Perioral Area Treatment (Wrinkles and Lines Around the Mouth)

The aging process of the perioral area

There are a number of factors involved in the aging process of the perioral area, which is located around the mouth. Generally, this area is greatly affected by the loss of hyaluronic acid and collagen in the skin, which is a result of intrinsic aging. In addition, this area may be disturbed by the natural loss of subcutaneous fat, which can reduce overall volume, as well as the loss of supportive bone density in the mandible. Extrinsic factors, such as UV exposure and smoking, also play an important role in skin aging, causing damage to the skin’s texture, elasticity, and structure.

Main concerns of patients

One of the main concerns in the perioral area is buccal fat descent, which subsequently causes marionette folds. Additionally, patients are concerned about perioral lip lines, which could arise from the constant pursing of the lips. Apart from that, patients are also often bothered by nasolabial folds, smoker’s lines, barcode lines, and lip thinning.

Main patient groups of treatment for the perioral area

The main demographic looking to revitalize this area is middle-aged women, although there are increasing numbers of young patients seeking treatment around their lips. Apart from that, smokers often undergo treatments in the perioral area to reduce the appearance of lines. Patients who have previously had unsuccessful lip procedures, including those with an over-injected vermilion border or uneven lips, also regularly seek perioral treatment.

Key factors to consider when treating and assessing the perioral area

In an anatomical diagnosis, doctors should carefully assess both the dental arcade and profile. Additionally, the relationship of the lips and teeth to the nose and chin should be carefully considered. Examine the patient from profile and frontal views. When performing a treatment on the perioral area, keep in mind that less is more. Multiple small treatment modalities tend to deliver safer and better treatment outcomes. When less product is used, there is a lower risk of causing vascular compression.

Also, It is important to consider the whole face when performing the procedure—not just the perioral area. One of the common pitfalls is to focus too much on 1 particular troubled area, while ignoring other aspects of the face. When treating the perioral area, it is important to take into account the patient’s desired outcome and expectations. Determine the most appropriate treatment approach based on this combination of factors.

Wrinkles and lines around the mouth or smoker’s lines

Before treating perioral lines, find out their underlying causes through proper diagnosis. There are different factors that are responsible for the formation of perioral lines, including genetic factors, smoking, and excessive sun exposure. The proper treatment approach differs depending on the underlying diagnosis and the severity of lines.

For early lines, it is recommended to administer Juvederm Volbella or Ultra 2 via microinjections into pursed lips. Botulinum toxin A can also be used to prevent the formation of dynamic lines. In addition, early lines can be treated using a needle-shaping device (e.g. Vibrance) to stimulate the synthesis of elastic fibers and collagenases. If support is needed around the vermilion border, small injections may be performed.

For longer-lasting results, remodel the skin through skin resurfacing. There are many ways of resurfacing the skin, including soft surgery (Plexr), peels (Enerpeel MA), vertical microneedling (Dermapen), and fractional ablative laser (iPixel).  

Treating volume loss in the lips

Due to the natural aging process, the lips gradually become thinner. When treating volume loss in the lips, beware of losing their symmetry. The ratio of the top to bottom lip should be 1:1.6. Carefully assess the proportion of the lips with regard to the face while keeping the patient’s profile in mind.

A cohesive filler (such as Restylane Kysse) should be used. The treatment approach varies depending on the desired treatment outcome and the patient’s perceptions of their profile and proportions. The vermilion border should be treated if the lip height needs to be increased.

The marionette area

In most cases, patients with marionette folds suffer from midface descent. Therefore, the midface should be assessed before treating these lines. It is recommended to adopt an indirect approach. However, if the patients insist to use a direct approach, they should be warned that the outcome may not be as effective.

A simple hyaluronic acid filler, such as Belotero Intense or Volume, can be injected into and near the affected areas. The main goal is not merely to fill the folds or lines, but to lift the area by supporting it. To ensure the blending of the cheek into the chin region, it is important not to overfill. At the same time, there should be adequate support for the upper and lower lips. An ideal product will have the right levels of cohesiveness, plasticity, and elasticity, as this will help to prevent any migration and movement of the product. In order to reduce the risk of bruising, use a cannula to administer the filler subcutaneously.

