The perioral area is one of the most complained about portions of the face that patients seek out preventative and corrective treatments. We know our lips thin as we get older, but signs of aging go well beyond our mouths. When we talk about the perioral area, we are referring to the supportive structures and tissues from the base of nose, the nasolabial folds, the outside of corner of lips, the marionette lines and all the way down to right above the mental crease.
Rejuvenation of this area can be a challenge due to complex aging process .Loss of bony support, decrease of deep supportive fat and descent, enlarging of superficial fat, and repeated use of muscle all contribute to result in clinical and visible changes to our surface anatomy. Some of the most common include:
- lengthening of the upper lip
-Upper lip loses its volume, lengthens and inverts.
-lower lip becomes thinner and rolls inward.
-loss of definition of the lip margin (vermillion borders)
-flattening and fading of the philtrum columns
-loss of projection of the cupid’s bow and peak
-creation of the marionette line and jowls
-lip lines/smokers lines
-Downturn of oral commissures (lip corners)
-Decreased display of upper anterior teeth.and greater exposures of lower anterior teeth
Many of these concerns can be addressed non-surgically, but do require an understanding of what is happening at each layer and what treatment or combination of treatments is best to achieve the most optimal outcomes.
Perioral Aging of The Bone
The combination of the loss of the maxillary (cheek and upper lip) and mandibular (chin , jaw , lower lip) bony support play a major role in the aging of the lip. Both areas resorb, with the initial changes seen in the maxilla/pyriform space, then causing tissue to collapse. The decrease in the maxillary angle and height leading to posterior positioning of the lip and deepening of the nasolabial folds can also lead to increased jowling.
The Fix: Using HA based dermal fillers, Radiesse or Sculptra to recreate and mimic the volume lost to bone resorption.
Perioral Aging of The Deep Fat Pads
The deep lateral chin compartment is a key augmentation target for volumization of the pre-jowl sulcus. As this fat pad starts to flatten, and lose support, the layer of muscles above start to pull in ways they couldn’t before causing indentations in the skin.
Within the upper lip, a fatty compartment exists deep to the orbicularis oris muscle. This retro-orbicularis oris fat (ROOrF) compartment also flattens with age and the deep pyriform space at the sides of the nose start to recess back, giving less support to the muscles of the upper lip
The Fix: Similar to restoring volume lost by bone resorption, we use dermal fillers to re-create structure and re-introduce support for the muscle and layers above.
Perioral Aging of the Muscles
The mandibular ligament is a wall that attaches from bone to skin that creates a division for lateral to medial tissues. As we age, this ligament loosens and as our fat pads from the lateral face shift down and inwards, the appearance of the jowls begin to form.
There are 12 facial muscles that affect the shape and function of the perioral area. With the loss of structure below, these muscles become hyper dynamic and facial expressions with age appear more exaggerated. The thinning skin gets pinched and tinged causing expedited premature aging to this area in comparison to other areas in the face. Ironically because of this, the lower lip tends to age better than the upper.
The Fix: The use of Botox is the most popular solution to address the many muscles that surround the mouth area. We also use dermal dermal fillers, which can cause myomodulation - volume of filler impacts muscular movement and can relax muscular movement.
Perioral Aging Of The Superficial Fat Pads
Along with housing a variety of muscles, the upper lip contains a series of superficial fat compartment. These subcutaneous compartments are quite thin and are in compartments that are directly attached to skin - becoming even thinner with age. Adjacent to these subcutaneous pads is a larger and more commonly known fat pad just outside the mandibular ligament- the jowl fat pad.
The lower lip contains a trio of superficial fat compartments: the central lower lip fat compartment, lateral lip compartment, and the inferior chin compartment.
In the perioral region especially, the skin is directly connected to the muscles of facial expression with the smallest amount of padding. When these already tiny fat pads shrink back, the wrinkled appearance of the skin becomes more apparent.
The Fix: Thin, diluted fillers placed superficially under the skin, along with Sculptra and Radiesse can help to soften the appearance of vertical lines and thinning of the skin. Morpheus8 and Evoke can also be used to tighten the skin and decrease the size of the jowl and fat pads above. Finally, if more advanced options are needed, Silhouette Instalift threads can be inserted to pull back and lift the jowl .
Perioral Aging Of The Skin
Epidermal thinning with flattening of the dermal-epidermal junction is caused by a loss of collagen and elastin leading to reduced elasticity of skin, a reduction in glycosaminoglycans leading to water loss and dry skin and a reduction in soft tissue volume, elasticity and repeated perioral muscle activity.
The Fix: To stimulate collagen and elastin and help thicken and hydrate the skin, a series of Beauty Booster treatments is one of our favourite treatments. Microneedling with PRP can also be done to boost collagen and make skin more resilient to muscular compression. For more advanced signs of aging, laser resurfacing using devices like Halo or TRL are ideal options to target etched in, static lines. Finally, dermal fillers can again be used to restore structure to lip borders, to columns to shorten lip distance and add volume to lip tissues that have lost their youthful projection.
Not All Is Fair In Love and Facial Aging
While perioral aging is a common concern for all of our patients, we do know that women experience visible signs of aging in this area of the face moreso than their male counterparts, In addition to what is happening at each of these 5 layers, there are a few more intrinsic factors that impact perioral aging for women. These include:
Men have more sebaceous glands and hair follicles Women do not have as many sebaceous and sweat glands that men have around their mouths, which help keep the skin supple and protects the skin from the drying effects of sun, wind and air pollutants. This is the case for men with or without facial hair because shaving is a form of dermaplaning that also helps to thicken the dermis.
Women have fewer blood vessels The skin closely surrounding a woman’s mouth and comprising her lips contain less blood vessels than male mouths. Less blood flow to an area of skin means that skin may not receive sufficient nutrients and oxygen levels that are beneficial to preventing the appearance of wrinkles. Making women more susceptible to lip lines from repetitive movements like pursing lips.
Hormones, Hormones, Hormones Another major gender difference that plays a significant role in the development of wrinkles around the mouth concerns hormones, specifically estrogen and progesterone. When a woman experiences menopause, the level of these hormones drops dramatically. Since estrogen contributes to skin health and stimulates blood flow, older women tend to have deeper wrinkles than men. Moreover, sebaceous glands do not release as much as sebum following menopause, which causes the skin to feel dry and less supple. In promising news, clinical studies involving women participating in hormone replacement therapy have further found that women on HRT experience less wrinkling around the mouth and other areas of the face.
How To Treat An Aging Lip and Mouth Area
While it remains one of the most popular areas of concern, the perioral area can be very complex to treat due to the numerous factors that impact aging. In order to determine the best course or combination of treatments, we always recommend coming in for a consultation to discuss your goals and desired aesthetic outcomes. In addition to everything we do in clinic, using the right skincare, avoiding smoking and applying sunscreen daily can always help to lessen decelerated extrinsic aging.