Aesth Plast Surg (2014) 38:1083–1089
DOI 10.1007/s00266-014-0401-8
ORIGINAL ARTICLE
A Typical Pattern of the Labial Arteries with Implication for Lip
Augmentation with Injectable Fillers
Tanvaa Tansatit • Prawit Apinuntrum •
Thavorn Phetudom
Received: 6 January 2014 / Accepted: 22 August 2014 / Published online: 30 October 2014
Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract
Background Anatomical knowledge of the vascular sup-
ply to the upper- and lower-lip vermilion is essential for lip
augmentation.
Methods The soft tissues of the whole face, including
arterial latex injection, were peeled off as a facial flap and
turned down for dissection. The mucosal flap was elevated
away from the orbicularis oris muscle and the lower facial
musculature. The superior and inferior labial arteries were
traced from the facial artery along the course of the
vermilion.
Results The facial artery branched into the superior labial
artery just above the labial commissure. This artery ran
4.5 mm deep along the upper lip between the oral mucosa
and the orbicularis oris muscle just above the vermilion-
mucosa junction to anastomose with the opposing artery.
The inferior labial artery originated as a common trunk
along with the labiomental artery once the facial artery
entered the oral vestibule deep to the platysma muscle. The
main arterial trunk coursed along the alveolar border within
the plane between the orbicularis oris muscle and the lip
depressors. From the arterial trunk emanated the inferior
labial artery, which accompanied the mental nerve to the
lower lip.
Conclusion The vermilion borders of the upper and lower
lips are safe for superficial filler injection. All areas of the
lower lip are safe because of the minute size of the
ascending arteries. To achieve a full upper lip, filler should
T. Tansatit
P. Apinuntrum (&)
T. Phetudom
Department of Anatomy, Faculty of Medicine, The Chula Soft
Cadaver Surgical Training Center, Chulalongkorn University
and King Chulalongkorn Memorial Hospital, 1873 Rama 4
Road, Pathumwan, Bangkok 10330, Thailand
e-mail: apinuntrum@gmail.com
AESTHETIC
be injected into the middle body of the lip, thereby
avoiding deep injection between the muscle layer and the
mucosa, minimizing the risk of injury to the anastomotic
arch of the superior labial arteries.
No Level Assigned This journal requires that authors
assign a level of evidence to each submission to which
Evidence-Based Medicine rankings are applicable. This
excludes Review Articles, Book Reviews, and manuscripts
that concern Basic Science, Animal Studies, Cadaver
Studies, and Experimental Studies. For a full description of
these Evidence-Based Medicine ratings, please refer to the
Table of Contents or the online Instructions to Authors
http://www.springer.com/00266.
Keywords Labial arteries
Lip augmentation
Injectable
fillers
Introduction
Cosmetic facial filler injections for lip augmentation have
become increasingly popular due to the possibility of
striking and rapid results without the need for operative
equipment and surgical skills. The augmentation procedure
has become widely accepted among the general public,
even though vascular injury may lead to serious compli-
cations such as skin necrosis, an infarction, or even
blindness. The injection areas that were involved when
visual impairment occurred included the upper and lower
lips, the perioral region, and the nasolabial fold; however,
the visual complications were not reported as resulting
from lip augmentation solely [1–3]. Most patients com-
plained of excruciating pain in the affected eye and visual
loss occurred immediately after the injections. Vision
was severely affected in those patients with iatrogenic
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ophthalmic artery occlusion, followed by central retinal

artery occlusion, and branch occlusion of the retinal artery,
respectively. With respect to the substances injected, autol-
ogous fat injection resulted in the worse visual acuity when
compared to hyaluronic acid or collagen injections [2, 3].
Despite the continuous reporting of the new cases of retinal
artery occlusion resulting from cosmetic filler injections, a
consensus on safer cosmetic injection techniques is not well
established. Precise knowledge of the courses of the labial
arteries is necessary and may help prevent vascular com-
plications and subsequent blindness. Therefore, we aimed to
investigate the courses of the labial arteries.
To enable the transformation of thin lips into a more
desired full and seductive ‘‘cupid-bow’’ appearance, aesthetic
physicians must employ an injection technique that minimizes
complications. As such, knowledge of the anatomy of the
vascular supply to the vermilion is essential for performing
good injection techniques and yielding excellent results.
