The Lip Split: A Retrospective Outcomes Study and Case Series following Central and Lateral Lip Split Access for Head and Neck Reconstructive Surgery

The Lip Split: A Retrospective Outcomes Study and Case Series following Central and Lateral Lip Split Access for Head and Neck Reconstructive Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Lip Split: A Retrospective Outcomes Study and Case Series following Central and Lateral Lip Split Access for Head and Neck Reconstructive Surgery Peter Gearing, Maxim Devine, Siyuan Pang, Felix Sim, Anand Ramakrishnan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4062093/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Mar, 2025 Read the published version in Oral and Maxillofacial Surgery → Version 1 posted 8 You are reading this latest preprint version Abstract Purpose: Surgical resection of oral cancers requires meticulous planning to achieve clear margins and minimize potential morbidity. This study aimed to compare postoperative surgical and functional outcomes following central and lateral lip-split approaches used for resection and reconstruction of oral tumours. Methods: A retrospective review of 79 cases involving lip-split procedures for head and neck cancers was conducted. Data were collected from a prospectively recorded database (December 2015 to December 2022). Statistical analyses compared patient demographics, intraoperative characteristics, and postoperative outcomes between central and lateral lip-split cohorts. Results: Lateral lip splits were associated with higher rates of postoperative complications (p = 0.008), including return to theatre (p = 0.015), and functional issues including asymmetric smile (p = 0.009). No significant differences were observed in readmission rates, length of stay, or time to oral diet commencement (p > 0.05). Six cases were selected to highlight the potential advantages and disadvantages of central and lateral lip split procedures. Conclusions: Lip-split procedures remain valuable for resection and reconstruction of oral and oropharyngeal tumours. Lateral lip splits are associated with poorer outcomes when compared to central approaches. Appropriate selection of lip splitting approaches should consider tumour location, resection margins, patient comorbidities and preferences, and surgical preferences. head and neck surgical access lip split mandibulotomy malignancy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1 BACKGROUND Surgical resection of oral cancers is the mainstay of treatment, with clear margins strongly associated with improved prognosis[ 1 ]. Planning access for excision and reconstruction of oral cavity cancers requires balancing of the advantages of extensive incisions which confer unparalleled visibility, hence aiding both resection and reconstruction, with the morbidity, both functional and cosmetic, of such incisions. The cramped anatomical environment provides operative challenges for accessing the posterior structures of the oral cavity and oropharynx, and the vasculature required for anastomosis and inset of free vascularized flaps[ 2 ]. Purely transoral approaches are useful and appropriate for many anterior resections and reconstructions[ 3 ]. Where transoral approaches are not technically viable or appropriate for obtaining clear pathological margins or inset of free flaps, various alternative approaches have been proposed. These include the lip-split mandibulotomy approach (LSMA), the modified visor approach with a drop-down of the tongue [ 2 , 4 – 6 ]. First described in 1836 by Roux and popularised in the 1970s, lip splitting approaches to the oral cavity provide significantly improved access for R 0 tumour resection (i.e., microscopically clear margins)[ 7 – 11 ], with excellent visualization and handling of posterior structures[ 12 , 13 ]. As recent literature has placed the lip-split (with or without mandibulotomy) approaches as less favorable in lieu of less invasive approaches[ 2 , 6 ], lip split operations have fallen in use over time[ 12 ]. Nevertheless, the lip-split remains an important tool for resection and reconstruction of many difficult to access oral and oropharyngeal tumors that may be inappropriate for alternative approaches due to anatomical or technical reasons[ 14 ]. Further, with the advent of free flap microsurgical reconstruction, lip split access assists deep intra-oral and pharyngeal flap inset and microsurgical vascular anastomosis[ 15 ]. Selecting the optimal approach to splitting the lip is critical. Various incisions have been proposed in literature, including the Roux-Trotter incision, McGregor incision, the Robson incision (Fig. 1), and the zigzag incision[ 7 , 16 ]. Hayter et al describe a modification of the McGregor incision with a chevron incision in the vermillion border [ 7 ], with Mehanna et al later describing an additional zigzag incision to the chin[ 16 ]. These approaches are aimed at reducing the cosmetic and functional morbidity associated with conventional midline lip splits, reducing scar formation, and preserving lip and chin mobility[ 16 , 17 ]. The Robson lip split incision is a lateral modification, to attempt to reduce scar contracture and its associated complications[ 7 , 8 ]. This approach does inevitably damage the branches of the mental and facial nerves travelling across the incision plane[ 7 , 18 ]. The Weber-Ferguson approach is a comparable approach used to split the upper lip for maxillectomy resection and reconstruction, and may be complicated by significant facial scarring, ectropion, and epiphora. Lip sparing approaches are also well described in literature and can be appropriately employed in many cases. The visor approach is one common access technique, undertaken with a mastoid-to-mastoid incision through a mid-neck crease. This approach leads to chin anaesthesia due to bilateral mental nerve sacrifice[ 5 ]. Two retrospective studies compared outcomes of lip splitting incisions with the lip sparing visor technique with no statistical difference in surgical-site complications nor operative duration (p > 0.05) [ 19 , 20 ]. The visor approach can also be combined with lingual release for improved access. Focusing on aesthetic and functional outcomes, Devine et al. retrospectively compared 90 patients that underwent lip-split mandibulotomy with 60 patients undergoing a lingual-release[ 21 ]. Resection margins were similar, while the lip-split cohort had significantly better speech, swallowing, and chewing quality-of-life outcomes (p < 0.05). The poorer functional outcomes were thought to occur secondarily to the lingual release procedure in the visor incision cohort [ 22 ]. Pull-through techniques are another lip-sparing alternative, where the anterior digastric and mylohyoid muscles are detached, and traction sutures are applied to the tongue. Cheng et al. retrospectively compared lip-split surgery with a pull-through approach for T4a tongue and floor of mouth (FOM) cancer resection (n = 91)[ 22 ], noting difficulty with the pull-through technique in cases of limited mouth-opening or those requiring marginal mandibulectomy, and that flap inset was more technically difficult. 24 Transoral laser surgery has also been compared with lip-split mandibulotomy in a small case-match study (n = 48) of oropharyngeal SCC resection with radial forearm free flap reconstruction [ 6 ]. Despite the significant variety in lip-splitting and lip-sparing techniques, there are limited literature comparing the outcomes of midline and lateral lip splits. Using a prospectively collected database of head and neck reconstructive surgical outcomes at a tertiary hospital head and neck reconstructive service, a cohort of 79 lip-split approaches were retrospectively identified for comparative analysis. 2 METHODOLOGY 2.1 Study Population This retrospective review of prospectively collected audit data was approved by the RMH Human Research Ethics Committee (HREC QA2024011), in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments. The prospectively recorded RMH head and neck database was screened by three researchers (PG, MD, and CP) for cases occurring between 16th December 2015, and 1st 12 2022. Of 488 head and neck reconstructive operations performed in this period, 79 cases were identified as having included a lip split procedure. A small number of missing datapoints for time to onset of dietary intake were then identified retrospectively from the Epic Electronic Medical Record (EMR). Further retrospective data collection included the reasons for return to theatre (RTT) and for readmission. Inclusion criteria: head and neck reconstruction for tumour resection, lip split access documented. Exclusion criteria: traumatic reconstruction. 2.2 Statistical Analysis Demographic and clinical characteristics are tabulated descriptively (Table 1 ). Factors associated with complications were analyzed using the Chi 2 test for categorical data, and the Student's t-test and Mann–Whitney U test for continuous data. Variable correlations were assessed using regression analysis. Statistical analyses were performed using SPSS 27, with p values < 0.05 considered statistically significant. 2.3 Case Series In addition to the statistical analysis, a small series of six cases were selected from the 79 total cases, to qualitative illustrate common complications associated with central and lateral lip splits. Patients underwent informed consent for publication of clinical photography (Figs. 3 –6). 3 RESULTS 3.1 Demographics Of 488 head and neck reconstructive operations performed between 16th December 2015, and 1st December 2022, 79 cases were identified as including a lip split procedure (16.2% of total cases). Of the 79 lip split procedures, 35 were lateral lip splits (44.3% of lip split cases) and 44 were central lip splits (55.7%) (Table 1 ). Most patients requiring lip split were male (68.4%) with mean age 62 years and were ASA class 3 (58.9%), with an active or past smoking history (55.7%), and non-diabetic (87.3%). A pre-operative percutaneous endoscopic gastrostomy (PEG) tube was indicated in 15.2% of cases. Operations were predominantly undertaken for malignancy (96.2%), with squamous cell carcinoma excised in 83.5% of cases. Tumours were typically of high T-classification, with 45 cases of T4 cancer (59.2%). Approximately half of cases were clinically node negative at time of resection (52.6%). The mean operative duration was 646 ± 112 minutes. A mandibulotomy was performed in 16 cases (20.3%) with 10 being central mandibulotomies (12.7%) and 6 lateral mandibulotomies (7.6%). A marginal mandibulectomy was performed in 14 cases (17.7%) and segmental mandibulectomies were performed in 38 cases (48.1%) of which 14 cases were segmental mandibulectomy with disarticulation of the temporomandibular joint (17.7%). The resection margins required skin excision in 4 cases (5.1%). Half of cases were reconstructed with soft tissue free flaps (50.6%) and the rest with bony free flaps (49.4%). When demographics were compared between patients that underwent lateral and central lip splits the cohorts were largely comparable. There was a significantly higher