Lips are a central part of facial aesthetics due to their color, surface texture, and shape. Well defined and full lips represent attractiveness and beauty. Loss of volume and elasticity of subcutaneous soft tissue, retraction of lip red, bone resorption, loss of teeth, smoking, and ultraviolet exposure contribute to perioral aging and loss of attractiveness. Furthermore, lips are exposed to irritants and environmental factors that challenge the barrier function of their thin horny layer. The lips are conceived as signs of aging, loss of attractiveness, and fragility.
Lips are part of the aesthetic unit that involves the mouth and the perioral tissue. Aging of this area is characterized by perioral fine lines, marionette lines, and fattening of the cupid bow. The philtrum becomes longer and ill defined, indirectly contributing to a thinner upper lip. Furthermore, the dynamics of lip movement change with age.
The smile, for instance, gets narrower vertically and wider transversely. People older than 50 years of age lose their ability of a high smile. Two additional signs of aging are seen in the area of the mentum, including the mentalis crease and peau d’orange. The mentalis muscle ﬁnds its origin at the incisor fossa and extends vertically and medially to fuse with the orbicularis oris. Its action is to evert the lower lip. The repetitive action of this muscle over time can lead to a transverse rhytid which is known as a mentalis crease, which gives an expression of doubt. Peau d’orange, the French term meaning orange skin, describes a condition of the lower lip of dimpling rhytids on the chin resulting from visible attachments of the superficial musculoaponeurotic system (SMAS) with the mentalis muscle, seen through aging thin skin. Finally, one of the more telltale signs of the aging face is the increasingly deep nasolabial folds that are formed by the malar fat overlying the complex of the orbicularis oris, levator labii superioris, and zygomaticus major muscles. Muscular activity and ptosis of skin and the SMAS contribute to their relative severity and depth.
In the modern aesthetic, full lips provide a youthful healthy appearance. The esthetic upper lip has a “lazy M” configuration at the vermilion–cutaneous junction, commonly referred to as “Cupid’s bow”. This junction has a “white roll,” which is a defning outline and the result of light refection from this area. The lower lip is more curvilinear and also frequently has a similar white roll. The other defning feature of the upper lip is the philtral complex, which consists of the philtrum and the philtral columns. This area is frequently overlooked when performing esthetic lip augmentation.
Dissatisfaction with labral appearance usually stems from tall ergotrids or thin lips, for which the term “leptocheilos,” borrowed from Greek roots lepto and cheilos connoting slender and lip, respectively. Their causes can be congenital, although acquired causes have been described extensively.Namely, philtral elongation is a byproduct of gravity, bone retraction, elastosis,and weakening fascial attachments. Other changes in the senescent ergotrid include diminution of pout and philtral fattening. Concurrently, the lips undergo soft-tissue atrophy, a process accelerated by sun exposure and smoking.
The most important aspects of the lip rejuvenation procedure are an understanding of the patient’s goals and an appreciation of her anatomy as it relates to these goals. Prior to any decision regarding which filler may be appropriate, it is worth discussing what the goals are. Providing a mirror and allowing the patient to talk about what she would like to see when she looks in the mirror will facilitate a better understanding of what will be perceived as a successful procedure for that individual. As with any cosmetic procedure, it is important to document the pre-treatment state with photographs and to capture any limitations (such as a constraint on the amount of material used) imposed during the consultation. Initial discussions must also include the range of products available for lip augmentation and the relative risks and benefits of the ones suitable for a particular patient.
Profile view of younger, “healthy,” attractive female lips. Reference points and Ricketts‘
lips projection reference E-line: 1 nasolabial sulcus, 2 nasal tip, 3 subnasale, 4 labrale superior, 5 stomion, 6 labrale inferior, 7 lip commissure, 8 labiomental sulcus, 9 soft tissue pogonion, 10 soft tissue menton, 11 Ricketts‘ E-line. The series of gentle curves from nasal tip to soft tissue menton characterize the lips profile
In cephalometric and photographic analysis, several reference lines have been introduced to assess anteroposterior position of the upper and lower lips. Ricketts’ ‘E’ line , Steiner’s S line , Holdaway’s ‘H’ line, Burstone’s ‘B’ line, and Sushner’s ‘S22 line are common lip assessment lines used. E-Line and S-Line are most commonly used reference lines in orthodontic diagnosis and treatment planning. E-Line is drawn from Pronasale (Pn) to soft tissue pogonion (Pog) and lip prominence with reference to this line is assessed. Upper lip to E-Line =-1mm and Lower lip to E-line = 0 mm. This means that upper lip is slightly behind E-line & lower lip touches E-line in balanced face. S-Line is drawn from midpoint between subnasale (Sn) and Pronasale (Pn) to soft tissue pogonion (Pog) and lip prominence with reference to this line is assessed. S-line though has been used cephalometrically but it has not been used on photograph to assess lip prominence. Its cephalometric norms are as follows: Upper lip to S Line (0±2mm), Lower lip to S Line (0±2mm). Steiner used S-Line with the idea that E-Line is affected by nose length.
