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The aging perioral region -- Do we really know what is happening?
Abstract
The perioral region is subject to a myriad of different treatments for rejuvenation, many of which are applied without a clear understanding of the underlying physiological processes of perioral aging. The results of these procedures are therefore sometimes not optimal and do not achieve a natural youthful appearance. The aim of this study was to put the results of three investigations into the perioral aging process into relation to clinical application in aesthetic medicine.
Three different investigations were performed to evaluate the complex 3-dimensional changes during the perioral aging process. Perioral proportions of 182 standardized subject photographs were measured in a photomorphometric study and correlated to age. In cranial MRI scans of 30 women aged 20-35 and 30 women aged 65-80 relevant anatomical dimensions were measured. Histological cross cuts of the upper lip complex of 20 individuals in two age groups, young (< 40 years, n = 10) and old (> 80 years, n = 10), were analysed. The results were then set into relation to today's lip rejuvenation procedures.
All studies showed a statistically significant lengthening of the aging upper lip. The photomorphometric study further showed an increase of prolabium skin at the cost of a decreasing visible upper lip vermilion. The MRI scans showed a decrease in thickness and redistribution towards a length increase but no total volume loss. Histomorphometric analysis revealed statistically significant thinning of the cutis, thickening of the subcutis and a degeneration of elastic and collagen fibers. The orbicularis oris muscle becomes thinner and shows a decrease of the forward curve defining the vermilion border. The results show that the main processes of lip aging are redistribution from thickness to length without total volume loss and a decrease of structural components of the lip, which leads to the decrease of pouting, an inversion of the vermilion and a ptosis of the lip.
A new and better understanding of the underlying physiological changes of perioral aging is essential and will lead to a better and more specific implementation of perioral rejuvenation procedures which will lead to more natural results.
... Obvious age-related changes include facial wrinkles, lack of firmness, and yellowish skin colour. Visible age-related changes in the mouth and teeth include elongation of the upper lip (Desai et al., 2009;Iblher et al., 2012), reduction in lip volume thickness (Iblher et al., 2012), darkening of tooth colour, discoloration of fractures and cracks along the enamel surface, wear and chipping of the enamel, and dentin exposure (Algarni et al., 2018;Lamster et al., 2016). ...
... Obvious age-related changes include facial wrinkles, lack of firmness, and yellowish skin colour. Visible age-related changes in the mouth and teeth include elongation of the upper lip (Desai et al., 2009;Iblher et al., 2012), reduction in lip volume thickness (Iblher et al., 2012), darkening of tooth colour, discoloration of fractures and cracks along the enamel surface, wear and chipping of the enamel, and dentin exposure (Algarni et al., 2018;Lamster et al., 2016). ...
... Regardless of oral health status, the perception of one's oral health and/or aesthetic appearance may influence the perception of OA (Larsson et al., 2021). Several studies have reported on the ageing of orofacial features in older adults' (He et al., 2021;Iblher et al., 2012;Mendelson & Wong, 2012;Swift et al., 2021) or addressed body image in older adults (Bhatia & Singh, 2021;Clarke & Griffin, 2008;Hurd, 2000;Krekula, 2016), especially that of women. However, the perspectives of older adults themselves on their ageing orofacial features are, to our knowledge, underrepresented in the research. ...
Objective
This study aimed to explore how people aged 65 years and older experience their orofacial appearance (OA).
Method
Semi-structured interviews were conducted with 20 strategically recruited participants aged 65–79 years from the Swedish National Study on Aging and Care—Blekinge (SNAC-B) in Karlskrona. A semi-structured interview guide was developed, and the interviews were analysed using thematic analysis to identify patterns in the data.
Results
The older adults’ experience of their OA was represented in four themes: (i) you kind of have to like the situation as it is now—to accept orofacial appearance in its current state; (ii) an ageing orofacial appearance—a slow continuous downhill slope; (iii) looking good for others to fit the social norm; and (iv) keeping up orofacial appearance—seemingly without effort.
Conclusion
The older adults in this study had a dual perception in relation to their own OA. Although society often values a younger looking appearance, striving for a youthful appearance is seen negatively, which may potentially reflect the complexities of the perceptions of one’s own ageing OA. Only those with dental issues found the impact of teeth on OA perception to be particularly significant.
... Facial aesthetics and attractiveness are influenced by various factors, including anatomical characteristics [1,2], psychological aspects [3], cultural background, and age [4,5]. The perioral region, which is crucial for facial aesthetics, is directly related to the smile and is affected by natural aging [6][7][8][9]. In today's society, there is a notable emphasis on the role of lips in social media, which significantly impacts the beauty industry [10]. ...
... Studies have shown that lip morphology and aesthetics vary based on age, region, and race [7,8,[11][12][13]. Changes in lip features such as lip lines, thickness, tonicity, and length can result in the upper lip losing volume and becoming thinner over time [11][12][13]. ...
... Current rejuvenation approaches [8,9] rely on volume augmentation to address volume loss in the aging upper lip or correct structural deficits [7]. Nonsurgical options are preferred due to their lower cost, reduced downtime, and avoidance of surgery. ...
The aim of this study was to evaluate changes in lip metrics before and after facial rejuvenation treatment with hyaluronic acid-based fillers and to compare them with those of a control group using stereophotogrammetry (3D).
This study included 63 Caucasian women divided into Group C (<30 years, n=30) and Group H (>30 years, n=33), which was further divided into before (HT0) and after (HT1) lip augmentation with hyaluronic acid (HA). Eleven anthropometric landmarks were identified for linear, angular, and surface area measurements. Three photos were captured in Group C, while Group H had photos taken at T0 and T1. Statistical analysis was conducted using the Shapiro–Wilk test to evaluate normality, the Kruskal–Wallis test and one-way ANOVA. Tukey’s post hoc and pairwise comparison tests were performed to analyze differences between variables (P value < 0.05).
There were significant differences between lip width (ChR–ChL) and philtrum width (CphR–CphL) (P<.001). The total heights of the upper (Ls–Li) and lower vermilion lips (Sto–Li) increased, and the heights of the upper (Sn–Ls) and lower (Li–Sl) cutaneous lips decreased. The angles related to the philtrum (ChR–CphR–Ls, P<.001; ChL–CphL–Ls, P<.001) and nasolabial angle (Prn–Sn–Ls) (P<.001) exhibited significant differences. The surface areas of the upper, lower, and total vermilion lip showed significant differences (P<.001). Tukey’s test indicated no significant differences in surface area after lip augmentation between the HT1 and C groups.
Analysis of lip morphology after a filler procedure revealed a reversal of age-related changes, with increases in vermilion lip height and surface area comparable to those of younger individuals.
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
... 47 Key underlying changes occurring with age include a fragmentation of structural components, an increase in subcutaneous adipose tissue, involution and reduced forward curvature of the orbicularis oris muscle, and thinning of the epidermis and dermis. 46 These processes manifest outwardly as an increase in prolabial length, reduced pout, inversion of the vermilion, and general ptosis of the lips. 46 In addition, the oral commissures typically turn downwards and "Cupid's bow" disappears. ...
... 46 These processes manifest outwardly as an increase in prolabial length, reduced pout, inversion of the vermilion, and general ptosis of the lips. 46 In addition, the oral commissures typically turn downwards and "Cupid's bow" disappears. 46,48,49 ...
... 46 In addition, the oral commissures typically turn downwards and "Cupid's bow" disappears. 46,48,49 ...
Background
Expansion of the aesthetic treatment armamentarium with novel injectable products has greatly improved our ability to reshape and enhance the facial profile. However, full‐face “profiloplasty” with injectables remain a nascent concept and is insufficiently considered in daily practice. While techniques have been widely published for treating the individual facial areas that constitute an attractive profile—including the forehead, nose, lips, jawline, and chin—the literature remains fragmented on more universal methods for profile improvement.
Aims
To collate disparate knowledge on profile optimization with injectables, and define a holistic, practical, and user‐friendly approach to profiloplasty and facial contouring.
Methods
Consideration is given to key anatomical aspects and the changes that occur with age; patient assessment parameters for planning profiloplasty; and the technical specifications, product selection, and essential safety considerations for minimizing the risk of complications and optimizing the effectiveness of treatment.
Results
Relevant case studies are presented.
Conclusions
Holistic approaches of this type are essential if we are to maximize the potential of full‐face treatment with injectables—both now and in the future.
... Like the rest of the face, lips are subjected to age-related changes. The most prominent of these changes include increased lip length along with decreased lip volume and nasolabial tissue thickness (1)(2)(3). Furthermore, several histopathological changes are apparent in the perioral region in aged patients, such as reduced cutis thickness, alongside collagen and elastic fiber fragmentation (2,4). In addition, the upper lip area of the Orbicularis Oris muscle shows signs of atrophy (4), contributing to the appearance of flattened and less defined philtrum columns (3) as well as perioral wrinkles. ...
... The most prominent of these changes include increased lip length along with decreased lip volume and nasolabial tissue thickness (1)(2)(3). Furthermore, several histopathological changes are apparent in the perioral region in aged patients, such as reduced cutis thickness, alongside collagen and elastic fiber fragmentation (2,4). In addition, the upper lip area of the Orbicularis Oris muscle shows signs of atrophy (4), contributing to the appearance of flattened and less defined philtrum columns (3) as well as perioral wrinkles. ...
... Patients and physicians consistently rate improvement similarly. Patients and physicians rated several parameters of lip appearance an average of one month after the final treatment using a Likert scale(1)(2)(3)(4)(5). Results represent as mean ± SEM, n = 32. ...
Lips undergo several changes with age, decreased volume, elasticity, turgor, and collagen content. Q-switched Nd:YAG laser are known to increase the production of procollagen and elastin and can promote the generation of collagen, which visibly improves facial imperfections. We aimed to determine the efficacy of a 1064 nm Q-switched Nd:YAG fractional laser on improving lip definition, color, and volume. 32 female patients were treated every 2–3 weeks for a total of 3–5 treatments. Improvement was measured in a follow-up visit a month after the final treatment (29.9 ± 1.4 days) by patients’ self-satisfaction questionnaire and physicians blinded evaluations (Likert scale). Patients achieved meaningful aesthetic improvement in in lip color (94% of patients), volume (72%), texture (91%), and overall lip appearance (82%). Furthermore, 91% were satisfied with treatment results and 100% from the overall experience. There were no associated side effects, and the associated pain level (on a 0–10 scale) was rated as 0 in 84% of individuals and 16% as 1. Therefore, laser treatment using a 1064 nm Q-switched Nd:YAG fractional laser on lips is a safe, noninvasive treatment that increases the color and volume of lips, with results that are maintained for at least one month following treatments.
... Age-dependent elongation of mouth width and philtrum width, and shortening of lower vermilion height was also demonstrated in Italian female adults 6 . Iblher et al. 37 demonstrated that aging causes redistribution of the lip due to thinning of the orbicularis oris muscle, thinning of the cutis, and degeneration of the elastic and collagen fibers. Thinning of the lip without volume loss results in the elongation of the upper lip 37 . ...
... Iblher et al. 37 demonstrated that aging causes redistribution of the lip due to thinning of the orbicularis oris muscle, thinning of the cutis, and degeneration of the elastic and collagen fibers. Thinning of the lip without volume loss results in the elongation of the upper lip 37 . Loss of structural support induces ptosis of the lip and loss of its natural turned-up pout 37,38 . ...
