Upper Lip Lines

What is botulinum toxin for upper lip lines?

Botulinum toxin for upper lip lines is the injection of a small amount of botulinum toxin into the muscle around the mouth to treat vertical lines in the skin of the upper lip that become more visible when you purse your lips. The aim is not to stop the muscle completely but to soften the contraction that deepens the lines. The everyday name ‘Botox®’ comes from a product name; the active ingredient is called botulinum toxin.

The way it works is the same as in other areas of the face. Facial wrinkles result from thinning of the skin together with repeated contraction of the muscle underneath. When a small amount of toxin is given into an overactive muscle, the muscle relaxes in that area and the skin above it softens. Examples of approved cosmetic uses in the US include lines on the upper face (between the brows, on the forehead and at the outer corners of the eyes); the area around the mouth is not one of these examples.

Studies of cosmetic use in the mid-face, lower face and neck also show that treatments in these areas largely fall outside approved uses. There are few controlled studies specifically on upper lip lines, and the authors of a study comparing doses state clearly that data on this are scarce. In expert consensus statements, lines around the mouth are included as an area treated with small doses.

Before treatment, you can ask about the licensing status in Türkiye of the product to be used and how it is used in this area. The dose, injection points and dilution are decisions made specifically for you by the doctor carrying out the treatment.

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What causes upper lip lines?

Vertical lines on the upper lip do not have a single cause. Ageing around the mouth involves a combination of sunlight, bone loss, repeated contraction of the muscles around the mouth, gravity, changes in the skin tissue and unhealthy habits. Botulinum toxin targets only one of these factors: muscle contraction.

Fine lines on the lips are one of the signs of ageing in this area. Other signs include deepening of the nose-to-mouth (nasolabial) folds and the lip-to-chin folds, lengthening and flattening of the upper lip, downturned corners of the mouth and thinning of the red part of the lip. In anatomical classifications, these vertical lines, popularly known as ‘smoker’s lines’, are treated as a separate type. They are distinguished from the oblique lines between the lip and the chin, the line in the middle of the chin and marionette lines (lines running down from the corners of the mouth).

Researchers have also looked at who is more likely to have prominent lines. In a study that assessed photographs of 143 people aged 21–91, the factors linked to the severity of wrinkles around the mouth were age, sex and the number of years of smoking. In a study of cadaver tissue, women had more and deeper lines in the skin of the upper lip, and female skin had fewer structures such as oil and sweat glands. The researchers see this as a possible explanation for why these lines are more common in women.

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The muscle around the mouth: orbicularis oris

For upper lip lines, the target is the orbicularis oris, the ring-shaped muscle that encircles the mouth. This muscle is used for speaking, eating, drinking and facial expression, so relaxing it is not the same as relaxing a muscle in the forehead.

Using toxin in the lower face is more complex than in the upper face, and the results are less predictable; side effects are also more common. The reason is anatomical: the muscles of the lower face lie very close together, interweave at different levels and depths, and work together for different functions such as speaking, eating, drinking and facial expression. Expert consensus also emphasises that the important functions of these muscles increase the risk of side effects and complications.

The structure of the muscle also varies from person to person. In a study that examined the upper lip muscle with ultrasound, the part of the muscle close to the lip border (pars marginalis) was present only as a trace in the midline in 20% of participants. It was well developed and continuous in 42.9% and discontinuous in 37.1%. According to the researchers, this variation should be taken into account when toxin is injected into the upper lip. This finding also suggests that the same response should not be expected in every lip.

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How strong is the evidence? A low-dose approach

The scientific evidence supporting the use of botulinum toxin for upper lip lines is more limited than for the upper face, and comes mainly from small studies and expert consensus. Expert consensus statements recommend small doses for this area; in a study specific to this area, side effects also became more frequent as the dose increased.

In this study, 60 women were given one of two different total doses and were followed up for 20 weeks. With the higher dose, line severity was significantly reduced up to week 20; with the lower dose, up to week 16. The responder rate (the proportion of people who responded to treatment) did not differ between the two doses up to week 12; at week 12, it was higher with the higher dose (77% vs 36%). The researchers concluded that the lower dose appeared sufficient for up to 16 weeks, because there was no clear dose–response relationship and there were fewer side effects. In short, the higher dose produced a response in more people at week 12, but side effects were also more common; these two findings need to be considered together.

According to expert consensus, volume loss in the lips can be treated with hyaluronic acid (HA) fillers, and lines around the lips with small doses of botulinum toxin. Another national expert consensus statement also covers lines around the lips and emphasises that each person should be assessed as a whole before treatment.

There is no agreement between countries on dosing. When expert consensus statements from different countries are compared, the US statement recommends a higher dose for wrinkles around the mouth than the others. A systematic review (a review that brings together studies on a topic) looked at uses in the mid and lower face; of the ten publications it included, only three concerned wrinkles around the mouth. Overall, the review reported positive results and no serious side effects; even so, the researchers state that more research is needed.

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How is it different from a lip flip?

