The Modification of Rotation - Advancement Flap Made in 1950

Abstract

The early techniques of cleft lip repair involved the straight-line technique, the triangular flap technique or some kind of geometric line (triangular, quadrangular closure). A turning point in cleft lip surgery was in 1955 when doctor. Millard presented his method: the rotation-advancement technique or flap, at the First International Congress of Plastic Surgery in Stockholm. Today, the technique, with or without some modifications, is used by more than 85% of cleft surgeons around the world. We are presenting a patient with complete unilateral cleft lip and palate who underwent surgery sixty-five years ago. The scar on his lip was similar to rotation advancement line. Cheiloplasty was performed by Professor Šercer in 1950, five years before Millard's publication. Professor Ante Šercer was an internationally recognized Croatian scholar in the area of ear, nose and throat diseases. He also gave a significant contribution to surgical management of velopharyngeal insufficiency and plastic surgery of the nose and ear.

Introduction

The early techniques of cleft lip repair involved a straight-line or some kind of geometric line (triangular, quadrangular closure). In 1843, Malgaigne described the cleft lip closure method with local flaps and that year was considered to be the beginning of plastic surgery of the cleft lip. The following year, Mirault modified Malgaigne's technique with a lateral flap across the cleft. All future methods of cleft lip closure have been based on Mirault's principle (1). The first straight line lip repair was performed by Ambroise Pare in 1568. W. Rose advocated curved incision, which included paired incision design that extended from the nasal floor to the vermilion border in 1879. In 1945, LeMesurier reintroduced the geometric lip repair technique, based on Hagerdon's description from 1892, of a laterally based quadrangular lip flap. The Tennison flap repair, which included a triangular flap from the inferior part of the lateral lip, was modified by Randall in 1959 (1, 2).

The First International Congress of Plastic Surgery in Stockholm in 1955 marked a turning point in cleft lip surgery when doctor Millard presented his technique: the rotation-advancement flaps. At the beginning of his clinical career, Millard used
LeMesurier method but he was not entirely satisfied with the results. Ralph Millard developed the rotation-advancement technique by operating the children with cleft lip during his military service in the Korean War. The design of rotation-advancement flap is based on a curved line (rotation) on the non-cleft side in order to balance the lip height discrepancy. With this technique a more symmetrical lip height, philtral column width and nasal base symmetry can be achieved. The symmetrical curved line is made on the cleft side with small extension beneath the nasal alla in order to achieve the access to the nose (2, 3).

No other technique has withstood the test of time like Millard's innovative principle (4). The technique is anatomically logical; it permits individual modifications, therefore, it can be adapted to each form of cleft lip. The type of scar and the patient’s skin dictate the treatment of the scar. Sometimes, the postoperative scar needs to be corrected. However, surgery is performed to fix the scar in cases where the scar does not respond to other noninvasive applications. Today the technique (Figure 1), with or without some modifications, is used by more than 85% of cleft surgeons around the world (5).

Figure 1.

The original rotation-advancement design conceived by D. Ralph Millard in
Korea and presented at the First International Congress of Plastic Surgery
in Stockholm in 1955 (10)

Case report

Was Ralph Millard the first surgeon to describe this technique?

We present a case of the patient with complete unilateral cleft lip and palate who underwent surgery in 1950, which had happened five years before the Millard's publication.

Recently, the patient was hospitalized at our emergency department due to zygomatic fracture. It was obvious that he had undergone the cleft lip and palate surgery. The bone cleft was also seen on MSCT scan when the fracture was diagnosed (Figure 2).

Figure 2.

MSCT scan of the patient

The scar on his lip was visible and it was similar to the rotation advancement line. The scar was hidden in the philtrum of the lip, and the line was curved on the medial side of the lip. It also seemed that the rotation was extended below the base of the columella. There was a clearly visible scar below the alla nasi of the cleft side which could form the advancement flap. Cheiloplasty was performed by Professor Šercer. We are enclosing a few photos which show the line of incision (Figure 3, 4).

Figure 3.

Scar of the lip

Figure 4.

Drawing of rotation advancement line

The patient was born on July 5 in 1950 and he underwent the surgery when he was six months old. The surgery was performed by professor Šercer at “Sestre Milosrdnice Hospital” in Zagreb. We tried to get his medical records from the ENT Department, but they seemed to be lost. Yet, the time of the surgery and the surgeon were well known.

Discussion

After Millard's presentation of the rotation advancement technique there were some concerns about the shortness of the lip. Millard later changed the technique with the back-cut to enable more rotation and length of the medial flap. The rotation advancement technique has been followed with some modifications which have been made by numerous cleft surgeons. Extended incision in the columella, insertion of small skin triangle on the non-cleft side for the elongation of the lip on the cleft side or some other small geometric modification on the line of rotation or some changes in subalar incision on the cleft side are some of them. Two flaps (rotation and advancement) as it was described in the original Millard’s publication in 1955 serve as basis for all further modification techniques.

Professor Ante Šercer was born in 1896 and he passed away in 1968. He was one of the founders of othorinolaringology in Croatia. Soon after completion of his medical studies in Prague (Czech Republic) and Graz (Austria), he attended the specialized courses in Othorinolaringology in Zagreb, Vienna and Prague. Having returned to his homeland, he worked at the ENT Department University Clinic in Zagreb from 1920 to 1945, and from 1929 he was head of department.

Today, in Croatia, the name of professor Šercer is a synonym for a leading figure in the field of medicine, teaching and research. In 1936/37 and in 1943/45, he was director of “The Sestre Milosrdnice Hospital” in Zagreb. He was head of Department of Ear, Nose and Throat Diseases (ENT) in 1946 which was transformed into a University Clinic in 1964. He was also a founder of the scientific Institute for the Study and Protection of Ear and Respiratory Organs. Šercer was the first Croatian clinician with international reputation for interpretation of the formation of nasal septum deviation and otosclerosis. Also, he discovered the nasothoracicle reflex. He was a leading surgeon in plastic and reconstructive surgery of the nose and ear not only in Croatia but also in this part of Europe (6).

He published scientific papers on cleft surgery in 1943 while he was using the techniques which were known at that time (7). His contribution to surgical management of velopharyngeal insufficiency and plastic surgery of the nose and ear is significant but probably not sufficiently associated with his name. He was an open rhinoplasty surgery pioneer (decortication) (8).

The book on plastic surgery of the nose, which was written by professor Šercer in 1962, should be emphasized as his most important work. It was written in German (9). He initiated and was the editor in chief of a Croatian medical Encyclopedia, which was one of the first books of that kind in the world (6).

Conclusion

There are three basic techniques for unilateral cleft lip repair: straight line, geometric line and rotation advancement technique. The revolutionary rotation-advancement procedure for cleft lip repair is an original and excellent technique developed by the American surgeon Ralph Millard. Today, the rotation advancement technique is one of the most widely used methods. Our case report deals with postoperative cleft lip of the patient operated by the Croatian ENT specialist Ante Šercer almost five years before Millard’s publication. It is not easy to explain the surgical technique used in this case since it was based on the postoperative scar which had been made sixty-five years before this surgery. Yet, if the scar line is carefully analyzed, it can be observed that Šercer’s technique is very similar to the rotation advancement method.