COSMETIC

Aging of the Upper Lip: Part I: A Retrospective

Analysis of Metric Changes in Soft Tissue on
Magnetic Resonance Imaging
Lisa Ramaut, M.D.
Background: In scientific literature, numerous theories on the mechanism of
Patrick Tonnard, M.D.,
facial aging can be found. The debate about facial sagging versus deflation
Ph.D.
is still ongoing. In this study, the metric changes in perioral soft tissue were
Alexis Verpaele, M.D., Ph.D. demonstrated. These data can contribute to a better understanding of physical
Koenraad Verstraete, M.D., changes in the aging perioral area.
Ph.D. Methods: Upper lip measurements were performed on cranial magnetic reso-
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVICwrFV2Grwd7k/eTuLUTGwCVsS0PdfcBK+d+O5aP3QP02TS2LEmr28= on 01/29/2019

Phillip Blondeel, M.D., nance images of 200 Caucasian subjects (100 men and 100 women). The study
Ph.D. population was aged between 20 to 30 and 65 to 80 years. The upper lip length
Ghent, Belgium and soft-tissue thickness were measured on sagittal and parasagittal section.
Cross-section surface area of the upper lip was measured in the sagittal sec-
tion to represent volume. The data were analyzed with a t test and results were
considered significant at p < 0.01.
Results: The upper lip in the old age group differed significantly in length
(19.24 percent in women and 18.24 percent in men), thickness (up to −40.55
percent in women and −32.74 percent in men), and volume (−20.89 percent
in women and −17.40 percent in men). Soft-tissue thickness at the alar nasola-
bial fold was significantly thinner in the old age group (−25 percent in women
and −25.7 percent in men) and showed significantly greater tissue loss than
elsewhere in the upper lip (p < 0.001).
Conclusions: These results suggest that the aging perioral area is affected
with a combination of soft-tissue lengthening, thinning, and volume loss. The
clinical implications of this study on perioral rejuvenating strategies will be
explained in part II.  (Plast. Reconstr. Surg. 143: 440, 2019.)

T
he mouth and perioral area play a primary
role in emotional expression and attractive-
ness of the face. Insight into the perioral
aging process is key for the aesthetic surgeon to
provide a comprehensive evidence-based thera-
peutic approach that fits the patients’ individual
needs. Unfortunately, the mechanisms of centro-
facial aging are poorly understood. The debate
about facial sagging versus facial deflation is still
ongoing. Many therapeutic strategies rely on
assumptions, and so far, no single approach has
risen to be the gold standard.
In the scientific literature, one can find numer-
ous attempts to answer the question of how facial
From the Department of Plastic and Reconstructive Surgery,
Burn Center, Ghent University Hospital; the Department of
Radiology, Ghent University; and Coupure Centre for Plas-
tic Surgery Ghent.
Received for publication February 14, 2018; accepted Au-
gust 16, 2018.
Copyright © 2019 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000005190
tissue ages over time. The maxillary bone, teeth,
and mandible constitute the solid framework that
defines the shape of the face. Bony resorption in
the aging face is most profound at the maxillary
level and at the alveolar ridge after tooth loss. The
flattening of the maxillary arch causes a posterior
displacement of the nasal base and upper lip and
leaves a redundancy in the soft-tissue envelope
of the perioral complex.1–3 Intrinsic soft-tissue
Disclosure: The authors have no financial interest
to declare in relation to the content of this article. No
funding was received.
A “Hot Topic Video” by Editor-in-Chief Rod
J. Rohrich, M.D., accompanies this article. Go
to PRSJournal.com and click on “Plastic Sur-
gery Hot Topics” in the “Digital Media” tab to
watch.

