Anatomic dissection of the arterial supply of the lips: an anatomical and analytical approach

Filling the Gap: Facial Anatomy and Safe Lower Lip Injection Practices

Background/Objectives: Anatomical knowledge of the arterial supply to the lower face is critical to prevent unnecessary harm to patients seeking cosmetic procedures, particularly lower lip dermal filler injections. Our study sought to characterize the prominent vascular structures of the lower lip: inferior labial (ILA), labiomental (LMA) and mental (MA) arteries. Methods: Forty-eight hemiface specimens from 30 formalin-embalmed donors were utilized in this study. Dissection was performed of the LMA, ILA, and MA to determine their diameter, branching pattern for characterization, and to assess their supply to the lip distally. Results: The ILA (mean diameter, 1.5 ± 0.49 mm) was found to be prevalent in 90% of sampled donors. The LMA (1.2 ± 0.53 mm) was found in 75% of donors. All 48 hemifaces were found to have a MA (1.6 ± 0.51 mm). 88% of ILAs, 43% of LMAs, and 96% of MAs were identified as directly supplying the lower lip. Mean location of the MA as it supplied the lower lip was determined to be (-17 mm, -8.2 mm) and (20 mm, -8.1 mm) in the left and right hemifaces, respectively. F-Test for variance found no significant differences amongst the horizontal (p = 0.82) and vertical distances (p = 0.41) bilaterally. Conclusions: Our findings demonstrate the high variability in vascular supply of the lower lip, suggesting the need for high-resolution ultrasound guidance and the integration of anatomical training within injection courses for the safe injection of dermal fillers.

Topographic and anatomical variability of the facial artery: Structure and physiology

A large number of complications associated with incorrect visualization of the facial artery or ignorance of the anatomy of the major facial vessel make this problem quite relevant. An in-depth understanding of anatomical variations, projections and topography, taking into account the depth of the facial artery, can help reduce the risk of adverse outcomes during cosmetic procedures. In addition, it assists plastic and maxillofacial surgeons in managing facial trauma and performing surgical procedures, including advanced endoscopic facelift techniques and endoscopic blepharoplasty, where the risk of vascular injury is higher. In cases of vascular injury, anatomical knowledge allows the selection of an optimal hemostatic approach. The aim of this review is to systematize current data on anatomical variations, topography, and external landmarks of the facial artery, providing a classification and visual representation of different patterns. This structured information will undoubtedly benefit clinicians in various fields.

The Depth of the Facial Artery, Meta-analysis

INTRODUCTION

The depth of the facial artery (FA) probably is the most crucial factor while performing aesthetic procedures. The course of FA varies on different levels. The knowledge of exact depth can help physicians to locate the FA more accurately, thereby enhancing the safety of filler injections. This research is the first meta-analysis focused on the quantitative comparison of depth on five different levels of facial artery including angular artery.

MATERIAL AND METHODS

Twelve research papers were included in the meta-analysis. The analyses were performed in five distinctive places: (1) on the horizontal level of cheilion, (2) between oral commissure and nasal alae, (3) on the horizontal level of nasal alae, (4) between nasal alae and medial eye canthus and (5) on the horizontal level of medial eye canthus.

RESULTS

A total of 794, 514, 1095, 414 and 450 arteries were analyzed at the following horizontal levels, respectively: at the level of cheilion, between the nasal alae and oral commissure, at the level of nasal alae, between the nasal alae and medial eye canthus and at the level of medial eye canthus. The final results were as follows: 9.72, 95% CI (6.50-12.94) [mm], 10.34, 95% CI (5.24-15.44) [mm], 9.21, 95% CI (7.05-11.38) [mm], 4.68, 95% CI (4.04-5.31) [mm] and 2.38, 95% CI (1.38-3.38) [mm], respectively.

CONCLUSION

It appears that performing filler injections up to a depth of 4.5 mm, superficially to the facial artery, is considered safe at the level of the oral commissure. The depth between nasal alae and oral commissure varies significantly. A USG exam during the initial consultation prior to any aesthetic procedure might be a reasonable solution in the upper parts of the nasolabial fold.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Novel Neurovascular Protection Method In Nasolabial Muscle Biomechanical Bionic Surgery For Secondary Unilateral Cleft Lip Repair: A Three-Dimensional Evaluation Of Short And Long-Term Results

BACKGROUND

Neurovascular protection within the upper lip muscles is essential in muscle tension reconstruction and functional recovery during surgery. This study aimed to investigate a novel neurovascular protection method based on the intramuscular neurovascular partitions of the upper lip applied to nasolabial muscle biomechanical bionic surgery for secondary unilateral cleft lip repair and to evaluate postoperative outcomes.

