Otolaryngology–Head and Neck Surgery (2010) 142, 286-287
CLINICAL TECHNIQUES AND TECHNOLOGY
Upper lip elongation in Möbius syndrome
Robin W. Lindsay, MD, Tessa A. Hadlock, MD, and Mack L. Cheney, MD,
Boston, MA; and Bethesda, MD
No sponsorships or competing interests have been disclosed for
this article.
M öbius syndrome is a rare congenital disorder charac-
terized by complete or partial facial paralysis, with or
without paralysis of other cranial nerves, and occasional
limb and/or orofacial malformations.1 It occurs in one of
every 50,000 live births, and affects boys and girls equally.2
Many patients have a foreshortened upper lip with exposed
incisors, and experience oral incompetence, poor articula-
tion, and exposure dental caries from bilateral facial paral-
ysis. Facial reanimation surgery performed using gracilis
muscle transfer has been shown to improve drooling,
speech, and facial animation.3 Despite successful facial an-
imation, many patients still experience speech difficulties
related to the foreshortened upper lip.
The purpose of this article is to describe a technique for
elongating and increasing the fullness of the upper lip in
patients with Möbius syndrome that can improve speech,
decrease dental exposure, and improve lip appearance. Lip
elongation was performed in two patients with Möbius
syndrome, using a dermal graft and a full-thickness skin
graft. The combination of dermal graft augmentation to
increase the fullness of the upper lip and full-thickness skin
grafting to lengthen the vestibule elongated the upper lip,
improving speech and lip position in both patients. This
study was approved by the institutional review board at the
Massachusetts Eye and Ear Infirmary.
Patients and Methods
Two patients underwent the lip elongation procedure, which
was performed by two surgeons at a single institution uti-
lizing the newly described technique, between March 2008
and July 2008.
Case Report 1
A 17-year-old male presented with Möbius syndrome. At
six years of age, he had undergone successful staged bilat-
eral gracilis transfers. However, he continued to be con-
cerned with oral incompetence and upper lip position. After
undergoing the lip elongation procedure, he noted improved
Received May 19, 2009; revised August 31, 2009; accepted September 30, 2009.
0194-5998/$36.00 © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2009.09.034
speech and upper lip appearance, which have remained
stable for the past 14 months.
Case Report 2
A 26-year-old female with Möbius syndrome, who did not
elect to undergo reanimation because by the age of 10 she
had a noticeable bilateral smile, presented to our institution.
She continued to be bothered by oral incompetence and
incomplete mouth closure, for which she underwent the lip
elongation. After undergoing the lip elongation procedure,
she noted improved speech and more complete mouth clo-
sure, which have remained stable for the past 10 months.
Surgical Marking
The intraoral incision was marked 2 to 3 mm onto the loose
gingiva to facilitate the inset of the full-thickness skin graft.
The vermillion border was marked at both commissures for
insertion of the dermal graft. The dermal graft harvest site
was marked elliptically around a preexisting abdomen
scar or low on the left abdomen. The ellipse was designed
with a length-to-width ratio of 3:1 to facilitate closure
(1.5 by 4.5 cm).
Surgical Technique
Surgical techniques for dermal fat graft harvesting have
been described previously4 for different recipient sites. Fol-
lowing nasal intubation, an elliptically shaped incision was
made in the left lower abdomen. The full-thickness skin
graft was harvested by carefully de-epithelializing the der-
mal graft with a 15-blade. The dermis was incised with a
15-blade, beveling the blade inward though the subcutane-
ous fat. Hemostasis was obtained after the graft was har-
vested, and the wound was closed in layers.
The gingival incision was then made, releasing the tight-
ness of the upper lip. The skin graft was then inset between
the edges of the gingival incision using 5-0 chromic suture.
One cm vermillion border incisions at the oral commissures
were made, and a narrow tunnel was created to join the two
incisions to accommodate the dermal graft. Next, the dermal
graft was introduced into the tunnel, with the dermis placed
superficially to provide contact with the subdermal plexus.
The vermillion incisions were then closed with a 6-0 chro-
Lindsay et al Upper lip elongation in Möbius syndrome
Figure 1 Preoperative upper lip position in a patient with Möbius syndrome after bilateral free gracilis transfer (case 1). Note the exposed
central and lateral incisors (A). Postoperative appearance of the upper lip after lip elongation. Note the improvement in upper lip position
with very little exposed dentition (B).
mic suture. Postoperative massage and stretching of the
upper lip were initiated after the skin graft had healed
completely (typically 4 weeks).
Results
Two patients underwent successful lip elongation with im-
proved speech and resting position of the upper lip. In both
patients, the intraoral incision healed without contracture,
with full skin graft take. Figure 1 demonstrates the improve-
ment in upper lip position obtained in our patients.
Discussion
Patients with Möbius syndrome, whether or not they desire
facial reanimation, can benefit from lip augmentation and
elongation performed using a combined dermal graft aug-
mentation to the upper lip and full-thickness skin grafting to
the upper lip vestibule. Dermal grafts have been safely and
successfully used to improve facial contour defects for de-
cades, with low absorption rates.4 This technique can be
performed on an outpatient basis, with minimal morbidity,
and permits more effective oral sphincter restoration by
providing much needed lip volume. The full-thickness skin
graft elongates the upper lip, diminishing excessive dental
exposure. These techniques may also improve the cosmetic
appearance of the upper lip.
Bilateral facial paralysis patients are significantly af-
fected by poor speech and oral incompetence.3 Speech and
oral competence improved in this pair of patients; however,
closer prospective evaluation of speech and swallowing
outcomes is required in the future. In addition, patients with
Möbius syndrome can have a foreshortened upper lip, which
worsens speech and produces a syndromic appearance, de-
spite a very low rate of mental deficits in this population.1,2
Conclusion
Lip elongation is a safe and effective technique that can be
utilized for patients with a congenitally foreshortened upper
287
lip secondary to Möbius syndrome. This technique can
potentially improve both speech and the appearance of the
upper lip by lengthening the vestibule and providing in-
creased fullness to the lip.
Author Information
From the Department of Otolaryngology/Head and Neck Surgery, Massa-
chusetts Eye and Ear Infirmary and Harvard Medical School (Drs. Lindsay,
Hadlock, and Cheney) Boston, MA; and the Department of Surgery,
Uniformed Services University of the Health Sciences (Dr. Lindsay), Beth-
esda, MD.
Corresponding author: Robin Lindsay, MD, Division of Facial Plastic and
Reconstructive Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles
St., Boston, MA 02114.
E-mail address: robin_lindsay@meei.harvard.edu.
Author Contributions
Robin W. Lindsay, data collection, writer; Tessa A. Hadlock, data col-
lection, reviewer; Mack L. Cheney, study design, data collection, re-
viewer.
Disclosures
Competing interests: None.
Sponsorships: None.
References
1. Kumar D. Moebius syndrome. J Med Genet 1990;27:122–6.
2. Miller G. Neurological disorders: the mystery of the missing smile.
Science 2007;316:826–7.
3. Zuker RM, Goldberg CS, Manktelow RT. Facial animation in children
with Mobius syndrome after segmental gracilis muscle transplant. Plast
Reconstr Surg 2000;106:1–8.
4. Davis RE, Guida RA, Cook TA. Autologous free dermal fat graft:
reconstruction of facial contour defects. Arch Otolaryngol Head Neck
Surg 1995;121:95–100.