440 www.PRSJournal.com
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 Volume 143, Number 2 • Aging of the Upper Lip
changes are a thinning cutis from degradation
of elastin and collagen fibers and distinct atro-
phy of the orbicularis oris muscle.4–6 Clinically,
the upper lip undergoes vertical lengthening and
appears deflated. Findings on photometric analy-
sis have shown that older patients show significant
lengthening of the upper lip with thinning of the
vermillion, decrease of incisor show, and loss of
anterior projection.7,8 Upper lip lengthening was
also shown by Iblher et al. on cranial magnetic
resonance imaging together with a significant
thinning of the upper lip with age. Because their
findings showed no volume loss, they claimed
that the upper lip changes resulted from caudal
redistribution of soft tissue instead of tissue loss.9
This conclusion conflicts with the widely adopted
technique of volume augmentation to rejuvenate
the upper lip.10–13 Such incongruences imply that
more profound metric data on soft-tissue propor-
tions are needed to understand the morphologic
changes caused by facial aging. Unravelling these
changes can provide the aesthetic surgeon with an
evidence-based foundation for rejuvenation ther-
apy. In this study, the soft tissue of the upper lip
unit was measured on magnetic resonance images
to evaluate the differences between young and
old women and men. Figure 1 illustrates how the
upper lip is displayed on these images and how
differences are visually apparent between young
and old individuals.
PATIENTS AND METHODS
The study group consisted of 200 patients who
underwent cranial magnetic resonance imaging
Fig. 1. The perioral area on cranial magnetic resonance imaging of a 22-year-old woman versus a
68-year-old woman.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
for intracranial abnormality. They were selected
by age and sex from a general population, which
eliminates the selection bias of patients who seek
perioral rejuvenation therapy. Among them were
100 women and 100 men, each subdivided into
two equal groups of 20 to 30 years old and 65 to
80 years old. The older group has a wider range
because of the numerous edentulous patients.
Exclusion criteria were edentulous patients and
image artifacts from movement or orthodontic
material. The images were selected from cra-
nial magnetic resonance imaging scans obtained
between January of 2010 and June of 2017 at the
Department of Radiology of the University Hos-
pital, Ghent, Belgium. These sagittal T1-weighed
images were obtained with a 1.5-T magnetic reso-
nance unit (Siemens, Erlangen, Germany). The
use of these images and this study were approved
by the institutional ethical committee, conform-
ing to the Declaration of Helsinki.
Measurements
Two hundred magnetic resonance images
were retrospectively analyzed to obtain metric
data of the upper lip and nasolabial fold. In the
human face, the upper lip originates from the
anterior nasal spine and nasal base and rests pos-
teriorly on the upper dental row. The median sag-
ittal section that contains these bony landmarks
was systematically selected so a reproducible
measuring method could be applied. To obtain
a three-dimensional quantification of the tissue
changes, the length and thickness of the upper
lip were also measured on a parasagittal section.
441
 Plastic and Reconstructive Surgery • February 2019

Fig. 2. In vivo illustration of the sagittal (yellow dotted line) and

parasagittal (blue dotted line) sections of the cranial magnetic reso-
nance image.

Fig. 3. Length (A), thickest portion (B), thinnest portion (C), and Fig. 4. Cross-section surface area measured on sagittal section.
thickness at the vermiliocutaneous junction (D) measured on
sagittal section.

We selected the section that contained the most

lateral portion of the nasal ala (Fig. 2).
The upper lip length was measured on sagit-
tal section between the tip of the anterior nasal
spine and the touching point between the upper
and lower lip (Fig. 3). Perpendicular to this line,
the thickness at the thickest portion (Fig. 3), the
thinnest portion (Fig. 3), and the thickness at
the vermiliocutaneous junction border of the
lip (Fig. 3) were measured. On the cross-section
of the upper lip, the surface area was measured
as an indicator for upper lip volume (sagittal
cross-section surface area) (Fig. 4). On the para-
sagittal sections, the dental axis served as a ref-
erence to make perpendicular measurements of
soft-tissue thickness. The nasolabial tissue thick- Fig. 5. Length (A), nasolabial tissue thickness (B), and lateral lip
ness was measured at the alar base. The lateral thickness (C) measured on parasagittal section.

