Sei sulla pagina 1di 5

Asian J Oral Maxillofac Surg 2003;15:1xx-1xx.

Amaratunga
Asian J Oral Maxillofac Surg 2004;16:5-9.
CLINICAL OBSERVATIONS

Combining Millard’s and Cronin’s Methods of Unilateral


Cleft Lip Repair — a Comparative Study

Nihal Asoka de Silva Amaratunga


Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka

Abstract
Objective: To determine whether Millard’s and Cronin’s methods of cleft lip repair could be combined to
retain the advantages and eliminate the disadvantages of each method.
Patients and Methods: Fifty nine patients with unilateral cleft lip and palate were randomly allocated for 3
methods of lip repair: Millard’s method, Cronin’s method, and a combination of the 2 methods. The design
of the combined method consisted of a modified Millard incision and a 2 mm triangular flap placed 1 mm
above the white roll. Muscle repair was done in all 3 methods. Three months after surgery, symmetry of the
lip and nose was assessed using the Cleft Lip Component Symmetry Index.
Results: The Cleft Lip Component Symmetry Index score of the philtral height, vermillion height, and Cupid’s
bow height achieved with the combined method was comparable to that achieved with Cronin’s method and
was superior to that obtained with Millard’s method. Further, the combined method achieved a Cleft Lip
Component Symmetry Index score for the philtral width that was not significantly different from that of
Millard’s method and better than that of Cronin’s method.
Conclusion: The advantages of Millard’s and Cronin’s methods, which are the most widely used methods of
cleft lip repair, could be retained and the disadvantages eliminated to a great degree by combining the 2
methods. A basic muscle repair could also be included in the new combined method.

Key words: Cleft lip, Cleft palate, Randomised study, Repair

Introduction the need for geometrical reconstruction of the


Of the several methods of cleft lip repair, those Cupid’s bow by rotational advancement or triangular
described by Millard1 and Cronin2 seem to have stood flaps,4,5 others seem to totally disregard the need
the test of time and are widely used in many parts of for muscle repair.6 All of these researchers claim to
the world. While Millard’s method is popular in the have produced excellent results in long-term follow-
USA and the UK,1 Cronin’s method seems to be up studies.
popular in Europe and parts of Asia, including Japan.2
These 2 methods focus on achieving lip symmetry When considering the possibility of combining
by bringing down the elevated summit of the cupid’s muscle repair with conventional methods such as
bow on the cleft side. Millard’s and Cronin’s methods, the question arises
as to whether elaborate muscle repair is absolutely
Recent concepts, however, have drawn attention necessary, or whether simple dissection aimed at
to the need for muscle repair,3 although there appears placing the orbicularis oris muscle in its correct
to be much controversy regarding the extent of muscle anatomical position would suffice. While most
dissection that is necessary. While some researchers researchers agree that muscle repair is beneficial,
emphasise muscle repair to the extent of excluding there does not seem to be sufficient evidence to
support the view that elaborate repositioning of labial
Correspondence:
Nihal Asoka de Silva Amaratunga, Faculty of Dental Sciences, as well as nasal muscles is essential. Good functional
University of Peradeniya, Peradeniya, Sri Lanka. as well as aesthetic results have been achieved without
Tel: (94 8) 2388 948; Fax: (94 8) 2388 948;
E-mail: nadesa@pdn.ac.lk such extensive muscle repair.7

Asian J Oral Maxillofac Surg Vol 16, No 1, 2004 5


Comparative Study of Cleft Lip Repair

An important consideration is whether a particular


method should be selected to suit a particular cleft
lip. Obviously, any method would give good results
when the defect is minimal such as incomplete cleft
lip without cleft palate. In the case of more extensive B
defects such as complete cleft lip with cleft alveolus A
and palate where the bony segments are malaligned,
the question arises as to whether there are morpho-
logical variations in the cleft lip that justify the
adaptation of different methods to suit different lips.

In this regard, it is known that Cronin’s method


brings down the caudally displaced Cupid’s bow more Figure 1. Incision lines of the combined method and area of
muscle dissection (shaded).
satisfactorily and achieves a better looking Cupid’s
bow than Millard’s method. Hence, it follows that above (Figure 1). McComb’s method9 was employed
Cronin’s method may be more suitable where the to correct the nasal defect in all patients. All patients
Cupid’s bow is greatly displaced. On the other hand, had a preoperative difference of more than 5 mm
the scar produced by Millard’s method looks more between the measurements A and B on Figure 1 —
natural as it is positioned to look like the philtral this is the distance between the summit of the Cupid’s
column and matches that of the non-cleft side. bow and the columella base on each side, which is a
measure of the displacement of Cupid’s bow on the
The obvious question that follows is whether cleft side. One surgeon operated on all the patients.
Millard’s and Cronin’s methods could be combined
to good effect through eliminating the disadvan- The results of the repair was assessed 3 months
tages of each method. The main goals of such a after surgery using the measurements given in Figure
combination would be to construct a better Cupid’s 2 and calculating the Cleft Lip Component Symmetry
bow and to position the scar to simulate the philtral
column. If basic muscle repositioning could be
achieved at the same time, then this would be an added
advantage.