METHODS

From November 30, 2019 to October 31, 2020, 50 consecutive patients with secondary unilateral cleft lips who underwent the modified biomechanical bionic surgery were reviewed retrospectively. Three-dimensional (3D) photographs of patients were collected preoperatively, 7-day postoperatively, and during long-term follow-up (at least 6 months). The Global Aesthetic Improvement Scale was used to evaluate surgical subjective outcomes, and statistical analysis of nasolabial measurements on 3D photographs was used to evaluate objective outcomes before and after surgery.

RESULTS

The Global Aesthetic Improvement Scale showed that 94% of patients had improved upper lip morphology and 92% had improved nasal morphology 7-day postoperatively. In all, 84% maintained favorable nasolabial morphology during long-term follow-up. Statistical results showed that the postoperative alar width, philtral depth, columellar angle, and nasal base inclination angle were significantly improved compared with preoperatively ( P <0.01). The differences between the above 4 indexes were not statistically significant ( P >0.05) between 7-day postoperatively and long-term follow-up, indicating that the postoperative lasting outcomes were satisfactory.

CONCLUSIONS

The novel method of neurovascular protection in nasolabial muscle biomechanical bionic surgery can achieve a long-term improvement of labial-nasal morphology and function in patients with secondary unilateral cleft lip.

Incisional Release and Fat Grafting for the Surgical Management of Perioral Fibrosis in Scleroderma: A Technical Report and Institutional Review

INTRODUCTION

Scleroderma (systemic sclerosis [SSc]) is a rare autoimmune, connective tissue disorder. Perioral fibrosis is a local cutaneous complication, negatively impacting functional capabilities and aesthetic satisfaction. Fat grafting has been postulated to aid in the management of SSc fibrosis thanks to stem cell enrichment. This technique's success has been demonstrated using different graft origin sites and different injection targets. We aim to demonstrate our SSc patients' success using abdominal fat and perioral target.

METHODS

We queried our records for patients with preexisting SSc who underwent incisional release and fat grafting for perioral fibrosis from 2018 to 2021. For perioral release, a semisharp cannula was tunneled under the vermilion border into the vermilion and along the skin. For grafting, cannulas were used to infiltrate the fat with a retrograde filling technique in a radial-fanning manner. Their autoimmune diagnosis, anesthetic risk assessment, systemic disease complications, and degree of presenting symptoms were reviewed along with their postoperative outcomes.

RESULTS

From 2018 to 2021, 16 patients diagnosed with SSc were treated with incisional release and fat grafting for the management of perioral fibrosis. Of the SSc patients, 8 presented with limited SSc, and 8 presented with diffuse SSc. The mean patient age was 54.31 years. All SSc patients presented with functional symptoms with the most common concern (n = 9) being "decreased mouth opening." Other common complaints were "difficulty eating" (n = 3) or "difficulty drinking" (n = 2). Some patients (n = 11) also presented with cosmetic concerns with "perioral rhytids" being the most common (n = 6). The mean number of systemic complications, at the time of presentation, was 3.06. The mean anesthetic risk assessment was 2.44. The average amount of fat grafted intraoperatively was 14.89 mL. Two patients with SSc required regrafting. For one patient, this was part of the original treatment plan and for the other due to fat resorption. Patients who followed up reported improved functionality and were pleased aesthetically.

CONCLUSIONS

Patients with perioral fibrosis due to SSc can benefit from autologous fat grafting. Incisional release in combination with fat grafting can enhance procedure outcomes. This technique provides beneficial functional and aesthetic outcomes. Patients with both diffuse and limited disease are appropriate candidates for this procedure.

Three-dimensional visualization of blood supply of the upper lip using micro-CT and implications for plastic surgery

INTRODUCTION

The anatomy of the arterial branches in the upper lip and their relationships to soft tissue are not well described in the literature. The purpose of this study was to explore a method for visualizing the microvessels and soft tissue three-dimensionally to gain better understanding of the upper lip blood supply.

MATERIALS AND METHODS

Seventeen stillborn fetuses were injected with lead oxide-gelatin and stained with iodine. Thirty-four half upper lip specimens were obtained and scanned by micro-computed tomography. The images were then examined and Inveon analysis software was used for three-dimensional reconstructions.

