2. A second incision is made from the upper extremity of the first incision downward from the nasolabial fold to a point on the cheek a little below and to the left of the left labial commissure. The flap being turned down, is sutured by its three edges to the lip of the quadrangular breach, after the lower edges of the flap has been freshened; this border being formed by the mucous membrane of the upper lip, the membrane is destroyed in order to permit of the edge being sutured to the horizontal branch of the loss of substance. The upper lip is then sutured vertically to the cheek. =Guinard Method.=—Guinard modifies the above method by making the operation bilateral and symmetrical instead of unilateral, thus giving marked facial symmetry; the mucous membrane forming the free edge of the upper lip, instead of being destroyed, is dissected, turned over, and is sutured in a groove in front of the maxillary in such a way as to reconstitute the buccal vestibule; the mucous membrane of the deep surface of the lip is sutured to the skin by eversion in order to form a new mucous border. With the above modification of the Larger method a considerable loss of substance can be restored, the new lip being constructed of normal tissue of the lip lined with mucous membrane retaining the saliva. Naturally the secondary deformity, while great, is one that only changes the physiognomy, leaving the face symmetrical with slight cicatrices. =Berger Method.=—Berger advocates replacing a large loss of skin from the lower lip, the result of burns, lupus, or syphilitic ulceration, by employing a pedunculated flap made from the arm. The free borders of the flap are sutured into the defect and the arm is bandaged to the head in the proper position. The pedicle on the arm is not divided until the flap has become thoroughly reunited, which is at the end of eight to twelve days. He dissects up and divides the free border of the mucosa until it is free from its attachments to fibers of the orbicularis muscle. This he utilizes in lining the flap. The flap taken from the arm may be made large enough to cover the entire anterior aspect of the chin. When the mucosa has been destroyed partially he advises releasing whatever remains of the mucous membrane, either as it may be, and loosening it so as to inclose the buccal orifice. He slides a flap taken from the subhyoid region to reconstruct the lip over this, or resorts to the Italian method just described. LABIAL DEFICIENCY Where the lip structure has become flattened and thinned as a result of tension following the exsection of a part of the lip, as in harelip, or the ablation of malignant growths, operations may be undertaken to give the tissue a better cosmetic appearance.