Perioral Rejuvenation - or rejuvenating the mouth area - Lip lifts and Lip advancements. The youthful mouth.
Dr. Sam Rizk, a nyc facelift surgeon and double board certified facial plastic surgeon, discusses the innovations in rejuvenating the area around the mouth.
The perioral region comprises the lower one third of the face, which consists of the upper and lower lips, the cheek-lip grooves or nasolabial folds, and the chin. As we age, the perioral region ages with time because of volume loss and bone loss in the maxilla and also because of gravity pulling the cheeks and jowls down. The absorption of bone is important since the bone supports the soft tissue of the upper and lower lips. The upper lip lengthens, the philthrum flattens, Cupid’s bow disappears, and the vermilion thins, leaving a flat, thin profile instead of the nice curvature seen in youth. The upper incisors are no longer visible in repose, vertical rhytides deepen and appear, the corners of the mouth droops with gravity and volume loss, and the nasolabial dolds deepen. Dr. Sam Rizk, a New York facelift surgeon, states that all of these changes result in a sad, tired look of old age.
The perioral region must be addressed in facial rejuvenation to achieve a complete, balanced, and more youthful appearance.
Accurate preoperative assessment is essential for perioral rejuvenation. Very often, the perioral area can be addressed at the same time as a facelift or necklift. The surgical or laser procedures or fillers depend on the desired change. Autogenous fat transfer has had a significant impact on rejuvenating this region, according to Dr. Sam Rizk, and particularly the PRP fat transfer procedure pioneered by Dr. Sam Rizk in New York. Flat lips require augmentation whereas thin lips can benefit from augmentation or advancement. An elongated upper lip can be corrected by excising excess tissue (lip advancement or subnasale lip lift). A downward turned oral commissure can be treated with a corner of the mouth lift or fillers/autogenous fat transfer. Vertical perioral rhytids are addressed by resurfacing procedures with a fractionated co2 laser or chemical peels as well as injectable fillers. Deep-cheek-lip grooves or nasolabial folds can be treated by a facelift to lift the cheek if severe or can be managed at a younger age with fillers if mild.
Dr. Sam Rizk, a nyc facelift surgeon and facial plastic surgeon defines certain anatomical landmarks. The upper lip extends to the subnasale (base of the nose). The lower lip is separated from the chin by the mentolabial sulcus. The cheek-lip grooves mark the lateral boundary of the perioral region. The upper lip comprises one third of the perioral region whereas the lower lip and chin make up two thirds. A change in this ration is seen with age when the upper lip elongates.
According to Dr. Sam Rizk, young attractive lips form a diamond shape. With age, the lips take on a more horizontal shape. The upper lips are noted to have two peaks that correspond to the philtral ridges forming a soft M known as Cupid’s bow. There is a central fullness to the upper lip that corresponds to the tubercle. The upper lips are 7-8 mm in height in the midline with an increase of 3-5mm at the philtral ridges. The interface of the upper and lower lips also form an M, but it is less pronounced. The lower lip is thicker than the upper lip with a central fullness of 10mm. The lower lip has a soft W shape that corresponds to the M of the upper lip.
On profile, Dr. Sam Rizk, a New York facelift surgeon, states that it is important for a natural appearance that the upper lip is more anterior than the lower lip and that both lips should protrude beyond a vertical line drawn from the subnasale to the most anterior point of the chin. There are male and female difference according to Dr. Sam Rizk and in men, the lower lip may be in line with the most anterior point of the chin and protrude less than in females. Dr. Sam Rizk further emphasizes that the subnasale/chin plane to be useful, the chin must be in an aesthetically pleasing position. Additonally, in repose, the upper and lower lips should not meet and there should be an interlabial gap with one third of the upper incisors visible. As a person ages, the elongation and inversion of the upper lip results in dental hooding. Before any planned surgery, issues of malocclusion should be addressed because malocclusion can affect lip position.