RESULTS

The main supplies to the upper lip were from the superior labial and inferior alar arteries. In some cases, the infraorbital and lateral nasal arteries also branched off to the upper lip. The anatomical variations were classified into six types on the basis of the observed vascular composition patterns. The skin was supplied by the subcutaneous vascular network, formed by the superficial ascending branches of the superior labial and inferior alar arteries. The mucosa was supplied by the submucosal vascular network, formed by the deep ascending branches of the superior labial artery and the labial branches of the infraorbital artery. The muscles were supplied by small vertical branches from the subcutaneous and submucosal vascular networks.

CONCLUSION

This study provides new anatomical insight into the upper lip by describing the microvessels and the relationship between the arteries and the soft tissue involved. This is important information for clinical applications in upper lip plastic surgery.

Anatomical Variations in the Course of Labial Arteries: A Literature Review

BACKGROUND

Nonsurgical lip enhancement using dermal fillers is a very popular procedure. The trend for enlarged lips has been popularized by media and social media. The lips have considerable aesthetic and functional importance, in addition to having a complex anatomy. Serious complications, including vascular compromise or occlusion leading to cutaneous necrosis and blindness, can occur as the result of lip enhancement using dermal fillers. Therefore, aesthetic practitioners require an in-depth understanding of the anatomy and vasculature of the lips and the perioral area prior to providing lip enhancement using dermal fillers.

OBJECTIVES

This literature review aimed to summarize existing data describing the origin, path, and depth of the superior and inferior labial arteries, and to help aesthetic practitioners in providing safer injections to the lips.

METHODS

A literature search was carried out to summarize the available data describing the origin, path, and depth of the labial arteries.

RESULTS

Analysis of the literature revealed that the labial arteries display great variability with respect to path (distribution), presence, and location.

CONCLUSIONS

Increasing the volume of lips through injections of dermal filler needs to be undertaken with caution, and awareness of the anatomical variation in artery location and path is a crucial concept that is essential when injecting the lips.

Anatomic study of the arterial territories of the face depending on the external carotid artery branches

AIM OF THE STUDY

Blood supply of the skin of the face is mainly provided by 3 branches of the external carotid artery: facial artery (FA), superficial temporal artery (STA) and transverse facial artery (TFA) which is a branch of the STA. The aim of the study was to describe the arterial territories of the skin of the face depending on the external carotid branches.

MATERIAL AND METHODS

After dissection of the first two centimeters of these arteries on one side, we performed an injection of India ink of different colors in the arteries in order to describe the arterial territories (angiosomes) of the face on 24 embalmed cadavers.

RESULTS

The lips and the tip of the nose were vascularized in most cases by the FA. The STA vascularizes the temporal and frontal areas and a part of the auricle. The buccal area blood supply is coming from the FA with a participation of the TFA which is variable (10/24 cases), and the zygomatic area blood supply is coming from the STA with a participation of the TFA (9/24 cases).

CONCLUSIONS

Variations in the angiosomes of the face have to be considered in reconstructive surgery, and in face transplantation.

Translucent and Ultrasonographic Studies of the Inferior Labial Artery for Improvement of Filler Injection Techniques

Lower lip augmentation by filler injection is an aesthetic procedure essential for achieving a feminine look and to enhance attractiveness. Complications as a result of injury to the inferior labial artery can result in undesirable outcomes.

METHODS

The translucent technique was used to study the origin of the inferior labial artery in 11 cadavers. Ultrasonography of the inferior labial artery was also performed in 20 volunteers, which provided supplemental data to this study, in relation to establishing recommendations for filler injection.

RESULTS

Five different types of inferior labial artery were described. These types were found in various combination patterns. Types 2, 4, and 5 are more vulnerable to arterial injury during filler injection. Ultrasonography revealed a depth of 6 mm and an arterial position at the vermillion border as the dangerous injection plane.

CONCLUSION

The origins and courses of the inferior labial artery are classified into 5 types. These types are often found in combination with each other in different faces, resulting in large anatomical variation between people. Types of combination influence severity of lower lip necrosis when arterial injury occurs. The physician should be aware of these anatomical variations during aesthetic treatments and reconstructive procedures to avoid the dangers of accidental arterial injury.

Italian consensus report on the aesthetic use of onabotulinum toxin A

BACKGROUND

The aesthetic treatment of facial and neck wrinkles with botulinum toxin is constantly increasing, thus making it necessary to collect procedures guidelines for the use of botulinum toxin in the treatment of wrinkles and/or cosmetic defects.

