title: Classification of the Aging Lips: A Foundation for an Integrated Approach to Perioral Rejuvenation.
abstract: BACKGROUND
  Although perioral aging is highly individual with several distinct processes taking part simultaneously, there is scarce systematic information which helps to indicate the right rejuvenation approach among the multitude of proposed procedures. Existing data about perioral aging has not yet been transformed into a consistent therapeutic concept. The intention of this study was to provide a simple, yet reproducible classification and to offer appropriate rejuvenation approaches.
  
  
  METHODS
  To identify reliable and constant landmarks of the ongoing process of perioral aging, 462 perioral photo documentations were morphometrically analyzed. Based upon the identified landmarks a two-dimensional classification was developed. The classification was validated by three plastic surgeons. Inter- and intra-rater reliability was calculated using Cohen's kappa coefficient.
  
  
  RESULTS
  Perioral aging can be broken down into changes of the lip shape and changes of the lip surface. Both processes can be classified into three stages each: Lip shape according to the shape in profile view, the lip length in relation to the frontal incisors, and the degree of vermilion inversion. Lip surface according to the presence and degree of radial wrinkles and the visibility of the structural elements Cupid's bow, philtrum, and white roll. Inter-observer reliability was rated very good (kappa values between 0.819 and 0.963) and perfect for intra-observer reliability (1.0).
  
  
  CONCLUSIONS
  A better understanding of perioral aging leads to a simple classification for the aging lips. Using the classification helps to tailor an appropriate treatment to the individual patient and aids to achieve a natural rejuvenation result.
authors.affiliation: Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, 79106, Freiburg, Germany.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Penna
authors.forename: G Björn
authors.initials: GB
authors.lastname: Stark
authors.forename: Matthias
authors.initials: M
authors.lastname: Voigt
authors.forename: Alexander
authors.initials: A
authors.lastname: Mehlhorn
authors.forename: Niklas
authors.initials: N
authors.lastname: Iblher
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000715:Anatomy / Q000145:classification; D003357:Cosmetic Techniques; D005260:Female; D006801:Humans; D008046:Lip / Q000033:anatomy & histology*; D008875:Middle Aged; D012060:Rejuvenation; D015203:Reproducibility of Results; D015595:Skin Aging