Aesthetic Lip Splits
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Transcript of Aesthetic Lip Splits
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TECHNICAL NOTE
Aesthetic lip splits
J. P. Hayter, E. D. Vaughan, J. S. Brown
Maxillofacial Unit, Walton Hospital, Liverpool, UK
SUMMARY. Both upper and lower lip splits, usually with osteotomy of the underlying jaw, improve access to
the deep structures of the head and neck. A simple modification to the midline lip spli t is to incorporate a chevron
in both the peri-oral skin and vermilion margin. The advantages are: accurate wound closure, no straight line
contracture and a broken line of the peri-oral scar. This improves the aesthetic result of the healed lip.
INTRODUCTION
The lip splitting incision improves oral access to
pathological conditions of the maxillofacial region.
The lower lip split with mandibulotomy displays the
oral cavity, pharynx and upper cervical spine. The
upper lip split displays the maxilla. If the disarticu-
lated maxil la is pedicled to the cheek flap, the parana-
sal sinuses, the nasopharynx and the base of skull
become readily accessible.
The final cosmetic result is optimised by restoring
the normal anatomical position of the maxilla and
mandible with stable fixation and careful approxi-
mation of the soft tissues. Transfacial approaches
incorporating lip splits attempt to use anatomical
landmarks and good principles of incision design to
hide the resultant scar line.3,4 However, the com-
monly used straight line incision across the lip skin
and vermilion margin can be the most obvious section
of the final scar, clearly indicating the surgical
approach used.
This paper describes a simple modification to the
design of both upper and lower lip splitting incisions
to improve the aesthetic result of the healed lip.
INCISIONS
Lower lip
1. Roux/Trotter
A midline split of the lower lip and mandible in the
surg ical approach to tumours of the anterior tongue
was first described by Roux in 18395 (Fig. I). Trotter6
extended this approach by dividing the tongue in the
midline to expose tumours of the posterior tongue
and pharynx. This midline incision lies in a relaxed
skin tension line4 and minimises injury to the muscles,
vessels and nerves of the lower lip. However, both
contracture of this straight line scar over the lower
lip below the vermilion border together with a
LOWER LIP
ROUXITROTTER
MCGREGOR
ROBSON
Fig. 1 - Lower lip splitting incisions.
432
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Aesthetic l ip splits 433
depression of the vertical line over the chin promi-
nence may combine to produce an unsightly scar.
2. McGregor
McGregor modified the midline lip splitting incision
to follow the outline of the labiomental groove and
chin prominence (Fig. 1). This modification breaks
up the straight line of the scar and attempts to
conceal the incision in the skin crease. However, the
semi-circular incision around the chin prominence
crosses vertica l relaxed skin tension lines along much
of its course with the potential to produce a more
noticeable scar. Contracture of the straight midline
scar over the lower lip below the vermilion border
may still occur.
3. Robson
The incision described by Robson descends in a
relaxed skin tension l ine beginning just medial to the
lateral commissure. An incision placed in this line
should produce an unobtrusive scar. However, this
lateral approach wil l damage the terminal branches
of the facial and mental nerves.
UPPER LIP
WEBER-FERGUSON
ALTEMIR
Fig. 2 - Upper lip splitting incisions.
Upper lip
I. Webrr-Ferguson
The incision Weber described to expose the maxilla
made a midline split of the upper lip to the base of
AESTHETIC MODIFICATION
UPPER LIP
LOWER LIP
Fig. 3 - Standard lip splitting incisions with chevron modification.
Fig. 4 - A,B) Operative planning of aesthetic lip splits
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434 British Journal of Oral and Maxillofacial Surgery
Fig. 5 - Postoperative results 8 month s top) a nd 5 years b ottom) following lower lip split. The peri-oral scar is virtually imperceptible.
The sem i-circular labiomental groove scar is noticeable w here it crosse s the relaxed skin tension lines.
the columella and then deviated to follow the nasal
contour to the medial canthus on the side to be
exposed. Fergusong described an infra-orbital lateral
extension of the incision from the medial canthus to
enhance exposure of the maxilla (Fig. 2). Although
this incision lies in a line of relaxed skin tension,
the straight vertical scar across the upper lip and
convexity of the vermilion margin may be notice-
able, even if the vermilion border i s carefully
apposed.