442
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 143, Number 2 • Aging of the Upper Lip
lip length was measured parallel to the dental
axis. The lateral lip thickness was measured at
the middle of this length (Fig. 5). Each bilat-
eral parasagittal measurement was merged into
one mean value. The difference in soft-tissue
thickness between age groups was calculated for
several locations in the lip, which allowed us to
evaluate whether certain locations show signifi-
cantly more difference than others. Anterior lip
projection of the vermillion was called “pout-
ing” and was calculated from a ratio between the
thinnest portion of the lip and the thickness at
the vermiliocutaneous junction. The calculated
differences between age groups were then them-
selves compared for statistically significant dif-
ferences between variables.
A power analysis was executed to determine
the required study sample size. The obtained data
were analyzed for statistical significance using
IBM SPSS Version 2.25 (IBM Corp., Armonk,
N.Y.) and results were registered as significant at
a level of p < 0.01.
RESULTS
Statistical Analysis
Statistical analysis of our data showed that all
variables had a normal distribution. This allowed
use of the t test to evaluate whether a statistically
significant difference from the null hypothesis was
apparent (the null hypothesis being that there are
no significant metric changes in length, thickness,
or volume of the upper lip between different age
groups).
Demographics
The mean age in the young group was 24.66
± 2.69 years for women and 24.76 ± 2.51 years for
men (range, 20 to 30 years). The mean age in
the old group was 71.32 ± 3.29 years for women
(range, 65 to 79 years) and 71.56 ± 3.12 years for
men (range, 65 to 78 years). This covers a lifespan
of approximately 47 years.
Table 1.  Mean Values of Lip Length Measured on Sagittal and Parasagittal Section in Women and Men*
Young (mm)
Women
 Sagittal 22.60 ± 2.51
 Parasagittal 22.00 ± 2.06
Men
 Sagittal 24.53 ± 2.20
 Parasagittal 23.73 ± 2.05
*The difference was calculated as an absolute value ± SD and as a percentage.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Measurements
Lip Length
The lip length was measured on sagittal and
parasagittal section and was significantly longer
(p < 0.001) in the older age group in both sexes.
The mean sagittal lip length was 19.70 percent
(4.45 ± 0.52 mm) longer in women and 18.39 per-
cent (4.51 ± 0.61 mm) longer in men. The mean
parasagittal lip length was 11.59 percent (2.45
± 0.42 mm) longer in older women and 12.14
percent (2.88 ± 0.50 mm) longer in older men
(Table 1). The difference between age groups
in sagittal lip length was significantly greater
(p < 0.001) than the difference in parasagittal lip
length in both sexes.
Lip Thickness and Pouting
Lip thickness was measured on three levels
on sagittal section and on one level on parasag-
ittal section. The upper lip showed a significant
(p < 0.001) decrease in thickness on all levels com-
pared between young and old female subjects and
male subjects, with the highest percentage at the
vermiliocutaneous junction: 40.55 percent (5.34
± 0.32 mm) in women and 32.74 percent (4.57
± 0.31 mm) in men. The smallest difference was
found for parasagittal lip thickness: 19.68 percent
(2.97 ± 0.28 mm) in women and 11.54 percent
(1.63 ± 0.27 mm) in men (Table 2).
Pouting was calculated to objectify anterior
projection of the vermillion. It is calculated as the
tissue thickness at the vermiliocutaneous junc-
tion divided by the tissue thickness of the thin-
nest portion of the upper lip on sagittal section.
Significantly less pouting was observed (p < 0.001)
in older women [−13.71 percent (−0.17 ± 0.04)]
and older men [−11.97 percent (−0.14 ± 0.03)]
(Table 3).
Nasolabial Tissue Thickness
The nasolabial tissue thickness was signifi-
cantly thinner in the older age group in both
women (−25.7 percent) and men (−25 percent)
(p < 0.001) (Table 4). The difference between
age groups in nasolabial tissue thickness was
Old (mm) Difference (mm) % p
27.05 ± 2.73 4.45 ± 0.52 19.70 <0.001
24.46 ± 2.17 2.45 ± 0.42 11.59 <0.001
29.04 ± 3.69 4.51 ± 0.61 18.39 <0.001
26.61 ± 2.91 2.88 ± 0.50 12.14 <0.001
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 Plastic and Reconstructive Surgery • February 2019

