|Year : 2017 | Volume
| Issue : 1 | Page : 26-33
Esthetic outcomes of unilateral cleft lip repaired by Millard technique through a proposed scoring system
Shivani Atri, Brijesh Mishra, Divya Narain Upadhayaya, Arun Kumar Singh, Vijay Kumar, Veerendra Prasad
Department of Plastic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||2-May-2017|
Divya Narain Upadhayaya
Department of Plastic Surgery, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Measurement of treatment outcome is vital in estimating the success of cleft management and for quality improvement, especially in the present age. Scoring systems for the measurement of cleft lip treatment outcome can be broadly divided into qualitative and quantitative methods. Millard's rotation-advancement technique is a commonly used technique for cleft lip repair. Aims and Objectives: The aim and objective of this study was to assess the esthetic outcome of unilateral cleft lip repaired by Millard technique through a scoring system. Materials and Methods: The study comprised fifty patients with unilateral cleft lip who presented to our department for lip repair. Specific preoperative assessment of the extent of deformity was done by photographic evaluation and scoring. The preoperative assessment was done using an initial scoring system (ISS). Different scores were allotted to each of the nose and lip components, so as to grade the deformity from nil to severe. On the basis of ISS scoring, the cleft lip patients' preoperative deformity was graded into three grades: Mild, moderate, and severe. All patients were operated by a single surgeon, with extensive experience in cleft care. Postoperative evaluation was performed on the same lines, using postsurgical score as proposed by Asher-McDade et al., and further graded into excellent, good, fair, poor, and very poor. Nasolabial areas were evaluated independently by a panel of five investigators preoperatively and postoperatively at 1 week, 1 month, 3 months, and 1 year, the mean value and standard deviation were calculated in each group. Statistical analysis was done in all patients using appropriate statistical tools, with a confidence interval of 95%. Results: Incomplete cleft lip has better esthetic outcome than complete cleft lip repair using Millard's technique. Conclusions: Esthetic outcome depends on the extent of preoperative deformity, and the Millard method of lip repair shows excellent outcome in incomplete lip repair.
Keywords: Cleft lip, esthetic outcome, Millard's technique, scoring system
|How to cite this article:|
Atri S, Mishra B, Upadhayaya DN, Singh AK, Kumar V, Prasad V. Esthetic outcomes of unilateral cleft lip repaired by Millard technique through a proposed scoring system. J Cleft Lip Palate Craniofac Anomal 2017;4:26-33
|How to cite this URL:|
Atri S, Mishra B, Upadhayaya DN, Singh AK, Kumar V, Prasad V. Esthetic outcomes of unilateral cleft lip repaired by Millard technique through a proposed scoring system. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2021 Oct 16];4:26-33. Available from: https://www.jclpca.org/text.asp?2017/4/1/26/205408
| Introduction|| |
Cleft lip and palate is the second most common congenital anomaly (after club foot) accounting for about 13% of all congenital anomalies, and the overall incidence is 1 in 1000 live births.
Measurement of treatment outcome is vital in estimating the success of cleft management and for quality improvement, especially in the present age, when evidence-based medical care and treatment guidelines regarding the best practice are becoming an integral part of contemporary clinical practice. Improvements in the appearance of lip and nose are the most frequently desired aspects of treatment by patients with clefts and their parents.
Rating systems for the measurement of nasolabial appearance can be broadly divided into qualitative and quantitative methods.
The methods of evaluation in different studies are also inconsistent; some of them are based on patients' or examiners' subjective satisfaction, whereas others are based on more objective criteria or digital evaluation of residual deformities.,
There is a growing appreciation of measurement of the outcome of cleft repairs to determine the chance of negative consequences, advising patients, predicting surgical outcomes, generating policies about safe clinical care, and allocating resources.
Measurement of cleft lip repair outcomes could serve as a benchmark for comparing several centers and may indicate critical areas that require attention and training. This may also finally facilitate the attainment of a gold standard in cleft management and adequate information to the patient about the expected treatment outcome after surgery.,
The purpose of the study was to assess the esthetic outcome of unilateral cleft lip repaired by Millard technique through a scoring system.
| Materials and Methods|| |
Fifty children (25 complete and 25 incomplete cleft lip deformities) above 3 months of age with unilateral cleft lip deformity, who were fit for surgery, were selected for this study. Patients with orofacial clefts, syndromic clefts, or with secondary clefts were excluded from the study. Surgical repair was performed under general anesthesia, by a single surgeon using Mohler's modification of Millard method of lip repair, in which C flap is used for collumella lengthening with no circumalar incision.
Ethical clearance was acquired for the study from the Institutional Ethics Committee. Written informed consent was obtained from all patients or their parents/guardians before enrollment in the study. Prior to this, detailed information and explanation of the scope of the study was provided to each patient or their parents/guardians.
On admission, a detailed history of each patient was taken, and a thorough general and physical examination was carried out in each case.
Specific assessment of the extent of deformity was done by two methods.
Color photographs were taken of each patient on presentation (preoperatively) and on subsequent review visits after the surgery within the study period. All photographs were taken in standardized illumination and background using the same digital camera. Photographs were captured in two standard projections:
- Frontal view
- Worm's eye view.
All patients and their photographs were coded.
Only nasolabial triangle was evaluated to reduce the influence of surrounding facial features and hide the individual's identity. The nasolabial area was projected on a white screen and estimated in the same illumination.
