Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1154e1160

A geometrically justified rotation advancementtechnique for the repair of completeunilateral cleft lip

Xing He a, Bing Shi b,*, Sheng Li a, Qian Zheng b

a Department of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu, Chinab State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu, China

Received 17 August 2007; accepted 16 December 2007

KEYWORDSGeometrically justifiedrotation advancementtechnique;Angular bisector;Rotation advancement;Face casts

* Corresponding author. Address: SDiseases, West China Dental School,Section 3, Ren Min Nan Road, Chengdu61153005; fax: þ86 18 85501570.

E-mail address: shibingcn@sina.co

1748-6815/$-seefrontmatterª2008Bridoi:10.1016/j.bjps.2007.12.087

Summary A modification of the Millard rotation advancement technique for repair ofcomplete unilateral cleft lip has been used in our medical centre for the past six years. Wedeveloped this geometrically justified technique based on our experience treating manypatients in our department. Based on the analysis of pre- and postoperative face casts of eachpatient, as well as based on the comparison between patients and controls, we found that ourtechnique achieved excellent cosmetic results, giving a natural-looking lip.ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

A modification of the Millard rotation advancement tech-nique for repair of complete unilateral cleft lip has beenused in our medical centre for the past 6 years. Thismodification was developed by analysing the treatment ofpatients in our department. We made face casts of eachpatient preoperatively, immediately postoperatively, andone year later when the patient returned for repair of thecleft palate (Figures 1e3).

tate Key Laboratory of OralSichuan University, No. 14,610041, China. Tel.: þ86 28

m (B. Shi).

tishAssociationofPlastic,Reconstruc

Patients and methods

Study approval

The research protocol was approved by the EthicalCommittee of Sichuan University. Parents of the patientsprovided written informed consent for the procedures.

Patient selection

For the past 6 years, our medical centre has been carryingout a geometrically justified rotation advance technique. Ithas been used exclusively to repair defects in a completeunilateral cleft lip and palate (CLP).

To evaluate this modification, we made a retrospectivestudy of 85 patients using measurements from face casts

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 1 Facial cast before primary repair of the lip. 1: lipheight on the cleft side. 2: lip height on the non-cleft side. 3:lip width on the cleft side. 4: lip width on the non-cleft side.

Figure 3 Facial cast one year after primary repair of the lip.1: lip height on the cleft side. 2: lip height on the non-cleftside. 3: lip width on the cleft side. 4: lip width on the non-cleftside.

A geometrically justified rotation advancement in complete unilateral cleft lip 1155

made preoperatively, immediately postoperatively, and 1year later when the patient returned for repair of the cleftpalate. Patients had undergone the geometrically justifiedmethod at the time of primary repair of the lip.

Fifty-eight patients were male and 27 were female. Theaverage age of patients when they underwent repair of the

Figure 2 Facial cast immediately after primary repair of thelip. 1: lip height on the cleft side. 2: lip height on the non-cleftside. 3: lip width on the cleft side. 4: lip width on the non-cleftside.

cleft palate was 18 months. The control group was 45patients who had an incomplete cleft palate only (CPO). Weconsidered the face of a patient with incomplete CPO to benormal. The average age of CPO patients was 17 months.

Lip height (distance from each peak of the cupid’s bowto the ipsilateral alar base), lip width (distance from eachpeak of cupid’s bow to the ipsilateral commissure) and theheight and width of the nostril were measured. Wecompared the measurements of both sides immediatelypostoperatively and at one year after primary surgery. Wecompared the measurements of complete unilateral CLPpatients one year after the primary operation with those ofthe control group of CPO patients (Table 1).

Statistical analyses

Paired t-test was used to compare parameters between thenon-cleft side and cleft side in the lip and nose area. Non-paired t-test was employed to compare the parameters inthe study group and control group. P Z 0.05 was consideredsignificant.

