The Lips -

45 Injection Techniques
for Esthetic Lip Treatment
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Regine Reymond available at the time of publication.
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[email protected] guarantees for any information regard-
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to take great care to check the package
insert leaflets of the products used and
Dr. med. Christian K~hler
to establish, if necessary by consulting a
PREVENTION-CENTER AG
specialist, whether the dosage recom-
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Utoquai 31
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_J
The Lips -
45 Injection Techniques
for Esthetic Lip Treatment

Regine Reymond
Christian K~hler

KVM
 ----- ---·----- -----

About the authors

Regine Reymond, alternative practitioner, pharmaceutical representative, and co-owner of the company"easinject"
is an expert in the area of esthetic lip treatment with hyaluronic acid (fillers). Based on her professional activities, she
is able to demonstrate almost 20 years of expertise in the use of minimally invasive injection techniques. Having
partially completed a university course in medicine, she worked as a marketing manager for international
pharmaceutical companies for several years; since then, she has either organized or personally led more than 150
workshops, seminars, and symposia on the topic of filler techniques.

Dr. med. Christian Kohler is an expert in esthetic surgery, non-surgical techniques, and esthetic laser treatments.
For more than 10 years, he has been heading up the Prevention Center in Zurich, Zug and Schaan, Switzerland. His
specialist areas include procedures such as breast augmentation, eyelid tightening, and facelifts. Dr. Kohler has more
than 18 years of hands-on experience in general, vascular, reconstructive, and plastic surgery. To date, he has also
performed more than 50,000 non-surgical treatments with botulinum toxin and fillers.

IV
 Foreword

Dear colleagues

The perfect, beautifully shaped mouth, with its soft fullness and healthy blush, really does exist: it is the mouth of a
child. The childish mouth with its pouting lips has a direct, disarming effect on adults, triggering a protective instinct.
In the adult face, this type of mouth takes on the attribute of sensuality - which is the desired effect in any lip
treatment using minimally invasive procedures.

A beautiful mouth has a rather magical quality. It can have a positive effect on an individual's appearance and
charisma, even where the proportions of the face are not entirely harmonious. Nevertheless, every mouth has its
own natural shape, and this shape is subjected to highly individual mimic activity. With increasing age, this mimic
activity influences not only the expression of the lips, but also the expression of the face as a whole, so that the
emotional traces of a lifetime can supposedly be read on a person's face.

Since the lips are in constant, three-dimensional movement, which changes their shape and thereby affects overall
facial expression, it is a huge challenge to shape or augment the lips with filler injections. Mistakes can be made
here, and these become obvious even if they involve only the tiniest deviations or areas of asymmetry. More than
one injection technique will be needed to reshape the lips. Even if we can say exactly how much of any particular
material needs to be placed at a specific location on the lip, we can be certain that this will produce different results
in each individual. There is no universal treatment regimen. Instead, we have multiple technical options at our
disposal, and their use must always be preceded by a profound analysis and good communication with the patient.
The better the interaction of these factors, the more likely a successful result will be achieved.

During my early professional days in esthetic medicine in 2001, the lips were injected using two techniques: the
contours were always treated first, followed by subtle linear filling starting from the mouth corners. Plumped
lips were not in fashion, and imperfections were not yet being corrected. It is incredible to see how rapidly
these techniques have been evolving over the years, and how this trend is now generating an enormous
demand for treatment. However, this also demonstrates the vital and changing nature of esthetic work, and
shows that a dedicated and experienced therapist can never stop adopting innovations or learning and
perfecting new refinements.

Injection treatment of the lips remains a challenge, even for highly experienced therapists, since the mouth does not
tolerate errors. Since lips are so well-perfused, they swell quickly, which can cause complications. The patient's
wishes represent an additional challenge of lip treatment, and one which must never be underestimated. Unfortunately,
what a patient wants is often shaped by unrealistic expectations or extreme fashion trends. As a therapist, you may
end up with a moral conflict and a dissatisfied patient, detracting from the enjoyment you derive from your work.

Some two years ago, the idea occurred to document the knowledge I had amassed over the past 20 years in
workshops, international training events, conferences, and online professional development courses, with the aim
of sharing this knowledge with my colleagues. Numerous conversations with eminent authorities of injection
treatment, extensive research, the active support of my friends and family, and the motivation provided by the
publisher, KVM, encouraged me to translate my idea into action. I have neither invented nor changed the techniques
presented here. The knowledge comes from various trainers, educators, speakers, and doctors working in esthetic
medicine, and shows different approaches and directions. I have collected and categorized all the techniques
presented in this book for quality and feasibility, optimizing some of them, and have done so in constant dialogue
and close cooperation with my co-author, Dr. Christian Kohler. The aim was to produce a practical manual about
injection techniques for use in the lip region, to be applied as required or according to preference.

V
 Foreword

The various problem-solving approaches form the focus of this book, which also strives to optimize the finer points
of injecting the lips with fillers; all this is presented under the aspect of realistic working practices. In this respect, we
have created a matrix that can be used as a guide to match up the indications most commonly occurring at esthetic
practices to the recommended techniques. However, this does not mean that therapists should reduce their skills to
this matrix - on the contrary, the many different approaches shown here will allow therapists to broaden their own
ranges and creatively elaborate the finer points of the treatment, perhaps even developing some of the techniques
further. The recommendations on filler volumes to be injected are based on average practice-based figures in Central
Europe. These values will vary according to regional beauty preferences or trends.

In the main, we have refrained from the use of before/after images, since these can easily lead to expectations that
may not necessarily relate to the individual face being treated.

