Introduction

The lips are a defining feature of youth and beauty. While they may represent a small portion of the face based on size, they can have a dramatic effect on a person’s overall appearance. Unfortunately, as we age, lips undergo some of the most dramatic changes of the entire face. Although these changes are a natural part of the aging process, they can be softened or reversed to give a more youthful and rejuvenated appearance.

The aging process on the lips

While this chapter will focus specifically on the rejuvenation of the lips, it is important to consider the lips in the larger context of the perioral region, demarcated by the nasal base, cheeks, and chin. There are a multitude of causes and effects of the aging process in the lower face. In addition to the intrinsic aging process, ultraviolet radiation can cause photoaging of the skin, resulting in mottled dyspigmentation and irregular texture. Additionally, as collagen fibers diminish and elastic tissue is degraded, perioral rhytides become more prominent. Furthermore, there is an overall loss of subcutaneous fat volume and bone. These changes result in an overall drooping of the perioral region, which may call attention to the lips. Therefore, in order to truly rejuvenate the patient’s lips, it may be necessary to rejuvenate the entire perioral region, including the nasolabial folds, melomental creases, and chin. These topics are covered elsewhere in this book, but should be considered in any cosmetic consultation.

The lips specifically are dramatically redefined by an overall loss of lip volume and structure throughout the aging process: the upper lip becomes thin and elongated, while the lower lip becomes thin and rolls inward. This results in a loss of the appearance of the pink vermilion of the lip, and a sagging of the corners of the mouth (which is further accentuated by the activity of the depressor anguli oris muscle). The result is a loss of show of the upper teeth, with an increase in the show of the lower teeth. The overall loss of lip volume leads to a loss of structure of the lip. The Cupid’s bow – the area defined by the two high arched points of the upper lip – becomes effaced and flattened; there is also a loss of definition of the two philtral columns of the upper lip. Over time, the beautiful, defined, arched structure of the upper lip is lost and in its place a thin, poorly defined upper lip develops. In conjunction with the overall loss of lip volume, there is also the chronic effect of activity of the orbicularis oris muscle, which leads to the formation of radiating deep perioral rhytides. Patients often complain that these rhytides cause ‘bleeding lipstick’ lines and are a frequent issue of discussion in cosmetic consultations.

Multiple assessment scales have been developed to quantify these changes. A numeric CKC scale (Table 20.1) was developed to aid in the initial assessment of patients, as well as their response to rejuvenation. Additionally, multiple lip-specific photographic scales have been developed in clinical studies. A recently presented abstract by Werschler et al developed, validated, and utilized a Lip Fullness Scale. Another recently presented abstract by Cohen et al validated the Perioral Lines at Rest (POL), Perioral Lines at Maximum Contraction (POLM), and Oral Commissure Severity (OCS) scales. Previous studies by Carruthers et al and Rossi et al have determined and validated photonumeric grading systems for assessing lip fullness, volume, and thickness (Figs 20.1 and 20.2). These scales may be of benefit in the initial assessment of patients and their clinical improvement following lip augmentation.

Figure 20.1 Photonumeric grading scale for assessing lip volume and thickness.

(Reprinted with permission from Rossi AB et al 2011 Development and validation of a photonumeric grading scale for assessing lip volume and thickness. J Eur Acad Dermatol Venereol 25(5):523-531.)

Figure 20.2 Validated lip fullness grading scale.

Reprinted with permission from Carruthers A, Carruthers J, Hardas B, et al 2008 A validated lip fullness grading scale. Dermatologic Surgery 34(suppl 2):S161-S166.

When done well, lip augmentation and rejuvenation can dramatically address many of these changes associated with aging lips to both replace the volume loss and redefine the lip structure. In a 2009 study by Werschler et al, after treatment with a hyaluronic acid (HA) filler (Juvéderm^® Ultra^®, Allergan Inc., Irvine, CA), multiple features of the lips were improved, including: (1) proportional lip size relative to the face, (2) proportional upper and lower central lip fullness, (3) sharp, well-defined vermilion borders, (4) distinct Cupid’s bow peaks and a well-defined philtrum, and (5) oral commissure fullness to support the lateral aspect of the lip. In the study, the investigators rated these five attributes as ‘adequate’ in only 32–48% of subjects prior to augmentation; after the augmentation was performed, the attributes were scored as ‘adequate’ in 80–90% of subjects.

However, in some cases, simply injecting soft tissue fillers into the lips alone may not achieve the best results. Judicious use of low-dose botulinum toxins around the lips may improve perioral rhytides, while botulinum toxin injections into the depressor anguli oris muscles may reduce the downturning of the oral commissures, and enhance the longevity of the fillers. However, while reported in the literature, these are off-label uses of botulinum toxin not approved by regulatory authorities such as the US Food and Drug Administration (FDA), Health Canada, or European regulatory authorities. In severe cases, resurfacing of the perioral skin with lasers or chemical peels may be necessary. Although this chapter will focus on the use of soft tissue fillers, in many cases a multimodality approach may be beneficial for patients to achieve optimal rejuvenation.

An approach to achieving youthful lips

The first issue to address with lip augmentation is to determine the treatment goals of the patient. Does the patient seek enhancement or restoration of the lips? Younger patients typically seek enhancement, whereas older patients typically seek restoration.