Recently, our training center participated in four international
hands-on training courses on dermal fillers, including a ses-
sion for expert lip augmentation. One of the most frequently
asked questions that we received during the cadaveric training
courses was how to perform a safe lip injection. There were
various opinions from the invited speakers on this topic that
we discuss here. We planned an investigation using meticu-
lous dissection of cadavers to determine which solution is the
most beneficial and which has the potential to be the most
dangerous. In addition, we include an explanation why a
particular technique should be recommended. Fig. 1 Common pattern of the labial arteries and the related course of
Understanding the anatomical blood supply of the peri- the facial artery. The superior labial arteries (SLA) run along the
oral region is necessary for avoiding vascular complications mucosal border of the upper lip, while the inferior labial arteries
during filler treatment. The purpose of the current study was (ILA) travel horizontally along the alveolar border of the mandible
beneath the labiomental fold. They then make a rostral turn to
to investigate the common pattern of the arterial supply of accompany the mental nerve to the lip
the lips and to assess the risk of vascular injury during
common filler injection techniques for lip augmentation.
orbicularis oris muscle and the lower-face musculatures. The
superior labial artery (SLA) and the inferior labial artery
Materials and Methods (ILA) were traced along their courses from the facial artery to
verify the anatomical relationship with the vermilion bor-
Twenty-six soft embalmed cadavers (13 female, 13 male) ders. The external diameters of the arteries were measured
with arterial latex injection were dissected to clarify the using a caliper. Two parasagittal cuts were performed at the
pattern of the arterial supply to the lip. The cadaver age upper lip on both sides of the middle third segment. The
ranged from 45 to 87 years. Incisions were made along the depths of each SLA from the skin near the vermilion border
mandibular margin encircling the whole face. The nasal and from the oral mucosa were measured at the cut surface.
mucosa and the septal cartilage were incised along the The lower lip was cut in the same manner to measure the
margin of the piriform aperture. All attachments of the depth of the ILA from the skin.
masseter and the temporalis muscles were scraped away
from the bone. The facial soft tissues were pulled off the
facial skull as a facial flap specimen to enable dissection Results
from the deep side. Dissection of the lower face from the
mucosal and periosteal views was performed using each Based on the anatomical findings, the common pattern of
specimen’s own exposed facial skeleton as reference land- the labial arteries with implication for lip filler augmenta-
marks. The mucosal flap was elevated from the underlying tion is illustrated in Figs. 1 and 2.

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Fig. 2 The superior labial artery lies between the orbicularis oris and
the mucosa at the level of the vermilion border. From it emanate the
cutaneous, mucosal, and vermilion branches
The Superior Labial Artery of the Upper Lip
The SLA was found in all cadavers, and it was the only main
artery of the upper lip. The mean diameter of the SLA was
1.1 ± 0.3 mm. Although the SLAs were mostly bilateral, the
arteries were usually asymmetric in size and course. In six
cadavers (23 %), the SLA was unilateral and crossed the
midline to supply the whole lip. In these cases the SLA could
not be traced to the opposite facial artery. All the SLAs orig-
inate directly from the facial artery in the nasolabial fold.
Unilateral SLAs were located predominantly on the right side
(4 of 6 cadavers). The origin of the SLA was located above the
level of the labial commissure where it entered the upper lip
5–9 mm above this facial landmark. This measurement was
difficult to perform because of the tortuous segment of the
facial artery. In eight sides of six cadavers the facial artery
coursed medial above the upper lip and medial to the labial
commissure before giving rise to the SLA. In the upper lip, the
SLA ran deep between the oral mucosa and the orbicularis oris
muscle just above the vermilion-mucosa junction to anasto-
mose with the opposite artery in 18 cadavers (69.2 %). This
course ran just below the level of the vermilion border but on
the opposite side behind the muscle (Figs. 2, 3a, b). The
anastomotic arch provided multiple perpendicular subcuta-
neous branches to the nasal ala and the septum. These
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branches formed arterial plexuses concentrated at the nasal tip.
