Perioral Rejuvenation: Lip Lifts, Corner of Mouth Lifts, and Vermillion Advancements

Abstract

Perioral rejuvenation is a critical component in the comprehensive approach to the aging face. The perioral region—comprising the lips, philtrum, and areas surrounding the oral commissures—plays a significant role in an individual's perceived age, attractiveness, and emotional expressions. However, the perioral region is often the “forgotten area” and has the potential to undermine the success of otherwise outstanding rejuvenation surgeries. This article will shed light on 40 years of experience in perioral rejuvenation surgery, demonstrating techniques and methodologies that have consistently yielded long-term, reliable results in my practice.

Keywords

lip rejuvenation - lip lift - corner of mouth lift

When viewed from the front, the face can be partitioned into vertical fifths and horizontal thirds. The perioral region is demarcated as the lower third of the face, extending laterally to include the middle three-fifths of the facial width. The upper boundary is formed by the subnasale and cheek–lip grooves, whereas the lower limit is defined by the mentum. This lower facial third can be further subdivided, with the upper third encompassing the upper lip and the lower two-thirds comprising the lower lip and chin.

The oral commissures should align with a vertical plane originating from the medial limbus of the iris. Ideally, the lips should touch upon occlusion, allowing for a 2- to 3-mm interlabial gap at rest. A subtle display of the upper incisors is acceptable but should not exceed two-thirds visibility during a smile.

In profile, the upper lip should project 2 to 3 mm beyond the lower lip. Various authors have quantified this protrusion relative to a line connecting the subnasale to the pogonion. For instance, Legan and Burstone suggest that the upper lip's most anterior point should be approximately 3.5 mm from this line, whereas the lower lip should be 2.2 mm.[1] However, these measurements are not universally applicable due to racial variations and differing aesthetic preferences. The lips' appearance is also influenced by the underlying skeletal and dental structures, necessitating a balanced approach to soft tissue analysis.

The chin extends from the mentolabial sulcus to the menton and can be evaluated using a vertical line drawn from the lower lip's vermillion border when the patient is aligned with the Frankfort horizontal plane. In men, the pogonion should align with this line, while in women, it may be slightly anterior. The mentolabial crease depth should approximate 4 mm. A vertical chin deficiency is indicated when the ratio of subnasale–stomion to stomion–menton exceeds 1:2.[2]

An aesthetically pleasing upper lip features a gentle M-shaped arch, known as Cupid's bow, which intersects the lower ends of the philtral ridges.[3] The upper lip may or may not display the central incisors when at rest, whereas the lower lip typically exhibits greater vermillion visibility and fullness. On profile, however, the lower lip sits more posteriorly compared to the upper lip[4] ([Fig. 1]).

Fig. 1 Ideal characteristics of lips.

These anatomical guidelines serve as foundational knowledge for facial analysis and preoperative planning. They should be interpreted in conjunction with sound clinical judgment. It's crucial to recognize dental–skeletal abnormalities like malocclusion, retrognathia, or vertical maxillary excess, as these may necessitate orthognathic surgery, which falls outside the scope of this discussion.[5]

Aging Changes in the Perioral Region

From the earliest stages of life, the lips exhibit remarkable definition, characterized by distinct landmarks that result from the fusion of facial placodes. As individuals transition through puberty, their lips gain volume, primarily due to hypertrophy of the orbicularis muscle and the glandular elements. However, as the aging process unfolds, this youthful definition gradually diminishes, leading to flatter lips with altered proportions. Notably, the upper lip elongates, the iconic Cupid's bow fades, and the oral commissures descend.

Various factors contribute to accelerated aging of the perioral area. Genetic predisposition, as well as the inherent size and fullness of the lips during youth, can play a role. Environmental factors like sun exposure and cigarette smoking can further expedite this aging process.[6] As the skin becomes thinner and the supporting orbicularis muscle atrophies, vertical lines, or rhytids, emerge around or above the vermilion border. The lips lose their fullness, procumbency, and definition. Additionally, the descent of the oral commissure and the loss of cheek soft tissue support contribute to the prominence of marionette lines.