2. Altemir
Altemir described a straight line lip split along the
philtral crest which is then extended as for the Weber-
Ferguson incision (Fig. 2). Access is provided, by
both this incision and also a palatal incision, for
osteotomy cuts to allow mobilisation of the maxilla
pedicled on the cheek soft tissues. The incision
through the lip follows a line of relaxed skin tension
but again the vertical straight scar across the lip and
vermilion margin may be noticeable.
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Aesthetic l ip splits 435
Fig. 6 - A,B) Postoperative results 9 months after Altemir approach with radial forearm flap reconstruction of the palate. N ote the
unobtrusive broken hne of the peri-oral scar.
__
METHODS References
We routinely use a simple modification of both the
Weber-Ferguson incision to split the upper lip and
McGregor incision to split the lower lip. A chevron
is incorporated into both the vermilion margin and
midline lip incisions (Figs 3 4) and extended to
the obicularis oris which is divided in the midline.
The wounds are closed in layers with accurate appo-
sition of the vermilion border.
1.
2.
3
4.
DISCUSSION
There are three main advantages provided by this
simple modification to the lip splitting incision.
First ly, there are more landmarks for accurate wound
closure. Secondly, the line of the scar is elongated
with several alterations in orientation which avoids
straight line contracture, especial ly across the peri-
oral skin. Finally, the stigmatising appearance of a
lip sp lit is avoided by the broken line of the peri-oral
scar (Figs 5 6).
Gooris PJJ, Worthington P, Evans JR. Mandi bulotom y: a
surgical approach to oral and pharyngeal lesions. Int J Oral
Maxillofac Surg 1989; 18: 3599364.
Alte mir FH. Transfacial access to the retromaxillary area.
J Maxillofac Surg 1986; 14: 1655170.
Kraissl CJ. The selection of appropriate lines for elective
surgical incisions. Plast Reconstr Surg 195 I; 8: I-14.
Borges AF, Alexander JE. Relaxed skin tension lines,
Z-plasties on scars, and fusiform excision of lesions. Br J Plast
Surg 1961; 15: 2422254.
Roux PJ. Cited in: Butlin HT, Spencer GJ eds. Diseases of the
tongue. London: Cassell, 1900: 359.
Trotter W. Operations for mali gnant diseases of the pharynx.
Br J Surg 1929; 16: 485-495.
McGregor IA. McDonald DG. Mandibular osteotomy in the
approach to the oral cavity. Head Neck Sur g 1983; 5: 457-462.
Robson MC. An easy access incision for the removal of some
intraoral malignant tumours. Plast Reconstr Surg 1979; 64:
8344835.
9.
10.
Weber 0. Vorste llung einer kranken
mit
Resection des
Unterkiefers Verhd ndhmgen des naturhist --med Vereins z
Heidelberg 1845; 4: 80--82.
Ferguson W. In operation of the upper jaw. A System of
Practical Surgery. Edinburgh: John Churchill. 1842: 484.
Previous descriptions of lip splits all share the
advantage of improving access to deep facial struc-
tures and often make use of similar anatomical fea-
tures to help hide the scar line. However, they also
share the disadvantage of a straight line incision
across the vermilion margin and peri-oral skin which
may produce an unsatisfactory scar. The described
modification extends the attempts of existing incision
designs to conceal the resulting facial scars. The
prime benefit of this simple modification is to disguise
the peri-oral scar to improve the aesthetic result .
The Authors
J. P. Hayter FRCS, FDSRCS
Senior Registrar
E. D. Vaughan FRCS, FDSRCS
Consultant
J. S. Brown FRCS, FDSRCS
Consultant
Maxillofacial Unit
Walton Hospital
Liverpool L9 1AE, UK
Correspondence and requests for offprints to J. P. Hayter
Acknowledgements
Paper received 16 May 1995
Accepted 18 July 1995
The authors thank Miss Tracey Boyle, Medi cal Artist and Mr
Richard Hancock, Medic al Photographer for preparing the illus-
trations and Miss Deborah Noonan, Medica l Secretary for prepar-
ing the manuscript.