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Cosmetic Surgery Times - Counter frown: Corner of the mouth

Cosmetic Surgery Times - Counter frown: Corner of the mouth

Counter Frown:  Corner of the mouth lift offers permanent alternative to fillers. 

Dr. Perkins
In cases in which a downward turn of the oral commissure grooves contributes to an aged or otherwise undesirable look, relatively simple procedures can help restore a more youthful appearance, according to one expert.

"As the corners of the mouth draw down, it looks like frowning," says Stephen W. Perkins, M.D. "This can contribute to an aged, sad, tired or angry look in spite of the fact that a patient may have had successful cosmetic procedures on other portions of the face. Correction of the grooves gives a more youthful, fresher appearance." Dr. Perkins is the president and founder of Meridian Plastic Surgery Center in Indianapolis. He is also a past president of the American Board of Facial Plastic and Reconstructive Surgery.

TREATMENT OPTIONS According to Dr. Perkins, use of injectable fillers is the best and most common treatment for management of prominent oral commissure grooves because the procedure is noninvasive. With careful technique, standard injectable materials, such as hyaluronic acid, Restylane and Perlane, can fill deep grooves as well as provide some lift to the oral commissure. Under good conditions, patients may see satisfactory results for six to 12 months. However, there are instances in which the grooves may be so sharp and deep that injected material does not provide adequate lift to the area. In these cases, he says, surgical intervention may be indicated.

The corner of the mouth lift provides an alternative to patients who desire a more permanent solution to the management of deep oral commissure grooves. If the grooves are deep and prominent, surgery may not provide 100 percent correction, but there is usually major improvement. And incases of the elderly patient, this lift may also serve a therapeutic purpose in the treatment of angular cheilitis, a chronic inflammation or infection in the corners of the mouth. This condition is brought about by constant drooling and may be exacerbated by the downward turn to the oral grooves.

TECHNIQUE IN DETAIL Dr. Perkins tells Cosmetic Surgery Times that the incision areas for the corner of the mouth lift should be marked while the patient is either seated or in a semi-recumbent position. From a dot placed at the oral commissure at the junction of the skin and the vermilion, a line is extended medially and diagonal to the superior aspect of the tragus, for approximately 1 cm but not to extend past the natural cheek-lip crease. A second line, equal in length to the first, is then drawn superiorly and medially from the original dot along the vermilion border. The two lines are then connected in a convex curvilinear fashion to form a triangle-shaped section of skin — approximately 7 mm in height, but no more than 9 mm — to be excised. Asymmetrical areas on either side of the mouth can be accommodated by slight adjustments to the markings.

Surgery is performed under local anesthesia with sedation and usually takes 20 to 30 minutes. The triangle of full thickness skin tissue is excised to the level of the orbicularis oris muscle but not into the actual muscle fibers. After hemostasis is obtained, 5-0 Dexon is used to close the wound from the oral commissure to the middle of the superior curvilinear line. The remainder of the wound is then approximated and everted with 6-0 Dexon sutures. The skin is closed with 7-0 Prolene running suture.

Post-operatively the stitches must be kept clean, and the patient is cautioned against opening the mouth wide (as in eating large portions of food). The sutures may be removed as early as five days post-op, and by the sixth day makeup can be used to hide any redness. Further discoloration or redness will fade over several months. The unavoidable side effect of the corner of the mouth lift is the permanent, slightly visible 1-cm scar that extends laterally from the oral commissure. Although good suture technique will minimize the chance of prominent scarring, Dr. Perkins reports that 10 percent to 15 percent of patients will require some degree of scar revision or light dermabrasion to the area.

He also noted that, in some cases, an unnatural "joker" smile may be created if the correction of the oral commissure has been overdone. "Because this procedure is not reversible, the physician should be reasonable and conservative with measurements," Dr. Perkins emphasizes.

INCREASING VISIBILITY The corner of the mouth lift is not a common procedure at this time, with Dr. Perkins reporting that he performed fewer than 20 of these surgeries in 2007. In contrast, he used filler injections in over 800 oral commissure grooves in the same period. But he believes that an awareness of the procedure is growing among surgeons as well as among patients, which may lead to an increased number of lifts being performed in the future.

"This procedure isn't for everyone," Dr. Perkins notes. "But I've talked about it for 15 or 20 years. Surgeons now know about it, they have seen the results, and they are bringing it up as an option for their patients."

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