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Upper Lip Anatomy, Mechanics of Local Flaps, and Considerations for Reconstruction

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Upper Lip Anatomy, Mechanics of Local Flaps, and Considerations for Reconstruction CLINICAL REVIEW Upper Lip Anatomy, Mechanics of Local Flaps, and Considerations for Reconstruction Alexis L. Boson, MD; Stefanos Boukovalas, MD; Joshua P. Hays, MD; Josh A. Hammel, MD; Eric L. Cole, MD; Richard F. Wagner Jr, MD Cupid’s bow, and philtrum, leads to noticeable deformi- PRACTICE POINTS ties. Furthermore, maintenance of upper and lower lip • Comprehensive knowledge of static and dynamic function is essential for verbal communication, facial structural support is imperative in reconstruction of expression, and controlled opening of the oral cavity. upper lip wounds. Similar to a prior review focused on the lower lip,1 we • The surgeon should evaluate deficient structures as conducted a review copyof the literature using the PubMed well as characteristics of the defect to select the most database (1976-2017) and the following search terms: appropriate reconstruction method for optimal func- upper lip, lower lip, anatomy, comparison, cadaver, histol- tional and aesthetic outcomes. ogy, local flap, and reconstruction. We reviewed studies that assessed anatomic and histologic characteristics of thenot upper and the lower lips, function of the upper Reconstruction of defects involving the upper lip can be challenging. lip, mechanics of local flaps, and upper lip reconstruc- The purpose of this review was to analyze the anatomy and function tion techniques including local flaps and regional flaps. of the upper lip and provide an approach for reconstruction of upper Articles with an emphasis on free flaps were excluded. lip defects. The primary role of the upper lip is coverage of dentition The initial search resulted in 1326 articles. Of these, and animation, whereas the lower lip is critical for oral competence,Do 1201 were excluded after abstracts were screened. Full- speech, and eating. The orbicularis oris (OO) and several other text review of the remaining 125 articles resulted in exclu- muscles contribute to upper lip function. There are various inser- sion of 85 papers (9 foreign language, 4 duplicates, and tion points for animation muscles, including the upper lip dermis, OO, and modiolus. Special attention should be paid to the philtrum, 72 irrelevant). Among the 40 articles eligible for inclusion, Cupid’s bow, and vermilion border during reconstruction. Advan- 12 articles discussed anatomy and histology of the upper tages and disadvantages of the Abbe, Estlander, and Karapandzic lip, 9 examined function of the upper lip, and 19 reviewed flaps are presented. Knowledge of mechanics, indications, and available techniques for reconstruction of the upper lip. properties of local flaps while considering unique characteristics of In this article, we review the anatomy and function of upper lip anatomy and function are crucial for optimal aesthetic and the upper lip as well as various repair techniques to pro- functional outcomes. vide the reconstructive surgeon with greater familiarity Cutis. 2021;107:144-148. CUTIS with the local flaps and an algorithmic approach for upper lip reconstruction. he upper lip poses challenges during reconstruc- Anatomic Characteristics of the Upper Lip tion. Distortion of well-defined anatomic structures, The muscular component of the upper lip primarily is T including the vermilion border, oral commissures, comprised of the orbicularis oris (OO) muscle divided Drs. Boson, Cole, and Wagner are from The University of Texas Medical Branch, Galveston. Drs. Boson and Cole are from the Division of Plastic Surgery, Department of Surgery, and Dr. Wagner is from the Department of Dermatology. Dr. Boukovalas is from the Division of Plastic and Reconstructive Surgery, Department of Surgery, The University of Tennessee Graduate School of Medicine, Knoxville. Dr. Hays is from the Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas. Dr. Hammel is from Dermatology Specialists, Atlanta, Georgia. The authors report no conflict of interest. The eTable is available in the Appendix online at www.mdedge.com/dermatology. Correspondence: Stefanos Boukovalas, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, The University of Tennessee Graduate School of Medicine, Knoxville, TN 37920 ([email protected]). doi:10.12788/cutis.0205 144 I CUTIS® WWW.MDEDGE.COM/DERMATOLOGY Copyright Cutis 2021. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. UPPER LIP RECONSTRUCTION into 2 distinct concentric components: pars peripheralis be achieved by placing sutures to reapproximate the and pars marginalis.2,3 It is discontinuous in some indi- muscle edges in smaller defects or anchor the remaining viduals.4 Although OO is the primary muscle of the lower muscle edge to preserve deep structures in larger defects, lip, the upper lip is remarkably complex. Orbicularis oris respecting the vector of contraction and attempting simu- and 3 additional muscles contribute to upper lip function: lation of the muscle function. Additionally, restoration of depressor septi nasi, the alar portion of the nasalis, and the continuity of OO also is important for good aesthetic levator labii superioris alaeque nasi (LLSAN).5 and functional outcomes. The modiolus, a muscular structure located just lateral Janis23 proposed the rule of thirds to approach upper to the commissures, serves as a convergence point for and lower lip reconstruction. Using these rules, we briefly facial muscle animation and lip function while distribut- analyze the available flaps focusing on animation, OO ing contraction forces between the lips and face.6 It is restoration, preservation of the modiolus position, and imperative to preserve its location in reconstruction to sensation for each (eTable). allow for good functional and aesthetic outcomes. The perialar crescentic flap, an advancement flap, can The upper lip is divided into 3 distinct aesthetic sub- be utilized for laterally located partial-thickness defects units: the philtrum and 1 lateral subunit on each side.7,8 affecting up to one-third of the upper lip, especially Its unique surface features include the Cupid’s bow, those adjacent to the alar base, as well as full-thickness vermilion tubercle, and philtral columns. The philtral defects affecting up to two-thirds of the upper lip.7,24 The columns are created by the dermal insertion on each OO continuity and position of the modiolus often are side of the OO, which originates from the modiolus, preserved, sensation is maintained, and muscles of ani- decussates, and inserts into the skin of the contralateral mation commonly are unaffected by this flap, especially philtral groove.2,9-11 The OO has additional insertions in partial-thickness defects. In males, caution should into the dermis lateral to the philtrum.5 During its course be exercised where non–hair-bearingcopy skin of the cheek across the midline, it decreases its insertions, leading is advanced to the upper lip region. Other potential to the formation and thinness of the philtral dimple.9 complications include obliteration of the melolabial The philtral shape primarily is due to the intermingling crease and pincushioning.7 of LLSAN and the pars peripheralis in an axial plane. Nasolabial (ie, melolabial) flaps are suggested for The LLSAN enters superolateral to the ipsilateral phil- repairnot of defects up to one-third of the upper lip, espe- tral ridge and courses along this ridge to contribute to cially when the vermilion is unaffected, or in lateral the philtral shape.2 Formation of the philtrum’s contour defects with or without commissure involvement.7,24-28 arises from the opposing force of both muscles pulling This flap is based on the facial artery and may be used as a the skin in opposite directions.2,5 The vermilion tubercle direct transposition, V-Y advancement, or island flap with arises from the dermal insertion of the pars marginalisDo good aesthetic and functional outcomes (Figure 1).29,30 originating from the ipsilateral modiolus and follows the There is limited literature regarding the effects on anima- vermilion border.2 The Cupid’s bow is part of the white tion. However, it may be beneficial in avoiding microsto- roll at the vermilion-cutaneous junction produced by the mia, as regional tissue is transferred from the cheek area, anterior projection of the pars peripheralis.10 The complex maintaining upper lip length. Additionally, the location anatomy of this structure explains the intricacy of lip of the modiolus often is unaffected, especially when the reconstructions in this area. flap is harvested above the level of the muscle, providing superior facial animation function. Flap design is critical Function of the Upper Lip in areas lateral to the commissure and over the modiolus, Although the primary purpose of OO is sphincteric as distortion of its position can occur.26 Similar to cres- function, the upper lip’s key role is coverage of dentition centic advancement, it is important to exercise caution in CUTIS12 and facial animation. The latter is achieved through male patients, as non–hair-bearing tissue can be trans- the relationship of multiple muscles, including levator ferred to the upper lip. Reported adverse outcomes of the labii superioris, levator septi nasi, risorius, zygomaticus nasolabial flap include a thin flat upper lip, obliteration minor, zygomaticus major, levator anguli oris, and buc- of the Cupid’s bow, and hypoesthesia that may improve cinator.7,13-17 Their smooth coordination results in various over time.30 facial expressions. In
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