34 PHI IT RUM CONTOURING AND CUPIDS BOW CONSTRUCTION
JYII OPERATED LIPS WITH BILATERAL CLEFT HANG LIKE CURTAIN
WITHOUT ANIMATION PHILTRUM DIMPLE OR CUPIDS BOW THIS CON
DITION IS EASILY UNDERSTOOD AS THERE IS NO MUSCLE IN THE PROLABIUM
AND THERE IS NO RESIDUAL OF THE NORMAL CUPIDS BOW OR DIMPLE IN
THE BILATERAL CLEFT DEFORMITY IF THE VERTICAL LENGTH OF THE LIP IS
WITHIN NORMAL LIMITS THE PROBLEMS OF THE CUPIDS BOW AND
PHILTRUM DIMPLE BECOME PRIORITIES IN FACT IF THERE IS EVER TO BE
BOW AND DIMPLEAND LIP WITHOUT THEM IS UNNATURALTHEY
MUST BE HANDMADE IF CORRECTLY DESIGNED CUPIDS BOW AND
DIMPLE CAN BE CREATED DURING THE PRIMARY SURGERY IF THEY WERE
NOT THEN SECONDARY BOW AND DIMPLE FORMATION IS NECESSARY
THERE ARE SEVERAL WAYS OF ACHIEVING THIS GOAL
DIMPLE MAKING
EVEN WHEN THE BILATERAL SCARS HAVE BEEN PLACED STRATEGICALLY IN THE
PHILTRUM COLUMN POSITIONS THE LIP STILL LOOKS UNNATURAL WITHOUT
PHILTRUM HOLLOW FLANKED BY EMINENCES
GOUGING PHITRUM
GERALD OCONNOR AND MAR MCGREGOR OF ST FRANCIS MEMORIAL
HOSPITAL SAN FRANCISCO NOTED IN 1958
OBVIOUS ANATOMICAL DIFFERENCES THAT IMMEDIATELY SINGLE OUT THE OPERATED
CLEFT LIP FROM THE NORMAL ARE
THE ABSENCE OR LACK OF DEVELOPMENT OF THE NORMAL PHILTRUM MEDIAN
GROOVE EITHER PRE OR POSTOPERATIVELY
439 AFAR IMCREGOR THE ABSENCE LACK OF DEVELOPMENT OR ALIGNMENT OF THE NORMAL PROMI RHE RHE NENCE THAT IS IN THE UPPER LIP SKIN JUST ABOVE JUNCRION AT VERMILION
BORDER THIS HAS BEEN CALLED THE WHITE LINE OR WHIRE ROLL GILLIES
THEY CALLED IT THE CUTANEOUS UPIWEEP OF THE UPPER LIP NOTED
THAT MARCKS AND TREVASKIS CLAIMED ITS PRESENCE IN ALL CASES AND OF EMPHASIZED ITS IMPORTANCE AS LANDMARK IN ALIGNMENT THE
CLEFT LIP ELEMENTS OCONNORAND MCGREGOR ELABORATED ON THE FUNCTION OF THE
PHILTRUM
THE OF RHE TWO MEDIAL THE PHILTRUM BESIDES BEING POSSIBLY JUNCTION POINT SIDEWALLS NASAL SECRETIONS TO RUN DOWN NASAL PROCESSES HAS ELEVARED TO PERMIT
LIKE FOR EITHER SIDE OF THE UPPER LIP AND THE CUTANEOUS UPSWEEP ACTS GUTTER FROM THE MOUTH PERSPIRATION OR NASAL SECRETIONS TO DRAIN AWAY OPENING
ALSO IN THE PHILTRUM AND CUTANEOUS UPSWEEP ARE SO CONSTRUCTED OUR
MOTIONS OF THE IN ALL OPINION TO PERMIT THE MANY AND VARIED LIPS DIRECTIONS
JO LITTLE IS NEEDED IN THE THE GIVING EXTRA MATERIAL WHEN PLAY UPPER LIP
EXCESS MATERIAL LIES IN SORT OF REVERSE FOLDED POSITION TO ACT AS READY
AND BACK THE RESERVE FOR ALL COMPLICATED LIP MOTIONS YET SPRING TO NORM
WHEN AT REST VT
AS THEY POINTED OUT
THE THIS PHILTRUM ABSENCE IS ACCENTUATED IN THE DOUBLE CLEFT LIP BY PROMI
