The most common wrinkles treated in the perioral area (area around the mouth) are lipstick lines, marionette lines and parentheses lines. Small lines that etch the lips and may extend vertically from the lips are commonly referred to as lipstick lines or smoker lines. They are typically not a result of smoking (although smoking can contribute). These lines can cause lipstick to bleed, which is how they have come to be called lipstick lines. Wrinkles, lines and folds may form in the oral commissures around the corners of the mouth. In many instances the oral commissure lines will extend downward from the mouth, which is where the terms ‘marionette’ and ‘puppet’ lines are derived. Oral commissure lines may also radiate from the corners of the mouth. Another set of wrinkles may form from an extension of the nasolabial folds. These lines typically arc around the corners of the mouth, looking in many instances like a set of parentheses. (See also: Nose Area Wrinkle section)
In this section, we will discuss how physicians are using advanced liquid face lift products, including dermal fillers, such as Juvederm® Ultra and Restylane®, as well as BOTOX®, to correct these various wrinkles and lines around the mouth.
Note: Before undergoing any procedure discussed on this web site, make sure that your physician has extensive experience with the specific procedure. Medical schools have only recently begun to teach some of these procedures. As with any medical procedure there are varying degrees of risk involved. Please consult your physician.
Lines that etch vertically from the upper or lower lips are commonly called lipstick lines or smoker lines. These lines are more prevalent on the upper lips. While they are sometimes called smoker’s lines, most individuals develop the lines for reasons other than smoking. The lines are a result of loss of volume that occurs with age, along with repetitive bunching of the tissue from muscular activity. These lines can contribute to lipstick bleeding, hence the name 'lipstick lines'.
Physicians typically treat lipstick lines with advanced dermal fillers, BOTOX®, or a combination of both. The depth of the lines and extent of puckering will influence treatment modalities. It is very common to use BOTOX® to treat lipstick lines regardless of the depth of the lines. BOTOX® will have a couple of positive effects on the lines over time. First, BOTOX® will help relax the lines, which tends to eliminate the more permanent etching that may have occurred. Secondly, BOTOX® will help extend the longevity of the advanced dermal fillers. BOTOX® is generally placed at certain points in the orbicularis oris muscle which surrounds the mouth, including the area of the vermilion border of the lips.
If the lines are a little deeper, then many physicians will place a soft, smooth dermal filler such as Juvederm® or Restylane® along the lines to help fill them in. Also some physicians may place a dermal filler such as Radiesse® or Juvederm® Ultra Plus underneath and horizontal to the lines to help elongate the area and stimulate collagen growth. This will help with the puckered look, as well as diminishing the furrowed lines.
Adding some bulk to the lips with dermal fillers such as Restylane® or Perlane® will also have a positive effect on the lipstick lines by further elongating the lip that has contracted over the years. Additionally, this treatment will help with lines on the lips themselves.
The area at the corner of the mouth where the upper lip meets the lower lip is called the oral commissure. The oral commissures usually experience a gradual depression over time. In many individuals, the depression contributes to the formation of wrinkles and lines, as well as contributing to a more angry or stern appearance. Oral commissure lines may extend downward from the corners of the mouth, giving an individual an unnatural puppet or marionette-type appearance. In other instances, oral commissure lines may fan out from the corner of the mouth.
Oral commissure lines are almost always treated with advanced dermal fillers. In instances where individuals have not developed deeper lines or folds, many physicians will place an advanced dermal filler such as Juvederm® or Restylane® under the lines. If the oral commissures have developed into deeper folds, the area may be treated with a bulking filler like Juvederm® Ultra Plus or Radiesse®. These fillers help push up and buttress the folds. Dermal fillers placed in other areas of the face (the upper cheeks for instance) may also give a subtle lift to the oral commissure area, which will help alleviate some of the oral commissure lines.
In some instances, BOTOX® is also used to help alleviate oral commissure lines. BOTOX®, injected properly, provides a subtle enhancement in the appearance of oral commissure lines and lip positioning (see Lip Contouring). Placement of BOTOX® for oral commissure correction varies from patient to patient, depending upon a patient’s particular characteristics. BOTOX® may be placed in the depressor anguli oris muscle (which extends from the chin to around the corners of the mouth) to help lift the corners of the mouth. This alleviates some of the oral commissure depression. BOTOX® may in some instances be placed in the origin of the mentalis (chin) muscle for those who express themselves with excessive chin movement. This may help relax some of the lines around the mouth and chin.
Like many other aesthetic procedures with liquid face lift products, it is important that a physician have extensive experience with BOTOX® and advanced dermal filler medical procedures. For example, if BOTOX® is placed in the depressor labii instead of the depressor anguli oris muscle, the patient may experience a temporary facial expression deformity or not be able to close the mouth properly. Among physicians with extensive experience, the probability of this happening is remote.
Some individuals develop lines that arc around the corners of the mouth and look somewhat like a set of parentheses. These lines are usually an extension of nasolabial folds. They are often shallow, fine lines that are treated much the same way as the marionette lines, with advanced dermal fillers, such as Juvederm® or Restylane®. The filler is usually placed along the line to help lift and fill the line.
As with other lines in this area, patients may see subtle improvement of parentheses lines with liquid face lift treatment of other facial areas, such as the cheeks. Liquid cheek augmentation, for example, will oppose some of the sagging that contributes to lower facial wrinkles.
Steven Hopping MD FACS, Washington DC, DC
Cynthia M. Poulos M.D., Northborough, MA
Kimberly J. Butterwick MD, San Diego, CA ~ Marlene J. Mash MD, Plymouth Meeting, PA
Richard Zienowicz MD, Providence, RI ~ Michael S. Godin M.D., Richmond, VA
Robert G. Graper MD, Charlotte, NC ~ Esta Kronberg, M.D., Houston, TX