The best filler injection techniques for older lips

Older lips are harder to treat with dermal fillers than younger lips. Lips change dramatically as we age making it much more of a challenge to achieve a good aesthetic result.

In this blog, Dr Tim Pearce describes the differing psychological, aesthetic, and anatomical approaches required when tackling older lips with dermal fillers, including those patients with upper lip lines. He will also touch on how to avoid the Homer Simpson look in older patients.

Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better practitioner, then step one is to register for the free webinars by Dr Tim.

How to consult older patients for lip filler treatments

The key to success starts with your consultation. We can break this down into considering the psychology of the patient in front of you, their personal aesthetic, and their underlying anatomy.

Psychology of the patient

Certain age groups have certain psychological tendencies and approaches to their ageing. It is common for this demographic to be in a defensive mindset – they are seeking certainty and restoration of their former self; they are not trying to change themselves or look significantly younger, so may be nervous if you start discussing ‘adding volume’ or terms which imply dramatic alterations. This stems from a fear of ‘looking done’ and drawing negative attention from their friends and family, such as the well-known insult of ‘mutton dressed as lamb’. Their aim is to look like a better version of themselves and maintain their identity.

Many older patients fall into the trap of requesting the wrong treatment to mitigate this fear of not wanting their lips ‘done’ like the youngsters. For example, if the request is to treat upper lip lines, but you don’t add some product to the body of the lip, then over time you end up with the Homer Simpson look, also likened to a simian or ape-face. Of course, this is counter to their original plan of not wanting to look over treated, because if the practitioner only addresses the upper lip lines, then they immediately appear over treated with an unnatural appearance.

To avoid this, your best tool is education during your consultation to dispel their fears. Explain the aesthetics of the lip and how your treatment approach will optimise this and not lead to overfilled, trout pout, or cartoon-like results, but a natural, restored, and beautiful lip area, even by directly treating the lip, which is ultimately going to give them what they are seeking.

Aesthetics of the patient

With ageing lips comes negative connotations surrounding emotions. In some cases, when patients look in the mirror, they think they have an angry-looking face because their lips are smaller, lined, and pursed. Others may note that they have a sad- or unhappy-looking face because of a downwards appearance at the corners of the mouth. The oral commissures are being pulled downwards by the depressor anguli oris muscle, with a loss of volume below the mouth leading to jowl and marionette line formation.

Both emotional interpretations of their face and lips can drive patients to seek treatment at a medical aesthetic clinic. Other small imperfections often get a mention too such as a loss of the definition in the vermillion border, a flattened Cupid’s bow, and the disappearance of the defined angles of the lip due to a decrease in the collagen and support structures with ageing. Lips can also become involuted whereby the top lip rotates inwards, and the white lip becomes dominant. In rare cases, the lower lip can also prolapse outwards whilst the upper lip involutes.

Colour and contrast in the lips also wanes with age – this cannot be addressed with cosmetic injectables, but you may be able to offer additional treatments to improve the full aesthetic result.

Anatomical situation

What is causing the anatomical changes in the lips as we age? The primary factor is the loss of volume which starts in an individual’s early 30s. As ageing progresses, the integrity of the lips is lost with a decrease in collagen and the formation of hypertrophic skin tissue.

Lost or increased volume elsewhere in the face can also have a direct impact on the lips, including volume loss below the mouth with jowl formation, or dental considerations such as tooth and bone loss.

Hypermobility due to the loss of fat pads around the lips can lead to increased pursing as the orbicularis oris muscle and others dominate the face, causing significant wrinkle formation which would otherwise be impeded by the presence of fat pads.

Types of ageing

As well as a good understanding of your patient’s anatomy, we must consider how people are ageing.

Hypertrophic and atrophic ageing

Hypertrophic ageing is characterised by deep furrows and a leathery appearance. Atrophic photo-ageing is characterised by telangiectasia and a smooth, relatively unwrinkled appearance, but a loss of the firmer structure of youth.

Glycation and skin ageing

Another consideration with types of ageing is glycation which is caused by higher levels of blood sugar. Advanced Glycation End products (AGEs) accumulate due to excessive blood sugar levels. These react with the macromolecules of the skin, with sun worsening the effect. This leads to a loss of protein function, impaired elasticity, and impairment to blood vessels, skin, and tendons – all of which accelerates ageing.

Skin cells become more brittle and fragmented with a cobblestone appearance to imperfections. If you attempted to stretch a wrinkle and the line at the base is pale or pink and not the same colour as the rest of the skin, then this is a sure sign that these are not true wrinkles that we can improve with dermal fillers and should instead be approached with resurfacing treatments such as CO2 lasers.

Injection techniques for the restoration of older lips

Starting with a holistic approach to your treatment plan, first determine if there is a downturn or negative shape to the lips and mouth area you are about to treat. What is the overall structure of the mouth? Consider the impact of nearby tissue including the chin and the jowls. Resting pursed lips would be indicative of a loss of fat pads which could also be reinforced and restored to provide support to the lip area. You are not just treating the lips, so you must consider evaluating the whole face to achieve the best results for the lips.

• Lip structure – Evaluate if the lip still has the important features and structures you associate with a lip – the vermillion border, the Cupid’s bow – what is lacking? As you embark on injecting, your first approach is to correct the structure.
• Lip volume – Assess the curvature and proportions of the lips, alongside the relative projections so you can determine where volume is lacking and target your injections appropriately.
• Lines and wrinkles – Finally, once the structure and volume of the lip is corrected, it is much easier to move on to assessing and treating any lines and wrinkles, and not before. This avoids the trap of causing a disproportionate result by focusing on a superficial line and adding volume that changes the shape of the lip in an undesirable way before you have addressed the lip itself.

Where to inject older lips

Finally, we can consider where to inject when restoring older lips.

• The lip body and vermillion border – The main parts of the lip treated to add volume and definition.
• The retro-orbicularis fat pad – This depletes with age and is a common cause of significant lines and wrinkles around the mouth as the muscle dominates the area, even at rest. It is not a common area to treat, however, but can be addressed.
• The hyperdermic fat above the muscle – This is a common area of restoration to address the superficial lines and wrinkles.

If you treat any of these areas in isolation, you are at significant risk of causing disharmony to the face of your patient, leading to an unnatural look. However, if you treat all of them, but without considering the rest of the face, then equally you risk an unsatisfactory result. Holistically, you must consider the whole face even though you are primarily looking to restore the lips. As both you and your patient learn what looks right for them, you may consider lower volume approaches to gradually improve their look – both of you can gain in confidence together.

Aesthetics Mastery Show

Catch up with detailed injection techniques and his product choices for treating older lips by watching Dr Tim Pearce discussing the restoration of older lips on the Aesthetic Mastery Show.

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Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

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