Lip ageing: how does it work?

According to the experts interviewed for this article, the loss of volume and thinning of the lips plays a major role, but the loss of lip definition seems to be as important. Looking at a face laterally, a youthful perioral area is like a ski jump. As the face ages, it loses this curve and flattens. The philtrum also flattens and loses its natural shape and definition. Ageing also takes its toll on the cupid’s bow, which loses its curve and character. Younger lips have a b-sound appearance. Attractive lips are typically characterised by the downward point in the centre of the upper lips. The vermilion border is larger and longer. At the corners of the mouth, the vermilion becomes thicker.

With age, the contours of the mouth are not a smooth line, but an undulated line (with mountains and valleys). The lines (also called smoker’s lines or barcode lines) around the mouth may cause lipstick to bleed, which only renders them more pronounced. According to Dr Hema Sundaram’s own clinical observations, waxing the upper lips as well as smoking may increase the barcode lines. The corners of the mouth also pull down and give a frowning and unhappy look. As well as losing their volume and definition, the lips also lose their colour and colour contrast. The vermilion border is the significant colour change at the junction between the cutaneous lip and the vermilion. In young lips, the vermilion border is like a white roll that creates a sharp colour contrast with the red of the lips, and gives a nice colour definition. With age and the lips flattening, the colour contrast becomes somewhat more transient and less defined. Hyperpigmentation can also be common if the lips are exposed to sunlight and unprotected, with sun spots around the mouth and the vermilion.

The upper lips seem to show more signs of ageing than the lower lip, which has a better resistance against drooping than its counterpart.

The ageing lip process comes mainly from two factors: muscle ageing and photoageing. The orbicularis oris muscle is a complex set of muscles in the lips that circle the mouth. With ageing, the muscle thins out and the lips appear deflated and lose their tone. Dr Lori Brightman highlights the repetitive puckering motion we do on a daily basis, which increases the formation of deep wrinkles around the lips. Smoking is one of the main causes of this puckering motion, but the sipping motion from drinking out of a straw or directly from a bottle can also contribute to formation of these lines

Photoageing speeds up the break-down of collagen, which results in the loss of cellular matrix support, and a reduction of water being retained in the tissue. The loss of collagen results in wrinkles and loss of volume.

The loss of skin tone in the lips is more of a microcirculation issue. The nice, bright pink or red of youthful lips is created by the blood vessels. As blood circulation and the blood vessels cease to work optimally with age, the vermilion loses the bright tone.

What are the latest cosmetic lip treatments?

Dermal fillers are the treatment of choice to enhance the lips, but using fillers to treat lips is much more complicated than one might think. Expert physicians such as Dr Sundaram use a combination of different fillers to firstly address the perioral frame, which supports the lips, and if necessary, will inject the lips themselves. To address deep volume loss from perioral and mid‑face fat compartments, deep fillers such as Restylane® Perlane (Q-Med, A Galderma Division, Uppsala, Sweden), Emervel® Volume (Q-Med, A Galderma Division), Radiesse® (Merz Aesthetics, Frankfurt, Germany), Juvéderm® Voluma (Allergan, Irvine, California), Teosyal® Ultimate (Laboratoires Teoxane, Geneva, Switzerland), and Belotero® Volume (Merz Aesthetics) are the products of choice. Fine perioral lines can be injected with softer fillers such as Juvéderm® Volbella (Allergan), Belotero® Soft (Merz Aesthetics), Teosyal® First Lines (Teoxane), or Emervel® Touch (Q-Med, A Galderma Division). And to inject the lips if still indicated, products such as Restylane® Lip Volume (Q-Med, A Galderma Division), Belotero® Balance (Merz Aesthetics), Juvéderm® Volbella (Allergan), Teosyal® Kiss (Teoxane), and Emervel® Lips (Q-Med, A Galderma Division) will restore volume and shape.

As well as which products to use, their placement is another key skill to master. Dr Raina Zarb Adami notes that dermal fillers can be placed at five different sites:  first the base of the nose where it meets the lips; then in the vermilion border with a retrograde application of the filler through linear threading parallel to the vermilion border, 1 mm inferior to it on the upper lip and 1 mm superior to it on the lower lip; a third site just underneath the corners of the mouth; a fourth in the chin; and finally, inside the cheeks to correct the drooping of the fat pads.

It is paramount to remember that as the lips are one of the most sensitive areas, injections could be painful and prone to side-effects. The pain has largely been addressed by the addition of lidocaine in the latest lip-specific monophasic hyaluronic acid (HA) fillers. The use of injection systems, however, has certainly changed the scene, according to Dr Zenker, who has been using them since 2005. In her experience, they lessen the use of nerve blocks and considerably reduce side-effects such as pain and swelling.

According to Dr De Boulle, the repetitive use of dermal fillers has a rejuvenation effect on top of the bulking effect of the filler. Dermal fillers stretch the fibroblasts and by doing so, prompt the formation of new tissue. This leads to an improvement in the surrounding skin and mucosa. According to his experience of dermal fillers, repeated treatments mean less product is needed, and the frequency of the treatment reduced.

Fillers and botulinum toxin can be a winning combination, especially to treat the depressions in the corners of the mouth. Dr Adami, in her thesis ‘The Use of Botulinum Toxin and Dermal Fillers for Non-Invasive Enhancement and Rejuvenation of the Female Peri-Oral Area, the Lower Third of the Face and the Upper Neck’, suggests that reducing the downward traction on the angles of the mouth by injecting botulinum toxin-A into the depressor anguli oris muscles may be a useful adjunct to fillers2. Furthermore, Dr De Boulle told PRIME that the use of the botulinum toxin may enhance the result of the filler, and even prolong it.