mean ASA classification in the lateral lip split cohort (p = 0.025). There was no statistically significant difference in sex, smoking history, diabetes status, or requirement for pre-operative PEG insertion (p > 0.05). The tumour type, clinical T-stage (cT), and clinical N-stage (cN) were also comparable between groups (p > 0.05). If mandibulotomy was performed, the site of mandibulotomy was related to the to the site of lip split (p = 0.002). There were significantly more segmental mandibulectomies in the lateral lip split cohort (p = 0.002). There was no difference in the rate of marginal mandibulectomy (p = 0.904) or skin excision (p = 0.205). There was no difference in the type of flap used (soft tissue or bony free flap; p = 0.918) nor the mean operative duration (p = 0.981). Table 1 Demographic & operative characteristics of included patients according to type of lip split Characteristic (ordinal variables) Total n = 79 (%) Lateral lip split n = 35 (%) Central lip split n = 44 (%) P value (Chi 2 ) Sex Male 54 (68.4) 25 (71.5) 29 (65.9) p = 0.600 Female 25 (31.6) 10 (28.6) 15 (34.1) ASA status 1 3 (4.1) 0 (0) 3 (7.0) p = 0.025 2 27 (37) 7 (23.3) 20 (46.5) 3 43 (58.9) 23 (76.7) 20 (46.5) Smoking history Yes 44 (55.7) 20 (57.1) 24 (54.5) p = 0.817 No 35 (44.3) 15 (42.9) 20 (45.5) Diabetes Yes 10 (12.7) 5 (11.4) 5 (11.4) p = 0.698 No 69 (87.3) 30 (85.7) 39 (88.6) Pre-operative PEG insertion Yes 12 (15.2) 4 (11.4) 8 (18.2) p = 0.406 No 67 (84.8) 31 (88.6) 36 (81.8) Tumour type SCC 66 (83.5) 29 (82.9) 37 (84.1) p = 0.903 Adenocarcinoma 2 (2.5) 1 (2.9) 1 (2.3) Salivary gland carcinoma 5 (6.3) 3 (8.6) 2 (4.5) Sarcoma 2 (2.5) 1 (2.9) 1 (2.3) Ameloblastoma 2 (2.5) 1 (2.9) 1 (2.3) Ameloblastic carcinoma 1 (1.3) 0 (0.0) 1 (2.3) Odontogenic myxoma 1 (1.3) 0 (0.0) 1 (2.3) Malignant tumour Yes 76 (96.2) 34 (97.1) 42 (95.5) p = 0.697 No 3 (3.8) 1 (2.9) 2 (4.5) cT-stage 1 3 (3.9) 2 (5.9) 1 (2.4) p = 0.737 2 17 (22.4) 6 (17.6) 11 (26.2) 3 11 (14.5) 5 (14.7) 6 (14.3) 4 45 (59.2) 21 (61.8) 24 (57.1) cN-stage Negative (N0) 40 (52.6) 15 (44.1) 25 (59.5) p = 0.181 Positive (N1+) 36 (47.4) 19 (55.9) 17 (40.5) Mandibulotomy No 63 (79.7) 29 (82.9) 34 (77.3) p = 0.014 Central 10 (12.7) 1 (2.9) 9 (20.5) Lateral 6 (7.6) 5 (14.3) 1 (2.3) Marginal mandibulectomy Yes 14 (17.7) 6 (17.1) 8 (18.2) p = 0.904 No 65 (82.3) 29 (82.9) 36 (81.8) Segmental mandibulectomy Segmental + disarticulation 14 (17.7) 7 (20.0) 7 (15.9) p = 0.002 Segmental 24 (30.4) 17 (48.6) 7 (15.9) No 41 (51.9) 11 (31.4) 30 (68.2) Skin excision Yes 4 (5.1) 3 (8.6) 1 (2.3) p = 0.205 No 75 (94.9) 32 (91.4) 43 (97.7) Flap type Soft tissue only 40 (50.6) 17 (48.6) 23 (52.3) p = 0.918 Bony 39 (49.4) 18 (51.4) 21 (47.7) Characteristic (continuous variables) Mean ± stdev Mean ± stdev Mean ± stdev P value (t-test) Age (years) 62.0 ± 13.4 65.0 ± 12.8 59.6 ± 13.5 p = 0.076 Operative duration (mins) 646 ± 112 646 ± 118 650 ± 108 p = 0.981 3.2 Lip splits over time The number of total reconstructive cases in the reconstructive head and neck database was relatively consistent over the years studied (mid-2015 to 2022); there was a mean of 61 cases per year with a range of 32 to 79 cases. Figure 2 demonstrates the trend in case load over time, with the subset of central and lateral lip splits highlighted. From 2015 to 2018, predominantly lateral lip splits were performed (67.6%), while from 2019 to 2022 there were predominantly central lip splits (76.2%). 3.3 Outcomes & complications Postoperative outcomes were compared between patients that underwent lateral and central lip splits (Table 2 ). Lateral lip splits were significantly associated with complications within 30 days postoperatively (p = 0.008) and trended towards a higher rate of postoperative collections (40% vs 25%; p = 0.154). Lateral lip split operations had a higher rate of return to theatre within 30 days postoperatively (51.4% vs 25%; p = 0.015). There was a trend to higher mean number of returns to theatre with lateral lip splits (0.86 vs 0.41; p = 0.100). Most returns to theatre were for recipient site complications including collections. There was no significant difference in readmission rates within 30 days (p = 0.802), with most readmissions again secondary to recipient site complications. There was no significant difference in mean length of stay (21.8 vs 21.6 days; p = 0.921), mean days to oral diet commencement (15.2 vs 13.1 days; p = 0.314), nor the rate of oral incontinence documented in follow-up (p = 0.522). Speech intelligibility was also comparable between groups (p = 0.522). Lip and smile outcomes were significantly poorer in the lateral lip split cohort. Lip notching was significantly more common after lateral lip splits (p = 0.012), as was asymmetric smiling (p = 0.009). Table 2 Outcomes according to type of lip split Outcomes (ordinal variables) Total n (%) n = 79 Lateral lip split (%) n = 35 Central lip split (%) n = 44 P value (Chi 2 ) Oral intake prior to discharge Yes 71 (89.9) 31 (88.6) 40 (90.9) p = 0.732 No 8 (10.1) 4 (11.4) 4 (9.1) Any complication (< 30 days postop) Yes 71 (89.9) 35 (100.0) 36 (81.8) p = 0.008 No 8 (10.1) 0 (0.0) 8 (18.2) Post-operative collection (< 30 days) Yes 25 (31.6) 14 (40.0) 11 (25.0) p = 0.154 No 54 (68.4) 21 (60.0) 33 (75.0) Superficial infection (< 30 days) Yes 12 (15.2) 4 (11.4) 8 (18.2) p = 0.406 No 67 (84.8) 31 (88.6) 36 (81.8) Flap failure (< 30 days) Complete 1 (1.3) 1 (2.9) 0 (0.0) p = 0.379 Partial 13 (16.5) 7 (20.0) 6 (13.6) No 65 (82.3) 27 (77.1) 38 (86.4) Return to theatre (< 30 days) Yes 29 (36.7) 18 (51.4) 11 (25.0) p = 0.015 No 50 (63.3) 17 (48.6) 33 (75.0) Return to theatre reason Flap failure 2 (2.5) 1 (2.9) 1 (2.3) p = 0.086 Other recipient site complication 25 (31.6) 16 (45.7) 9 (20.5) Donor complication 1 (1.3) 1 (2.9) 0 (0.0) Positive margins 1 (1.3) 0 (0.0) 1 (2.3) Readmission (< 30 days) Yes 26 (32.9) 11 (31.4) 15 (34.1) p = 0.802 No 53 (67.1) 24 (68.6) 29 (65.9) Readmission reason Flap failure 1 (1.3) 1 (2.9) 0 (0.0) p = 0.313 Other recipient site complication 11 (14.1) 7 (20.0) 4 (9.3) Donor complication 6 (7.7) 1 (2.9) 5 (11.6) Sepsis 1 (1.3) 0 (0.0) 1 (2.3) Pain 1 (1.3) 0 (0.0) 1 (2.3) Malnutrition 4 (5.1) 1 (2.9) 3 (7.0) Trauma 1 (1.3) 1 (2.9) 0 (0.0) Oral incontinence Yes 26 (32.9) 11 (31.4) 15 (34.1) p = 0.522 No 52 (65.8) 23 (65.7) 29 (65.9) Speech Dysarthria 29 (36.7) 13 (37.1) 16 (36.4) p = 0.522 Intelligible 49 (62.0) 21 (60.0) 28 (63.6) Smile Asymmetrical 10 (12.7) 4 (11.4) 6 (13.6) p = 0.009 Normal 22 (27.8) 4 (11.4) 18 (40.9) Lip notching Yes 9 (11.4) 2 (5.7) 7 (15.9) p = 0.012 No 26 (32.9) 7 (20.0) 19 (43.2) Outcome (continuous variables) Mean ± stdev Mean ± stdev Mean ± stdev P value (t-test) Length of stay (days) 21.7 ± 11.5 21.8 ± 11.7 21.6 ± 11.4 p = 0.921 Days to oral diet commencement 14.0 ± 8.6 15.2 ± 9.14 13.1 ± 8.19 p = 0.314 Returns to theatre (n) 0.6 ± 1.2 0.86 ± 1.46 0.41 ± 0.92 p = 0.100 4 CASE SERIES Six of the reviewed cases of lip split access procedures were selected for qualitative discussion in the form of a short case series, to highlight the potential advantages and disadvantages of central and lateral lip split procedures. 4.1 Lateral lip split cases Case 1 An ECOG 1, 71-year-old female smoker with a history of ischaemic heart disease presented to a local otolaryngologist with left-sided tinnitus, bilateral sensorineural hearing loss, and intermittent vertigo. Examination & subsequent biopsy revealed a right parapharyngeal mucoepidermoid carcinoma. Following multidisciplinary meeting, she proceeded to an uncomplicated wide excision with access lateral lip split and mandibulotomy, ipsilateral neck dissection, tracheostomy, and left radial forearm free flap reconstruction. Initial postoperative recovery was complicated by mediastinitis secondary to the tracheostomy. The lateral lip split wound slowly deteriorated and dehisced, requiring return to theatre post-operative day 9. Intraoperatively, purulent material was present over mandibular metalware, which was washed out and directly repaired. Unfortunately, the repair was unsuccessful, requiring 6 further returns to theatre for wash-out and debridement, including further reconstruction with a pectoralis major myocutaneous flap to cover exposed metalware. She was discharged home after a 51-day admission and received post-operative radiotherapy. Figure 2 demonstrates the completed reconstruction three months following primary resection. Case 2 A 60-year-old ECOG 0 woman, with type 2 diabetes and a 10-year smoking history, presented with a twenty-year history of mandible pain, with imaging and biopsy demonstrating a right mandibular mucoepidermoid carcinoma. She proceeded to right segmental mandibulectomy via a lateral lip split incision, partial maxillectomy, ipsilateral neck dissection, tracheostomy, and right fibular free flap. Neck erythema was noted day 5 post-operatively, which improved with intravenous antibiotics. At day 8, a small intra-oral dehiscence was noted at the lip split incision. Operative exploration demonstrated partial flap compromise, requiring further reconstruction with a right radial forearm free flap. The patient was discharged home after 28 days in hospital. At a recent one-year review, she has ongoing issues with speech intelligibility and dribbling secondary to right lower lip paresis and scar notching. Case 3 A 67-year-old ECOG 0 man presented to an oral maxillofacial surgeon with biopsy proven well-differentiated cT2N0 squamous cell carcinoma of left mandibular gingiva. He proceeded to segmental mandibulectomy via a lateral lip split incision, partial maxillectomy, ipsilateral neck dissection, tracheostomy, and fibular free flap reconstruction. Early post-operative course was uncomplicated. A small left neck collection was managed with CT-guided drainage day 12 post-operatively. At two-year follow-up, the patient has mild oropharyngeal dysphagia, incomplete lip seal, but otherwise functional reconstruction, with intelligible speech and tolerating soft diet. 4.2 Central lip split cases Case 4 An ECOG 0 67-year-old man and heavy smoker presented with a two-month history of an exophytic left mandibular alveolus lesion, with incisional biopsy demonstrating well-differentiated squamous cell carcinoma. He proceeded to left segmental mandibulectomy via a central lip split incision, ipsilateral neck dissection, and virtual surgical planned (VSP) right fibular free flap reconstruction. Surgical access was excellent (Fig. 4 ), and postoperative stay was uncomplicated. At two-year review, he has left lower lip paraesthesia, functional swallow, and speech albeit with mildly reduced articulation. Case 5 A 46-year-old male, ECOG 0, ex-smoker presented to the head and neck service with a painful left tongue lesion. Biopsy demonstrated poorly differentiated cT2N0 squamous cell carcinoma, so he proceeded to left subtotal glossectomy via central lip split and mandibulotomy, bilateral neck dissection, and right anterolateral thigh free flap reconstruction (Fig. 5 ). The early post-operative stay was uncomplicated. Two years post-operatively he has good oral intake and generally intelligible speech, with slowly improving dribbling. He remains self-conscious of his appearance secondary to external scarring of the lip, chin, and neck. Case 6 An 82-year-old ECOG 1, heavy smoker presented to the head and neck service with a left retromolar trigone T3N1 squamous cell carcinoma, proceeding to left segmental mandibulectomy via a central lip split incision, partial maxillectomy, ipsilateral neck dissection, tracheostomy, and right fibular free flap reconstruction. The post-operative course was complicated by partial flap failure requiring four returns to theatre and further reconstruction with a myocutaneous pectoralis major free flap. Functional outcomes were poor. Twelve months postoperatively, the patient had poor speech and oral intake, with dependence on percutaneous endoscopic gastrostomy (PEG) feeding, oral incompetence, and an oronasal fistula. Botulinum toxin injection of the submandibular gland was partially successful in reducing drooling. 