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 split 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

LOWER LIP

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 disarticulated maxilla is pedicled to the cheek flap, the paranasal 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 approximation 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 commonly 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.

ROUXITROTTER

MCGREGOR

ROBSON

INCISIONS
Lower lip
1. Roux/Trotter
A midline split of the lower lip and mandible in the
surgical 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

Fig. 1 - Lower

432

lip splitting

incisions.

Aesthetic

depression of the vertical line over the chin prominence may combine to produce an unsightly scar.

lip splits

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

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 vertical 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.

AESTHETIC

MODIFICATION

UPPER LIP

3. Robson

The incision described by Robson descends in a

relaxed skin tension line beginning just medial to the
lateral commissure. An incision placed in this line
should produce an unobtrusive scar. However, this
lateral approach will damage the terminal branches
of the facial and mental nerves.

LOWER LIP

UPPER LIP
Fig. 3 - Standard

WEBER-FERGUSON

lip splitting

incisions

with chevron

modification.

ALTEMIR

Fig. 2 - Upper

433

lip splitting

incisions.

Fig. 4 - (A,B)

Operative

planning

of aesthetic

lip splits

434

British

Journal

of Oral

and Maxillofacial

Surgery

Fig. 5 - Postoperative results 8 months (top) and 5 years (bottom) following lower lip split. The peri-oral scar is virtually imperceptible.
The semi-circular labiomental groove scar is noticeable where it crosses 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 noticeable, even if the vermilion border is carefully
apposed.

2. Altemir
Altemir described a straight line lip split along the
philtral crest which is then extended as for the WeberFerguson 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.

Aesthetic

Fig. 6 - ( A,B) Postoperative

results 9 months
unobtrusive
broken hne of the peri-oral
scar.

after

Altemir

approach
__

METHODS

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 apposition of the vermilion border.
DISCUSSION

There are three main advantages provided by this

simple modification
to the lip splitting incision.
Firstly, 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, especially across the perioral skin. Finally, the stigmatising appearance of a
lip split is avoided by the broken line of the peri-oral
scar (Figs 5 & 6).
Previous descriptions of lip splits all share the
advantage of improving access to deep facial structures and often make use of similar anatomical features 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.
Acknowledgements
The authors
thank
Miss Tracey
Boyle, Medical
Artist
and Mr
Richard
Hancock,
Medical
Photographer
for preparing
the illustrations
and Miss Deborah
Noonan,
Medical Secretary
for preparing the manuscript.

with

radial

forearm

flap reconstruction

of the palate.

lip splits

Note

435

the

References
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FH. Transfacial
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J Maxillofac
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3_ Kraissl CJ. The selection of appropriate
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Plast Reconstr
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4. Borges AF, Alexander
JE. Relaxed skin tension lines,
Z-plasties
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DG. Mandibular
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9. Weber 0. Vorstellung
einer kranken
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Unterkiefers
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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

Paper received 16 May

Accepted
18 July 1995

1995

for offprints

to J. P. Hayter