Read on for real ways to fix an upside-down smile!

You’re in a great mood. 

The sun is out, you’ve finished work early, and you’re excited to meet up with friends. 

In fact, the day couldn’t get much better – you feel confident and on top of the world!

That great feeling, however, goes down the tubes when your friends greet you.

‘Are you upset?’

‘Why are you so sad?’

‘Did something happen?!”

 

Constantly being asked if you’re having a bad day even when you’re not? Over time, the assumption that you’re ‘sad’ can erode self-esteem and confidence. No wonder so many people are anxious over their ‘resting’ smile. Image by wayhomestudio on Freepik

Whether you call it a downturned smile or – everyone’s favorite – the resting five-letter face, some folks just laugh it off. I applaud you. But for many people? Regular greetings like the examples above – especially on good days – can slowly erode self-esteem and your confidence. 

So today I want to talk about what causes the permanent frowny look and the things you can really (and safely!) do to turn things right-side-round. 

 

Anatomy and Aging

Some signs of aging are well known, obvious, and widely discussed – greying hair, wrinkles, sunspots, the appearance of jowls, sagging of the neck – the stereotypes. A less discussed feature of aging – the down turning that happens at the corners of the mouth – is often much more subtle. 

The corners of the mouth tend to turn downwards as we age and the causes are multifaceted and cumulative – loss of volume, the emergence of marionette and nasolabial folds, wrinkling around the upper lip, gravity – it all plays a part. Image by pressphoto on Freepik

One of the main reasons our mouths appear more downturned as we age is due to the activity of the depressor anguli oris (DAO) muscles. These muscles originate from the mandible and insert into the angle of the mouth – they’re the muscles that allow you to pull your mouth down (ie: depress) into a frown and they’re important for speaking and eating. Hyperactivity of these muscles can lead to a constant state of ‘pulling down’ (frowning) even when you don’t mean them to be. 

Another major contributing cause of frowning as we age is the volume loss that occurs universally over the face as we age. This volume loss can contribute to developing marionette lines, nasolabial folds, and jowls, which can all draw and push the mouth downwards. And then there’s good old gravity helping pull everything downwards. 

 

Signs of aging around the perioral area include:

• Wrinkles of the upper subcutaneous lip (smoker’s lines)
• Elongation of the Philtrum (upper lip)
• A less defined philtral column 
• Thinning of the lip from age related volume loss
• Less definition of the cupid’s bow
• Down turning of the corners (oral commissures)
• Pronounced nasolabial folds and marionette lines
• Enhanced asymmetries 

 

Beyond the aging process, there are anatomical features that can predispose someone to a frowning appearance, even at a younger age. 

One of these features is a ‘turning in’ of the upper lips along the lateral sides. It can make the mouth appear to turn downwards and it’s often anatomical, not age related (though the aging process can certainly emphasize this effect). 

Some upper lips naturally roll inwards along the lateral sides (towards the corners). This anatomical feature can lead lips to appear ‘frowny’ at an earlier age – though it’s by no means a guarantee. Image by Freepik

That can be really tough. It’s common-sense politeness that commenting on someone’s features – a nose, acne, hairline – is in poor taste. But when it comes to asking if someone is sad or tired? Not so much. It’s no wonder so many people are self-conscious and anxious about their smiles. 

 

Though aging plays a part in emphasizing a frown, there are anatomical features to the mouth that can give the appearance to the young as well. Age isn’t the only factor Image by Freepik

So, what are some realistic solutions? 

 

Fillers

On the non-surgical front, fillers (hyaluronic acid) can be used to smooth wrinkles of upper cutaneous lips. This isn’t my favourite solution, however, as filler can migrate and make the upper lip look heavy. There’s also the risk of a Tindell effect, where skin can take off a bluish tinge.

Fillers and neurotoxins are option for addressing a frowny smile but be aware of what they can and cannot do. Too much filler in the smile area can lead to aesthetic (and medical) complications and though neurotoxins can achieve great results, they can’t replace surgery. Image by ArtPhoto_studio on Freepik

You can also inject filler directly into the oral commissure (at the corner of the mouths) in an attempt to lift them, and into the marionette and nasolabial folds to try and smooth those regions. There’s always a point where you run the risk of overfilling, and there are added risks of nodules, migration, infection, and vascular occlusion. Filler around the mouth tends to only last (on average) 3-9 months, possibly due to this being an area of high movement. 

