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.