Basics of Millard Rotation-

Advancement Technique for

Repair of the Unilateral Cleft

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~ i Deformitv
6
Iohn A. Ness, M . D., and Ionathan M. Sykes, M . D.

Preparing the unilateral cleft lip deformity presents
an opportunity to learn from the lessons of history.
Many methods of cleft lip reconstruction have been
evaluated and discarded after their flaws were recog-
nized. A conceptual improvement in design and tech-
nique resulted in the Millard rotation-advancement
technique, which is the most commonly employed
method of repair at present in the United States. This
procedure can be mastered with a comprehensive un-
derstanding of the concepts and technical design of
the flaps along with the appropriate training to maxi-
mize the usefulness and flexibility of this technique in
differing cleft situations. This article reviews the basic
Millard rotation-advancement, its advantages as well
as disadvantages, and some practical applications.
The historical development of unilateral cleft lip
repair followed a logical thought progression and
has been comprehensively reviewed by Millard.1
Many forms of repair have been proposed, used, and
discarded as technical improvements were made.
Most recently geometric closures of modified Z-
plasties, including quadrangular flaps2 and triangu-
lar flaps,%swere designed to decrease the amount of
lip shortening that occurred and to improve orbicu-
laris oris muscle function. Tennison's triangular re-
pair3 and Millard's rotation-advancement technique6
made the biggest advancements because they recog-
nized the importance of repositioning the orbicularis
oris muscle fibers in their correct anatomic orienta-
tion and these techniques result in functional im-
provement. These basic techniques were foundational
and other surgeons merely made modifications. The
basic disadvantage of the geometric designs is the
violation of the normal philtral column on the non-
cleft side, creating a scar which crosses the bound-
aries of known anatomic subunits. Additionally
geometric repairs require exacting presurgical mea-
surement and lack flexibility in surgical application.
Although not widely performed, lip adhesions and
straight line repairs have some advocates.7.8 These
repairs accomplish closure of the cleft, but often do
not perform good orbicularis oris closure and result
in lip shortening, tissue waste, and unappealing scars.
Millard6 considered the advantages and disadvan-
tages of his predecessors' efforts and then designed
rotation-advancement flaps for repairing the uni-
lateral cleft lip deformity. He was able to show con-
sistently how his design could be applied to a wide
variety of cleft lip deformitiesand how flexibility and
artistry could be incorporated into these repairs.
COMPARISON OF TECHNIQUES
The Millard technique requires a complete under-
standing of the defect and the goals of cleft lip repair.

Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical

Center, Sacramento, California

Reprint requests: Dr. Sykes, Department of Otolaryngology-Head and Neck Surgery, University
of California, Davis Medical Center, 2500 Stockton Blvd., Sacramento, CA 95817

