How to Treat the Perioral Area

The aging process of the perioral area

Chronological aging strikes us all indiscriminately, and it occurs at all tissue levels in the face, from skin down to bone; no tissue is spared. One of the main contributors to the appearance of old age is developments in perioral region. This region includes the lips. The lips start as short, full, and curvaceous, but as senescence approaches, the corners of the mouth start to undergo ptosis. Repeated contractions of the orbicularis oris muscle establishes the upper and lower vertical rhytids on the lips.
These are especially noticeable in females because they have thinner skin and far less hair follicles and subcutaneous fat in this area than men. The vermilion border starts to lose its sharp demarcations as a result of both fat and muscle atrophy. It continues on with prominent buccolabial folds that start to develop lateral to the oral commissures. Over time, the actions of the depressor anguli oris muscle forms a saddened expression and marionette lines typically exhibited by the elderly.
There is also a gradual lengthening of the distance between the columella and the Cupid’s bow. A further drooping is seen when the muscles for the lip elevators, the depressors and modiolus, which together form a sling-like anatomy to support the lips, are weakened due to the loss of muscle tone and atrophy. The mentalis muscle is also subject to atrophy and ptosis that reduces support for the lower lip and chin. Skeletal maxillary and mandibular bone resorption and loss of dental integrity further enhances perioral aging. All these are further compounded by the negative cumulative effects from exposure to UV radiation and gravitational pull that work together to further produce an appearance of the loss of lip tissue and accentuated folds.

Main concerns of patients

The preoccupations are typically marionette lines, ptosis of the surrounding soft tissue, and visible changes in skin, including folds and wrinkles, and these developments occur much more frequently in an older age group. These physical features project a sense of old age and a significant divergence from beauty standards and their ideal ratios. Younger patients, on the other hand, usually only want a slight touch-up treatment on their lips (i.e. volume treatments). Because of this, treatment desires of younger patients are usually less demanding than older patients.
It is important to note this, as the treatment, expense, and recovery will be significantly different for the patient who want treatment for volume, outline, lipstick lines, and oral commissures versus the patient that just wants a slight volume augmentation of the lips

Main patient groups of treatment for the perioral area

In 2017, there were a total of 1,790,832 cosmetic surgical procedures done in the U.S alone. From this figure, 30, 862 individuals (28, 616 of whom were female) underwent cosmetic correction for lip augmentation.

The age group can are broken down as follows:

• 13-19 years old: 288 individuals for lip augmentation.
• 20-29 years old: 1425 individuals for lip augmentation.
• 30-39 years old: 3,865 individuals for lip augmentation.
• 40-54 years old: 10,814 individuals for lip augmentation.
• 55 years old and above: 13,405 individuals for lip augmentation.

As can be seen, patients aged 55 years old and above are the largest group of individuals that seek treatment for the perioral area, with a decreasing trend towards the younger age groups. For the U.S., most of these patients are usually from the East South Central (AL, KY, MS, TN) and West South Central (AR, LA, OK, TX) area⁴.

Key factors to consider when treating and assessing the perioral area

The patient who seeks out cosmetic correction for the perioral area will usually be middle age or older, as displayed above; therefore, the chances of underlying medical problems are higher. Be vigilant of this, and tackle issues that may affect the surgery negatively (e.g. hypertension, smoking, coagulopathy, hormone replacement therapy).
Hypertension increases the risk of postoperative hematomas; smoking causes delayed wound healing; and common dietary supplements, such as fish oil, ginseng, and vitamin E and medications such as non-steroidal anti-inflammatory medications (NSAIDs) promote excessive bleeding. Postoperative deep vein thrombosis (DVT) and the much-dreaded pulmonary embolism can also be a possibility since women in this age group are much more likely to be on hormone replacement therapy.
Discuss the patient’s expectations since factors such as the facial skeleton, weight of facial soft tissue, depth and location of folds, and quality of skin can modify the expected results from surgery.

Understand the anatomical relations of the perioral area because what patients see is usually their primary concern, and the area of correction may not be as straightforward. Use old photographs to compare so that you can determine the aging changes and locations they want corrected.
Patient involvement will help them understand the extent of surgery. The entire face should be properly assessed to look for the equality of the facial thirds, degree of symmetry, and overall shape. Particular areas of focus are the forehead, eyelids, cheeks, the perioral area, and the neck.
Patients with complaints about the perioral area may benefit more from this since achieving a harmonious result most often involves treatment in many of these areas.
The surgeon must act and think like a sculptor and view the face at all angles. The plumpness of the lips, dental show, and elongation of the upper lip must be assessed alongside the severity of the wrinkles and folds. Pre-procedure photographs are extremely important and should show frontal, oblique, and profile views. Changes can be subtle in some patients, so a reliable record serves as impeccable proof of effectiveness.