Table 2.  Mean Values of Lip Thickness Measured on Three Levels in the Sagittal Section and One Level on
Parasagittal Section in Women and Men*
Thickness Young (mm) Old (mm) Difference (mm) % p
Women
 Sagittal one-third 13.92 ± 1.64 11.03 ± 1.55 −2.90 ± 0.32 −20.83 <0.001
 Sagittal two-thirds 10.74 ± 1.51 7.48 ± 1.51 −2.36 ± 0.30 −22.00 <0.001
 Sagittal VCJ 13.17 ± 1.77 7.83 ± 1.43 −5.34 ± 0.32 −40.55 <0.001
 Parasagittal 12.50 ± 1.56 9.53 ± 1.27 −2.46 ± 0.42 −19.68 <0.001
Men
 Sagittal one-third 16.04 ± 1.57 12.88 ± 1.40 −3.16 ± 0.30 −19.70 <0.001
 Sagittal two-thirds 11.97 ± 1.38 9.13 ± 1.38 −2.84 ± 0.28 −23.73 <0.001
 Sagittal VCJ 13.96 ± 1.69 9.39 ± 1.46 −4.57 ± 0.32 −32.74 <0.001
 Parasagittal 14.20 ± 1.12 12.56 ± 1.58 −1.64 ± 0.27 −11.54 <0.001
VCJ, vermiliocutaneous junction.
*The difference was calculated as an absolute value ± SD and as a percentage.

Table 3.  Pouting and the Difference in Pouting Calculated in Young and Old Women and Men
Young Old Difference % p
Women 1.24 ± 0.14 1.07 ± 0.21 −0.17 ± 0.04 −13.71 <0.001
Men 1.17 ± 0.11 1.04 ± 0.14 −0.14 ± 0.03 −11.97 <0.001
*The difference was calculated as an absolute value ± SD and as a percentage.

Table 4.  Mean Values of Nasolabial Tissue Thickness Measured on Parasagittal Section in Women and Men*
Young (mm) Old (mm) Difference (mm) % p
Women 12.50 ± 1.56 9.53 ± 1.27 −3.13 ± 0.24 −25 <0.001
Men 12.21 ± 1.38 9.96 ± 1.23 −3.15 ± 0.26 −25.7 <0.001
*The difference was calculated as an absolute value ± SD and as a percentage.

Table 5.  Mean Values of Sagittal Cross-Section Surface Area Measured in Women and Men*
Young (mm2) Old (mm2) Difference (mm2) % p
Women 260.19 ± 39.25 205.84 ± 29.38 −54.35 ± 6.93 −20.89 <0.001
Men 323.74 ± 39.73 267.41 ± 44.39 −56.33 ± 8.42 −17.40 <0.001
*The difference was calculated as an absolute value ± SD and as a percentage.

significantly greater when compared to the dif-
ference in lateral lip tissue thickness in both
sexes (p < 0.001).
Volume
The sagittal cross-section surface area was sig-
nificantly smaller in the older age group in both
sexes (p < 0.001). Women had an average differ-
ence of 20.89 percent and males had a difference
of 17.40 percent (p < 0.001) (Table 5).
Women versus Men
Women have in general thinner soft tissue in
the perioral region (up to 31.79 percent difference
in older individuals) compared with men. There
is slightly more pouting (5.64 percent) in young
female subjects than in male subjects (p = 0.01),
but this difference was not significant in the old
age group (2.8 percent; p = 0.361). Men in both
age groups have a significantly higher volume of
the upper lip compared with women (p < 0.001).
DISCUSSION
Aesthetic surgeons proposed many theories in
an attempt to unravel the dynamics of the aging
face. Although genetics mostly determines how
well soft tissues withstand aging and external
damage, the extent of sun exposure, stress, hor-
mones, and nicotine and alcohol use are known
to contribute to the process as well.7,13–15 Folds
and wrinkles deepen and sagging appears as the
skin envelope loses elasticity. The contour of the
face changes as the envelope’s content shrinks
and shifts. As the current rejuvenation strategy
contains soft-tissue repositioning and volume aug-
mentation, aesthetic surgeons benefit from met-
ric data on the changing proportions of the aging