Technique

Markings for unilateral complete cleft

Preoperative markings for the unilateral complete cleft aredemonstrated in Figure 4. The points to be marked are thecentral point of cupid’s bow and the right peak of thecupid’s bow on the non-cleft side (point 1, point 2) andboth alar bases (point 9, point 10); the other points aremarked on a geometric basis. The distance from point 2to point 10 is measured, and an equal distance from point

Table 1 Measurements in the lip and nose area

Immediately after surgery P1 One year after surgery P2 Control group P3

mean SD mean SD mean SD

Lip height on cleft side 9.8 1.57 12.04 1.75 12.14 2.36 0.911Lip height on non-cleft side 10.91 1.6 0.00 13.23 1.69 0.3 12.06 1.85 0.155Lip width on cleft side 19.15 2.03 20.65 3.58 24.35 1.9 0.015Lip width on non-cleft side 20.47 2.32 0.024 21.5 2.87 0.312 25.29 1.32 0.002

P1 reflects the symmetry between the cleft side and non-cleft side of each parameter immediately postoperatively; P2 reflects thesymmetry between the cleft side and non-cleft side of each parameter one year after surgery; P3 reflects the similarity of eachparameter between the study group and the control group one year after surgery.

1156 X. He et al.

9 to the peak of cupid’s bow on the cleft side (point 4) ismarked. The distance between points 1 and 2 is measured,and an equal distance from point 1 to the left peak ofcupid’s bow on the non-cleft side (point 3) is marked. Point5 is on a line bisecting the angle of 2-1-3, which allows point5 to move along the line. We always mark this point at theposition where the bisector of angle 2-1-3 and the philtralcolumn intersect. Point 6 divides the columella base as 1/3cleft part and 2/3 non-cleft part. Point 7 and point 8 are theends of the incisions on the lip. The wet line on thevermilion on each side is marked so it can be matched atthe time of closure of the vermilion. The incisions on the lipand vermilion of this modified technique are seen in Figures4 and 5, respectively.

Modified Millard rotation-advanced technique

The modified rotation advancement incision starts frompoint 5, is extended superiorly towards point 6, and carrieddownward to point 3. The line connecting point 5 and point 3in our modified technique is not a curve, but an angle. Frompoint 3, the incision on the white lip extends superiorly alongthe white skin roll towards the nose. The incision on thevermilion is a Z shape (Figures 4 and 5).

Figure 4 Points of reference. 1: central point of cupid’s bow.2: right peak of cupid’s bow on the non-cleft side. 3: left peakof cupid’s bow on the non-cleft side. 4: peak of cupid’s bow onthe cleft side. 5: junction of the line bisecting the angle 2-1-3and the philtral column on the non-cleft side. 6: base of thecolumella. 7e8: end of the incision on the lip. 9e10: base ofthe ala.

Surgery continues with rotation advancement incisionthrough the skin, maintaining the integrity of muscle andmucosa. The muscle is dissected free from skin and mucosafor a distance of 3e4 mm. A horizontal cut is made throughthe muscle under the columella to rotate the displacedmuscle into a normal position, from where it attaches tothe base of the columella and anterior nasal spine. The endof the horizontal cut can extend underneath point 5 toachieve sufficient rotation of point 3.1

When incision and dissection of the medial lip iscomplete, we cut through the skin on the cleft side frompoint 4 to point 8 along the white skin roll, and from point 8to point 9 horizontally. The incision on the vermilion on thecleft side is shown in Figures 4 and 5. Muscle is dissectedfree from skin and mucosa for �3e4 mm depending on thewidth of the cleft and the degree of tension.

Dissection of the displaced muscle from the maxillae willrotate the peak of cupid’s bow downward on the cleft side.An incision of 1 cm is made along the vestibular sulcus onthe cleft side. This incision cuts through the periosteum ofthe alveolar process, and the periosteum is undermined.The periosteum is undermined from the alar base to themargin of the piriform aperture. Dissection of the orbicu-laris oris muscle from its abnormal attachment is importantto establish normal shape and function of the lip.