NENCE OF THE PROLABIUM AND THE PRESENCE OF THE FLATTENED SURGICAL JUNCTION
SCARS ON EITHER SIDE OF THE PROLABIUM
AND TO IMITATE THE PHILTRUM GROOVE CUTANEOUS UPSWEEP THEY ELEVATED THE SKIN OF THE PROLABIUM MIDVERTICAL SUBCUTANEOUS AND DOWN THE MIDDLE EACH FLAP BASED INFERIORLY WAS CUT SPLIT OF THE PRONGWHEN THREADED LATERALLY INTO TUNNEL ALONG THE ARCH
LEFT CENTRAL BOW JUST UNDER THE MUCOCUTANEOUS JUNCTION LINE THE SKIN HOLLOW AND EMPHASIZED THE BILATERAL UPSWEEP PROLABIAL MAINTAIN THE WAS SUTURED DEEP INTO THE HOLLOW IN AN ATTEMPT TO
GROOVE HIS RESIDENTS RECENTLY MAR MCGREGORNICKNAMED FEARLESS BY ASKED BECAUSE OF HIS WILLINGNESS TO TAKE ON ANY PROBLEM WAS HOW
REMINISCED THAT HE FELT ABOUT HIS PHILTRUM OPERATION TODAY HE
THEY HAD DONE FOUR OF THESE PROCEDURES AND HAD BEEN ENCOURAGED
AFTER FOR BY THE RESULTS OVER PERIOD OF ABOUT YEAR WHICH ONE
440 THE REASON OR ANOTHER PATIENTS WERE LOST TO FOLLOWUP THUS THEIR AND INGENIOUS ORIGINAL PRELIMINARY REPORT NOW15 YEARS WITHOUT RECORDS THAT OCONNOR AND PFLOTOGTAPLLL SUGGESTS MCGREGOR COMBINED THE ECONOMY OF THE SCOTS IN ITS CONCEPTION WITH HIT
OF THE IRISH THEREAFTER IN OF OF THE BLARNEY SPITE THE INGENIOUS FRE TENDS DESIGN FOR SHIFTING PHILTRUM TISSUE NATURE TO SMOOTH OUT WEVTT MANMADE DEPRESSIONS IN THE UPPER LIP WHICH ALWAYS HAVE BEEN
AND CONTINUE TO BE AS ELUSIVE AS LEPRECHAUNS
AND ALPS VALLEYS
AR THE ROME INTERNATIONAL CONGRESS IN 1967 AUSTRIAN OTTO
NEUNER OF BERNE UNIVERSITY DENTAL INSTITUTE SWITZERLAND PRE
SENTED SOME IMPRESSIVELY ARTISTIC SECONDARY CORRECTIONS OF BILATERAL
CLEFTS ONE OF THE METHODS HE DESCRIBED WAS REMARKABLY SIMILAR TO OF THAT OCONNORAND MCGREGOR HE TRANSPOSED TWO INFERIORLY
BASED SUBCUTANEOUS FLAPS FROM THE MIDVERTICAL TO THE LATERAL
HORIZONTAL POSITION TO CREATE PHIFTRUM HOLLOW AND THE ELEVA OF BOW RIONS CUPIDS CURVE THE CASE HE PRESENTED HAD PHOTO
GRAPHIC EVIDENCE OF DIMPLE TO THIS HE ADDED BILATERAL VY OTTO NEUNER VERMILION ADVANCEMENTS TO ACCENTUATE THE RED LIP EVERSION AND THE CENTRAL RUBERCLE OF THE BOW
II
II
THE ROLLOVER
THERE IS ALSO POSSIBLE APPLICATION IN THE BILATERAL CLEFT LIP OF ONIZUKAS 1971 UNILATERAL PHILTRUM ROLLOVER FLAP
441 ALSO FOLLOWS ONIZUKAS PHIL AN EVEN BETTER DOUBLE ROLLOVER THE OF TAKING TISSUE TRUM ADAPTATION OF GREAT GENERAL PRINCIPLE IT WHERE IT IS NEEDED FROM WHERE IT IS NOT WANTED AND MOVING TO
CHONDROCUTANEOUSPHILTRUM
STATED IN INNOVATIVE EDWARD SCHMID OF STUTTGART GERMANY
