Millard presented the rotation-advancement technique at the First International Congress of Plastic Surgery, held in Stockholm, Sweden, in August Over the ensuing years, he further refined this technique.
In his original description, there were three flaps, labeled A, B, and C: A was the medial rotation flap; B, the lateral advancement flap carrying the flared alar base; and C, the small triangular flap attached to the columella which was originally advanced across the nasal floor Fig.
Millard believed that this typically was caused by inadequate rotation of the medial flap, but it led him to introduce the addition of a back-cut at the top of the rotation incision to enable greater downward movement of the medial lip segment. The function of the C-flap then evolved to fill the defect created by the back-cut, and thus to lengthen the columella. Several surgeons have advocated the addition of a small triangular or rectangular flap from the lateral element into the lower part of the repair to provide additional length, break up the line of the incision, and preserve the contour of the vermilion.
He and others also advocated the incorporation of a triangular lateral vermilion flap to augment the deficient vermilion of the medial lip segment. Some surgeons have objected that the scar produced by the Millard repair obliquely and unnaturally crosses the philtrum in the upper third of the lip.
In he reported a study of philtral shape in school children without clefts. He classified them into three groups based on whether the philtral columns were divergent or convergent and, in the latter case, whether they converged at or below columellar-lip junction Fig. He subsequently altered the design of his repair for such patients in the superior portion of the lip so as to mirror the philtral shape on the noncleft side.
In his technique, the rotation incision is drawn in a curvilinear fashion to mimic the shape of the normal philtral column and extended into the base of the columella. A degree back-cut is made in the columella without crossing the normal philtral column, allowing downward rotation of the medial lip segment. The C-flap is advanced into the defect at the columellar base and used to lengthen the shortened columella on the cleft side 44 Fig.
A more recent addition to cleft lip repair techniques is the anatomic subunit approximation technique, described by David Fisher 47 from the Hospital for Sick Children in Toronto, who published this technique in Using both the principle of Rose-Thompson lengthening as well as a lower Randall-Tennison type of triangular flap, Fisher designed this repair to maintain the scars at the seams of the anatomic subunits of the lip and nose Fig.
Modifications and long-term results of this technique, which are described in detail in a later chapter, have recently been reported by others. The incisions used have evolved from a straight-line closure on each side to various types of flaps like those used in unilateral clefts. Historically, many surgeons would simply replicate their unilateral repair patterns on each side.
Some brought flaps back from the lateral side of the cleft to the midline below the prolabium to lengthen the central lip. In William Rose pared the central tubercle in a V-shaped manner and curved his incisions in the lateral segments, bringing them together in the midline below the apex of the central segment. Le Mesurier applied his quadrilateral flap design to the bilateral defect, also transposing flaps below the prolabium. Brown, McDowell, and Byars introduced a pair of triangular flaps that were brought together under the prolabium and described several variations to accommodate either a long or short prolabium.
Louis Schultz of Chicago contributed significantly to the bilateral repair in the s by emphasizing the importance of muscle approximation from the lateral elements behind the central prolabial segment. As early as , Pierre Joseph Desault of Paris advocated surgical closure of both sides at the same time after initial premaxillary compression by a cloth bandage. He pared the cleft edges, approximated the lip segments using the prolabium for the central portion of the lip, and fixed the repair with through-and-through sutures in a figure-eight fashion.
Other surgeons were in favor of a staged repair of the bilateral cleft deformity. These surgeons choose to close the wider cleft first to pull the deviated premaxilla back to the midline. The protruding premaxilla was one of the first challenges in the history of the bilateral lip repair. In early repairs, it often was excised completely, leading to a loss of incisors, collapse of the lateral maxillary segments, severe restriction of anterior maxillary growth, and a marked anterior cross bite Fig.
Pancoast 53 did not excise the premaxilla, but instead forcefully fractured it to a better position. Other historic attempts to reposition the protruding premaxilla have included removal of the buccal plate of the alveolus, usually with destruction of the incisor teeth. More recently, orthodontic appliances have been used to reposition the premaxilla. This has been done both actively with screw attachments for retropositioning the premaxilla and for repositioning the lateral maxillary segments and passively with staged dental plates.
This approach has now reached a high degree of sophistication and has evolved to include additional appliances to reshape the nasal tip cartilages and to lengthen the columella. The lip adhesion procedure was another method developed to reposition the protruding premaxilla. First described by Gustav Simon in , this procedure attached flaps from the lateral lip segments to the prolabium to reshape the lip and underlying alveolus before definitive lip repair. Menu Button. Recently Visited.
View More Results Loading What is cleft lip and palate? How is cleft lip and palate treated? Conditions that may be associated with cleft lip or palate include: Velocardiofacial syndrome chromosome 22q It was soon discovered that my condition had had an effect on the way my ears worked.
My parents were told not to take me swimming and to avoid getting water in my ears, as they were unable to drain fluid properly. As you can imagine, this led to even more hospital appointments. Once I was old enough I underwent surgeries to place T-tubes in my ears to help drain fluid. It was just the sound of the pipes as the heating was switched on. It had done the same for years yet I was only hearing it for the first time.
With the ear problems came the severe ear infections. I would have at least 3 a year, where I would scream in agony for days. I can vaguely remember these appointments and I was soon told that I would no longer need to attend them as I had responded so well to the therapy.
The speech therapy team said they would still keep a close eye on me at my annual reviews. Every year, all the cleft professionals on my team would meet together in a room with me sitting in the middle and them around the edge with my parents talking about my progress, treatments, and the next steps.
The professionals on my team included an orthodontist, a plastic surgeon, a speech therapist, and a doctor from the ENT department. I was treated like a bit of a celebrity. Some of these professionals had been on my team since the day I was born, when they came to examine me in my hospital cot. They were lovely, caring, and wonderful people. At the age of about 10, my orthodontist began work to change the layout of my teeth, mouth, and jaw.
Between the ages of 10 and 16 I was given braces, palates, retainers, and train tracks sometimes at the same time but never with a break in-between. This was the part I found the hardest. I hated wearing braces, with a passion. When I was in Year 7 at school, my plastic surgeon and my orthodontist decided it was time for me to have an Alveolar Bone Graft, where bone would be taken from my hip and put into my jaw. I was not prepared for my hip to be a lot more painful than my mouth post-surgery but this was indeed the case.
Appointments continued month after month — the ENT clinic, orthodontist clinic etc.
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