The muscle, subcutaneous tissue and skin are approxi-mated after dissection of the orbicularis oris muscles. With

Figure 5 Incisions for this new technique are marked on thelip and vermilion.

A geometrically justified rotation advancement in complete unilateral cleft lip 1157

elevation of the cleft side nasal rim, the C-flap movesupward and can be sutured on the cleft side of the colu-mella without tension. The skin flap medial to the alar baseon the cleft side is turned over 90� and sutured to the skinflap of the columella and the C-flap to close the anteriorpart of the nasal floor (Figure 6).

The wet line on the vermilion on each side of the cleft ismatched at the time of closure of the vermilion. This colourmatch of the vermilion produces an improved cosmeticresult. The triangular flap is the main technique for closingthe vermilion and mucosa. Many small triangular flaps canmake the vermilion and mucosa appear more natural. Thevestibule is closed by suturing the mucosa on the cleft sideto the frenulum and periosteum of the alveolar process onthe non-cleft side, which closes the fistula between the oraland nasal cavities.

Results

Parameters in the labionasal area (Table 1) were measuredusing face casts and are discussed below.

Average lip height on the cleft side was 9.8 mm and was10.91 mm on the non-cleft side immediately post-operatively. The height of the lip on the non-cleft side wassignificantly larger than on the cleft side (P Z 0.000). Oneyear postoperatively, the height had increased to 12.04 mmand 13.23 mm, respectively; the difference between thetwo sides was not significant (P Z 0.3). Lip height betweenthe study group and control group was not significantlydifferent (cleft side, P Z 0.911; non-cleft side, P Z 0.155).

Average lip width (distance between lateral commissureand ipsilateral peak point of cupid’s bow) of the cleft sidewas 11.5 mm and was 20.47 mm on the non-cleft sideimmediately postoperatively. The width of the lip on thenon-cleft side was significantly longer than on the cleft side(P Z 0.024). One year later, the width increased to20.65 mm and 21.5 mm, respectively, with no significant

Figure 6 The C-flap moves upward and sutures to the cleftside columella. The skin flap medial to the alar base on thecleft side is turned over 90� and sutured to the skin flap of thecolumella and C-flap (arrowed).

difference between the two sides (P Z 0.312). Lip width inthe study group was significantly shorter than in the controlgroup (cleft side, P Z 0.015; non-cleft side, P Z 0.002).

These data show that both parameters were asymmet-rical between the cleft and non-cleft side immediatelypostoperatively, but the difference between the two sidesmarkedly decreased. One year later, both parameters weresymmetrical between the cleft and non-cleft side. Incomparison with the control group, the lip height of thestudy group was normal one year after surgery, but the lipwidth was significantly shorter than normal on both sides.This was the result of the design of our procedure.

Preoperative and postoperative examples of thisgeometrically justified procedure are shown in Figures 7e15.

Discussion

The validity for this geometrically justified rotationadvancement technique for primary repair of the lipincludes several important scientific aspects, which arediscussed below.

Applying the principle of geometry topreoperatively mark points and incisions

Literature reviewMillard’s technique focuses on repositioning of theanatomical structures to make the lip look as normal aspossible. It is the most widely accepted techniqueworldwide.

Millard’s technique is good for repair of the completeunilateral cleft lip, but has some disadvantages. Thetechnique for repositioning of the anatomical structures isa ‘cut as you go’ technique. This makes it difficult todetermine the end of the medial incision, so the lip heightusing Millard’s technique tends to be too short.2

Why our department proposed the geometrically justifiedrotation advancement techniqueThe modified technique applies several principles ofgeometry to mark the points and incisions preoperatively.

Figure 7 Patient 1: is the frontal picture taken preoperatively.

Figure 10 Patient 2: is the frontal picture takenpreoperatively.

Figure 8 Patient 1: is the frontal picture taken 7 days aftersurgery when the stitch was removed.

