Lip lines

Facelift by by Dr. BCK Patel MD, FRCS in Salt Lake City and St. George, Utah


 There are four major types of lip lines that bother us when they appear! Before we look at these lines, it is important to bear in mind the normal (and beautiful!) shape of ideal lips and the mouth! A careful study of youthful lips allows the particular plastic surgeon to know the surface anatomy that is so vital to recreating lip structure after trauma, tumours or for aesthetic purposes. I have analysed the lips below in detail not found in standard plastic surgery text books.
lip lines normal lip proportions and anatomy
lip lines normal lip proportions and anatomy
lip lines normal lip proportions and anatomy
lip lines surgery before and after CO2 laser and fat grafts to the lips and mouth region by Dr. BCK Patel MD, FRCS

“I have fillers done to my lips because they give me confidence and I think they are my best feature. Dr. Patel always talks me out of over-filling them and I am glad he does as I work in medicine and would not like patients to think I look funny. Although I like fuller lips, he shapes them beautifully and no-one realizes I get fillers to make my beautiful lips look even better. I know it is shallow of me because I look after cancer patients but many of my patients pass comments on my “beautiful lips” and I enjoy talking to them about things other than cancer”  L. Restori  29 Yrs Old with Gorgeous Lips in London- London, England


 Understanding the surface anatomy described above, the relationships between the wet and dry zones of the lips, the vermillion border, the gradual but defined decrease in fullness of the normal lip as one gets to the lateral edges and the importance of preserving and recreating the lip mound (I call it “the earthworm that sits on the lip’s edge” giving it the prominence and beauty of a normal lip) allows the cosmetic and reconstructive surgeon to use his cosmetic understanding and respect for proportions to be applied to reconstructive cases.

lip lines surgery before and after repair of lip defect after Mohs resection of basal cell carcinoma

“My husband actually asked me the other day when I was going to see Dr. Patel as he loves my lips after I have filler done by Dr. Patel. It is always invisible to everyone and I don’t know how but he makes those two vertical lines for me and what he calls the cupid’s bow to give me a hollow between the lines which makes my lips look much younger. I have fine lines on my lips which look much better after the filler and I like having my lips fuller again. I would like them fuller still but he tells me to be conservative “don’t spoil a perfectly good result” is what he told me and so I am sticking with just one vial of restylane filler for my lips!”  Mary S  49 Yrs Old with Lips in Park City, Utah


lip lines surgery before and after treatment Dr. BCK Patel MD, FRCS
lip lines surgery lip lines surgery before and after CO2 laser to lip lines and micro fat grafts to the lips


 Vertical lip lines are variously called “smoker’s lines”, “straw lines”, “marionette lines” (which is an incorrect use of the descriptor “marionette”), “whistle lines” and just plain “old lady lines”.

Interestingly these occur much less impressively in chaps: whether hormones have anything to do with them is unknown. Those men that do get them are generally smokers. Genetics has an important role, as is lifestyle (smoking, sun damage, etc). Although over decades these lines become deeper, the first lines are often seen in the third decade in non-smokers (and white Caucasians) and in even in the second decade in smokers.

The lines are much less common in people with darker skin: melanin protection has some part to play.

lip lines surgery lip lines surgery before and after CO2 laser to lip lines and micro fat grafts to the lips


The downward turn of the corners of lips leads to a “sad” look. Hence these are called “sadness lines”, “Marionette lines” – which points to the continuation of the downward turn of the corners of the mouth into the mento-labial folds, “Cruella lines”, and more recently, “handmaiden lines”.  

As one develops laxity of the lower face, and, in particular jowls, these corners of the lips turn further downwards. The depressor angularis oris muscle also, over time, seems to dynamically pull the corners of the lips downwards. 

Downturning corners of lips seem to affect all races, but the depth of the lines are less deep in races with more pigment.
lip lines surgery before and after lip lines surgery before and after CO2 laser to lip lines and micro fat grafts to the lips


This is less common as a cosmetic concern than the first two types of lines described. As can be sen in the photos below, there is generally a gentle depression between the lower lip and the chin. In youth, it is rarely deep, but does deepen with time. At what level it becomes cosmetically objectionable is undefined. In my experience, some people are bothered by it more than others. A number of tissue release and augmentation with fillers or fat may be used to improve the deep crease, as seen in some of the results shown further below. 

lip lines surgery horizontal line of aging


This is the least common of the lines around the lips that is seen and needing attention. However, when it is present, it becomes accentuated when one smiles and gives a rather pronounced look to the perioral region. Those people who have it, know about it and do not like it!! 


As is understandably obvious, lines generally do not occur in isolation: one often sees the vertical lines together with one or more of the other lines. Treatment is therefore focused on the particular anatomical and physiological changes to achieve the best results. 