METHODS

A group of nine Italian doctors, plastic and maxillo-facial surgeons, dermatologists and aesthetic physicians, experts in face and neck aesthetic treatments with onabotulinum toxin A, discussed on procedures used in their clinical practice. From the data collected and discussed by the board, some recommendations on aesthetic treatment with onabotulinum toxin A were developed.

RESULTS

Recommendations have been made on pretreatment, reconstitution of onabotulinum toxin A, as well as on treatment procedures, in terms of injection sites and total dose of onabotulinum toxin A for the following indications: glabellar lines, crown's feet lines, forehead lines, eyebrow shaping, lower orbicularis oculi hypertrophy, bunny lines, sagging nasal tip, gummy smile, masseter hypertrophy, perioral lines, marionette lines, hypertonic mentalis, and platysma bands.

CONCLUSIONS

The use of onabotulinum toxin A in the aesthetic field requires careful initial assessment of the patient in its complexity and individuality. Moreover, this treatment needs the use of standardized procedures to achieve the effectiveness and safety of onabotulinum toxin A in clinical practice.

The facial artery: A Comprehensive Anatomical Review

The facial artery is the major vessel supplying blood to the face so its location and course are very important for the safe manipulation of both surgical and non-surgical interventions. This study documents current anatomical information about the facial artery and its tributaries. The terminology of the facial artery tributaries was revisited with reference to the Terminologica Anatomica and novel nomenclature was suggested with anatomical features. The tributaries to the lower lip (inferior labial artery), labiomental region (horizontal and vertical labiomental artery), upper lip (superior labial artery), nose (inferior and lateral alar artery and nasal septal artery), angular and ocular region (angular artery and detoured branch) and the course, layers and location of the facial artery main trunk were revisited with contemporary anatomical studies. The facial artery and its tributaries have close topographical connections to the facial expression muscles, nasolabial groove, and vermilion border, and these also distinguish facial landmarks comprising the cheilion, stomion, and gonion. Interestingly, in contrast to previous descriptions, some terminal branches did not take a straight course but a detoured course. The angular artery was connected to the ophthalmic artery branches and in some cases did not originate from the facial artery. Vascular complications of the facial artery tributaries are frequently seen in the angular, dorsum of the nose, tip of the nose, and glabellar region. This detailed review focusing on facial arterial topography in the various areas of the face would help to enhance quality of treatment. Clin. Anat. 31:99-108, 2018. © 2017 Wiley Periodicals, Inc.

Facial Danger Zones: Techniques to Maximize Safety during Soft-Tissue Filler Injections

Given the short recovery and immediate results, facial fillers have become a popular alternative to surgical rejuvenation of the face. Reported complications arising from facial filler injections include erythema, tissue loss, blindness, stroke, and even death. In this article, the authors describe their anatomically based techniques to minimize risk and maximize safety when injecting in the facial danger zones, including the glabella/brow, temporal region, perioral region, nasolabial fold, nose, and infraorbital region. Complications generally arise secondary to vasculature injury and/or cannulation with filler. The authors have outlined their preferred injection techniques in the facial danger zones with respect to the pertinent anatomy in an attempt to minimize risk and maximize results. Most importantly, the practitioner should be able to recognize complications and address them immediately.

Reverse superior labial artery flap in reconstruction of nose and medial cheek defects

BACKGROUND

Angular artery, lateral nasal artery, and infraorbital artery pedicled nasolabial flaps have been used for reconstruction of lower nose and medial cheek defects. An alternative pedicle to raise a flap in the nasolabial area is the superior labial artery. Superior labial artery is a constant branch of the facial artery, arising above or at the angle of mouth and anastomoses with its counterpart in the middle of the upper lip. This makes a reverse superior labial artery pedicle possible for elevation of a nasolabial flap.

PATIENTS AND METHODS

Reverse superior labial artery island flaps were used for reconstruction of lower nose and medial cheek defects in 12 patients. Eleven patients presented with malignant skin lesions and 1 with a traumatic defect of the lower nose. Auricular cartilage graft to support the alar rim and nasal tip was combined to the flap in 3 patients.

RESULTS

All flaps survived completely. Temporary venous congestion was observed in 3 flaps in the early postoperative period but this resolved in 3 to 5 days. All patients healed without any postoperative complications and the final results were considered satisfactory.