Dr. Christian Kohler, MD has demonstrated the techniques on models in video recordings. These are available
to you as additional visual aids via the QR codes included in the book, which are a valuable add-on to the
information on the various injection techniques described in the text. I would like to extend my warm thanks
to Dr. Kohler and his team for their wonderful, highly positive collaboration as well as for the superb quality of
the injection procedures depicted.

A further word on the 45 filler injection techniques that are presented here and form the core of this book: for each
of these techniques, the images and videos of the lip treatment procedure are supplemented with details of the
technique, the direction of needle insertion, skin layer, material and volume, type of injection needle, and anesthesia.
All of these particulars are in line with our recommendations and experience-based values, but they should not be
seen as requirements set in stone. In addition, each technique includes a "Treatment protocol" box with a key points
summary of the technique as well as an "Important notes" box, which also lists the possible and undesirable side
effects for each treatment technique. These may occur at varying severity in most lip injection procedures and need
to be borne in mind: the principal side effects include asymmetries, inflammation, hematomas, nodules, necrosis,
reddening, pain, swellings, and overcorrection. These two text boxes, which inherently contain repetitions, should
provide a useful reminder of all the key aspects of the lip treatment for each individual technique.

This book is aimed at medical doctors and licensed therapists with experience of filler injection treatment. The
endorsement and use of the demonstrated techniques remain the responsibility of the individual therapist
conducting the treatment. It is important to remember that each lip is unique, and that no hard and fast
formulae exist: the use of any of the presented techniques must be preceded by an assessment and by the
therapist's decision, made in agreement with the patient, regarding when and to what extent a particular
technique can be used in that patient.

VI
 Acknowledgments

Acknowledgments

Many people have provided me with their active and passive support in the form of their studies and publications.
In this respect, I would like to extend particular thanks to Dr. Tom van Eijk, Dr. Daniel Brusco MD, Dr. Niklas lblher MD,
Prof. Vincenzo Penna MD, Prof. Bjorn G. Stark, Dr. Petra Becker-Wegerich MD, Dr. Philippe Snozzi MD,
Dr. James Bouzoukis, Dr. Phillip Chang, Dr. Anil Rajani, Dr. Polsak Worakrai, and Zita Hesse. My warm thanks also go
to all of those who have given their kind permission to publish their images.

Particular credit needs to be given to the graphic representations in this book. With admirable patience, David Kuhn
from KVM has provided outstanding depictions of every detail. This has made it possible to illustrate the various
points described in the book, making them clear and easy to understand. The photographic services of Martin Frick
and the filming by Andreas Grabherr also provide vivid visualizations of descriptions given in the text, closing any
remaining gaps in the written material. My warmest thanks go to them for doing this!

Last but not least, my thanks go to my dear husband, Dr. Jean Fran~ois Reymond MD; with his clear head and
constructive criticisms, he was a valuable though strict mentor, and helped me to make the procedures comprehensible
even for less experienced therapists.

I wish my readers not only professional and practical gain, but also enjoyment in reading this volume. In addition, I
hope it will stimulate you to question familiar and established practices and to try new ones, and thereby to advance
your continued professional development. In doing so, you might have the same experience as I did, having discovered
three additional, relevant techniques after the press deadline for this book. I look forward to your feedback. Should
you be aware of any techniques that have won you over but are not described herein, I would be pleased to include
these, once tried and tested, in the next edition.

Basel, October 2021

Regine Reymond

VII
 Table of Contents 4.8 Filler Products for Very Deep Augmentation ...... 74
4.9 Filler Navigator 75

1 The Lips 1

5 Anesthetic Methods 77
1.1 Beauty 2
1.2 Function 3
5.1 Maximum Compression of the Lip 78
1.3 Anatomy 3
5.2 Application of Cold Stimuli 78
1.4 Aging Process of the Mouth Region 20
5.3 Topical Anesthetic Cream 78
1.5 Lip Shape and Expression 24
5.4 Direct Lidocaine Application 79
1.6 Analysis of the Lip Region 27
5.5 Anesthetic Skin Wheals at the Injection Site 80
1.7 Merz Scales 43
5.6 Nerve Block using the Mucosal Block or
Micro-Nerve Block Technique 80
5. 7 Conduction Anesthesia . . . . . . . . . . .. . . . .. . .. . . . . . . . . . . . . . . . . . 82
2 Consultation 47 5.8 Complications of Local Anesthesia 84

2.1 Patient's Wishes 48

2.2 Medical History and Examination 50 6 Complications, Side Effects,
2.3 Contraindications 50 Follow-Up Assessment 85
2.4 Analysis and Findings 51
2.5 Documentation 51 6.1 Discoloration .......... . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 86
2.6 Counseling, Information Session 51 6.2 Edema 86
2.7 Budgeting 51 6.3 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 86
2.8 Treatment Planning 52 6.4 Nodules 87
6.5 Vascular Complications 87
6.6 Follow-Up Assessment 87
3 Documentation 59

3.1 Patient Documentation 60 7 Practice Fittings and Facilities,

3.2 Photographic Documentation 60 Materials, Patient Management 89

7 .1 The Practice Ambience 90

4 The Dermal Filler Hyaluronic Acid ..... 65 7.2 Furnishings 90

7.3 Hygiene 92

4.1 Requirements for Hyaluronic Acid 7.4 Equipment used in Pre- and
in Lip Treatment .. . .. . .. . .. .. .. . . 66 Post-Treatment Care 92
4.2 Filler Properties 66 7.5 Patient Management during the Treatment ........ 98
4.3 Dermal Filler Products . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 67
4.4 Filler Products for Treatment of the Lips
and Perioral Region 68 8 Injection Techniques 107
4.5 Filler Products for Revitalization and Hydration .... 70
4.6 Filler Products for Medium Augmentation 72 8.1 Introduction . 108
4.7 Filler Products for Deep Augmentation 73 8.2 Injection according to Skin Layer ......•. . . . . .. . . . . .. 108

