What is the perioral area?
The perioral area refers to the region and tissues surrounding the mouth. While this area is frequently affected by a myriad of aesthetic deformities, correcting these issues might be somewhat difficult, as the causes of the cosmetic problems are usually multifaceted.
How does the perioral area age?
The perioral area ages via two distinct pathways: intrinsic aging and extrinsic aging. The former refers to the biological aging of the body that is governed by one’s genetics. This usually results in retardation of cellular growth and repair, leading to the loss of numerous dermal cells like collagen and hyaluronic acid, which in turn causes the skin to lose its tone and elasticity. Loss of skin elasticity is usually exacerbated when the orbicularis oris muscle, which is found underneath the perioral area, suffers from atrophy and loses tone and functionality. Some patients may also experience intrinsic aging in the form of unintentional loss of subcutaneous fat, which results in the decrease of skin structure and plumpness. In addition to the loss of dermal cells, muscles, and fat pads, the density of the bone in the mandibular and perioral areas regresses. Overall, the general structural support of the perioral area slowly erodes away due to biological aging, and patients will then display the inevitable signs of aging as a result. Extrinsic aging, on the other hand, is used to refer to environmental and lifestyle factors that worsen the aging process. Cigarette smoking, excessive ultraviolet (UV) exposure due to sunbathing or tanning beds, and pollution all contaminate the skin with a number of harmful free radicals, which are toxins that interfere with the normal cellular turnover rate, worsen the aging process, and amplify the signs of aging.[2-4]
What are the common deformities that affect the perioral area?
One of the most commonly complained aesthetic issues that affect the perioral area is the down-turned corners of the mouth — a condition known as marionette fold — which is caused by the descent of buccal fat. Besides that, many patients also display perioral lip lines that are particularly evident while pursing the lips via the use of the orbicularis oris muscle. The thinning of the lips is another aesthetic deformity, but patients may only need gentle enhancement to rectify the issue. All of these deformities give an aged look to the perioral area that, if left untreated, will not accurately reflect a person’s age accurately.
Who would be interested in this treatment?
The majority of patients concerned about perioral deformities are middle aged and older women (typically in their 40s and 50s). However, many young patients also require treatment to correct already-augmented lips that display undesirable side effects, such as lumps, uneven lip, and over-protrusion. Such issues occur when the vermilion border is over-injected with soft tissue filler. Besides these two categories of patients, smokers who display vertical lip lines around the perimeter of their lips also seek aesthetic treatments to smoothen the appearance of the fine wrinkles. That being said, there are also non-smokers who are still affected by deep static lines in the perioral area.
What are the important considerations that must be made when assessing and correcting the perioral area?
Perioral treatment session can only be effective and successful when extensive clinical and aesthetic assessments have been done, as they will allow for a correct anatomical diagnosis to be made. It is imperative that health care practitioners not only focus on the perioral region but also on the overall facial area to ascertain the severity of aesthetic issues. Hence, physicians must be thoroughly familiar with the dental profile, as well as the relationship between the teeth, lips, nose, and the chin. This knowledge will also help to determine the effective treatment combination that is most suitable for patients. Accurate anatomical diagnosis can be made when the patients are assessed from various angles, like frontal and profile views. During the treatment session, smaller treatment modalities result in far safer and more effective aesthetic outcomes than more drastic approaches. Additionally, patients will be at lower risk of adverse health effects, like vascular compression, if the physicians are not using excessive amounts of product.
How are perioral deformities corrected?