In eight of these midline anastomoses, a columellar artery
arose perpendicular to the anastomotic point to the nasal
septum. Double columellar arteries were found in the other ten
cadavers. The superior labial arch also sent multiple minute
perpendicular mucosal branches on the mucosal side of the
orbicularis oris muscle. In 17 cadaver heads, very delicate fiber
bands of the orbicularis oris muscle covered the posterior
surface of the SLAs. This was in contrast with the course of the
facial artery, which usually ran tortuously in the submuscular
plane and then occasionally in the subdermis. No part of the
SLA lay between the muscle and the skin. Minute branches of
the SLA passed through the orbicularis oris muscle to the skin
as direct cutaneous perforators. Based on the external diame-
ter, the SLA was dominant on the right side in 11 of the
bilateral specimens and on the left side in 9 of the cases.
The Inferior Labial Artery of the Lower Lip
The ILA originated as a common trunk with the labiomental
artery in most specimens. In eight cadavers (30.8 %), the
facial artery had another short transverse labiomental artery
in one or both sides before giving rise to the main trunk. In
other cadavers, these branches were very small and insig-
nificant. In 11 specimens, the facial artery on the opposite
side gave rise to only a small redundant ILA (a single ILA in
these faces), seven on the left side and four on the right side of
the face. The ILA trunk arose at the point where the most
tortuous segment of the facial artery entered the oral vesti-
bule deep to the platysma muscle. The mean diameter of the
ILA was 1.3 ± 0.2 mm. This common trunk coursed along
the anterior wall of the oral cavity above the line of mucosal
attachment at the alveolar border of the mandible. This was
parallel to the inferior border of the buccinator and orbicu-
laris oris muscles, deep to the labiomental fold (Fig. 3c, d). In
eight cadavers, the common trunk passed through the fibers
of the orbicularis oris muscle, while in seven cadavers it
traveled in the plane between the orbicularis oris muscle and
the lip depressors. Along its course, small perpendicular
branches were given off, running upward and parallel to each
other toward the lower lip. One sizable branch accompany-
ing the mental nerve was named the ILA, and then the main
trunk continued as the labiomental artery. A short, small
marginal artery connected the perpendicular branches,
including the ILA of the common trunk, together in the
middle-third segment of the vermilion of the lower lip. In
three cadavers (11.5 %), aberrant ILA originated bilaterally
as a common trunk with the SLA. In these cases, the ILA ran
directly along the vermilion-mucosa junction within the
orbicularis oris muscle, make the vermilion a high risk as an
injection site. In this case it is dangerous for the injection to
be performed deep in the lower lip near the oral commissure
and along the vermilion-mucosa junction.
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Fig. 3 Typical course of the superior (SLA in a and b) and inferior
labial arteries (ILA in c and d). The facial specimen was turned down
to study the periosteal and mucosal views. The two ovoid holes in a,
b, and d are nostrils. The oral mucosa was dissected from the
Depths of the Labial Arteries
Forty-six SLAs were clearly identified in the cut surfaces
of the upper lips in the 26 facial flaps. The SLA runs deep
to the orbicularis oris muscle, lies close to the oral fissure,
and lies closer to the oral mucosa than to the skin. The
depths of the SLA measured from the skin, oral mucosa,
and the lower margin of the upper lip were 4.5 ± 0.8,
2.6 ± 0.3 and 5.6 ± 1.2 mm, respectively. The ILA
courses over the alveolar margin of the mandible, which is
far from the vermilion of the lower lip, before giving off
ascending branches to the vermilion. The average depths of
the 41 ILAs, which travel along the inferior border of the
oral vestibule, from the skin and the oral mucosal reflection
were 4.7 ± 1.0 and 2.3 ± 1.5 mm, respectively.
Discussion
Blindness is one of the most serious complications following
filler injections. Although extremely rare, case reports [4–6]
in the medical literature show that blindness after filler
injections pose a threat to all aesthetic physicians. There is no
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Aesth Plast Surg (2014) 38:1083–1089
orbicularis oris muscle and held to reveal the labial arteries. Note the
course of the arteries related to the vermilion at the level of the oral
fissure (indicated by arrowheads in c). The mental nerve on the left
was removed to reveal the accompanying ILA traveling to the lip
evidence to suggest that filler injections for lip augmentation
directly cause blindness, but a suitable injection technique
using the knowledge of the vascular anatomy of the lips
would be beneficial. Avoiding direct injection of the labial
arteries should help minimize the risk of vascular compli-
cations and was the objective of the current study.