Normal lips span over 25 percent of labral height, which equates to a philtral-labial score below 3. Average philtral height is said to fall between 18 and 20 mm,whereas ideal upper lip height has been placed at 7 to 8 mm.These numbers give rise to philtral-labial scores between 2.5 and 2.9.
Also its important to analysie the lip volume and perioral rhytides. A validated 5-point photonumeric lip scale, the lip fullness scale (LFS) has been developed by Carutthers et al. Separate grading for upper and lower lips is recommended. The scale ratings are: very thin (0), thin (1), moderately thick (2), thick (3), and full (4).The 5-point photonumeric scale differentiates no visible folds (0), visible fold with slight indentation (1), moderately deep folds not visible when skin is stretched (2), very long and deep folds (3), and extremely long and deep folds (4).
When assessing the lips, divide patients into three basic categories:
- Group 1 – those that have good shape and definition but who desire augmentation of certain features of their lips
- Group 2 – those that have atrophic lips requiring augmentation
- Group 3 – those that have loss of lip definition and/ or perioral rhytids.
After analysis and understanding the patient expectations and limitations of non surgical modalities. classification of patients under the following types help decide the treatment
Dermal fillers can be subdivided into temporary and permanent fillers. Fillers based on crosslinked hyaluronic acid (HA) fillers. This filler type consists of biphasic (particulate) and monophasic fillers (gel only).
Optimal lip rejuvenation is focused on two main principles: volume enhancement and vermiliocutaneous enhancement. Volume enhancement is indicated in older patients and patients with thin lips. Vermiliocutaneous enhancement benefits both young patients with adequate volume and aging patients, as a complement to volume enhancement.
Linear threading and/or serial puncture techniques are used for both volume enhancement and vermiliocutaneous enhancement.. This is accomplished starting at the oral commissures and proceeding lateral to medial. A cross-radial technique is employed around the commissures and marionette lines to lift the corners of the mouth . Usually, 0.5 ml to 1.5 ml of HA are used for each lip. Care must be taken to avoid superficial injection, because a visible bluish hue can result.
In the lips, injection can be carried out in the submucosal level, within the superficial orbicularis oris muscle. This depth of injection helps avoid visibility while augmenting total volume. Palpation for any contour irregularities is important both while injecting and immediately afterward. If any HA migrates away from the injection site or intended tunnel, it should be addressed immediately with massage to correct the contour deformity. Delaying this task results in more discomfort for the patient and risks an inferior result. Minimal injection of the philtral columns can further supplement the perioral volume.
- Soft filler with a lower stiffness is preferred even if the durability is more limited. Stiffer fllers would impair the delicate motion of the lips when speaking, singing, or smiling.
- Loss of volume of the upper lips is often associated with fattening of the vermillion border and partial loss of
Cupid’s bow. Subdermal injection of filler along the philtrum columns by threading technique improves not only the three dimensional appearance of the philtrum but Cupid’s bow as well.
- The position of the upper lip is modifed by the nasolabial fold and the cheek fat pads. A minor lift of the upper lip with an improved show of the wet roll is possible by liquid lift of the cheeks . Very thin lips, however, will not benefit from this technique.
- Loss of volume of the upper lips is often associated with fattening of the vermillion border and partial loss of
Cupid’s bow. Subdermal injection of fller along the philtrum columns by threading technique improves not only the three dimensional appearance of the philtrum but Cupid’s bow as well.This creates the distinctive peaks that are the signature of the Paris lip.
- In any case, serial puncture or linear threading techniques can be used. It is important to stretch and compress skin to visualize fold, and to inject medial to the fold to avoid further cheek ptosis. The needle should be beveled up and injected during withdrawal to decrease the risk for intravascular injection.
- Female lips are, on average, a little fuller than male lips. They bulge forward more than male lips — In other
words, they are slightly more “pouty.” Female lips are not noticeably bigger when you see them from the front
but they do bulge forward more as seen from the side. We need to keep this in mind while treating male and
female lips. Overvolumization of the male lip can result in feminization of the area.
- In case of advanced bone resorption or dental problems and loose connective tissue, in cases where ratio of philtrum to lip >5 advanced volumizing may lead to an undeserved ptosis (duck-bill look) and loss of fine lip motion. In such cases, plastic surgery and dental restoration may be more appropriate.
- When injecting the lips with HA fillers, physicians must consider the three injectable components:
(1) vermillion border or white roll, (2) wet–dry junction of the red lip, and (3) dental arcade that
provides volume throughout the mucosa to the superior lip. As a rule of thumb, the upper lip should
be approximately 75% to 80% the volume of the lower lip and the central lower lip should protrude
slightly beyond the upper lip.
- The lower lip should be fuller with more vermillion show than the upper lip . In Caucasian women, it is advisable to follow the golden ratio of 1:1.618 in terms of volume in the upper and lower lip. Black and Asian women may have proportions that approximate 1:1.