AN ABSENT PHILTRUM HAVE GIVEN SO FAR NONE OF THE ATTEMPTS TO RECONSTRUCT RESULT IN PRACTICED PHILTRAL IMITATION SATISFACTORY LEXER PARTICULAR OF BILATERAL CLEFT FOTMATION IN WHOMNO AFTERDEVELOPMENT IN PATIENTS WITH OUR SOLUTION IS TO TAKE SUITABLE CURANEOCARTI THE PHILTRUM CAN OCCUR THESE AS FROM THE EAR AND TRANSPLANT COMPOSITE GRAFTS LAGINOUS FRAGMENTS OBRAINED PERMANENT TROUGHSHAPED GROOVES ARE INTO THE UPPER LIP ELEVATIONS TO THE SIDES OF THE WHICH ARE BORDERED BY LATERAL CORRESPONDING TO THE BY THE CARTILAGE IT IS POSSIBLE PHILTRUM OWING TO SUPPORT GIVEN IN THE CENTER WHICH ARE SHORTENED STRETCH LIPS SLIGHTLY
EDWARD SCHMID WITH THE CENTRAL SCHMID USED COMPOSITE AURICULAR GRAFTS POR THINNED TO AID IN PHILTRUM TION OF THE CARTILAGE OR PERFORATED OF THE WAS HOLLOW CONSTRUCTION WHEN THE ENTIRE SKIN PHILTRUM THE GRAFT SCARRED THE ENTIRE PHILTRUM WAS REPLACED BY COMPOSITE
442 AND COMMONER MORE INTRIGUING APPLICATION OF THIS PRINCIPLE QN INVOLVED USE OF PHILTRUMSHAPED AURICULAR CARTILAGE PERFORATED
IN THE CENTER AND CARRYING WITH IT ONLY THE AMOUNT OF SKIN NECES THE OF THE BOW AS DESCRIBED SARY TO CREATE TIP PHILTRAL BY SCHMID
OF THE THE VERMILION IS FROM THE AND IN THE ZONE PHILTRUM SEPARATED LIP
MADE IN THE LATTER TUNNEL IS THE CARTILAGE FRAGMENT WITHOUT SKIN CAN NOWBE
INTRODUCED INTO THE SUBCUTANEOUS SPACE WHILE THE SKIN ATTACHED TO THE
IS SUTURED BETWEEN THE AND CARTILAGE LIP THE VERMILION WHICH WAS RETRACTED DOWNWARDS
OF IN THE HAVE PIECES CARTILAGE LIP NEVER BEEN PARTICULARLY ENTICING
TO MC BUT SCHMID FACED THE PROBLEM HEAD ON
HAVE BEEN ASKED WHETHERSUCH OF DID IMPLANTATIONS CARTILAGE NOT IMPAIR THE
PATIENT SENSITIVITY EG DURING KISSING HAVE ASKED MY PATIENTS THIS AND
THEIR ANSWERS HAVE REASSURED ME
OTHER STIFF UPPER LIPS
NEUNER OF BERNE CONFIRMED IN ROME IN 1967 THE VALUE OF
SCHMIDS AURICULAR IN FORMATION CARTILAGE GRAFT THE OF PHILTRUM HOLLOW IFE ADVOCATED USE OF THE CARTILAGE WITH PREFORMED
HOLLOW FROM THE SCAPHOID FOSSA OF THE EAR INSERTED THROUGH MIDVERTICAL MUCOSAL INCISION
CUPIDS BOW IN BILATERAL CLEFTS
IN THE BILATERAL THERE IS OF ORIGINAL CLEFT NO VESTIGE CUPIDS BOW AND ONLY BY SHAPING THE PROLABIUM AND EVEN ITS INFERIOR BORDER
443 AND IN LATERAL VERMILION OR VERMILION POSSIBLY BRINGING FLAPS FLAPS
RIDGED WITH MUCOCUTANEOUS WHITE ROLL RIDGE CAN SEMBLANCE
OF BOWBE CREATED IF THIS PROCEDURE HAS NOR BEEN DONE PRIMAR
ILY THERE ARE WAYS AND MEANS OF SECONDARY BOW CONSTRUCTION
TRANSFORMING BLAIRBROWN INTO HAGEDORNLEALESURIER
WHEN TRIANGULAR FLAPS FROM THE LATERAL LIP SEGMENTS HAVE BEEN
SLID TOWARD EACH OTHER BELOW THE INFERIOR EDGE OF THE PROLABIUM
TO TOUCH TIP TO RIP AS IN THE BLAIRBROWN METHOD OFTEN SINGLE