Loss of volume in the lips

The Cupid’s bow usually becomes wider with volume loss; in this case, it should be made narrower by augmenting the vermilion border of the lips to enhance its definition and provide better projection. When injecting the lip borders to improve outline, needle placement is critical.
A potential space exists between the mucosa and orbicularis oris muscle, and this space should the target for border outline. Place the injection deep to the mucosa because if it is too superficial the Tyndall effect will be pronounced. The philtrum columns are also augmented at the mid-dermal level.
Massage the tissue as the filler is injected. The labial artery lies in the posterior third of the lip at about the incisor level. Take great care in avoiding the labial arteries. It is important to inject patients in an upright position because gravity will distort a supine patient's normal anatomy. 

The upper lip is almost always more atrophied than the lower lip, so restoration efforts should be more concentrated on improving volume.  In youth, the upper lip constitutes about one-third of the total lip volume, while the lower lip constitutes about two-thirds of the volume. Try to achieve the so-called “golden ratio” of 1: 1.61 for the upper and lower lip, respectively. When volumizing, the needle is inserted at the wet/dry line deep into the central lip. The center of the lip is generally a safe plane to avoid the lips arteries.

For an effective volume replacement procedure, the deposition technique is important. The two most popular are linear threading and serial puncture. Linear threading involves inserting the needle and injecting the filler in a straight line while continuously moving in a backward direction. This process would be analogous to placing a line of toothpaste on one's toothbrush, laying down a seam of calking, or decorating a cake. The serial puncture technique involves placing small boluses of filler in multiple punctures along the lip or wrinkle. In reality, many instances call for a combination of both techniques. 

Lines and wrinkles, or “lipstick lines”/“smoker’s lines,”  around the mouth

These lines are perpendicular to the orbicularis oris muscle and are largely a result of this muscle's function over the years. Lip rhytids can be vertical, angular, and radial. Patients must understand that the wrinkle can be improved at rest, but will be visible during animation.
To truly improve these lines, they are injected in conjunction with lip volumization or vermilion outline. By volumizing the lips with deeply-placed filling and outline, the skin will stretch and improve the appearance of perioral lines. After the lip is plumped and the white roll reestablished, the lipstick lines are then injected. Less viscous fillers with lower G primes, such as Restylane Silk, Volbella, and Belotero, perform better in this area, as their target is the superficial dermis.
Patients with severe lines will have a better outcome with treatment that uses a combination of procedures; for example, such a treatment could involve the use of Botox, filler, and laser resurfacing. Patients must understand that these lines will be reduced significantly, not eliminated completely.

Nasolabial folds

Due to the numerous muscles merging at the modiolus, this is a complex anatomic area.

Combining neuromodulator (neurotoxin) treatment of the depressor anguli oris muscle with injectable fillers in the area can yield a better result than treatment with a single agent alone. A small amount of filler can be injected directly into the fold in the commissure but this is a region where the filler can move laterally, so only a small amount is injected. The goal is to fill this crevice and upturn the corner of the mouth without creating a puffy appearance. After a small amount of filler is placed directly in the commissure, the distal corner of both lips are filled at the commissure. It is important to have a distinct angle at the commissure because this also helps elevate the mouth corners.

The marionette area

The marionette area (melomental fold) is treated by establishing a base or pillar to support the sagging commissure. Exercise greater caution here because the fillers have a tendency to migrate laterally in this area, so the injector must carefully control the deposition of material.
To create the base, a broad band of filler is placed in the deeper subcutaneous tissues under the fold. A second layer is placed in the mid-subcutaneous layer, and a final layer is placed in the dermal layer. 

Improving skin texture and overall appearance at the clinic

Facial resurfacing is the controlled removal of the upper layers of skin to treat pigment disorders, smooth irregularities, and promote tightening. This can be performed either with dermabrasion, chemical peels, or laser resurfacing. These procedures can be done at the clinic because they are relatively fast and safe to perform.

Chemical peeling involves the chemically aided removal of the outer layers of damaged skin to promote collagen formation and the improvement of pigment disorders. The degree of tissue removal varies with the type of agent used and may extend down to the papillary or reticular dermis. In the clinic, however, superficial peels are preferred due to their low risk for complications. Typical agents used for superficial peels are trichloroacetic acid, salicylic acid, and glycolic acids.