Lip Augmentation or enlargement
Who is a candidate-The ideal candidate for lip augmentation are patients who have thin lips or disproportionate lips. Augmentation can be accomplished with surgery or injections. Autogenous PRP fat transfer is an excellent method of enlarging and creating a more attractive lip using the patients own fat harvested from the abdomen. It usually lasts for up to 5 years or longer . Other fillers that may be used include Juvaderm or Restylane and they last for an average of 6 months. Perlane lasts a few months longer than Restylane. Dr. Sam Rizk prefers using the patient’s own fat as it lasts longer and has a higher retension rate. Dr. Rizk does not use silicone for lip injections as it is not FDA approved for that use and has a high rate of complications.
Fat injections for lip augmentation is a safe and effective method of enlarging lips with a low complication rate. The fat is harvested from a donor site such as the anterior abdomen or thighs and then purified and filtered and then injected with microscopic cannulas. Disadvantages or possible complications of fat transfer or injection into the lip may include a possible yellow discoloration to the lips, and variable absorption or resorption with time leading to possible irregularities or lumpiness but this is uncommon. Thus repeated injections may be necessary to even out areas of irregularities.
Lip augmentation can also be performed with a minor surgical procedure like placing Alloderm (life Cell corporation) or Gor-Tex for bulk. Of these 2 methods, Dr. Sam Rizk prefers the Alloderm than the Gor-Tex since it feels and looks soft and more natural. Gor-Tex can feel hard and look tubular. Alloderm will absorb to some extent with time as well as fat injections. Gor-Tex does not absorb with time as it is a tubular implant.
Dr. Sam Rizk, a nyc facelift surgeon and board certified facial plastic surgeon, has had success with Fat transfer to the lip as well as Alloderm for lip augmentation. Dr. Sam Rizk believes that no matter how deep the Gor-Tex is placed, it still has a palpable firmness that makes it unacceptable in intimate situations. Other disadvantages of Gor-Tex is infection, like any alloplastic implants, although this is rare. Before implantation, Alloderm or Gor-Tex are soaked in antibiotic solution. All of Dr. Sam Rizk’s patients receive intraoperative and postoperative antibiotics to prevent infection. Patients must understand that if Gor-Tex is used that it will be palpable or felt to some degree. There is also significant postoperative swelling with Gor-Tex that resolves with time.
Shortening the long upper lip
Laxity of the tissue with age results in elongation of the upper lip. Dr. Sam Rizk, a nyc facelift surgeon and facial plastic surgeon, discusses the options for improving the upper lip region. Shortening of the long upper lip can be accomplished by lip advancement and subnasale lip lift. Lip advancement is preferred by Dr. Rizk over a subnasale lip lift in cases in which Cupid’s bow is not well defined or in cases where the vermilion border is not sharp. Both techniques result in a shortened upper lip and allow some eversion of the upper lip and incisor show.
Lip advancement is also sometimes called vermilion advancement can improve the shape, volume, and upper lip length. Although this procedure has a strong role in lip shortening, patients must be chosen carefully because of the location of the scar right on the lip border. Hypertrophic scarring may occur, requiring injection of steroids into the scar. In addition, patients may sometimes feel lip tightness and an unnatural smile. Lip advancement is performed by first marking out the upper and lower vermilion borders of the lips while the patient is sitting. The desired amount of vermilion advancement is outlined with surgical calipers. For the upper lip, the area outlined is approximately 5mm above the vermilion border at the level of the philtral colmns and 3mm at the central upper lip. The outline is then extended laterally from the philtral columns paralleling the lateral upper lip and tapering down to the vermilion 5mm from the oral commissure on each side. This approximates Cupid’s bow overlying the philtrum. For the lower lip, 5mm is outlined for most of the vermilion border and tapered upward into the area of the oral commissure at 5mm from the commissure. The incisions are carried out but not through the orbicularis oris muscle. Undermining should not be performed because it results in a more flattened appearance to the lip on profile. The mucosa of the upper and lower lip are then advanced into this newly created vermilion border and set in place with several interrupted 7-0 blue prolene sutures followed by a running 7-0 blue prolene suture.