... Thinning of the lip without volume loss results in the elongation of the upper lip 37 . Loss of structural support induces ptosis of the lip and loss of its natural turned-up pout 37,38 . ...
Background:
Understanding the age-related morphological changes of facial soft tissue is fundamental in achieving improved outcomes of rejuvenating procedures. Three-dimensional (3D) photogrammetry is a reliable and convenient anthropometric tool to assess facial soft tissue.
Objective:
The aim of this study was to establish age-related facial soft tissue morphology in Korean adult females using non-invasive 3D photogrammetry.
Methods:
One hundred and ninety-two female participants were divided into three groups based on age: the younger group (aged 20~39 years), middle group (40~59 years), and older group (60~79 years). Thirty-six landmarks were identified via 3D photogrammetric scanning (Morpheus 3D, Morpheus Co., Ltd., Seongnam, Korea). Forty-one facial dimensions were analyzed using the imaging software to find significance between the age groups.
Results:
Smaller upper-facial volume (p=0.019) and shorter upper-facial height (p=0.034) were observed in the older group than in the younger group. In the mid-face, narrowed palpebral fissure (p<0.001) with elongated upper eyelid height (p<0.001) and widened nose (p<0.001) were observed in the older group compared with the younger group. Longer lower-facial height (p<0.001) with longer and wider philtrum (p<0.001, p=0.004, respectively), shorter lower vermilion height (p<0.001), wider mouth width (p<0.001), and smaller lower vermilion angle (p<0.001) were seen in the older group when compared with the younger group. Moreover, greater angles of nasofrontal, nasomental, and labiomental angle (p=0.015, p=0.015, p=0.080, respectively), and smaller nasofacial angle (p=0.034) were observed in the older group than in the younger group.
Conclusion:
Our results provide clues of aging-related facial morphological characteristics in Korean female population.
... 84 Increasing severity of nasolabial folds is also associated with midface volume loss, 78 The perioral region loses definition, shape, and fullness as the lips flatten and retrude, the ergotrid lengthens, the vermilion border and Cupid's bow become less pronounced, the Cupid's peaks widen, and perioral wrinkles and folds form. 2,50,86,87 Changes to the orbicularis oris muscle represent the most important factor affecting this area. 87 In youth, this muscle has well-defined bundles and fascicles surrounded by a thin layer of connective tissue, but with age, the muscle thins and weakens and the connective tissue thickens. ...
... 2,50,86,87 Changes to the orbicularis oris muscle represent the most important factor affecting this area. 87 In youth, this muscle has well-defined bundles and fascicles surrounded by a thin layer of connective tissue, but with age, the muscle thins and weakens and the connective tissue thickens. These changes cause the forward curve of the muscle to decrease, 88 and as the shape of the muscle changes, structural support beneath the lips diminishes, causing lip retrusion and the lengthening and thinning of the vermilion border (loss of the upper lip pout). ...
... These changes cause the forward curve of the muscle to decrease, 88 and as the shape of the muscle changes, structural support beneath the lips diminishes, causing lip retrusion and the lengthening and thinning of the vermilion border (loss of the upper lip pout). 86,87,89 Bony changes in the perioral region include a shrinkage of the mandible with an overall reduction in the bony bulk of the mandible and dentoalveolar regression, 10 resulting in a change in the structural foundation of the mandible from an L shape to a thinner and more slanted I shape. This, together with maxillary retrusion, causes a dramatic shift of the overlying soft tissue. ...
The normal course of aging alters the harmonious, symmetrical, and balanced facial features found in youth, not only impacting physical attractiveness but also influencing self-esteem and causing miscommunication of affect based on facial miscues. This evidence-based paper aims to provide a comprehensive overview of the latest research on the etiology and progression of facial aging by explaining the aging process from the “inside out”; that is, from the bony platform to the skin envelope. A general overview of the changes occurring within each of the main layers of the facial anatomy are presented, including remodeling of the facial skeleton, atrophy or repositioning of fat pads, changes in muscle tone and thickness, and weakening and thinning of the skin. This is followed by an in-depth analysis of specific aging regions by facial thirds (upper, middle, and lower thirds). This review may help aesthetic physicians in the interpretation of the aging process and in prioritizing and rationalizing treatment decisions to establish harmonious facial balance in younger patients or to restore balance lost with age in older patients.
... These wrinkles are affected by the orbicularis oris and 10 other circumferential muscles [7], as well as changes in lip and skin strain [8,9]. Vertical perioral lines in the upper lip develop with aging [10] and are more expressed in women [11]. ...
... These wrinkles are affected by the orbicularis oris and 10 other circumferential muscles [7], as well as changes in lip and skin strain [8,9]. Vertical perioral lines in the upper lip develop with aging [10] and are more expressed in women [11]. The transverse upper labial crease was recently described to be located in the mid-philtral area below the nose [12]. ...
... The almost plateau level of ULHL prevalence that remained between all age groups suggests that subjects who have ULHL at an early age will still display it at an elderly age. The slight decrease in ULHL prevalence with aging can be explained by the drop of the upper lip [10,34,35] and muscle fatigue [36]. This can be explained due to the fact that maximal horizontal smile decreases with aging (decrease in activity of m. ...
Background: Upper lip appearance received major attention with the introduction of diverse treatment modalities, including lip augmentation, rhinoplasty surgery, and dental treatment designed to support the upper lip. Our objectives were to define the prevalence and characteristics of the upper lip horizontal line (ULHL), which is a dynamic line appearing during a smile, in relation to gender, malocclusions, aging, and facial morphology. Methods: First, the prevalence and gender distribution of ULHL was examined from standardized en-face imaging at full smile of 643 randomly selected patients. Second, cephalometric and dental cast model analyses were made for 97 consecutive patients divided into three age groups. Results: ULHL appears in 13.8% of the population examined, and prevailed significantly more in females (78%). The prevalence of ULHL was not related to age nor to malocclusion. Patients presenting ULHL showed shorter upper lip and deeper lip sulcus. The skeletal pattern showed longer mid-face, shorter lower facial height and greater prevalence of a gummy smile. Conclusions: Female patients with short upper lip, concavity of the upper lip, and gummy smile are more likely to exhibit ULHL. The ULHL is not age-related and can be identified in children and young adults. Therefore, it should be considered when selecting diverse treatment modalities involving the upper lip.
... Furthermore, skeletal changes occur as age progresses; some areas continue to grow, while others present bone resorption, promoting new angles between the facial bones (22,23) . The transformation of muscular insertions associated with reduction in elasticity of the dermis, reduction of the mobility and tension of facial muscles, and increase of the subcutaneous adipose layer, make up facial flaccidity, a characteristic of aging (24)(25)(26)(27) . Examples of these modifications combined in the stomatognathic system were evidenced by this study's sample. ...
... These findings were confirmed by magnetic resonance imaging and histological examination, which evidenced a significant reduction in the thickness of the medium level of the upper lip and an inversely proportional relation between the decrease in thickness of the skin and the increase of subcutaneous adipose tissue. It is worth noting that great interindividual anatomical variations produce biases in research on perioral aging (25) . ...
... Several studies associate these changes in appearance and mobility of the face with age progression, especially compared with young individuals (22)(23)(24)(25) . However, this progressive relationship was not found in the present article, probably because the sample is composed exclusively of patients aged 60 years or older, where structural changes are believed to be already in place and tend to advance slowly. ...
Purpose
to understand the main orofacial characteristics of functionally independent elderly individuals and to investigate their association with age, gender, socioeconomic level, and dental status.
Methods
an observational, cross-sectional, and analytical study was carried out with a non-probabilistic sample. Inclusion criteria: minimum age of 60 years, individual in good health conditions according to a pre-established protocol published by the health care service. In order to collect the data, we used the validated Orofacial Myofunctional Evaluation with Scores for Aged Protocol.
Results
The elderly individuals presented normal patterns in more than 60% of the appearance and mobility parameters. Significant alterations observed were: pronounced nasolabial sulcus; flaccid or arched cheeks; labial sealing with tension or absence of sealing; and depressed labial commissures. Alterations in mobility were few, between 20.6% and 33.8%, with higher prevalence of alterations when raising the tongue, lateralizing air inflated in cheeks and jaw. There was no relationship between these findings and the progression of age and socioeconomic classes. Women were more likely to show normal appearance of lips and some alterations in lips mobility. The number of teeth was associated with the volume and shape of lips and with jaw mobility. In addition, the use of dental prosthesis was shown to be significantly related to the nasolabial sulcus aspect and the configuration/tension of cheeks.
Conclusion
This study suggests normal patterns of oromyofacial system in most functionally independent elderly individuals. It supports multidisciplinary action for prevention, promotion, and treatment of the elderly population’s oral functions.
... With age, there is an increase in the length of the upper lip and a decrease in the exposure of the maxillary incisors, especially in men (Drummond S & Capelli J, 2016). Studies have shown that with ageing, there is a redistribution without total loss of volume of the upper lip, by decreasing its thickness and increasing its length ( Iblher N et al., 2012). While, histomorphometric analysis revealed thinning of the upper lip with evidence of atrophy of the orbicularis muscle ( Penna V et al., 2009). ...
... The aging upper lip also experiences a degeneration of the elastic fibers and collagen fibers which affects its elasticity. (Iblher N et al., 2012;Penna V et al., 2009) In addition, Perenack JD & Biggerstaff T 2006 explained the lengthening of the aging upper lip by a generalized loss of volume following the muscle's atrophy as well as a progressive weakening of the facial attachments suspending the soft tissues of the lip. Chetan P et al.,2013 attributed the increase of the resting upper lip length to the loss of the muscle tonus at rest, the increased flaccidity and the redundancy with aging. ...
Abstract
Background: This study aimed to assess the smile dimensions according to gender, age, and the perception of the
overall quality and attractiveness of the smile. Methods: A cross-sectional study including 204 Moroccan men and
women distributed over five age categories was conducted between January and September 2021. Gender, age,
satisfaction and auto-evaluation of the smile were collected using questionnaire. Then, two images of each
participant, one at rest and one upon the largest smile were taken. The following distances were measured on the
images: length of the lips and width of the mouth at rest and upon smile, gingival and maxillary central incisor
displayed upon smile. Results: Dimensions were significantly more important in men. Women displayed
significantly more gingiva. With age, the length of the upper lip at rest increased significantly until the age of 50
and the width of the mouth upon smile continued increasing significantly. 74% of the participants were satisfied
with their smile. Participants' satisfaction with their smile was not associated with the degree of gingival display.
Conclusion: Males have more important dimensions of the lips and the mouth. Females display more gum than
males. Age influences the upper lip length at rest which increases up to the age of 50, and the mouth width upon
smile which continues to increase with age. Practical Implications: The definition of specific facial norms for each
ethnic group considering gender and age groups is essential to establish diagnoses and orthodontic treatment plans.
... With increasing age, maxillary tooth exposure is minimized 22 , due to loss of elasticity 23 and loss of volume. 24 Additional factors must be taken into consideration when determining incisal edge display such as lip length 25 , lip mobility 26 and presence of lip fillers which can affect lip length. If only one arch is being treated, then the opposing occlusion is assessed for any gross tooth malpositions which should be addressed prior to the full arch solution of the opposing arch. ...
... Once the facial support is determined, then the incisal edge display at rest and upon smiling should be commensurate with the patient's age or with a rejuvenated appearance provided that lip length or mobility doesn't deviate from normal architecture and function. [22][23][24][25][26] Proper alveolar reduction allows for adequate restorative material for the final restoration (NobelProcera® milled bar and acrylic restoration, or a milled Zirconia restoration), and should ensure that the transition zone of the prosthesis to gingiva is not evident upon maximal smiling. ...
