g., Facial palsy). BTX can be used to correct asymmetries of neurological or muscular origin. We recommend an injection through the EMG system for physicians not thoroughly comfortable with facial surface anatomy.
Mouth and Lips Filler Injections
Can we establish any rules for augmenting the perfect lip? There are two essential areas to observe in looking at the aging lip. One is the shape of the lips themselves, secondly the volume, and in an aging face, one must note the importance of the support provided to the lower third of the face by dentition and bone structure. There are several aspects to be considered when rejuvenating the lips, such as redefining the vermilion border, replenishing lost volume, and degree of poutiness.
Volumetric changes can be handled surgically or treated with non-surgical reshaping (tightening) or refilling using synthetic dermal fillers or autologous fat transfer. New techniques for volume restoration have resulted in treatment moving toward a global, 3-dimensional, and multi-site approach comprising muscle relaxation, filling, and volume restoration.
I must analyze lip shape before volume. The lips should be complete and well-defined. Regardless of the filling technique, patients with thin lips will always have thin lips. It is difficult to change the size of the lip, and lip augmentation with any material merely enhances the natural lip shape. There is a definite limit to how much augmentation can be performed on any lip before the results look unnatural and distorted. Asymmetries of the mouth associated with smiling can be improved upon but not resolved with lip augmentation.
They should be injected without blunting the edge of the vermilion border of the lips or strange fullness above the lips. A physician must also focus on restoring the ends of the lips and the building of buttresses at these ends to restore height to the lower third of the face, correcting the labio-mandibular grooves and oral commissure.
The Perfect Lip
Through all races and cultures, certain female face features have attracted males. These features consist of a large upper face, a small lower face, large round eyes, a tiny nose, and, finally, large full lips. When lips are full and well defined, lips impart a sense of youth, health, attractiveness, and sexuality to the bearer. For years, models and actors have attempted to enhance their lips and correct perioral radial rhytids by using lipsticks, covering agents, or cosmetic tattoos.
The lips are responsible for the aesthetic balance of the lower third of the face. The various gestures they perform give life to an infinite number of expressions, which characterize the personality of everyone. The anatomical study of the lips shows that they are far more than an external sphincter. The rims have numerous functions: they help with mashing food, saliva continence, and chewing.
Cosmetic lips mean different things to different people, as beauty is in the eye of the beholder. They help as well during phonetics, breathing, and facial morphogenesis. Finally, they have a primarily aesthetic function, forming part of the total facial harmony, including the utterly mimicked expression.
Lips Filler Injection
With their malleability and superior patient satisfaction and acceptance, non-permanent hyaluronic acid (HA) fillers are prominent in the filler armamentarium, particularly for the lips and perioral region.
There are several HA formulations available; the optimal filler for augmentation around the mouth is one that can be diluted with a local anesthetic for patient comfort and to ‘construct’ individualized filler viscosity and flow characteristics appropriate for the different treatment areas (e.g., more diluted for the lips, more viscous for applications in the jaw and chin.
The perioral region is a sensitive area with extensive sensory innervations from multiple nerves; the perioral nerve block should be strongly considered for optimal comfort—applying ice before and after the procedure and massage. Selection of the smallest suitable needle, slow infiltration, and minimizing the number of needle punctures can also improve patient comfort. Successful lip augmentation is highly dependent on filler material, which is based on what the physician and patient are attempting to accomplish.
There are five main elements of lip rejuvenation to consider:
White Roll Outline and Cupid’s Bow Area (Lip definition)
Enhancement of the white roll is achieved by injecting along with the vermillion–cutaneous junction to prevent “lipstick bleeding” into the vertical rhytids of the lip. The filler will flow in the correct space and not “well up” as a lump. The goal here is to accentuate the white roll and Cupid’s bow area to define, especially in the “lazy M” region.
On the other hand, if the filler is placed too deeply, it spreads out and does not provide the desired “roll” effect. In other words, if you are attempting to make a white roll outline, you want to be in the potential space just under the lip mucosa at the vermilion–cutaneous junction.
Philtral Column Augmentation (lip definition)
Esthetic lips usually have a well-developed philtral complex. The philtrum is distinct, and the paired philtral columns are well defined. This is one of the most undertreated areas when performing lip augmentation. The filler is injected intradermally to accentuate the existing columns or make new ones. Avoid obliterating the Cupid’s bow and creating the “sausage” or “duck” lip.