VIII
 Table of Contents

8.3 Injection Techniques and Effects - - TECHNIQUE 16: Subtle Volume Replacement
Sharp Needle . 110 (Sharp Needle).......... . 190
8.4 Injection Techniques and Effects - - TECHNIQUE 17: Subtle Lip Augmentation
Blunt Cannula . 118 (Sharp Needle) 194
8.5 Technical Notes, Experience-Based - TECHNIQUE 18: Classic Augmentation
Observations, and Practical Tips... 122 (Sharp Needle) 198
- TECHNIQUE 19: Moderate Augmentation
(Blunt Cannula) 202
9 45 Techniques for Lip Treatment ..... 127 - TECHNIQUE 20: Classic to Strong
Augmentation (Blunt Cannula) 206
9.1 Hydration, Revitalization 128 - TECHNIQUE 21: Extreme Augmentation -
- TECHNIQUE 1: Hydration and Revitalization -- Bolus and Fanning Technique (Sharp Needle)... 210
Cutaneous Part of the Lip (Sharp Needle) ...... 128 - TECHNIQUE 22: Augmentation from the
- TECHNIQUE 2: Hydration - Cutaneous Part DryMl et Boundary (Sharp Needle) 214
of the Lip (Blunt Cannula).. .. 132 - TECHNIQUE 23: Augmentation from the
- TECHNIQUE 3: Hydration -- Vermillion Mucous Membrane (Sharp Needle) ......... ..... 218
(Blunt Cannula) .... . . .. . .. 136 -- TECHNIQUE 24: Volumization with or without
- TECHNIQUE 4: Revitalization - Vermillion Tubercle Accentuation (Sharp Needle)........... 222
(according to Patrick Trevidic, Sharp Needle) ... 140 - TECHNIQUE 25: Volumization -
9.2 Accents 144 Bolus Technique (Sharp Needle) 226

TECHNIQUE 5: Fresh Up (Sharp Needle) ... ..... 144 - TECHNIQUE 26: Volumization - Cutaneous
- TECHNIQUE 6: Contouring and Part of the Lip Technique (Sharp Needle) 230
Enhancement (Sharp Needle) 148 - TECHNIQUE 27: Extreme Volumization
- TECHNIQUE 7: Contouring (Blunt Cannula) ... 152 and Shaping - Multiple Injection Technique

- TECHNIQUE 8: Contouring/Reshaping of (Sharp Needle) 234

the Cupid's Bow (Sharp Needle) ........ 156 - TECHNIQUE 28: Volumization and Shaping -

- TECHNIQUE 9: Contouring of the Philtrum "Lip Tenting Technique" according to

(Sharp Needle) 160 Tom van Eijk (Sharp Needle) 238

- TECHNIQUE 10: Modeling of the Philtrum 9.5 Perioral Volume 242

and Cupid's Bow (Sharp Needle) 164 - TECHNIQUE 29: Volumization -
9.3 Perioral Lines 168 Labiomental Fold (Sharp Needle) 242

- TECHNIQUE 11: Linear and Fishbone - TECHNIQUE 30: Augmentation -

Technique for Perioral Lines (Sharp Needle) .... 168 Chin Region (Sharp Needle)............ . 246

- TECHNIQUE 12: Perioral Point Technique, - TECHNIQUE 31: Volumization - Vertical

Modification by Stretching or Compression Injection Technique (Sharp Needle) . 250
(Sharp Needle) 172 - TECHNIQUE 32: Volumization -
- TECHNIQUE 13: Perioral Blanching Fine Marionette Lines I (Sharp Needle) 254
Technique (Sharp Needle) 178 - TECHNIQUE 33: Volumization -
- TECHNIQUE 14: "Fern Pattern Technique" Fine Marionette Lines II (Sharp Needle) .......... 258
according to Tom van Eijk (Sharp Needle) 182 - TECHNIQUE 34: Augmentation -
9.4 Lip Volume 186 Marionette Lines (Sharp Needle) 262
-- TECHNIQUE 15: Minimal Four-Point Volume - TECHNIQUE 35: Augmentation --
Replacement (Sharp Needle) 186 Marionette Lines (Blunt Cannula) 266

IX
 Table of Contents

- TECHNIQUE 36: Augmentation - Case Examples ................................. 319

Windmill Technique: Marionette Lines, Lips,
Perioral Region (Blunt Cannula) ... 270 11.1 Perioral Lines, Atrophied Mouth ...................... 321
9.6 Shaping, Beautification _. 274 11.2 Older Mouth with Thin Lips 322
-TECHNIQUE 37: Subtle Mouth Corner 11.3 Previously Treated Lips 323
Lift (Sharp Needle) 274
11.4 Oral Commissure Lines, Thin Lower Lip,
- TECHNIQUE 38: Classic Mouth Corner Lift
Minor Asymmetries, Dry Upper Lip 324
(Sharp Needle) 278
11.5 Perioral Shadows and Areas of Asymmetry ...... 325
-- TECHNIQUE 39: Subtle Volumization -
11.6 Asymmetric Mouth 326
Tubercle Definition (Sharp Needle) 282
11.7 Beautification of Young, Full Lips .................. 327
- TECHNIQUE 40: Contouring of the Perioral Line
11 .8 Thin Lips with Poorly Defined Contours 328
according to Phillip Chang (Sharp Needle) ..... 286
11 .9 Small Mouth with a Prominent
-TECHNIQUE 41: Indentation in the Center
Medial Tubercle 329
of the Lip (Sharp Needle) 290
11.1 O Sad, Young Mouth 330
- TECHNIQUE 42: Widening the Arch of the
11.11 Dry Lips 331
Lower Lip (Sharp Needle) 294
- TECHNIQUE 43: Correcting a Previously
Treated Lip (Sharp Needle) 298
- TECHNIQUE 44: Correcting Areas of 12 Appendix 333
Asymmetry (Sharp Needle/Blunt Cannula) ...... 302
- TECHNIQUE 45: Augmentation of the References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . .. . .. . . . . . . . . . 334
Upper Lip -"Pillar Technique" according to Video Register ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Anil Rajani (Sharp Needle) 306 Web Links • 339
Image Sources . 339
Index . 340
1O The 45 Lip Treatment
Techniques: An Overview 311

