The perioral region extends vertically from the subnasale to the menton (the inferior-most point on the chin), thereby including both upper and lower lips, the labiomental fold, and the chin. It is bounded superolaterally by the paired nasolabial (NL) folds and inferolaterally by the marionette (M) lines, which represent extensions of the nasolabial folds onto the chin. Each of these is commonly treated during perioral rejuvenation and face lifting. The perioral region does not include the nose, the base of which instead marks the limit of its cranial extent. The perioral region consists of skin, subcutaneous fat, and a number of key muscles of facial expression including the orbicularis oris, depressor labii inferioris, depressor anguli oris, and mentalis. It also includes the insertions of the zygomaticus major, zygomaticus minor, levator labii superioris, levator labii superioris alaeque nasi, depressor septi nasi, and buccinators where they join with the orbicularis oris. The mentalis muscles are vertically and obliquely oriented paired muscles of the chin located on the mandible. These muscles originate from the incisive fossa of the mandible and insert into the skin of the chin creating the mentolabial sulcus or groove. They serve to elevate, evert, and protrude the lower lip and cause wrinkling during animation. While there are differences between patients in terms of soft tissue and bony anatomy, the fundamentals of the perioral region are consistent across patient groups.1
The depressor septi nasi is one of the facial mimetic muscles of the upper lip. It is a paired muscle located on either side of the nasal septum with attachments to the medial crura of the lower lateral cartilages, the anterior nasal spine, and the orbicularis oris muscle. In some patients, it acts to either pull the nasal tip downward or shorten and elevate the upper lip during animation which some patients do not like. Accordingly, it may be chemically denervated with botulinum toxin injection or surgically severed, as an independent procedure or as part of a rhinoplasty procedure.1,2 The other muscles all serve to elevate the upper lip during a smile with the zygomaticus major being the primary smile muscle. They each insert onto the orbicularis oris, which acts as a concentric muscle to close the oral commissure. In relation to perioral rejuvenation, knowledge of the underlying muscles is important and learning to modify their action can be important in improving aesthetics.
The upper lip has defined anatomic components and knowledge of them is key to perioral rejuvenation, planning and executing its treatment, and ensuring clear, concise documentation. The key anatomic structures may each be targeted with filler in a structural manner or the lip more generally volumized with filler. The lips comprise the orbicularis oris muscle which is lined internally with mucosa of the oral cavity. Externally, the lips have skin and subcutaneous tissue over the orbicularis. Linking the surfaces of the external skin and internal mucosa is the vermilion which is the red colored zone of the lip that has a specialized stratified squamous epithelial surface. The vermillion is subdivided into wet (internal) and dry (external) components. The join between the skin of the lip and the vermillion is called the white roll or white line. Cupid’s bow represents the central V-shaped section of the upper lip at the junction of vermilion and skin. The vertical ridges that link this to the nose are the philtral columns and these represent ridges formed by decussation of the orbicularis oris. The channel they create is called the “philtral column.” The tubercle is the term normally used to describe the midline prominence at the lower part of the upper lip. Sometimes multiple tubercles are described: three to the upper lip and two to the lower lip in relation to aesthetics of the lips. These simply represent natural areas of fullness of prominence that may also be enhanced with injectable fillers (Fig. 114.1).1,2 Fig. 114.1 Lip architecture. (From Coleman SR. Structural Fat Grafting. Thieme, 2004.) Philtrum Cupid’s bow White roll Tubercle Oral commissure Wet line Labiomental crease
When meeting a patient in the office to discuss perioral rejuvenation, the same approach should be considered when conducting a standard medical or surgical history. One of the key elements is to ensure that you are aware of what treatments the patient has tried previously, what has worked well, and what has not. This helps you filter the best treatments likely to benefit them. Sometimes patients are vague about what they have had done and this may be simply because they are unsure what filler or neurotoxin was used, nor where exactly it was placed or the dose given. Conversely, some patients know exactly what was done and have fine detail about it to provide to you. The interview will be most effective if open-ended questions are used to explore the patient’s aims and objective. This forms a basis to develop a plan that is likely to be effective and provide patient’s satisfaction. A series of closed questions alone may be time-efficient but may miss key elements required. The usual risks for surgery such as diabetes, smoking, and hypertension all apply to nonsurgical and surgical interventions and so must be explored. Smoking and diabetes can lead to increased risks for infection, either following injections or after the procedures. Understanding what current skin care is being used (this can range from nothing to a complex recipe of products) is important, as certain treatments may affect options for further treatment under your care. Key things otherwise to pick up on include a history of hypertrophic or keloid scarring, of acne and treatment, and a history of herpes labialis.1–3
The key element to consider when performing an examination of the perioral area with a view to rejuvenation is that the exam must include assessment at rest and animated in order to assess static and dynamic rhytids, the smile dynamics, the nasolabial and marionette folds, the lip competence, facial symmetry, and hyperactivity of orbicularis oris. Assessment of the skin is also key, but there are more than three elements to consider. Skin characteristics that need to be assessed include its thickness, abnormal pigmentation, texture, scarring, wrinkling patterns (static vs. dynamic), acne activity and its sequelae, and evidence of pathological skin lesions and actinic damage (i.e., actinic keratosis, squamous cell carcinoma, basal cell carcinoma, melanoma). The Fitzpatrick skin type classification is useful to quantify when deciding upon treatment plans as skin resurfacing approaches differ according to skin type. The Glogau scale can be used to quantify and record photoaging.1 Lip volume and architecture should be assessed as well. The ratio of subnasale–stomion to stomion–submentum should normally be 1:2, and the surface area of lip display of upper lip to lower lip should display a ratio of 2:3.2 The relationship of the lips to dental structure at repose and smile should be considered. Incisal display in repose should be 3 to 4 mm for women but is less for men at 2 to 3 mm.
