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Aging of the Upper Lip

Methods: Upper lip measurements were performed on cranial magnetic resonance images of 200 Caucasian subjects (100 men and 100 women). 

The study population was aged between 20 to 30 and 65 to 80 years. 

Results: The upper lip in the old age group differed significantly in length (19.24 percent in women and 18.24 percent in men),

 thickness (up to −40.55 percent in women and −32.74 percent in men), 

and volume (−20.89 percent in women and −17.40 percent in men). Soft-tissue thickness at the alar nasolabial fold was significantly thinner in the old age group (−25 percent in women and −25.7 percent in men) and showed significantly greater tissue loss than elsewhere in the upper lip (p < 0.001).

Conclusions: These results suggest that the aging perioral area is affected with a combination of soft-tissue lengthening, thinning, and volume loss. The clinical implications of this study on perioral rejuvenating strategies will be explained in part II.

The mouth and perioral area play a primary role in emotional expression and attractiveness of the face. 

In the scientific literature, one can find numerous attempts to answer the question of how facial tissue ages over time. 

The maxillary bone, teeth, and mandible constitute the solid framework that defines the shape of the face. 

Bony resorption in the aging face is most profound at the maxillary level and at the alveolar ridge after tooth loss. 

The flattening of the maxillary arch causes a posterior displacement of the nasal base and upper lip and leaves a redundancy in the soft-tissue envelope of the perioral complex.1–3 Intrinsic soft-tissue changes are a thinning cutis from degradation of elastin and collagen fibers and distinct atrophy of the orbicularis oris muscle.4–6 

Clinically, the upper lip undergoes vertical lengthening and appears deflated. 

Findings on photometric analysis have shown that older patients show significant lengthening of the upper lip with thinning of the vermillion, decrease of incisor show, and loss of anterior projection.7 , 8 

Upper lip lengthening was also shown by Iblher et al. on cranial magnetic resonance imaging together with a significant thinning of the upper lip with age. 

Because their findings showed no volume loss, they claimed that the upper lip changes resulted from caudal redistribution of soft tissue instead of tissue loss.9

 This conclusion conflicts with the widely adopted technique of volume augmentation to rejuvenate the upper lip.10–13 

Such incongruences imply that more profound metric data on soft-tissue proportions are needed to understand the morphologic changes caused by facial aging. 

Unravelling these changes can provide the aesthetic surgeon with an evidence-based foundation for rejuvenation therapy. In this study, the soft tissue of the upper lip unit was measured on magnetic resonance images to evaluate the differences between young and old women and men. 

Figure 1 illustrates how the upper lip is displayed on these images and how differences are visually apparent between young and old individuals.

The study group consisted of 200 patients who underwent cranial magnetic resonance imaging for intracranial abnormality. 

They were selected by age and sex from a general population, which eliminates the selection bias of patients who seek perioral rejuvenation therapy. 

Among them were 100 women and 100 men, each subdivided into two equal groups of 20 to 30 years old and 65 to 80 years old. 

Two hundred magnetic resonance images were retrospectively analyzed to obtain metric data of the upper lip and nasolabial fold. 

Lip Length
The lip length was measured on sagittal and parasagittal section and was significantly longer (p < 0.001) in the older age group in both sexes. The mean sagittal lip length was 19.70 percent (4.45 ± 0.52 mm) longer in women and 18.39 percent (4.51 ± 0.61 mm) longer in men. The mean parasagittal lip length was 11.59 percent (2.45 ± 0.42 mm) longer in older women and 12.14 percent (2.88 ± 0.50 mm) longer in older men (Table 1). The difference between age groups in sagittal lip length was significantly greater (p < 0.001) than the difference in parasagittal lip length in both sexes.

