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 Table of Contents  
CME ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 157-162

Millard's rotation advancement technique for unilateral cleft lip repair


The Charles Pinto Centre for Cleft Lip, Palate and Craniofacial Anomalies, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India

Date of Submission28-Apr-2021
Date of Acceptance28-Apr-2021
Date of Web Publication7-Jun-2021

Correspondence Address:
Dr. Puthucode V Narayanan
The Charles Pinto Centre for Cleft Lip, Palate and Craniofacial Anomalies, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_12_21

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  Abstract 


The unilateral cleft lip deformity includes defects of the lip and also the associated deformities in the nose. The Millard's rotation advancement technique is a versatile one for the repair of these deformities. The principle of the technique is that the raised Cupid's bow point medial to the cleft is brought down level with its noncleft side counterpart by a rotation incision, which extends to the base of the columella and ends with a back cut. The resulting defect beneath the base of the columella is filled with an advancement flap from the cleft side. The advantages of the techniques are many. The most significant one is that it adheres to the basic principles of esthetic surgery, with the main scars being along the relaxed skin tension lines. It is a versatile technique producing optimal results in all types in unilateral cleft lip patients ranging from the microform to the widest of complete clefts. The incision in this technique is so placed that there is easy access to address the associated defects of the nose. Technical refinements have been added to the classical description of the procedure to address the deficiencies in the repair. We describe important refinements introduced at our center by Dr. H. S. Adenwalla. Universally, this technique is still the most popular.

Keywords: High riding nostril, Millard's, primary cleft lip nose correction, rotation advancement, unilateral cleft lip repair, vermillion notch prevention


How to cite this article:
Narayanan PV. Millard's rotation advancement technique for unilateral cleft lip repair. J Cleft Lip Palate Craniofac Anomal 2021;8:157-62

How to cite this URL:
Narayanan PV. Millard's rotation advancement technique for unilateral cleft lip repair. J Cleft Lip Palate Craniofac Anomal [serial online] 2021 [cited 2021 Jun 17];8:157-62. Available from: https://www.jclpca.org/text.asp?2021/8/2/157/317777




  Introduction Top


The lip that is centrally placed on the face is certainly a cynosure, and hence, even the slightest blemish therein draws the attention of an onlooker. When one views the repair of the unilateral cleft lip in this context, one readily understands the necessity for near-perfect results as even the most minor blemishes become glaring.

The unilateral cleft lip deformity involves all parts of the lip such as vermillion, white roll, and Cupid's bow. The latter is distorted with the part of it just medial to the cleft being raised with a shortened lip [Figure 1].
Figure 1: The unilateral cleft lip deformity

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The deformity does not spare the nose, which presents with an open nasal floor, short hemicolumella, alar flare, depressed and grooved ala on the cleft side, and deviated nasal septum anteriorly to the noncleft side.[1]

An ideal technique used for the repair of such a deformity should address all of these components and at the same time comply with the basic tenets of reconstructive surgery, such as attention to the relaxed skin tension lines and tension-free repair.

Although there exist several techniques used to repair such clefts, the most popular one universally is the Millard's rotation advancement procedure.[2],[3],[4] This has stood the test of time.


  Principle Top


The raised Cupid's bow point medial to the cleft is brought down by a curvilinear rotation incision, which ascends from the raised Cupid's bow point to the base of the columella, hugs this base for two-thirds of its width, and culminates in a back cut.[5],[6]

With such a rotation, one is able to lower the raised Cupid's bow point to a level corresponding to its noncleft side counterpart.

The resulting defect beneath the columella is filled by an advancement flap drawn from the cleft side.


  Advantages Top


It is readily evident that a transverse incision is inevitable on the lip to lower the raised Cupid's bow and lengthen the lip. In Millard's technique, this happens beneath the columella in such a way that the scar is well hidden.[7]

The longitudinal part of the rotation incision mimics the philtral ridge and is along the Langer's lines.

The Millard's cinch suture draws the paranasal muscles from the alar base on the cleft side to the midline, thus correcting the alar flare.

The short cleft side hemicolumella is lengthened using a part of the C flap arising from the rotation incision.

The advancement incision allows easy and direct access for a closed dissection of the ala, and this improves the nasal appearance significantly.