Volume Restoration (Deep Injection)
If the surgeon is trying to add volume to the lips, a deeper injection is warranted to provide pout and make the lip larger from within. I can do this in addition to white roll augmentation or as an isolated procedure. The needle is inserted more in-depth into the lip to increase lip volume, in about one-third to half of the lip thickness. With this technique, I usually inject at the wet-dry line and use the linear threading technique, where I am pumping on the way out.
Frequently, I will confine most of the injection to the commissure. Some patients look better with the middle one-third augmented (what I call the kissing part of the lip), whereas others can use augmentation out to the commissures. Again, it is better to be conservative as you can always add more. Elevation of the oral commissures is achieved by placing filler in the most lateral aspect of the lower lip to support the commissures. This effort can be supported by BOTOX placement in the depressor anguli oris muscles (DAO).
Vertical lip lines
Because vertical lip rhytids, called ‘smoker’s’ or ‘lipstick’ lines, can range from faintly etched multiple lines to deep grooves, treatment techniques will vary. Injections can be placed along the length of the line, slightly perpendicular, or across the lip platform, and I may use any combination of these approaches.
Treatment of the entire lip platform may benefit patients with multiple small lines. The platform is filled conservatively, beginning injections laterally above the white roll and using the push-ahead technique, decreasing the number of injection sites required for correction. I may need multidirectional inoculations on the lip platform for widespread correction of perioral rhytids.
Revision of the oral commissures requires augmentation to fill the lines and folds and lift the mouth’s corners. Concomitant injections of BOTOX into the DAO can reduce its downward pull against the zygomatic complex, elevating the corners of the lips and extending the filling agent’s duration by reducing repetitive muscular activity.
Injecting the lateral upper lip and lateral lower lip and extending the filling agent support inferiorly down the Melo-mental fold to the mandibular margin can increase the longevity of the result. Simultaneous neurotoxin relaxation of the DAO, platysma, and mentalis are also helpful. In some cases, injections may need to continue into the white roll of the upper lateral lip or higher to elevate the angle of the mouth.
Cross-hatching may be used in patients requiring extensive correction or to fill the triangular area of the commissures. The needle is inserted 1 cm below the lip, and a linear threading technique is used to inject along the lip and into the marionette lines. 1.5 mL of HA may be used on each side to provide adequate fullness, particularly in older patients.
Mouth corners often cannot be addressed without adding extra support to the pre-jowl and peri-mental areas. The placement of the Marionette line can support this effort line, and the nasolabial fold is critical to a successful outcome are a crucial element in overall lip enhancement; otherwise, results are destined to be disappointing to both the patient and the physician.
Tips on How to Inject Dermal Fillers into Lips
Every lip is different, and there is no set formula to ensure desired results. There are, however, some basic premises to follow gleaned from Prof Moawad’s experience: must be considered:
- As with all aesthetic procedures, the first step is accurate and comprehensive aesthetic analysis. Any asymmetries, previous injection sites, irregularities, and scars should be noted and pointed out to the patient and improved upon if feasible.
- Regardless of the modality chosen, the physician must have anatomic knowledge, technical skill, and aesthetic sense to create natural-looking, youthful, and luscious lips.
- Optimal lip rejuvenation involves two main components: volume enhancement and red lip-skin border enhancement.
- Volume filling is often required in older patients and those with thin lips. Red lip-skin enhancement is usually needed in younger individuals with enough volume, but it is also indicated in older patients and volume augmentation.
- Inject the upper lip first, so post-injection swelling will not prevent the correct anatomic proportions between the upper and lower lips.
- Intra-injection and post-injection palpation for surface irregularities are essential. If material tracks away from the intended injection plane and creates a tunnel, the physician should institute immediate massaging, as this is the best time to achieve molding and shaping.
Mouth and Lips Fat Injections
The principal areas of the lower face that benefit from fat augmentation are the pre-jowl sulcus, labio-mandibular recess, labio-mental sulcus, lateral jawline, and anterior central mentum. Of these five areas, the pre-jowl sulcus can be considered the most significant enhancement to provide maximal straightening of a descended jawline.
The period region is amended for improvement with milli-fat, micro-fat, and nano-fat. The addition of SVF and PRP may also be beneficial. Besides, pyriform augmentation with milli-fat will affect the lifting of the upper lip.
Therefore, the canine fossa is grafted routinely with 1 mL of fat to lift the lateral alar area of the base of the nose in the pre-periosteal plane. 1 mL is then placed in each nasolabial fold and 1 mL in the upper perioral cutaneous lip. Although periodical grafting has had limited success with long-term results, the benefit of a short-term result with some long-term benefit warrants grafting in this area.