The cheek–lip grooves are formed by the juxtaposition of the tightly adherent skin of the upper lip to the orbicularis oris muscle and fascia against the more loosely adherent skin and thicker subdermal fat of the cheek. These folds extend from the nasal ala to the modiolus, demarcating the aesthetic unit of the cheek from the perioral region. Aging leads to the descent of the malar fat pad due to weakening of the malar and orbital ligaments, causing these folds to become more pronounced. Various classification systems have been proposed to guide treatment options, ranging from dermal fillers for superficial grooves to soft tissue or alloplastic implants for more defined, deeper cheek–lip grooves.[7]

Lastly, the aging process manifests conspicuously along the mandible. The depletion of subcutaneous fat creates a prejowl sulcus, situated between the chin and the sagging lower cheek, and anterior to the masseter muscle. The weakening of the soft tissue attachments to the mandibular symphysis can result in ptosis of the pogonion soft tissues seen on the lateral view.[8]

Subnasal Lip Lift

An optimal procedure for rejuvenating the upper lip aims to reduce the aging elongated upper lip while restoring its natural curvature, accentuate the philtrum, optimize dental show, and revive the diamond shape characteristic of a youthful mouth. This transformation can be achieved in carefully chosen patients by executing a subnasal lip lift, either as a standalone treatment or in conjunction with other facial rejuvenation techniques. Pioneered by Cardosa and Sperli[9] in 1971, and later substantiated by Rozner and Isaacs[10] through a comprehensive series of cases a decade later, this procedure is technically straightforward. It entails the surgical excision of an elliptical section of skin and subcutaneous tissue directly beneath the base of the nostrils.[11]

An aesthetically pleasing philtral length usually falls at or below 15 mm. However, many patients with aging faces exhibit lengths between 18 and 22 mm, contributing to a lip that appears elongated and simian-like.[12] While commonly employed to address the aging upper lip, the procedure is also beneficial for younger individuals with congenitally elongated upper lips or inadequate dental display. Other candidates may present with a thin or poorly defined upper lip, asymmetry, or unsatisfactory responses to lip fillers. Men can also benefit from this procedure as shown in [Fig. 2]. It's crucial to exercise discernment in patient selection; those with more than 2 mm of visible central incisors and/or “gummy smile” should be cautioned, as the lift could lead to an unflattering “Bugs Bunny” appearance. Similarly, those with maxillary–mandibular imbalance or unappealing dentition could benefit from consulting with an oral surgeon or cosmetic dentist.[13] For patients with minimal lateral vermillion show, performing a sub nasal lip lift alone can exacerbate this deficiency. In these patients, combining a lateral upper lip advancement with the subnasal lip lift will give a more balanced vermillion show. Additionally, patients with a short nasal base and wide mouth (above average distance between the oral commissures) will have an undesirable result with a subnasal lip lift, and a full upper lip advancement with creation of the cupids bow should be considered.

Fig. 2 Male subnasal lip lift result, 1-year postoperative.

In a subnasal lip lift, meticulous attention to the excision outline is paramount, often following the classic “bullhorn” lip lift design ([Fig. 3]). The initial step involves marking the upper incision line across the entire nasal base, adhering to the natural contours of the alar–facial and alar–labial creases. This line tapers laterally where the alar–facial crease ends, near the alar groove. Care must be taken to avoid extending the incision beyond the well-defined boundaries of these creases, as this could lead to distortion, scarring, or even an undesirable pleat from the cheek to the nose. The incision then proceeds beneath the nose, cautiously avoiding the nasal sill; in cases with hypotrophic nasal sills, a generous amount of tissue should be intentionally preserved. The marking advances centrally to culminate in a peak, which may align either with the uppermost point of the philtral column or the divergence of the medial crural footplates around the nasal spine. Notably, these peaks may not always align with the philtral column. These two paramedian peaks are then connected by a slight inferior dip at the junction of the lip to the base of the columella, creating a wavy incision line that helps to camouflage the scar.[13] The distance to be excised is then marked between these peaks, completing the superior incision line and setting the stage for the inferior line. The amount of skin to be excised is then measured using millimeter calipers at the two paramedian lines. This typically ranges from 5 to 7 mm. The inferior incision is then drawn parallel to the upper incision with the edges tapered appropriately to avoid excessive bunching of tissue. Asymmetries should be noted preoperatively and accounted for in the markings.

Fig. 3 Incision design for subnasal lip lift.