Synoptic Table . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

X
 Abbreviations

The following abbreviations are used in this book:

Medical abbreviations St Stomion (oral fissure when the lips are closed)
ft) Sharp needle Trg Tragus
fi1 Blunt cannula Tri Trichion (hairline)
A Viscous (HA material) TWN Thin wall needle

•
Ala
Soft (HA material)
Attachment point of the wing of the nose
UL
UTWN
Upper lip
Ultrathin wall needle
AN Tip of the nose (apex nasi)
B' Soft tissue B-point (the deepest point of Editorial abbreviations

the labiomental fold) C. Circa (approximately)

BDDE Butanediol diglycidyl ether cf. Confer/conferatur (compare with)
C Cervical point (junction of the submental e.g. Exempli gratia (for example)
and neck contours, neck-throat junction) et al. Et alteri (and others)
Cm Columella nasi (fleshy external end of the etc. Et cetera (and so on)
nasal septum) i.e. Id est (that is)
CPM Cohesive polydense matrix f. And the following page
DCLT Dynamic cross-linking technology ff. And the following pages
DN Dorsum nasi (bridge of the nose) Fig. Figure
GI Glabella (skin of the forehead between max. Maximum
the eyebrows) n.d. No date
HA Hyaluronic acid No. Number
Li Labiale inferius (foremost edge of p/pp Page/pages
the lower lip) Syn. Synonym
LL Lower lip Tab. Table
Ls Labiale superius (foremost edge of
the upper lip) Units of measurement

Me' Soft tissue menton (the most inferior point % Percent

on the soft tissue of the chin) Degrees
N' Soft tissue nasion G Gauge
NASHA Non-animal stabilized HA g Grams
Or' Soft tissue orbitale L HA particle size for a thick material with lifting
Pg' Soft tissue pogonion capacity
Ph Philtrum M HA particle size for a material of medium
PL Perioral zone of the lower lip thickness with lifting capacity
Pn Pronasale mg Milligrams
Por Porion (external auditory meatus) ml Milliliters
PU Perioral zone of the upper lip s HA particle size for a material with weak
RHA Resilient hyaluronic acid lifting capacity
SMART Supreme monophasic and reticulated XL HA size for a very thick material with strong
technology lifting capacity
SMAS Superficial musculoaponeurotic system XS HA particle size for a thin material with no
Sn Subnasale lifting capacity

XI
XII
Illustrated Guide "The Lips"

The Lips

1.1 Beauty 2

1.2 Function 3

1.3 Anatomy 3

1.4 Aging Process of the Mouth Region 20

1.5 Lip Shape and Expression 24

1.6 Analysis of the Lip Region 27

1.7 Merz Scales 43

 The Lips

1 The Lips However, it is particularly in the current age of selfies, taken by the
million and posted on lnstagram with a prominent pout, that extreme
lip augmentation has gained in significance - regardless of whether
this lip shape fits harmoniously into the face.

1.1 Beauty In the past two years, celebrities and influencers have also effected
Regardless of era or culture, the lips always play a key role as a fea- changes in the conventional features of lip beauty, so that a dispropor-
ture of beauty. Full, mobile, well-perfused, moist red lips are associ- tionately enlarged upper lip with an altered shape is now seen as at-
ated with youthfulness, health, sensuality, and the sexual attractive- tractive. This can then often lead to an unnatural result in some circles,
ness that goes with them. A full mouth is generally seen as an ideal having thick, "bee-stung" (or " dinghy") lips is equivalent to wearing
of beauty and attracts attention to itself -- and this has been the case certain designer brands.
since time immemorial.
Symmetry, or the balance between the lips and rest of the face, is de-
This begs the question of a neutral evaluation of lip beauty that is liberately ignored, causing conspicuous disruption in the harmony of
not dependent on fashion. A pertinent investigation was reported the facial features: the artificial lips are put on show with pride and
in the "JAMA Facial Plastic Surgery" study by the surgical team carried on the body like a work of art.
headed by Natalie Popenko (University of California, Irvine), in
which USA researchers showed portraits of pale-skinned women to An association between lip shape and character is another aspect that
580 subjects. Lip shape, the ratio of upper lip to lower lip (UL : LL), is under discussion. This subject is less well researched, although there
and the size of the lip surface relative to the lower third of the face are many disputed, popular science interpretations of this (Bunte.de
were altered in these portraits. The UL : LL ratio of 1 : 2 was as- Redaktion magazine website 2018),e.g.:
sessed as the most attractive, with the highest mean and highest
proportion of "most attractive" placings, while the UL: LL ratio of • Harmonious lips convey calmness and serenity.
2 : 1 was rated as the least attractive. • Thin lips stand for grimness, lack of passion, single-mindedness,
perseverance.
1 • Large lower lips stand for impulsiveness.
• Lopsided, crooked lips stand for a loving, trustworthy nature.

