J Oral Maxillofac Surg 67:229-230, 2009 A Modified Lip Split Incision Vyomesh Bhatt, MDS, FDSRCS, MRCS,* Prav Praveen, FDSRCS, FFDRCSI, MRCS,† Jason Green, FDSRCS, MRCS,‡ and Peter D. Grime, FDSRCS, FRCS§ The lip splitting incision along with a mandibulotomy or mandibulectomy increases access to intraoral, pharyngeal, and parapharyngeal tumors and also the cervical spine.1 It has been used in head and neck surgery for access since the mid-19th century when it was first described.2 Any transfacial approach that incorporates lip splits must attempt to use good principles of incision design to hide the resultant scar line.3 The original incision is associated with bothersome esthetic and functional sequelae that include unsightly scar, vermilion notching, loss of chin pad contour, decreased lip sensation, decreased mobility, and oral commissure incontinence.1 To overcome these drawbacks, several modifications to the original midline incision have been proposed.4-9 The original incision proposed by Roux in 18392 (Fig 1A) was a midline incision of the lower lip that lies in a relaxed skin tension line and minimizes injury to the muscles, vessels, and nerves of the lower lip. However, contracture of the straight line incision over the lower lip, vermilion, and chin may combine to produce an unsightly scar. McGregor and McDonald7 modified the original incision to follow the outline of the labiomental groove (Fig 1B) that resulted in the break-up of the straight line scar and attempted to hide it in a natural skin crease. However, over the chin prominence the semicircular incision crosses vertical relaxed skin tension lines that may potentially produce a more prominent scar. Hayter FIGURE 1. Schematic representations of various incisions. (A) Roux-Trotter incision. (B) McGregor incision. (C) Hayter et al modification of the McGregor incision. (D) Robson incision. Bhatt et al. Modified Lip Split Incision. J Oral Maxillofac Surg 2009. et al9 modified the McGregor incision (Fig 1C) to incorporate a chevron into the vermilion margin and midline lip incisions that facilitates accurate apposition of the vermilion border. Robson5 (Fig 1D) described an incision as a relaxed skin tension line just medial to the commissure that produces an unobtrusive scar but will damage the terminal branches of the facial and mental nerves. We present a simple modification to the design of the lower lip splitting incision to improve the esthetic outcome of the healed lip (Fig 2). Above the labio- *Specialist Registrar, Oral and Maxillofacial Surgery, West Midlands Rotation, West Midlands, United Kingdom. †Specialist Registrar, Oral and Maxillofacial Surgery, West Midlands Rotation, West Midlands, United Kingdom. ‡Specialist Registrar, Oral and Maxillofacial Surgery, West Midlands Rotation, West Midlands, United Kingdom. §Consultant, Oral and Maxillofacial Surgeon, University Hospital North Staffordshire, NHS Trust, Stoke-on-Trent, United Kingdom. Address correspondence and reprint requests to Dr Bhatt: West Midlands Rotation, Oral and Maxillofacial Surgery, New Cross Hospital, Wolverhampton, West Midlands WV10 0QP, UK; e-mail: Vyomeshb@aol.com FIGURE 2. Schematic representation of the modified lip split incision incorporating a vermilion flap. © 2009 American Association of Oral and Maxillofacial Surgeons 0278-2391/09/6701-0036$34.00/0 Bhatt et al. Modified Lip Split Incision. J Oral Maxillofac Surg 2009. doi:10.1016/j.joms.2008.07.007 229 230 MODIFIED LIP SPLIT INCISION FIGURE 3. Posthealing photograph showing esthetic (A) and functional (B) outcome. Bhatt et al. Modified Lip Split Incision. J Oral Maxillofac Surg 2009. mental groove we take the skin incision up to the vermilion but not across it. Instead, the incision is taken along the vermilion border with skin and then across vertically and brought back to the midline on the mucosal side of the lip thus creating a vermilion flap. This allows very accurate apposition of the vermilion border (Fig 3). Discussion The advantage offered by this modification is that it provides greater anatomic landmarks for accurate apposition of the vermilion border while breaking up the straight-line incision with multiple alterations in orientation thus avoiding straight line contracture. The final resultant perioral scar is esthetically very pleasing and functionally sound because it retains its midline position. Previous descriptions of lip splits all use similar anatomical features to hide the scar line but cross the vermilion in a straight line from the skin. Hayter et al9 describe a disadvantage in straight line incision across the vermilion. However, we find the results are quite pleasing when the straight line incision across the vermilion originates in the vermilion border and does not cross it from the skin across the border onto the vermilion, but rather crosses in a stepped fashion, producing a vermilion flap. The prime benefit of our modification is improved esthetic result. The senior author (P.D.G.) has been using this incision for over 12 years with reproducible results. A formal audit of outcomes has been initiated although an informal survey shows good esthetic and functional result. References 1. Gooris PJJ, Worthington P, Evans JR: Mandibulotomy: A surgical approach to oral and pharyngeal lesions. Int J Oral Maxillofac Surg 18:359, 1989 2. Roux PJ: in Butlin HT, Spencer GJ (eds): Diseases of the Tongue. London, England, Cassell, 1900, p 359 3. Kraissl CJ: The selection of appropriate lines for elective surgical incisions. Plast Reconstr Surg 8:14, 1951 4. Babin R, Calcatera TC: The lip-splitting approach to resection of oropharyngeal cancer. J Surg Oncol 8:433, 1976 5. Robson MC: An easy access incision for the removal of some intraoral malignant tumors. Plast Reconstr Surg 64:834, 1979 6. Tashiro H, Ohnishi M: Cosmetic improvement of the lateral mentolabial incision. J Oral Maxillofac Surg 40:252, 1982 7. McGregor IA, McDonald DG: Mandibular osteotomy in the surgical approach to the oral cavity. Head Neck Surg 5:457, 1983 8. Ramon Y, Hendler S, Oberman M: A stepped technique for splitting the lower lip. J Oral Maxillofac Surg 42:689, 1984 9. Hayter JP, Vaughan ED, Brown JS: Aesthetic lip splits. Br J Oral Maxillofac Surg 34:432, 1996