1% lidocaine with 1:100,000 epinephrine is infiltrated, and the patient is prepared and draped in an appropriate fashion. The incisions are made and extended down into the subcutaneous tissue. The skin and subcutaneous tissue are then dissected free from the underlying orbicularis muscle and removed. In the author's experience, undermining is limited to the lateral segments. Undermining of the central segment can efface the contour of the philtral columns, philtral dimple, and Cupid's bow, flattening this anatomy and cause an increase in postoperative swelling. After careful hemostasis, a meticulous, tension-free, three layered closure is critical to avoiding an undesirable scar postoperatively. The incision is closed sequentially from central to lateral, beginning with the two paramedian points previously marked. Sutures used for the three layer closure are 5–0 clear monocryl, 6–0 polysorb, and 6–0 mild chromic in a running, interlocking skin closure. Antibiotic ointment is then applied to the incision.

Postoperatively, antibiotic ointment and hydrogen peroxide are used to maintain hygiene. Chromic sutures are removed at 5 to 7 days postoperatively. With a tension-free closure of the subnasal lip lift, hypertrophic scarring is rare but can be addressed postoperatively with 5-fluorouracil and/or triamcinolone injections. Other scarring concerns, while uncommon, typically benefit from laser and dermabrasion resurfacing. Upper lip stiffness and swelling are expected for a few months postoperatively.

The author's 40-year experience of using this technique has demonstrated consistent and reliable long-term results ([Fig. 4]). A quantitative retrospective analysis regarding the longevity of this technique was published by the author (S.W.P.) in 2022[14] demonstrating the percentage retention of the 5-mm lift and percentage improvement of lip measurements were maintained over time with a slow decline. [Fig. 5] shows a 3- and 22 year result in the same patient.

Fig. 4 Subnasal lip lift 3-year and 22-year postoperative result.

Fig. 5 Subnasal lip lift and lower lip advancement, 1-year postoperative.

Corner of Mouth Lifts

One of the many features that contribute to the aging appearance of the perioral region is the downward turn to the oral commissures. This downward turn, which often extends to a significant oral commissure groove and ''marionette'' appearance, gives a sad, tired, almost angry look in some patients. This senility can be extreme and causes lateral oral commissure drooling and angular cheilitis in some patients.

The downward turn to the corner of the mouth can be the single remaining aging factor that ''spoils'' an otherwise excellent rejuvenate surgical effort. In fact, in many cases, this is the area patients are most bothered by and wish that their facelift had corrected. In preoperative evaluation and consultation, one must show patients the improvements in the marionette groove by lifting the jowl tissues, but specifically point out that the corner of the mouth does not lift and that the downward turn and groove persist. Alternatively, one can also show that, if you pull the skin tissues taut enough to lift the corner of the mouth, the face then has an unnatural, pulled, operated appearance.

Therefore, physicians must offer consultative, prospective patients adjunctive procedures to correct the downward turn and help efface the deep oral commissure grooves.

Injectable fillers, specifically hyaluronic acids, are the best and most commonly used treatment for filling and effacing the oral commissure groove. With proper techniques, one can achieve an actual lift to the oral commissure, even though temporary. Using small amounts of neurotoxin—two to three units on each side—to prevent the depressor anguli oris muscle from pulling down the corner of the mouth can, in fact, add to the temporary improvement.[15]

However, some patients either have such severe and often asymmetrical downward turn to the corner of the mouth or dislike this aspect so much that they desire a more direct surgical definitive and lasting solution. The corner of the mouth lift then becomes a reasonable alternative preferred procedure. It has advantages and disadvantages and is usually not the primary procedure offered to a patient, because of the resulting scar that is a natural consequence of the operation. It is a definitively designed surgical procedure that directly lifts the corner of the mouth and partially corrects the oral commissure, marionette groove, and even some of the redundancy of the modiolus.

