Mature Lips

Rosanne Joseph-Anthony discusses shifting the needle on lip trends, to achieve natural results for patients desiring a youthful look

Over the past decade, the prevalence of lip augmentation using injectable fillers has escalated significantly, positioning lip fillers among the most performed cosmetic procedures worldwide.1 This surge is primarily attributed to the substantial influence of social media and celebrity culture, which have been primary catalysts for transformation within the aesthetic and beauty sectors. Influencers disseminate trending procedures and beauty ideals that consumers subsequently adopt.2 Recent augmentation techniques, such as “Russian lips,” “Bratz lip,” and “Alien lips,” have gained popularity among patients desiring pronounced lip volume and a distinctive aesthetic. However, as most trends and content are directed at a younger demographic, the desires and requirements of mature patients needs must also be adequately considered and addressed.

Both extrinsic and intrinsic factors — including nutritional status and genetic predisposition — significantly impact skin health and contribute to the ageing process. These factors lead to epidermal thinning, reduction of subcutaneous adipose tissue, flattening of the dermal-epidermal junction, and loss of elastin, collagen, and growth factors.3 Age-related changes are particularly pronounced in the perioral region, resulting in lip thinning, loss of definition, and the formation of perioral rhytids (wrinkles). While these concerns are most prevalent among older individuals, they also affect those exhibiting premature signs of ageing due to excessive ultraviolet radiation exposure and detrimental lifestyle choices such as smoking. Despite the focus of most anti-ageing skincare products on facial skin, the lips often remain a neglected indicator of the ageing process.

Addressing the aesthetic needs of mature patients requires a nuanced approach that considers the anatomical and physiological changes associated with ageing. Techniques such as the strategic use of hyaluronic acid fillers can restore lip volume, enhance definition, and ameliorate perioral wrinkles, thereby addressing the specific concerns of this demographic. Furthermore, personalised treatment plans and patient education are essential for achieving optimal outcomes and high levels of patient satisfaction.

LIP AGEING

The process of lip ageing can be broken down into the following: Degradation of collagen and elastin Elastin fibres are a resilient component of the extracellular matrix (ECM), providing structural support to cells and tissues alongside other proteins. These fibres endow the skin with elasticity, allowing it to recoil when stressed. However, elastin exhibits a low turnover rate, limiting its synthesis and repair capacity. Over time, elastin fibres accumulate damage due to various biological influences, leading to fragmentation and thinning that adversely affect skin elasticity.⁴ Consequently, with advancing age, lip tissue becomes less capable of returning to its original shape after stretching or manipulation, resulting in the wrinkling and sagging observed in and around the lips. Collagen, the primary structural protein in the ECM, plays a crucial role in connective tissues by contributing to skin strength and elasticity. Natural collagen loss occurs through intrinsic ageing processes, and extrinsic factors such as ultraviolet radiation and environmental stressors. A significant reduction in collagen production is typically observed after the mid-twenties.⁵ As collagen degrades and is not sufficiently replaced with age, the collagenous framework within the lip tissue diminishes, leading to a loss of structural integrity.

Cross-linking of collagen involves the formation of intra and intermolecular covalent bonds between collagen molecules. Glycation — a non-enzymatic reaction where sugars bind to proteins — can induce cross-linking, forming advanced glycation end-products (AGEs). This process results in the stiffening and rigidity of collagen bundles, reducing skin elasticity and contributing to tissue stiffness in the perioral area.⁶ The accumulation of AGEs is associated with age-related changes in skin appearance and function, further exacerbating the signs of ageing in the lips.

Epidermal thinning

Advancing age leads to thinning of the epidermis, primarily due to a decline in epidermal stem cell production and a reduction in keratinocyte proliferation.⁷ This decreased cellular turnover impairs the skin’s regenerative capacity. Combined with the loss of collagen throughout all layers of the skin and subcutaneous fat depletion, there is a gradual reduction in lip volume over time. The thinning epidermis also exacerbates transepidermal water loss (TEWL), resulting in increased dryness within the cellular layers and compromising the integrity of the epidermal barrier. Additionally, the age-related slowdown in cellular repair mechanisms prolongs the healing process of the lips, further aggravating moisture loss and dryness.⁷ ⁸

Changes in vascularity and colour

Age-related changes also affect the vascularity and colour of the lips. With advancing age, there is a reduction in capillary density and blood flow within the dermal layers. This decrease in microcirculation leads to diminished oxygenation and nutrient delivery to the tissues, resulting in a loss of the natural rosy hue characteristic of youthful lips.⁹ The lips may appear paler and less vibrant, which not only affects aesthetic appearance but also contributes to delayed wound healing and increased susceptibility to environmental damage. Furthermore, the decline in melanocyte activity can lead to uneven pigmentation, causing hyperpigmented or hypopigmented areas on the lips. Addressing these vascular and pigmentary alterations is essential when formulating aesthetic interventions for mature patients, as treatments that enhance blood flow and restore natural colouration can significantly improve lip appearance and patient satisfaction.

