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