Indications for the corner of the mouth procedure are the existence of the downward turn to the oral commissure or corner of the mouth. This feature can result in a frowning look of the mouth that must be corrected. In severe cases involving drooling, the corner of the mouth lift can be a therapeutic option to treat not only the drooling but also angular cheilitis

The corner of the mouth lift is an immediate cosmetic correction of the problem. Essentially no residual downward turn to the corner of the mouth is present at the end of the operation. The improvement in the oral commissure chin–cheek groove (''marionette line'') is immediately apparent and improves the overall rejuvenative efforts of all other aging face procedures performed on the patient

Incisions for the corner of the mouth lift should be marked while the patient is in the sitting or semirecumbent position. A dot is placed at the oral commissure, precisely at the junction of the skin with the vermilion. A triangle of skin is marked just above each oral commissure by extending the line medially from the dot in a line directly diagonal to the superior aspect of the tragus, ending at approximately 7 mm, but definitively never past the natural cheek–lip groove or crease. The lateral aspect of this incision is limited by where that crease folds around the lateral oral commissure area. A second line is then drawn along the vermilion border an equal length to the diagonal that was already drawn superiorly along the upper lip vermilion border. Then, in a curvilinear fashion, the two diagonals are connected forming a convex top to a triangular amount of tissue to be excised ([Fig. 6]). The height of this curve from the oral commissure to the highest part of the arch of the curve is usually 7 mm and no more than 9 mm maximally. This shape can be adjusted asymmetrically depending on which side of the corner of the mouth is more severely depressed. This triangle of full thickness skin tissue is then excised down to the orbicularis oris muscle but not including muscle fibers. Appropriate hemostasis is obtained and no undermining is required. The wound is closed initially from the oral commissure to the mid portion of the superior arch with a 5–0 clear monocryl buried subcutaneous suture. Then, the remainder of the wound is carefully approximated and everted with 6-0 polysorb sutures, taking care not to leave a dog-ear and to compensate for uneven lengths of both sides of the skin and vermilion tissues. The skin edges are then closed with a running 7–0 blue Prolene suture in a simple fashion. Sutures remain in place 5 to 7 days.

Fig. 6 Corner of mouth lift surgical marking.

Within 8 days, the pink scar can be camouflaged with makeup and tends to fade over 2 to 3 months. Rarely, a light dermabrasion or small scar revision is indicated if one portion of the scar indents and is more noticeable than the natural rhytid of the area.

One disadvantage of the corner of the mouth lift to be weighed against its advantages is the visible scar that is permanent and extends approximately 1 cm lateral in the oral commissure ([Fig. 7]). The scar is usually minimally noticeable and can be easily camouflaged but is the reason this procedure is often not offered as a first-choice procedure. Initially, a slightly overcorrected appearance to the oral commissure can occur and, if overdone, can almost give an unnatural ''joker's'' smile appearance. The deep oral commissure chin–cheek groove is only partially corrected, but it is improved.

Fig. 7 Corner of mouth lift result, 1.5-year postoperative.

Vermillion Advancement

Vermillion advancement procedures can be performed to increase the vertical height of the red lip by advancing the vermillion border superiorly onto the white lip. The procedure involves resecting a portion of the white lip along the vermillion border and then repositioning the lip skin and mucosa as an advancement flap to a new vermillion border location. With utilization of the subnasal lip lift, full upper lip vermillion advancements are typically reserved for reconstructive cases; however, upper lateral lip advancements are commonly combined with subnasal lip lifts when there is a short nasal base and/or more lateral red upper lip show is desired. Lower lip advancements are commonly combined with sub nasal lip lifts when more lower lip vermillion height is needed to achieve a balanced look. The lower lip advancement is performed by excising a 3-mm crescent of skin along the lower lip vermillion border ([Fig. 8]). Dissection is down to the level of the orbicularis muscle. The dermis is then meticulously approximated with 6–0 polysorb and the skin is approximated with 7–0 prolene in a simple running fashion. Sutures are removed at 5 to 7 days. Patients should be followed closely postoperatively for vermillion border irregularities, as scars along the vermillion border can be very noticeable to casual observers. Many irregularities will improve with massage and time; however, utilization of 5-fluorouricil and/or triamcinolone injections can be considered. Rarely, local revisions can be performed for depressed scars and irregularities that are persistent.

Fig. 8 Lower lip advancement surgical marking.

Combining Procedures for Optimal Perioral Rejuvenation

Like many areas in facial rejuvenation, subunits of the perioral region do not age in isolation. Therefore, achieving optimal results in perioral rejuvenation often necessitate a multiprocedural approach. This decision is deeply rooted in a comprehensive understanding of the patient's unique anatomical features, aesthetic aspirations, and the specific aging changes they have undergone. For example, many patients present with a complex array of aging signs, such as elongated upper lips, downturned corners of the mouth, and diminished vermillion visibility. A single procedure like a subnasal lip lift will not suffice in such cases. Combining these procedures offers a more holistic solution, optimizing a balanced and natural result.