Copyright 01993 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
FACIAL PLASTIC SURGERY Volume 9, Number 3 July 1993
The primary goals are to reconstruct normal lip anat-
omy and restore lip function. The secondary goals
are closure of the nasal floor and correction of nasal
tip asymmetry.
The advantages and disadvantages of Millard's
technique are summarized in Table 1. The main ad-
vantage of this technique is its flexibility in applica-
tion. Although other methods of cleft repair adhere
to strict geometric principles, the Millard technique
allows continuous modifications during the design,
incisions, and execution of the repair. Closure of the
cleft lip is performed so that the eventual incision
and scar line creates a new philtral column. The
design of the flaps is performed so that the incision
line (the new philtral column) is the mirror image of
the philtral column on the noncleft side. Adherence
to this known aesthetic subunit enables camou-
flaging of the scar. This is opposed to most geometric
designs which violate the philtral subunit. Another
principle of the rotation-advancement flap is to dis-
card minimal tissue. Geometric repairs, by design,
incorporate excision of normal tissue as part of the
technique.
In the past, cleft lip repairs have focused primarily
on lip function and form. Early attention toward
aesthetic and functional improvement of the nose
has, for the most part, been overlooked. The Millard
technique provides excellent access for alar and
lower lateral cartilage repositioning for primary re-
pair of the nasal deformities that accompany uni-
lateral cleft lips.9 Early attention to the nose mini-
mizes the eventual nasal deformity and may lessen
the need for definitive cleft rhinoplasty. In the Mil-
lard technique, in which there is complete mobiliza-
tion of the ala, the ability to place the ala were de-
sired and to create a symmetrical nasal base exists.
The nasal sill and floor of the nose can be primarly
reconstructed with correction of the lateralized cleft
nasal base. Incisions for nasal tip repositioning are
made in the alar-facial groove and are camouflaged
in this crease.
The main disadvantage of this technique is that
experience and artistry are required. Because precise
presurgical measurements are less important to the
execution of the rotation-advancement technique
than some of the geometric designs, small judgment
mistakes may translate into obvious cosmetic con-
cerns. As with any wide cleft, wide undermining
Table 1. Millard Rotation-Advancement Re~air
Advantages Disadvantages
Flexible Requires experienced surgeon
Minimal tissue discarded Possible excessive tension
Good nasal access Extensive undermining required
Camouflaged suture line Vertical scar contracture
Tendency toward small nostril
and persistent excess tension across the suture line
may cause constriction of maxillary growth. The ver-
tical component of the suture line is also subject to
the normal consequences of healing. Vertical scar
contracture with vermilion notching is possible if the
flap is not properly designed.
The inexperienced surgeon may also have a ten-
dency to excessively narrow the nostril with active
placement of the cleft alar base. If too much tissue is
removed, nostril width can be narrowed. The sur-
geon should aim for a slightly larger nostril on the
cleft side, as it is clearly easier to correct a slightly
large nostril than it is to correct nasal stenosis.
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OPERATIVE TECH NlQUE
Operative Preparation
The operative table is reversed so that the child is
positioned at the foot of the bed to allow leg room for
the surgeon to sit comfortably. A small towel is rolled
into a scroll and positioned under the infant's head to
prevent head motion. General inhalation anesthetic
is used and an uncuffed RAE (Ring-Adair-Elwyn,
Mallinckrodt Inc., Glens Falls, NY) tube is preferred.
The tube should be carefully secured in the absolute
midline of the chin and lower lip to prevent lip dis-
tortion.
Marking and Measuring
The important reference points of the rotation-
advancement flaps are summarized in Table 2 (Fig.
lA, B). Brilliant green on a sharpened applicator stick
is used for markiing the lip; however, methylene blue
or gentian violet are also suitable. The first point (1)
to identify is the low point of Cupid's bow on the
noncleft side (NCS). Point 2 is the lateral peak of
Cupid's bow on the NCS. Point 3 is a measured piont
which will represent the new peak of Cupid's bow on
the NCS. Point 4 represents the midpoint of the alar
Table 2. Millard Rotation-AdvancementTechnique:
Reference Points
1. Center (low point) of Cupid's bow-noncleft side (NCS)
2. Peak of Cupid's bow-lateral NCS
3. Peak of Cupid's bow-medial NCS
4. Alar base-NCS
5. Columellar base-NCS
X. Back-cut point-NCS
6. Commissure-NCS
7. Commissure-Cleft side (CS)
8. Peak of Cupid's bow-CS
9. Medial tip of advancement flap-CS
10. Midpoint of alar base-CS
1 1. Lateral alar base-CS
 MILLARD TECHNIQUE-Ness, Sykes

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Figure 1. A: Basic reference points of the Millard rotation-advancement technique. B: lntraoperative photo-
graph of reference points after marking.