Patients and Methods


An attempt was made to design a method of unilateral
cleft lip repair that would combine the features of b
Millard’s and Cronin’s methods and also include
muscle dissection. The design consists of the a
modified Millard’s incision line8 and a triangular flap g c
with a base of 2 mm placed 1 mm above the white
e
roll (Figure 1). Muscle dissection could be carried f
out to the extent shown by the shaded area in Figure
d
1. This method was employed to repair the cleft lip
of 20 patients (combined method group) with
unilateral cleft lip and palate. Millard’s method was
employed for another 18 patients (Millard group) with
similar defects, and Cronin’s method was used for
21 patients (Cronin group). These 59 patients were
randomly allocated to one of the 3 methods. Muscle Figure 2. Measurements for the calculation of the Cleft Lip
repair was carried out in all patients as described Component Symmetry Index.

6 Asian J Oral Maxillofac Surg Vol 16, No 1, 2004


Amaratunga

Index10 for each of the following components of the Results


lip and nose: nostril width (a), nostril height (b), Table 1 gives the age and sex distribution of the
philtral height (c), vermillion height (d), Cupid’s bow patients at the time of surgery in relation to the
width (e), and Cupid’s bow height (f). different methods of cleft lip repair. Average Cleft
Lip Component Symmetry Index values for each lip
An additional measurement not included in the and nose component in relation to the different
previously described Cleft Lip Component Symmetry treatment groups are presented in Table 2. An
Index was carried out to determine the symmetry of the important finding was that there was no statistically
philtral columns in the transverse plane by measur- significant difference between the scores for the
ing the horizontal distance from the midline to the philtral height in the Cronin group and the com-
philtral ridge (scar in the cleft side) at a level midway bined method group while the value in the Millard
between the columellar base and the white roll (g). group was significantly different from that of the
Measurements were made directly on the patient other 2 groups (p < 0.01). There was no statistically
under oral sedation using a vernier caliper accurate significant difference in the philtral width Cleft
to 0.1 mm. The Cleft Lip Component Symmetry Lip Component Symmetry Index score between
Index was calculated using the formula given below: the combined method group and the Millard group.
Cleft Lip Component Symmetry Index However, this score was increased in the Cronin group
for philtral height = compared with the other 2 groups (p < 0.01).
Philtral height on the cleft side C
x 100 = 2 x 100 The Cleft Lip Component Symmetry Index score
Philtral height on the normal side C1
for Cupid’s bow height was decreased in the Millard
A Cleft Lip Component Symmetry Index score group compared with the other 2 groups, while the
of 100 would indicate the perfect symmetry of each values for Cupid’s bow width showed no significant
component and a value either less or more would difference between the 3 groups (p < 0.01). The
mean a degree of asymmetry. The significance of the vermillion height symmetry index of the combined
difference between the scores for each component in group was not different from that of the Cronin group,
the different methods was determined using student’s but the value for the Millard group was reduced
t-test. compared with the other 2 groups (p < 0.01). Scores

Age (days) Millard’s group (n = 18) Cronin’s group (n = 21) Combined method group (n = 20)
Male Female Male Female Male Female
70-84 1 0 2 1 2 0
85-98 1 0 0 2 1 2
99-112 6 4 8 3 6 2
113-126 2 0 1 2 3 2
127-140 1 3 2 0 1 1
Total 11 7 13 8 13 7
Table 1. Age and sex distribution of patients at surgery.

Component Millard’s group (n = 18) Cronin’s group (n = 21) Combined method group (n = 20)
Nostril width (a) 95.7 98.6 95.3
Nostril height (b) 93.1 92.5 91.7
Philtral height (c) 88.2 98.7 98.3
Vermillion height (d) 87.3 97.1 96.5
Cupid’s bow width (e) 95.3 99.6 96.4
Cupid’s bow height (f) 76.5 86.1 87.2
Philtral width (g) 97.4 111.3 96.8
Table 2. Cleft Lip Component Symmetry Index average scores in each treatment group.

