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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.