The factors above contribute to the characteristic signs of ageing in the lips and other age-related changes in facial tissues and musculature. For instance, skin atrophy resulting from collagen loss during menopause is significantly more pronounced, intensifying the appearance of lines and wrinkles and exacerbated by the characteristic menopausal skin dryness.¹⁰ The lengthening of the philtrum is facilitated by the gradual weakening of facial muscles, which reduces the vertical height of the lips that already have a diminishing structural framework. Combined with epidermal sagging, this can create the illusion of smaller lips.¹¹ Inversion of the lip tissue can be attributed to volume loss, moisture depletion, and perioral muscle weakness. The result is thinner lips, where the lip tissue inverts into the oral cavity rather than projecting outward along the facial plane.¹²

The advent and increased utilisation of injectable treatments such as hyaluronic acid (HA) fillers, botulinum toxin type A, and polynucleotides have provided practical strategies to address these age-related concerns. HA fillers can restore lost volume, redefine lip contours, and enhance hydration due to their hygroscopic properties.¹³ Botulinum toxin can relax hyperactive perioral muscles, reducing the appearance of perioral lines and preventing further muscle-mediated lip inversion.¹⁴ Polynucleotides promote tissue regeneration and improve skin elasticity by stimulating fibroblast activity and collagen synthesis.¹⁵ Collectively, these interventions enable patients to rejuvenate the lip area, correct asymmetry, and ameliorate deep grooves within the lip body, thereby counteracting the signs of ageing.

CASE STUDIES

Figures 1 and 2: Case study 1: Patient before and after treatment using HA filler to lips

A47-year-old female patient presented to the clinic, who explained that she wasn’t satisfied with the result of her HA lip filler from a previous practitioner. She desired a more lifted look, concerned about volume loss in the lip due to menopausal hormone changes, but it was clear that a natural, polished look was the goal. On assessment of the patient’s lips for evidence of the previous filler and overall anatomy for the procedure and opted for 1ml of Teosyal RHA KISS for the top and bottom lips combined. The filler was injected directly into the lips where appropriate using a 30-gauge needle, without cannulation, to allow better control of the product administration. The patient’s lips were noticeably fuller along the vermillion borders leading to the oral commissures. A volume difference was noted, particularly by projection of the lower lip, with a visible smoothing of deeper lip grooves.

Figures 3 and 4: Case study 2: Patient before and after treatment using HA filler to lips

Our second patient, a 62-year-old female, presented to the clinic who had also had HA filler previously. On examination, discovered a lump of HA during an ultrasound assessment that had migrated in the past on the left side of the patient’s lip. The patient did not want the lump to be dissolved using hyalase; therefore, administered gentle massage techniques to assist in the degradation of the old HA filler. A year later, after the lump was assessed using ultrasound again, and had reduced considerably, 1ml of Teosyal RHA1 to the top and bottom lips combined. HA filler was administered as per case study 1. The patient desired a plumper lip, to maintain a natural but youthful appearance. The patient’s lips were visibly fuller, volume was greater evenly across both lips, with a distinct reduction in perioral rhytids and wrinkles.

Figure 5: Case study 3: Patient after treatment with botulinum toxin treatment to lips

A 49-year-old female patient presented to the clinic with postmenopausal changes to the skin and lip area. Patient did not want filler, as she preferred a subtle, natural looking result that would not be obvious to others in her line of work. On consultation with the patient and opted for Allergan’s toxin, to evert the lip and demonstrate fullness where visibly the lip had become thinner and more inverted. As this was the patient’s first treatment, it was advised that particular movements with the lips would be restricted post-treatment. Administered four units of Botox to the vermilion border using a 30-gauge needle, placing where appropriate for the desired outcome. This image was captured three weeks after the procedure to give enough time to assess the lip eversion. Lips were visibly more defined at the upper vermillion border, with a measurable height increase over both lips. Treatment had also corrected the patient’s asymmetry at the cupid’s bow.

Maintaining satisfactory results requires regular assessments, patient education on lip care, adherence to post-injection protocols, and standard follow-up consultations to ensure the patient’s well-being and satisfaction with the outcomes. Aligning expectations during follow-up visits is also essential, as it allows for addressing any concerns and making necessary adjustments to sustain and enhance the achieved results. In these case studies, we worked closely with the patients to realise their desired outcomes, carefully assessing facial structure and musculature to achieve harmonious results for those opting for subtle enhancements over more pronounced effects.

PATIENT OUTCOMES ARE IN OUR HANDS:

A comprehensive patient consultation is essential for optimal lip augmentation procedure outcomes. It allows patients to express their concerns and discuss sensitive issues related to ageing, aesthetics, genetics, hormonal changes, and other personal factors affecting their lip appearance. Additionally, the consultation enables practitioners to identify and diagnose existing lip conditions, address complications from previous treatments, and tailor interventions to the individual’s specific needs. Critically, this dialogue facilitates aligning and managing patient expectations, ensuring that desired results are realistic and achievable. By thoroughly exploring treatment options and mitigating patient apprehensions, potential adjustments to the treatment plan can be made before any procedure is undertaken.

ROSANNE JOSEPH-ANTHONY

Rosanne Joseph-Anthony is the founder, clinical director, and leading aesthetic nurse practitioner at Healthium Clinics. With over thirty years of experience as a registered general nurse, she has specialised in intensive care and cardiac care nursing and holds a particular interest in injectable-based aesthetics. Joseph-Anthony is a qualified trainer and assessor in clinical practice and provides education and support to health professionals worldwide.