As mentioned, aging changes around the mouth take different forms and at different rates. These changes vary
according to age, race, sex, history of smoking, degree of sun damage, type of skin and
familial hereditary characteristics.
The youthful mouth has the following characteristics:
- The distance from the nose to the upper lid margin is short, about one half of the distance between the lower lip and the chin.
- Smooth upper and lower lips with no vertical lines
- Pronounced cupid’s bow and vertical philtral columns and and an inter-column depression
- Distinct white roll
- Good lip volume with a balance whereby the lower lip is roughly twice as full as the upper lip
- Gentle nasolabial folds with a smooth transition from the perioral region to the cheeks
- Lack of Marionette lines with horizontal or slightly upward slant to the lateral commisures
- Pronounced chin with no ptosis of the chin fat pad
- Smooth chin with no visible pores
- No visible quivering of the mentalis muscle
- A smooth jawline with a lack of jowls or pronounced depressions
The overall changes that may be seen are summarized in the following drawing:
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“Well, the last time I had a picture taken I could hardly see my eyes because of the weight of heavy eyelid. Then I paid attention to how I was actually using my eyes and I really noticed when I was looking at anything especially the computer I was straining my forehead to see better. Since I have had it done I no longer have to lift the forehead and tilt my head to see. It is amazing! I love…” D. Rock 63 Yrs Old with Fat Droopy Eyes – Salt Lake City, UT
TREATMENT OF THE ELONGATED UPPER LIP
As we age, the distance between the nose and the upper lip elongates. When significant, this distance can be narrowed
using a “bull-horn” technique where radiofrequency instruments are used to give an almost invisible scar.
Tissue removed can be de-epithelialized and used to augment the upper and/or lower lip as well.
TREATMENT OF THE SHORT UPPER LIP
As we age, the distance between the nose and the upper lip elongates. When significant, this distance can be narrowed using a “bull-horn” technique where radiofrequency instruments are used to give an almost invisible scar. Tissue removed can be de-epithelialized and used to augment the upper and/or lower lip as well.
TREATMENT OF THE LARGE LOWER LIP
Macrocheily is an excessively enlarged lip: it is seen in a number of conditions. These large lips are reduced with an anatomically planned resection of a longitudinal wedge of mucous membrane deep inside the lower lip so that the subsequent scar is well hidden.
TREATMENT OF VERTICAL LIP LINES
The eyelids and lips are unique in that there are muscles which have no deep attachment to the periosteum but only attachments to the cutaneous structures. This results in vertical lines around the lips and crows’feet around the eyes. The vertical upper and lower lip lines are variously called “lemon wrinkles”, “smokers’ lines”, and “bleed lines”.
Lip lines can be treated using several techniques, each chosen with the patient’s skin type, age and pigmentation in mind. Dermabrasion, chemical peels, radiofrequency peels, laser peels and other methods are available to treat these.
Lip lines can be treated using several techniques, each chosen with the patient’s skin type, age and pigmentation in mind. Dermabrasion, chemical peels, radiofrequency peels, laser peels and other methods are available to treat these.
TREATMENT OF LOSS OF CUPID’S BOW AND VERTICAL COLUMNS
Suture and incision techniques now allow us to obtain subtle but impressive elevation of the cupid’s bow and some accentuation of the philtral columns. These are minimally invasive techniques which yield a reliable outcome. This particular technique is called philtropexy.
TREATMENT OF THE “FROWNY MOUTH”
A frowny mouth is the term used to describe the down-turning corners of the mouth or lip commissures. This downward turn gives the face a sad, pessimistic facial expression. Even with well-performed facelifts, this downward angulation of the lip commissures can be difficult to correct. Using “Optimistic suture” that were designed by Dr. Panfilov, we have had excellent results. This correction may be performed at the same time as a facelift or in isolation.
TREATMENT OF LOSS OF WHITE ROLL
There is a clear reflection of lips just above the pink edge of the lips called the vermillion border. This “white roll” is lost with age, as we lose the definition between the upper lip and the vermillion border. Together with this loss of the white roll, we also lose the vertical columns called the philtral collumns. In youthful lips and mouths, these philtral columns are separated by a hollow, the inter-philtral groove, which gives the upper lip and the area between the nose and the upper lip structure. Caucasian races lose these structures (the white roll, the philtral columns, the inter-philtral groove) earlier than other races. Even without surgery, with the proper use of fillers of various kinds, one can recreate these youthful anatomical landmarks as seen here.
TREATMENT OF LOSS OF LIP VOLUME AND BALANCE
The balance of the upper and lower lips has to be remembered but differences between countries should also be considered. For example, in Brazil, the upper and lower lips are balanced equally. In most of northern Europe, the creation of the cupid’s bow with philtral columns and a larger lower lip is considered more attractive.
