2.0 ANCC CE Contact Hours Understanding the Perioral Anatomy Tracey A. Hotta , RN, BScN, CPSN, CANS gently infl ate and cause lip eversion. Injection into Rejuvenation of the perioral region can be very challenging the lateral upper lip border should be done to avoid because of the many factors that affect the appearance the fade-away lip. The client may also require injec- of this area, such as repeated muscle movement caus- tions into the vermillion border to further highlight ing radial lip lines, loss of the maxillary and mandibular or defi ne the lip. The injections may be performed bony support, and decrease and descent of the adipose by linear threading (needle or cannula) or serial tissue causing the formation of “jowls.” Environmental puncture, depending on the preferred technique of issues must also be addressed, such as smoking, sun the provider. damage, and poor dental health. When assessing a client Group 2—Atrophic lips ( Figure 2 ): These clients have for perioral rejuvenation, it is critical that the provider un- atrophic lips, which may be due to aging or genetics, derstands the perioral anatomy so that high-risk areas may and are seeking augmentation to make them look be identifi ed and precautions are taken to prevent serious more youthful. After an assessment and counseling adverse events from occurring. as to the limitations that may be achieved, a treat- ment plan is established. The treatment would begin he lips function to provide the ability to eat, speak, with injection into the wet–dry junction to achieve and express emotion and, as a sensory organ, to desired volume; additional injections may be per- T symbolize sensuality and sexuality. To accomplish formed into the cupid’s bow and/or philtral columns this multitude of functions, lips require a complex system to further contour the lips. of muscles and supporting structures. The surrounding Group 3—Lip atrophy and vermillion disappearance complex of anatomical relationships of the muscles at- (Figure 3): The perioral lines are observed at the tached to the lips may be organized by classifi cations of edge of the white roll of the lip where the orbicu- aging or by anatomical region. laris oris is attached to the dermis with no interposed fatty layer. These lines typically start in the 30s and increase in length and depth with aging. They may CLASSIFICATIONS OF AGING be more apparent with increasing sun exposure, Aging lips can be classifi ed into three categories ( Beer, smoking (free radical theory of degradation), lifestyle 2007 ): (poor nutritional diet, exercise, and rest habits), and genetic predisposition. Group 1 — Nice shape and defi nition ( Figure 1 ): These clients have a nice shape (vermillion) and defi ni- Other contributing factors of the aging lip include soft- tion (vermillion border) but wish for enhancement. tissue volume loss, maxillomandibular resorption, and The vermillion is composed of numerous capillar- repetitive pursing of the lips. These contributing factors ies, which give its characteristic pink color. Around result in lengthening of the upper lip with loss of defi ni- the mouth is the vermillion border, a fi ne white line tion of the lip margin, fl attening of the philtral columns, that accentuates the color difference between the loss of projection of the cupid’s bow, and creation of the vermillion and normal skin. Lip enhancement typi- marionette line. cally involves injection of the wet–dry junction to These clients have loss of lip defi nition and/or peri- oral lines and require more attention to technique and other adjunctive treatments. Injection treatment may in- Tracey A. Hotta, RN, BScN, CPSN, CANS, is the owner and president volve fi lling each individual perioral line and/or defi n- of TH Medical Aesthetics. She is the past president of ASPSN, Editor of ing the lip border by injecting and strengthening the the Plastic Surgical Nursing journal, and is a Managing Partner of ACE+ vermillion border to minimize the appearance of the Academia a div of HsuHotta Inc. perioral lines. The author has not received any funding for this work. The author reports no confl icts of interest. Address correspondence to Tracey A. Hotta, RN, BScN, CPSN, CANS, ANATOMICAL REGION 75 Cricklewood Cres, Thornhill, ONT L3T-4T8, Canada (e-mail: tracey@ hotta.ca ). There are 12 facial muscles that affect the shape and DOI: 10.1097/PSN.0000000000000126 function of the perioral area. 12 www.psnjournalonline.com Volume 36 Number 1 January–March 2016 Copyright © 2016 American Society of Plastic Surgical Nurses. Unauthorized reproduction of this article is prohibited. PPSN-D-15-00044_LRSN-D-15-00044_LR 1122 223/02/163/02/16 88:52:52 PPMM FIGURE 1. Lip classifi cation 1. Photography by Tracey Hotta. Used with permission. FIGURE 3. Lip classifi cation 3. Photography by Tracey Hotta. Used with permission. Muscles in the perioral region can be classifi