Thus, to sum up, the Millard's technique addresses the main aim of reconstructing the Cupid's bow in an esthetically pleasant manner and simultaneously provides avenues to rectify other associated defects of the columella, alar base, and, in fact, the entire nasal stigmata. With this background, one readily appreciates why this is the still the most popular technique for unilateral cleft lip repair globally.


  Procedure Top


Marking

The apex of the Cupid's bow and the peak on the noncleft side are marked. This distance is measured and another point is marked medial to the apex to identify the corresponding peak [Figure 2].[8]
Figure 2: Markings for the Millard's rotation advancement technique

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The rotation incision ascends from this point to the base of the columella and continues along two-thirds of its base. The rotation incision is completed by the back cut which should be perpendicular to the incision. An important precaution is to avoid extending the back cut through the noncleft side philtral ridge to avoid lengthening that side also. If this is done, it will perpetuate the difference in height between the two philtral ridges.

On the cleft side, the lateral point is marked. There are several ways of doing this:

  • By measuring the height of the philtral columns on the noncleft side
  • To use the distance from the alar base to the corresponding peak of the Cupid's bow on the noncleft side
  • By measuring the distance on the noncleft side from the oral commissure to the Cupid's bow peak
  • By identifying the broadest part of the dry vermillion (between the white roll and the red line of Noordhoff).


The very fact that there are so many ways to measure this point is testimony to the fact that it is an ambiguous one and may be difficult to mark.

The advancement incision ascends from this point along the cleft edge to the alar base and then is marked along the base of the ala. This part of the incision has drawn criticism because of the scar resulting for its improper marking. Some surgeons avoid this altogether and instead take the incision into the nose. We continue to use the perialar advancement incision but limit its extent to the minimum necessary. This incision enables us to perform the closed alar dissection better and also to place the alar cinch suture under direct vision.


  Procedure Top


After infiltration with 1 in 200,000 adrenaline solution, the cleft edges are incised. The frenum is divided. The rotation incision is made through the full thickness of the lip, and a back cut is done. One can assess the adequacy of the rotation by ensuring that the Cupid's bow point is level with its noncleft side counterpart. The vermillion is pared leaving behind a good cuff of orbicularis oris muscle to be used as a filler to avoid a notch. The skin and mucosa are undermined.

On the cleft side, after paring the edge, the advancement incision is made hugging the base of the ala and limiting the lateral extent of the incision to the minimum necessary. The vermillion is pared, leaving behind a cuff of muscle as on the medial side.

An extensive lateral subperiosteal mobilization is performed from the alveolar shelf inferiorly to the infraorbital foramen superiorly and from the zygomatic prominence laterally to the edge of the maxilla medially. The mucoperiosteal lining is dissected off the underlying maxilla, releasing any tethering effect in the pyriform area. With such an extensive mobilization, even the widest of clefts can be brought together without any tension.

Medially, an incision is made over the septomaxillary junction, extending posteriorly to the vomer. Anteriorly, it connects with the frenular base incision. The mucoperichondrium is dissected off the underlying nasal septum; septal repositioning is done in all patients as will be discussed later.


  Closure Top


The nasal floor is created by suturing the septal mucoperichondrium medially with the mucoperiosteum on the maxilla laterally. Anterior palate repair is done to the extent possible. Ideally, we would like to close it till the hard and soft palate junction.

When there is a discrepancy anteroposteriorly at the alveolar shelf level, it can be minimized by performing an unequal Z plasty described by Jackson. More than one such Z plasty will be needed when there is gross alveolar disparity.

The Millard's cinch suture is placed with a nonabsorbable suture anchoring the paranasal muscles on the cleft side to the nasal septum. However, of late, we have been anchoring it to the midline mucoperiosteum with 4-0 monocryl.


  Correction of the Primary Cleft Lip Nasal Deformity Top


A closed alar cartilage dissection is done using curved Kilner scissors introduced through the columella base incision medially and the advancement incision laterally, in a plane between the lateral cartilages and the skin. Although this was not part of the classical Millard's procedure, it is facilitated by the location of the Millard's incision.[9],[10]

Primary septal cartilage repositioning is done in all complete unilateral cleft lip patients. The nasal septal cartilage is separated off the perichondrium on both sides. The dissection is facilitated by an incision at the cartilage–vomerine junction. Such a dissection has not shown any deleterious effect on the growth. The nasal septal cartilage used to be anchored to the newly formed nasal floor previously. However, as we found that these caused the nasal septum to deviate to the cleft side in the long term in some patients, we are now anchoring it to the mucoperiosteum in the midline. This was also not part of the classical Millard but added on as a refinement at our center by Dr. Adenwalla in the 1970s.[8]


  Orbicularis Oris Muscle Reconstruction Top


The false attachments of the orbicularis oris muscle are detached; the muscle is released from the mucosa and skin, more on the lateral aspect than on the medial. Nonabsorbable 5-0 polypropylene sutures are used to approximate the muscle for long-term stability. These have not been found to be the nidus for any infection later.


