Perioral Rhytids

Sara Hogan

Mara Weinstein Velez

Kenneth A. Arndt

BACKGROUND

Perioral rhytids, also known vertical lip lines, bar code lines, or smoker’s lines, are a major cosmetic feature of the lower face. A 2015 survey of aesthetically oriented women over the age of 50 years found that 54% selected perioral skin as the “most likely to treat” area of the face.¹

PRESENTATION

Patients present with a complaint of vertical lip lines, or smoker’s lines, around the mouth.

DIAGNOSIS

Clinical Diagnosis

In the evaluation of a patient with perioral rhytids, a detailed history should be completed of previous cosmetic and facial plastic surgical procedures. Assessment of other lower face features, including the nasolabial and labiomental folds, must be considered. Carruthers et al developed a 5-point validated grading scale for meliomental (marionette) lines as follows: (0) no visible folds, (1) visible folds with slight indentation, (2) moderately deep folds not visible when skin is stretched, (3) long and deep folds, and (4) extremely long and deep folds.² Although helpful, this scale does not address dynamic movement of the lower face. The Fitzpatrick classification of facial wrinkling was developed to assess the efficacy of laser resurfacing on rhytids and incorporates skin elasticity to classify perioral, as well as periorbital, rhytids³ (Table 4.3.1).

Histopathology

Women exhibit a statistically significant greater number and severity of perioral rhytids than men. This correlates on histopathology with significantly fewer appendages than in male skin.⁴ Rhytids have been shown to be shallower in specimens with higher sebaceous gland density.⁵ Histologic analysis revealed that the perioral skin of men displayed a significantly
higher number of sebaceous glands (P = .000; 95% confidence interval [CI], 23.6-53.2) and sweat glands (P = .002; 95% CI, 2.1-8.1) and a higher ratio between vessel area and connective tissue area in the dermis (P = .009; 95% CI, 0.003-0.021). The amount of hair follicles did not significantly differ between men and women, although the average number of sebaceous glands per hair follicle was greater in men (P = .002; 95% CI, 0.33-1.28).⁴ In addition, specimens with higher sebaceous gland density correlated with thicker dermis and less solar elastosis.⁵ Sebaceous gland density seems to be one of the multiple factors that prevents wrinkle deepening, particularly in the perioral region.

TABLE 4.3.1 Fitzpatrick Classification of Facial Wrinkling

Class	Score	Wrinkles	Degree of Elastosis
I	1-3	Fine wrinkles	Mild (fine textural changes with subtly accentuated lines)
II	4-6	Fine to moderate-depth wrinkles	Moderate (distinct papules elastosis, wrinkles, moderate individual papules with yellow translucency, dyschromia)
III	7-9	Fine to deep wrinkles, numerous lines with or without skin redundancy	Severe (multipapular and confluent elastosis, thickened yellow and pallid cutis rhombodalis)
From Fitzpatrick RE, Goldman MP, Satur NM, et al. Pulsed carbon dioxide laser resurfacing of photo-aged facial skin. Arch Dermatol. 1996;132:395.

Subtypes

Penna and colleagues most recently analyzed 462 perioral regions in Caucasian women with patient photographs, magnetic resonance imaging (MRI) scan, and histology to develop a 2-dimensional classification based on lip aging³ (Table 4.3.2). Surface changes and lip shape changes are then scored and correspond with suggested treatment.

PATHOGENESIS

The process of perioral aging varies greatly among individuals and results from several simultaneous processes (Figure 4.3.1). First noted in the early third decade, perioral rhytids become more apparent in the fifth decade around the time of menopause.⁶ The perioral skin receives a great deal of sun exposure. Photoaging produces epidermal and dermal atrophy, elastic and collagen fiber degeneration, asymmetry, dyspigmentation, and uneven skin texture. Smoking cigarettes intensifies these features. However, neither photodamage or smoking history is necessary for the presence of perioral rhytids.

Hard-tissue structures, such as the mandible, maxillary bone, and teeth, provide a foundation for the perioral complex, against which soft tissues exert constant
pressure. Special attention should be given to patients who present with poor dentition, as severe malocclusion, dental misalignment, and deficient teeth may negatively affect treatment.⁵ Clinicians should advise patients to first address dental deficiencies before pursuing perioral soft tissue augmentation.

TABLE 4.3.2 Treatment Options for Perioral Rhytids Based on Grade

Shape Change
1	Rejuvenation not necessary
2	Structural and volume augmentation to address increased length
3	Lip lift. Careful with isolated augmentation
Surface Change
A	Rejuvenation not necessary
B	Resurfacing with laser or chemical peel. Add definition to white roll and philtrum with fillers or fat
C	Deeper resurfacing with ablative laser, filler/fat for vertical rhytids and restoration of lip structure
Reprinted from Penna V, Stark GB, Voigt M, Mehlhorn A, Iblher N. Classification of the aging lips: a foundation for an integrated approach to perioral rejuvenation. Aesthetic Plast Surg. 2015;39(1):1-7.

