Bart Nierzwicki¹ and Thaer Daifallah²

¹Private Practice, Millennium Surgical, Chicago, Illinois, USA

²Department of Oral and Maxillofacial Surgery, University of Missouri–Kansas City, Kansas City, Missouri, USA

A technique of repairing congenital lip defects utilizing a three-layer closure of skin, muscle, and mucosa to achieve nasal and labial symmetry and normal lip function with minimal visible scarring.

Indication

1. Unilateral or bilateral, complete or incomplete cleft lip deformity

Contraindications

1. No absolute contraindications
2. Adequate patient’s age, weight, and hemoglobin (“rule of 10s”)

Anatomy

1. Orbicularis oris muscle
2. Columella
3. Philtral ridges and tubercle (procheilon)
4. White skin roll (epidermis–vermilion junction line)
5. Red line (vermilion–mucosa junction line)
6. Alar cartilage
7. Lower lateral cartilage
8. Nasal septum
9. Anterior nasal spine

Modified Millard’s Rotation-Advancement Flap Technique

1. The patient is placed supine on the operating table and orally intubated with a RAE endotracheal tube.
2. The oral cavity and face are prepped with povidone–iodine and draped.
3. A sterile marking pen or methylene blue on a 30G needle tip are used to mark the rotational flap (M flap), advancement flap (L flap), columella flap (C flap), and turbinate flap. Points of the Cupid’s bow are marked on the epidermis–vermilion junction line (the white skin roll), and the vermilion–mucosa junction line (the red line) is also marked (Figure 27.1; see also Figure 27.3 in Case Report 27.1). Important landmarks in marking order:
   • Landmark 2 is the top of the Cupid’s bow on the noncleft side.
   • Landmark 3 is the end of the white roll on the noncleft side.
   • Landmark 1 represents the middle of the Cupid’s bow.
   • Landmark 3’ is the end of the white roll on the cleft side.
   • Landmark 4 is the noncleft-side labial commissure.
   • Landmark 5 is the cleft-side labial commissure.
   • Landmark 6 is the center of the columella.
   • Landmark 7 is the base of the columella on the noncleft side.
   • Landmark 8 is the base of the columella on the cleft side.
   • Ideally, the distance from 4 to 2 should be equal to that from 5 to 3’; however, it is not always possible.
   • The distance from 2 to 7 must equal that from 3 (and 3’) to 8.
4. Local anesthetic containing a vasoconstrictor is infiltrated into above flaps (weight-based dosage).
5. The nasal cavities are packed with oxymetazoline-soaked cottonoids.
6. Incisions are made with a #15c scalpel blade around the rotation flap and C flap, extending across the white roll into the vermilion.
7. Elevation of mucosal flaps in the submucosal plane; all abnormal orbicularis oris attachments are removed from the premaxilla.
8. The M flap is elevated in the submucosal plane, and the C flap in the subdermal plane.
9. The orbicularis oris muscle is elevated from the overlying skin and mucosa within the rotation flap and completely detached from the nasal floor and anterior nasal spine for downward rotation.
10. An incision from the C flap is extended into the caudal nasal septal base through the mucosa and partially through the mucoperichondrium with sharp dissect/>
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