MUCOCURANEOUS ARC IS CREATED WITH THE SUGGESTION OF CENTRAL
VERMILION WHISTLING DEFORMITY THE ADVANTAGE OF THE HAGE
DORNLEMESURIER METHOD WAS THAT IT CREATED AN ARTIFICIAL CUPID
BOW THUS BY TURNING THE TRIANGULAR FLAPS WITH ADDITIONAL
EXCISIONS INTO QUADRILATERAL FLAPS WIDER AT THEIR MEDIAL ENDS THE
SEMBLANCE OF CUPIDS BOW IS ACHIEVED EVEN WITH MIDLINE TUBERCLE
WEEKS POSTOPERATIVE
THE UNNATURAL POSITION OF THE SKIN SCARS OF COURSE IS MORE
NOTICEABLE WEEKS AFRER BUT FOREVER THREE SURGERY WILL DETRACT IN
SOME DEGREE FROM THE ULTIMATE RESULT
444 BOW GIUJES CUPIDS OPERATION
ANOTHER SECONDARY METHOD OF CREATING AN ARTIFICIAL CUPIDS BOW
SIR HAROLD GILLIES IN THIS WAS INGENIOUSLY DESIGNED BY 1932 WAS
INCIDENTALLY THE ONE OF HIS ARTISTIC PROCEDURES THAT PROPELLED ME
FOR OF TO CROSS THE ATLANTIC STUDY WITH HIM WENT TO LEARN AND OF BOWSBUT IN THE WAS ALSO PHILTRUMS CUPIDS PROCESS TAUGHT
OF TROUTS TRICKS OF SHOESAND SHIPSAND SEALINGWAXOF CABBAGESAND KINGS
OF THE SIX IN IT WAS SAID THAT GILLIES WAS ONE TOP FLYFISHERMEN
HE AND HIS STRETCH OF THE ENGLAND ONE DAY WERE STROLLING ALONG THE THE SECTION OF RIVER TEST IN MAYFLY SEASON MY MIND WAS ON LIP
OUR BOOK REALIZED THAT WHEN THE MUCOCUTANEOUS LINE CURVES
WITHOUT ANY PEAKS BUT THE LIP IS LOOSE WITH NO REASON TO INSERT AN
ABBE FLAP THE GILLIES CUPIDS BOW PROCEDURE CAN BE USEFUL TRIED
TO DRAW HIM OUT ON THIS SUBJECT BUT HE SIMPLY COUNTERED BY
HOOK OF TOBACCO TIN AND WITH FLOSS SILK TIED PICKING OUT GREEN
COCKS HACKLE AND FLUE FOR AND IDENTICAL FLY OF BROWN WINGS TAIL
TO THE PALE WATERY OLIVE MAYFLIES HOVERING OVER THE QUIET RIVER THAT
AFTERNOON ONLY AFTER CATCH WAS SIR HAROLD WILLING TO RETURN TO
THE CUPIDS BOWAND THEN AND THERE WE COMPOSED FEW LINES FOR
OUR 1957 PRINCIPLES AND ART
FIRST ESTIMATE BY MEASUREMENT FROM THE ALAR BASE THE DESIRED LIFT MATK THE
ELLIPTICAL SKIN AREAS AND EXCISE THEM THEN UNDERMINE THE LIP MUCOSA FROM
SORR ITS MUSCLE EXCEPT AT THE CENTRAL POINT WHICH IS TO REMAIN FIXED NICK THE
RIGHT MUSCLE BANDS AT THE CENTRE OF EACH HOW OR PERHAPS EVEN EXCISE
SMALL TRIANGLE WHICH WILL INCREASE THE SIDE TO SIDE LENGTH OF THE LIP AS THE
FRESH VERMILION EDGE IS ADVANCED UP INTO ITS NEW POSITION THE CENTRAL POINT
TILTS FORWARD
445 LOCK EXCISIONS
OF SKIN
FREEING THE VERMILION
446 THIS WAS AN OPERATION BARRETT BROWN ATTACKED WITH VIGOR
SAYING
MAKE BOW ONLY GOD CAN CUPIDS
AND THEN ELABORATING
II THAT THE TESULTANT SCATS OF THESE IN SOME INSTANCES IT IS THOUGHT OPERATIONS THAN THE ABSENCE OF THE BOW MAY BE MORE DEFOTMING
II
II METICULOUS MUSGRAVE ECHOED THIS SAME FEELING DECADES LATER II