  Prevention of a Vermillion Notch Top


A vermillion notch [Figure 3] is a discontinuity on the free border of the vermillion and may be caused by inadequate rotation, inversion of skin at the suture line, inadequate orbicularis oris muscle, or contraction of the straight scar. These have been addressed at our center by Dr. Adenwalla using the Charles Pinto Centre protocol.[8],[11] This consists of an adequate rotation and an ample back cut, undermining of skin and mucosa, leaving behind an excess of orbicularis oris as a filler at the time of paring and suturing this muscle with 6-0 nylon sutures, and a Z plasty on the mucosa. This method helps us consistently avoid a notch.[11]
Figure 3: Vermillion notch

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Thus, it can be seen that Millard's rotation advancement technique is even today a very useful technique that corrects most of the blemishes in a unilateral cleft lip, while simultaneously being designed to be esthetically pleasant [[Figure 4]a, [Figure 4]b and [Figure 5]a, [Figure 5]b.
Figure 4: (a and b) Partial unilateral cleft lip preoperative and postoperative result

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Figure 5: (a and b) Complete unilateral cleft lip preoperative and postoperative result

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There remain some problems of the unilateral cleft lip, especially the complete form that remain uncorrected in the classical Millard.[11]

These include a lateral vermillion deficiency (shorter vertical height of the dry mucosa on the cleft side) and the cleft lip nasal stigmata associated with a unilateral cleft lip. These are not unique to the Millard's technique, and we have found that these are seen even when other techniques such as the triangular repair have been used.

The “high riding nostril” [Figure 6] on the cleft side, when the alar base is superiorly placed[12] compared to its counterpart, is probably because of the discrepancy in the anteroposterior alignment of the medial and lateral maxillary elements. These can be minimized or may even be eliminated by aligning the shelves preoperatively using nasoalveolar molding. When such disparity persists at the time of primary surgery, we have been using the unequal Z plasty described by Jackson to avoid the high riding nostril.
Figure 6: High riding nostril on the cleft side

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Similarly, we believe that the lateral vermillion deficiency also arises because of the bony disparity and can be prevented by presurgical orthodontics. When there is persistent disparity, we have been unable to correct it at the primary repair. We use a V-Y mucosal advancement with muscle build up to correct it secondarily[11] [Figure 7]a and [Figure 7]b.
Figure 7: (a) Lateral vermillion deficiency. (b) Secondary correction with a V-Y mucosal advancement

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  Nostril Web Top


A nostril web is commonly noted at the end of the repair. This can be minimized but not eliminated by sutures straddling the web. Excision of the web has been advocated by Patel and Mulliken,[13] but we do not resort to this as we have found that the excess tissue is handy at the time of a subsequent rhinoplasty. Previously, we used the Pinto's Z plasty to deal with the web. However, we rarely use it now for fear of damage to the alar cartilage beneath.[8]


  Nasal Sill Top


A nasal sill approaching the normal appearance has been elusive, and none of the presently used techniques have succeeded in this regard.

While there have been several advantages to the Millard's techniques, there are some drawbacks attributed to the technique.

Scarring

A contracture of the straight scar is a known complication.[11] This happens sometimes in the early preoperative period but settles later if the original rotation and lateral lip height have been optimal. Often, the rotation is inadequate when a back cut has not been made. In some patients, even though there has been adequate rotation, the lateral lip height is short. Millard advocates shifting of the lateral point laterally by 1 mm laterally and the upper extent by 1 mm superiorly. This can lead to a short horizontal length of the lip which is not pleasant. Very rarely, despite all these maneuvers, there remains a shortening of the lip which, if noticed at the time of lip repair, can be adequately corrected by a tiny Z plasty just above the white roll, restricting the size of the two flaps to the minimum required.

