Introduction
The lips are the focal point of the face during social interactions. The lips are composed of skin, muscle, and mucosa, and they lack direct bony attachments or infrastructure. Hence, the lips are elastic and pliable; these characteristics are both advantages and disadvantages during surgical reconstruction.
The lips play many important roles and are particularly important in both verbal and nonverbal communication. They are necessary for articulation of the letters B, F, M, N, and V.1 In addition, people use their lips to communicate a variety of feelings through facial expression. The lips serve important functions in eating and imbibition. The competence of the oral sphincter is important during chewing and sucking through a straw.
Because the lips are vital for interpersonal relations, even the slightest asymmetry is easily detected and can cause devastating consequences for the patient. Therefore, maintaining the functional and cosmetic integrity of the lips during surgical reconstruction is of the utmost importance.
Relevant Anatomy
The lips are divided into 3 main sections: cutaneous, vermilion, and mucosal. The upper cutaneous lip is bordered superiorly by the nasal sill and columella, laterally by the nasolabial fold, and inferiorly by the vermilion lip. The upper lip is composed of 3 cosmetic units: 2 lateral and 1 medial. The lateral units are bordered by the nasolabial groove laterally and by the philtral crests medially. The medial philtral subunit is composed of the 2 convex philtral crests and the central philtral groove.
The Cupid's bow is the downward projection of the philtral unit, which gives the lip its characteristic appearance. The white roll is the light linear projection that circumferentially outlines the upper and lower lip at the border of the cutaneous and vermilion lip. Reconstruction of the Cupid's bow and the white roll is crucial in preserving the aesthetic nature of the lip; even slight alterations or misalignments of these areas are overtly noticeable.
The lower cutaneous lip is bordered superiorly by the lower vermilion lip; laterally by the extension of the nasolabial folds; and inferiorly by the mental crease, which separates the lower lip from the chin. This portion of the lip makes up 1 cosmetic unit. The relaxed skin tension lines emanate from the vermilion in a radial fashion and are perpendicular to the fibers of the orbicularis oris muscle.
The vermilion portion is the most cosmetically apparent portion of the lip. This portion is a modified mucosal membrane that lacks pilosebaceous units, eccrine glands, and salivary glands. The pink-to-red color of the vermilion lip is due to the extensive superficial vasculature in this area. The wet, or mucosal, lip abuts the teeth and contains minor salivary glands, which empty onto its surface. The red line is where the upper and lower lips meet, and this line corresponds to the transition zone between the vermilion lip and the mucosal lip.
Knowledge of the cross-sectional anatomy of the lip is important to the dermatologic surgeon. Starting from the external surface, the layers are as follows: epidermis of the cutaneous lip, dermis of the cutaneous lip, subcutaneous tissue of the cutaneous lip, orbicularis oris, submucosal of the mucosal lip, and mucosa of the mucosal lip.
The arterial supply of the lips comes from the inferior and superior labial arteries, which branch off the facial artery at the oral commissures. The labial arteries can be found between the orbicularis oris and the submucosa deep to the vermilion-mucosal transition zone. Identifying the labial artery is critical for hemostasis during lip surgery. Variations in the arterial supply occur in the labiomental region, and surgeons should be aware of such variability.2
The sensory innervation of the upper lip is derived from branches of the trigeminal nerve (cranial nerve V). The upper lip is supplied by the infraorbital nerve, which exits the maxilla at the infraorbital foramen. Sensation in the lower lip is derived from the mental nerve, which exits the mandible at the mental foramen. The identification of these nerves is useful in performing nerve blocks for lip surgery. Motor innervation of the perioral muscles is supplied from the facial nerve (cranial nerve VII). The buccal branch of the facial nerve innervates the orbicularis oris muscle and the lip elevators. The marginal mandibular branch of the facial nerve innervates the orbicularis oris and lip depressors. This nerve is most susceptible to injury at the middle portion of the mandible, where it is most superficial.