4 DISCUSSION A recent systematic review reported the outcomes of 3,872 patients (54 studies) that underwent lip-split and mandibulotomy access procedures[ 2 ]. The complication rates were low, with 5.4% osteoradionecrosis, 5.7% fistula formation, and 4.9% non-union. The authors concluded that lip-split mandibulotomy has an acceptable complication rate and should “definitely remain” in use today, despite many proposed lip-sparing approaches that may not provide adequate operative exposure for safe tumour clearance[ 8 ]. A small study evaluated patient satisfaction after central and lateral lip incisions, finding the chevron-chin modification of the McGregor midline approach to have the most optimal outcomes[ 23 ]. To our knowledge there are no other studies comparing midline and lateral lip-split outcomes regarding immediate complications. In our study, 16% of head and neck reconstructive procedures included a lip split during the seven-year study period. Earlier in the study period (2015 to 2018), predominantly lateral lip splits were performed (67.6%), while later in the study (2019 to 2022) there were predominantly central lip splits (73.8%). Lateral lip splits were significantly associated with postoperative complications (p = 0.048), including double the rate of returns to theatre (50.0% vs 25.6%; p = 0.025). Most returns to theatre were for recipient site complications (89% of returns to theatre) including collections. There was no significant difference between the lip split cohorts in readmission rates (p = 0.479), mean length of stay (21.9 vs 21.5 days; p = 0.870) nor mean days to oral diet commencement (14.9 vs 13.2 days; p = 0.417). There was no statistical difference in the type of flap used (p = 0.918) between cohorts. Six cases were selected from the cohort to discuss the potential benefits and pitfalls associated with central and lateral lip splits. Cases 1 and 2 highlight the potential for severe morbidity following early lateral lip split wound breakdown and dehiscence, while case 6 demonstrates similarly poor outcomes following a central lip split procedure. Cases 3 and 5 demonstrate more tolerable (but still troublesome) issues that may still result after lateral lip split, including incomplete lip seal and scarring. Lateral lip splits provide excellent access to posterior structures in the oral cavity and oropharynx; cases 4 and 5 exemplify the capacity for central lip splits to provide appropriate surgical access. Lateral lip splits facilitate excellent access to many tumours of the oral cavity, including those located posteriorly (e.g. oropharynx) or laterally. However, due to the lateralised neurovascular supply of the face, lateral lip splits inevitably lead to injury to the branches of the facial and mental nerves, and the inferior and superior labial vessels [ 8 ]. This is particularly important if the contralateral labial vessel if small or absent, as the lip will be de-vascularised, leading to poor wound healing. Central lip splits preserve the mental and marginal mandibular nerves, reducing risk of paraesthesia. However, scarring following central lip incisions can lead to notching, fistula, and reduced lip mobility[ 8 ]. Further, in cases involving resections in the anterior oral cavity and mandible, residual central lip tissue may be devascularised by subsequent tumour resection. Appropriate selection of midline or lateral lip splitting approach should therefore consider tumour location and resection margins, patient comorbidities and preferences, and surgeon preferences. For both central and lateral lip-splitting approaches, careful approximation of skin and mucosal with layered sutures is important for functional and aesthetic outcomes. There are several limitations to our study. Primarily the retrospective design limits direct comparison of groups. While the central and lateral lip split cohorts were largely comparable, there was a trend to higher ASA classification in the lateral lip split cohort (p = 0.046), and there were significantly more segmental mandibulectomies in the lateral lip split cohort (p = 0.005). This suggests a more complex cohort of patients receiving lateral lip splits, which may contribute to the trends to poorer outcomes in the lateral lip split cohort. 5 CONCLUSION The excellent access to resection and reconstruction of posterior oral and oropharyngeal tissues provided by lip splitting is unlikely to be superseded by alternative approaches. Given its ongoing role in head and neck surgery, optimisation of the lip split technique is warranted. This study of 79 patients undergoing lip-split access procedures for oral and oropharyngeal tumours demonstrates an association of lateral lip split access (e.g., the Robson approach) with poorer outcomes. Randomised prospective data is needed to compare approaches. This research should focus on surgical outcomes (including margin clearance, locoregional recurrence, and complications), functional outcomes (including speech and swallowing), and cosmetic outcomes including patient satisfaction. Declarations CONFLICT OF INTEREST All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. There is no funding to declare. CONTRIBUTIONS All authors contributed to the study conception and design, supervised by Felix Sim & Anand Ramakrishnan. Material preparation, data collection and analysis were performed by Peter Gearing, Maxim Devine, and Siyuan Pang. The first draft of the manuscript was written by Peter Gearing and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. ETHICS DECLARATION & CONSENT This retrospective chart review study involving human participants was in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments. The Royal Melbourne Hospital Human Research Ethics Committee (HREC QA2024011) approved this study. The authors affirm that human participants provided informed consent for publication of the images in Figures 3-6. Informed consent was obtained from all individual participants included in the study. The data that support the findings of this study are available from the corresponding author upon reasonable request. References Wang Y, Zhou B, Liu Z, Rui T, Pan C, Chen W (2022) Modified submandibular mandibulotomy approach without lip-splitting in tongue cancer. J Plast Reconstr Aesthet Surg 75:3877–3903. https://doi.org/https://dx.doi.org/10.1016/j.bjps.2022.08.074 Hedayat F, Jerry Htwe KK, Vassiliou L-V, Kyzas P (2022) Morbidity related to the lip-split mandibulotomy approach: a systematic and narrative review. Br J Oral Maxillofac Surg 60:430–436. https://doi.org/https://dx.doi.org/10.1016/j.bjoms.2021.09.019 Liu C-J, Fang K-H, Chang C-C, Lin E-T, Chang G-H, Shen J-H, Chen Y-T, Tsai Y-T (2019) Application of parachute technique for free flap reconstruction in advanced tongue cancer after ablation without lip-jaw splitting: A retrospective case study. Medicine 98:e16728. https://doi.org/https://dx.doi.org/10.1097/MD.0000000000016728 Li W, Li R, Safdar J, Huang S, Xu Z, Tan X, Sun C (2014) Modified visor approach applied to total or subtotal glossectomy and reconstruction: avoidance of lip splitting and mandibulotomy and cutting off mental nerve. Tumour Biol 35:7847–7852. https://doi.org/https://dx.doi.org/10.1007/s13277-014-2036-4 Shah JP (2007) Surgical Approaches to the Oral Cavity Primary and Neck. Int J Radiation Oncology*Biology*Physics 69:S15–S18. https://doi.org/10.1016/j.ijrobp.2007.03.069 Williams CE, Kinshuck AJ, Derbyshire SG, Upile N, Tandon S, Roland NJ, Jackson SR, Rodrigues J, Husband DJ, Lancaster JL, Jones TM (2014) Transoral laser resection versus lip-split mandibulotomy in the management of oropharyngeal squamous cell carcinoma (OPSCC): a case match study. Eur Arch Otorhinolaryngol 271:367–372. https://doi.org/https://dx.doi.org/10.1007/s00405-013-2501-5 Bhatt V, Praveen P, Green J, Grime PD (2009) A modified lip split incision. J Oral Maxillofac Surg 67:229–230. https://doi.org/https://dx.doi.org/10.1016/j.joms.2008.07.007 Baek C-H, Lee S-W, Jeong H-S (2006) New modification of the mandibulotomy approach without lip splitting. Head Neck 28:580–586. https://doi.org/10.1002/hed.20373 Babin R, Calcaterra TC (1976) The lip-splitting approach to resection of oropharyngeal cancer. J Surg Oncol 8:433–436. https://doi.org/10.1002/jso.2930080510 Butlin HT (1885) Diseases of the tongue. Clinical manuals for practitioners and students of medicine Pitak-Arnnop P, Witohendro LK, Tangmanee C, Subbalekha K, Sirintawat N, Auychai P, Meningaud J-P, Neff A (2022) Benefit-risk appraisal of lip-split mandibular swing vs. transoral approaches to posterior oral/oropharyngeal carcinomas using number needed to treat, to harm, and likelihood to be helped or harmed. Surg Oncol 44:101837. https://doi.org/https://dx.doi.org/10.1016/j.suronc.2022.101837 Hartig G (2011) Avoidance of lip split: a response. Microsurgery 31:353–354. https://doi.org/https://dx.doi.org/10.1002/micr.20875 Stathopoulos P, Kaplani MED, Kostis N, Igoumenakis D, Smith WP (2021) The impact of lip-split mandibulotomy on patients treated for pT2 oral tongue squamous cell carcinoma: a study of 224 patients. Oral Maxillofac Surg 25:313–318. https://doi.org/https://dx.doi.org/10.1007/s10006-020-00918-8 Pitak-Arnnop P (2023) Is lip-split mandibulotomy approach to posterior oral cavity and oropharyngeal carcinomas really obsolete? J Plast Reconstr Aesthet Surg 76:301–302. https://doi.org/https://dx.doi.org/10.1016/j.bjps.2022.10.042 Chen W-L, Zhou B, Huang Z-X, Chen R, Hong L, Dong X-Y (2023) Maxillectomy and Flap Reconstruction of Maxillary Defects After Cancer Ablation Through the Lip-Split Parasymphyseal Mandibulotomy Approach in Patients With Advanced-Stage Maxillary Malignant Tumors. https://doi.org/https://dx.doi.org/10.1097/SCS.0000000000009221 . J Craniofac Surg Mehanna P, Devine J, McMahon J (2010) Lip split and mandibulotomy modifications. Br J Oral Maxillofac Surg 48:314–315. https://doi.org/https://dx.doi.org/10.1016/j.bjoms.2009.06.231 Blackburn T, Re P, Mehanna J, Devine J, McMahon (2010) Lip split and mandibulotomy modifications [Br. J. Oral Maxillofac. Surg. 48 (2010) 314–315]. Br J Oral Maxillofac Surg 48:561. https://doi.org/https://dx.doi.org/10.1016/j.bjoms.2010.06.010 Hayter JP, Vaughan