ed accord- ing to their origins and insertions, as well as by their loca- INNERVATION tions, with respect to the major structures. Cranial nerve V ( trigeminal nerve) is the largest of the Group 1 — Muscles that insert into the modiolus : The cranial nerves and the most important sensory nerve of modiolus is a fi brous meeting point where seven the face. It branches into three divisions ( Table 4 ): oph- muscles connect. It is located lateral and slightly su- thalmic (V ), maxillary (V ), and mandibular (V ). perior to each angle of the mouth. It derives its motor 1 2 3 The sensory innervation to the perioral region is from nerve supply from the facial nerve and its blood sup- the maxillary and mandibular branches. ply from labial branches of the facial artery ( Table 1 ). The infraorbital nerve, which is the terminal branch Group 2 — Muscles that insert into the upper lip : These of the maxillary nerve, exits the infraorbital foramen ap- muscles originate from the maxilla below the proximately 4–7 mm below the orbital rim. It travels be- infraorbital foramen and insert into the orbicularis neath the levator labii superioris and superfi cial to the muscle of the upper lip. The nerve supply is from levator anguli oris; it innervates the side of the nose, ala, the facial nerve, and these muscles act to elevate columella, medial cheek, and upper lip. the upper lip. Along the upper vermillion–skin Branches of the mandibular nerve innervate the lower border, there are two medial elevations known as lip and chin. One of the branches is the inferior alveolar the philtral columns. The philtral columns form a nerve, which travels through the body of the mandible midline depression called the philtrum and are re- to exit at the mental foramen. This foramen is located sponsible for the formation of the cupid’s bow. The below the second mandibular bicuspid and has 6–10 mm philtrum extends from the vermilion superiorly to of lateral variability. the columella ( Table 2 ). The infraorbital and mental nerves exit though a fo- Group 3—Muscles that insert into the lower lip : These ramen along with its corresponding artery. To prevent muscles originate from the lower border of the man- complications when injecting dermal fi llers, identify these dible and insert into the skin of the lower lip. The nerves by putting pressure on the foramen with a fi nger- nerve supply is from the facial nerve, and they act to tip, which causes a soreness or sensitive pressure point. depress the lower lip. The labiomental crease passes Cranial nerve VII (facial nerve) is the major motor horizontally in an inverted U-shape across the lower nerve of the facial muscles. It divides into fi ve prominent lip, which intraorally corresponds to the depth of branches following a pattern much like the outstretched the gingivolabial sulcus; the labiomental crease can fi ngers placed on the side of the face. The branches from become more prominent as we age ( Table 3 ). the top include temporal, zygomatic, buccal, mandibular, and cervical. The perioral muscles are innervated primarily from the buccal and mandibular branches of cranial nerve VI; they pass through the parotid gland and form multiple interconnections as the exit the parotid gland ( Table 5 ). THE VASCULAR PATHWAY Injection into or occlusion of a blood vessel can be a serious complication resulting from the use of dermal fi llers. Understanding the vascular structure of the face FIGURE 2. Lip classifi cation 2. Photography by Tracey Hotta. Used can help decrease the risk of complications. The facial with permission. artery should be considered for embolization following Plastic Surgical Nursing www.psnjournalonline.com 13 Copyright © 2016 American Society of Plastic Surgical Nurses. Unauthorized reproduction of this article is prohibited. PPSN-D-15-00044_LRSN-D-15-00044_LR 1133 223/02/163/02/16 88:52:52 PPMM TABLE 1. Group 1: Muscles That Insert Into the Modiolis Group 1 Muscles That Insert Into the Modiolus 1. Orbicularis oris • Purses the lips and presses them against the teeth upon contraction. • Deep orbicularis oris is responsible for the sphincter action of the lips. • Composed of long vertical segments that curl outward at the superior and inferior free margins to form a marginal protrusion. • Innervated by the buccal and mandibular branches of the facial nerve. • In the upper lip, the orbicularis oris fi bers have dermal insertions approximately 4–5 mm lateral from the midline, sparing the central region. This serves to pull the skin medially at these dermal insertion points, forming the philtral columns. 2. Levator anguli oris • Arises from the canine fossa of the maxilla beneath the infraorbital foramen. • Elevates the commissure. • Innervated by the buccal and zygomatic branches of the facial nerve. • The facial artery and the infraorbital nerve travel in a plane on the superfi cial surface of the muscle.