Pre-jowl Groove (genio-mandibular) Fat Transfer
The pre-jowl area creates a strong, uninterrupted aesthetic line from the chin to the posterior mandible (like the effect of a pre-jowl implant), which cannot be achieved by lifting the jowl alone. It results in a highly desirable improvement on both the male and female faces. Fat transfer of the pre-jowl is typically performed with a 4 cm long, 0.7-mm (22-gauge) injection cannula from injection sites over the mandibular border and on the perioral area.
Fat is placed in all tissue layers between the periosteum and skin. From 1 to 3 mL of fat are typically placed on each side in the pre-jowl area, depending on the size of the depression present, but occasionally more is indicated. Without risking contour deformity, I can place a generous amount of fat into the pre-jowl sulcus. Fat placement should be made along the anterior and inferior aspects of the mandibular body to achieve a three-dimensional, cylindrical reshaping of the pre-jowl depression.
Lip enhancement indications can be divided into lip volume and lip definition. For lip volume enhancement, I will deliver most of the fat. When the surgical plan includes a fat transfer of the lips, the prep of the face should consist of the upper and lower gingivobuccal sulci, the labial surface of the anterior teeth, and the tongue (if it protrudes into the surgical field). The lips are typically treated after all other areas of the face have been fat grafted, but before the face-lift begins, the surgeon must insert their fingers inside the mouth.
A 5 cm long, 0.7-mm (22-gauge) cannula is used to infiltrate fat into the lips. The injection is made from access incisions at each stomal angle, and fat is infiltrated superficially and submucosally into the lip. The priority of injection consists of the upper lip white role, lower lip white roll, lower lip tubercles on both sides (oblong balls), central lower lip, frenulum of the lower lip, and finally, the middle portion upper lip have been injected.
I can enhance the white roll with a 21-gauge sharp needle injection or a blunt 0. 7 mm cannula inserted immediately sub-dermally. I am threading the roll and injecting upon withdrawal. On average, one cc is injected in the white roll of both the upper and lower lip. The philtral columns can be enhanced by sharp needle intradermal fat transfer (SNIF) with the same needle. An average volume of 0.25 cc per column is used.
Bi-digital palpation is used to check the homogenous distribution of the injected fat. If more lip protrusion is desired, additional fat is placed submucosally beneath the dry vermillion. If more vertical lip show is desired, I can place fatter submucosally along the wet-dry junction of the vermilion on the inner aspect of the lip. A total of 1 to 1.5 mL (upper) to 1.5 to 2 mL (lower) is usually placed on each side of each lip for 2 to 3 mL in the upper lip and 3 to 4 mL in the lower lip. The puncture holes are not closed. The average volumes are 0.5 to 2.0 cc per half lip. Thus, the total volume for a full mouth rarely exceeds eight ccs.
Treating the lips with fat has distinct advantages and disadvantages. Still, suppose the procedure is booming, and graft take is good. In that case, patients are spared the inconvenience, discomfort, and expense of undergoing repeated filler treatments and the many problems associated with lip implants and various other types of lip grafts. Fat transfer also produces a soft, natural-appearing improvement and usually an under-correction that is appropriate and desirable for typical patients having face-lifts who need some improvement in their mouths.
Fat transfers to the lips have the disadvantage that it usually produces a large amount of swelling that is slow to resolve and that the take of the graft varies from patient to patient. Patients seeking a quick recovery, a specific lip size or shape, or subtle changes are not optimal candidates for the procedure. Patients should also be advised that it is impossible to create a highly stylized cover-girl lip appearance seen in fashion magazines when using fat.
These appearances are best obtained using non-autologous fillers. In Prof Moawad’s experience, lip augmentation with fat is rarely permanent. However, occasionally, the results are surprisingly reasonable; for that reason, patients are often encouraged to augment the lips if they are also doing other areas of the face. When performing several procedures, the lips are saved for the very last step to avoid contaminating the different areas of the face.
Traditional resurfacing by peel, laser, or dermabrasion provides an incomplete solution for patients with perioral pucker lines. These procedures only address the skin and do nothing to replenish the age-associated loss of perioral subcutaneous fat. Fat transfer provides a means by which I can improve outcomes, and fat typically situated between skin and orbicularis oris muscle near the vermillion-cutaneous junction can be replenished.