Do those drawbacks make filler a bad choice? It can be a great solution for the right patient but be aware of the risks and have reasonable expectations. 

 

Neurotoxin

Neurotoxins can be a great (and safe) option for targeting the DAO muscles along the mandible, decreasing the amount of downwards pull on the mouth. If these muscles are a major cause of your frown, it can be a low risk/low-cost option (neurotoxin can last 3-6 months). Be aware that your injector needs to be experienced in this area. You don’t want to have the neighbouring DLI (depressor labii inferioris) muscles affected, which are necessary for the function of the lip. 

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Other non-surgical options

Laser resurfacing can be an option to address wrinkles around the mouth (CO2, Erbium:YAG). Chemical peels can work as well (and sometimes be less expensive) but be aware that wrinkles around the mouth tend to be stubborn, so deeper peels are often more effective. Radio frequency with microneedling can also work for the right patient. 

Thread lifts are also having a resurgence in popularity – some designed to pull the lips up, others to build collagen – though I’m not a fan. There are a lot of complications, the results don’t last, there’s an added risk of infection and they’re expensive. 

 

Surgical Solutions

Face Lift

If the dissection is done anteriorly enough, a deep plane facelift with full ligament release can improve the look of both the nasolabial folds and marionette lines. They can’t always address the oral commissures (the downturned corners), so if that’s the source of your frown, it may not be the best strategy. 

 

Lip lifts

A bullhorn-style lip lift (my modified version is called the Elelyft) can help a smile a few different ways. It can increase the arch of the lip, introduce balance by creating an ideal philtral distance (between the base of the nose and top of the upper lip), and can give you better tooth show. All these aspects can give the mouth a significantly more youthful appearance. 

Poor scarring and infection are risks with any cosmetic surgery, but a lip lift has the added risk of speech changes if the underlying muscle is altered. For patients who have minimal upper red lip to start with and a curving in of the lateral lip (near the corners of the mouth) a lip lift can potentially make a frown worse. A lip lift mostly addresses the area right under the nose, so – depending on starting anatomy – it can lead to a bell-shaped upper lip and create an optical illusion of downturned corners. 

Which leads us to the corner lip lift. For patients who experience this bell shape arch after a lip lift (or have it naturally) or have lips that anatomically turn down laterally, a corner lip lift – which exposes more of the upper red vermilion border at the corners of the mouth – can give the lip a fuller, gentler curve. It’s another surgical way to improve or rejuvenate the mouth area and, for the right candidate, it can be a fantastic option. 

 

IMAGE EXAMPLE OF CORNER LIP LIFT FROM CITY FACIAL PLASTICS

https://cityfacialplastics.com/lip-lift-photo-gallery/#mygallery-8

 

For the right patient, a corner lip lift can achieve great things. A corner lip lift I performed gave this wonderful patient’s upper lip more balance. 

Typically, I perform my modified bullhorn lip lift (Elelyft) and then ‘wait and see’ if a corner lip lift is appropriate. The reason is that it can be very difficult to predict whether a patient will need the second surgery or how they will scar, and as corner lip lift scars are more prominent, it’s a good thing to know. To hide the scars of a corner lip lift (once I know how a patient heals), I blend the incision in with the vermillion border and don’t extend past the corners. For the right patient, this can be a great surgery and make a real improvement. 

Another version of a corner lip lift – sometimes called a ‘grin lift’ – is where triangular incisions are made right at the corner of the mouth, and extended outwards, so that the lip can be tilted upwards. The scars can resemble those of the comic book ‘Joker’. I avoid this version of a corner lip lift because if the patient doesn’t heal well, those scars can be really prominent and difficult to hide. 

 

Which solution is best?

There’s no such thing as one size fits all when it comes to anything in cosmetic surgery. Context is key. If you have a frown that really bothers you, I encourage you to consult with an expert and determine what the cause is. If neurotoxin is something that may give you a great result, that’s wonderful, but if the underlying issue is better addressed surgically, then chasing non-surgical options could leave you feeling dissatisfied.

Speaking of experts…

If you’re considering lip augmentation or any other cosmetic procedure, check out our Beauty Experts page or stop by City Facial Plastics to explore the gallery or book a consultation.   

 

The content of this newsletter is for entertainment and educational purposes only. This content is not meant to provide any medical advice or treat any medical conditions. Patients must be evaluated by an appropriate healthcare provider on an individual basis and treatment must be tailored to meet that patient’s needs. Results and particular outcomes are not guaranteed.