1158 X. He et al.

Based on the evaluation of healthy children, the ‘W’ isdepicted using five points: bilateral ala bases, the two peakpoints of cupid’s bow, and the base of the columella. Thelatter and the two high points of cupid’s bow form anisosceles triangle. In patients with complete unilateral CLP,the integrity of the W is interrupted, and the isoscelestriangle disappears. After observing numerous patients withcomplete unilateral CLP, we discovered that the point onthe bisector of the angle 2-1-3 and point 2 and point 3organise another isosceles triangle. So, the bisector of theangle 2-1-3 can be considered to be the inclining midline ofthe upper lip because of the cleft. When point 3 is rotateddownward to the same horizontal level as point 2, thebisector of the angle 2-1-3 is rotated to the middle of theupper lip. Thus, the midmost position of the isoscelestriangle of the upper lip is recreated.

Geometry dictates that if point 5 is taken as the centreof a circle and point 3 is needed to rotate downward, the

Figure 9 Patient 1: is the frontal picture taken one yearafter primary surgery.

longer the distance from point 5 to point 3 in the verticaldirection, the shorter the distance point 3 will rotatedownward. The longer the distance from point 5 to point 3in the horizontal direction, the longer the distance rotateddownward at point 3. So point 3 will have more downwardrotation when point 5 moves infer-laterally. In Millard’stechnique, the end of the medial incision is always locatedsuperiorly and medially to the bisector,3 so point 3 may notget sufficient descent, and lip height on the cleft side willbe too short. Conversely, the end of the medial incision isalways located inferiorly and laterally to the bisector inTennsion’s technique, so point 3 may get sufficient descent,and lip height on the cleft side may be too long.

Figure 11 Patient 2: is the frontal picture taken 7 days aftersurgery when the stitch was removed.

Figure 12 Patient 2: is the frontal picture taken one yearafter primary surgery.

Figure 14 Patient 3: is the frontal picture taken 7 days aftersurgery when the stitch was removed.

A geometrically justified rotation advancement in complete unilateral cleft lip 1159

Not only the level of vertical rotation of the peak pointof cupid’s bow, but also the horizontal level of extension ofthe tip point of C-flap is determined by geometry. Similarly,point 5 is taken as the centre of a circle and point 3 isneeded to extend to the cleft. The shorter the distancefrom point 5 to point 3 in the vertical direction, the shorterthe distance point 3 will extend to the cleft. The longer thedistance from point 5 to point 3 in the horizontal direction,the shorter the distance point 3 will extend to the cleft. Sopoint 3 can get more extension when point 5 moves supe-rior-medially. In Tennsion’s technique, the end of themedial incision is always located inferior and lateral to thebisector,4 so tip point of C-flap (point 3) may not getsufficient extension, and the tension on the upper lip is

Figure 13 Patient 3: is the frontal picture takenpreoperatively.

greater. Conversely, the end of the medial incision is alwayslocated superior and medial to the bisector in Millard’stechnique, so tip point of C-flap (point 3) may get sufficientextension, and the tension on the upper lip is light.

Our technique gives an improved appearance forcomplete unilateral CLP in comparison with the Millardtechnique. The key foundation is the theory of the angularbisector demonstrated above: the end of the medial inci-sion is located on the angular bisector.

The other principles of geometry in our techniqueBased on geometry discipline and research, we discoveredthat no matter how the line between point 3 and point 5

Figure 15 Patient 3: is the frontal picture taken one yearafter primary surgery. Lip shape is good one year after primaryrepair.

Figure 16 Regardless of the shape of the line between point3 and point 5, the distance of descent of point 3 is fixed if point3 and point 5 are unchanged.

Figure 17 Cutting through the skin, muscle and mucosaalong different incisions.