This article describes two case reports of immediate full-arch dental implant- supported prostheses using facial parameters to determine the anticipated incisal edge (AIE) position. Treatment planning the terminal dentition is driven by several facial parameters. A frontal photo is obtained to assess the facial thirds and the symmetry in the lower third. A profile photo allows the clinician to measure Holdaway's angle, nasolabial angle, and labiomental sulcus depth and anatomy. Facial assessment is a diagnostic tool that assists the clinician in addressing the challenges of ideal tooth position in the absence of dental landmarks to achieve dentofacial esthetics.
... It has been known that with aging, the height of the upper lip decreases while the lip width increases. [4][5][6] Additionally, studies have reported an increase in perioral region wrinkles with aging. [7][8][9] However, most of lip aging studies were conducted on a small scale owing to relying on instrumental measurement methods. ...
Background
The lips play a significant role in shaping facial aesthetics. Due to the distinct attributes of lips in contrast to other facial skin, a unique approach is imperative for managing lip aging. We analyzed lip characteristics (morphology, wrinkles, and color) to investigate visual changes and distinctive attributes of aging lips.
Methods
By utilizing image data processing methods, including facial landmark detection, pattern recognition, and color quantification, we extracted 11 lip characteristic indices (four morphological indices, four wrinkle indices, and three color indices) from high‐resolution images of 1000 Korean women aged 20–69. Correlation tests were conducted to assess the relationship between lip characteristic indices and age, and also between lip morphological and wrinkle indices.
Results
Lip height significantly decreased, while lip width and lip ratio (lip width divided by the sum of the upper and lower lip height) significantly increased with aging. Lip wrinkles significantly increased with aging, whereas lip colors (redness and yellowness) decreased. The lip wrinkle indices, which are segmented for the first time in this study, exhibited significant correlations with lip width, and three of them additionally were correlated with lip ratio (p < 0.05). The results imply such morphological changes can be associated with wrinkle formation of human lips.
Conclusion
The indices suggested in this study can be used for assessing lip aging characteristics, and the study results can contribute to deeper understanding of lip aging.
... A região perioral perde definição, forma e plenitude à medida que os lábios se achatam e retraem, o ergotrid se alonga, a borda do vermelhão e o arco do Cupido tornam-se menos pronunciados, os picos do Cupido se alargam e as rugas e dobras periorais se formam (Friedman, 2005). Alterações no músculo orbicular da boca representam o fator mais importante que afeta esta área (Iblher, 2012). Na juventude esse músculo apresenta feixes e fascículos bem definidos circundados por uma fina camada de tecido conjuntivo, mas com a idade o músculo afina e enfraquece e o tecido conjuntivo engrossa fazendo com que a curva anterior do músculo diminua (Penna, 2009). ...
A demanda por procedimentos estéticos está aumentando globalmente, tornando-se um dos mercados mais aquecidos e em constante desenvolvimento em busca de técnicas eficazes que atendam às expectativas dos clientes. Os procedimentos minimamente invasivos são cada vez mais procurados devido à sua menor invasividade, reduzindo os efeitos adversos e possibilidades de intercorrências, realização em ambientes ambulatoriais, rápida recuperação e menor custo. É fundamental que os profissionais conheçam o processo de envelhecimento e as mudanças em cada camada tecidual para diagnosticar adequadamente as queixas dos pacientes e escolher a técnica de tratamento mais adequada. Esta revisão narrativa tem como objetivo abordar as mudanças provocadas pelo envelhecimento no terço inferior da face e os tratamentos minimamente invasivos mais comuns que podem prevenir ou corrigir os sinais do envelhecimento nesta área.
... These changes are the result of genetics, photoaging, smoking, gravity, repetitive pursing of the orbicularis oris, changes in dentition and bone resorption [2,3] at the maxillo-mandibular level. Jaw resorption can also contribute to the loss of upper lip support, resulting in the formation of perioral wrinkles, commonly known as "smoker lines" [4]. The facelift ideally repositions the ptosis, superior soft tissue, to restore facial volume and a younger appearance. ...
Facelifting is increasingly popular among the population. It exceeded the limits of post-traumatic facia-reconstruction. Both the demand and the methods available are getting increasingly diverse. The minimally invasive technique revolutionized the facelift, although it took some time to completely comprehend the mechanics. The roles of vitamin D in numerous physiological processes in which it is involved have mostly been elucidated in the last decade. Our hypothesis is based on one of these roles, that is, vitamin D intervenes in changing the type of collagen by changing its location; therefore, collagen will have a supporting role for the subcutaneous tissue. A group of 156 patients with different facelifting methods was followed: 93 minimally invasive (NC), 49 classical surgery (C) and 14 with the combined technique (NC + C). The change in the subcutaneous tissue was monitored by an elastograph. The level of vitamin D was monitored in order to assess the immediate and long-term effects of vitamin D on the progression of subcutaneous fibrosis. It was proven that an optimal level of vitamin D has a beneficial effect in maintaining the volume of subcutaneous tissue in patients from the NC and NC + C groups, the best results being in the NC + C group. An increase in the subcutaneous volume was recorded, which leads to a decrease in elasticity (statistical significance p < 0.05) and the lowering of the subcutaneous tissue, and an increased amount of lowering corresponds to a lowering of vitamin D levels.
... Retrusion of the lips is observed in our results from adolescence to adulthood, especially in females, which is consistent with the findings of Ferrario et al. [38] who report earlier completion of upper lip dimensions in girls. This can be linked to age-related thinning of orbicularis oris, loss and redistribution of lip volume along with degeneration of elastin and collagen fibres [39], diminished lip support and further increasing of the nasolabial angle [34]. Finally, cheeks retrude with age, much more in males than in females, which is consistent with literature [40]. ...
Background and objective(s)
(1) To derive descriptive statistics of three-dimensional (3D) facial shape, lip and cheek muscle pressure in subjects of European descent with normal dental occlusion. (2) To analyse the effect of age and sex on 3D-facial soft tissue morphology and muscle pressure in the same sample. (3) To assess the independent effect of muscle pressure on face shape.
Method
129 subjects with normal occlusion were cross-sectionally recruited and divided into: children (mixed dentition), adolescents and adults (permanent dentition, < and ≥18 years respectively). Muscle pressure was recorded using the Iowa Oral Performance Instrument. MeshLab, MeVisLab and Meshmonk tool box were used to clean, annotate landmarks and generate the 3D images. Two-way analysis of variance and post-hoc tests were used to analyse age and sex differences in face shape and muscle pressure. The effect of muscle pressure on face shape was analysed by Pearson correlation and Partial Least Square regression.
Results
Significant facial differences were observed between adults and adolescents and adults and children in both sexes, showing flattening of cheeks and lips and protrusion of nose and chin. Significant cheek protrusion and retrusion of the vertical midface were found in adult women compared to men. Lip and cheek pressure increased with age, but their effect on face shape was not significant.
Conclusions
This study provides 3D age- and sex-specific facial models and muscle pressure of subjects without malocclusion. These can be used as a reference for clinicians focused on facial assessment in treatment planning and follow-up.
... The upper lip lengthens and sags, while the lower lip becomes shorter [19]. The lip vermilions become narrower, due to the resorption of the upper and lower jaws, the atrophy of the orbicularis oris muscle and their inversion [20]. Typically, there is a formation of the chin ptosis and jowl [21], the appearance of the nasolabial fold [22] and the depression of mouth commissures. ...
Background
Facial ageing is a result of superficial wrinkling combined with changes to the underlying soft tissues and skeleton. The influence of tooth loss, as a geriatric characteristic, on facial appearance is still poorly explained. The aim was to evaluate the facial characteristics of older adults, correlate these characteristics with the dentition and make comparisons with young adults using a non-invasive 3D methodology.
Methods
90 participants older than 65 years, classified into 3 subgroups (edentulous, partially edentulous, toothed) and 30 young adults were evaluated. Their faces were scanned with an optical Artec 3D-scanner. Cephalometric analyses were made using the RapidForm computer program. An independent t-test and ANOVA were used for the comparisons. Pairwise, post-hoc tests were applied with respect to the significant differences (P < 0.05).
Results
The faces of older adults are wider and longer because of the longer middle facial height. Older adults also have a longer upper lip, a larger nose, a smaller nasolabial angle (due to the nasal ptosis), narrower upper- and lower-lip vermilions and larger facial and lower-facial-height angles, resulting in a flat facial profile.
The facial changes due to ageing are the most pronounced in the edentulous. In comparison with the toothed, they have a smaller facial height due to the smaller lower facial height, larger nasolabial angle, smaller mouth width, shorter upper lip and narrower lip vermilions. Their profile is flatter and their lips are more retruded.
Conclusions
The proportions of the whole face are changed in older adults and they are the most expressed when this is combined with tooth loss.
... In elderly patients, lip aging occurs due to bone resorption, labial collapse, loss of muscle tone, subcutaneous tissue, and dermal density loss. These changes cause labial collapse, increased distance between the nasal base and upper vermilion (from 12-15 mm to 18-20 mm [6], perioral wrinkles, dehydration, thinning and lateral elongation of the vermilion, lattening of the philtrum, loss of cupid's bow de inition and lip contour, loss of lip projection, and de lation of the commissures with the appearance of marionette lines [15][16][17] to recover their elasticity with iller injection. A larger amount of hyaluronic acid is not indicated for very atrophic lips as this may lead to a "heavy" appearance. ...
The lips and perioral region play an important role in facial aesthetics. Aging induces a loss of volume and contour of the lips, a flattening of the cupid's bow, and the appearance of perilabial wrinkles. Thus, aesthetic procedures are common in this area because fillers can reduce these alterations, improving facial harmony. Although the application of the fillers is based on some systematized framework, undesirable results could occur. The Lip Up technique is a method that applies a very small amount of small-particle hyaluronic acid, only 0.4 ml, to six specific points of the lips. The objective of the technique is to provide lifting of the labial commissures, highlighting some labial points, such as the Glogau-Klein points of the cupid's bow and its equivalent points on the lower lip. After the application of this technique, it is possible to observe an improvement of the lips with very natural-looking results.
... [1][2][3][4] Manifestations of volume loss in the upper lip include decreased tissue elasticity, lip ptosis, decreased lip thickness relative to length, loss of lip volume, contour and vermilion border eversion, and skin textural changes. 2,5,6 Fine vertical rhytides above the upper lip and under the lower lip are primarily related to repetitive movements, photoaging with thinning of the skin and subcutis, 7 and resorption of underlying bone and dentition. ...
Background:
The perioral region is highly mobile and subject to multifactorial changes during aging. Resilient Hyaluronic Acid Redensity (RHAR), an RHA filler, was developed with the aim of optimizing outcomes in dynamic facial areas.
Objective:
This randomized, blinded, multicenter clinical study aimed to demonstrate superiority of RHAR over no-treatment control for correction of moderate-to-severe dynamic perioral rhytides.
Materials and methods:
Blinded live evaluator assessments of efficacy included improvement in perioral rhytides severity using a proprietary scale (Perioral Rhytids Severity Rating Scale [PR-SRS]) and the Global Aesthetic Improvement Scale. Subjects self-assessed their results with FACE-Q, a validated patient-reported outcome measure, and satisfaction scales. Safety was monitored throughout the study based on common treatment responses (CTRs) and adverse events (AEs).