ED, Brown JS (1996) Aesthetic lip splits. Br J Oral Maxillofac Surg 34:432–435 Cohen LE, Morrison KA, Taylor E, Jin J, Spector JA, Caruana S, Rohde CH (2018) Functional and Aesthetic Outcomes in Free Flap Reconstruction of Intraoral Defects With Lip-Split Versus Non-Lip-Split Incisions. Ann Plast Surg 80:S150–S155. https://doi.org/https://dx.doi.org/10.1097/SAP.0000000000001373 Cilento BW, Izzard M, Weymuller EA, Futran N (2007) Comparison of approaches for oral cavity cancer resection: lip-split versus visor flap. Otolaryngol Head Neck Surg 137:428–432 Devine JC, Rogers SN, McNally D, Brown JS, Vaughan ED (2001) A comparison of aesthetic, functional and patient subjective outcomes following lip-split mandibulotomy and mandibular lingual releasing access procedures. Int J Oral Maxillofac Surg 30:199–204 Cheng S-J, Ko H-H, Lee J-J, Kok S-H (2018) Comparison of long-term outcomes between pull-through resection and mandibular lip-split surgery for T4a tongue/floor of mouth cancers. Head Neck 40:144–153. https://doi.org/https://dx.doi.org/10.1002/hed.24994 Rapidis AD, Valsamis S, Anterriotis DA, Skouteris CA (2001) Functional and aesthetic results of various lip-splitting incisions: A clinical analysis of 60 cases. J Oral Maxillofac Surg 59:1292–1296. https://doi.org/10.1053/joms.2001.27517 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Mar, 2025 Read the published version in Oral and Maxillofacial Surgery → Version 1 posted Editorial decision: Revision requested 28 Dec, 2024 Reviews received at journal 30 May, 2024 Reviewers agreed at journal 30 May, 2024 Reviewers agreed at journal 30 Apr, 2024 Reviewers invited by journal 13 Mar, 2024 Submission checks completed at journal 12 Mar, 2024 Editor assigned by journal 12 Mar, 2024 First submitted to journal 10 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4062093","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":279357706,"identity":"d9c77b27-56e3-4d92-8f6e-bad7850d0d5e","order_by":0,"name":"Peter Gearing","email":"","orcid":"","institution":"The Royal Melbourne Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Gearing","suffix":""},{"id":279357709,"identity":"14c9128a-c232-40b9-bee2-ac0fb9eeed41","order_by":1,"name":"Maxim Devine","email":"","orcid":"","institution":"The Royal Melbourne Hospital","correspondingAuthor":false,"prefix":"","firstName":"Maxim","middleName":"","lastName":"Devine","suffix":""},{"id":279357711,"identity":"f097d243-decc-413e-9a70-b7dd9d41e4ca","order_by":2,"name":"Siyuan Pang","email":"","orcid":"","institution":"The Royal Melbourne Hospital","correspondingAuthor":false,"prefix":"","firstName":"Siyuan","middleName":"","lastName":"Pang","suffix":""},{"id":279357712,"identity":"8a482932-6d7f-43f4-95db-165bca157c01","order_by":3,"name":"Felix Sim","email":"","orcid":"","institution":"The Royal Melbourne Hospital","correspondingAuthor":false,"prefix":"","firstName":"Felix","middleName":"","lastName":"Sim","suffix":""},{"id":279357713,"identity":"3c2e11ae-f175-4642-8523-803a8691dcb9","order_by":4,"name":"Anand Ramakrishnan","email":"data:image/png;base64,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","orcid":"","institution":"The Royal Melbourne Hospital","correspondingAuthor":true,"prefix":"","firstName":"Anand","middleName":"","lastName":"Ramakrishnan","suffix":""}],"badges":[],"createdAt":"2024-03-10 05:44:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4062093/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4062093/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10006-025-01355-1","type":"published","date":"2025-03-06T15:58:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52786849,"identity":"0f1d1578-109b-4d85-9039-97c85813e244","added_by":"auto","created_at":"2024-03-15 18:55:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":105295,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic representations of lip split incisions (source: Bhatt et al [7])\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4062093/v1/7f3c6025f17e463cef07ab28.png"},{"id":52786916,"identity":"1e3f2350-354c-4b12-9853-718dc7fc76a5","added_by":"auto","created_at":"2024-03-15 18:55:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39547,"visible":true,"origin":"","legend":"\u003cp\u003eLip split procedures as a proportion of total procedures per year\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4062093/v1/40b066fa6e5f03286e0bfca1.png"},{"id":52786876,"identity":"d7448557-fd16-4cd6-a57e-e2cf4a0ee333","added_by":"auto","created_at":"2024-03-15 18:55:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":325872,"visible":true,"origin":"","legend":"\u003cp\u003eClinical photography (Case 1) at three-month postoperative review\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4062093/v1/e914b2e1624e9de5d4b2538c.png"},{"id":52786970,"identity":"8c4e9d3e-1a94-4c42-b35f-f15affbf6120","added_by":"auto","created_at":"2024-03-15 18:55:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":391855,"visible":true,"origin":"","legend":"\u003cp\u003eClinical photography (Case 3) at one month review\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4062093/v1/29efdd8fa4274e61e0c00206.png"},{"id":52786912,"identity":"44543e71-d42f-4a42-8432-540d30002472","added_by":"auto","created_at":"2024-03-15 18:55:22","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":457981,"visible":true,"origin":"","legend":"\u003cp\u003eClinical photography (Case 4) demonstrating healed central lip split scar (McGregor incision)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4062093/v1/91209c49a2ccbfc236d7dbb8.png"},{"id":52786869,"identity":"d7466def-8c10-4d95-8e6a-9c38f7e3d428","added_by":"auto","created_at":"2024-03-15 18:55:16","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":740198,"visible":true,"origin":"","legend":"\u003cp\u003eintraoperative clinical photography demonstrating excellent surgical access for resection and reconstruction (left) and completed soft tissue reconstruction (right) following central lip split incision (McGregor incision)\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-4062093/v1/10dd7ffbfcebafaeb9f8413e.png"},{"id":78190692,"identity":"aaeff546-c1fd-4ed6-b905-4da53bc6b1e7","added_by":"auto","created_at":"2025-03-10 19:50:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2902324,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4062093/v1/ecfdd6f1-36c3-4f08-9ab7-f0c1203a4ec4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Lip Split: A Retrospective Outcomes Study and Case Series following Central and Lateral Lip Split Access for Head and Neck Reconstructive Surgery","fulltext":[{"header":"1 BACKGROUND","content":"\u003cp\u003eSurgical resection of oral cancers is the mainstay of treatment, with clear margins strongly associated with improved prognosis[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Planning access for excision and reconstruction of oral cavity cancers requires balancing of the advantages of extensive incisions which confer unparalleled visibility, hence aiding both resection and reconstruction, with the morbidity, both functional and cosmetic, of such incisions. The cramped anatomical environment provides operative challenges for accessing the posterior structures of the oral cavity and oropharynx, and the vasculature required for anastomosis and inset of free vascularized flaps[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Purely transoral approaches are useful and appropriate for many anterior resections and reconstructions[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Where transoral approaches are not technically viable or appropriate for obtaining clear pathological margins or inset of free flaps, various alternative approaches have been proposed. These include the lip-split mandibulotomy approach (LSMA), the modified visor approach with a drop-down of the tongue [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFirst described in 1836 by Roux and popularised in the 1970s, lip splitting approaches to the oral cavity provide significantly improved access for R\u003csub\u003e0\u003c/sub\u003e tumour resection (i.e., microscopically clear margins)[\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], with excellent visualization and handling of posterior structures[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As recent literature has placed the lip-split (with or without mandibulotomy) approaches as less favorable in lieu of less invasive approaches[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], lip split operations have fallen in use over time[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Nevertheless, the lip-split remains an important tool for resection and reconstruction of many difficult to access oral and oropharyngeal tumors that may be inappropriate for alternative approaches due to anatomical or technical reasons[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Further, with the advent of free flap microsurgical reconstruction, lip split access assists deep intra-oral and pharyngeal flap inset and microsurgical vascular anastomosis[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSelecting the optimal approach to splitting the lip is critical. Various incisions have been proposed in literature, including the Roux-Trotter incision, McGregor incision, the Robson incision (Fig.\u0026nbsp;1), and the zigzag incision[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Hayter et al describe a modification of the McGregor incision with a chevron incision in the vermillion border [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], with Mehanna et al later describing an additional zigzag incision to the chin[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These approaches are aimed at reducing the cosmetic and functional morbidity associated with conventional midline lip splits, reducing scar formation, and preserving lip and chin mobility[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The Robson lip split incision is a lateral modification, to attempt to reduce scar contracture and its associated complications[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This approach does inevitably damage the branches of the mental and facial nerves travelling across the incision plane[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The Weber-Ferguson approach is a comparable approach used to split the upper lip for maxillectomy resection and reconstruction, and may be complicated by significant facial scarring, ectropion, and epiphora.