- The Glogau- Klein point (the elevation or ski slope in the upper lip where the skin turns into red vermillion
at the arches) can be enhanced to project the upper lip and create the ski slope to look characteristic of younger lips.
- There are natural prominences in the upper and lower lips that must be maintained to achieve the pouty look. These include the two tubercles that lie lateral to the midline on both sides of the lower lip, the tubercle that lies in the midline of the upper lip, and the two tubercles that lie in the lateral corners of the upper lip. Fillers for upper lip restrict to middle 1/3 to 1/2 and taper it laterally.
Lip wrinkles are ﬁne or deep lines that can be observed around the mouth. They appear as vertical lip lines perpendicular to the vermillion border and can be divided in static and dynamic wrinkles .
Static wrinkling can be caused by several factors, such as age, sun exposure, cigarette smoking, as well as unknown causes like genetics, gender differences, and intrinsic soft tissue characteristics.
Dynamic perioral wrinkles are caused by muscle contractions, which can be voluntary (e.g., smoking or playing wind instruments) or involuntary (e.g., smiling or grimacing).
The perioral muscles are arranged in interlacing and decussating bundles organized in several
layers. They can be classiﬁ ed into three groups based
• Group I muscles insert into the modiolus; they are orbicularis oris, buccinator, levator anguli oris, depressor anguli oris, zygomaticus major, and risorius.
• Group II muscles insert into the upper lip; they are levator labii superioris, levator labii superioris alaeque nasi, and zygomaticus minor.
• Group III muscles insert into the lower lip; they are depressor labii inferioris, mentalis, and platysma.
The Orbicularis Oris
Because of its circular shape, it is recommended to treat both the upper and lower portions to maintain balance.
Injections must be superﬁ cial, performing it in the lower dermis and no deeper than the dermo-subcutaneous junction.The dilution of BOTOX® should be 100 U vial of BOTOX® with anywhere from 1 to 4 ml of normal saline. In this way, it can spread over the superﬁcial ﬁbers of the orbicularis oris, treating the multitude of vertical lines across the lips. In this way we can use only 1 or 2 U for each quadrant, with a total treatment dose of 4–6 U for
the whole area.Injections can be performed either into the border between the pars peripheralis and pars
marginalis or 3–5 mm above the vermillion border into the lateral pars of the orbicularis oris, at least 1 cm from the mouth corner and avoiding the philtrum column area, for risk of ﬂ attening its
Depressor Anguli Oris
Its function is to pull the corners of the mouth downward, moving the marionette lines down . Injections should be superﬁ cial in the lower third of this muscle, with the needle directed laterally. It is recommended a total treatment dose of 6 U, which must be divided between two injection sites, one per side. Injections should be per-
formed in the projection of the muscle, 1 cm lateral and 1.5 cm below the oral commissure.
Its contraction raises the chin, elevates the skin of the lower lip upward, and protrudes and everts
the lower lip during drinking. Its hyperactivity can cause a deep wrinkle between the lower lip and the prominence of the mandible. Moreover, with loss of collagen and subcutaneous fat that occurs with aging, it can
appear as chin dimpling. It is recommended that a total dose of 6 U be divided equally between two injection sites, one per side. Injections should be performed subcutaneously or intramuscularly at two symmetrical
points located close to the chin midline, 1 cm above the lower edge of the jaw.
Although injections of small amounts of botulinum toxin A are used to improve perioral lines in younger and middle aged females, we would not recommend this method for elderly subjects. Intrinsic and extrinsic aging eventually causes lines in rest that cannot be corrected by botulinum toxin.
The downward turn of the corners of the mouth can be seen in subjects of various ages. Whereas in younger individuals the strength of the platysma and depressor anguli oris is responsible and can be corrected by botulinum toxin injections, this is rarely the case in elderly women.
Full Article on PDO threads read here. PDO Thread Lift
Ablative resurfacing is defined as wounding the skin to levels of the dermis. The tools available to do this
include peeling agents, dermabrasion, and various laser treatments. During the healing process, the
dermis produces smoother, firmer, rejuvenated skin.
Several peeling agents are available and their use is largely dictated by the depth of penetration desired. For example, 88% phenol alone may be used for medium-depth resurfacing, and is the main ingredient of Baker-Gordon peeling solution. Alternatively, Jessner’s solution in combination with 35% trichloroacetic acid creates a maximumdepth peel while maintaining a good safety profile. Treatment of the perioral area with peel solutions
requires special attention to the transition area between the facial skin and the lip, which is often inadequately peeled. Treatment of this area is facilitated by stretching out the vermillion borders and flattening them to provide even distribution over vertical rhytids along the lip.
Laser resurfacing of perioral regions for grade 1 and 2 rhytides.
Permanent make up
With age the distinction between lip and skin fades which is called lip bleed. Though fillers can give the elevation to white roll. permanent make up is a good modality to get the definition of lips.