Results:
The primary efficacy end point was achieved, with the treatment group showing statistically significant superiority over the control group at Week 8 (80.7% vs 7.8% responder rate by PR-SRS, p < .0001). Most patients (66%) were still responders at Week 52 (study completion). Most AEs were CTRs after perioral injection of a dermal filler, and none was a clinically significant treatment-related AE.
Conclusion:
Resilient Hyaluronic Acid Redensity is effective and safe for the correction of dynamic perioral rhytides in all Fitzpatrick phototypes, with marked durability.
... Physiological changes with age, including muscle atrophy and dermal thinning as well as degradation of collagen and elastin, all contribute to development. 1 Treatment of perioral fine lines has ranged from chemical and physical dermabrasion, to laser resurfacing, chemical peels, chemical denervation, and, most recently, soft tissue fillers. 2 Initially, soft tissue fillers comprised of hyaluronic acids (HAs) were too dense and hydrophilic to place delicately into the very fine lines that encircle the mouth. 3 With the advent of more refined HA fillers, the treatment of vertical, perioral fine lines became more effective with more natural-appearing results with animation and less risk for Tyndall effect. ...
Background
Perioral rhytids are a bothersome sign of aging for many patients. While multiple treatments exist, choosing an optimal modality may be difficult taking into consideration that rhytids in this region are fine and the anatomy dynamic.
Objective
To compare the efficacy and safety, and patient satisfaction of a small-particle hyaluronic acid filler with 0.3% lidocaine (SP-HAL, Restylane Silk®) and cohesive polydensified matrix hyaluronic acid filler (CPM-HA, Belotero Balance®) in reducing uperficial perioral rhytids.
Methods
The study was double-blinded, and 48 subjects with moderate to severe superficial perioral rhytids were enrolled. Subjects were randomized to receive either CPM-HA in the left perioral region and SPHAL in the right, or vice versa. Rhytid severity was measured by patients using a linear analog scale, and for investigators a validated 5-point scale, for 180 days following treatment.
Results
Both SP-HAL and CPM-HA achieved a reduction in rhytid severity, and neither treatment group returned to baseline after 180 days. Investigator-reported scores for rhytid severity were significantly better for SP-HAL compared to CPM-HA and remained so at 180 days (p < 0.05). SP-HAL also proved significantly better for reducing rhytids according to patient scores, although this difference occurred between 120 and 180 days only. Adverse events included rash and mild acne for CPM-HA, while SP-HAL was associated with one post-inflammatory nodule and two occurrences of Tyndall effect.
Conclusion
While both SP-HAL and CPM-HA are effective at reducing perioral rhytid severity and have similar safety profiles, SP-HAL possesses a longer duration of effect.
... Senescent lips were defined in the presence of one or all of these conditions: thin and dehydrated lips, loss of Cupid's bow, flattened philtral columns, loss of projection of the lips, commissures downturned, and/ or loss of definition and roughness of vermillion borders. 7,11 All those lips not presenting these features were classified as young. Before including patients in the study, an informed consent form was obtained to collect data and photographs. ...
Background:
The request for lip improvement treatments with injectable hyaluronic acid (HA) is increasing. However, as the patient's needs can be extremely different, it is unconceivable to use the same technique/product for clinical different lips to grant customized results.
Aims:
To provide a specific treatment approach for clinically different lips based on the Author's clinical experience.
Patients/methods:
Patients belonged to four clinical groups: young lips requiring volume enhancement or a reshaping intervention, and senescent lips requiring rejuvenation or a rebuild intervention. At first visit T0, subjects underwent a pretreatment evaluation and the investigator performed an individual treatment based upon patient's esthetic goals and lip's baseline features. Lip fullness was assessed by the investigator using a Medicis Lip Fullness Scale (MLFS) at first visit (T0) and at 2 weeks (T1). Subjects and investigator answered to the Global Aesthetic Improvement Scale (GAIS) at 2 weeks T1 and at 12 weeks (T2). A photographic evaluation was undertaken at T0 and T2.
Results:
Only, in the two groups requiring volumization there was 1 grade of improvement in the MLFS (young lips-volume and senescent lips-rebuild). Nonetheless, the performed combination of techniques/products was overall very satisfactory: 80% of the subjects reported a much improved/very much improved outcome in the GAIS, and the same was reported by the investigator in 90% of the subjects. A weak positive correlation was found between MLFS responses and subject's GAIS at T1 in all groups.
Conclusions:
This customized treatment approach, consisting in choosing the right gel technology injected in minimum quantities with the right technique, ensures a harmonic result avoiding aberrations and standardizations.
... Two-and three-dimensional evaluations of the lips have been described in the literature. 14,16,21,24 This study used three-dimensional surface imaging to capture the data. Landmark plotting and measurement completion have been proven to be repeatable and precise using this method. ...
Objectives
To test smile dimension variations in adult African American and Caucasian females and males.
Setting and Sample Population
The University of Alabama at Birmingham School of Dentistry and Hospital. Three hundred and ninety‐four participants were recruited; African American females and males distributed over five age groups: 20‐30, 30‐40, 40‐50, 50‐60 and older than 60.
Material & Methods
Three‐dimensional surface imaging was used to acquire two images of each participant, one at rest and one upon smile. Landmarks were plotted on the lips and linear distances measured to assess the length of the upper and lower lips, mouth width at rest and upon smile, gingival and dental display upon smile.
Results
Linear dimensions are larger in males than in females, and in African Americans than in Caucasians, except for the length of the upper lip that does not differ between male African American and Caucasian males, in any given age group. Gingival display and dental display decrease with age in all groups.
Conclusion
Norms should reflect race, age and sex in order to optimize treatment goals.
... Dit veroorzaakt samen met het dunner worden van de huid een geleidelijke verlenging van de bovenlip waarbij het lippenrood en de bovendentitie minder zichtbaar worden (afb . 3) (Iblher et al, 2012). Ook ontstaan dan, de esthetisch vaak storende, verticale rimpels in de bovenlip. ...
The perioral region is unique and important in the face, both from a functional and an aesthetic point of view. There is a strong relationship between the perioral soft tissues, such as the lips and the corners of the mouth, and the underlying dentition and the jaws. Perioral ageing phenomena, such as depressed corners of the mouth, volume loss and wrinkles, can be improved, however, to a limited extent with intraoral treatment. These ageing phenomena can usually be treated more effectively with several extraoral treatment modalities that also enhance perioral aesthetics. The perioral cosmetic treatment options can be divided into various lifting procedures and volumising techniques. Considering that the dentist has to deal regularly with patients with perioral aesthetic wishes and also functional problems, it is important that one has knowledge of the different perioral treatment options, for both cosmetic and functional options.
... Genetic factors may explain the localized accelerated degeneration in woman subjects. [24] Rzany et al. also found a greater propensity towards lip wrinkles among women. [12] Principal component analysis was performed to extract common dimensions of our scale. ...
Background:
Estimation of facial aging has assumed growing importance due to the advent of several antiaging therapies. Evidence-based estimation of global facial aging is often necessary, especially for validation of these treatment modalities. Most available methods are expensive and have been used in fair skinned individuals.
Aim:
We attempted to develop a clinical rating scale for the estimation of global facial aging applied on an Indian population which has brown to black skin. We have also measured the association of this rating scale score with the chronological age.
Methods:
Initially, a 14- item summated rating scale was developed with inputs from five dermatologists and a clinical pharmacologist. The rating scale was applied to 105 consenting subjects with healthy facial skin, between 30 to 90 years of age. Intra- and inter-rater reliability was assessed.
Results:
The summated rating score showed a significant positive correlation with the chronological age (Pearson's correlation coefficient 0.834, P < 0.001). We omitted one item from the scale due to a low inter-rater agreement. The resulting 13-item rating scale was internally consistent (Cronbach's alpha: 0.905), with substantial inter- and intra-rater reliability (intraclass correlation coefficient: 0.973 and 0.788, respectively). Principal components and predictive equation for perceptible age were identified on further computation.
Limitations:
Participants of this study were limited to a particular ethnic group from West Bengal and other neighboring states of Eastern India.
Conclusions:
We have developed and validated a 13-item rating scale for the quantification of global facial aging suitable for Indian (brown to black) skin type. This scale can be utilized effectively for clinical estimation of global facial aging.
... During ageing, lips undergo volume, length, shape, and colour transformations. Recent histological and MRI studies (Iblher et al., 2012) have highlighted redistribution from thickness to length without total volume loss, in contrast to what was previously thought (Rozner and Isaacs, 1981;Hinderer, 1995;Santachè and Bonarrigo, 2004), and a decrease of structural components, which leads to decreased pouting, vermilion inversion, and ptosis. A long lip can also appear in young people as a phenotypic variation, as well as in patients who have undergone rhinoplasty, lip fillers, Le Fort I advancement with iatrogenic vertical maxillary deficiency (Jeter and Nishioka, 1988), or facial palsy. ...
Background
Ideal lip augmentation techniques have good longevity, low complication rates, and optimal functional and aesthetic results. No systematic review is currently available regarding the efficacy of lip augmentation techniques. This review will focus only on non-filling procedures for lip augmentation (NFPLAs).
Methods
Current databases Elsevier Science Direct, PubMed, Highwire Press, Springer Standard Collection, SAGE, DOAJ, Sweetswise, Free E-Journals, Ovid Lippincott Williams & Wilkins, Willey Online Library Journals and Cochrane Plus were scrutinized and relevant article reference sections were studied for additional publications. The search heading sequence used was (“Lip” OR “Mouth” OR “Perioral” or “Nasolabial”) AND (“Augmentation” OR “Enhancement” OR “Surgery” OR “Lift” OR “V-Y” OR “Corner”).
Results
Exclusion criteria applied to 6436 initial keyword-search retrievals yielded 12 articles. Eight more articles were retrieved from reference sections, for a total of 18 papers assessed. Only one article made a direct comparison of efficacy between two surgical techniques for lip augmentation, and none directly compared complications associated with different NFPLAs.
Conclusions
Although this systematic review revealed a lack of quality data in comparing the efficacy and complications among different NFPLAs, it is important to review and pool the existing studies to better suggest proper treatment to patients.
Aesthetic rejuvenation of the perioral, submental, and neck regions is a complex topic with multiple different treatment approaches. Aging changes in the skin, muscles, fat and soft tissue, and bones are driven by multiple internal and external factors. To obtain the best cosmetic outcome, a deep understanding of the perioral, submental, and neck region and proper patient evaluation are necessary. Here, we discuss the process of evaluating patients and planning treatment for perioral, submental, and neck rejuvenation.
Patients presenting for evaluation of perioral, submental, and neck aging may have multiple aesthetic complaints. The approach to evaluating patients should be comprehensive and consistent. This involves careful history taking and consideration of medical co-morbidities, a thorough evaluation of the skin, tone, dynamic movement, and soft-tissue distribution of each subunit, and individualized pretreatment counseling to discuss risks and set expectations.
An individualized plan may consist of either nonsurgical, surgical or a combination of approaches. Nonsurgical approaches excel at addressing aging skin, volume deficits, and overactivation of facial musculature. Surgical approaches address more severe manifestations of skin aging, uneven volume distribution, loss of contour in the jaw and neck, and bony deformities.
