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