A stepped technique for splitting of the lower lip

Received from The Walter C. Guralnick Oral and MaxilloFacial Clinic. The Department of Oral and Maxillo-Facial Surgery, The Chaim Sheba Medical Center, Tel-Hashomer, RamatGan and The School of Dental Medicine, Sackler Faculty of Medicine, Tel-Aviv Universitv, Tel-Aviv. Israel. Address correspondence and reprint requests to Dr. Ramon: Department of Oral and Maxillo-Facial Surgery. The Chaim Sheba Medical Center. Tel-Hashomer. Ramat-Gan 52621. Israel.
was recently reported,6 and, although the author recommends this method, he states that scar contracture, eversion of the lip. and formation of a small groove are frequently observed postoperatively. To overcome some of the disadvantages of the median split technique, the so-called S-shaped technique has been advocated. In this technique, incision starts at the midline of the vermilion, borders the superior and lateral aspect of the mentalis muscle, and reaches the lower mandibular border in the midline (Fig. 3). The incision can be continued into a collar incision according to need. This incision seems to cause less notching of the vermilion and preserves the roundness and smoothness of the chin protuberance, but, as far as the symmetrical appearance of the chin is concerned, the esthetic results are often disappointing (Fig. 4). The stepped flap technique, commonly used in
690
STEPPED
LOWER
LIP SPLITTING
FIGURE lip. FIGURE adaptation
3.
Top. The S-shaped
splitting
technique
of the lower shows poor
4. Borro/n. The S-shaped technique and deformity of the lip and chin.
of the
MD, AND
Adequate surgical exposure of malignant lesions of the oral cavity is often difficult because the mouth opening is not large enough. This can be overcome by splitting either the upper or lower lip, or both, and by using a collar incision to divide the cheek and neck tissues from the mandible. This paper presents a step technique of splitting the lower lip. Splitting of the lower lip was advocated by Dieffenbach in 1834, by Bernard in 1853,2 and by Burow in 1855.3 all of whom advocated a simple, straightline vertical split of the lower lip to the middle of the mandibular symphysis. The incision was then extended into a collar incision according to the surgical requirements (Fig. 1). Although this technique is a simple, reliable surgical procedure, it has cosmetic and functional disadvantages. Often the scar contracts and leaves a notched vermilion. The round, smooth shape of the chin is always disturbed, which is also objectionable from a cosmetic standpoint (Fig. 2), especially when the lip and chin muscles are contracted. Of historical interest is a technique advocated by Langenbeck in 1877.4 The exposure of the oral cavity is enlarged laterally, either on the right or left side, by a vertical incision starting at the angle of the mouth, going through the cheek to the lower border of the mandibular ramus (if necessary, the incision can be continued into a collar incision). This surgical approach cuts through the masseter muscle, the buccinator muscle, and the facial motor nerve supply to the lower lip, resulting in an unacceptable deformity. Konig,’ in 1922, described a splitting technique of the lower lip in which a vertical incision is made
TECHNICAL NOTES
J Oral Maxlllofac 42569-691. 1964 Surg
A Stepped
YOCHANAN
TeLeabharlann Baiduhnique for Splitting Lower Lip
RAMON, MD, DMD, SHMUEL HENDLER, MORDECHAI OBERMAN, DMD
FIGURE 1. Top, The median split of the lower lip: 1 = mentalis muscle: 2 = depressor labi inferior muscle; 3 = orbicularis oris muscle: 4 = depressor anguli oris muscle. FIGURE 2. Boftorn. The repair of the vermilion is very satisfactory with the median splitting technique, but the round, smooth shape of the chin is disturbed.
starting about 1.5 cm medially to the oral commissure and descending vertically to the lower mandibular border. This incision can be elongated into a collar incision as well. A case using this technique
result.
Late postoperative
result with the stepped
RAMON ET AL
691 of the chin. As the incision is supposed to reach the mandibular midline at the lower border of the symphysis, encroachment on the mentalis muscle is unavoidable. To get a good functional and esthetic result, this incision should go around the mentalis muscle and end on the lateral aspect of the muscle at the lower mandibular border, keeping a margin of about 2 mm. The stepped splitting technique is, in our opinion, an improvement on the S-shaped splitting technique. The incision crosses the midline of the vermilion and the orbicularis oris. passes below the main superficial muscular bundles of the orbicularis, splits only medial fibers of the depressor labi inferior, and reaches the lower anterior border of the mandible. The innervation of the lip muscles is not disturbed, and the repair of this incision allows full anatomic and functional reconstruction. The right angles of the “steps” allow accurate apposition of the tissues, and the resulting scar is inconspicuous. In many surgical procedures of the oral cavity and the jaws, wide exposure of the oral cavity by a collar incision is indicated. This collar incision can be safely replaced in many cases by the stepped split incision.
FIGURE lip.
5,
Top. The stepped Early
splitting
technique
of the lower with the
FIGURE 6. Cents,. stepped technique. FIGURE 7. technique. Botforn.
postoperative