This cross-sectional observational study aimed to evaluate and compare facial metrics in women aged 20–65 years using a three-dimensional (3D) stereophotogrammetry system and to establish standardized values for facial metric variations in different age subgroups. This study included 84 Caucasian women divided into two groups based on their age: group 1 (G1) included women aged 20–40 years and group 2 (G2) included women aged 41–65 years. Twenty-one morphometric points on the face were identified, and the facial images were captured using a 3D stereophotogrammetry system, Twenty-three linear measures and 12 angular measures were evaluated, revealing statistically significant differences in 11 linear and 5 angular measures between the groups. In the G2 group, nasal and mouth width, lip philtrum height, Tragus-Nasion and Tragus-Pronasale lengths were increased, along with increased nasofrontal angle, decreased palpebral fissure inclination, and lip vermilion angles. However, palpebral fissure width and height, binocular width, and lip vermilion height were reduced. The aging process in women causes substantial changes in facial features, particularly in the middle and lower thirds of the face. Conversely, no major changes were observed in the upper third of the face. Our study findings provide potential insights for clinicians in developing facial rejuvenation procedures as well as for forensic purposes and surgical planning. The standardized facial metrics values in different age subgroups can guide clinicians in determining appropriate treatment plans for patients seeking facial rejuvenation.
Just as priceless procedure of art and science needs the visual frame to bring out the subtle proportion to your face and bring out the best frame for the smile. Lip augmentation procedures with hyaluronic acid dermal fillers have become increasingly popular worldwide because full lips are often considered beautiful and youthful. The objective of a lip augmentation procedure is to create smooth lips with adequate volume and a natural appearance and not to be over corrected. Various techniques for lip augmentation have been used and described.
The article reviews the ageing changes of the midfacial and maxillary bones, the mandible, the overlaying soft tissues and the smile, and presents clinical guidelines aiming to rejuvenate older faces by means of orthodontic therapy. With regard to the ageing changes, the maxillary skeleton appears to rotate clockwise inferior to the orbit and becomes retrusive, and as a general pattern the midface contracts and deteriorates with age. Resorption below the mental foramen, reduction in alveolar height, loss of bone at the chin region, and relative increase in size and shape are signs of an aged mandible. Epidermal thinning and decrease in collagen in combination with the effect of gravity and various external factors contribute to the ageing of the skin. Atrophy of the superficial and deep fat, changes in ligamentous tissues and changes in muscle structure, position and tone, all contribute to the stigmata of the aged face. In the article, two late adulthood orthodontic cases are discussed as examples, and general guidelines for orthodontic management of the older face aiming at reversing the ‘shrinkage’ of the tissues by restoring the facial shape and tightening the soft tissue mask are described. The possible mechanisms explaining the changes observed on the faces of the clinical cases are also discussed. A properly planned and executed orthodontic intervention reversing changes from the inside-out before embarking on cosmetic surgery might have a synergistic effect multiplying the benefits for adult patients.
BACKGROUND. Facial ageing is a result of superficial wrinkling and the changes of the underlying soft tissues and skeleton. The influence of tooth loss as geriatric characteristic on facial appearance is still poorly explained. The aim was to evaluate the facial characteristics of older adults in correlation with the dentition and compare them with young adults using a non-invasive 3D methodology.
METHODS. 90 participants older than 65 years, classified into 3 subgroups (edentulous, partially edentulous, toothed) and 30 young adults were evaluated. Their faces were scanned with an optical Artec 3D-scanner. Cephalometric analyses were determined using the computer program RapidForm. An independent t-test and ANOVA were used for the comparisons. The pair-wise post-hoc tests were applied with respect to the significant differences (P < 0.05).
RESULTS. Older adults' faces are wider and longer because of a longer middle facial height. Older adults have longer upper lip, larger nose, smaller nasolabial angle due to the nasal ptosis, narrower upper and lower lip vermilions and larger facial and lower facial height angles, resulting in a flat facial profile.
The ageing facial changes are the most pronounced in the edentulous. In comparison with the toothed they have a smaller facial height due to the smaller lower facial height, larger nasolabial angle, smaller mouth width, shorter upper lip and narrower lip vermilions. Their profile is more flat and lips more retruded.
CONCLUSIONS. The whole face proportions are changed in older adults and they are the most expressed with the tooth loss.
Background:
Hyaluronic acid (HA) is an effective dermal filler for facial rejuvenation. This study aimed to observe the clinical efficacy of HA injection for lip augmentation in Chinese patients.
Methods:
From May 2019 to April 2020, 70 patients with lip fullness scale (LPS) ≤3 underwent local HA injection using the "three-point" injection technique. All patients were followed up to observe the clinical efficacy, LPS, adverse events, and complications.
Results:
All 70 patients were followed up for 12 months. Statistically significant improvements were observed in the height of lips within 6-9 months post-treatment (p < 0.05). The LFS improved significantly at follow-up compared with baseline (p < 0.05). Local redness occurred in two patients, and serious swelling occurred in three patients. These adverse events were generally tolerated and disappeared gradually within 1 week. No other serious adverse events and complications were reported in the remaining patients.
Conclusions:
Hyaluronic acid injection can be used for lip augmentation in the Chinese population. The "three-point" technique is simple, safe, and effective and does not cause serious complications.
Background
Lip augmentation using dermal fillers is a widely performed procedure, which gives immediate and gratifying results. However, the cost associated with it is a major concern and reservation for a lot of patients. An innovative minimalistic technique can be used to enhance the lips using minimal amount of filler to provide maximum results, especially in aging lips. Though a simple and effective method, this technique has not yet gained popularity worldwide.
Aim
To present a case demonstrating a new and innovative technique for lip augmentation as a part of lower face rejuvenation.
Method
A 55-year-old female patient underwent augmentation of lips using the described technique. Since she had a limited budget, treatment was planned to rejuvenate her face in just 1 ml of filler. Areas on the face which would give maximum impact with minimal amount of filler were treated. Treatment was done using Juvederm Ultra Plus XC (JUVX+; 24 mg/ml) dermal filler.
Results
Using this technique, we were able to demonstrate that a small quantity of filler when used suitably with an understanding of the areas of concern could provide an impact on the overall rejuvenation.
Conclusion
The described technique is an effective method of lip enhancement with minimal cost, especially in aging patients. Skillful application of a suitable injection technique is required to achieve a desired esthetic outcome.
In old age the lips become wider and thinner, i.e. the intercommissural distance increases, the visible upper lip vermilion decreases due to the elongation of the lips, the anterior projection decreases, the lips become flatter and less voluminous. The upper incisors are no longer visible when the mouth is opened. The number and visibility of the radial lip wrinkles increase linearly in proportion to age. These factors influence the perceived age of a person.
Background
The lip is of important aesthetic value and highly subjected to aging. Collecting anthropometric baseline data and understanding age‐related changes of labial morphology can help with diagnosis of deformity, assessment of aging, and planning of cosmetic procedures. Many studies have focused on Caucasians, while there is a lack of anthropometric data on Chinese women.
Methods
A total of 169 women were enrolled in this cross‐sectional study and divided into four consecutive age groups. Linear distances, angles, and surface area data were obtained via stereophotogrammetry. Intergroup comparisons between different age groups were performed to find age‐related differences.
Results
Lip width significantly increased with age while philtrum width seemed to show no obvious change. Cutaneous upper and lower lip height increased, lengthening the lip in the vertical dimension. Decrease of upper vermilion height and changes in angles indicated that aging process shortened the upper vermilion and flattened the vermilion border. Surface area also showed age‐related changes. Intergroup comparison showed no statistical significance in most variables between 20s and 30s or 30s and 40s, while age‐related changes in some variables were significant between 40s and 50s.
Conclusion
This study provided anthropometric data of labial morphology across a wide age range. Aging process affected a variety of labial anthropometric variables. Age‐related changes accelerated after 40 among Chinese women.
Asians view an evenly rounded forehead without angular protrusions as beautiful, although the preferred forehead shapes may differ across different cultures. Unfortunately, bilateral frontal eminence exists in the frontal bone from birth. The supraorbital rim projects forward which can create a hollowness between the frontal eminence and supraorbital rim.
Background
Aging affects the perioral region, resulting in folding, wrinkles, and drooping of the corners of the mouth. This might cause esthetic and functional problems. Here, we demonstrate a new suspension technique to lift the descending corners of the mouth.
Method and results
Two case reports are presented. A wraparound mouth corner lift is combined with an additional suspension method. A suspension suture is fixated at the commissure and subcutaneous layer in the nasolabial fold just lateral of the alar base to provide an extra lift of the corners.
Conclusion
Ptosis of the corners of the mouth can be corrected naturally with the additional suspension technique. Further investigations are necessary to provide insight into the long-term results.
Objective
Age‐related changes in lip morphological and physiological characteristics are key indices for estimating age based on facial features, as reported in many studies. Yet, a majority of studies have focused on Caucasian individuals, with few studies characterizing these changes in Asian female populations. Therefore, the aim of this study was to investigate lip morphological and physiological characteristics in a cohort of Korean women.
Methods
A total of 114 volunteers participated in the study. Linear distances (length of philtrum, length of lip, width of lip, and lengths of lower and upper oral commissures), angle of the upper lip, 3D lip heights, and wrinkles were calculated and averaged for each age‐group. We also measured lip color, hydration, trans‐epidermal water loss (TEWL), and blood flow. Statistical analyses were performed using SPSS version 20.0 (significance level P < 0.05).
Results
Length of the philtrum and lip width significantly increased with age while upper and lower lip lengths and length of the lower oral commissure significantly decreased with age. The angle of the upper lip tended to decrease with age, but this finding was no significance. Three‐dimensional height of the upper lip, wrinkles, and TEWL also decreased with age while hydration increased with age. Finally, redness of the upper and lower lips as well as blood flow significantly decreased with age.
Conclusion
Lips tended to shorten in length and widen with age, resulting in a thinner and longer appearance. With regard to physiological parameters, there were important age‐related changes in hydration and lip color.
Glycation and advanced glycation endproducts (AGE) damage skin which is compounded by AGE‐induced oxidative stress and inflammation. Lip and facial skin could be susceptible to glycation damage as they are chronically stressed. As Gromwell (Lithospermum erythrorhizon) root (GR) has an extensive traditional medicine history that includes providing multiple skin benefits, our objective was to determine if GR extract and its base naphthoquinone, shikonin, might protect skin by inhibiting glycation, increasing oxidative defenses, suppressing inflammatory responses, and offering ultraviolet (UV) absorptive potential in lip and facial cosmetic matrices.
We show GR extract and shikonin dose‐dependently inhibited glycation and enhanced oxidative defenses through nuclear factor erythroid 2‐related factor 2 (Nrf2)/antioxidant response element (ARE) activation. Inflammatory targets, nuclear factor kappa light chain enhancer of activated B cells (NFκB) and tumor necrosis factor alpha (TNFα), were suppressed by GR extract and shikonin. Glyoxalase 1 (GLO1) and glutathione synthesis genes were significantly upregulated by GR extract and shikonin. GR extract boosted higher wavelength UV absorption in select cosmetic matrices.
Rationale for the use of GR extract and shikonin are supported by our research. By inhibiting glycation, modulating oxidative stress, suppressing inflammation, and UV‐absorptive properties, GR extract and shikonin potentially offer multiple skin benefits.
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Die ästhetische Dermatologie entdeckt das Alter. Dazu sind Verfahren und Techniken, die bei Jüngeren Anwendung finden, auf die speziellen Bedürfnisse der Älteren zuzuschneiden.
