ANATOMY

Surgical Technique
Marking Lip and Chin Landmarks
• The cutaneous incision is marked in the midline and oriented vertically.
• The anterior vermilion line (mucocutaneous junction) and the posterior vermilion line
(wet-dry line) are marked to facilitate reapproximation of the lip at the completion of
the case.
• For the anterior vermilion line, the back of the tip of the surgical blade is used to mark
the transition between the vermilion and the skin.
• A needle and methylene blue dye are used to temporarily tattoo the wet-dry line, and
the marked line is preserved until the end of the procedure.

Lip and Chin Incisions

• The lip is split through the skin, orbicularis oris muscle, and mucosa.
• Terminal branches of the inferior labial artery are cauterized.
• The incision is extended vertically along the chin and submental area down to the level
of the hyoid bone.
• An incision is made in the midline down to the periosteum of the mandible.
• Intraoral incisions are then carried laterally in the gingivobuccal sulcus, and a 5- to 8-
mm cuff of vestibular mucosa is left attached to the bone to facilitate closure at the
completion of the procedure.
• The periosteum is incised sharply, then carefully elevated for about 2 cm on both sides
of the osteotomy site.
• The elevation of this cheek flap should be enough to provide good exposure of the
anterior aspect of the mandible where the mandibulotomy will take place.
 • The inferior border of the mandible is well exposed.
• The origin of the anterior belly of the digastric muscle is identified in the inferior border
of the mandible.
• If possible, exposure of the mental foramen and nerve is avoided to decrease the risk
of injury to the nerve and postoperative numbness. If the nerve is exposed,
meticulous dissection around it should be performed using sharp instruments
(surgical blade) to release the nerve from the periosteum of the mandible.

Mandibulotomy Approach
The transoral approach can provide limited access for oncologic resection of tumors of the
oropharynx, posterior maxilla, infratemporal and parapharyngeal spaces. In these cases, the
midline or paramedian mandibulotomy can improve access for oncologic resection and
reconstruction.

In the midline mandibulotomy, a full-thickness vertical incision through the midline lower lip is
designed and carried along midline through the chin or laterally around the chin. Incisions
are made in a full-thickness fashion, through periosteum and onto bone to expose the
anterior mandible. The mandibulotomy is designed with a vertical osteotomy at or lateral to
midline extending superiorly through the interproximal region between adjacent teeth or
through an extraction site of an incisor. The osteotomy is planned anterior to the mental
foramen in a stepped fashion. Prior to completing the osteotomy, one or two 4-hole
miniplates are adapted to the anterior mandible at the site of the osteotomy and screw
fixation holes are predrilled to allow ease of fixation and maintenance of dental occlusion.
The mandibulotomy is then completed with a reciprocating saw ( Fig. 111.8 ).
Figure 111.8
Mandibulotomy approach for base of tongue tumor.
The mandibular segments are lateralized by separating the bony segments from the lingual
mucoperiosteum and mylohyoid muscle, stripping attachments as necessary for adequate
exposure.
LIP-SPLITTING
The lip splitting incision along with a mandibulotomy or mandibulectomy increases
access to intraoral, pharyngeal, and parapharyngeal tumors and also the cervical

spine. It has been used in head and neck surgery for access since the mid-19th
century when it was first described. Any transfacial approach that incorporates lip
splits must attempt to use good principles of incision design to hide the resultant scar
line. 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.

To overcome these drawbacks, several modifications to the original midline incision

have been proposed. The original incision proposed by Roux in 1839 ( Fig 1 A) 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 McDonald modified the

original incision to follow the outline of the labiomental groove ( Fig 1 B) 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 et al modified the McGregor incision ( Fig 1 C) to incorporate a

chevron into the vermilion margin and midline lip incisions that facilitates accurate

apposition of the vermilion border. Robson ( Fig 1 D) 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.

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.

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 labiomental
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 ).

Figure 2
Schematic representation of the modified lip split incision incorporating a vermilion flap.
Bhatt et al. Modified Lip Split Incision. J Oral Maxillofac Surg 2009.

Figure 3
Posthealing photograph showing esthetic ( A ) and functional ( B ) outcome.
Bhatt et al. Modified Lip Split Incision. J Oral Maxillofac Surg 2009.

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 al 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.

Mandibulectomia
Tumours in the oral cavity are most often treated by surgery (+/- DXT). This may
involve resection of a portion of the mandible in order to obtain adequate margins.
The common types of mandibular resection are either a marginal or segmental
mandibulectomy ( Fig 8 ). A marginal resection involves removing a section of the
cortex or alveolar bone, preserving the continuity of bone. This is often difficult to
recognise at imaging. A segmental resection involves an entire segment of the
mandible, which is often reconstructed using an osseous free flap (fibula or scapula).
This will result in the mandible having two full-thickness osteotomies, and the
resultant reconstructive plates, versus the intact mandible of a marginal
mandibulectomy when only its cortex is removed. Larger tumours within the floor of
the mouth or oral cavity may require a jaw split procedure. This involves a single
central mandibular osteotomy to improve surgical access to the mouth.
Figure 8
Types of mandibulectomy. (a) Marginal mandibulectomy consists of resection of a portion of the
cortex or alveolar bone, leaving the bone in continuity. (b) Segmental mandibulectomy involves
removing a full-thickness segment of mandible that will require a bone flap reconstruction.