II
NOTE THE ARTIFICIAL APPEATANCE OF THIS MANUFACTURED CUPIDS BOW
GERHARD PFEIFER OF HAMBURG EXPRESSED GERMAN RESISTANCE TO
THE OPERATION
DO NOT THINK WE OUGHT TO USE EXCISIONS AT THE VERMILION BORDER AFTER
GILLIES SINCE EVEN THE FINEST SUTURE CANNOT IMPROVE THE NATURAL BORDER OF
LABIAL RED AND WHITE
IT IS QUITE TRUE THAT WHEN THIS METHOD IS EXECUTED INARTISTICALLY ACCRUED YET THERE THE UNNATURALNESS CREATED CANCELS OUT ANY ASSETS
ARE SEVERAL POSSIBLE MODIFICATIONS TO REFINE THE DESIGN
RE 447 PRESERVE THE MUCOCUTANEOUS RIDGE
THE ORIGINAL PROCEDURE CAN CREATE SEMBLANCE OF BOW WITH
IMPROVEMENT IN CERTAIN CASES AS THE NORMAL WHITE ROLL OF THE
MUCOCUTANEOUS JUNCTION WAS DESTROYED IN GILLIES PLAN THE
RESULTS CONSEQUENTLY PRESENT IN THE LIP AREA FALSEFACE EFFECT
THUS TO COUNTERACT BROWNSMUSGRAVES AND PFEIFERS CRITICISM IT
IS SUGGESTED THAT THE WHITE ROLL OF THE MUCOCURANEOUS JUNCTION BE
SPARED AS HAS BEEN SHOWN IN SECONDARY UNILATERAL CLEFT CORREC
TIONS AND THE EXCISIONAL LIFT BE CARRIED OUT JUST ABOVE IT PRESERV
ING THE SKIN RIDGE OF THE MUCOCUTANEOUS JUNCTION TO REFLECT
HIGHLIGHT ALONG THE WHITE ROLL
INCORPORATING THE
ALBERT FACUNDO BORGES THE CZAR OF SCARS FORMERLY OF HAVANA
UNIVERSITY AND NOWOF FALLS CHURCH VIRGINIA WROTE AN EXCELLENT
WTOZ ATLAS ENTITLED ELECTIVE INCISIONS AND SCAR REVISIONS HE ADVO
CATED OF THE BE THAT TRANSVERSE EXCISIONS LIP MADE AS WPLASRIC
TYPE SCARS AND FURTHER INSISTED THAT THIS PRINCIPLE IS APPLICABLE TO
THE SKIN EXCISIONS IN THE CUPIDS BOW OPERATION EVEN WHEN THE
EXCISIONS ARE CARRIED OUT ABOVE THE SALVAGED MUCOCUTANEOUS
WHITE ROLL RIDGE BORGES CLAIMS THE WFPLASTIC MANEUVER WILL
GIVE SUPERIOR END RESULT IN 1977 HE WROTE ALBERT BORGES
YOUR MODIFICATION OF GILLIES PROCEDURE IN WHICH THE MUCOCUTANEOUS RIDGE
IS PRESERVED IS AN INGENIOUS ONE AND WILL GET GREAT IMPROVEMENT THE COR
RECTION OF DISPLACED ANATOMICAL LANDMARKS SUPERSEDES IN COSMETIC IMPROVE
MENT ANY DELETERIOUS EFFECT CREATED BY THE PRESENCE OF SCAR THE UNFAVORABLE
OR NOT RESULT OF TRANSVERSE SCAR ON THE LIP SHOULD BE JUDGED NOT ONLY WITH
THE PATIENTS LIPS IN REPOSE BUT SPECIALLY WITH THE PATIENT SMILING OR TALKING
ALTHOUGH HAVE NOT PERFORMED THE FOLLOWING WPLASTIC TECHNIQUE TO COR
RECT ASYMMETRY OF THE TWO ARCS OF CUPIDS BOW SECONDARY TO CLEFT LIP REPAIR
HAVE PERFORMEDIT FOR POST TRAUMATIC DROOPING AS SEEN IN FIGURE 10 OF MY
BOOK ON SCARS THE SCHEMATIC REPRESENTATION OF THE TECHNIQUE IS ENCLOSED
NOTE HOW THE WIDEST TRIANGLES CORRESPOND TO THAT SEGMENT MEDIAL THIRD