The primary muscle of the lip is the circumferential orbicularis oris muscle. This muscle has no direct bony attachments, but rather, it is suspended from the surrounding muscles that attach into it. The orbicularis primarily acts as a sphincter, closing the mouth and keeping the lips closed. However, through complex movements, this muscle also functions in puckering, sucking, whistling, blowing, and creating facial expressions. The lip elevators are composed of the levator labii superioris alaeque nasi, levator labii superioris, zygomaticus major, zygomaticus minor, and levator anguli oris muscles. The upper lip retractors are the zygomaticus major, zygomaticus minor, and levator anguli oris muscles. The lip depressors are the depressor anguli oris and depressor labii inferioris muscles. The lower lip retractors are the depressor anguli oris and platysma muscles. The mentalis muscle causes the lower lip to protrude.
Contraindications
No absolute contraindications exist for this procedure.
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References
Salasche SJ, Bernstein G, Senkarik M. Surgical Anatomy of the Skin. Stamford, Conn: Appleton & Lange; 1988:223-40.
Pinar YA, Bilge O, Govsa F. Anatomic study of the blood supply of perioral region. Clin Anat. Jul 2005;18(5):330-9. [Medline].
Leonard AL, Hanke CW. Second intention healing for intermediate and large postsurgical defects of the lip. J Am Acad Dermatol. Nov 2007;57(5):832-5. [Medline].
Gloster HM Jr. The use of second-intention healing for partial-thickness Mohs defects involving the vermilion and/or mucosal surfaces of the lip. J Am Acad Dermatol. Dec 2002;47(6):893-7. [Medline].
Zitelli JA, Brodland DG. A regional approach to reconstruction of the upper lip. J Dermatol Surg Oncol. Feb 1991;17(2):143-8. [Medline].
Huang CC, Arpey CJ. The lips. Excision and repair. Dermatol Clin. Jan 1998;16(1):127-43. [Medline].
Tromovitch TA, Stegman SJ, Glogau RG, eds. Flaps and Grafts in Dermatologic Surgery. Chicago, Ill: Yearbook Medical; 1989:169-82.
Calhoun KH. Reconstruction of small- and medium-sized defects of the lower lip. Am J Otolaryngol. Jan-Feb 1992;13(1):16-22. [Medline].
Ducic Y, Athre R, Cochran CS. The split orbicularis myomucosal flap for lower lip reconstruction. Arch Facial Plast Surg. Sep-Oct 2005;7(5):347-52. [Medline].
Webster JP. Crescentic peri-alar cheek excision for upper lip flap advancement with a short history of upper lip repair. Plast reconstr surg (1946). Dec 1955;16(6):434-64. [Medline].
Kaufman AJ. Bilateral vermilion rotation flap. Dermatol Surg. May 2006;32(5):721-5; discussion 725. [Medline].
Jabaley ME, Clement RL, Orcutt TW. Myocutaneous flaps in lip reconstruction. Applications of the Karapandzic principle. Plast Reconstr Surg. May 1977;59(5):680-8. [Medline].
Renner GJ, Zitsch RP 3rd. Reconstruction of the lip. Otolaryngol Clin North Am. Oct 1990;23(5):975-90. [Medline].
Goslen JB, Thomas JR. Cancer of the perioral region. Dermatol Clin. Oct 1989;7(4):733-49. [Medline].
Panje WR. Lip reconstruction. Otolaryngol Clin North Am. Feb 1982;15(1):169-78. [Medline].
Abbe R. A new plastic operation for the relief of deformity due to double hairlip. Med Record. 1898;53:447.
Estlander JA. Eine methode aus er einen ippe substanzverluste der anderen zu ersetzein. Arch Klin Chir. 1872;14:622.
Goldberg LH, Peterson SR, Silapunt S. Reconstruction of a large surgical defect involving the upper lip. Dermatol Surg. Feb 2005;31(2):206-9. [Medline].
Further Reading
Keywords
healing by secondary intention, primary repair, advancement flaps, unilateral advancement flaps, bilateral advancement flaps, crescentic perialar advancement flaps, island pedicle advancement flaps, rotation flaps, transposition flaps, melolabial transposition flaps, full-thickness transposition flaps, skin grafts