base on the NCS and point 5 is the superior extent of

the rotation incision at the base of columella. If back-
cutting of the rotation flap is necesasry, it is per-
formed from point 5 to point X in a 45" angle for a
distance of 1-1% mm.
The commissures are marked as point 6 on the
NCS and point 7 on the cleft side (CS). Point 8 is a
measured point which describes the inferior extent
of the advancement incision and the eventual peak of
Cupid's bow on the CS. Point 9 is the superior-most
extent of the advancement flap which will eventually
insert into the defect created by the rotation inci-
sions. Point 10 is located at the midpoint of the alar
base on the CS and point 11is located in the alar-facial
crease and represents the lateral extension of the
advancement incision.
I
Although the rotation-advancement technique is
not based on precise measurements, a few measure-
ments are used to improve symmetry (Table 3). The
first measurements establish the width of the philtral (2-4 mm)
dimple (Fig. 2). Measuring from point 1to point 2
Figure 2. Diagram illustrating determination of point 3
establishes the distance from point 1to point 3. The and the eventual width of the philtral dimple.
range for this first measurement is 2 to 4 mm but
if the cleft is repaired at 3 months the measurement
will probably be closer to 2 mm, making the philtral
dimple 4 to 5 mm at its base. Calipers are also used to measured. This distance, which is usually approx-
determine the lateral lip length on the NCS and then imately 20 mm, is then used to confirm the distance
applied to the CS (Fig. 3). The distance from the NCS and position of Cupid's peak on the CS (8). It is
commissure (6) to the peak of Cupid's bow (2) is important to note that the measurement on the NCS
is made with the tissues at rest. The measurement on
the CS should be made with a slight stretch on the
Table 3. Measurements for Flap Design tissue to estimate the medial pull of the recon-
1 to 2 = 1 to 3 = 2-4 mm stituted orbicularis oris on the reconstructed lip. An-
2to6=8to7=20mrn other measurement used in Millard's initial descrip-
2 t o 4 = 8 to10 = 9-11 mm tion includes comparing the diatances from the alar
3to5+X=8to9
base to the peak of Cupid bow on both sides of the lip
FACIAL PLASTIC SURGERY Volume 9, Number 3 July 1993
/2t05.8t07
(20 mm)
Figure 3. Diagram illustrating determination of point 8
and the eventual length of the lateral lip segment on the cleft
side.
(Fig. 4). The distance from the NCS alar base (4) to
the peak of the Cupid's bow (2) should be compared
with the distance from the CS alar base (10) to the
new Cupid's peak (8). This comparison will give the
surgeon an idea of how much lengthening needs to
occur on the CS.
The final measurement used by Millard in the
rotation-advancement flap technique includes com-
parison of the lengths of the rotation and advance-
ment incisions. These lengths should be equal. Al-
though this often can be performed subjectively, an
L21o4.8to101
(9-11 mm)
Figure4. Diagram illustratingdetermination of lip height
by measuring from the base of the columella to the peak of
Cupid's bow on both sides of the lip.
objective assessment of the relative incision lengths
can be made with a 26 gauge wire (Fig. 5A, B). The
wire is first bent to correspond to the length of the
rotation flap (3 to 5 + X). The wire can then be
straightened to assess the length of the advancement
flap incision (8 to 9). Therefore, the distance from
3 to 5 + X should be equivalent to the distance from
8 to 9. If the measurements are not equal, then minor
modifications need to be made. Modifications are
usualy made in the positions of point 8 or 9, to
increase or decrease the length of this advancement
flap. This objective measure is not always made by
an experienced surgeon because with practice the
visual estimate of flap equivalency is adequate and
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accurate.
The rotation-advancement flap design is a "cut-as-
you-go" application and the measurements are not
always absolutes. They should be used as guides
along with visual perceptual information to restore
symmetry to the reconstructed lip. The flaps that
will be designed by the previously identified points
of reference and incisions are summarized in Table 4
(Fig. 6).
After skin points are determined, incision lines
drawn, and final visual inspection has been made,
local infiltration of a vasoconstrictor is performed to
minimize bleeding, which may obscure previous
marking. We use 0.5% lidocaine with 1:200,000 epi-
nephrine and infiltrate the columella, the base and
tip of the nose, the mucosal incision sites and both
the labial commissure. Only a small amount of infil-
tration (less than 2 cc) is done to maximize hemo-
stasis while minimizing tissue distortion.
Incisions
Mucosal incisions are made with a no. 11 knife
blade. Skin scoring is performed with a no. 15cblade
and deeper plane dissection is accomplished with a
no. 15 blade. By habit, the rotation flap A is first
incised with or without an initial back-cut for extra
length. The advancement flap B is then incised. In
the area of alar facial crease, the incision is placed
just medial to this aesthetic junction to allow for
eventual lateral migration of the incision line into the
crease. Flap c, the byproduct of the rotation incision
at the columellar base, is incised and carefully ele-
vated in a subcutaneous plane. Flap D at the alar rim
of the CS is a by-product of the advancement flap
incision (alotomy). The residual vermilion mucosa,
which previously lined the cleft, is also preserved for
later use and reconstruction. These flaps are appro-
priately labelled m and 1 for medial and lateral mu-
cosal flaps.
The plane of dissection is different for each flap.
The rotation-advancement flaps are in the submus-
 MILLARD TECHNIQUE-Ness, Sykes