Fig. 1.1 Facial expressions show feelings that

change the shape of the lips, creating visually
identifiable emotions. A mouth with its corners
pulled down is a display of sorrow or disgust.

2
 Beauty, Function, Anatomy

However, the movements made when speaking and eating, the mus- Since the lips contain numerous nerve endings, they comprise one of
cle tone of the lips, and the changes in shape caused by the facial the most sensitive regions of the body. The thin skin of the lips feels
muscles as an expression of feelings (- Fig. 1.1), which can make a pleasantly soft and reacts with enormous sensitivity to external stim-
mouth beautiful or special but can also express a negative attitude, uli such as temperature, touch, and pain. The lips act as an organ of
all exist independently of the anatomical structures and the geneti- touch for infants and have a highly sensitive function as an eroge-
cally determined shape of the lips. These movements may be sym- nous zone in sexuality, e.g. during kissing. Thus, beautiful lips can
metric and harmonious in themselves, or asymmetric and crooked, increase a person's sexual attractiveness.
lending a personal note to the overall appearance. Regardless of the
shape of the lips when relaxed, these influences can make a pair of
lips seem sensual, charismatic, erotic, pinched, disdainful, lascivious,
etc. Inferences about an individual's character are made as a result of
1.3 Anatomy
lip expression: this person has a labile mouth, an intelligent mouth, The lips are the soft tissue folds formed in the lower, anterior part
an idiotic mouth, an aggressive mouth, and so on. of the face, and they seal off the oral cavity against the outside
world. They possess inherent mobility, and, with the cheeks (buc-
cae), they form the vestibule of the mouth (vestibulum oris). The lips
are embedded in the oral and chin region, forming its center (Doc-
1.2 Function
Check Flexikon 2019). In this book, we have concentrated predom-
The lips have important functions far beyond their role as a feature inantly on this region, leaving out treatment of the nasolabial zone,
of beauty. They are intended for food ingestion. Their musculature as any complete treatment of that zone would also affect treatment
makes them very mobile so that they can hold onto food items and of the upper half of the face. We had to draw a line here. We have
convey them into the mouth. Closing the lips produces an airtight also taken a selective approach in the anatomical depictions, and
seal, holding food and saliva inside the mouth and keeping out un- have refrained from describing regions that have no relevance to
wanted objects. This airtight seal is also important when taking in injection treatment in the lip area, such as the maxilla, even if these
food by suction. In addition, lip closure and lip shape are of great structures are of significance to the changes in appearance that
significance when producing sounds (-+ Fig. 1.2) by speaking, sing- occur during the aging process.
ing, whistling or playing wind instruments. 1

Fig. 1.2 An example of lip shape during

singing.

3
 The Lips

1.3.1 Mouth region

The outer part of the mouth, i.e. the extraoral region, is distinct from from the aperture of the mouth to the labiomental fold. Thus, the
the oral cavity. The section between the nose and aperture of the vermillion is only one part of the lip.
mouth is referred to as the upper lip, while the lower lip is the region

Topographic Anatomy of the Mouth Region (=» Figs. 1.3-1.18)

,.. Zygoratic region

a
lnfraorbital region
/

"""
�--
Oral region

Buccal region

��
- Parotideomasseteric
region

t 2
Mental (chin) region
%
Sternocleidomastoid I Muscular triangle
region of the neck
(trigonum musculare/
1 Posterior cervical
omotracheale)

Lateral cervical

' "'
region region

Fig. 1.3 Mouth region (oral and mental region), anterior view (hatched in red).

} yqomatic re@ion
A\ulctlat (ear) fe(lo
Nasal region

lat0I( [e(Of -'

'[nfraorbital fe&ion
-

Rotr@mandibular toss }
ll Oral region

Sternoclerdomastoid region '' 55ParotideomasseteriC Te&IO

[

m Buccal region

•
Posterior cervical region ------

� Mental (chin) region

(fott(tittle h}'
"'-
� � '--- Submental triangle
�
Vertebra prominens
(7th cervical vertebra) � Submandibular triangle

Lateral cervical region Muscular triangle of the neck

(trigonum musculare/omotracheale)

Fig. 1.4 Mouth region (oral and mental region), lateral view (hatched in red).

4
 Anatomy

I
7

Philtrum Cupid's bow

I
Cutaneous part
of the upper lip
Philtral ridge

\, (vertical upp
Ii bulge)

ine re ·
the lip

Stomion superior

I
Labiomental fold

Fig. 1.5 Anatomical terms used to describe the outer lip region.

Nasolabial told

L
Fig. 1.6 The oral region is bounded on both sides by the nasolabial fold. In children and adolescents, this fold may be effaced when the face is at rest.
However, it is always visible when a person smiles. It becomes permanent with increasing age; its prominence depends on the volume of cheek fat

5
 The Lips

Fig. 1. 7 Distribution of
subcutaneous fat (extensive
yellowish-white structure) in
the mouth region. In the lip
region, the subcutaneous fat
layer is comparatively thin.

f4ff
superius
(upper lip)

Rimaoris
(aperture of -' id
the mouth)
ff}t4Ml
inferius Lepfe'sof [blf
(lower lip) inferioris muscle

Depress0f afull
orismuscle

Alon[alls fts(le

1 Subcutaneous fat distribution in the mouth region

Levator labii
Zygomaticus Levator labii superioris alaeque Greater alar Lateral nasal Lobular
minor muscle superioris muscle nasi muscle cartilage cartilage connective tissue

»a
Fig. 1.8 The oral cavity is
enclosed laterally by the
buccinator muscle, which