There are a number of predictable changes in the lip that occur with advancing age. These include a loss of volume and subsequent loss of architecture, lengthening of the lip with inversion, loss of orbicularis oris tone, and an increased display of teeth at rest. In addition, there are often skin changes with skin thinning and development of both fine vertical lines and deeper static rhytids (Fig. 114.2). These changes are addressed with perioral rejuvenation techniques. The loss of volume and definition can be improved with injection of temporary or permanent fillers. The fine rhytids can be improved with skin resurfacing techniques and the lip length can be addressed with surgery to reduce its overall height.1–3 Fig. 114.2 Aging changes in the lips. (From Coleman SR. Structural Fat Grafting. Thieme, 2004.)
When planning for ablative facial resurfacing, patients should undergo topical home treatment of tretinoin (up to 0.1%) four times per day for at least 3 to 4 weeks. This provides a uniform thinning of the epidermis, which can improve penetration of chemical peels and decreased healing times after ablative skin treatments. Pretreatment with topical hydroquinone 4% twice daily for 3 to 4 weeks prior to ablative skin resurfacing procedures, and 1 to 2 months postprocedure after re-epithelialization has begun, is intended to reduce unwanted pigmentary changes. It is generally indicated for darker skin tones. Antiviral prophylaxis when undergoing skin resurfacing of the perioral region is warranted even when there is no history of cold sores. An antiviral such as acyclovir rather than tretinoin is used for this. All patients undergoing resurfacing should start this 1 day prior to treatment and continue for 2 weeks after treatment. Following ablative skin resurfacing treatment, the treated area should be kept moist with ointment or an occlusive dressing. Sunscreen should be worn for 3 months posttreatment once healing is complete to minimize unwanted pigmentary changes. Milia, acne, and prolonged erythema are all potential complications of skin resurfacing, but tretinoin does not specifically target these problems.1–6
Vertical fine lines on the lips can be troublesome for patients and are often associated with prior smoking and high levels of sun exposure. They are difficult to eradicate, but methods to improve them include skin resurfacing, volume-enhancing fillers, and neurotoxin injections. When injecting botulinum toxin into the lips, it is normal to inject once in each lip quadrant (not once to each lip). The toxin is injected into the muscle (orbicularis oris). It is key to use small doses only, otherwise there will be a high risk of causing problems with speech and eating secondary to lip weakness and oral incompetence, which patients will find extremely distressing. The dosage will therefore be far less than that usually required for periorbital rejuvenation. The effects are temporary and repeat treatments will be needed well before 1 year. It is reasonable to combine filler and neurotoxin treatments as they target different problems but are complimentary to one another. However, the two do not need to be physically mixed together.1,2
Injection of nonpermanent fillers into the lip is most commonly performed with hyaluronic acid, as this is safe, easy to use, has a low risk of adverse reactions, is reasonably cost-effective, and can be reversed if the effect is undesired. The main products available are FDA approved, although some are used “off label.” For example, Restylane Silk and Juvederm Volbella do have specific FDA approval for lip augmentation, where many other products have approval for other areas including the nasolabial fold. Products such as Juvederm, Restylane, Prevelle Silk, and Belotero balance contain local anesthetic in the form of lidocaine but can still be painful to inject especially in the lip. It is therefore ideal to use an infraorbital nerve block prior to injecting the lips, as just a small volume of local anesthetic placed into the upper gums can provide patient comfort without distorting the lip appearance. Alternatively, topical anesthetic such as EMLA or LMX4 can be used but is less effective than a nerve block. When injecting nonpermanent filler into the lip, it can be for an overall volume increase, or to define certain anatomic elements of the lip such as the white roll, Cupid’s bow, tubercle, or the philtral columns. There are similarities in the technique with either approach, but they are subtly different. For example, when placing filler to improve structural elements, a threading technique with a 30-gauge needle superficially into the dermal and subdermal plane would usually be preferred. Volumes should be very low and product placement needs to be very precise. When injecting primarily for overall lip volume increases, product placement can be less precise and delivered in greater volumes more deeply within tissue to minimize surface irregularity. A larger needle such as a 25-gauge may be used instead with a volumizing technique. Alternative products for injection include calcium hydroxylapatite (CaHA) such as Radiesse, poly-L-lactic acid such as Sculptra, polymethylmethacrylate (PMMA) such as Bellafill, and collagen based such as Zyderm. These tend to be used for deeper injections than hyaluronic acid which is well suited to the lips.1–4
