Age Grouping to Optimize Augmentation Success

GROUPING BY AGE
The majority of times, the goal of lip and perioral augmentation is to reverse the signs of aging. These signs include loss of volume, definition, and flaccidity of tissue. These are direct visual aesthetic results of gravity, soft-tissue maturation, skeletal remodeling, and muscular facial activity. The lips reach their maturity in late adolescence. Women arrive at maxillary lip maturity at 14 years of age and mandibular lip maturity at 16 years of age. Men reach maxillary and mandibular lip maturity around 18 years of age. Yet throughout the decades of our lives, there are substantial changes per age group and the oral/facial skeletal dimensions continue to grow (Figures 1 to 4).

From the late teens to the third decade of life, there is an average increase in the vertical dimension of our face from nasion to menton of 2.7 mm. Other studies tend to support the idea of anterior facial growth well into the fourth decade of life.

Understanding these oral facial changes better prepares the practitioner to treatment plan aesthetic lip and perioral augmentation.

Beginning in the mid- to late 30s, changes become apparent throughout the face. Wrinkles and fine lines appear around the eyes and mouth. The dermal thickness is still relatively intact as in the earlier years of life, although gravity has weighed the face down. The telltale signs of aging occur in the upper face first. It is commonly believed that the weakest link in the chain of events to cause aging or drooping of the facial skin is the cohesive ability of the dermis and remodeling of fat distribution around the face. The lips still have significant tonicity to them and any request for augmentation will usually be for cosmetic volume increase, rather than any substantial sculpting.

In our 40s to 50s, the dermis tends to thin out due to hormonal changes and the loss of estrogen, which is particularly apparent in women. We see a decrease in the production of dermal collagen and a subsequent reduction in dermal thickness. We see labial rhytides develop around this time. The constant constriction of the orbicularis forms “sunbeam-like” wrinkles around the mouth. We also may start to develop “marionette lines” or a “Chinese mustache” at the angles of the mouth descending down to the inferior border of the mandible. This is the onset of ptosis that is commonly associated with the skin.

As faces mature through the ages of the 50s and 60s, the jaw line sags and the corners of the mouth droop down. The lack of tonus from the musculature and the pull of gravity draw the overall expression of the mouth down. The intercommissural distance increases with age, whereas lip height decreases. As we mature, photographs will reveal that the lower incisors have become more prevalent when we talk. In photographs of younger people, on the other hand, the lip-line is higher during conversation and the incisal edge of the maxillary teeth is present.

Defining and grouping patients by decades reveal several trends. Volume is lost in the lip and perioral area as we mature, and definition of lip anatomy diminishes as well.

This becomes important particularly when treatment planning how much material needs to be used to acquire the desired outcome. For example, a patient in her 30s may only require one syringe of filler material to augment her oral facial area. A patient in her 50s may very well require 2 to 3 syringes, which can become rather expensive at 6- to 8-month intervals for reaugmentation. The latter patient may fare better with a conventional facelift and then sequential filler therapy, which would require less syringes and less cost to the patient (Table 2- word doc).