CONCLUSIONS

Reverse superior labial artery pedicled nasolabial island flap proved to be a good choice for reconstruction of the lower nose and moderate sized medial cheek defects. This pedicle should be considered where the defect is located on the course of lateral nasal artery or angular artery. Arc of rotation and reliability of this new flap is considered superior to angular artery and infraorbital artery-based nasolabial flaps where these arteries could also be used as pedicle.

A typical pattern of the labial arteries with implication for lip augmentation with injectable fillers

BACKGROUND

Anatomical knowledge of the vascular supply to the upper- and lower-lip vermilion is essential for lip augmentation.

METHODS

The soft tissues of the whole face, including arterial latex injection, were peeled off as a facial flap and turned down for dissection. The mucosal flap was elevated away from the orbicularis oris muscle and the lower facial musculature. The superior and inferior labial arteries were traced from the facial artery along the course of the vermilion.

RESULTS

The facial artery branched into the superior labial artery just above the labial commissure. This artery ran 4.5 mm deep along the upper lip between the oral mucosa and the orbicularis oris muscle just above the vermilion-mucosa junction to anastomose with the opposing artery. The inferior labial artery originated as a common trunk along with the labiomental artery once the facial artery entered the oral vestibule deep to the platysma muscle. The main arterial trunk coursed along the alveolar border within the plane between the orbicularis oris muscle and the lip depressors. From the arterial trunk emanated the inferior labial artery, which accompanied the mental nerve to the lower lip.

CONCLUSION

The vermilion borders of the upper and lower lips are safe for superficial filler injection. All areas of the lower lip are safe because of the minute size of the ascending arteries. To achieve a full upper lip, filler should be injected into the middle body of the lip, thereby avoiding deep injection between the muscle layer and the mucosa, minimizing the risk of injury to the anastomotic arch of the superior labial arteries.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Vermilion lower lip cross flap - An anatomic study on 22 fresh cadavers

Context:

Vermilion lower lip cross flap is indicated for reconstruction of upper lip in residual deformities following trauma or cleft lip. Flap survival depends on incorporation of inferior labial artery in pedicle.

Aims:

This article reports measurement of vertical distance between inferior labial artery and vermilion surface under light microscope in midline sagittal cross-sectional specimens harvested from 22 fresh male cadavers, to design cross lip vermilion flap more accurately and reduce morbidity of donor site.

Settings and Design:

This study is designed to measure vertical distance between uppermost parts of inferior labial artery to vermilion surface in 22 fresh male cadavers. Tissue specimens were taken from lower lip midline in sagittal plane. Histological sections stained with Hematoxylin-eosin were reviewed by Pathologist.

Materials and Methods:

Measurements were done by staged micrometer which was calibrated in 10 μm subdivisions under light microscope. Vertical distance was measured in millimeter and artery location was defined as submucosal, in superficial muscle and deep muscular layer.

Statistical Analysis Used:

Descriptive study.

Results:

Analysis of data shows that mean distance was 2.42 ± 1.67 mm. In 77.27% of cases, the artery was in submucosal layer and in 13.64% of cases this artery was located in superficial muscular layer.

Conclusions:

As a result 4-mm depth incision of lower lip vermilion that incorporate superficial layer of orbicularis oris muscle will ensure blood supply of lower lip vermilion cross flap.

Aneurysm of the superior labial artery

This is a case report of a true and dissecting aneurysm of the superior labial artery in a 51-year-old patient without risk factors for vascular pathology. The patient complained of swelling of the upper lip, mostly on the left side. A Doppler ultrasonography was used in the diagnosis. The definitive treatment was surgical resection, and the histopathological analysis confirmed the diagnosis. The progress of the patient was satisfactory, leaving a slight change in sensitivity in the area. This seems to be the first reported case of true and dissecting aneurysm of the superior labial artery in the medical literature.

Calibre-persistent labial artery: often misdiagnosed as a mucocoele

The authors present five cases of calibre-persistent labial artery (CPLA) all of which were diagnosed clinically as a labial mucocoele. The purpose of this article is to bring this rarely reported lesion to the attention of clinicians.

Face skin necrosis following embolization for arteriovenous malformations: a case report

INTRODUCTION

Arteriovenous malformations (AVMs) are rare in the oral and maxillofacial regions.

DISCUSSION

AVMs may induce severe complications such as uncontrollable bleeding. Superselective intra-arterial embolization is an effective method for this bleeding that is refractory to conservative treatment. Arterial embolization may cause ischemic complications. We report the case of a patient who developed face skin necrosis following bilateral facial artery embolization.