Ablative laser resurfacing also removes outer skin layers, albeit in a more precisely controlled manner, to promote tightening and improvement of discoloration or pigmentation abnormalities. The proponents of ablative laser resurfacing feel that there is greater secondary collagen tightening and more precision versus chemical peels, but they both work to give the skin a smoother and fresher look. Fractional ablative lasers operate via the creation of numerous microscopic columns of thermal damage involving the epidermis and dermis.  Evidence in support of the efficacy of ablative fractional lasers for the treatment of photoaged skin is increasing.

Improving overall appearance using home care

Broad-spectrum sunscreen covering both UV-A and UV-B is essential to prevent premature aging of the skin. Ultraviolet (UV) irradiation tends to be the strongest at peak hours (10 AM to 4 PM) and during summer months and at high altitudes. Water, snow, and concrete can reflect up to 90% of the UV rays, whereas shade can decrease the amount of UV by up to 50–90%^{12, 13}. Using a broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or greater or applying a lower SPF sunscreen twice may ensure proper protection.

Hydroquinone is a topical agent that is often regarded as the gold standard for treating conditions that create an uneven skin tone, such as freckles, postinflammatory hyperpigmentation, and melasma. It acts by inhibiting the conversion of dihydroxyphenylalanine to melanin by inhibiting the activity of the enzyme tyrosinase, thus reducing the formation and melanization of melanosomes.

Azelaic acid is a similar topical agent to hydroquinone in that it also inhibits tyrosinase and has selective cytotoxic and antiproliferative effects on abnormal melanocytes via the inhibition of mitochondrial enzymes and DNA synthesis.

Retinoic acid is applied for a smoother and less oily skin. It can also help treat photoaging and reduce pigmentation by increasing collagen production, inducing epidermal hyperplasia, and decreasing keratinocyte and melanocyte atypia. Skin irritation, redness, and peeling are potential adverse effects of topical tretinoin, so they are best applied together with moisturizers¹².

What are some of the risks practitioners need to be aware of in the perioral area, and how can you reduce these risks?

Hematomas typically develop within 12 hours of the procedure and are usually due to aspirin or other NSAID intake and hypertension in the postoperative period. Stop nonessential medications that impairs coagulation and platelet function for at least three weeks. Vascular compromise is a major adverse event since the site of interest is almost always close to both the superior and the inferior labial arteries. Numerous articles state that vascular compromise from fillers occurs via one of two mechanisms.
The most common and undisputed cause of vascular compromise is direct injection of filler material into the vasculature, which can cause antegrade flow with total obstruction that leads to blindness and/or soft tissue devitalization. Vascular compression is often attributed as a cause of vascular compromise via injection of the filler itself and exacerbated by secondary inflammation and edema, which increases the amount of pressure on the vessel and leads to decreased skin perfusion.
Always check for intravascular reach by aspirating first before injecting. To avoid overtreatment, undertreatment, and asymmetry (i.e. contour irregularities or material visible through skin), novice injectors should start with younger patients with small deficiencies and work their way up to more difficult challenges.

Final piece of advice

The availability of numerous cosmetic fillers has given the medical professional an invaluable asset in the area of minimally invasive facial rejuvenation. The proper assessment, technique, and choice of filler will be the key to creating a natural appearance that is in line with the expectations of patients. 
The effects of these fillers generally last from six months to one year and are effective in treating facial rhytidosis and atrophy. Facial areas with greater animation—the lips, for example—tend to break down these products more quickly versus the more static areas of the face, like the periorbital area. However, repeat injections with hyaluronic acid have been shown to increase the duration of its effects. In addition to understanding the vascular anatomy of the face, the medical professional must also be astute since compromising blood flow will result in disastrous complications.
The future of cosmetic surgery lies in minimally invasive procedures, and dermal fillers are capable of fulfilling this niche.

Permanent makeup for enhancing the lip

The main purpose of permanent makeup for the lips is to help delineate the lip line. It starts by adding pigments onto the skin that aims to increase the perception of lip volume. This will ultimately help in delaying the appearance of old age in the lip. Usually, a lip blush is used to help merge both the lip line and the lips together, which will add definition and a color-wash effect. If only done on the lip line, the outcome may not be as satisfactory, as it would appear more unnatural. Dermal fillers can augment the effects of permanent makeup by introducing more lip volume. It is recommended that the dermal filling procedure be performed six weeks before to reduce the risk of complications.