It is best that perioral deformities are corrected individually for beautiful yet natural-looking cosmetic results. The unique treatment approaches for each perioral problem is as follows:
- Vertical lip lines: This condition is commonly known as smoker’s lines or lipstick lines and is characterized by the formation of tiny lines around the perimeter of the lips. Although it is commonly seen in patients who smoke due to the repetitive act of puckering the lips during smoking, it can also appear in non-smokers. Nevertheless, a thorough assessment will determine if the lines form due to genetics or lifestyle habits, such as smoking, using vaporizers, or excessive sunlight exposure. Patients who still smoke or sunbathe may not be good candidates for treatment. Also, the treatment options depend on the severity of the vertical lip lines. For example, patients with early stages of lipstick lines that only require support around the vermilion border can be treated by injecting a suitable dermal filler into the lip border. Soft tissue implants, like Juvederm Ultra 2 or Juvederm Volbella, can be administered into the lip border via a series of micro injections while the patients purse their lips. On the other hand, if the wrinkles are dynamic in nature (i.e. caused by muscle contractions), physicians can administer a botulinum toxin A solution that will temporarily relax the muscles and prevent the formation of lines in the first place. Needle shaping technique can also be employed to trigger collagenases and increase the synthesis of elastic fibers, resulting in delicate improvements to those early Smoker’s Lines. Once the dynamic lines turn static, implantation of Belotero Soft filler via blanching technique can be performed. Clients wanting relatively long-lasting aesthetic improvements may be treated using various skin remodeling methods, such as fractional ablative laser (e.g. iPixel), peel (e.g. Enerpeel MA), and vertical microneedling (e.g. Dermapen). Specfically, Enerpeel MA provides a specific peel for the perioral area with potentially remarkable outcomes. Soft surgery (e.g. Plexr) is also another great option to rid the perioral region of deep static lines: just one or two treatment sessions is adequate to improve the appearance of the perioral area.
- Nasolabial folds: Also known as nasogenian furrows, smile lines, or laugh lines, these unsightly skin folds extend from the side of the nose to the corner of the mouth and can be very prominent during smiling. In order to successfully treat this imperfection, the exact cause of the nasolabial fold must be determined. Although the nasolabial fat pads can be the last fat compartments in the face to deteriorate, smile lines may develop due to the loss of the mid and lateral cheek fat compartments. Additionally, other factors like the widening of the nasal aperture and the nose, and the deepening of the alar triangle will all give the impression of an overhanging shadow and that the nasogenian furrow is much bigger than it actually is. Lifting and pushing the triangle forward with a suitably-textured implant will help to reduce the shadow and shrink the apparent depth of the nasogenian furrow. Instead of treating the individual smile lines, it is best that the mid-face is lifted altogether so that areas of volume loss are adequately plumped without adding more weight to the lower face region.
- Marionette lines: This condition is characterized by the formation of long vertical lines that laterally circumscribes the chin, thus creating an effect where the face bears a resemblance to a marionette puppet (hence the name). Marionette lines usually form due to a degree of descent in the mid-face area. Because of this, the mid-face must be thoroughly assessed during the pre-procedural step to determine the extent of indirect treatment needed. It is advisable to not treat the individual marionette lines directly, as it could result in unfavorable outcomes. The best approach would be to inject a simple hyaluronic acid-based filler, like Belotero Volume or Belotero Intense, in and around the problematic regions. Instead of just filling the depression, physicians should restore the lost structural support and lift the surrounding areas. During the treatment session, it is vital that physicians do not overcorrect the deformities. They must ensure that the cheek and chin areas are seamlessly blended, and that the lower and upper lips are sufficiently supported. Since the perioral region is a highly movable region, the chosen dermal filler must have the right blend of cohesiveness, plasticity, and elasticity to reduce the risk of implant migration. Cannula can be used to subcutaneously administer the aesthetic gel with minimal risk of bruising. The treatment goal is to push the marionette lines forward so that sufficient color refraction is achieved.
