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The Corner of the Mouth Lift and Management of the Oral Commissure Grooves

One of the many features that contribute to the aging appearance of the perioral region is the


downward turn to the oral commissures. This downward turn, which often extends to a


significant oral commissure groove and “marionette” appearance, gives a sad, tired, almost angry


look in some patients. This senility can be extreme and it causes lateral oral commissure


drooling and angular cheilitis in some patients.



The downward turn to the corner of the mouth can be the single remaining aging factor that


“spoils” an otherwise excellent rejuvenative surgical effort. In fact, in many cases, this is the


area the patient is most bothered by and wishes that their facelift had corrected. In preoperative


evaluation and consultation, it is imperative that one show the patient the improvements in the


marionette groove by lifting the jowl tissues, but specifically point out that the corner of the


mouth does not lift and the downward turn and groove persist. Alternatively, one can also show


that, if you pull the skin tissues taut enough to lift the corner of the mouth, the face then has an


unnatural “pulled” operated appearance. In addition, it is imperative to point out that with


standard rhytidectomy techniques the fold of tissues at the modiolus, just lateral to the oral


commissure, is minimally effaced.



Therefore, it is crucial to point out to the consultative, prospective patient that one needs to offer


adjunctive procedures to correct the downward turn and help efface the deep oral commissure


grooves. Augmentation filling of this area is the “mainstay” for correcting and maintaining


ongoing improvement. Fat has been used with variable success to fill this area and it is readily


available from submental liposuction. The problem with fat in this area of motion is that it


usually absorbs sooner or later. Otherwise, occasionally a “lump” of fat remains or even


enlarges, creating a visual lumpy deformity.



Injectable fillers are by far the best and most commonly utilized treatment method for filling and


effacing the oral commissure groove. Done with proper techniques, one can achieve an actual


lift to the oral commissure, even though temporary. Using small amounts of Botox (botulin


toxin), 2-3 units on each side, to prevent the depressor anguli oris (DAO) muscle from pulling


down the corner of the mouth can, in fact, add to the temporary improvement. Some surgeons


(Wayne Little of Washington DC) advocate direct transsection of the DAO at the time of


facelifting surgery to “lift” the corner of the mouth. The most commonly used fillers that last


6-12 months are hyaluronic acid or calcium hydroxyapatite. The latter has more of a tendency to


“clump” and form lumps or become visible because it is white in that area.



These are the most common ways to treat the downward turn of the corner of the mouth because


they are the least invasive and do not leave an external scar. They are definitely the initial


treatment recommendations that I offer a new prospective patient. However, these are patients


who either have such severe and often asymmetrical downward turn to the corner of the mouth,


or dislike this aspect so much, that they desire a more direct surgical definitive and lasting


solution. The corner of the mouth lift then becomes a reasonable alternative procedure of choice.


It has advantages and disadvantages and is usually not the primary procedure offered the first


time to a patient because of the resulting scar that is a natural consequence of the operation. It is


a definitively designed surgical procedure that directly lifts the corner of the mouth and partially


corrects the oral commissure, marionette groove, and even some of the redundancy of the


modiolus.


Indications for Corner of the Mouth Lift


Indications for the corner of the mouth operative procedure are the existence of the downward


turn to the oral commissure or corner of the mouth. This can result in a frowning look of the


mouth that needs to be corrected. It is indicated when these are persistent oral commissure


grooves, despite the patient having undergone facelift, possibly mid-facelift, fat or other


injectable augmentation fillers. In severe cases involving drooling, corner of the mouth lift can


be a therapeutic option to treat, not only the drooling but also angular cheilitis.



Advantages of the Corner of the Mouth Lift


The corner of the mouth lift is immediate cosmetic correction of the problem. There is


essentially no residual downward turn to the corner of the mouth at the end of the operation. The


improvement in the oral commissure chin-cheek groove (“marionette line”) is immediately


apparent and improves the overall rejuvenative efforts of all other aging face procedures


performed on the patient.


Planning and Design Technique for Corner of the Mouth Lift


Incisions for the corner of the mouth lift should be marked out while the patient is in the sitting


or semi-recumbent position. A dot is placed at the oral commissure, precisely at the junction of


the skin with the vermilion. A triangle of skin is marked out just above each oral commissure by


extending the line medially from the dot in a line directly diagonal to the superior aspect of the


tragus, ending approximately 1 cm in length or no more than 1.5 cm in length, but definitively


never past the natural cheek-lip groove or crease. The lateral aspect of this incision is limited by


where that crease folds around the lateral oral commissure area. A second line is then drawn


along the vermilion border an equal length to the diagonal that has already been drawn superiorly


along the upper lip vermilion border. Then, in a curvilinear fashion, the two diagonals are


connected forming a rounded top to a triangular amount of tissue to be excised. The height of


this curve from the oral commissure to the highest part of the arch of the curve is usually 7 mm


and no more than 9 mm maximally. This can be adjusted asymmetrically depending on which


side of the corner of the mouth is more severe than the other. This triangle of full thickness skin


tissue is then excised down to the orbicularis oris muscle, but not including muscle fibers.


Appropriate hemostasis is obtained and no undermining is required. The wound is closed


initially from the oral commissure to the mid portion of the superior arch with a 5-0 Dexon


buried subcutaneous suture. [??In a carefully approximating evert] the remainder of the wound


with 6-0 Dexon sutures, taking care not to leave a dog-ear and compensate for uneven lengths of


both sides of the approximating tissues. Skin is then closed with a running 7-0 blue Prolene


suture in a simple fashion. Sutures remain in place 5-7 days, preferably removed at


approximately 5 days.



Within 8 days, the pink scar can be camouflaged with makeup and tends to fade over a 2-3


month period of time. Very rarely, a light dermabrasion or small scar revision is indicated if one


portion of the scar indents and is more noticeable than the natural wrinkle of the area.




The Disadvantages of the Corner of the Mouth Lift


One of the disadvantages of the corner of the mouth lift, which is weighed against its advantages,


is the visible scar that is permanent and does extend about 1-1.5 cm lateral in the oral


commissure. The scar is usually minimally noticeable and easily camouflaged by the patient but


is the reason one does not gravitate toward offering this procedure as a first choice procedure in


most cases. There can initially be a slightly over corrected appearance to the oral commissure


and, if over done, can almost given an unnatural “joker’s” smile appearance. There is only


partial correction of the deep oral commissure chin-cheek groove, but it is improved.



Summary


The downward turn to the oral commissure of the mouth is often a presenting complaint by many


patients who note that this gives them a more aged, somewhat tired, angry appearance. It is very


hereditary in nature and is not easily corrected, even by simple injectable materials. However,


most patients are adequately treated, at least on a temporary basis with temporary filler materials.


The downward turn of the oral commissure and marionette groove is aggravated by descending


and aging facial soft tissues, which can be improved by cheek rhytidectomy lifting techniques.


However, persistence of the oral commissure groove and downward turn to the corner of the


mouth can necessitate a more definitive surgical direct approach. The corner of the mouth lift


offers this direct approach and can be a very satisfying operation in selected patients.



Stephen W. Perkins, M.D.




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