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Rejuvenation of perioral area requires more than just lip service, surgeon says

Barcelona, Spain — Most attempts at perioral rejuvenation fail to address the key problem of exposed lower teeth created by drooping of the mouth over time, according to one expert.

"The most dominant aspect of an old mouth is its position with respect to the underlying teeth," says J. William Little, M.D., clinical professor of surgery at Georgetown University. "There's been some acknowledgment of that in a whole host of operations to shorten the upper lip so as to expose more of the upper teeth. But I consider those procedures limited in what they can achieve, and I don't like the (creation) of external scarring on the upper lip."

More important Far more important in rejuvenating an aging mouth than uncovering upper teeth, he says, is correcting for exposed lower teeth.

"I ask every patient who comes in to have a facelift to relax their mouth and let it fall open.Then I hand them a mirror and ask whether they see upper or lower teeth. Ninety-five percent of the time in patients over 50, all they see are the lower teeth. That reposed position predicts what will show when we speak," Dr. Little says.

To correct such problems, Dr. Little says his approach to "stomapexy" (or internal elevation of the mouth) employs up to nine steps, which he performs in conjunction with facelifts.

"When I describe stomapexy," he says, "I depict a wheel around the mouth almost like the numbers on a clock face from one to nine. I almost never use all nine steps in one patient, but I'm routinely using six or seven. Some of them are intrinsic to the procedures I'm doing, whether it's a midface lift at the subperiosteal plane or a subcutaneous lift at the superficial plane. Others are optional steps I do with minor incisions inside the mouth."

The process Dr. Little describes the process:

When performing a midface lift, he frees the pyriform aperture to foster elevation of the mouth.

When suspending the midface, placing sutures low in the midface creates not only more volumetric impact on a patient's appearance, but also more influence over mouth position. "Sutures placed low in the periosteum of the midface will have a significant raising effect of the mouth," Dr. Little says.

When performing subcutaneous facelifts, he says, "I elevate the fatty region of the jowl directly with fine absorbable sutures. By directly, I mean that I undermine to the commissure in all patients. The line to which I perform this plication is never more than 1.5 to 2 cm above the modiolus. The sutures I use to correct jowl malposition also tend to bring the mouth up with them, as they're tied and placed. And they're intrinsic to the superficial facelift (external jowl lift) that I do."

Another factor intrinsic to superficial facelifts is Dr. Little's use of vertical vectors.

"Just as my vector for moving fat is purely vertical," he explains, "my vector for moving skin is nearly vertical. It's vertical-oblique. That also helps elevate the mouth."

Dr. Little adds, "If I open the neck because it is presenting challenges either in excess fat or excess redundancy — in other words, if I place an incision under the chin in the submental region (which he does in 25 percent of facelifts) — I will divide partially or completely the platysma muscle. It is an accessory depressor of the corner of the mouth that assists the depressor anguli oris. By dividing the platysma, which we do for other reasons in correcting the neck, we also weaken the action by which it pulls (the corner) down."


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