Perialar scarring has been a bane following the advancement incision. We use a restricted transverse advancement incision without going all around the alar base as we used to previously. This makes the scar minimal. Some surgeons avoid[14] this transverse incision and extend the lateral incision into the nostril base to get the required advancement. While this avoids the unpleasant alar base scar, it also makes the placement of the alar cinch suture and the closed alar dissection more difficult.

The Millard's technique requires a lot of clinical judgment that comes with experience. There is ample scope for improvisation in this technique allowing for variations depending on the individual patients. There is no stencil model that can be applied universally to all clefts. This versatility itself is an advantage of the technique but can be a difficulty for the beginners.


  Conclusion Top


With better understanding of the pathological anatomy of unilateral cleft lips, all the different techniques have evolved over the years and incorporated refinement to address the deformity overall. The Millard's procedure is no exception. Our preference for this technique over others is because the original technique itself is versatile and has avenues to address not only the basic deformities but also the associated deformities such as those of the nose, while adhering to the basic principles of esthetic surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Huffmann WC, Lierle DM. Studies in the pathologic anatomy of the unilateral hare-lip nose. Plast Reconstr Surg 1949;4:225-34.  Back to cited text no. 1
    
2.
Millard DR Jr. Personal approach to cleft lip. In: Millard DR Jr., editor. Cleft Craft. The Evolution of the Surgery. The Unilateral Deformity. Vol. 1. Boston Little: Brown; 1976. p. 165-73.  Back to cited text no. 2
    
3.
Millard DR Jr. Rotation-advancement principle in cleft lip closure. Cleft Palate J 1964;12:246-52.  Back to cited text no. 3
    
4.
Millard DR Jr. A radical rotation in a single hare lip. Am J Surg 1958;95:318-22.  Back to cited text no. 4
    
5.
Millard DR Jr. Increasing the vertical length of the cleft edge. In: Millard DR Jr., editor. Cleft Craft. The Evolution of the Surgery. The Unilateral Deformity. Vol. 1. Boston Little: Brown; 1976. p. 90-100.  Back to cited text no. 5
    
6.
Millard DR Jr. Full thickness flaps for vertical lengthening. In: Millard DR Jr., editor. Cleft Craft. The Evolution of the Surgery. The Unilateral Deformity. Vol. 1. Boston Little: Brown; 1976. p. 102-3.  Back to cited text no. 6
    
7.
Adenwalla HS, Narayanan PV. Unilateral cleft lip. In: Mani V, editor. Surgical Correction of Facial Deformities. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2010. p. 142-52.  Back to cited text no. 7
    
8.
Adenwalla HS, Narayanan PV, Agarwal K. Unilateral cleft lip. In: Agarwal K, editor. Text book of Plastic, Reconstructive and Aesthetic Surgery. Head and Neck Reconstructive. Vol. 3. Delhi: Thieme Medical and Scientific Publication (P) Ltd; 2019. p. 37-62.  Back to cited text no. 8
    
9.
Narayanan PV, Adenwalla HS. Primary rhinoplasty at the time of unilateral cleft lip repair: A review and our protocol. Cleft Lip Palate Craniofac J 2015;2:92-7.  Back to cited text no. 9
    
10.
Adenwalla HS, Narayanan PV. Primary unilateral cleft lip repair. Indian J Plast Surg 2009;42 (Suppl):S62-70.  Back to cited text no. 10
    
11.
Narayanan PV, Adenwalla HS. Unfavourable results in the repair of the cleft lip. Indian J Plast Surg 2013;46:171-82.  Back to cited text no. 11
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12.
Jackson IT. In: Mustarde JC, Jackson IT, editors. Plastic Surgery in Infancy and Childhood. 3rd ed. Edunburgh: Churchill Livingstone; 1988. p. 7.  Back to cited text no. 12
    
13.
Patel KB, Mulliken JB. Correction of the vestibular web during primary repair of unilateral cleft lip. Plast Reconstr Surg 2014;134:600e-7.  Back to cited text no. 13
    
14.
Kuo-Tine Chen P, Noordhoff MS, Kane A. Repair of unilateral cleft lip. In: Nelligan PC, editor. Plastic Surgery. 3rd ed. London: Elsevier; 2012. p. 517-49.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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  In this article
Abstract
Introduction
Principle
Advantages
Procedure
Procedure
Closure
Correction of th...
Orbicularis Oris...
Prevention of a ...
Nostril Web
Nasal Sill
Conclusion
References
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