Botulinum toxin for upper lip lines and a lip flip are given into the same muscle, but their aims differ. With botulinum toxin for upper lip lines, the aim is to soften vertical lines. With a lip flip, the aim is for the red part of the upper lip to turn slightly outwards and become a little more visible.

A lip flip is a botulinum toxin treatment intended to enhance the outline (contour) and fullness of the lips without adding volume. A review that brought together studies on this subject was able to include only seven studies. A short case report describing three patients defined the lip flip as partial relaxation of the part of the muscle close to the lip border (pars marginalis); besides a slight outward turning of the lip, a reduction in vertical lines was also seen. However, there were very few patients, no comparison group, no blinded assessment and a short follow-up, so the researchers state that these results should be regarded as preliminary findings.

Because both treatments target the same muscle, effects reported with a lip flip, such as difficulty whistling and drinking through a straw, may also occur with this treatment. The structure of the upper lip muscle varies from person to person, so which of the two treatments addresses your concern, or whether neither does, is determined at a consultation. Details about the lip flip are given on the Lip Flip page.

RELATEDLip Flip

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Static lines and use with filler

Botulinum toxin gives a more noticeable result for lines that appear when you purse your lips (dynamic lines). For lines that are visible even when the lips are at rest (static lines), its result on its own is more limited.

For these lines, a low-viscosity hyaluronic acid filler is usually injected close to the surface of the skin. Botulinum toxin can support the result of the filler by reducing lines caused by movement. An expert guideline for the lower face goes further: it states that filler plays a more important role than toxin in this area. It recommends using filler first for structure and support, and considering toxin after that for lines that appear with movement.

In a study directly comparing the two methods, 90 women aged 35–55 were divided into three groups: hyaluronic acid filler alone, botulinum toxin alone, and both together. In the group that received both, improvement from baseline was greater than in the single-method groups on all the measures assessed and at most time points. However, the study used specific products and included only women, so it would not be right to generalise this result to everyone.

The two methods do different jobs: toxin relaxes the muscles that contribute to the lines, while filler replaces lost volume. The specific risks of lip filler and the layout of the blood vessels in the lips are covered separately on the Lip Filler page.

RELATEDLip Filler

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Limits of this treatment

Botulinum toxin for upper lip lines reduces only the part that muscle contraction plays in forming the lines. It does not repair skin damage, it does not replace lost volume, and its effect is not permanent. The effect wears off on its own over time; to maintain it, the treatment needs to be repeated.

Ageing around the mouth is the combined result of sun damage, bone loss, muscle contraction, gravity, changes in the skin tissue and habits. Of these, toxin acts only on muscle contraction. Changes such as bone loss, changes in the skin tissue, or lengthening and flattening of the upper lip are outside its reach. For this area there is a wide range of methods, from temporarily relaxing the muscle with toxin to operations that change the size and shape of the lips, and the choice is made according to each person’s needs.

This is how these limits show up in practice:

• For deep lines that are visible even when the lips are at rest, the result is more limited than for lines that appear with movement.
• The results of toxin use in the lower face are less predictable than in the upper face.
• In the study comparing doses for upper lip lines, side effects became more frequent as the dose increased. Because the muscle is involved in how the mouth works, increasing the dose to get more softening can also make side effects more likely.
• The expert guideline for the lower face also states that filler plays a more important role than toxin in this area.

This information is not meant to put you off, but to help you keep your expectations realistic. How long the effect lasts, repeat treatments and general safety issues are covered on the Botulinum Toxin page. Which option is right for you (botulinum toxin, another method or no treatment at all) is decided through the assessment at your consultation and by your own decision.

RELATEDBotulinum Toxin

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Known risks

With this treatment, most side effects relate to how the mouth works: difficulty speaking, drinking through a straw or whistling, and asymmetry in lip movement. In studies, these effects were mostly reported as mild and temporary; even so, while they last, they can affect your daily life. The figures below come from studies in other people; they cannot be used to calculate your personal risk.

A review of the safety of aesthetic botulinum toxin treatments, covering 8,787 people, reported lip asymmetry and imbalance at a rate of 6.9% after lower-face treatments; all of these effects were reported to have resolved on their own. In the study comparing doses for upper lip lines, most side effects were described as mild or moderate and as effects typically seen with lip treatments; their frequency increased with the dose.

With a lip flip, which is given into the same muscle, mild and temporary side effects such as difficulty whistling and drinking through a straw have also been reported to resolve within a few weeks. In studies of complications after facial treatments, problems with mouth function are generally listed among mild problems that resolve on their own; however, the level of scientific evidence on how to manage complications is low.

The lower-face muscles lie very close together and interweave at different depths; this is among the reasons this area is considered more difficult and side effects are more common. Injection-site effects such as bruising and swelling, conditions that need special care such as neuromuscular disorders, and the lack of data on pregnancy and breastfeeding are covered on the Botulinum Toxin page. If your work or a hobby depends on lip movement, such as speaking or playing a wind instrument, it is important to mention this at your consultation.

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