Microlipofilling of facial structures with autologous fat grafts can be used for different parts of the face, including the upper and lower lips. Variable amounts of properly treated fat are injected into the upper and lower lips. There is always postoperative swelling which can make the augmentation look excessive, but this invariably settles to a level where one wishes more had been done! There is a variable degree of absorption of the transplanted fat, but as I always tell my patients, the 50 – 60% that survives is forever (almost)!
Other options of augmenting lips include fillers which are presented and discussed elsewhere. We also use the SMAS we remove during facelift surgery to augment parts of the face, including lips as needed.
Other options of lip augmentation include the use of orbicularis muscle removed from eyelids, temporalis fascia or other fascia or muscle, depending upon what other surgery may be performed. Fascial and muscle graft
absorption is about 50%.
Microlipofilling of facial structures with autologous fat grafts can be used for different parts of the face, including the upper and lower lips. Variable amounts of properly treated fat are injected into the upper and lower lips. There is always postoperative swelling which can make the augmentation look excessive, but this invariably settles to a level where one wishes more had been done! There is a variable degree of absorption of the transplanted fat, but as I always tell my patients, the 50 – 60% that survives is forever (almost)!
Other options of augmenting lips include fillers which are presented and discussed elsewhere. We also use the SMAS we remove during facelift surgery to augment parts of the face, including lips as needed.
Other options of lip augmentation include the use of orbicularis muscle removed from eyelids, temporalis fascia or other fascia or muscle, depending upon what other surgery may be performed. Fascial and muscle graft
absorption is about 50%.
TREATMENT OF NASOLABIAL FOLDS
Nasolabial folds are the folds one develops between the nose and the mouth. These folds deepen with age and make the midface look older, casting a shadow below the cheek. There are several approaches to improving nasolabial folds. Non-surgical approaches include the use of fillers which may be performed in clinic and will give results that
last up to 9 months.
last up to 9 months.
TREATMENT OF MELOLABIAL FOLDS
Melolabial folds are the folds between the corners of the mouth to the jawline: these give us what we call “frowny faces” with the downturning of the corners of the mouth. This area is treated using three techniques. Botox can be injected in the depressor angularis oris muscle which allows the depressor of the corner of the mouth to relax, hence giving us a “happier” look. A similar result can also be obtained by surgically weakening the depressor angularis oris and elevating the angles of the mouth with proper plastic surgery techniques:
surgical reduction of the depressor angularis oris muscle may be used, but botox can achieve the same result, albeit on a more temporary basis.
improvement in the melolabial folds and the angle of the mouth using the lifting surgical technique together with surgical weakening of the depressor angulari soris and fat augmentation of the mesolabial folds.
Surgical markings for angular lift and weakening of the depressor angularis oris muscle.
Fillers can be used in the melolabial folds and along the jawline to improve the shadows cast by the deep melolabial folds and the area in front of the jowl.
TREATMENT OF THE WITCH’S CHIN
The witch’s chin is the description used for the droop in the chin that occurs with age. In the lateral view, it shows as a “dropped chin”, with the inferior edge of the chin extending below the neck line, giving the so-called witch’s chin. We always address this when we perform facelifts and necklifts to improve the profile view of the face and neck:
TREATMENT OF CHIN PORES
The skin around the mouth and chin ages much more than the skin on the rest of the face because it is made up of thicker, more sebaceous skin and also because of the constant wear-and-tear that this area undergoes. Indeed, changes like a deep crease just below the lower lip, pores on the chin, quivering of the chin muscles (the mentalis muscles), vertical lip lines, nasolabial folds, melolabial folds, jowls, and lengthening of the upper lip all conspire to give us an older look. In plastic surgery, when we perform facelifts and necklifts, we address each of these changes to give the rest of the face a nice balanced result. Some of these changes can be addressed with fillers, botox and lasers.
TREATMENT OF THE QUIVERING CHIN
As we age, the mentalis muscle often develops a quiver which gives us depressions on the chin. This change can be nicely managed with the use of botox injections. If there are any depressions, fillers or fat grafts improve the changes without resorting to the use of chin implants, which are reserved for the genuinely recessed chin (hypoplastic chin).
TREATMENT OF JOWLS
The best treatment for jowls is a properly performed facelift and necklift. This allows the creation of a strong jawline, the reduction of jowls and the recreation of a youthful face and neck. Isolated liposuction of the jowls does not give reliable or effective results.
TREATMENT OF PRE-JOWL SULCUS
On occasion, when a patient does not desire to undergo surgery, the hollow in front of the jowl can be partially filled with a filler which gives a straighter jawline. Although the results are not as good as seen with a well-performed facelift and necklift, they are still excellent. In particular, when photographs are taken, these pre-jowl hollows (sulci) cast a shadow which makes people remark “I don’t like my photos to be taken”. Improving this jawline
makes photographs much more pleasing!
makes photographs much more pleasing!
FAQs
WHAT KIND OF ANESTHESIA WILL BE USED?
Facelifts are performed in an operating theatre for the sake of sterility and your comfort. We have a team of anesthesiologists and nurses who are trained to specifically look after patients undergoing these procedures.