FIGURE 4.3.1 A 2-dimensional classification of perioral aging. (Left) Grading of upper lip length changes: (1) short concave lip with 2 to 3 mm of upper incisors visible and prominent everted vermillion; (2) Moderately elongated and straighter upper lip with upper incisors at lower border of upper lip and mild degree of vermilion inversion; (3) strongly elongated upper lip forming convex curve around frontal teeth, upper incisors not visible, and vermilion inverted. (Right) Grading of surface changes: (A) distinct philtral columns and Cupid minor dynamic radial wrinkles; (B) flattened philtral columns and Cupid bow, indistinct white roll, beginning static wrinkles, and strong dynamic radial wrinkles; (C) invisible philtral columns, Cupid bow, white roll, and considerable static radial wrinkles. From Penna V, Stark GB, Voigt M, Mehlhorn A, Iblher N. Classification of the aging lips: a foundation for an integrated approach to perioral rejuvenation. Aesthetic Plast Surg. 2015;39(1):1-7.

The musculature of the perioral complex consists of copious muscle fibers arranged in interwoven layers. A large elliptical muscle, the orbicularis oris has upper and lower components that separately attach to the modiolus. Each component has a pars marginalis, which runs arcuately from the mouth corners and functions as a sphincter, and a pars peripheralis, which courses laterally under the cutaneous lip and functions as a dilator.⁴ Insertion of the orbicularis oris into the deep dermis of the lip creates the wet-dry vermillion border⁴ (Figure 4.3.2). The orbicularis oris is in constant motion, deforming the lips to produce the dynamic movements of speaking, smiling, sucking, and whistling. Fine lines develop radially outward from the vermillion border, perpendicular to orbicularis oris force of contraction, and become deeper and longer with age.

At the time of puberty, the orbicularis oris is full, giving lips a voluminous appearance, but then flattens with age.⁵ Iblher and colleagues utilized frontal face photography, MRI volume changes, and histological evaluation and determined that the main process of lip aging is a redistribution from thickness to length, whereas the total volume is preserved.⁷ Decreased pouting and vermillion inversion result and are perceived as thinning and ptosis of the lip. The intercommissural distance increases as lip height decreases, such that people over the age of 50 years lose their ability to make a high smile.⁶,⁸ Perioral adipose is arranged in 2 compartments, superficial and deep to the orbicularis oris and mentalis muscles, respectively, and is also lost over time.⁹ Although men experience a similar loss of soft and hard tissue volume with advancing age, they are less likely than women to develop perioral rhytids owing to the increased subcutaneous adipose surrounding terminal hair follicles.¹⁰

FIGURE 4.3.2 Structural anatomy of perioral face. A, Anterior view. B, Sagittal view.

TREATMENT

Treatment of perioral rhytids should address volume loss with augmentation, overlying skin changes with surface enhancement, and ptosis with surgical intervention for lifting.¹¹ In 2008 consensus recommendations, cosmetic dermatology experts agreed on a combination of filler and botulinum toxin as the standard for lower face rejuvenation.¹² Current techniques for improving surface changes and enhancing volume are discussed later (Algorithm 4.3.1).

Medical

Topical Therapy

Topical agents, both prescription and over the counter, have been used to treat perioral rhytids. Among these, antioxidants, retinoids, peptides, and hyaluronic acid are the most well studied. One study showed up to 34% reduction in perioral rhytids following 90-day application of a retinaldehyde and hyaluronic acid preparation nightly.¹³ Another study of daily application of a topical preparation of palmitoyl tripeptide-5, dipeptide diaminobutyroyl benzylamide diacetate, ubiquinone, and vitamins C and E demonstrated >50% reduction in perioral rhytids at 3 months.¹⁴

Cosmetic

Surface Changes

Chemodenervation. Onabotulinumtoxin A (Botox-A, BTX-A) is not Food and Drug Administration (FDA) approved for use in the perioral area or lips, and treatment is primarily based on clinical experience. Use of BTX-A and other neuromodulators in the lower face is more complex, less reliable, and more prone to adverse effects, as lower facial muscles have a longer lasting response to BTX-A than upper facial muscles.⁴,¹⁵

This is in part due to the size of target muscles—with the glabellar complex, for instance, muscle mass is simpler to assess and patient response easier to predict. Doses in the lower face should therefore be decreased to approximately half or one-third of the dose injected in the upper face.

ALGORITHM 4.3.1 Treatment algorithm for perioral rhytids. CO₂, carbon dioxide laser; Er:YAG, erbium yttrium aluminum garnet laser; RF, radiofrequency. (Courtesy of Macrene Alexiades, MD, PhD.)

Semchysyn and Sengelmann showed that treatment with BTX-A improved the appearance of rhytids, enhanced lip eversion, and increased lip fullness.¹⁶ Botulinum injections address fine vertical rhytids secondary to muscle contraction but do not significantly affect deep rhytids or rhytids secondary to smoking or photoaging. Results are short-lived, about 3 to 6 months, in the perioral area owing to constant movement and use. Patients with static rhytids are best treated with a combination of therapies.

There is a narrow therapeutic window in which desired cosmesis is achieved and mouth function is preserved. Patients should always be counseled about potential lip dysfunction, such as difficulty pursing lips, pronouncing “p’s,” sucking from a straw, or playing a wind instrument.¹⁷ The target injection area is along the vermillion border in the middle of each upper and lower half-lip, as motor end plates are most concentrated in the center right and center left orbicularis oris quadrants¹⁷,¹⁸ (Figure 4.3.3).

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