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FiguIre 5. A: Diagram illustrating
use of 26 gauge wire to measure and
compare the relative lengths of the ro-
tation and advancement incisions. The
wire is bent to measure the entire rota-
tion incision (3 to 5 + X) and then
straightened to equal the advance- 1
ment incision (8 to 9). B: Intraopera- 1
tive photograph depicting use of 26
wire to measure proposed flap
)n length.

cular plane along the face of the maxilla. The plane of

the c flap is subcutaneous and this dissection is
carried into the columella superficial to the medial
crura. This begins the nasal dissection.
On completion of the deep dissection, the aber-
rantly directed fibers of the orbicularis oris should be
completely separated from their alar base and colu-
mellar attachments (Fig. 7A, B). This muscle is also
separated from its cutaneous and deep mucosal at-
tachments by undermining 2 to 3 mm with a no. 15c

Table 4. Flaps Labels and Designations

A: Rotation flap
B: Advancement flap - -
c: Columellar base soft tissue, NCS Figure 6. Diagram illustrating flap design and alphabeti-
D: Alar rim-CS cal designation. A: rotation flap; B: advancement flap;
m: Medial mucosal flap c: central columellar flap; D: alar base flap; m: medial
I: Lateral mucosal flap
mucosal flap; I: lateral mucosal flap.
FACIAL PLASTIC SURGERY Volume 9, Number 3 July 1993
Figure 7. A: Schematic diagram illustrating separation of the soft tissue attachments of the nasal base from the
pyriform aperture. B: lntraoperative photograph demonstrating use of scissors to release nasal base soft tissue
attachments.
blade (Fig. 8). This will allow careful approximation
of the fresh muscle edges of the rotation and advan-
cement flaps. It is meticulous approximation of these
muscle edges that establishes the framework for a
postoperative lip that is full in appearance and func-
tions normally on animation. Additionally, skin un-
dermining allows careful eversion of the skin edges
at the time of epithelial closure.
It is important that, on completion of undermining
all lip flaps and prior to lip closure, evaluation of
tension across the cleft is performed. This can be
accomplished by placing a single pronged hook in
opposing orbicularis oris muscles at the level of the
vermilion border (Fig. 9A, B). Two hooks are crossed
to determine if the lip elements have been ade-
quately released to accomplish a tension-free clo-
sure. If excessive tension is found with this maneu-
ver and not relieved with additional undermining,
the resulting lip may appear short or tight and the
scar may become unsatisfactorily wide.
Alatomy and Tip Rhinoplasty
Cleft rhinoplasty is performed by actively placing
the ala in an aesthetically pleasing position. A peri-
alar incision is made just above the alar-facial groove
to allow for later migration of the scar into the even-
tual alar crease. The extent of the alotomy is related
to the width of the lip cleft and the extent of the nasal
deformity. If the cleft lip is complete and the alar
deformity is significant, the perialar incision is ex-
tended until full mobilization of the alar rim is ac-
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complished so as to move the entire complex, includ-
ing the advancement flap of the upper lip and the
lateral alar rim, into the correct anatomic position.
It is important to realize that complete mobilization
of the lateral alar rim is often necessary to enable
active placement in the proper position. This may
require dissection of the ala off of the face of the
maxilla with a posterior cut that extends onto the
turbinate in wide clefts (Fig. 7A, B).
An important goal of the nasal repair is to com-
pletely close the nasal floor and sill and recreate a
symmetrical nasal base. Prior to re-creation of the
floor of the nose, dissection over the nasal tip is
accomplished. Skin is undermined medially from
the medial crura in a superficial plane. Dissection
laterally is accomplished by inserting a tenotomy
scissors in the perialar incision and undermining the
skin over the lateral crus of the lower lateral cartilage
(LLC). The dissection plane should be completed so
that the external skin is completely undermined
from the underlying cartilage skeleton. Dissection of
the vestibular skin from the deep surface of the LLC
is suggested by some cleft surgeons, but is not rec-
ommended.
After complete undermining is performed and re-
creation of the nasal floor is accomplished by actively
placing the lateral alar rim, suture repositioning
of the LLC on the CS is accomplished. This is done by
placing one or two 4-0 nylon sutures through the
LLC over an internal and external Dacron bolster to
reposition the LLC. The CS LLC should be reposi-
tioned to a more medial and anteriorly projected
position. This will improve nasal tip definition and
improve projection on the cleft side.
 MILLARD TECHNIQUE-Ness, Sykes