WHAT KIND OF ANESTHESIA WILL BE USED?
General anesthesia is best for facelifts, although in some instances, sedation anesthesia may also be used.
WHAT KIND OF SUTURES ARE USED?
With a 3-D procedure, there are several layer of sutures, accurately placed to give the lifting, tightening and filling, without leaving any tell-tale pull-lines. Some are slow dissolving sutures, others are more permanent. The skin sutures are generally removed between 7 and 14 days.
DO YOU USE LASERS FOR THIS SURGERY?
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, rather than performing quick or weekend or one-hour facelifts is that it allows us to give you a remarkable improvement not only in the structure and appearance of the face, but also the health and smoothness of the skin as seen here:
HOW LONG DOES THE SURGERY TAKE?
Facelift surgery can take between 3 and 5 hours of surgery time, depending upon the planned procedures, patient’s face-type, age and other factors.
WHAT ARE THE MOST COMMON RISKS OF FACELIFTS?
Bruising and swelling are de rigeur! However, significant long-lasting complications are rare.
Bleeding is not common as we pay close attention to proper hemostasis. On rare occasions, a small hematoma may collect.
Everyone will experience some numbness in the face: this resolves over weeks to months. This occurs because of the dissection of the face. This is not a complication.
Because of the dissection and repositioning of the tissues, it is common for there to be small differences in the smile between the right and left sides: this is usually only noticeable to the patient and to Dr. Patel! It recovers over a few weeks.
All faces have asymmetry and there will be some degree of asymmetry. This is to be expected.
Permanent weakness of nerves and muscles is rare.
The scars are usually very well hidden. However, some patients may have a tendency to cause hypertrophic scarring: in such cases, certain lasers and treatments will help. By-and-large, scars are rarely a problem. With Caucasian skin, pinkness of scars is to be expected for several weeks. With darker skin, some hyperpigmentation may occur.
Bleeding is not common as we pay close attention to proper hemostasis. On rare occasions, a small hematoma may collect.
Everyone will experience some numbness in the face: this resolves over weeks to months. This occurs because of the dissection of the face. This is not a complication.
Because of the dissection and repositioning of the tissues, it is common for there to be small differences in the smile between the right and left sides: this is usually only noticeable to the patient and to Dr. Patel! It recovers over a few weeks.
All faces have asymmetry and there will be some degree of asymmetry. This is to be expected.
Permanent weakness of nerves and muscles is rare.
The scars are usually very well hidden. However, some patients may have a tendency to cause hypertrophic scarring: in such cases, certain lasers and treatments will help. By-and-large, scars are rarely a problem. With Caucasian skin, pinkness of scars is to be expected for several weeks. With darker skin, some hyperpigmentation may occur.
HOW MUCH BRUISING AND SWELLING WILL I HAVE?
Bruising around the jawline and upper neck is common for the first two weeks. The face itself usually will not get much bruising, but may be pink from any laser work. Swelling is to be expected because of the extent of the surgery: the swelling abates over about two weeks.
DOES INSURANCE COVER FACELIFTS?
Only if insurance will buy you a Rolls Royce (Phantom, of course).
HOW PAINFUL IS A FACELIFT?
A sensation of firmness will be there because of the swelling: this is present for the first few days. Most patients do not need prescription pain medication after the first two to three days.
ARE THERE ANY RESTRICTIONS AND WHEN MAY I RETURN TO WORK?
We will provide you with a special neck dressing which you will wear as much as you can for the first couple of weeks. You will also apply a moisturizer (any brand will do) to the face as healing skin and lasered skin requires moisturizer. Icing the face also helps for the first two to three days. Many of our patients will ice the face for longer as it feels good. You may be up-and-about the day after surgery. Gentle exercise (treadmill and stationary bicycle) may be commenced by day 3. More vigorous exercise like skiing and tennis may be resumed by about day 10.
SHOULD I LOSE WEIGHT BEFORE MY FACELIFT?
Ideally, you should be within about 3 – 5 pounds of your desired weight. Whereas I can create the most beautiful angles and curves in slim patients, if you are able to get close to your ideal weight, we can wonders as can be seen in this patient who lost some weight before her surgery and is absolutely chuffed at her result:
In the first few days, everyone will experience some degree of dryness and blurry vision. You will also feel that your lids look a little tight on the outer corner where you will also feel some of the deeper sutures if you put your finger there: this is of no concern. The tightness and the bumps under the skin settle over a few weeks.
More serious complications which are very rare include excessive bleeding, hemorrhage and loss of vision.
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Contact Info
Dr. BCK Patel MD, FRCS
1025E 3300S
Salt Lake City, Utah 84106, USA
(801) 413-3599 (phone/text)
E-Mail: bckpatelmd@gmail.com
bckpatel.info
Dr. BCK Patel MD, FRCS
617 E Riverside Dr Suite 101
Saint George, UT 84790, USA
(435) 215-0014
E: drbckpatel@gmail.com
