A Systematic Review of Lower Lip Anatomy, Mechanics of Local Flaps, and Special Considerations for Lower Lip Reconstruction

December 2017 | Volume 16 | Issue 12 | Original Article | 1254 | Copyright © December 2017

Stefanos Boukovalas MD, Alexis L. Boson BS, Joshua P. Hays BS, C. Helen Malone MD, Eric L. Cole MD, and Richard F. Wagner Jr. MD

University of Texas Medical Branch at Galveston, TX


Reconstruction of defects of the lower lip can be very challenging. The aim of this review is to analyze the unique characteristics of lower lip anatomy and provide a systematic approach for lower lip reconstruction. A review of current literature was performed using the PubMed database. Articles analyzing the anatomic and histologic characteristics of the lower lip, mechanics of local faps, and different lower lip recon-struction techniques were included. Articles focused on lower lip reconstruction with free faps were excluded. The orbicularis oris has been described as the main supportive mechanism, however, a number of other structures have been shown to provide mechanical support to the lower lip, including septations of connective tissue extending from the epithelium to the orbicularis oris, a fbroelastic meshwork located in the mentolabial sulcus, and subdermal muscular fbers with dermal terminations in the area of the modiolus. Depending on the location, size, and depth of the wound, a number of reconstruction options are available. Preservation of the competency of orbicularis oris, relation-ship of the modiolus with associated muscles, and sensation, are critical components of functional reconstruction. Primary closure and local faps are assessed for these 3 components and analysis is provided. In conclusion, knowledge of the static and dynamic structural support of the lower lip, as well as the characteristics of different reconstructive options, is imperative for optimal functional and aesthetic outcomes.

J Drugs Dermatol. 2017;16(12):1254-1261.


The lower lip is a complex structure with a significant functional and aesthetic role. There is extensive literature on the different surgical approaches for lower lip reconstruction driven by the complexity of that anatomical area. The concepts of the “reconstruction ladder” can be very helpful as a general guide, but the surgeon will have to customize and individually approach every patient, analyzing the cause of the defect, the size, depth, location of the wound, and its relationship with adjacent structures. Compared to other areas of the human body, the face, and particularly the lower lip has relatively limited soft tissue and skin available for closure of wounds. Grafts or local aps can be utilized to improve outcomes and provide adequate coverage.1,2 It is crucial to understand the mechanics of those reconstructive options.3-5 The limited soft tissue of the lower lip and the close proximity of the oral cavity, pose an additional challenge in the selection of the optimal reconstructive method. Distortion of the mechanical support of the lower lip can cause significant deformity with poor functional and aesthetic outcome.3,6 Oral incompetence can interfere with speech and eating and result in lower lip ptosis and drooling, requiring further treatments and surgical procedures. The aim of this review is to analyze the unique characteristics of the lower lip anatomy and provide a systematic approach of lower lip reconstruction. For that purpose, the mechanics of different reconstructive approaches will be analyzed including grafts and local and regional aps. Additionally, modifications in the design of common reconstruction techniques, in order to achieve optimal aesthetic and functional outcomes, will be presented.


A systematic review of current literature was performed using the PubMed database from 1972 to 2016. The key words used for the review included ‘lower lip anatomy’, ‘cadaver’, ‘lower lip reconstruction’, ‘face reconstruction’, ‘local aps’ and ‘ ap mechanics’. We included articles that analyzed the anatomic and histologic characteristics of the lower lip, the mechanics of local aps, and the different lower lip reconstruction techniques including skin grafts, local aps, and regional aps. Only original articles in English language were included. Articles focused on reconstruction with free aps were excluded.


Five-hundred twenty articles met our inclusion criteria, among which 345 were excluded through abstract screening. One-hundred seventyfive full text articles were then assessed and 158 were excluded (25 of foreign language, 8 with free ap