Asian J Oral Maxillofac Surg Vol 16, No 1, 2004 7


Comparative Study of Cleft Lip Repair

for nostril height symmetry were significantly This is one of the main disadvantages of Cronin’s
reduced below the ideal symmetry score of 100 in all method. The combined method, by making the flap
3 groups. However, the nostril width symmetry score smaller, attempts to overcome this problem while
was significantly increased in the Cronin group breaking the linear scar at the same time. Adequate
compared to the other 2 groups (p < 0.01). rotation is ensured by the combination of Millard’s
incision line with the triangular flap. In the new
Discussion combined method, the triangular flap is placed 1 mm
Lack of consensus for an ideal method for the repair above the white roll as advocated by Cronin, thereby
of the unilateral cleft lip is reflected in the widely avoiding distortion of the continuity of the white roll,
differing opinions and claims submitted by operators which could happen when the flap is placed over the
who practice different methods. Millard’s method had white roll.
been modified by Millard himself and also by others.
Cronin’s method is an improvement on the triangular The results of the present study show that the
flap method designed by Randall11 and Tennison.12 philtral width symmetry achieved in Cronin’s method
Some surgeons introduce their own modifications is poor. The scar is positioned laterally and therefore
to the Millard’s method such as a small (1 mm) does not match the philtral column of the non-cleft
triangular flap over the white roll. Omitting the alar side. The combined method brings the scar medially
base incision in the lateral segment (into which the C by adapting Millard’s incision line. The results show
flap is inserted) is yet another modification. that the philtral width symmetry is satisfactory with
this method and compares favourably with the scar
Although an attempt to combine Cronin’s and positioning achievable with Millard’s method.
Millard’s methods have not been previously reported
some of the above-mentioned modifications could In this study, a basic muscle dissection was
be considered to be such attempts. Attempts to performed for all the methods. In the original methods
combine other methods have previously been of Millard and Cronin of unilateral cleft lip repair,
reported.13 The present study assesses the results of a no muscle dissection had been included. The im-
definite attempt to combine Millard’s and Cronin’s portance of muscle dissection was realised with the
methods of cleft lip repair where the critical features better understanding of the abnormality in the muscles
of Millard’s and Cronin’s methods are retained of the cleft lip.14,15 Authors who advocate extensive
while omitting the disadvantages. The results reveal muscle repair disregard the need for geometrical
that the philtral column symmetry achieved in the correction of philtral height, Cupid’s bow, and so
combined method is better that that of Millard’s on.4,16 The present study demonstrates that all these
method and is closer to Cronin’s method, which concepts can be combined to achieve better results.
could be considered to be the best for achieving a
symmetrical Cupid’s bow. References
1. Millard DR. Complete unilateral clefts of the lip.
The reasons for the less than satisfactory philtral Plast Reconstr Surg 1960;25:595-605.
height symmetry experienced with Millard’s method 2. Cronin TD. A modification of the Tennison type
could be due to the inadequacy of rotation and lip repair. Cleft Palate J 1966;3:376-382.
contracture of the straight line scar. Cronin’s method 3. Kernahan DA. Muscle repair in unilateral cleft
attempts to solve both these problems by lip based on findings on electrical stimulation.
mathematically calculating the distance of rotation Ann Plast Surg Surg 1978;1:48-53.
required and breaking the line of the scar by the 4. Delaire J. General consideration regarding
introduction of the triangular flap. However, with this primary physiologic surgical treatment of labio-
technique the triangular flap could have a base as maxillopalatine clefts. Oral Maxillofac Surg
large as 4 mm in patients where the Cupid’s bow is Clinics 2000;12:361-378.
displaced to a large degree. Such a large flap may 5. Thatte RL, Prasad S. Radical muscle mobilization
produce a fairly large scar placed across the philtrum. in the surgical repair of a unilateral cleft lip:

8 Asian J Oral Maxillofac Surg Vol 16, No 1, 2004


Amaratunga

a follow up report. Br J Plast Surg 1984;37: 12. Tennison CW. The repair of the unilateral cleft
296-302. lip by the stencil method. Plast Reconstr Surg
6. Katsuki T. Atlas of cleft lip surgery. Tokyo: 1952;9:115-125.
Kuesochitsusesu; 2002:30-54. 13. Wang MK. A modified LeMesurierTennison
7. Sawhney CP. Geometry of single cleft lip repair. technique in unilateral cleft lip repair. Plast
Plast Reconstr Surg 1972;49:518-521. Reconstr Surg 1969;26:190-196.
8. Millard DR. Cleft craft. Vol I. The unilateral 14. Fara M. Functional anatomy of lip and palate and
deformity. Boston: Little Brown & Co.; 1976: its application to cleft lip and palate surgery. In:
449-485. Jackson IT, editor. Recent advances in plastic
9. McComb H. Treatment of the unilateral cleft lip surgery. Vol 2. Edinburgh: Churchill Livingstone;
nose. Plast Reconstr Surg 1975;55:596-601. 1981:145-163.
10. Amaratunga NA de S. A comparison of Millard’s 15. Kernahan DA, Dado DV, Bauer BS. The anatomy
and LeMesurier’s methods of repair of the com- of the orbicularis oris muscle in unilateral
plete unilateral cleft lip using a new symmetry cleft lip based on three-dimensional histologic
index. J Oral Maxillofac Surg 1988;46:353-356. reconstruction. Plast Reconstr Surg 1984;73:
11. Randall P. A triangular flap operation for the 875-879.
primary repair of unilateral clefts of the lip. Plast 16. Precious DS. Unilateral cleft lip and palate. Oral
Reconstr Surg 1959;23:331-347. Maxillofac Surg Clinics 2000;12:399-420.

Asian J Oral Maxillofac Surg Vol 16, No 1, 2004 9

Potrebbero piacerti anche