\u003c/p\u003e \u003cp\u003eLip sparing approaches are also well described in literature and can be appropriately employed in many cases. The visor approach is one common access technique, undertaken with a mastoid-to-mastoid incision through a mid-neck crease. This approach leads to chin anaesthesia due to bilateral mental nerve sacrifice[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Two retrospective studies compared outcomes of lip splitting incisions with the lip sparing visor technique with no statistical difference in surgical-site complications nor operative duration (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The visor approach can also be combined with lingual release for improved access. Focusing on aesthetic and functional outcomes, Devine et al. retrospectively compared 90 patients that underwent lip-split mandibulotomy with 60 patients undergoing a lingual-release[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Resection margins were similar, while the lip-split cohort had significantly better speech, swallowing, and chewing quality-of-life outcomes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The poorer functional outcomes were thought to occur secondarily to the lingual release procedure in the visor incision cohort [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePull-through techniques are another lip-sparing alternative, where the anterior digastric and mylohyoid muscles are detached, and traction sutures are applied to the tongue. Cheng et al. retrospectively compared lip-split surgery with a pull-through approach for T4a tongue and floor of mouth (FOM) cancer resection (n\u0026thinsp;=\u0026thinsp;91)[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], noting difficulty with the pull-through technique in cases of limited mouth-opening or those requiring marginal mandibulectomy, and that flap inset was more technically difficult. \u003csup\u003e24\u003c/sup\u003eTransoral laser surgery has also been compared with lip-split mandibulotomy in a small case-match study (n\u0026thinsp;=\u0026thinsp;48) of oropharyngeal SCC resection with radial forearm free flap reconstruction [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the significant variety in lip-splitting and lip-sparing techniques, there are limited literature comparing the outcomes of midline and lateral lip splits. Using a prospectively collected database of head and neck reconstructive surgical outcomes at a tertiary hospital head and neck reconstructive service, a cohort of 79 lip-split approaches were retrospectively identified for comparative analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"2 METHODOLOGY","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Population\u003c/h2\u003e \u003cp\u003e This retrospective review of prospectively collected audit data was approved by the RMH Human Research Ethics Committee (HREC QA2024011), in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments. The prospectively recorded RMH head and neck database was screened by three researchers (PG, MD, and CP) for cases occurring between 16th December 2015, and 1st 12 2022. Of 488 head and neck reconstructive operations performed in this period, 79 cases were identified as having included a lip split procedure.\u003c/p\u003e \u003cp\u003eA small number of missing datapoints for time to onset of dietary intake were then identified retrospectively from the \u003cem\u003eEpic\u003c/em\u003e Electronic Medical Record (EMR). Further retrospective data collection included the reasons for return to theatre (RTT) and for readmission.\u003c/p\u003e \u003cp\u003eInclusion criteria: head and neck reconstruction for tumour resection, lip split access documented.\u003c/p\u003e \u003cp\u003eExclusion criteria: traumatic reconstruction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Statistical Analysis\u003c/h2\u003e \u003cp\u003eDemographic and clinical characteristics are tabulated descriptively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Factors associated with complications were analyzed using the Chi\u003csup\u003e2\u003c/sup\u003e test for categorical data, and the Student's t-test and Mann\u0026ndash;Whitney U test for continuous data. Variable correlations were assessed using regression analysis. Statistical analyses were performed using SPSS 27, with p values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Case Series\u003c/h2\u003e \u003cp\u003eIn addition to the statistical analysis, a small series of six cases were selected from the 79 total cases, to qualitative illustrate common complications associated with central and lateral lip splits. Patients underwent informed consent for publication of clinical photography (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;6).\u003c/p\u003e \u003c/div\u003e"},{"header":"3 RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Demographics\u003c/h2\u003e \u003cp\u003eOf 488 head and neck reconstructive operations performed between 16th December 2015, and 1st December 2022, 79 cases were identified as including a lip split procedure (16.2% of total cases). Of the 79 lip split procedures, 35 were lateral lip splits (44.3% of lip split cases) and 44 were central lip splits (55.7%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most patients requiring lip split were male (68.4%) with mean age 62 years and were ASA class 3 (58.9%), with an active or past smoking history (55.7%), and non-diabetic (87.3%). A pre-operative percutaneous endoscopic gastrostomy (PEG) tube was indicated in 15.2% of cases. Operations were predominantly undertaken for malignancy (96.2%), with squamous cell carcinoma excised in 83.5% of cases. Tumours were typically of high T-classification, with 45 cases of T4 cancer (59.2%). Approximately half of cases were clinically node negative at time of resection (52.6%). The mean operative duration was 646\u0026thinsp;\u0026plusmn;\u0026thinsp;112 minutes. A mandibulotomy was performed in 16 cases (20.3%) with 10 being central mandibulotomies (12.7%) and 6 lateral mandibulotomies (7.6%). A marginal mandibulectomy was performed in 14 cases (17.7%) and segmental mandibulectomies were performed in 38 cases (48.1%) of which 14 cases were segmental mandibulectomy with disarticulation of the temporomandibular joint (17.7%). The resection margins required skin excision in 4 cases (5.1%). Half of cases were reconstructed with soft tissue free flaps (50.6%) and the rest with bony free flaps (49.4%).\u003c/p\u003e \u003cp\u003eWhen demographics were compared between patients that underwent lateral and central lip splits the cohorts were largely comparable. There was a significantly higher mean ASA classification in the lateral lip split cohort (p\u0026thinsp;=\u0026thinsp;0.025). There was no statistically significant difference in sex, smoking history, diabetes status, or requirement for pre-operative PEG insertion (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The tumour type, clinical T-stage (cT), and clinical N-stage (cN) were also comparable between groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). If mandibulotomy was performed, the site of mandibulotomy was related to the to the site of lip split (p\u0026thinsp;=\u0026thinsp;0.002). There were significantly more segmental mandibulectomies in the lateral lip split cohort (p\u0026thinsp;=\u0026thinsp;0.002). There was no difference in the rate of marginal mandibulectomy (p\u0026thinsp;=\u0026thinsp;0.904) or skin excision (p\u0026thinsp;=\u0026thinsp;0.205). There was no difference in the type of flap used (soft tissue or bony free flap; p\u0026thinsp;=\u0026thinsp;0.918) nor the mean operative duration (p\u0026thinsp;=\u0026thinsp;0.981).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic \u0026amp; operative characteristics of included patients according to type of lip split\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristic (ordinal variables)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;79 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLateral lip split\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;35 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral lip split\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;44 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value (Chi\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (71.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (34.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eASA status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (46.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (58.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (76.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (46.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (55.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.698\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 (87.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39 (88.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePre-operative PEG insertion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.406\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (84.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (88.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (81.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eTumour type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (83.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (82.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (84.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.903\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSalivary gland carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmeloblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmeloblastic carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdontogenic myxoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMalignant tumour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (96.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (97.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42 (95.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ecT-stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.737\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (26.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (59.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (61.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ecN-stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative (N0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.181\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive (N1+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (40.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMandibulotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (79.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (82.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 (77.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (20.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarginal mandibulectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.904\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (82.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (81.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSegmental mandibulectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSegmental\u0026thinsp;+\u0026thinsp;disarticulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSegmental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (68.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSkin excision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (94.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (91.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43 (97.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFlap type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSoft tissue only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (50.