Subnasale lip lift also has a role in shortening of the upper lip in well-selected patients. Dr. Sam Rizk performs this lip lift if the patient understands the scar which will be placed under the nose does form a white line in an area which may be visible but in a white patient that may be acceptable. The scar is hidden between the upper lip and nostril sill. Patients must have a nasal base to lip ratio of 1 to 2. A smaller ratio will result in less lift of the lateral lip than the central lip. This may accentuate a downward turned corner of the mouth. A wavy ellipse is marked out in a subnasale lip lift under the nose following the contour of the nose lip junction just outside the nasal sill while the patient is sitting. The superior incision extends along the entire nasal base and both alar creases and the inferior incision parallels the superior incision but is tapered to meet the superior incision at the junction of the nasal ala and cheek-lip groove. The width of the excision depends on how much lift is desired-being as narrow as 3mm to as wide as 10mm. The amount excised should be overcorrected by one third to allow for postoperative relaxation. The incisions are extended down into the subcutaneous tissue. The muscle is left intact. The skin and subcutaneous tissue are dissected away from the underlying muscle. The subnasale defect is closed in three layers.
Corner of the mouth lift-One of the features that contributes to the sad, tired look of old age according to Dr. Sam Rizk, a nyc facial plastic surgeon and a nyc facelift surgeon, is the downward turn corner of the mouth. A patient’s projected image can be improved by elevating the corner of the mouth. The corner of the mouth lift can also correct drooling or angular cheilitis caused by a downward turned corner of the mouth. The incisions for the corner of the mouth lift should be marked out while the patient is sitting. A dot is placed at the oral commisure precisely at the junction of the skin and vermilion. A triangle of skin is marked out just above each commissure by extending a line medially from the dot along the skin vermilion junction for approximately 12-16mm. Another line is then drawn from the dot at the oral commissure along a line that extends to the top of the ear. This line should fall short of the cheek-lip groove or nasolabial folds. These two lines are then connected by an arc to form a rounded skin triangle. The height of the triangle depends on the lift desired but should measure 5mm-9mm. The triangle is excised with the incision extending extending through the skin and subcuticular fat. The disadvantage of the corner of moth lift must be weighed against the advantages. There is a visible scar extending 1cm-1.5cm lateral from the oral commissure. There is an initial slightly overcorrected appearance to the oral commissure. There is only a partial correction of the deep oral commissure-chin-cheek groove. It, however, may be the preferred procedure for a given patient when all other techniques have been tried and the marionette crease persists.
Perioral rhytids or wrinkles-With aging, rhytids or wrinkles develop around the perioral region or area around the mouth for various reasons including smiling, talking, smoking, and related muscle motions thousands of time a day throughout life. The vertical rhytids around the lips are especially prominent because of constant motion around the mouth. These rhytids often can be temporarily effaced with injectable fillers. As the perioral rhytids become more pronounced with increasing age, resurfacing techniques must be considered such as fractionated co2 laser resurfacing or peels. Peels can be used for more superficial rhytids and the laser treatments are better for the deeper rhytids. Dr. Sam Rizk, a New York facelift surgeon, prefers the laser techniques as it is more controlled than the peeling techniques. Dr. Sam Rizk often will use a combination of autogenous fat transfer and laser resurfacing to both fill and resurface the wrinkles around the mouth. All patients who undergo perioral resurfacing are placed on antiviral medications to prevent a herpetic infection. Patients who have a known history of herpetic outbreak are started on oral antiviral medication 3 days before surgery. In addition, all patients are given prophylactic antibiotics to prevent a bacterial infection. With this regimen, Dr. Sam Rizk has successfully prevented bacterial and viral infections. Disadvantages of perioral resurfacing are pigmentation problems, scarring, and residual rhytids but these advantages are rare. The redness does resolve over several weeks, depending on the depth of laser resurfacing, and can be camouflaged with makeup after one week. Hyperpigmentation, although rare, may occur and can be treated with bleaching creams. Hyperpigmentation is more common in darker skin patients than white patients. Scarring is preventable for the most part by avoiding deep penetration with the laser or peels. Residual rhytids or wrinkles can be treated with further laser resurfacing, further peeling, or fillers.
Written by Dr. Sam Rizk