WHERE ONE DESIRES THE GREATEST EXCISION OF TISSUE THUS THE GREATEST UPWARD
PULL THE LOWERMOSTANGLES OF THE WEXCISION TEACHES TO BUT DOES NOT TRAN
SECR THE MUCOCUTANEOUS RIDGE THE EXCISION SHOULD NOR BE ANY HIGHER SINCE
THIS WOULD REQUIRE GREATER WIDTH OF THE WPLASRIC TISSUE EXCISION TOO
448 WHICH WIDE AN EXCISION COULD CREATE DOG EARS AT THE ENDS OF THE EXCISION
WOULD REQUITE VERTICAL FUSIFORM EXCISION OF TISSUE FOR ITS CORRECTION THE END
RESULT WOULD BE AN ELASRIC CONCERTINALIKE TRANSVERSE SCAR ON THE LIP THAT WOULD
NOT HINDER THE NORMAL LAUGH OF THE PATIENT NOR WOULD IT MAKE THE PATIENT
THIS SCAT WOULD BE OF ALMOST VERTICAL TL STOP LAUGHING COMPOSED VERY SMALL SCARS TB IS SCAT WILL BE SUPERIOR IN THEORY AND IN PRACTICE THAN ANY
TRANSVERSE LONG SCAR RUNNING AGAINST THE RSTL
THIS MAY BE TRUE BUT HERE THE SCAR SKIRTS THE MUCOCUTANEOUS THE RIDGE AND PERSONALLY PREFER TO KEEP THE SCAR PARALLEL TO CURVE ABOVE THE OF THE RIDGE LINE RATHER THAN TRY TO IT JUST RIDGE
ALONG THE ENTIRE WIDTH OF THE LIP
449 TO MAKE BOW AND DIMPLE
FURTHER IMPROVEMENT IN THIS OPERATION IS SUGGESTED THE
BILATERAL TRIANGULAR OR ELLIPTICAL SKIN EXCISIONS SHOULD NOT BE
REMOVED IN THE USUAL MANNER AND THE NOTCHES SHOULD NOT BE CUT
OUT OF THE FREE EDGE OF THE ORBICULARIS OTIS MUSCLE INSTEAD THE
SKIN TRIANGLES SHOULD BE DEEPITHELIALIZED AND THEN INCISED AS
IF DERMOMUSCULAR FLAPS BASED AT THE CENTER OF THE BOW SUBCURA THE NEOUS TUNNELS VERY CLOSE TO THE SKIN ARE DISSECTED ALONG IDEAL BASE OF THE PHILTRUM COLUMN LINES TOWARD THE COLUMELLA THE
DERMOMUSCULAR FLAPS CAN BE TUGGED INTO THESE TUNNELS WITH
PULLOUT SUTURES THIS OPERATION WILL NOW CREATE CUPIDS BOW
WITH MUCOCUTANEOUS RIDGE CENTRAL TUBERCLE AND PHILTRUM
COLUMNS WITH CENTRAL DIMPLE
SUCH AN OPERATION AS ALWAYS IS AVAILABLE FOR SHORTENING LONG
LIP BUT THESE REFINEMENTS MAKE IT POSSIBLE SIMULTANEOUSLY TO
FASHION MORE NATURAL CUPIDS BOW AND TO CONTOUR PHILTRUM THE CHARACTER BY THE RELATIVE RISE OF THE OVERLAY PRINCIPLE PHIL
TRUM COLUMNS AND HOLLOW CAN BE ACHIEVED WITHOUT THE NECESSITY
OF DIVIDING BY GOUGING THE MIDLINE MUSCLE UNION ACROSS THE LIP
AGAIN IF THE PRIMARY CLEFT OPERATION WAS EXECUTED CORRECTLY II THERE WILL BE NO NEED FOR SUCH SHENANIGANS THIS IS BUT SECOND
OF LAST REFINED TO MAKE THE MOST OF FLAT ARY PROCEDURE RESORT
SITUATION
II
450 DE EPITHEHALIZING THE SKIN BUT BASED PRESERVING MEDIALLY THE MUCOCUTANEOUS SUBCUTANEOUS
JUNCTION RIDGE MUSCLE PEDICLE
BEING DISSECTED
AND
ELEVATED
AS FLAPS
DISSECTED
FLAPS BEING PULLED INTO TUNNELS TO CREATE CUPIDS BOW PHILTRUM COLUMNS AND DIMPLE
7LA
II
451