One-stage inferior labial flap and its pertinent anatomic study

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.

Complete Philtrum Reconstruction on the Partial-Thickness Cross-Lip Flap by Nasolabial Muscle Tension Line Group Reconstruction in the Same Stage of Flap Transfer

Importance

The blood supply pattern of the partial-thickness musculomucosal pedicle flaps is different from the traditional Abbe flap. The arterial blood supply and venous drainage are highly reliable during clinical practice.

Objective

To describe the reconstruction of the philtrum in the cross-lip flap transfer using nasolabial muscle tension line group reconstruction.

Design, Setting, and Participants

From January 1, 2014, through June 31, 2015, a total of 6 patients with upper lip defect were treated with philtrum reconstruction in the same stage of the split cross-lip flap transfer at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. These patients underwent reconstruction of the philtrum by nasolabial muscle tension line group reconstruction. The patients were compared with a randomly chosen group of 5 individuals without upper lip defects by measuring the 3-dimensional scans.

Interventions

In the patient group, the split flap was elevated from the posterior portion of the oris orbicularis muscle after the inferior labial arteries were divided. Then the partial-thickness flap was rotated 180° horizontally and inverted 180° upward to the upper lip defect. The philtrum was reconstructed using the nasolabial muscle tension line group reconstruction.

Main Outcomes and Measures

Three-dimensional scans were performed from the 2-month to 28-month revisits.

Results

A total of 11 individuals were included in the study: 6 in the patient group (mean [SD] age, 17.0 [4.8] years; 2 [33.3%] female and 4 [66.7%] male) and 5 in the control group (mean [SD] age, 15.2 [6.0] years; 2 [40.0%] female and 3 [60.0%] male). In the patient group, 5 of 6 musculomucosal pedicle flaps were viable. A stable philtrum with philtral ridge and philtral dimple was reconstructed on the 5 flaps. The shape of the philtrum was natural according to the 3-dimensional scan measurement. One flap partially necrosed, and the scar retraction was severe postoperatively.

Conclusions and Relevance

The blood supply of the partial-thickness cross-lip flap was from the small vascular network of the lower lip. It is reliable to reconstruct a philtrum in this stage of flap transfer. A complete philtrum structure can be reconstructed by applying muscle tension on the flap.

Level of Evidence

4.

Rescue of lip switch flap at risk of necrosis due to venous congestion for cleft lip deformity

In a 21-year-old male with bilateral cleft lip who developed marked venous congestion of a lip switch flap, we returned the grafted flap to the donor site to improve blood circulation of the flap and then re-transplanted it, which prevented flap necrosis. Here, we report the procedure and case.

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.

An innovative cross-lip flap with a musculomucosal pedicle based on the vascular network of the lower lip

The Abbe flap has been used for full-thickness defects of the upper lip with the inferior labial artery as the pedicle. Using the fine artery anatomy of the lower lip, the authors developed an innovative partial-thickness myocutaneous flap based on the vascular network of the submucosal and subcutaneous layers, which derived mainly from the horizontal labiomental artery or the vertical labiomental artery. From 2010 to 2011, this new technique was used in 33 patients with upper lip defects. The split flap was elevated from the posterior portion of the oris orbicularis muscle after the inferior labial artery was divided. All 33 cases of musculomucosal pedicle flaps were viable. The flap was perfectly symmetrical after the first-stage operation, and the operative time was reduced significantly.

One-stage vermilion switch flap procedure for the correction of thin lips in patients with bilateral cleft lips

In this article, we describe the operative method for correction of thin lips in patients with bilateral cleft lips. Two transverse triangular flaps were designed in the lower vermilion and elevated along with the labial arteries and the surrounding tissues. These flaps were inserted into the recipient site on the upper vermilion through the subcutaneous tunnels at the oral commissure through a one-stage process; the donor site was closed directly. Two patients with bilateral cleft lip underwent this operation for thin lips, and satisfying results with less morbidity were obtained. The upper lip retained its volume postoperatively, and the donor-site scar was inconspicuous. Our method enabled both the augmentation of the upper vermilion and the reduction of the lower vermilion in a one-stage procedure.

The inferior labial artery island flap

The Abbe flap procedure has typically been indicated in cases of tissue defects of the upper lip after injury or tumour excision. However, this method requires two-stage reconstruction. In this report, we describe for the first time a novel one-stage reconstruction method using the inferior labial artery island flap. A 54-year-old man presented with a left upper lip defect and a scar contracture between the upper lip and the left cheek. We planned to reconstruct the lip defect using the inferior labial artery island flap. The inferior labial artery island flap was harvested with a vascular pedicle, and the vascular pedicle was returned through the inside of the flap. The flap survived completely, and liquid leakage from the lip and the appearance of the injured area were clearly improved. For this new technique, we converted the inferior labial flap to a vascular pedicled island flap, which increased its flexibility. This long vascular pedicle could be returned through the inside of the flap. Thus, this flap appears to be ideal for one-stage reconstructions of full-thickness upper lip defects.

