Aging causes lengthening of the upper lip skin, reducing the visible mucosal surface. Loss of subcutaneous fat flattens the lips and reduces the definition of anatomical landmarks such as the vermillion border, Cupid’s bow, and philtrum columns. This thinning combined with the repetitive movement of the orbicularis oris muscle results in “lipstick lines” or vertical rhytids emanating from the vermillion and extending onto the white upper lip skin. The skin is further thinned by degradation of elastin and collagen fibers which occurs with aging, and women have thinner soft tissue in the perioral region compared to men.
Hyaluronic acid fillers are commonly used to improve lip volume and to sculpt and define the vermillion and philtral border as they flatten with age. Filler placed between the skin and the orbicularis muscle provides improved skin structure and support to the upper lip. Filler should not be placed in the orbicularis oris muscle as the muscle houses the labial vascular supply, risking intravascular injection and subsequent necrosis. Neurotoxins, while they help weaken muscles causing lines, are detrimental to upper lip rejuvenation, as they do nothing to improve skin structure and may exacerbate elongation of the upper lip. Injectable agents do not shorten the elongated upper lip. Surgery, such as a lip lift to shorten the vertical skin in this area, may be a good adjunctive procedure.
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