With dermal filler injections now being a fairly commonplace procedure, it is time aesthetic practitioners looked beyond the immediate ‘snapshot’ outcomes at factors affecting longer-term retention of optimum results. Aarti Narayan-Denning draws attention to the patient and product factors that impact these outcomes, and encourages further investigation
Background:
Age-related changes in fat compartments have yet to be fully characterized. Uncertainty remains in terms of volume gains/losses or shape fluctuations over time. The authors' aim was to determine the evolution of subcutaneous fat in the aging upper face, focusing on shifts in volume and dimension.
Methods:
Over the course of 4.5 years, 100 faces of living female Caucasian patients were prospectively studied using high-resolution magnetic resonance imaging. Subjects were stratified by age as follows: group 1, 18 to 30 years; group 2, 30 to 60 years; and group 3, older than 60 years. Superficial temporal and central forehead compartments were delimited, analyzing respective volumes and dimensions by group.
Results:
In 85 patients studied, superficial temporal fat (mean volume, 5.14 cm) increased 35.48 percent in total volume between youth and old age (p = 0.046). Overall height and magnitude of the lower one-third also increased with aging. Central forehead fat (mean volume, 2.56 cm), studied in 83 patients, showed a 209.75 percent volume gain in group 2 (versus group 1) and a 17.59 percent volume loss in group 3 (versus group 2) (p = 0.001).
Conclusion:
Subcutaneous facial fat fluctuates with aging, increasing in the upper face and promoting ptosis through basal compartmental expansion.
Purpose:
Anthropometric data can provide valuable support for the attending physician in planning surgical and nonsurgical esthetic procedures with regard to a patient's age. The purpose of the present study was to identify age-related orolabial changes in younger and older Caucasian women.
Materials and methods:
In the present cross-sectional study, anthropometric landmarks were identified using indirect anthropometry (2-dimensional photometry) in younger (≤35 yr) and older (≥50 yr) Caucasian women to analyze age-related parameters and proportions of the orolabial region, especially of the lower and upper lip vermilion areas. The Mann-Whitney U test was applied to compare the results between the younger and older populations.
Results:
The study population consisted of 45 women. The cohort was divided into a younger population (24 participants; mean age, 27.4 yr) and an older population (21 participants; mean age, 58 yr) to evaluate age-related differences. Increases of upper lip height, cutaneous height of the upper lip, and cutaneous height of the lower lip were observed in older women. In contrast, the vermilion height of the lower lip decreased considerably with increasing age.
Conclusion:
These results show changes of the orolabial region occur in Caucasian women with increasing age. The statistically relevant decrease of the vermilion height of the lower lip should be given particular attention for (age-appropriate) diagnostic and esthetic and prosthetic treatment planning.
Objective:
This trial compares the effectiveness and safety of HYC-24L (Juvéderm Ultra XC; Allergan plc, Dublin, Ireland) (24 mg/mL of hyaluronic acid, 0.3% lidocaine) and CPM-22.5 (Belotero Balance; Merz Aesthetics, Raleigh, NC) (22.5 mg/mL of hyaluronic acid) for the treatment of perioral lines.
Materials and methods:
Men and women aged 35 years or older with moderate-to-severe perioral lines were recruited for this randomized controlled, rater-blinded, 2-arm trial. The primary endpoint was a comparison of rater-assessed responder rates by the validated 4-point Perioral Lines Severity Scale at Month 6; responders were those who showed a ≥1 point improvement. A secondary endpoint was subject-assessed change in perioral lines measured by the Global Assessment of Change Scale.
Results:
A total of 136 subjects received treatment and 132 completed the trial (mean age: 58 ± 8 years). Total volume injected was 1.18 mL (HYC-24L) and 1.32 mL (CPM-22.5). At Month 6, a significantly greater proportion of HYC-24L subjects responded to treatment (87%) than CPM-22.5 subjects (72%) (p < .04). At all time points, HYC-24L subjects reported significantly greater improvement in their perioral lines than CPM-22.5 subjects, with the greatest difference at Month 6. No unexpected adverse events occurred.
Conclusion:
HYC-24L subjects showed a higher response rate and a greater improvement in their perioral lines than CPM-22.5 subjects for up to 6 months.
Esthetic dermatology discovers older age. Methods and techniques which are useful in younger people need modifications to meet the special needs of the elderly. These aspects are discussed with a focus on the aging face. Esthetic dermatology is most successful when using principles of regenerative medicine.
Traditional views on facial aging and associated therapies focused on soft tissue descent and skin texture changes. Recently, revolumization for age-related lipoatrophy has become increasingly popular. Researchers are now reporting objective studies examining processes of structural and volumetric changes with age in increasing frequency as well. To better understand and treat facial aging, the surgeon should review all available data. Presented here are current evidence-based studies regarding age-related changes in the facial skeleton and soft tissue envelope. By reviewing these changes by each anatomic subsite, the surgeon will be better equipped to develop an appropriate treatment plan, individualized for each patient.
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
: Reliable evaluation of the complex three-dimensional anatomy of the face has proven to be extremely difficult. Three-dimensional surface scanning technology has not yet reached widespread acceptance in clinical research in plastic surgery. This study aimed to describe two parameters that allow quantification of soft-tissue movements and to compare the surface changes of the lower face during positional changes and with increasing age.
: Two groups, each with 20 voluntary female subjects aged 20 to 35 and 45 to 60 years, were examined with a three-dimensional surface scanner in both supine and sitting positions. After registration of the two surface scans, the soft-tissue mobility of the lower face was examined using two new parameters. Deformability describes the mean distance between the surfaces and stretchability describes the relative stretching of one surface when mapped onto the other.
: Both parameters show highly significant differences for tissue mobility of young versus old lower faces. The trend for the soft tissues to lose projection in the upper posterior aspect and gain projection in the lower anterior aspect increases strongly. In the older subjects, larger parts of the examined area show tissue displacements of up to 6 mm, whereas in the young faces the displacement is far less and does not exceed 4 mm.
: Computational analysis of the authors' experimental results using two new parameters shows a statistically significant increase of facial tissue displacement and surface stretching when comparing young and old subjects.
The objective of this study was to supply information about: (1) normal sex-related dimensions of mouth and lips (linear distances, ratios, angles, area, volume); and (2) growth changes between childhood and old age. The three-dimensional coordinates of several soft-tissue landmarks on the lips and face were obtained by a non-invasive, computerized electromagnetic digitizer in 532 male and 386 female healthy subjects aged 4-73 years. From the landmarks, linear distances (mouth width, width of the philtrum, vermilion heights of the upper, lower and total lips, total lip height), the vermilion height-to-mouth width ratio, areas (vermilion of the upper, lower and total lip) and volumes (upper, lower, and total lip volume) were calculated and averaged for age and sex. Comparisons were performed by factorial analysis of variance. Mouth width, width of the philtrum, total lip height, and lip volumes were significantly larger in men than in women (p<0.01), increased with age (p<0.001), and had age x sex interactions (p<0.001). Vermilion areas and heights of the lower and total lips progressively increased with age until late adolescence, and then decreased with aging (p<0.001). The vermilion height-to-mouth width ratio was larger in women than in men (p<0.001), and decreased with age (p<0.001). Data collected in the present investigation could serve as a database for the quantitative description of human lip morphology during normal growth, development and aging. Forensic applications (evaluations of traumas, craniofacial alterations, teratogenic-induced conditions, facial reconstruction, aging of living and dead persons, personal identification) may also benefit from age- and sex-based data banks.
Objectives:
The objectives of this study were to: 1) determine if a genetic algorithm in combination with morphing software can be used to evolve more attractive faces; and 2) evaluate whether this approach can be used as a tool to define or identify the attributes of the ideal attractive face.
Study design:
Basic research study incorporating focus group evaluations.
Methods:
Digital images were acquired of 250 female volunteers (18-25 y). Randomly selected images were used to produce a parent generation (P) of 30 synthetic faces using morphing software. Then, a focus group of 17 trained volunteers (18-25 y) scored each face on an attractiveness scale ranging from 1 (unattractive) to 10 (attractive). A genetic algorithm was used to select 30 new pairs from the parent generation, and these were morphed using software to produce a new first generation (F1) of faces. The F1 faces were scored by the focus group, and the process was repeated for a total of four iterations of the algorithm. The algorithm mimics natural selection by using the attractiveness score as the selection pressure; the more attractive faces are more likely to morph. All five generations (P-F4) were then scored by three focus groups: a) surgeons (n = 12), b) cos-metology students (n = 44), and c) undergraduate students (n = 44). Morphometric measurements were made of 33 specific features on each of the 150 synthetic faces, and correlated with attractiveness scores using univariate and multivariate analysis.
Results:
The average facial attractiveness scores increased with each generation and were 3.66 (+0.60), 4.59 (+/-0.73), 5.50 (+/-0.62), 6.23 (+/-0.31), and 6.39 (+/-0.24) for P and F1-F4 generations, respectively. Histograms of attractiveness score distributions show a significant shift in the skew of each curve toward more attractive faces with each generation. Univariate analysis identified nasal width, eyebrow arch height, and lip thickness as being significantly correlated with attractiveness scores. Multivariate analysis identified a similar collection of morphometric measures. No correlation with more commonly accepted measures such as the length facial thirds or fifths were identified. When images are examined as a montage (by generation), clear distinct trends are identified: oval shaped faces, distinct arched eyebrows, and full lips predominate. Faces evolve to approximate the guidelines suggested by classical canons. F3 and F4 generation faces look profoundly similar. The statistical and qualitative analysis indicates that the algorithm and methodology succeeds in generating successively more attractive faces.
Conclusions:
The use of genetic algorithms in combination with a morphing software and traditional focus-group derived attractiveness scores can be used to evolve attractive synthetic faces. We have demonstrated that the evolution of attractive faces can be mimicked in software. Genetic algorithms and morphing provide a robust alternative to traditional approaches rooted in comparing attractiveness scores with a series of morphometric measurements in human subjects.
A lack of scientific data about the complex three dimensional changes in relation to the rest of the face is the reason for the multitude of rejuvenation approaches to the aging upper lip. In this study the underlying anatomic changes and facial proportions of the senile upper lip are scientifically evaluated for the first time.
(1) In 182 standardized subject photographs proportions of the upper lip were measured, compared to facial dimensions and correlated to age. (2) In cranial MRI scans of 30 women aged 20-35 and 30 women aged 65-80 relevant anatomical dimensions were measured.
Both studies showed a statistically significant lengthening of the aging upper lip. The photomorphometric study further shows an increase of prolabium skin at the cost of a decreasing visible upper lip vermilion. The MRI scans showed a decrease in thickness. A loss of volume could not be shown.
Isolated volume augmentation is not a causal method of upper lip rejuvenation and it may therefore rather lead to an unnatural 'blown up' look.
Discussing aesthetic issues and their management with patients is a growing area of dermatologic practice. Sometimes treatment options within one's own discipline are rapidly discussed, without a clear idea of the various aspects of the face which all combine to produce beauty and attractiveness. We review various features leading to the impression of beauty and attractiveness. Familiarity with these concepts should facilitate a broader discussion with the patient on the aspects of beauty and attractiveness beyond the borders of one's own discipline and also lead to multidisciplinary treatment options. We also examine the question how much the personality of the beholder himself is involved in the perception of attractiveness and beauty (of the person sitting opposite to him).