~d-'· ~
merges into the orbicularis oris
muscle further anteriorly.
Several individual muscles run
toward the mouth at the side
'
of the nose and are capable of
Zygomaticus
major muscle
l.": . duce
lifting the upper lip in several
directions, depending on the
, Levator anguli
angle of insertion. Originating

'-=-+I-, ----
isoriu muscle • oris muscle from the zygomatic arch, they
Leva!of an@ult -"
oris muscle
· 1- / J Buccinator
muscle
-4ndibula!
show an oblique course. The
risorius muscle and the
(rbiulati -" platysma run horizontally. The
oris muscle '7· ramus
lower lip is also reached by
Platys(na t Z i Kot'\OH
mandible muscles that can pull it in all
~i[! directions. This radial arrange-
Depressor angul 2' S Depressor an&ull
if 1\JI '
@TT
coae [ �,' oris muscle ment of the musculature is a
�
I

Depressor labrr -.,,� •

::}'
U, Depressor labl key prerequisite for the
inferioris muscle , ' 4 inferioris muscle impressive range of move-
l ments shown by the mouth.
The junction of muscles at the
corners of the mouth is
Mentalis muscle referred to as the modiolus.
Here, fibrous tissue holds the
Musculature of the mouth region with the deeper sites and insertion points exposed various muscle fibers together.
(in the right half of the image)

_ _J
6
 Anatomy

;
7
1
I
Fig. 1.9 The mouth region 1s
I supplied by two branches of
I
the external carotid artery and
one branch of the internal
Dorsal nasal artery
carotid artery: the facial artery
lpffofpMtlt[efly originates from the external
carotid artery and runs along
Kid Angular artery the lower edge of the mand-
ible to arrive at the oral
commissure. Here, it sends out
two branches, the inferior and
Superior labial artery
superior labial arteries.
''Bucal alefy
After continuing its course
't

�
��I �
rt
•
- \ (---
• +Inferior labial artery

Facial artery
along the nose, it anastomo-
ses with the dorsal nasal
artery, which originates from
the ophthalmic artery, that is,
Alon!al artefy
i
from the internal carotid
... artery. Originating from the
Submental artery external carotid artery, via the
maxillary artery, the infraorbit-
al artery not only exchanges
anastomoses with the facial
artery, but also independently

Arterial supply of the mouth region, lateral view

supplies the cheek and lip
region.
1
Another vessel that originates
from the maxillary artery, and
thus also from the external
carotid artery, is the mental
Transverse Angular Infraorbital Maxillary Zygomaticofacial branch of the inferior alveolar
facial artery artery artery artery artery artery, which runs below the
mandible and supplies the
�\ lower lip and chin region.
However, the chin region is
.. � . S / --...,/ also supplied by direct branch-
es of the facial artery, i.e. the
submental artery.

-----=-
Posterior
massetenc artery
i Anterior
J/ masseteric artery
t' } Superior labial

,R., T I Inferior labial

artery
(
facial aefv

llental at[ey

Submental artery

Arterial supply of the mouth region, anterior view

7
 The Lips

°
.-
>="�
R g
.),

ga= F
-..a..,---��

1.
•
<! �-�
l, - ,"!-=
_External nasal vein
N

...,., __.,.
.aa!!::s�;;;=----

.. Superior labial vein

Infraorbital vein

��(nomatico acia
Fig. 1.10 The venous drain-
age from the cheek and lip
region takes place mainly via
the facial vein, and thus into
the internal jugular vein.

However, venous blood also

drains through the mental
foramen into the inferior

5 alveolar vein, which runs into

rgr
.1"
-7 4
-Deep lacal vein

I'
~... the pterygoid plexus. The
infraorbital vein also drains
into the pterygoid plexus.

it y,<'wawa
do �
eaoaroot
the inferior alveolar vein
.)

4S _- submentat vein

1 Venous drainage in the mouth region, lateral view

Transverse lnfraorbital Zygomaticofacial

facial vein vein vein

Superior
labial vein

'Bee Internal jugular

vein

Venous drainage in the mouth region, anterior view

8
 Anatomy

I
I Fig. 1.11 The sensory innerva-
) dew tion of the mouth region is
I \ ' _ Zygomaticofacial nerve provided by the infraorbital
nerve and the mandibular

I ,ms
/'WWA
'@t.
'
itie. '
«
nerve. The motor innervation
of all the muscles of facial

.. zr
- Lateral (or external)
expression is provided by the
facial nerve. The chewing
pterygoid nerve muscles are innervated by the
h3ft!tlf fl@ft motor branch of the mandibu-
be_Zyqomatic branches
lar nerve.
" 7Vyvr '
• • 7 I ' ] all Masseteric nerve
4 -i+,
'Buccal nerve (CN VII)
#
AN -Fial nenye (Cly\/l])

� ���
: Mental nerve
t-

,.,,.____

Innervation of the mouth region, lateral view

1

lnfraorbital Inferior palpebral Zygomatic

A,
g,
'/ EE: �*
/ft
� �
.
·au
J
«
-·-

I'

..: Buccal
' branches (CN VII)

�:���b���
Marci0al

I
$
:�;,
n£:
' J
.-----_-_-_-:_-_-_-_ Mental nerve (CN V3)
__ Cervical branch
(of facial nerve.
VII)

I CNVII)

Innervation of the mouth region, anterior view

I

I
L_

9
 The Lips

�--
1

.. .

Fig. 1.12 Images depicting

the network of blood vessels
and nerves that serve the
mouth region clearly show
how intricately this area is
perfused and innervated.