Lip Thickness and Pouting
Lip thickness was measured on three levels on sagittal section and on one level on parasagittal section. The upper lip showed a significant (p < 0.001) decrease in thickness on all levels compared between young and old female subjects and male subjects, with the highest percentage at the vermiliocutaneous junction: 40.55 percent (5.34 ± 0.32 mm) in women and 32.74 percent (4.57 ± 0.31 mm) in men. The smallest difference was found for parasagittal lip thickness: 19.68 percent (2.97 ± 0.28 mm) in women and 11.54 percent (1.63 ± 0.27 mm) in men (Table 2).

Pouting was calculated to objectify anterior projection of the vermillion. It is calculated as the tissue thickness at the vermiliocutaneous junction divided by the tissue thickness of the thinnest portion of the upper lip on sagittal section. Significantly less pouting was observed (p < 0.001) in older women [−13.71 percent (−0.17 ± 0.04)] and older men [−11.97 percent (−0.14 ± 0.03)] (Table 3).

Nasolabial Tissue Thickness
The nasolabial tissue thickness was significantly thinner in the older age group in both women (−25.7 percent) and men (−25 percent) (p < 0.001) (Table 4). The difference between age groups in nasolabial tissue thickness was significantly greater when compared to the difference in lateral lip tissue thickness in both sexes (p < 0.001).

Volume
The sagittal cross-section surface area was significantly smaller in the older age group in both sexes (p < 0.001). Women had an average difference of 20.89 percent and males had a difference of 17.40 percent (p < 0.001) (Table 5).

DISCUSSION

genetics mostly determines how well soft tissues withstand aging and external damage, the extent of sun exposure, stress, hormones, and nicotine and alcohol use are known to contribute to the process as well.

 Folds and wrinkles deepen and sagging appears as the skin envelope loses elasticity. The contour of the face changes as the envelope’s content shrinks and shifts. As the current rejuvenation strategy contains soft-tissue repositioning and volume augmentation, aesthetic surgeons benefit from metric data on the changing proportions of the aging face. Even though this study examined unpaired groups, the percentages from compared averages can be used as a directive for individual therapy planning.

The association found in this study between an increase in length and thinning of the upper lip with older age confirms the clinical observation of this apparent feature of the aging face

The parasagittal portion of the lip was shown to be less affected by lengthening and thinning than the sagittal section, whereas the most profound thinning was observed at the vermiliocutaneous junction. 

This relates to our finding that there is significant loss of anterior projection (pouting) of the upper lip with age. 

Because the vermiliocutaneous junction contains the thickest portion of the orbicularis oris muscle (pars marginalis), there is a possible relation between senile muscle atrophy and the loss of pouting. 

our results showed that the lengthening and thinning of the upper lip is more than a caudal redistribution of tissue and that volume loss is an obvious feature of the aging upper lip. Apparently, a larger study sample was required to reveal the volume loss in the aging upper lip.

Clinically, the aging upper lip becomes surrounded by deepening nasolabial folds. At the depth of this fold, there is a junction between two areas with different degrees of dermal adherence. The descending malar fat pad bulges over the firmer adhered area over the orbicularis oris muscle and creates a fold.20–22 The levator labii superioris alaeque nasi and levator labii superioris muscles insert into the orbicularis oris and thus suspend the firmly adhered area further underneath the bulging malar fat pad. Contraction of these muscles accentuates the fold,5 , 10 , 23 whereas the fold is relieved in patients with facial paralysis.24 In this study, a significant thinning of the soft tissue was found at the alar base where the levator labii superioris alaeque nasi muscle inserts into the orbicularis oris muscle. In addition, a more profound tissue loss was measured at this point when compared to the tissue loss in the parasagittal upper lip. This finding suggests the presence of influencing factors in this area that induce additional tissue loss.

CONCLUSIONS
Our results suggest that the aged perioral area is affected with variable degrees of soft-tissue lengthening, thinning, and volume loss. These findings contribute to a better understanding of the mechanics of aging in the perioral area. The implications of this study on perioral rejuvenating strategies are explained in part II.