- Thinning of the lips: While the shape and size of lips is determined by one’s genetics and ethnicity, it actually thins with age. The shape and size of the lips can only be augmented after taking into consideration the patients’ own perception, as well as the symmetry and proportions of the lip with respect to the face. Some patients may report that their top lip is completely invisible while they smile; hence, it is imperative that physicians assess their patients exercising various expressions, like smiling and kissing, to ascertain the severity of the lip deformity. Inadequate lip height and shapeless Cupid’s bow can be corrected by injecting soft tissue implants into the vermilion border and the Cupid’s bow, respectively. Furthermore, generally thin lips can be easily augmented via filler injection into the pink body of the lip. Fillers like Restylane Kysse, Juvederm Ultra Smile, and Juvederm Volbella are suitable for non-surgical lip augmentation due to their impeccable cohesiveness. On the other hand, patients suffering from a loss of true volume within the vermilion border may instead be treated with Belotero Intense, a volumizing filler that is meant to be administered into the subcutaneous plain to reduce the risk of accidentally injecting the superior labial artery. Besides the classic hyaluronic acid-based fillers mentioned above, healthcare practitioners can also use Profhilo, which is a type of mesotherapy product made of stabilized injectable hyaluronic acid, to enhance tissue regeneration and improve the quality of cells in the dermis and epidermis skin layers. Regardless of the filler type, it is important that the symmetry of lips is always maintained after the procedure, with the top to bottom lip ratio ideally one of 1:1.6.
How can patients improve their overall skin condition at home?
Before patients undergo any aesthetic treatments, like Intense Pulsed Light (IPL), peels, or lasers, it is important that they invest in high quality skincare products and regimens for at least 2 to 4 weeks. In fact, their quality of skin can be determined using Visia Complexion Analysis. Patients can then be prescribed with products that contain potent skin-rejuvenating ingredients, including Vitamin A (sometimes known as retinol) and Vitamin C. These powerful antioxidants are proven to increase fibroblast activation, which results in improved collagen synthesis. Besides that, a combination of either hydroquinone or non-hydroquinone product with retinol can also help to even the texture and pigmentation of skin drastically. In addition, gentle physical and chemical exfoliators will help to remove dead cells and improve the overall appearance of skin. Physicians must also emphasize the importance of using a good quality sunblock regularly, so as to reduce the aging effects of chronic UV exposure.
How can patients improve their overall skin condition?
At the clinic, the aesthetic procedure is almost always started off with a thorough review of patient’s medical history that is followed by an assessment of patient’s skin condition. The skin must be checked for different imperfections, such as dehydration, oiliness, enlarged pores, rough texture, and dullness. In turn, the imperfections can be easily combated and rectified using various aesthetic procedures like chemical peel and fractional ablative laser treatment. These approaches address rough skin texture, uneven pigmentation, and vascular changes caused by aging and chronic sun exposure, and both have a brief downtime period of only 2 to 3 days. These fillers contain hyaluronic acid to hydrate and rejuvenate the skin from deep within, resulting in tighter and radiant-looking skin. These treatment approaches can even be combined with each other to deliver the best possible outcomes for patients.
What are some of the risks associated with perioral area treatment?
Since the perioral oral is highly vascular due to the extensive network of blood vessels, only physicians who are very familiar with the anatomy of the superior and the inferior labial arteries and vascular compromise should perform the procedure. This will help to reduce the risk of the following side effects: hematoma (blood clots), swelling, bruising, vascular occlusion caused by incorrect placement of the product into the superior or inferior labial artery, and necrosis.
These side effects can have devastating impacts on the patients; hence, physicians are advised to use cannula when administering dermal fillers to minimize the risk of unintentional intravascular injections. As for laser skin resurfacing treatment, there is a risk of hypopigmentation and hyperpigmentation. During the consultation session, physicians must explain in detail all probable risks and health complications that patients may face before said patients can give an informed consent to treatment.
Aesthetic procedures to treat perioral deformities must have goals that both doctors and patients agree on. For example, deep lines cannot be erased altogether, but they can have their appearance softened. It is very important that patients understand the expected outcomes of the procedure. Besides that, dermal fillers also cannot be injected in large, bolus quantities, as it will only result in unattractive and unnatural “trout pouts.” Most importantly, the functionality and the integrity of the lips must still be retained following the procedure.