Almost everyone can point to their nasal labial folds—the lines that run from the outside of the nostrils down to the corners of the mouth. The widespread popularity of fillers has put a spotlight on correcting or minimizing these lines. But can you find your pyriform aperture? If you put your finger at the top of your nasolabial fold where it meets the side of your nose you will be touching the pyriform aperture. This area might not get a lot of press, but bone loss here is the cause of one of the earliest and most profound areas of facial aging.
In a youthful lip posture with the mouth relaxed and slightly open, the tips of the 4 central teeth should be visible and lower teeth are hidden. The gradual loss of volume of bone in the pyriform aperture undermines the support system for the upper lip causing the lip to slip down, eventually covering the upper teeth. As aging occurs, the tips of the upper teeth are covered by a descending upper lip. At the same time bone loss in the chin area renders the lower lip elevator muscles less efficient, exposing the lower teeth. As the upper lip continues to slip off its bony support the lip elongates and thins. In the early stages thinning of the lip is what is most commonly noticed by patients. At that point, the symptoms can be treated by injections into the red lip to augment the volume of the red lip. Fillers can also help correct thinning of the skin over the white lip which leads to vertical wrinkles both at rest and during animation.
A further anatomy lesson involves an area called the oral commissure—another word for the corners of your mouth. Descent of the upper lip contributes to descent and downward inclination of the corners of the mouth leading to a sad or despondent expression. Downward inclination of the oral commissure is also seen when the cheek sags, adding downward pressure. True correction at this juncture involves a facelift to elevate the deep tissues between the skin and muscle eliminating pressure on the oral commissure. If there is significant atrophy of the tissues both at the corners of the mouth and just below the lower lip, either fillers or a commissure graft may be advised.
A lip lift performed under local anesthesia is nothing short of dramatic in terms of restoring youthfulness to the lower third of the face. In my experience it is a common prescription in two specific scenarios:
As an isolated exercise where the patient realizes their upper lip is aged and elongated and requests treatment targeting this area.
The other is my suggestion to the patient as part of a global facial rejuvenation effort. In this scenario patients are typically skeptical or afraid of the changes to the upper lip and secondarily the potential scarring at the base of the nose. In my opinion this is due in large part to the overly dramaticized lips present on Park Avenue. These notions are dispelled by taking the patient through my photo gallery of pre and post op photos and/or speaking to patients who have had the procedure. Most patients have a “eureka” moment when they see the power of this simple procedure.
Why are lip lifts shrouded in misconception, kept mysterious or ignored altogether? There are many procedures in plastic surgery that have a poor reputation that is undeserved. This “bad rap” is promulgated from person to person regardless of facts. For those who feel that the lip scar would be obvious—I would raise the point that nostril reductions are routinely performed with little angst about scarring. The lip lift scar is in the same location. As with any procedure, you have to do your homework and trust in surgical skill and judgment, demonstrated experience and results in the surgeon’s photo library. Any operation can be overdone. It is not the nature of the operation that is at fault, but the way in which it is performed.
I strongly contend that rejuvenation of the perioral region is critical to a harmonious facial rejuvenation. This becomes most obvious when facelifts are performed and there is little or no attempt to rejuvenate the mouth. This approach ignores some of the earliest signs of facial aging brought on by loss of bony support.
It is clear to me after 20 years of treating facial rejuvenation patients that the mouth is the focus of attention during discourse. Therefore aging elements present will be firmly ingrained in the observer’s mind and the absence of correction in an otherwise rejuvenated face will only call attention to what was left “undone.”