Most previous studies reported on diameters, measured
distances, and the various patterns of the arterial branches
of the facial artery, but the anatomical relationships with
the soft tissue landmarks, especially the labial commissure
and the vermilion, have not been discussed much in the
literature [2, 7–9]. A study by Nakajima et al. [10] was
similar to ours; they radiographically studied major bran-
ches of the facial artery in the upper lip and nose using a
lead oxide-gelatin injection. Without performing any dis-
section, they correctly described the position of the SLA as
running between the white and red lips and covered by the
oral mucosa. It anastomosed with the contralateral artery
and separated into superficial and deep ascending branches
to supply the mucosa and skin [3, 9–12]. We found this to
be the case in the current study (Fig. 2) as did Pinar et al.
[12]. The SLA lies above the junction between the red lip
and the oral mucosa at the level of the vermilion border but
Aesth Plast Surg (2014) 38:1083–1089
Fig. 4 Typical course of the superior labial artery in the upper lip
between the oral mucosa and the orbicularis oris muscle and the
inferior labial artery at the level of the gingival fornix in the lower lip
(white arrows) in a paramedian sagittal section of the head, just lateral
to the nasal ala
on the opposite (inner) side of the upper lip. This finding
agrees with that of Magden et al. [8] in which the artery lies
in a more posterior position to the vermilion. The distance
of the SLA from the anterior border of the red lip was
7.6 mm and from the posterior border 3.2 mm. We con-
firmed this common pattern of the labial arteries (Fig. 4)
and the anastomosis that forms the arterial arcade close to
the oral mucosa of the upper lip. In the current study, the
depths of the SLA measured from the skin, oral mucosa,
and the lower margin of the upper lip were 4.5 ± 0.8,
2.6 ± 0.3, and 5.6 ± 1.2 mm, respectively.
Although the lip vascular system does vary and most of
the arteries are not symmetrical, mapping a common pat-
tern of the labial arteries is still useful (Fig. 5). The upper
lip has a submuscular arterial arcade at the vermilion-
mucosa junction. The arteries lie in the submucosa, among
the beads of the minor salivary glands, between the lower
border of the orbicularis oris and the mucosa of the upper
lip. Superficial injection no more than 3 mm deep just
beneath the vermilion for more lip projection can be con-
sidered safe. Deep injection using a 27G blunt cannula
inserted longitudinally along the middle of the lip to create
fullness of the lip may be possible because the SLA is not
usually embedded in the core of the upper lip. The ver-
milion border is a safe area for superficial filler injection
with a 27G needle or 30G microcannula to create a cupid-
bow appearance. Filler should not be injected deep into the
muscle layer or close to the mucosal side to avoid injury to
the anastomotic arch of the SLA. On the other hand,
injection at the lower lip is safe in most areas because the
ILA runs outside the lower lip at the alveolar margin. Most
of the labial branches enter the vermilion perpendicularly,
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Fig. 5 Common pattern of the superior and the inferior labial
arteries. The superior labial arteries (SLA, arrowheads) run along the
mucosal border of the upper lip, while the inferior labial arteries
(ILA, arrows) travel horizontally along the inferior vestibular border
beneath the labiomental fold and from them emanate ascending
branches to accompany the mental nerve to the lower lip
and the marginal artery connecting these terminal branches
in the vermilion is very small.
When the vermilion has to be stretched for precise
needle or cannula insertion, simultaneously compressing it
against the teeth is helpful to temporarily obliterate an
underlying artery. This maneuver creates high luminal
arterial pressure that prevents escape of the filler into the
arterial system. Therefore, compression of the SLA within
1 cm above the oral commissure, at the point where it runs
close to the mouth angle, is recommended. Also, the
arterial anastomosis formed by the SLA was observed to be
just above the mucosa-vermilion border, running between
the mucosa and the orbicularis oris muscle. No part of the
anastomosis lies between the muscle and the skin. This
course makes the vermilion border safe for the needle
threading technique, in both the upper and the lower lip, to
elevate and enhance the red lip borders.
Al-Hoqail et al. [1] described the SLA as lying just
superior to the upper lip while the ILA coursed along the
margin of the inferior lip. They did not discuss the depth of
the arteries, which may lead to the false conclusion that the
vermilion border is a high-risk area for filler injection. Our
finding was in agreement with that of Pinar et al. [12] that
the ILA and the labiomental artery come off at the level of
the inferior border of the buccinator muscle (Figs. 1, 4) and
run anteriorly, passing deep to the depressor anguli oris
muscle. We point out that the ILA usually accompanies the
mental nerve to the lower lip after it travels horizontally at
the level of the labiomental fold.