The “ideal” face has an average profile with slightly protrusive and full lips. Attractiveness increases with average features and symmetry. Moreover, particular features such as the scheme of childlike characteristics combined with aspects of maturity and expression make a female face appear especially beautiful. Which attributes contribute to attractiveness of a man's face are controversial. Clear male signals such as a strong chin are likely not to increase attractiveness.
Given the recent boom of the cosmetic industry, there is a wealth of new products available to patients and physicians, including soft-tissue fillers. Bio-Alcamid polyacrylamide gel (Polymekon, Milan, Italy) is a filler that has potential to cause adverse reactions.
Two patients who had previously been treated with Bio-Alcamid outside of the United States presented with different manifestations of inflammatory responses to the product. These reactions were challenging to treat.
Despite claims of safety, Bio-Alcamid and possibly other soft-tissue fillers available worldwide have the potential to cause adverse reactions. Physicians should be aware of the various presentations and treatment options for these reactions.
Various injectable fillers are used for soft-tissue augmentation, including liquid injectable silicone [LS]. This study evaluates patient satisfaction and long-term results after [LS] for lip augmentation. A total of 179 patients, who received medical grade [LS] for lip augmentation, were included in the study. The microdroplet technique was used in all cases, and not more than 1cc per lip per session was injected. The follow-up period varied from 3 years to 7 years. The long-term results (3-7 years), satisfaction level and complications were evaluated. As many as 171patients had upper lip injections and most had 1cc silicone injected. Eighty-seven had lower lip injections. Eight-five percent of the patients considered having excellent or good results. Most (76%) patients considered their lips to be as soft as before treatment. No complications were recorded for 91.1% of the patients. Complications encountered by the rest were minor and temporary, such as ecchymoses and haematoma in 6.2% and invisible but small palpable nodules in 2.2%. In our experience, the injection of [LS] by the microdroplet technique is safe for a period of 3-7 years, gives high satisfaction to the treated persons and has minimal complications.
Bio-alcamid is one of the newest agents on the market for soft tissue augmentation. Seven studies were documented in the medical literature that examined the safety of Bio-alcamid (Polymekon, Brindisy, Italy); all reported no cases of tissue migration, foreign body granulomas, allergenicity, or interference with the control of cell proliferation. On 2 separate occasions, a woman who had recently undergone lip augmentation presented at our hospital with submucosal nodules of the lip. Histologic examination revealed multiple foreign body-type granulomas composed of giant cells, epithelioid cells, and chronic inflammation of the lip. Efforts to produce a cosmetic material that fulfills all the criteria as an "ideal" agent has not yet been found because all injectable foreign agents have the potential to induce adverse reactions. Caution must be exercised in all cases and the risks explained to the patient before its use.
Upper lip rejuvenation is achieved by a large variety of different treatment approaches that clearly lack a unified theoretical background of the aging processes of the upper lip complex. In this study, the histological changes that occur in the aging upper lip were systematically evaluated for the first time.
Histological cross-cuts of the upper lip complex of 20 individuals in two age groups, young (<40 years, n = 10) and old (>80 years, n = 10), were analyzed. The specimens were collected during the autopsies of individuals with no facial injuries. Hematoxylin-eosin and elastica van Gieson staining was performed, and the relevant anatomical structures were measured and compared using Student's t test.
Histomorphometric analysis revealed statistically significant thinning of the cutis, thinning of the orbicularis oris muscle, and an increase of the orbicularis oris muscle angle defining the vermilion border in the old lip group. Elastic and collagen fibers in the cutis undergo degeneration processes during aging. The orbicularis oris muscle is not subject to fatty or fibroblastic degeneration, but shows signs of atrophy.
The histomorphometric and histomorphological analyses shed light on the, so far, only unsystematically and episodically described process of upper lip aging on a histological level. The distinct changes add further evidence to the theory that the aged look is due to a loss of elasticity and resultant ptosis of the upper lip rather than to often-postulated but unproven total volume loss.
As average life expectancy is increasing, the ageing of skin presents a growing problem for dermatologists. When considering ageing it is important to distinguish between the effects of true biological ageing and environmental factors, such as exposure to sun. Epidermal changes associated with ageing involve the flattening of its underside, a reduction in the number of Langerhans cells and of melanocytes, and a decline in the number of melanosomes synthesized, leading to reduced pigmentation. Dermal changes involve a reduction in the collagenous and elastic fibres, fibroblasts, mast cells and macrophages, and dilation of the lymphatic channels. The number of hair follicles declines with age, but their structure remains unchanged. Ageing does not affect the sebaceous glands, but some changes occur in the exocrine sweat glands.
Attention is brought to a seldom-considered sign of aging--the lengthening of the upper lip. It is easily corrected by excising a wavy ellipse of lip skin and hiding the scar up under the nose. A vertical midline component may be added. The scars are minimal, and the results have been excellent in 83 patients.
Thin, atrophied lips are a stigma of old age. This paper discusses the so-called lip lift, an operation that consists of lifting, everting, and increasing the bulk of the upper and lower lips by means of a simple but meticulous procedure along the vermilion border. An introductory study on lip aesthetics is presented. Preoperative planning is greatly emphasized. This technique has been used by the author in 32 cases as an adjunct to facial lifts or as a separate procedure. The patients were followed for up to 3 years. The results were quite satisfactory.
The changing appearance of the upper lip may be a significant component in the "ageing face" syndrome. Its typical features are described. These can be corrected by a simple "lip lift". Complications are few and the manoeuvre has proved to be an excellent adjunct in restoring a more youthful outlook. It has little effect on "purse-string" lines of the upper lip that usually require dermabrasion or a chemical peel.
Senile changes in the upper lip produce not only alterations in the length and shape of the vermilion border but also elongation of the skin area and vertical wrinkles. Correction of these changes can be obtained by means of the surgical technique described in this paper. The surgical technique must be exact and performed patiently. The complications are temporary and not serious. The results are satisfactory.
Thin lips and an aging lower third of the face are increasingly the focus for surgical improvement. Thin and tightly pursed lips imply a certain resignation or even bitterness, especially in older women. Excessive application of lipstick to enhance the shape and color of thin lips was a solution but a poor camouflage. The desire for well-defined and full lips, as seen today on many models and actresses, is the motivation behind the increasing demand of women with relatively normal looking lips to turn to cosmetic surgery. They often present the surgeon with photographs of the shape and fullness of lips they desire to achieve. In this article the author recommends the use of the direct upper-lip lifting method as a more effective and successful approach to enhancing the shape of the upper lip. For plumping the lower and upper lip, the author recommends using autologous collagen augmentation.
The signs of aging of the upper lip, the pathogeny, and different treatments proposed up to now are discussed. A personal technique used since 1992 is presented. It is based on an earlier personal technique, described in 1970, which consisted of dissecting the skin from the orbicularis muscle and inserting a temporary (three weeks) silicone sheet. The present technique consists of a skin excision at the nasolabial junction, based on that described by Cardoso and Sperli in 1971. However, I dissect the skin of the vermilion border and insert a trapezoidal graft of the pretemporal areolar tissue, taken during rhytidectomy. The graft is fixed with Vicryl sutures at the level of the nasolabial folds. In a few patients this has been combined with a peel. The technique corrects both the superficial and the deep wrinkles caused by the retraction of the fibers that join dermis and orbicularis muscle. It achieves an eversion of the vermilion, enhancing its convexity and producing a fuller look, and shortens the lip, which adopts a concave, youthful appearance because of the improvement of the philtrum and of Cupid's arch. Our technique has been used in 15 patients who were satisfied with the results.
To determine differences in postoperative outcomes, complications, and adverse effects between phenol chemical peel (CP) and the carbon dioxide laser peel, when used for facial skin resurfacing.
Nonrandomized prospective comparison of 2 facial skin resurfacing techniques using a split-face paradigm. In this initial study, 18 months of follow-up data are available, including the patients' subjective evaluations, the surgeons' objective assessments, and a histological analysis of 1 patient by a blinded pathologist.
A facial plastic surgery clinic associated with a university medical center.
Four female patients with actinic-damaged facial skin and facial rhytids, aged 61 to 73 years.
The left side of each face was treated with a phenol-based CP formula according to standard procedure. The right side was resurfaced using the Sharplan Silktouch Flashscanner carbon dioxide laser. Patients were photographed before treatment and at regular intervals postoperatively. One patient underwent rhytidectomy at 2 months posttreatment, and specimens were obtained for histological analysis.
Evaluation of observable clinical improvement in skin quality, postoperative swelling, erythema, pigmentary alterations, healing time, and complications.
All 4 patients experienced transient initial discomfort on the CP side that subsided within 24 hours after treatment. The laser side was noted to have slightly more prolonged stinging, erythema, and edema. Erythema was noted to be more uniform in the laser-treated areas. Final clinical improvement in rhytids was evaluated by 4 surgeons who reviewed color slide presentations of each patient 1 year or more postoperatively. Uniform wrinkle improvement was noted around the eyelid and lateral cheek areas on both the CP and laser-treated sides. A moderate advantage in the degree of wrinkle improvement was noted on the laser-treated sides of the upper lip and forehead. Thick-skinned, glandular skin areas, such as the nasolabial fold and chin, were found to be substantially smoother in the laser-treated areas. Histological studies indicate that the CP side was noted to have a deeper injury, extending into the reticular dermis. The skin treated with the laser was injured more superficially, down to the papillary dermis.
Phenol CP is as effective as the laser in diminishing rhytids in the thin-skinned areas of the face. The laser produces improved results in the thick, glandular areas of the face, but also produces more intense hypopigmentation, longer periods of patient discomfort, and longer periods of postoperative erythema. Both phenol CP and laser resurfacing remain useful clinical tools.
Various alloplastic injectable implants have been developed for soft tissue augmentation without surgery, but different local or systemic adverse reactions have limited their use for cosmetic purposes.
To examine the problems associated with silicone injection.
Case report and literature review.
We describe an adverse granulomatous reaction after the injection of liquid silicone for lip augmentation, causing facial disfigurement. Although the initial response to steroids was poor, after 3 years of follow-up the nodules have almost disappeared spontaneously.
We advise that silicone injection be performed solely by trained physicians using medical-grade silicone or consider other injectable materials.
To evaluate the effects of Cymetra (micronized AlloDerm tissue) in rejuvenating the aging and atrophic lip.
Forty-four patients aged 32 to 80 years who reported age-related changes in the size and contour of the upper lip.
Patients were randomized to treatment with either Cymetra or glutaraldehyde cross-linked bovine collagen (Zyplast). Standardized photographs of each subject were taken before and after treatment initially and 3, 6, 9, and 12 months after initial treatment. Patients were monitored for signs of hypersensitivity, infection, and inflammation.
Digital photographs were analyzed for changes in the nasolabial angle, percentage of the total lip accounted for by the exposed red lip in the midline and on the lateral view, the visible red upper and lower lip surface areas, and the anterior projection of the upper and lower lips.
All patients tolerated treatment well without any significant local or systemic complications. Nineteen patients were treated with Cymetra and 25 with Zyplast. Cymetra-treated patients were more likely than Zyplast-treated patients at 12 months (3 months after the previous treatment) to have increased the percentage of red lip in the midline (84.6% vs 38.9%; P =.01), the vermilion height in the upper lip midline (84.6% vs 38.9%; P =.01), and the exposed red lower lip on the lateral view (69.2% vs 33.3%; P =.048) by at least 20%; increased the lower lip projection by 0.5 mm or more (69.2% vs 27.8%; P =.02); and decreased the nasolabial angle by at least 10 degrees (46.2% vs 16.7%; P =.07).