1 Network of blood vessels and nerves supplying the mouth region, lateral view

L
Network of blood vessels and nerves supplying the mouth region, anterior view

10
 Anatomy

Facial vein Angular vein Levator labii Zygomaticus Orbicularis

and artery and artery superionis muscle minor muscle oculi muscle

Fig. 1.13 The mouth is sur-

rounded by muscles of facial
expression that run toward it
from almost every direction. The
central section of the lips is
formed by the orbicularis oris
muscle (see Fig. 1. 15). The
arteries in this superficially
Buccal located muscle layer of the
branches (CN VII) mouth region branch off from
Bucesl tat � � Masseter muscle the facial artery, which sends out
pad branches to the nose, the cheek.
J4 4/ Zygomaticus
major muscle and both the upper and lower
bUper1Of
labial vein j@ «ors moss lip. The lower lip region is also
�· supplied by the mental branch
Inferior rm.
__set Buccal nerve (CN V3)
labial vein
(see fig. 1.15), which originates
5s~$t5%7$ vs from the alveolar artery and
s ? A Depressor angul emerges through the mental
-�'----',-,.;=-------
f't�� �
�:��
ons muscle foramen. Venous blood from the
·,- Depressor lab superficial mouth region is
sf"j
y,
tirorsmuse
drained via the facial vein, while
all the muscles of facial expres-
sion are innervated by branches
of the facial nerve. Motor
I
Mentalis muscle
innervation of the chewing

Musculature, vascular supply (left) and innervation (right) in the mouth region, superficial layer
muscles is provided by the motor
root of the trigeminal nerve,
1
which is distributed to the target
areas via the mandibular nerve
(see Fig. 1.11). Sensory innerva-
tion of the mouth region is
provided by the trigeminal nerve.
Zygomaticofacial Superior Angular artery Levator labii Facial nerve Zygomaticofacial
artery and vein labial vein and vein
�pe,,o,is m�de (CN VII) V,1

ts.mm , y "'';r Fig. 1.14 Removing the

zygomaticus minor/major
muscles, the risorius muscle,
i

' and the platysma exposes the

it
entire lengths of the levator
labii superioris muscle, the
superficial part of the masseter
muscle, and the levator anguli
oris muscle, with visible origins
Orbicularis oris -Levator anguli
muscle eris muscle
and insertions. The buccinator
muscle is partly visible.
E
Superior labial '{ t Buccinator muscle
artery
Masseter muscle,
facial artery superficial part
and vein Buccal nerve (CN V3)
<
r,
Inferior labial e;st.rm
artery and vein Eid

ii' -
Depressor anguli

r�
-"
Re
ei

..,
E ca

�l�<'l
Submental vein 1nfenons muscle

-"iv 'z
Marginal mandibular

an

Mentalis Mental
muscle branches (CN V»)

Musculature, vascular supply (left) and innervation (right) in the mouth region,
zygomaticus minor/major muscle, risorius muscle, and platysma removed

11
 The Lips

�. , ��;;:J:2[
Zygomaticofacial Orbicularis Infraorbital nerve Facial nerve Zygomaticofacial
artery and vein oculi muscle Angular artery (CNV) (CN VII) nerve (CNV)

I·".!� . ._ ., •
�- ..___.....,r.tl
��
N /y - � .
Fig. 1.15 The facial artery
originates from the external
carotid artery and reaches the
i, facial region with its mandibu-

ii lar branch. After running

I [JjEa]
kaer ¥ II]
diagonally over the cheek and
along the side of the nose,
where it is referred to as the
h.7i
Orbicularis
eris muscle
Superior labial
f
i 5@@j] j
}}
Erz°
a.cram.me
angular artery, it anastomoses
with the dorsal nasal artery, a
terminal branch of the oph-
artery
ft
II
Buccal nerve
''4
�+-- ,
Ala
thalmic artery, which in turn
[• ' «CNV)
Facial artery -"Masseter mus(le,
--,�". {}=--- originates from the internal
~~Zl'Lt,', We
A. .-'
soehca!par
Marginal mandibular
carotid artery. The angular
vein runs across and above the
artery and vein
branch (CN VII) levator labii superioris muscle,
while the angular artery runs

�.-,��"·"-'" .W��
,::::::: :�::---�-- �-� ;@ .
�
�,.,,.../'f--------
� ���;i�sr������le below it. The facial artery
takes a highly convoluted
course in the cheek region
and is stretched when the
mouth opens. The facial vein
shows considerably fewer
twists and turns in this region.
Mentalis Mental
It extends accordingly when
muscle branches (CN V3)
1 the mouth opens.

Musculature, vascular supply (left), and innervation (right) in the mouth region,
superficial muscles of facial expression removed

Superficial
temporal artery Zygomaticofacial Infraorbital lnfraorbital Facial nerve Zygomaticotacial

Ma\"' l�
'°'C , , 7:;o 1/
V;I:
""O aod ,eio ICN Ml) �•• ICN V;I
Fig. 1.16 Removing the

/,
$ • e
. levator labii superioris and
levator anguli oris muscles
exposes the infraorbital
) ' foramen. After running
through the infraorbital canal,
the infraorbital artery and vein
d =f
respectively run inward and
Protid (duct s \
a Bu(Cina!Of
emerge at this point, forming
muscle numerous anastomoses with
(rbycularts the angular artery and vein.
bUper\Of labial ors muscle
ts_I
lll The infraorbital nerve also
artery and vein
lase\er mus(le, - uccal nerve
(CNV) n leaves the infraorbital canal

�
;%

superficial part here. The cheeks and the lip

Inferior labial t , JiijY Marginal
region are served by branches
artery and vein
'"', ' mandibular
branch (CN VII)
of the infraorbital artery and
vein in the maxilla, and by the
facial artery tf
and vein
_r Mental nerve mental branches of the
g} .'NVa)
inferior alveolar artery and
--=�---- , ·
.y";d; !' {1iJ2'1-1
Mental artery -� Corpus mandibulae
and inferior -"' � · ·� , (body of mandible)
vein in the mandible. Substan-
alveolar vein, , ·, tial tributaries also originate
mental branch '}
from the facial artery or drain
1,Iii a into the facial vein. Corre-
spondingly, sensory innerva-
Submental Mentalis Mental branches
tion is provided by the infraor-
artery and vein muscle (CNV) bital nerve and the mental
nerve. The buccal nerve
Musculature, vascular supply (left), and innervation (right) in the mouth region,
provides sensory innervation
orbicularis oris muscle exposed, levator labii superioris and levator anguli oris muscles removed to the cheek.