An example of this is demonstrated in [Fig. 9]. This patient presented with elongated upper lip, limited, asymmetrical upper vermillion show, and downturned corners of the mouth. A combination of a subnasal lip lift (taking into consideration her asymmetry) and corner of mouth lift restored her overall aesthetic balance in this region.

Fig. 9 Subnasal lip lift, corner of mouth lift result 1-year postoperative.

Additionally, while outside the focus of this manuscript, resurfacing procedures are also commonly performed with the above detailed procedures. The author's primary choice for perioral resurfacing is dermabrasion, which in the appropriate hands, yields the best possible results. Laser resurfacing and chemical peels can also be considered.

Conclusion

Perioral rejuvenation is an intricate and nuanced field that demands a comprehensive understanding of facial anatomy, aging processes, and surgical techniques. The perioral region, often overlooked, holds the power to significantly impact the overall success of facial rejuvenation efforts. Through 40 years of clinical experience, this manuscript has elucidated the key anatomical landmarks, aging changes, and surgical interventions—ranging from subnasal lip lifts and corner of mouth lifts to vermillion advancements—that can effectively address the challenges posed by perioral aging. By adopting a multiprocedural approach tailored to each patient's unique needs, clinicians can achieve harmonious and long-lasting results that not only enhance the perioral area but also contribute to a more youthful and balanced facial appearance. This comprehensive guide serves as a cornerstone for any practitioner aiming to master the art and science of perioral rejuvenation.

Conflict of Interest

None declared.

• References

• 1 Legan HL, Burstone CJ. Soft tissue cephalometric analysis for orthognathic surgery. J Oral Surg 1980; 38 (10) 744-751
• 2 Calhoun KH, Stambaugh KI. Facial analysis and preoperative evaluation. In: Bailey BJ, Johnson JT. et al., eds. Head and Neck Surgery—Otolaryngology. Philadelphia: Lippincott William and Wilkins; 2006: 2481-2497
• 3 Guerrissi JO, Sanchez LI. An approach to the senile upper lip. Plast Reconstr Surg 1993; 92 (06) 1187-1191
• 4 Cheng JT, Perkins SW, Hamilton MM. Perioral rejuvenation. Facial Plast Surg Clin North Am 2000; 8 (02) 223-233
• 5 Frodel JL, Sykes JM, Jones JL. Evaluation and treatment of vertical microgenia. Arch Facial Plast Surg 2004; 6 (02) 111-119
• 6 Maloney BP. Aesthetic surgery of the lip. In: Papel ID. ed. Facial Plastic and Reconstructive Surgery. 2nd ed.. New York: Thieme; 2002: 344-352
• 7 Karsan N, Ellis DAF. The lip-cheek groove: a new analysis with treatment options. Arch Facial Plast Surg 2006; 8 (05) 324-328
• 8 Perkins SW, Sandel IV HD. Anatomic considerations, analysis, and the aging process of the perioral region. Facial Plast Surg Clin North Am 2007; 15 (04) 403-407 , v
• 9 Cardosa AD, Sperli AE. Rhytidoplasty of the upper lip. In: Hueston JT. ed. Transactions of the Fifth International Congress of Plastic and Reconstructive Surgery. Australia: Butterworth; 1971
• 10 Rozner L, Isaacs GW. Lip lifting. Br J Plast Surg 1981; 34 (04) 481-484
• 11 Waldman SR. The subnasal lift. Facial Plast Surg Clin North Am 2007; 15 (04) 513-516 , viii
• 12 Jacono AA. The art and science of extended deep plane facelifting and complementary facial rejuvenation procedures. QMP; 2021
• 13 Talei B. The modified upper lip lift: advanced approach with deep-plane release and secure suspension: 823-patient series. Facial Plast Surg Clin North Am 2019; 27 (03) 385-398
• 14 Nagy C, Bamba R, Perkins SW. Rejuvenating the aging upper lip: the longevity of the subnasal lip lift procedure. Facial Plast Surg Aesthet Med 2022; 24 (02) 95-101
• 15 Perkins SW. The corner of the mouth lift and management of the oral commissure grooves. Facial Plast Surg Clin North Am 2007; 15 (04) 471-476 , vii

Publication History

Accepted Manuscript online:
23 October 2024

Article published online:
15 November 2024