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBony\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (49.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (47.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristic (continuous variables)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;stdev\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;stdev\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;stdev\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eP value (t-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.0\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOperative duration (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e646\u0026thinsp;\u0026plusmn;\u0026thinsp;112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e646\u0026thinsp;\u0026plusmn;\u0026thinsp;118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e650\u0026thinsp;\u0026plusmn;\u0026thinsp;108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.981\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Lip splits over time\u003c/h2\u003e \u003cp\u003eThe number of total reconstructive cases in the reconstructive head and neck database was relatively consistent over the years studied (mid-2015 to 2022); there was a mean of 61 cases per year with a range of 32 to 79 cases. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the trend in case load over time, with the subset of central and lateral lip splits highlighted. From 2015 to 2018, predominantly lateral lip splits were performed (67.6%), while from 2019 to 2022 there were predominantly central lip splits (76.2%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Outcomes \u0026amp; complications\u003c/h2\u003e \u003cp\u003ePostoperative outcomes were compared between patients that underwent lateral and central lip splits (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Lateral lip splits were significantly associated with complications within 30 days postoperatively (p\u0026thinsp;=\u0026thinsp;0.008) and trended towards a higher rate of postoperative collections (40% vs 25%; p\u0026thinsp;=\u0026thinsp;0.154). Lateral lip split operations had a higher rate of return to theatre within 30 days postoperatively (51.4% vs 25%; p\u0026thinsp;=\u0026thinsp;0.015). There was a trend to higher mean number of returns to theatre with lateral lip splits (0.86 vs 0.41; p\u0026thinsp;=\u0026thinsp;0.100). Most returns to theatre were for recipient site complications including collections. There was no significant difference in readmission rates within 30 days (p\u0026thinsp;=\u0026thinsp;0.802), with most readmissions again secondary to recipient site complications. There was no significant difference in mean length of stay (21.8 vs 21.6 days; p\u0026thinsp;=\u0026thinsp;0.921), mean days to oral diet commencement (15.2 vs 13.1 days; p\u0026thinsp;=\u0026thinsp;0.314), nor the rate of oral incontinence documented in follow-up (p\u0026thinsp;=\u0026thinsp;0.522). Speech intelligibility was also comparable between groups (p\u0026thinsp;=\u0026thinsp;0.522). Lip and smile outcomes were significantly poorer in the lateral lip split cohort. Lip notching was significantly more common after lateral lip splits (p\u0026thinsp;=\u0026thinsp;0.012), as was asymmetric smiling (p\u0026thinsp;=\u0026thinsp;0.009).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes according to type of lip split\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOutcomes (ordinal variables)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal n (%)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;79\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLateral lip split (%)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral lip split (%)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;44\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value (Chi\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOral intake prior to discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (89.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (88.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40 (90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAny complication\u003c/p\u003e \u003cp\u003e(\u0026lt;\u0026thinsp;30 days postop)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (89.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (18.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost-operative collection (\u0026lt;\u0026thinsp;30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.154\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (75.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSuperficial infection (\u0026lt;\u0026thinsp;30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.406\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (84.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (88.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (81.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFlap failure\u003c/p\u003e \u003cp\u003e(\u0026lt;\u0026thinsp;30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.379\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePartial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (13.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (77.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (86.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReturn to theatre\u003c/p\u003e \u003cp\u003e(\u0026lt;\u0026thinsp;30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (63.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (75.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eReturn to theatre reason\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFlap failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther recipient site complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (45.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (20.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDonor complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive margins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReadmission\u003c/p\u003e \u003cp\u003e(\u0026lt;\u0026thinsp;30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.802\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (67.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (68.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (65.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eReadmission reason\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFlap failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.313\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther recipient site complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDonor complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMalnutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOral incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (65.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (65.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSpeech\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDysarthria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (37.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntelligible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (62.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (63.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsymmetrical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (40.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLip notching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (43.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOutcome (continuous variables)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;stdev\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;stdev\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;stdev\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eP value (t-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLength of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.921\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDays to oral diet commencement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eReturns to theatre (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e4 CASE SERIES\u003c/h3\u003e\n\u003cp\u003eSix of the reviewed cases of lip split access procedures were selected for qualitative discussion in the form of a short case series, to highlight the potential advantages and disadvantages of central and lateral lip split procedures.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Lateral lip split cases\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCase 1\u003c/strong\u003e \u003cp\u003eAn ECOG 1, 71-year-old female smoker with a history of ischaemic heart disease presented to a local otolaryngologist with left-sided tinnitus, bilateral sensorineural hearing loss, and intermittent vertigo. Examination \u0026amp; subsequent biopsy revealed a right parapharyngeal mucoepidermoid carcinoma. Following multidisciplinary meeting, she proceeded to an uncomplicated wide excision with access lateral lip split and mandibulotomy, ipsilateral neck dissection, tracheostomy, and left radial forearm free flap reconstruction. Initial postoperative recovery was complicated by mediastinitis secondary to the tracheostomy. The lateral lip split wound slowly deteriorated and dehisced, requiring return to theatre post-operative day 9. Intraoperatively, purulent material was present over mandibular metalware, which was washed out and directly repaired. Unfortunately, the repair was unsuccessful, requiring 6 further returns to theatre for wash-out and debridement, including further reconstruction with a pectoralis major myocutaneous flap to cover exposed metalware. She was discharged home after a 51-day admission and received post-operative radiotherapy. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the completed reconstruction three months following primary resection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 2\u003c/strong\u003e \u003cp\u003eA 60-year-old ECOG 0 woman, with type 2 diabetes and a 10-year smoking history, presented with a twenty-year history of mandible pain, with imaging and biopsy demonstrating a right mandibular mucoepidermoid carcinoma. She proceeded to right segmental mandibulectomy via a lateral lip split incision, partial maxillectomy, ipsilateral neck dissection, tracheostomy, and right fibular free flap. Neck erythema was noted day 5 post-operatively, which improved with intravenous antibiotics. At day 8, a small intra-oral dehiscence was noted at the lip split incision. Operative exploration demonstrated partial flap compromise, requiring further reconstruction with a right radial forearm free flap. The patient was discharged home after 28 days in hospital. At a recent one-year review, she has ongoing issues with speech intelligibility and dribbling secondary to right lower lip paresis and scar notching.