Experience with combined dermabrasion or laser resurfacing and perioral fat injections suggests that healing and the overall outcome are better when resurfacing procedures are combined with fat transfer, beyond the improvement gained by simple volume addition, and this may be attributable to a “stem cell effect.”
When injecting the perioral area, care must be taken not to mistakenly overfill the white upper lip (the space between the base of the nose and the vermillion-cutaneous junction) in a well-intended but misguided attempt to reduce upper lip wrinkles because
It can lengthen patients’ upper lips, It can diminish the dental show, and abnormal convex simian contours in the profile can result. A better strategy is to concentrate efforts on and near the white-roll area, where the wrinkles are typically the deepest and appear most objectionable and place the most fat in this area. Less fat is then placed more superiorly.
Buccal recess area Fat transfer
Buccal atrophy is consistently seen in the fourth decade of life and beyond, as is buccal hollowing caused by previous overzealous excision of buccal fat or human immunodeficiency virus-associated facial wasting. Fat transfer of the buccal hollow is typically performed with a 4 cm long, 0.7-mm (22-gauge) injection cannula from injection sites situated on the midface and medial lower cheek. Fat is placed subcutaneously and in sub-SMAS (buccal space) locations.
Between 2 and 5 mL of fat are typically placed on each side in the buccal recess area, depending on the degree of the problem, but occasionally more is indicated. Asymmetrical fat placement is often required on the right and left sides because of the frequent buccal asymmetry seen preoperatively in many patients.
Chin Fat transfer
Fat transfer can correct age-associated loss of chin volume, loss of chin projection, and loss of vertical chin height and, in some cases, can rival the kind of improvements obtained when small chin implants are placed. Fat transfer of the chin can also correct an atrophic and feeble appearance. When indicated, the button shrinks with age by broadening and strengthening it and filling the labio-mental and submental creases.
Typically, treatment of the chin must be undertaken in conjunction with the pre-jowl groove, and the two areas overlap in most cases. Fat transfer of the button is typically performed with a 4cmlong, 0.7-mm (22-gauge) cannula from injection sites slightly lateral to the treated area. Occasionally a third incision is used near the midline of the lower lip. Fat is typically placed in all tissue layers from the periosteum and skin.
Jawline Fat transfer
Although not intuitively obvious, strengthening the jawline and posterior mandibular border makes the patient appear more youthful, fit, and attractive and is an artistically powerful adjunct to a face-lift that helps avert the deficient, frail, and lackluster mandibular contour typically seen in aging and old faces that is usually made worse when a face-lift is performed.
Fat transfer of the jawline is beneficial in patients with secondary face-lifts and long faces seeking facial rejuvenation or improvement. Fat transfer of this area allows the front to be broadened and overall proportions improved. Fat transfer in the jawline area is intermediate in the difficulty of the jawline and can enhance patients’ facial shapes and produce the kind of improvements obtained when mandibular border and Taylor-style mandibular angle implants are placed.
Fat transfer along the mandibular border can also correct an atrophic and feeble appearance as the mandibular border shrinks with age by broadening and strengthening it. Treatment of the jawline typically must be undertaken in conjunction with the pre-jowl groove, and the two areas overlap in most cases. Fat transfer of the jawline is performed with an 8 cm long, 1.2-mm (18-gauge) injection cannula from injection sites on the perioral area and mandibular border.
Fat is placed deep in a preperiosteal/submasseteric position on the surface of the bone. Depending on the deficiency present, between 3 and 6 mL of fat are typically placed on each side, but occasionally more is indicated. The jawline and chin can take as much as 20 mL of autologous fat. Note that fat is not injected subcutaneously into the parotid or the masseter muscle.
The jawline is filled with anterior and inferior planes by wrapping fat around the mandible. This area is approached through multiple incision sites perpendicular to the jawbone, fanning laterally and inferiorly. In addition, the skin of the chin may be treated with mesotherapy using nano-fat to reduce pore size and resurface the photodamaged skin.
Hence, the fat ends 1 cm below the hard border on the superior portion of the neck. In the author’s experience, this delineates the jawline and seems to borrow skin from the neck. The submental area and pre-jowl sulcus are filled in the same manner, forming a sling to support the chin and separate it from the uppermost portion of the central neck.
Around the Mouth and Lips Injections. Complications
Complications describe skin necrosis after fat injections, irregularities, palpable nodules after the fat transfer, unsightly scars after Uplift, and resurfacing techniques.