Cymetra is a suspension of particulate dermal matrix that seems to increase the upper lip bulk, vermilion, and lower lip projection after a threshold of Cymetra has been administered. There are few differences in any measured long-term (3 months after treatment) variables until the 12-month visit, when there were statistically significantly more Cymetra-treated patients with improved lip aesthetics than those treated with Zyplast. With repeated treatments, Cymetra seems to accumulate, producing a long-term effect superior to Zyplast in many patients.
Aging of skin is a continuous process that may be enhanced by sun exposure. Photoaging may provoke changes different from aging. Epidermal changes involve thinning of stratum spinosum and flattening of the dermo-epidermal junction. The senescent keratinocytes becomes resistant to apoptosis and may survive for a long time giving time for DNA and protein damage to accumulate with possible implication for carcinogenesis. The numbers of melanocytes decrease with age with dysregulation of melanocyte density resulting in freckles, guttate hypo-melanosis, lentigines and nevi. The number of dendritic Langerhans cells also decreases with age and the cells get less dendrites and have reduced antigen-trapping capacity. Aging involves dermal changes such as damage to elastic and collagen fibers giving thickened, tangled, and degraded non-functional fibers. Collagen intermolecular cross-links are stable and essential for stability and tensile strength. Cross-links increase with age converting divalent cross-links into mature trivalent cross-links of, e.g. histidinohydroxylysinonorleucine. Two mechanisms are involved; an enzyme-controlled process of maturation and a non-enzymatic glycosylation, the Maillard reaction leading to cross-links in proteins such as in collagen between arginine and lysine. Such may be seen with age and in diabetes mellitus. However, autofluorescence studies have shown that UVR reduces collagen cross-links. Natural photoprotection involves thickening of stratum corneum by sunlight and increased pigmentation. This leads to a factor 2 increase in photoprotection from spring until after-summer. The constitutive pigmentation is independent of age and thickness of stratum corneum is likewise independent of age. The minimal erythema dose is thus the same through life, when corrected for pigmentation or measured in areas with constitutive pigmentation.
The ability of botulinum toxin A (BTX-A) to improve the appearance of facial lines was first reported among patients who had been receiving injections for facial dystonias or surgical procedures. Since that time, there has been very extensive use of this treatment for relaxation of a wide variety of facial muscles and also for platysmal lines of the neck. Considerable experience over the last decade or longer confirms the safety and efficacy of BTX-A in the treatment of upper facial lines. BTX-A has been used also lower facial indications, but published papers are mainly uncontrolled observations on patients. Unlike the placebo-controlled studies on the upper face, there is a lack of controlled studies for lower face and neck BTX-A treatment. This article will summarize the use of BTX-A for the lower face and its role as combination treatment. Examples of combinations that may be used with BTX-A resurfacing, nonablative skin rejuvenation and skin fillers. Although little used at present, Botulinum Toxin B will be briefly discussed.
Rejuvenative therapy of the lower face has traditionally been surgical in nature, with office-based treatments such as soft tissue fillers relegated to "second tier" status. However, traditional rhytidectomy does not significantly affect the perioral complex and leaves the central lower face unaltered and unimproved. If it is left untreated, there is a clear disparity between the rejuvenated neck and aged perioral area. Soft tissue augmentation of the perioral area can provide rapid aesthetic improvement. Careful analysis of this area and appropriate treatment can harmonize these areas and produce a globally aesthetic result.
In Europe, numerous dermal fillers have been utilized for the past decade. A lot of drawbacks have been reported and sometimes, severe complications occurred.
Our purpose is to report the clinical aspects of the adverse reactions following injections of some of the dermal fillers. Histological aspects of complications are also described.
Adverse reactions secondary to biodegradable products are usually time limited, but with the non-biodegradable products, we have observed severe, persistent, and recurrent complications. Histological examinations, in cases of non-biodegradable products, may show the presence and persistence of the filler.
For the moment, there is no ideal dermal filler. All fillers can lead to adverse events and we need to inform patients fully before injecting. Clinical studies with long-term follow-up before launching a new product on the market are recommended. We believe that in Europe, at present, the CE mark is not a guarantee of safety of dermal fillers.
Background:
Artefill is one of several new materials being introduced to the U.S. market as a soft tissue augmenting agent.
Objective:
The objectives were to evaluate the safety and efficacy of injecting Artecoll (Rofil Medical International Breda, the Netherlands) in facial wrinkles compared with injecting Zyderm or Zyplast (INAMED, Santa Barbara, CA, USA) and discuss the practical lessons learned.
Methods:
Thirty-eight patients were randomly selected to receive Artecoll or Zyderm/Zyplast into facial defects. Wrinkles were evaluated by the treating physician, the subject, and masked physician evaluators. Similar evaluations were performed on several collagen patients crossing over to Artecoll. Adverse reactions were recorded. RESULTS. All evaluators felt Artecoll to be superior to collagen in all treated areas except for the glabella and upper lip lines. In these areas, differentiation by photographs between the two products became more difficult for the masked evaluators. The adverse side effects of Artecoll were almost equal with those of collagen, but most were of minimal consequence. Three patients developed persistent nodules (all in perioral sites), which were treatable with intralesional steroids. CONCLUSION. Artecoll treatment of wrinkles and folds was found to be effective, long lasting, safe, and associated with a high percentage of patient acceptance. There is a learning curve in injecting this thicker, more permanent product.
The use of injectable agents, specifically soft tissue fillers and botulinum toxin type A, has risen dramatically over recent years, due to the increased demand for minimally invasive techniques. In fact, today they represent the most commonly performed cosmetic procedures in the United States, with botulinum type A injections topping the list. In the treatment of the aging face, these agents, when used individually or in combination, can effectively decrease rhytids and restore lost volume. The result is a fuller, smoother, more youthful appearance. This article provides an overview of botulinum type A (Botox Cosmetic; Allergan, Inc., Irvine, CA) and the two injectable fillers most commonly used in our practice, namely hyaluronic acid (Restalyne; Medicis Aesthetics, Inc., Scottsdale, AZ) and human-derived collagen (Cosmoderm and Cosmoplast; Inamed Aesthetics, Inc., Santa Barbara, CA). Although we commonly use autologous fat as an injectable filler for facial-volume augmentation, its discussion is beyond the scope of this article. Conceptually, the aging face can be divided into upper, middle, and lower thirds. Using this framework, we will discuss our treatment strategies for addressing each facial region. General principles, preinjection evaluation, and specific approaches and techniques for each anatomic region will be discussed, with particular emphasis on the benefit of using dermal fillers in conjunction with botulinum toxin type A to achieve optimal aesthetic results for facial rejuvenation.
ArteFill, the successor product to Artecoll, is an injectable wrinkle filler composed of polymethylmethacrylate microspheres and bovine collagen, which offers long-lasting and probably permanent augmentation of wrinkles and skin contour deformities. The pivotal U.S. Food and Drug Administration study consisted of 251 subjects at eight centers in the United States who received injections of ArteFill or bovine collagen dermal filler (control) in 1334 wrinkles of the glabella, nasolabial folds, radial upper lip lines, and corners of the mouth. The efficacy data generated by masked observers using a photographic Facial Fold Assessment Scale demonstrated a significant improvement with ArteFill compared with collagen at 6 months (p < 0.001) in the nasolabial folds. In the ArteFill group, 12-month follow-up was obtained for 111 subjects (86.7 percent) and showed persistence of significant wrinkle correction. A subgroup of 69 patients who received ArteFill were recalled 4 to 5 years later. Five patients reported six late adverse events that occurred from 2 to 5 years after the initial injection; four of the adverse events were mild cases of lumpiness and two were severe. The total number of late adverse events was six of 272 (2.2 percent) wrinkles injected. Among the 272 wrinkles evaluated at 5 years, two events (0.7 percent) in one patient were rated as severe (a nodular, minimally inflammatory to noninflammatory reaction in both nasolabial folds). Investigator Facial Fold Assessment ratings at 4 to 5 years were improved from baseline by 1.67 points (p < 0.001).
To evaluate the clinical outcomes with the use of a dual-porosity expanded polytetrafluoroethylene implant for midfacial rejuvenation.
An institutional review board-approved retrospective chart review was conducted of all patients who underwent implantation with the dual-porosity expanded polytetrafluoroethylene implant between 2001 and 2005.
A total of 170 patients, with 612 implants, were evaluated. Only 8 patients had minor complications, 3 of which necessitated implant removal. The overall results of independent observer analysis of outcomes were favorable in the majority of cases.
The dual-porosity expanded polytetrafluoroethylene implant is safe and reliable to use for midfacial implantation.
An increasing number of soft tissue fillers have been introduced to the beauty market and these filler substances are widely used as non-toxic, non-immunogenic and relatively harmless injectable alternatives to surgical rejuvenation. Generally, facial fillers are injectable - or surgically insertable - products that are used to fill up the volume loss in the aging face. Depending on bioavailability, chemical composition and degradation, fillers can be classified as temporary or permanent, organic or inorganic and autologous or heterologous.
A plethora of new products has swamped the beauty market since face rejuvenation has become socially acceptable as well as affordable to a wider population, but adverse reactions cannot be excluded. We present 4 patients with complications after injection of facial fillers [including Artecoll(polymethylmethacrylate microspheres), Restylane (hyaluronic acid), DermaLive (hyaluronic acid plus acrylic hydrogel particles) and Newfill (polylactic acid)] and surgical correction.
Surgical intervention led to good aesthetic and functional results after multiple unsuccessful conservative therapies.
We recommend that only physicians familiar with the injection techniques and the biological and chemical characteristics of the various injectable products should perform such interventions. Especially permanent fillers should be used with utmost reticence in cosmetic surgery and we would recommend their application only in reconstructive procedures. Additionally, documentation and reporting of all adverse effects must be mandatory.
As the range of soft tissue augmentation products proliferates, most will be used (with varying degrees of success) to shape and augment the lip. The range of outcomes for this indication depends on the skill of the injector, the anatomy of the patient and the intrinsic properties of the product. Permutations of these interacting factors are infinite and it is the range of combinations that is responsible for the complexity (and fascination) of lip rejuvenation with injectable products. Based on personal experience, the perfect lip is the one that "wows" the patient and makes them happy with the procedure. Individualizing the injection is of paramount importance and should take priority over a formulaic approach that defines each lip injection as identical. This review will discuss some of the factors that should be considered prior to injecting a lip with soft tissue augmentation products.
Dentists need to be aware of soft-tissue lesions resulting from cosmetic facial/lip procedures that involve the use of injectable materials. Common side effects detected on clinical examination may include edema, bruising and noninflammatory lip nodules.
A 51-year-old woman visited a dental clinic with the chief complaint of a lump on the mucosal aspect of her lower lip. She reported having noted the lesion a few weeks before seeking care at the clinic. Several weeks later, the lesion persisted and new lesions were detected. The clinician excised the initial lesion only.
The lip nodules were associated with a cosmetic procedure and were inflammatory in nature. This is the first granulomatous response reported as a result of injections with calcium hydroxylapatite (Radiesse, BioForm Medical, San Mateo, Calif.). Poor patient recollection of his or her medical history may result in confusion with pathological processes such as infection, neoplasia or malignancy.
Esthetic surgery of the aging lip
- I Pitanguy
- P Muller
- N Piccolo
- L Freitas
- I. Pitanguy