1160 X. He et al.

shapes, the rotation of point 3 is in such a way that point 5is the centre of a circle, and the linear distance betweenpoint 3 and point 5 is the radius. So the descent of point 3 isfixed if the points are unchanged. We now designed theshape of the line between point 3 and point 5 as a solid line(Figure 16) because it made the postoperative scar ofincision straighter and more closed to the normal philtrumcolumn. It can reduce the oblique scar of the upper lip onthe cleft side, which is uglier and more uncomfortable thanthe rectilinear scar. It can also prevent the nares on thecleft side getting smaller.

The peak of cupid’s bow on the cleft side is determinedby lip height on the non-cleft side. This method of markingcan keep the symmetry of lip height between both sidesthroughout the primary lip repair, and prevents the lipheight from being too short on the cleft side, as may beseen in Millard’s technique. Shortening of the lip height onthe cleft side is the main disadvantage of Millard’stechnique.2

In some cases, distance from the peak of the cupid’s bowto the lip commissure may be quite short on the cleft side.The horizontal length of the lip is sacrificed to keep thesymmetry of the vertical height of the lip. A lip that isvertically short is far more conspicuous than one that ishorizontally short. Gundlach et al.5 feel that a high valueshould be set on the symmetrical height of the upper lipwhen estimating the cosmetic results of lip surgery. We donot adopt the triangular flap described by Noordhoof et al.6

above the white skin roll; it increases the number of inci-sions, and a more obvious scar above the white skin roll isseen in Asians. Cutting et al.7 said that deficiencies in lipwidth show a statistically significant normalization as thepatient grows, whereas Saunders et al.2 said a repairedunilateral cleft lip retains the height determined at thetime of initial repair. We therefore believe our technique ofmaintaining the symmetry of lip height by sacrificing thewidth of the horizontal lip is rational.

Point 6 divides the columella base as 1/3 cleft part and2/3 non-cleft part. It is good for correcting the oblique

columella. We adapted this mark based on the suggestionproposed by Cutting.7

The theory of rotation advancement step by step

We cut through the skin, muscle and mucosa along eachincision: this is a key feature of our technique. Literaturereview shows that most authors cut through the entire layerof the upper lip, including skin, muscle and mucosa, sothere is only one incision when the cut is made.6,8 Theincision on the skin forms the C-flap used to elongatethe columella. The muscle incision is on the line where themalpostioned muscle attaches to the base of the columella.The medial incision under the columella separates themalpositioned muscle from the anterior nasal spine, andthe end of this incision is on the angular bisector. Thehorizontal incision on the mucosa goes through point 3 andterminates on the angular bisector (Figure 17). Skin, muscleand mucosa all descend to a similar level as the rotationtake place in this process.

References

1. Shi B. The study of operative design in unilateral cleft lip-repairbetween individual procedural method as compared to rotationadvancement and triangular flap method. Hua Xi Kou Qiang YiXue Za Zhi 2001;19:28e31.

2. Saunders DE, Maler A, Karandy E. Growth of the cleft lipfollowing a triangular flap repair. Plast Reconstr Surg 1986;77:227e37.

3. Millard RD. Primary correction of unilateral cleft nose: a moreaccurate diagram. Plast Reconstr Surg 1999;103:2094.

4. Lazarus DD, Hudson DA, Fleming AN, et al. Repair of unilateralcleft lip: a comparison of five techniques. Ann Plast Surg 1998;41:587e94.

5. Gundalach KK, Schmitz R. Late results following differentmethods of cleft lip repair. Cleft Palate J 1982;19:167e71.

6. Noordhoof SM, Chen KT. The surgical technique for thecomplete unilateral cleft lip-nasal deformity. Oper Tech PlastReconstr Surg 1995;1:167e74.

7. Cutting CB, Dayan JH. Lip height and lip width after extendedMohler unilateral cleft lip repair. Plast Reconstr Surg 2003;111:17e23 [discussion: 24e6].

8. Mohler L. Unilateral cleft lip repair. Plast Reconstr Surg 1987;80:511.