For perioral fat transfer, the main problems can be categorized as underfilling, overfilling, and mal-positioning: Underfilling is easy to correct; overloading is challenging to repair and less acceptable to the patients. Mal positioning of fat is prevented by meticulous preoperative planning, marking, and technique.
In a lip lift, the main problems are caused by an incorrectly designed excision pattern and a sloppy suturing technique. The scar should not visibly cross the nostril sill—inadequate lateral excision results in an unnatural pouting of the central lip. Over-resection of lip skin can lead to the impossibility of mouth closure and is virtually irreversible.
With resurfacing, the main problems are under-correction, scarring, hypopigmentation, and hyperpigmentation: Under-correction results from resurfacing too superficially and is easily solved by a cautious touchup procedure. We never promise our patients complete wrinkle removal but a significant wrinkle reduction.
Overcorrection may lead to scarring and can be caused by a concurrent bacterial or viral infection by resurfacing too profoundly. Herpes simplex prophylaxis is routinely administered, and meticulous wound care and close follow-up for three months postoperatively are essential for infection prevention.
- The surgeon should not exaggerate; patients will forgive the need for a touchup procedure more quickly than reconstructive surgery for an overcorrection.
- The surgeon should think about definition and shape and not so much in terms of volume.
- I must educate patients; most patients need to be informed of the different components of aging. Pictures of their youthful appearance are a great tool to help them understand the deflation mechanisms and lengthening of the upper lip.
- The shift from a two-dimensional focus to a three-dimensional approach to minimally invasive facial rejuvenation has reinforced the idea of creating overall facial harmony and balance within cultural, ethnic, and gender-related goals and ideals.
- It is now recognized that relaxing the lower face muscles can play a crucial role in combination with fillers. In addition, BOTOX treatments, begun at earlier ages, can aid in line prevention.
- Resurfacing with light/laser treatments or chemical peels, along with line management, volumizing, and recontouring, has proven safe and effective.
- A combination of fat transfer, lifting, and resurfacing should be used; this combination is much more potent than isolated use to correct a single feature of aging.
- Cosmeceuticals protect against photodamage, aid in retexturing the skin and serve as an essential adjunct to other aesthetic products and procedures.
Rejuvenating the period has classically been a challenge with traditional surgical methods. Besides, procedures such as chemical peels, dermabrasion, and laser resurfacing do not address the length of the senile upper.
In these cases, surgical reduction is needed to address the elongated upper lip typically seen in aging populations. Extended deep plane face-lifts, direct nasolabial fold excision, and even midface lifting techniques have been tried with varied success.
Surgical correction of the senile upper lip can give patients a more youthful appearance and restore a more aesthetic frame. Lip lifting procedures are valuable tools for decreasing the central white lip area while increasing the red lip. O correct the senile upper lip, namely, top lip advancement (LA), used to enhance the vermilion red show, and sub-nasal lip lift (SNLL), used to decrease elongated white display.
In the LA procedure, the vermilion red show is increased by removing skin and subcutaneous tissues to advance the upper lip mucosa. This technique, however, does not reduce senile white display; thus, it may be more appropriate for a younger population.
Orthognathic procedures for either maxillary or mandibular hypoplasia may be necessary to correct the craniofacial skeleton and enhance the perioral area in a particular case. The SNLL procedure reduces the elongation of the upper lip by removing excess skin and subcutaneous tissues. In both methods, the underlying fascial support is left undisturbed.
Chin Surgery (Genioplasty)
Genioplasty is a type of surgery done on the chin. Both plastic and maxillofacial surgeons (surgeons who work on the mouth and jaw) can do this. Genioplasty is most often a cosmetic surgery, meaning people choose to have it for looks and not because of a medical problem.
A “witch’s chin” is often a problem in elderly women. It is prominent in a frontal and caudal direction. We make a spindle-like skin excision to reduce it, including skin in front and behind the submental skin crease. Then we remove a slice of mental subcutaneous connecting and fat tissue if liposuction alone is not enough to reduce the chin volume sufficiently.
Buccal Fat Removal
Buccal fat removal aims to thin the cheeks, specifically around the cheek hollows. Although a naturally soft and filled-out face is considered youthful, some people find that their face feels too full, even chubby.
A buccal fat removal removes the buccal fat pad, a naturally occurring fat pad in the hollow cheek area. The size of the buccal fat pad varies with each patient, and the buccal fat pad in each cheek may be varied sizes. Buccal fat pad extraction surgery is typically not performed in people with thin, narrow faces, as removal of the fat may cause the face to look bonier with age.