Nasolabial folds

Instead of correcting individual nasolabial folds, the practitioner should augment the area to provide a lift to the midface. This allows for the correction of volume loss at the lower part of the face without weighing it down. These lines usually stem from the loss of lateral and mid-cheek fat compartments. Therefore, these areas should be prioritized during the treatment.

Enhancing the overall look with home care

Before using intensive treatments, patients should be enrolled into a skin health program for approximately 2 to 4 weeks. Then, they should use retinol, hydroquinone, and/or non-hydroquinone products to even out skin texture. These products can be used alone or in combination to correct skin pigmentation. Part of the vitamin A family, retinol helps activate fibroblasts to promote collagen regeneration. Vitamin A is able to improve dull skin by stimulating cell renewal. Products like Environ allow for a step-up treatment with varying Vitamin A levels.

In addition, products that contain epidermal growth factor (EGF) and vitamin C can also be used to treat the perioral area. This includes AlumierMD, Image Skincare and Tebiskin. For texture-related skin problems, it is recommended to use the ZO range, which consists of retinol, vitamin C, salicylic acid pads, and exfoliators. While on home care, patients should use sunscreen on a regular basis to avoid further skin pigmentation and aging.

Improving the skin’s overall appearance texture at clinics

Firstly, perform a diagnosis and assess the medical history of the patient. Then, examine the skin’s condition (i.e. degree of oiliness, dehydration, dullness, and roughness). Check if there is enlarged pore size. Fillers such as Juvederm Volite are able to improve skin hydration, elasticity, and texture, delivering visible results after 1 session. Restylane Skinboosters helps to hydrate and enhance the perioral area. Different dosages of trichloroacetic acid (TCA) chemical peels can be used to enhance skin texture. The skin-smoothing effects of TCA peels are often superior to other treatment modalities. Due to their ability to tighten pore size and promote collagen synthesis, laser peels can also be used for skin rejuvenation

For best results, a combination of different treatments can be used to create synergistic effects. In general, fractional ablative laser treatments and chemical peels are able to deliver dramatic results with minimal downtime. They are especially useful in treating skin pigmentation and vascular changes associated with sun damage and aging.

The risks of treating the perioral area

The treatment of the highly vascularized perioral area could result in a variety of complications, such as swelling, necrosis, bruising, and hematoma. When placing fillers, care must be taken to minimize tissue trauma. Intravascular injections can potentially lead to severe complications, such as vascular occlusions. In addition, there is a risk of placing the product into the inferior labial or superior labial artery. To minimize the risk of complications, a cannula should be used for administration, and syringe aspiration should be performed during administration. Other procedures, such as laser skin resurfacing, are associated with a risk of hyperpigmentation and hypopigmentation. Patients should be informed of all the potential risks before undergoing any treatment in the perioral area.

Final piece of advice

As with all procedures, it is essential to understand the patient’s expectations and educate them about realistic results. For example, patients should understand that deep lines in the lips cannot be completely removed, as the treatment is only intended to soften the look of lip lines. Apart from that, practitioners should be wary of over-injection. When performing treatment on the perioral area, care must be taken to keep the lip functions intact.

Permanent makeup to enhance the lips

The appearance of the lips can also be enhanced by applying pigment into the skin. The lip line often fades due to aging, resulting in the loss of fullness and definition. Permanent makeup helps to define the lip line, thereby creating the appearance of more volume.

A lip blush can be used to blend the lip line into the lips, creating a color-wash effect while defining the lip line. Doing the lip line alone may result in an artificial appearance. Dermal fillers can be used in conjunction with permanent makeup if more lip volume is needed. However, permanent makeup treatments should be performed 6 weeks after filler injections or prior to them to reduce the risk of complications