suture. This active placement determines the nostril

size and position as compared to the nostril on the
NCS. The cleft lip is the closed in layers. Closure of
the mucosa is accomplished with interrupted 5-0
chromic sutures. Suturing begins laterally in the
sulcus and advances medially. Excess or redundant
mucosa from the m and 1flaps can be used to create a
sulcus or excised if redundant.
A temporary suture of 6-0 nylon is placed at the
vermilion border to ensure accurate vermilion re-
alignment (Fig. 10). This stitch is cut long to be used
as a traction device to allow proper alignment of the
rest of the lip. Muscle closure is then accomplished
with three to four sutures of 4-0 PDS (Fig. 11A, B).

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The key muscular suture is placed at the base of the
columella suturing the muscle of the advancement
flap into the opening created by the rotation flap. If
these sutures are carefully and accurately placed, the
remaining cutaneous and mucosal sutures can be
placed with minimal tension.
Cutaneous closure is accomplished with a com-
bination of 6-0 black nylon suture and 6-0 fast ab-
Figure8. Diagram illustratinguseof no. 15 blade for skin sorbing gut suture (Ethicon, Somerville, NJ). The 6-0
undermining for improved cutaneous closure. nylon suture that was initially placed at the ver-
milion border to help align the muscular edges is
now removed if necessary to ensure precise approx-
imation of opposing vermilion-cutaneous junctions.
Closure of the Lip The second important nylon skin suture is placed at
the base of the columella. This is done by inserting
The nasal floor is closed first with 5-0 chromic the cutaneous tip of the advancement flap into the
sutures following elevation of a small inferior septa1 open defect of the rotation flap. At this point, a
flap. The alar base on the cleft side is then "set" using careful visual inspection is made to ensure that ade-
a 4-0 PDS (Polydioxanone, Ethicon, Somerville, NJ) quate lip length has been achieved and that the rota-

