Summary

Today’s facial surgeons have more options than ever before to rejuvenate the perioral area. It is essential to have a thorough understanding of both perioral anatomy and perceived signs of aging to put the correct treatment plane. The patient and physician need to understand the types of defects that can be improved using noninvasive 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.

Mouth and Lip (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,” 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 vermillion 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.
• In general, the lower lip should have 25% more volume or fullness than the upper lip.
• Finally, the upper lip should protrude beyond the lower lip by 1 to 2 mm.
• The lower lip is more curvilinear and frequently has a similar white roll.
• The lower lip shows fullness in the central portion.
• Analysis of the lateral view is more straightforward. The lower lip should likewise 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 show should be absent, with the lower lip eclipsing them by enough superior positioning.

Lip Aging

• In youth, the perioral skin is smooth, 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 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 rhytides 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, presumably from the presence of 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.

In youth, the perioral skin is smooth, 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 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 rhytides are often associated with the lengthening of the upper cutaneous lip. Vertical lines result from heredity, photodamage, or excessive use of the mouth.  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 not seen in males from the presence of 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 the youth as a genetic characteristic, and/or acquired, and with advancing age. Various 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 three components: teeth, gums, and lips. An attractive smile depends on the proper proportion and arrangement of these three elements. 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 the result of 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. Besides, delayed passive eruption is a developmental problem of the teeth, resulting in excess gum covering the dental crown. Gum is evident more in dynamic motion. Gingivectomy and vestibulopathy can correct by a cosmetic dentist or an oral maxillofacial surgeon.

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 in any given lip before the results look unnatural and distorted, i.e., without blunting the edge of the vermilion border of the lips or strange fullness above the lips. Asymmetries of the lip associated with smiling can be improved upon but not resolved with lip augmentation.

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 is the result of the descends of malar fat pads. The prominent nasolabial fold draws attention to the aging around the mouth area that necessitates attention.

Traditional facelift techniques do not sufficiently address the mouth area. With new advancements in cosmetic medicine, nonsurgical 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.

In looking at the aging mouth, there are two vital areas to see. 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 lips end, the building of buttresses to restore height to the lower third of the face, correcting the labio-mandibular grooves and oral commissure.

Today’s facial surgeons have more options than ever before to rejuvenate the perioral area. It is essential to have a thorough understanding of both perioral anatomy and perceived signs of aging to put the correct treatment plane. 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. 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. Many products and devices are available to physicians to address these issues and obtain favorable results from dark lips to perioral wrinkles.

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
• Photorejuvenation or light therapy
• Botox injections
• Filler injections
• Fat Injections
• Microneedling
• 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 rhytides and laxity. Chronic ultraviolet exposure also causes hyperpigmentation, solar lentigines, telangiectasias, and rough texture.

One of the essential components of any antiaging treatment plan is topical skincare. A basic skincare regimen includes a cleanser, moisturizer, and sunscreen. 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, which stimulate neocollagenesis 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 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), 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 towards 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 electrically, uses bipolar radiofrequency in the skin to allow the passage of drugs (antiaging, whitening, and antiacne) painlessly without needles.

MSI Skin rejuvenation peel is a comprehensive antiaging, anti-acne, 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, and anti-acne, antiaging dermal roller, dermapen, no needles mesotherapy (electroporation), microdermabrasion, fractional laser, and radiofrequency.

Unlike chemical peels and dermabrasion, laser skin resurfacing (LSR) with the CO2 laser generates heat, which results in immediate tightening because of shrinkage of collagen, which forcefully shortens the collagen fibers by 30%. Collagen fibers shortening translates clinically into the smoothing out of 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. The laser continuously stimulates healthy new collagen and elastic fibers in the skin for six months after resurfacing. Therefore, any wrinkles or scars will continue to improve for up to one year. Nonablative or minimal ablative fractional CO2 provides a double benefit, i.e., treating skin texture  (acne scarring, wrinkles, and skin pigmentation  (melasma, hyperpigmented scars, lentigines, and pigment alteration).

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 remodeling dermal 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 to invoke thermal wound healing mechanisms. The two types of photorejuvenation are available; the Intense-Pulsed Light (IPL) and the Light-Emitting Diode (LED) treatments

Fractional radiofrequency (FRF) delivers heat energy creating zones of heat-affected skin adjacent to unaffected areas. The treated areas result in thermal damage of collagen fibers, stimulating wound healing, dermal remodeling, new collagen, elastin, and hyaluronic acid formation. FRF improves acne scars and large facial pores, wrinkles, and facial laxity reduction.

The unaffected areas serve as a cells reservoir that promotes and accelerates wound healing. The most common sequence effects are erythema and edema, which are transient (few days). You may use a topical anesthetic cream before the treatment to minimize pain. In a new approach, Prof Moawad offers his patients FRF to make tiny holes into the skin to overcome the stratum corneum to enhance PRP or nanofat penetration. The results are doubles, and you will enjoy both the rejuvenating effect of the FRF resurfacing system and the regenerative effect of growth factors and stem cells.

The basis of microneedling (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 microneedling 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 (Mesolift), platelets rich plasma (PRP), and nanofat (vampire facelift) and even botulinum toxin microinjection (mesobotox) into the deep layer of skin and subcutaneous tissue.