Like the appearance of the back of one’s hands, the mouth area can be a telltale sign of one’s age. The best facelift ever done will do little for this expressive island of the central face. Focused treatment strategies must be applied to the lips and mouth. As their aging problems do not respond to other lifting and excisional tissue techniques that work well for the rest of the face.
What is it about the mouth are that makes it age? Most will think of an older mouth as one that looks ‘shrunken and wrinkled’, or at least is headed down that pathway. The lips thin, vertical wrinkle lines develop and the entire mouth seems smaller and less supported. While there are many factors that can contribute to this appearance, most pertinently the support and presence of the underlying teeth, the visual perception of volume loss certainly seems to be a major factor.
In the July 2009 issue of the journal Plastic and Reconstructive Surgery, a published study identified one of the major issues of facial aging, fat loss. As a continuum of their ongoing and longitudinal anatomical studies of facial fat and what happens to it as we age, they have studied the submuscular fat compartments of the mouth. (perioral facial region) Cross-sectional anatomic sections were analyzed of older cadavers, ages 59 to 72. The highlights of their work demonstrated that there is fat deep to the sphincteric orbicularis oris muscles of the lip[and large vertical-oriented mentalis muscle that envelopes the chin. This fat layer is distinct from that which exists just under the skin of the chin or the mucosa and vermilion of the lips. It is postulated that loss of this fat contributes to lip ‘collapse’ (inversion) and deepening of the labiomental sulcus with aging.
How does this information help with mouth and perioral rejuvenation methods? It strongly suggests that the traditional techniques of laser resurfacing for wrinkles and augmentation of the vermilion-cutaneous borders of the lips alone is not a comprehensive approach. Neither treats one of the fundamental causes but is directed to the symptoms of the aging problem. It also suggests and explains why some augmented lips by injectable fillers may look unnatural and not ideally rejuvenated.
While increasing the visible lip roll (vermilion-cutaneous border) is the most common area where injectable fillers are placed, it misses one of the important areas of what creates a youthful lip. The wet-dry border, or rolling out or exposing of the wet-dry mucosa, is one of the signs of a fuller and more youthful lip. As the authors of this paper have pointed out, adequate volume of the submuscular fat can help recreate a more natural curvature and projection of the lips.
These deeper fat compartments of the lip and chin are not areas that are injected today by most practitioners. Besides an underappreciation of its significance is that their treatment requires a good local anesthetic block and a fair amount of injection filler volume to do so. That is a rate-limited step for some patients, particularly when the effect may only be temporary.
But in the operating room and as part of a more complete facial rejuvenation surgery, fat injections to the submuscular perioral compartments make more sense and is easy to do. While injectable fat is not always predictable, placement into deeper submuscular areas may be associated with better survival rates.
Dr. Barry Eppley