444
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 143, Number 2 • Aging of the Upper Lip
face. Even though this study examined unpaired
groups, the percentages from compared averages
can be used as a directive for individual therapy
planning.
The association found in this study between
an increase in length and thinning of the upper
lip with older age confirms the clinical observa-
tion of this apparent feature of the aging face.7,9,15–
19
The parasagittal portion of the lip was shown to
be less affected by lengthening and thinning than
the sagittal section, whereas the most profound
thinning was observed at the vermiliocutaneous
junction. This relates to our finding that there is
significant loss of anterior projection (pouting)
of the upper lip with age. Because the vermilio-
cutaneous junction contains the thickest portion
of the orbicularis oris muscle (pars marginalis),
there is a possible relation between senile muscle
atrophy and the loss of pouting. This atrophy
was shown by Penna et al. on histologic analysis,
together with an increase in adipose subcutane-
ous tissue in the old upper lip. The significant
difference in changes between sagittal and para-
sagittal measurements can be explained by the
difference in mobility between these two planes.
The sagittal section is subject to higher muscle
tension and is therefore possibly more affected by
fat resorption and ptosis. Although Iblher et al.
failed to demonstrate a difference in volume on
magnetic resonance imaging comparing two age
groups,9 our results showed that the lengthening
and thinning of the upper lip is more than a cau-
dal redistribution of tissue and that volume loss is
an obvious feature of the aging upper lip. Appar-
ently, a larger study sample was required to reveal
the volume loss in the aging upper lip.
Clinically, the aging upper lip becomes sur-
rounded by deepening nasolabial folds. At the
depth of this fold, there is a junction between
two areas with different degrees of dermal adher-
ence. The descending malar fat pad bulges over
the firmer adhered area over the orbicularis oris
muscle and creates a fold.20–22 The levator labii
superioris alaeque nasi and levator labii superi-
oris muscles insert into the orbicularis oris and
thus suspend the firmly adhered area further
underneath the bulging malar fat pad. Contrac-
tion of these muscles accentuates the fold,5,10,23
whereas the fold is relieved in patients with facial
paralysis.24 In this study, a significant thinning of
the soft tissue was found at the alar base where
the levator labii superioris alaeque nasi muscle
inserts into the orbicularis oris muscle. In addi-
tion, a more profound tissue loss was measured at
this point when compared to the tissue loss in the
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
parasagittal upper lip. This finding suggests the
presence of influencing factors in this area that
induce additional tissue loss.
This study revealed that soft-tissue proportions
change in varying degrees at different points. This
association between time and soft-tissue changes
does not imply causality. In this manner, it does
not contribute to answering the etiologic ques-
tion of aging soft tissue. However, it does provide
a clearer view for the aesthetic surgeon on how to
combat the three-dimensional dynamic changes
of the aging perioral area. To gain deeper under-
standing of these changes, and to determine
whether the changes occur in a linear fashion
over time or not, data from age groups in between
those investigated in this study would be neces-
sary. Although this might reveal certain associa-
tions (e.g., slope changes around menopause in
women), the strongest association can only come
from paired analysis. However, because magnetic
resonance imaging was only introduced in 1977,
the technology is not yet old enough to cover the
47-year lifespan investigated in this study.
CONCLUSIONS
Our results suggest that the aged perioral
area is affected with variable degrees of soft-tissue
lengthening, thinning, and volume loss. These
findings contribute to a better understanding of
the mechanics of aging in the perioral area. The
implications of this study on perioral rejuvenating
strategies are explained in part II.
Patrick Tonnard, M.D., Ph.D.
Coupure Centrum for Plastic Surgery Ghent
Coupure Rechts 164
B-9000 Ghent, Belgium
patrick@coupurecentrum.be
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