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 3\u003c/strong\u003e \u003cp\u003eA 67-year-old ECOG 0 man presented to an oral maxillofacial surgeon with biopsy proven well-differentiated cT2N0 squamous cell carcinoma of left mandibular gingiva. He proceeded to segmental mandibulectomy via a lateral lip split incision, partial maxillectomy, ipsilateral neck dissection, tracheostomy, and fibular free flap reconstruction. Early post-operative course was uncomplicated. A small left neck collection was managed with CT-guided drainage day 12 post-operatively. At two-year follow-up, the patient has mild oropharyngeal dysphagia, incomplete lip seal, but otherwise functional reconstruction, with intelligible speech and tolerating soft diet.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Central lip split cases\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCase 4\u003c/strong\u003e \u003cp\u003eAn ECOG 0 67-year-old man and heavy smoker presented with a two-month history of an exophytic left mandibular alveolus lesion, with incisional biopsy demonstrating well-differentiated squamous cell carcinoma. He proceeded to left segmental mandibulectomy via a central lip split incision, ipsilateral neck dissection, and virtual surgical planned (VSP) right fibular free flap reconstruction. Surgical access was excellent (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e), and postoperative stay was uncomplicated. At two-year review, he has left lower lip paraesthesia, functional swallow, and speech albeit with mildly reduced articulation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 5\u003c/strong\u003e \u003cp\u003eA 46-year-old male, ECOG 0, ex-smoker presented to the head and neck service with a painful left tongue lesion. Biopsy demonstrated poorly differentiated cT2N0 squamous cell carcinoma, so he proceeded to left subtotal glossectomy via central lip split and mandibulotomy, bilateral neck dissection, and right anterolateral thigh free flap reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The early post-operative stay was uncomplicated. Two years post-operatively he has good oral intake and generally intelligible speech, with slowly improving dribbling. He remains self-conscious of his appearance secondary to external scarring of the lip, chin, and neck.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 6\u003c/strong\u003e \u003cp\u003eAn 82-year-old ECOG 1, heavy smoker presented to the head and neck service with a left retromolar trigone T3N1 squamous cell carcinoma, proceeding to left segmental mandibulectomy via a central lip split incision, partial maxillectomy, ipsilateral neck dissection, tracheostomy, and right fibular free flap reconstruction. The post-operative course was complicated by partial flap failure requiring four returns to theatre and further reconstruction with a myocutaneous pectoralis major free flap. Functional outcomes were poor. Twelve months postoperatively, the patient had poor speech and oral intake, with dependence on percutaneous endoscopic gastrostomy (PEG) feeding, oral incompetence, and an oronasal fistula. Botulinum toxin injection of the submandibular gland was partially successful in reducing drooling.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 DISCUSSION","content":"\u003cp\u003eA recent systematic review reported the outcomes of 3,872 patients (54 studies) that underwent lip-split and mandibulotomy access procedures[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The complication rates were low, with 5.4% osteoradionecrosis, 5.7% fistula formation, and 4.9% non-union. The authors concluded that lip-split mandibulotomy has an acceptable complication rate and should \u0026ldquo;definitely remain\u0026rdquo; in use today, despite many proposed lip-sparing approaches that may not provide adequate operative exposure for safe tumour clearance[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A small study evaluated patient satisfaction after central and lateral lip incisions, finding the chevron-chin modification of the McGregor midline approach to have the most optimal outcomes[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. To our knowledge there are no other studies comparing midline and lateral lip-split outcomes regarding immediate complications.\u003c/p\u003e \u003cp\u003eIn our study, 16% of head and neck reconstructive procedures included a lip split during the seven-year study period. Earlier in the study period (2015 to 2018), predominantly lateral lip splits were performed (67.6%), while later in the study (2019 to 2022) there were predominantly central lip splits (73.8%). Lateral lip splits were significantly associated with postoperative complications (p\u0026thinsp;=\u0026thinsp;0.048), including double the rate of returns to theatre (50.0% vs 25.6%; p\u0026thinsp;=\u0026thinsp;0.025). Most returns to theatre were for recipient site complications (89% of returns to theatre) including collections. There was no significant difference between the lip split cohorts in readmission rates (p\u0026thinsp;=\u0026thinsp;0.479), mean length of stay (21.9 vs 21.5 days; p\u0026thinsp;=\u0026thinsp;0.870) nor mean days to oral diet commencement (14.9 vs 13.2 days; p\u0026thinsp;=\u0026thinsp;0.417). There was no statistical difference in the type of flap used (p\u0026thinsp;=\u0026thinsp;0.918) between cohorts.\u003c/p\u003e \u003cp\u003eSix cases were selected from the cohort to discuss the potential benefits and pitfalls associated with central and lateral lip splits. Cases \u003cspan refid=\"FPar2\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e2\u003c/span\u003e highlight the potential for severe morbidity following early lateral lip split wound breakdown and dehiscence, while case \u003cspan refid=\"FPar7\" class=\"InternalRef\"\u003e6\u003c/span\u003e demonstrates similarly poor outcomes following a central lip split procedure. Cases \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"FPar6\" class=\"InternalRef\"\u003e5\u003c/span\u003e demonstrate more tolerable (but still troublesome) issues that may still result after lateral lip split, including incomplete lip seal and scarring. Lateral lip splits provide excellent access to posterior structures in the oral cavity and oropharynx; cases \u003cspan refid=\"FPar5\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"FPar6\" class=\"InternalRef\"\u003e5\u003c/span\u003e exemplify the capacity for central lip splits to provide appropriate surgical access.\u003c/p\u003e \u003cp\u003eLateral lip splits facilitate excellent access to many tumours of the oral cavity, including those located posteriorly (e.g. oropharynx) or laterally. However, due to the lateralised neurovascular supply of the face, lateral lip splits inevitably lead to injury to the branches of the facial and mental nerves, and the inferior and superior labial vessels [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This is particularly important if the contralateral labial vessel if small or absent, as the lip will be de-vascularised, leading to poor wound healing. Central lip splits preserve the mental and marginal mandibular nerves, reducing risk of paraesthesia. However, scarring following central lip incisions can lead to notching, fistula, and reduced lip mobility[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Further, in cases involving resections in the anterior oral cavity and mandible, residual central lip tissue may be devascularised by subsequent tumour resection. Appropriate selection of midline or lateral lip splitting approach should therefore consider tumour location and resection margins, patient comorbidities and preferences, and surgeon preferences. For both central and lateral lip-splitting approaches, careful approximation of skin and mucosal with layered sutures is important for functional and aesthetic outcomes.\u003c/p\u003e \u003cp\u003eThere are several limitations to our study. Primarily the retrospective design limits direct comparison of groups. While the central and lateral lip split cohorts were largely comparable, there was a trend to higher ASA classification in the lateral lip split cohort (p\u0026thinsp;=\u0026thinsp;0.046), and there were significantly more segmental mandibulectomies in the lateral lip split cohort (p\u0026thinsp;=\u0026thinsp;0.005). This suggests a more complex cohort of patients receiving lateral lip splits, which may contribute to the trends to poorer outcomes in the lateral lip split cohort.\u003c/p\u003e"},{"header":"5 CONCLUSION","content":"\u003cp\u003eThe excellent access to resection and reconstruction of posterior oral and oropharyngeal tissues provided by lip splitting is unlikely to be superseded by alternative approaches. Given its ongoing role in head and neck surgery, optimisation of the lip split technique is warranted. This study of 79 patients undergoing lip-split access procedures for oral and oropharyngeal tumours demonstrates an association of lateral lip split access (e.g., the Robson approach) with poorer outcomes. Randomised prospective data is needed to compare approaches. This research should focus on surgical outcomes (including margin clearance, locoregional recurrence, and complications), functional outcomes (including speech and swallowing), and cosmetic outcomes including patient satisfaction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. There is no funding to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design, supervised by Felix Sim \u0026amp; Anand Ramakrishnan. Material preparation, data collection and analysis were performed by Peter Gearing, Maxim Devine, and Siyuan Pang. The first draft of the manuscript was written by Peter Gearing and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS DECLARATION \u0026amp; CONSENT\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This retrospective chart review study involving human participants was in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments. The Royal Melbourne Hospital Human Research Ethics Committee (HREC QA2024011) approved this study. The authors affirm that human participants provided informed consent for publication of the images in Figures 3-6. Informed consent was obtained from all individual participants included in the study. The data that support the findings of this study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang Y, Zhou B, Liu Z, Rui T, Pan C, Chen W (2022) Modified submandibular mandibulotomy approach without lip-splitting in tongue cancer. J Plast Reconstr Aesthet Surg 75:3877\u0026ndash;3903. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1016/j.bjps.2022.08.074\u003c/span\u003e\u003cspan address=\"10.1016/j.bjps.2022.08.074\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHedayat F, Jerry Htwe KK, Vassiliou L-V, Kyzas P (2022) Morbidity related to the lip-split mandibulotomy approach: a systematic and narrative review. Br J Oral Maxillofac Surg 60:430\u0026ndash;436. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1016/j.bjoms.2021.09.019\u003c/span\u003e\u003cspan address=\"10.1016/j.bjoms.2021.09.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu C-J, Fang K-H, Chang C-C, Lin E-T, Chang G-H, Shen J-H, Chen Y-T, Tsai Y-T (2019) Application of parachute technique for free flap reconstruction in advanced tongue cancer after ablation without lip-jaw splitting: A retrospective case study. Medicine 98:e16728. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1097/MD.0000000000016728\u003c/span\u003e\u003cspan address=\"10.1097/MD.0000000000016728\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi W, Li R, Safdar J, Huang S, Xu Z, Tan X, Sun C (2014) Modified visor approach applied to total or subtotal glossectomy and reconstruction: avoidance of lip splitting and mandibulotomy and cutting off mental nerve. Tumour Biol 35:7847\u0026ndash;7852. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1007/s13277-014-2036-4\u003c/span\u003e\u003cspan address=\"10.1007/s13277-014-2036-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah JP (2007) Surgical Approaches to the Oral Cavity Primary and Neck. Int J Radiation Oncology*Biology*Physics 69:S15\u0026ndash;S18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijrobp.2007.03.069\u003c/span\u003e\u003cspan address=\"10.1016/j.ijrobp.2007.03.069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams CE, Kinshuck AJ, Derbyshire SG, Upile N, Tandon S, Roland NJ, Jackson SR, Rodrigues J, Husband DJ, Lancaster JL, Jones TM (2014) Transoral laser resection versus lip-split mandibulotomy in the management of oropharyngeal squamous cell carcinoma (OPSCC): a case match study. Eur Arch Otorhinolaryngol 271:367\u0026ndash;372. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1007/s00405-013-2501-5\u003c/span\u003e\u003cspan address=\"10.1007/s00405-013-2501-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatt V, Praveen P, Green J, Grime PD (2009) A modified lip split incision. J Oral Maxillofac Surg 67:229\u0026ndash;230. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1016/j.joms.2008.07.007\u003c/span\u003e\u003cspan address=\"10.1016/j.joms.2008.07.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaek C-H, Lee S-W, Jeong H-S (2006) New modification of the mandibulotomy approach without lip splitting. Head Neck 28:580\u0026ndash;586. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/hed.20373\u003c/span\u003e\u003cspan address=\"10.1002/hed.20373\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBabin R, Calcaterra TC (1976) The lip-splitting approach to resection of oropharyngeal cancer. J Surg Oncol 8:433\u0026ndash;436. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/jso.2930080510\u003c/span\u003e\u003cspan address=\"10.1002/jso.2930080510\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButlin HT (1885) Diseases of the tongue. Clinical manuals for practitioners and students of medicine\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePitak-Arnnop P, Witohendro LK, Tangmanee C, Subbalekha K, Sirintawat N, Auychai P, Meningaud J-P, Neff A (2022) Benefit-risk appraisal of lip-split mandibular swing vs. transoral approaches to posterior oral/oropharyngeal carcinomas using number needed to treat, to harm, and likelihood to be helped or harmed. Surg Oncol 44:101837. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1016/j.suronc.2022.101837\u003c/span\u003e\u003cspan address=\"10.1016/j.suronc.2022.101837\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHartig G (2011) Avoidance of lip split: a response. Microsurgery 31:353\u0026ndash;354. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1002/micr.20875\u003c/span\u003e\u003cspan address=\"10.1002/micr.20875\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStathopoulos P, Kaplani MED, Kostis N, Igoumenakis D, Smith WP (2021) The impact of lip-split mandibulotomy on patients treated for pT2 oral tongue squamous cell carcinoma: a study of 224 patients. Oral Maxillofac Surg 25:313\u0026ndash;318. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1007/s10006-020-00918-8\u003c/span\u003e\u003cspan address=\"10.1007/s10006-020-00918-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePitak-Arnnop P (2023) Is lip-split mandibulotomy approach to posterior oral cavity and oropharyngeal carcinomas really obsolete? J Plast Reconstr Aesthet Surg 76:301\u0026ndash;302. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1016/j.bjps.2022.10.042\u003c/span\u003e\u003cspan address=\"10.1016/j.bjps.2022.10.042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen W-L, Zhou B, Huang Z-X, Chen R, Hong L, Dong X-Y (2023) Maxillectomy and Flap Reconstruction of Maxillary Defects After Cancer Ablation Through the Lip-Split Parasymphyseal Mandibulotomy Approach in Patients With Advanced-Stage Maxillary Malignant Tumors. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1097/SCS.0000000000009221\u003c/span\u003e\u003cspan address=\"10.1097/SCS.0000000000009221\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. J Craniofac Surg\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehanna P, Devine J, McMahon J (2010) Lip split and mandibulotomy modifications. Br J Oral Maxillofac Surg 48:314\u0026ndash;315. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1016/j.bjoms.2009.06.231\u003c/span\u003e\u003cspan address=\"10.1016/j.bjoms.2009.06.231\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlackburn T, Re P, Mehanna J, Devine J, McMahon (2010) Lip split and mandibulotomy modifications [Br. J. Oral Maxillofac. Surg. 48 (2010) 314\u0026ndash;315]. Br J Oral Maxillofac Surg 48:561. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1016/j.bjoms.2010.06.010\u003c/span\u003e\u003cspan address=\"10.1016/j.bjoms.2010.06.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayter JP, Vaughan ED, Brown JS (1996) Aesthetic lip splits. Br J Oral Maxillofac Surg 34:432\u0026ndash;435\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen LE, Morrison KA, Taylor E, Jin J, Spector JA, Caruana S, Rohde CH (2018) Functional and Aesthetic Outcomes in Free Flap Reconstruction of Intraoral Defects With Lip-Split Versus Non-Lip-Split Incisions. Ann Plast Surg 80:S150\u0026ndash;S155. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1097/SAP.0000000000001373\u003c/span\u003e\u003cspan address=\"10.1097/SAP.0000000000001373\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCilento BW, Izzard M, Weymuller EA, Futran N (2007) Comparison of approaches for oral cavity cancer resection: lip-split versus visor flap. Otolaryngol Head Neck Surg 137:428\u0026ndash;432\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevine JC, Rogers SN, McNally D, Brown JS, Vaughan ED (2001) A comparison of aesthetic, functional and patient subjective outcomes following lip-split mandibulotomy and mandibular lingual releasing access procedures. Int J Oral Maxillofac Surg 30:199\u0026ndash;204\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng S-J, Ko H-H, Lee J-J, Kok S-H (2018) Comparison of long-term outcomes between pull-through resection and mandibular lip-split surgery for T4a tongue/floor of mouth cancers. Head Neck 40:144\u0026ndash;153. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://dx.doi.org/10.1002/hed.24994\u003c/span\u003e\u003cspan address=\"10.1002/hed.24994\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRapidis AD, Valsamis S, Anterriotis DA, Skouteris CA (2001) Functional and aesthetic results of various lip-splitting incisions: A clinical analysis of 60 cases. J Oral Maxillofac Surg 59:1292\u0026ndash;1296. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1053/joms.2001.27517\u003c/span\u003e\u003cspan address=\"10.1053/joms.2001.27517\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"head and neck, surgical access, lip split mandibulotomy, malignancy","lastPublishedDoi":"10.21203/rs.3.rs-4062093/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4062093/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e \u003cp\u003eSurgical resection of oral cancers requires meticulous planning to achieve clear margins and minimize potential morbidity. This study aimed to compare postoperative surgical and functional outcomes following central and lateral lip-split approaches used for resection and reconstruction of oral tumours.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA retrospective review of 79 cases involving lip-split procedures for head and neck cancers was conducted. Data were collected from a prospectively recorded database (December 2015 to December 2022). Statistical analyses compared patient demographics, intraoperative characteristics, and postoperative outcomes between central and lateral lip-split cohorts.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eLateral lip splits were associated with higher rates of postoperative complications (p\u0026thinsp;=\u0026thinsp;0.008), including return to theatre (p\u0026thinsp;=\u0026thinsp;0.015), and functional issues including asymmetric smile (p\u0026thinsp;=\u0026thinsp;0.009). No significant differences were observed in readmission rates, length of stay, or time to oral diet commencement (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Six cases were selected to highlight the potential advantages and disadvantages of central and lateral lip split procedures.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eLip-split procedures remain valuable for resection and reconstruction of oral and oropharyngeal tumours. Lateral lip splits are associated with poorer outcomes when compared to central approaches. Appropriate selection of lip splitting approaches should consider tumour location, resection margins, patient comorbidities and preferences, and surgical preferences.\u003c/p\u003e","manuscriptTitle":"The Lip Split: A Retrospective Outcomes Study and Case Series following Central and Lateral Lip Split Access for Head and Neck Reconstructive Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-15 18:45:57","doi":"10.21203/rs.3.rs-4062093/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-28T15:32:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-30T18:23:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227897464161872686420888243451237187012","date":"2024-05-30T12:54:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150181781850978968210559155011658175029","date":"2024-04-30T18:01:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-13T22:37:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-12T23:53:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-12T23:53:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Oral and Maxillofacial Surgery","date":"2024-03-10T05:33:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2d8c9efd-fbe0-44b1-ac0d-a43b914d1f29","owner":[],"postedDate":"March 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-10T19:47:42+00:00","versionOfRecord":{"articleIdentity":"rs-4062093","link":"https://doi.org/10.1007/s10006-025-01355-1","journal":{"identity":"oral-and-maxillofacial-surgery","isVorOnly":false,"title":"Oral and Maxillofacial Surgery"},"publishedOn":"2025-03-06 15:58:36","publishedOnDateReadable":"March 6th, 2025"},"versionCreatedAt":"2024-03-15 18:45:57","video":"","vorDoi":"10.1007/s10006-025-01355-1","vorDoiUrl":"https://doi.org/10.1007/s10006-025-01355-1","workflowStages":[]},"version":"v1","identity":"rs-4062093","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4062093","identity":"rs-4062093","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}