A new flap design for reconstruction of full-thickness defects of the lower lip: The extended upper lip island (EULI) flap

The extended upper lip island (EULI) flap has two advantages. It provides a wide mucosal surface, like that of the facial artery musculomucosal flap and does not leave a pedicle across the mouth. Aesthetic results with the EULI flap are almost as good as those with the cross-lip flap. An 89-year-old woman presented with squamous cell carcinoma of the lower oral vestibule. Full-thickness lower lip resection and marginal mandibulectomy, including resection of the surrounding gingiva and mucosa, were performed. The defect was reconstructed with an EULI flap that included the facial artery and vein. There were no severe postoperative complications, but two mild complications did occur: mild congestion of the distal end of the skin paddle and mucosa for two days after surgery and partial paralysis of the orbicularis oris and levator anguli oris muscles. The EULI flap is useful for extended lower lip reconstruction.

Arterial anatomy of the lower lip: a cadaveric study

The aim of the study was to investigate the arterial anatomy of the lower lip. The location, course, length, and diameter of the inferior labial artery and the sublabial artery were revealed by bilateral meticulous anatomic dissections in 14 adult male preserved cadaver heads. Another cadaver head was used for silicone rubber injection to fill the regional arterial tree. The inferior labial artery was the main artery of the lower lip and in all cases branched off the facial artery. The mean length of the inferior labial artery was found to be 52.3 mm (range, 16 to 98 mm). The mean distance of the origin of the inferior labial artery from the labial commissura was 23.9 mm. The mean external diameter of the inferior labial artery at the origin was 1.2 mm. The sublabial artery was present in 10 (71 percent) of the cadavers. Mean measurements of this artery were 1 mm for diameter, 23.4 mm for length, and 27.6 mm for distance from the labial commissura. The sublabial artery may originate from the facial artery or the inferior labial artery. This study found that this region does not have a constant arterial distribution, the inferior labial artery and the sublabial artery (if it exists) can be in different locations unilaterally or bilaterally, and the diameter and the length may vary.

[Full thickness defects of the lips. Reconstructive techniques and indications]

The full-thickness tissue loss of the lip leads to the loss of lip continuity. The classic principle is to repair a lip with a lip, giving the best results. Although the size of tissue lost can force to use local flaps, these could be naso-labio-jugal, labio-mental or submental. Even though the microsurgical labial replantation is the technique of choice, unfortunately, most of the time it cannot be done as a result of the situation and the conservation of the avulsed fragment.

Anatomy of the arterial vascularization of the lips

The findings from 12 dissections of previously injected facial masks, 8 dissections of the face following intraarterial injection of a red solution of Latex Neoprene, and a corrosion cast specimen allowed us to study the arterial supply of the lips. The arterial supply of the upper lip arises mainly from the superior labial arteries, but also from the subseptal arteries and from the subalar arteries. There is a figure of 8 shaped anastomotic system between these arteries lying on the upper lip. The arterial supply of the lower lip arises from the inferior labial arteries and from branches of the mental artery. A constant inferior labial arterial network was shown at the level of the lower lip arising in a fifth of cases from a T-shaped inferior labial artery. All these recent anatomic findings help us to improve our understanding of plastic surgery of the lips.

Galea and subgalea graft for lip augmentation revision

In this paper we will review the results obtained during the last 2 years with the aponeurotic galea and subgalea for vermillion lip augmentation. The survey was carried out on 42 patients who displayed either an absence of or reduction in the vermillion of one or both lips or a senile lip. In all cases the surgical procedure introduced aponeurotic galea and subgalea in the space found between the orbicular lip muscle and the vestibular mucus, just behind the vermillion. All the operations were performed under local anaesthetic. The size of the aponeurotic galea fragment removed varied in length between 10 and 12 cms. and in width between 1 and 2 cms., using the following parameters for its dimensions: the previous volume of the lips, and the distance between the two buccal commissures when in the "smile position."

Bipedicled axial cross-lip flap for correction of major vermilion deficiency after cleft lip repair

Vermilion irregularities are common secondary deformities after cleft lip repair. Particularly severe in bilateral clefts, vermilion deficiency attracts considerable attention and detracts from an otherwise excellent lip repair. Minor and moderate vermilion deficits can be corrected with upper lip advancement, rotation flaps, tongue flaps, or grafts. Major defects defy correction with local flaps, because of an absolute shortage of upper-lip tissue. A technique is described for correction of large absolute tissue deficits of the upper-lip vermillion using a bipedicled lower to upper cross-lip visor flap. A lower lip wet vermilion/mucosal flap is based bilaterally near the commissures on the coronary arteries and transferred to a releasing incision at the wet/dry vermilion border of the upper lip. The commissural pedicles are divided and inset at a second stage 10 days later to complete the transfer. The procedure provides ample bulk and lining for major upper-lip vermilion augmentation and tubercle reconstruction without disturbing the obicularis oris muscular oral sphincter. In addition it balances the lips and allows for feeding. The technique is illustrated in two patients with major upper-lip vermilion defects after repair of bilateral cleft lips.