Figure 9. A: Schematic diagram illustrating single-pronged hooks placed in the vermilion border to assess lip
tension. B: lntraoperative photograph of skin hook use to assess wound closure tension and relative lip length.
FACIAL PLASTIC SURGERY Volume 9, Number 3 July 1993
Figure 10. Schematic diagram illustrating traction suture
placed at vermilion border.
tion and advancement flaps are accurately matched.
The remainder of the cutaneous incision can then be
closed with 6-0 fast absorbing gut sutures and 6-0
nylon at potential tension sites.
Postoperative Care
The face is gently cleaned with sterile warm saline
and bacitracin ointment is applied to the incision
line. We do not use antitension-strips, dressings or
Logan's bows at the time of the lip closure. Soft arm
restraints are always placed on the child prior to
extubation and are strictly used for 3 weeks. The
nurses and the parents are instructed to clean the
incision site three times per day with diluted hydro-
gen peroxide and cotton tipped applicators and ap-
ply bacitracin ointment for 3 days. The diet is mod-
ified to include syringe feedings with a soft-tipped
catheter only. No nipples or pacifiers are to be used
for 3 weeks. The nylon sutures from the lip are
removed on postoperative day 6 and the fast absorb
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A
Figure 11. A: Schematic diagram illustrating closure of
orbicularis oris muscle with three to four interrupted buried
4-0 PDS sutures. (Figure continued on next page)
ing gut sutures are left to dissolve and usually fall
out at about a week. The nasal bolsters and sutures
are removed at 10 to 14 days postoperatively.
An example of a complete unilateral cleft lip re-
paired with the Millard rotation-advancement tech-
nique is shown in Figure 12A and B. A second exam-
ple of an incomplete unilateral cleft lip repaired
with the Millard rotation-advancement technique is
shown in Figure 13A and B.
CONCLUSION
The Millard rotation-advancement flap technique
is well suited to a variety of unilateral cleft lip defor-
mities. A comprehensive understanding of the de-
sign and attention to the technical details of this
procedure make it the procedure of choice for clos-
ing the unilateral cleft lip. Awareness of the possible
complications of this procedure, especially vertical
scar contraction and a small nostril, is the first step
toward prevention.
 MILLARD TECHNIQUE-Ness, Sykes

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Figure 11, cont. B: lntraoperative
photograph showing orbicularis oris
closure with the aid of a vermilion
traction suture.

Figure 12. A: Preoperative photo-

graph of a complete unilateral cleft lip.
B: Postoperative photograph of child
at 1 year of age after repair with the
rotation-advancement technique.
FACIAL PLASTIC SURGERY Volume 9, Number 3 July 1993
REFERENCES
1. Millard DR Jr: Cleft Craft: The Evolution of Its Surgery. I. The
Unilateral Deformity. Boston: Little, Brown, 1976
2. LeMesurier AB: A method of cutting and suturing the lip in
the treatment of complete unilateral clefts. Plast Reconstr
Surg 4:1, 1949
3. Tennison CS: The repair of unilateral cleft lip by the stencil
method. Plast Reconstr Surg 9:115, 1952
4. Skoog T: A design for the repair of unilateral cleft lips. Am J
Surg 95:233, 1958
5. Randall P: A triangular flap operation for the primary repair
of unilateral clefts of the lip. Plast Reconstr Surg 23:331,1959
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Figure 13. A: Preoperative photo-
graph of an incomplete unilateral cleft
lip. B: Postoperative photographof the
child at 18 months of age after repair
with the rotation-advancement tech-
nique.
6. Millard DR Jr: A primary camouflage of the unilateral hare-
look. Transactions of the First International Congress of Plastic
Surgery. Stockholm, Sweden, 1957
7. Randall P: Lip adhesion for wide unilateral and bilateral
clefts of the lip. In Bardach J, Morris HL (eds): Multidisciplin-
ary Management of the Cleft Lip and Palate. Philadelphia: WB
Saunders, 1990, pp 163-165
8. Lesavoy M: Lip adhesion in unilateral and bilateral cleft lip
repair. In Bardach J, Morris HL (eds): Multidisciplinary Man-
agement of the Cleft Lip and Palate. Philadelphia: WB Saunders,
1990, pp 166-173
9. Sykes JM, Senders CW: Surgery of the cleft lip nasal de-
formity. Op Tech Otolaryngol Head Neck Surg 1:219-224,
1990