true? The nasolabial folds are a frequent primary focus for patients attending clinic. They tend to deepen with age due to a combination of factors including the effects of repeated animation, relaxation of facial ligamentous supporting structures, and prominence of the malar regions. Noninvasive treatments for minimizing the nasolabial folds include fillers. These may be temporary such as hyaluronic acid or permanent such as fat. When injecting the nasolabial fold directly, it is useful to do so with an inverted cone shape which leaves a greater volume of filler close to the alar grooves and less toward the commissure. Marionette lines are also treated similarly with the nasolabial folds, but with less product volume. Filling the marionette lines may give a secondary benefit to the downturned oral commissure, by providing a subtle lift to it. There has been debate regarding placement of filler to enhance the nasolabial fold and in techniques such as the “liquid” or “injectable” facelift, filler is placed in a number of specific locations throughout the face to volumize areas and provide a lift. These injections are often at the level of periosteum. Doing so in the malar region can help reduce the nasolabial fold depth and appearance. Often a combination of the malar and nasolabial injections is helpful. The nasolabial folds may be treated with surgery either by placing dermal grafts or by direct excision. The downside to the latter, in particular, is that permanent scars are placed in the folds, which may be unacceptable to many patients.1,2
Surgical treatment of the severely drooping oral commissure may be considered where more conservative approaches have been exhausted. The “commissure lift” involves resection of skin around the corner of the mouth. The markings for this procedure are as follows. With the patient in the sitting position, mark the commissure and draw a line diagonally toward the superior tragus extending 1 to 1.5 cm (this should not pass beyond the NL fold). A second diagonal line of equal length should then be drawn medially from the commissure vermillion. A third line completing the triangle superiorly in a curvilinear fashion is then drawn. The height of the arched line is approximately 5 to 7 mm (Fig. 114.3). This surgical approach has the advantage of effectively lifting the commissure and reducing the “miserable” appearance a downturned commissure can create, in a permanent fashion and with immediate changes evident. The downside is that it leaves a permanent visible scar lateral to the commissure that can be unacceptable to some patients. This can be described as a “Joker smile deformity” and may benefit from postsurgery resurfacing to help conceal it.1–3
patient? The subnasal lip lift may be optimal for patients with a long upper lip and decreased incisal display where there is a normal cupid’s bow. It involves removal of 4 to 5 mm of skin and soft tissue from the junction between the upper lip and nose. It should therefore be used only in patients with lips longer or taller than 15 mm. The scar is generally well hidden in cupid’s bow, but this procedure can cause distortion of the nasal sill (Fig. 114.4). An alternative to the subnasal technique for addressing the long upper lip is the vermillion border lip lift. This has the added advantage of correcting an inadequate cupid’s bow which was not required in this scenario. The incision is made at the vermillion–skin junction. A disadvantage with this technique is that it leaves a less well concealed scar and can obliterate the white roll of the upper lip. In the setting of a maxillary deficiency, an apparently long lip may be improved with maxillofacial intervention such as a LeFort osteotomy with bone grafts. It would not be required in this case. Manipulation of the dentition can be advantageous in order to change dental show; however, in the setting described, it would be addressing a different problem to the one that exists and making the dentition excessively long can affect function while eating and speaking. Injectable approaches to the lip can be helpful to fill out lip volume and thereby reduce length; they can also help increase length by adding volume in some cases. In this case, however, a surgical approach would be preferable and longer lasting.1–3 Fig. 114.3 M lines and downturned oral commissure. 1020 Part VII ■ Aesthetic Surgery