Millard Rotation Principle

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Rotation-Advancement Principlein Cleft Lip Closure

D. RALPH MILLARD, JR., M.D., F.A.C.S.Miami, Florida

Correction of prealveolar, alveolar, and postalveolar clefts poses a five-

fold project: natural appearance, functional dentition, unimpaired hearing,

normal speech, and well-adjusted personality. This multifaceted task takes

a team of specialists: pediatrician, prosthodontist, orthodontist, pedo-dontist, otolaryngologist, speech therapist, plastic surgeon, and psychi

atrist. I t is natural and commendable that each specialist show enthusiasm

for his own specific responsibility yet it never should be forgotten that the

cumulative effect of all working together promises the closest approach to

a normal end point. I t is well, however, to put first things first; for no

matter how excellently the patients hears, bites, or sings, if he ends up

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 the final appearance of the

patient, but then so is the construction of the lip and nose.

A most vital decision toward this goal is th e optimum time for lip

surgery. The primary surgical repositioning of the lip and nose at present

is being carried out at about three months by this author. This tentative

date has 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 the maxillary

components. Closure of th e lip with moderate tension, high across the

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 the noncleft side over the cleft side, then lip closure will force

them into overlapped collapse. In such cases it would seem that postpone-

ment of surgery is indicated until prosthodontic manipulation can align

both maxillary components. Once this has been achieved, lip closure withit s muscle molding effect will cont inue to improve th e situation.

In order to transform a cleft lip with nasal deformity into normal, it is

essential first to define the normal. Then a careful detailed study of what

is present in each individual case is essential before i t is possible to utilize

to the best advantage what we have to make what we want.

Dr . Millard is affiliated with the Department of Surgery, University of MiamiSchool of Medicine.

Presented at th e 1963 Convention of th e American Cleft Palate Association,Washington, D. C.

246



ROTATION-ADVANCEMENT 247

FIGURE 1. An example of the normal with its landmarks.

The Normal (Figure I)

The nonnal nose has a straight columella of adequate length backed by

a straight septum. Symmetrical alar arches are supported by equivalent

alar cartilages and rest on equally balanced alar bases. Equal nasal floors

arc bounded by nostril sills. The normal upper lip with its intact orbicularis

oris musculature has a philtrum with curved column prominences bounding

a central dimple. The gentle curving cupid's bow with it s midline vermilion

tubercle is highlighted by a white skin roll along its upper mucocutaneous

junction. The natural position of the lips places the loose upper lip, with

eversion of its lower portion, over and slightly in front of th e lower lip.

There must be an adequate and symmetrical bony platform to support the

soft tissues of the nose and lip.

Cleft Variations

Each cleft lip deformity varies but in broad generalities the lip-nose

distortion can be divided into unilateral incomplete cleft with nasal de

formity, unilateral complete cleft with nasal deformity, bilateral incom-

plete cleft with adequate collumella, bilateral complete cleft with inade

quate columella, and various degrees of the rare median cleft. Whether

or not there is an alveolar defect and/or associated postalveolar palate

cleft is also important. Maxillary and premaxillary prosthodontic and

orthodontic manipulation, alveolar bone grafting, palate closure, and

lengthening will not be discussed in this paper.

Unilateral Deformity and Its Correction

In a unilateral cleft of the lip with nasal deformity there are varying

degrees of absence of tissue as well as actual distortion. The vital primary



248 }vf llard

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.



252 Millard

Summary

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

2121 Biscayne Boulevard

Miami, Florida 33137

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.,

13, 20-39, 1954.

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Millard Rotation Principle