One should be aware of the possibility of an aberrant
ILA. If the SLA and the ILA arise as a common trunk, the
ILA may take a higher-than-usual course in the vermilion;
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this was encountered in 4.2 % of the cases in one report 3. Inject only a small amount of filler at a time to
[4]. When an abnormal vascular channel is in the way of minimize the size of embolus, thus causing only
the needle, the SLA or ILA may be tortuous or take an subclinical symptoms.
abnormal course, lying close enough to the vermilion to 4. Avoid injecting large amounts in a stiff tissue plane, which
present a high risk of vascular injury. Iatrogenic embolism creates high pressure within the tissues being injected.
of filler materials might occur by accidental arterial can- 5. Use a blunt cannula for deeper injections in areas that
nulation in this case. have a high chance of arterial injury to avoid direct
Another factor that can affect the severity of vascular arterial cannulation that can be caused by a sharp needle.
complications is the amount of filler material that is acci- 6. Gently move a blunt cannula to avoid vascular tearing
dentally carried through the bloodstream. Local hemody- and to stimulate temporary constriction of the native
namic conditions at the moment of injection can be used to vessels.
determine that severity. These conditions include artery 7. To facilitate needle insertion into a tight area, pretun-
diameter (main artery, arterial branch, or arteriole), degree neling or subcision of adhesion using a 18G needle is
of constriction, pressure gradient (difference between safer than hydrodissection by filler materials.
luminal pressure and injection pressure), direction of blood
Some of these recommendations are practical while
flow across the anastomosis (toward the eye or the lips), and
others may require more time and effort for their clinical
size of the puncture hole in the arterial wall (in a case where
use. Some may not be relevant to specific areas but most of
the needle tip is close to the leaking artery). Accidental
them should be followed as the risk of injury increases for
injection of filler material downstream along the branching
each recommendation that is not followed. The obvious
distribution is easier to do than retrograde upstream injec-
sign of an inadvertent intra-arterial injection is the
tion toward the origin of the arteries. Retrograde injection of
appearance of blood in the needle hub when the plunger is
filler into a larger artery from an arterial branch theoreti-
drawn back. In our experience, signs of an inadvertent
cally should be more difficult. However, if the filler does
intra-arterial injection include unbearable pain and
enter the facial artery, the material can spread widely
blanching of both the injected area and the area along the
throughout the arterial tree during the systolic phase,
course of the artery distal to this site. Physicians should be
potentially resulting in small portions of an embolus
aware of the potential complications relevant to the area of
crossing the ophthalmic-facial anastomosis. To fill both
interest when designing the procedure for correcting and
facial and ophthalmic arterial areas via the facial-ophthal-
sculpting the patient’s lips and lower face.
mic anastomosis when injecting the lips, where the labial
artery is a branch of the facial artery, retrograde injection
from the labial artery to the facial artery and then to the
Conclusion
ophthalmic artery would require intra-arterial injection of
large amounts of filler material under high injection pres-
The upper and lower lip vermilion borders are safe for
sure. Although this can be a serious complication, its
superficial filler injection. All areas of the lower lip are safe
occurrence is rare. With respect to the cannula, a large 25G
for filler injection because of the minute ascending arteries.
cannula allows a large bolus injection, but it is less likely to
To achieve a full upper lip, filler should be injected into the
cause arterial injury. On the other hand, a 30G microc-
middle of the lip, avoiding deep injection between the
annula limits the amount injected, but it is easier to inad-
muscle layer and the mucosa to prevent injury to the
vertently tear the arterial wall.
anastomotic arch of the superior labial arteries.
A summary of the general recommendations that were
emphasized during the training courses is provided below. Acknowledgments Miss Yasmina M. E. Sahraoui and Miss Hannah
Although Lazzeri et al. [2] provided excellent tips and E. Greenwood from the University of Liverpool kindly revised this
techniques for decreasing the risk of intravascular injec- manuscript.
tions, in general, aesthetic physicians have to incorporate
Conflict of interest The authors have no conflicts of interest to
knowledge of the vascular supply to the vermilion into disclose.
their technique for safe and practical injections:
1. Pull back the plunger to make sure the needle is not in
the artery or vein before injecting the product.
2. Avoid the course of a sizable artery, i.e., diame- References
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