Some lip lines may be treated in isolation with lasers with or without fillers. More often, a combination of tissue manipulation, augmentation, laser use, tissue repositioning and repair of surrounding tissues (jowls, folds, grooves, volume deficiency, volume excess, etc) is used to give the best possible results. 
lip lines surgery before and after CO2 laser and fat grafts by Dr. BCK Patel MD, FRCS
Improvement in the mental crease gives a better looking lower lip and chin. Also improved are the vertical upper and lower lip lines, the downward turn to the corners of the lips and the marionette lines. We generally address as many of the four different lines that occur around the mouth to give a congruous and pleasing result
lip lines surgery before and after lip lines surgery before and after CO2 laser and fat grafts by Dr. BCK Patel MD, FRCS
Here we see improvement in the vertical lip lines, the corners of the lips, the chin changes, an improvement in the mental groove and a generalized thickening of the peri-oral tissues surrounding the lips giving a much more robust and youthful look to the mouth and lips
lip lines surgery before and after lower face and necklift by Dr. BCK Patel MD, FRCS
The sub-mental crease has been shallowed, giving the chin a more youthful look. The corners of the lips and the marionette lines have been addressed as have the vertical lines on the upper lip. Lip shaping with appropriate fillers can now be performed to give more projection without looking like “overfilled lips”.
lip lines surgery before and after lip lines surgery before and after lower face and necklift by Dr. BCK Patel MD, FRCS
Here, the marionette lines, the downward turning lips, the lateral lip grooves, the few lip lines and the proportions of the lips have been addressed. With age, one loses the normal proportions of lips: paying attention to recreating these proportions pays dividends!


In this patient, three of the four types of lines were addressed. However, to make lips and the perioral region look more attractive, attention must be paid to the tissues surrounding lips and the mouth, viz. the jowls, the jawline, the nasolabial folds and also any lower facial deformities. 

In this case, a lower cervico-facial rhytidectomy (facelift) allowed us to improve the jowls, achieve elevation of the descended cheek fat pads, augmentation of the jawline and the lips with fat and the use of lasers to the perioral pores and rhytids. This rejuvenates the whole region. it is a mistake to try to improve just one single change that may affect the lips: results are then incongruous. 

​Lip augmentation can be undertaken after the cosmetic reconstructive surgery is complete, giving a nice chape and age-appropriate fullness to the lips. 


If you are an active smoker, treatment of the lips with lasers can be undertaken, but your healing will be slower, there is a greater risk of infection and the risk of scarring is also increased. These are just facts that you ned to know. If you have completely stopped smoking, these risks reduce over time!

In many cases, these lines are seen in non-smokers. Certainly, in the modern world, second-hand smoke does have a part to play in the development of some of these changes. Genetics, sun exposure and lifestyle also have a bearing on the speed with which these appear and progress.

​In the absence of other surrounding changes (jowls, labio-mental lines, neck laxity, etc), isolated treatment of the lips can give very gratifying results as seen here. 

lip lines surgery before and after CO2 laser to lip lines and micro fat grafts to the lips
Vertical lip lines, even in non-smokers, can appear in the third decade. Whilst there is no way of preventing them, treatment with a combination of appropriate lasers, fillers and/or fat grafts gives very nice results.
lip lines surgery before and after lip lines surgery before and after lip lines surgery Lip lines treated with fat grafts and the fractionated co2 laser by Dr. BCK Patel MD, FRCS Reduction of the long upper lip with lip lift lip lines surgery facelift by Dr. BCK Patel MD, FRCS


With great care and attention to surrounding surface anatomical contours and changes


“I had a excellent eye lift done by Dr. Patel. He knows what he is doing and is very pleasant. Dr.Patel was easy to get an appointment and he works with you. The office staff was very pleasant and made you feel calm.”  D. Gull Highly recommended for eye lift surgery – Salt Lake City, UT



Treatments for lips may be undertaken during surgery or in the clinic using local anesthesia with or without sedation
Surgical lip lift to shorten the vertical height of the lip is performed with or without sedation in a sterile surgical center setting. Other treatments like lasers and fillers can be performed with topical and injection anesthetic in the sterile minor operating theatre in the clinic

A combination of dissolving sutures and more permanent sutures (which are removed after a few days) are used for surgical procedures around the mouth and involving the lips

Lasers will be used to treat peri-oral lines, “sleep lines” on the cheeks and other skin irregularities. The advantage of using all the skills and modalities available to us gives us the best results
If any surgical procedures are being performed in addition to other procedure like a facelift, necklift or a Hammock Lift, the procedure is performed in the same surgical setting. If individual treatments are performed, they generally take 20 – 40 minutes

Although we can rejuvenate the mouth area and the lips consierably, every single lip line cannot be wiped away! Patients may need further laser treatments as well, depending upon your history of previous smoking, habits, ethnic background and other factors

The lips and the mouth area do bruise for a few days with surgical procedures performed
Cosmetic procedures are not covered by insurance
Because we use local anesthetic nerve blocks, the procedures is then painless. After the procedures, simple moisterizing of the skin is required. Most patients do not even need simple tylenol for discomfort
The pinkness after laser treatments to the mouth region and the lips can last a number of days and even two to three weeks later, some pinkness will be there. You can use makeup as early as day 7 after treatment. The pinkness is a sign of tissue change and is an excellent indicator of the improvements you will see




Do you have questions or need more answers?

    Contact Info

    ​Dr. BCK Patel MD, FRCS
    ​1025E 3300S
    Salt Lake City, Utah 84106, USA

    (801) 413-3599 (phone/text)

    Dr. BCK Patel MD, FRCS
    617 E Riverside Dr Suite 101
    ​Saint George, UT 84790, USA
    (435) 215-0014