12
 Anatomy

Superficial
temporal artery Zygomaticofacial Infraorbital Infraorbital Zygomaticofacial

✓
,
an:Cn/ '"'..':'" -
•rte,y �ed ::. Maxilla nerve (CN V)
arteo v,1

,I
"'" (CN

( Fig. 1.17 The outer walls of

g> M/, .. the oral cavity are formed
4 l predominantly by the orbicu-
f . ·w''i sh laris oris muscle together with

. .e f the buccinator muscle. In this

respect, the paired buccinator
muscles and the orbicularis

� i ,�,,
r�Facial
oris muscle, taken together,
may easily be seen as a contin-
Transverse facial nerve (CN VII)
uous muscle system, even
Inferior alveolar
artery
asate.co 'i'lAyj Ea}" nerve (CN V)
Buc&al nerve
though they are separate
muscles. This muscular system
External carotid
artery
----X
st

• ._ s as.a.c..vise (CN Va)

Buccinator nerve
is normally in balance with the
tongue and determines the

M
Marginal mandibular space for the dental arches.
branch (CN VII)
artery and vein

Facial artery and vein

Ml
tl
.
'f
' Orbiculanis Oris muscle

Mental nerve (CNV)

Mental artery and ,
inferior alveolar vein, j

I mental branch

I
Submental Inferior labial Mentalis
artery and vein artery and vein muscle
1
Musculature, vascular supply (left), and innervation (right) in the mouth region,
orbicularis oris muscle exposed, masseter dissected

Superficial
temporal Zygomaticofacial lnfraorbital lnfraorbital nerve Zygomaticofacial
artery and vein artery and vein artery and vein (CNV) Maxilla nerve (CN V)

••
(
A

/ Z
"
i :

' p
Fig. 1.18 The vestibular oral
mucosa of the cheeks and lip
region is served by branches
of the infraorbital artery and

{
vein in the maxilla, and
branches of the mental artery
and vein in the mandible.
Correspondingly, sensory
[ Interior alveolaf innervation is provided by the
nerve (CN V3) infraorbital nerve and the
facial artery
Buccal nerve mental nerve. The buccal
Buccal artery {Y, (CN Va) nerve provides sensory
Parotid duct Buccinator innervation to the cheek.

I 'LL1 muscle
Blan(dibulaf
ramus

halal vein
tlental flefve
Facial artery '
(CNV3)
Mental artery and
inferior alveolar vein,
mental branch

Submental artery and vein Body of mandible

Musculature, vascular supply (left), and innervation (right)

in the deepest layer of the mouth region

13
 The Lips

1.3.2 Lips, Teeth, Periodontium, The intermediate zone ­ usually known as the vermillion or red mar­
and Alveolar Processes gin ­ is the transitional zone between the outer and inner side. It
covers the lips in the area between the outer skin and the oral muco­
sa. This intermediate zone is coated with a thin, multilayered, trans­
■ Anterior Mouth Region (Fig. 1.19) lucent, squamous epithelium that is weakly cornified and unpigment­
The alveolar processes and the teeth are bounded by the tongue ed and contains isolated sebaceous glands. The epithelium is partic­
from the inside and by the lips (and then laterally by the cheeks) ularly thin and hairless over the papillae. The vermillion also lacks
from the outside. Correct, natural alignment of the incisors requires salivary glands and therefore constantly needs to be moistened with
the cutting edge of the maxillary incisor to overlap the cutting edge saliva. This takes place predominantly by means of the salivary film
of the mandibular incisor (overbite). The biomechanical ideal is for that is formed when speaking or eating. The loose connective tissue
the cutting edge of the mandibular incisor to abut onto the maxil­ of the lamina propria (a thin, subepithelial connective tissue layer) is
lary incisor at the point of inflection between the maxillary incisor's traversed by capillary loops, which give the lips their intense color.
palatal concavity and the convexity of its tubercle. Consequently,
the cutting edge of the maxillary incisor sits slightly in front of the The inner oral side of the lip, known as the mucosal zone (the mu­
labial surface of the mandibular incisor (overjet). The position of the cous membrane side), is characterized by its lining of lip mucosa, with
dental axes is significantly influenced by the forces exerted by the an uncornified, relatively thick epithelium. The lamina propria is thin
tongue and the lips. In this respect, however, swallowing and and contains loose connective tissue traversed by elastic fibers. The
speaking have less of an effect than the constant push and pressure submucosa contains fat deposits, along with numerous individual
of the tongue and lips. salivary glands, jointly known as the labial glands. Blood vessels and
nerves run through this area as well, with branches that extend into
the lamina propria. Free nerve endings also extend into the epitheli­
l Upper and Lower Lip (­» Fig. 1.20)
um. The muscular layer (also known as the tunica muscularis) consists
On its outer side, the lip carries the typical hairy skin of the epidermis. of striated muscle tissue (DocCheck Flexikon 2019).
Below it is the connective, tissue­rich dermis that houses the sweat
glands, hair follicles, and sebaceous glands.
1

14