Rotation-Advancement Principle in Cleft Lip Closure D. RALPH MILLARD, JR., M.D., F.A.C.S. Miami, Florida Correction of prealveolar, alveolar, a n d postalveolar clefts poses a five- fold project: natural appearance, functional dentition, unimpaired hearing, normal speech, an d well-adjusted personality. This multifaceted task takes a team of specialists: pediatrician, prosthodontist, orthodontist, pedo- dontist, otolaryngologist, speech therapist, plastic surgeon, a n d psychi atrist. It is natural and commendable that each specialist show enthusiasm for his own specific responsibility y e t i t never should be forgotten that th e cumulative effect of all working together promises th e closest approach to a normal en d point. I t is well, however, to p u t first things first; for no matter how excellently the patients hears, bites, or sings, if he ends u p looking like a hare, we have failed. Granted th e growth of the maxilla an d position of the teeth are a vital part of t h e final appearance of th e patient, b u t then so is th e construction of th e li p and nose. A most vital decision toward this goal is th e optimum time for lip surgery. The primary surgical repositioning of t h e lip an d nose a t present is being carried o u t at about three months b y this author. This tentative date h a s been se t to allow th e soft tissues to increase in quantity and to avoid an y inhibiting effects from surgery on th e growth of th e maxillary components. Closure of th e li p with moderate tension, high across th e arch as in the technique suggested here, seems to give excellent molding. Yet if there is malpositioning of th e maxillary components with over- riding of th e noncleft side over th e cleft side, then lip closure will force them into overlapped collapse. I n such cases i t would seem that postpone- ment of surgery is indicated until prosthodontic manipulation ca n align both maxillary components. Once this ha s been achieved, lip closure with its muscle molding effect will cont inue t o improve th e situation. I n order to transform a cleft lip with nasal deformity into normal, i t is essential first to define th e normal. Then a careful detailed study of what is present in each individual case is essential before is possible to utilize to th e best advantage what we have to make what we want. Dr. Millard is affiliated with the Department of Surgery, University of Miami School of Medicine. Presented at th e 1963 Convention of th e American Cleft Palate Association, Washington, D. C. 246
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action is to visualize what is normal and to shift the tissue into a normal
position. These clefts, among other deficiencies, have an inherent vertical
shortness along each side involving both the nose and th e lip. This, accord
ing to Stark (7) may be due to the lack of adequate mesodermal ingrowth
which would force a filling out of the lip with normal downward displace
ment. Instead, however, the potentiallo>ver part of the lip actually main
tains it s high attachment to the nose on either side of the cleft. Thus the
noncleft side shmvs a twisted distortion with lack of vertical length from the
FIGURE 2. \V. Downward rotation of A fo r correct placement of cupid's bow,
philtrum and dimple. Upward advancement of C to lengthen the unilateral shortness
of the columella. X. Suture of C into columella before it s lateral advancement to make
the nostril sill. Y. JYiedial advancement of lateral flap B into the rotation gap to main
tain the ne w position of A and to correct th e alar flare and width of nostril floor. Cdoes not advance to the extent of th e lateral incision, but is aided by a V-Y closure.
Z. Note cupid's bow, philtrum, dimple, alar base, and columella are in correct align
ment. Scars ar e camouflaged in natural positions. \Vhcther th e cleft is complete or
incomplete, severe or minor, the final end point is more or less th e same.
bilateral incomplete cleft with a short prolabium but a normal columella.
The rotation-advancement technique is carried out one side at a time
advancing the upper lateraLcomponent medially between prolabium and
columella base. The lateral vermilion turndown flap overlaps the turn
down of prolabium vermilion to form one side of the cupid's bow. One
month later the opposite side is rotated and advanced in similar fashion
(Figure 5) (1, 3). In the bilateral complete cleftwith a pn:>truding pre'-
maxilla and shortness of the columella, not only is there no cupid's bowand
philtrumdimpleto<preserve, but there is not enough columella. To addto
the difficulty, the entire distorted premaxillary midsection has grown unin
hibited far out in front ofits lateral maxillary flankers. This is a complex
and fascinating problem. which can be benefitted by rotation-advance
ment technique only in a broad application of the principle. Median
clefts pose a midline problem. which is beyond the scope of this technique.
FIGURE 5. In bilateral incomplete clefts when th e prolabium is short an d th e
columella is normal the rotation-advancement principle can be used to advantage.
Half the prolabium is rotated down and th e latenH element is advanced into this gap.A wedge of varying size is excised from th e nasal • loor. A vermilion.· flap from th e
lip element is used to overlap th e prolabium vermilion to form one half of a cupid'sbow. One month later the same procedure is carried ou t on th e opposite side.
The rotation-advancement technique of cleft lip closure was designed
to preserve the natural landmarks of the cupid's bow-philtrum-dimplecomponent and to rotate them into normal position. Maintenance of this
rotation is achieved by medial advancement of the lateral lip element
which also reduces the alar flare and width of the nostril floor. The strategic
positioning of the scars manages to place the main oblique scar along
the natural line of a philtrum column while the interdigitations are hidden
in the shadow of the nostril sill and nasal floor. The minimal discard of
tissue and the ease of secondary correction are additional dividends.
References
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1. MILLARD, D. R., JR., Adaptation of th e rotation-advancement principle in bilateral
cleft lip. In A. B. Wallace (Ed.), Trans. Internat. Soc. Plastic Surgeons, Second Con
gress, London, 1959. Edinburgh and London: E. & S. Livingston Ltd., 50-57, 1960.2. MILLARD, D. R., JR., A primary camouflage of the unilateral harelook. Presented at
First International Congress of Plastic Surgeons, Stockholm, 1955. Internal. Con-
gress Transactions, 1957.3. MILLARD, D. R., JR., A primary compromise for bilateral cleft lip. Surg., Gyn., Obst.,
3, 557-563, 1960.4. MILLARD, D. R., JR., A radical rotation in single harelip. Amer. J. Surg., 95, 318-322,
1958.5. MILLARD, D. R., JR., Complete unilateral clefts of th e lip. Plastic reconstr. Surg., f25,
595-605, 1960.6. MILLARD, D. R., JR., Refinements in rotation-advancement cleft lip technique. Plastic
reconstr. Surg., 33, 26--38, 1964.7. STARK, R. B., Th e pathogenesis of harelip and cleft palate. Plastic reconstr. Surg.,