The preoperative score (or initial scoring system 1) was derived from Mortier et al's. method of objective analysis of cases. Different scores were allotted to each component of the nose and lip, so as to grade the deformity from nil to severe [Figure 1], [Table 1] and [Table 2].
|Figure 1: Pictorial diagram showing scores allotted to each component of the nose and lip|
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|Table 2: Grading of preoperative deformity on the basis of initial scoring system scoring in the cleft lip patients|
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The postoperative evaluation was performed on the same lines as the preoperative assessment.
The general technique of taking the photographs was the same as that of preoperative photographs for the sake of uniformity.
The evaluation was performed using a modified rating scale, which was proposed by Asher-McDade et al. The rating system is constructed based on the principle of giving points to each element characterizing the cleft and nasal deformities. The total sum of points demonstrates the level of correction of deformities. The more difficult correction of secondary deformity of cleft lip and nose, the higher will be the total score. The postsurgical scoring (PSS) consists of the following [Table 3]a,[Table 3]b,[Table 3]c,[Table 3]d and [Table 4]:
|Table 4: Grading of postoperative esthetic outcome of unilateral cleft lip deformity on the basis of postsurgical scoring|
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- White lip
- Red lip
- Nasal symmetry.
To verify the reliability of the scoring system and to prevent inaccuracy during the scoring procedure, nasolabial areas were evaluated independently by a panel of five investigators including two plastic surgeons, excluding the operating surgeon, one dental surgeon, one plastic surgery resident, and an artist, preoperatively once and postoperatively at 1 week, 1 month, 3 months, and 1 year. The mean value and standard deviation (SD) were calculated in each group.
Statistical analysis was done in all patients using appropriate statistical tools such as t-test, Chi-square test, and Mann–Whitney U-test, with a confidence interval of 95%.
| Observations and Results|| |
A total of fifty patients of unilateral cleft lip, more than 3 months, were selected for surgery and their photographic evaluation was done. The mean age group of patients was 14.67 ± 45.33 months.
The mean duration of surgery was 75.08 ± 3.46 min.
[Table 5] depicts the overall comparison of pre- and post-operative scores among the unilateral cleft lip patients repaired through Millard's repair. It can be clearly seen that the overall mean ISS showed severe deformity preoperatively resulting in an excellent outcome 1 week postoperative and good outcome at 1, 3, and 12 months postoperatively as depicted by PSS. The difference between postoperative 1st week and further postoperative periods showed statistical significance.
|Table 5: Mean comparison of pre - and post-operative score of unilateral cleft lip|
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Hence, it can be clearly stated that overall the esthetic outcome of Millard shows good results in spite of severe deformity, with best outcome noted 1 week postoperatively.
[Table 6] shows that there is statistically significant difference in ISS and PSS (1 week, 1 month, 3 months, and 12 months) of both the groups, with severe preoperative deformity and good esthetic outcome in case of complete cleft lip patients [Figure 2], [Figure 3], [Figure 4], [Figure 5] and moderate preoperative deformity and excellent esthetic outcome in incomplete cleft lip patients [Figure 6], [Figure 7], [Figure 8].
|Figure 2: Preoperative (a and b) and 1 week postoperative (c and d) images of complete cleft lip patient repaired by Millard technique|
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|Figure 3: Preoperative (a and b) and 12-month postoperative (c and d) images of complete cleft lip patient repaired by Millard technique showing notching, scar contracture, and low-lying left ala with defect in alar rim|
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|Figure 4: Preoperative (a and b) and 12-month postoperative (c and d) images of complete cleft lip patient repaired by Millard technique showing excellent esthetic outcome|
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|Figure 5: Preoperative (a and b) and 12-month postoperative (c and d) images of complete cleft lip patient repaired by Millard technique showing lip notching scar hypertrophy and contracture|
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|Figure 6: Preoperative (a and b) and 1-week postoperative (c and d) images of incomplete cleft lip patient repaired by Millard technique showing excellent outcome|
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|Figure 7: Preoperative (a and b) and 1-month postoperative (c and d) images of incomplete cleft lip patient repaired by Millard technique showing excellent symmetrical outcome|
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|Figure 8: Preoperative (a and b) and 3-month postoperative (c and d) images of incomplete cleft lip patient repaired by Millard technique showing excellent esthetic outcome|
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Hence, it shows that there is statistically significant difference in the esthetic outcome of complete and incomplete cleft lip patients when repaired through Millard technique, being better in incomplete cleft lip [Graph 1].
On evaluating each group with regard to complete and incomplete cleft lip, we applied Mann–Whitney U-test for significance and found that there was a significant difference in ISS of complete and incomplete cleft lip patients as the deformity is moderate in incomplete patients as compared to severe in complete cleft lip patients. There was statistically significant difference in PSS (1 week, 1 month, 3 months, and 12 months) among complete and incomplete cleft lip patients, with the mean ± SD of PSS of incomplete being less at all times.
| Discussion|| |
Patients in each group were evaluated preoperatively and postoperatively using ISS  and PSS. In spite of significant difference in preoperative scoring, there is extremely statistically significant difference in the esthetic outcome of complete and incomplete cleft lip patients too; when repaired through Millard method, incomplete cleft lip patients showed excellent outcome as compared to good outcome shown by complete cleft lip patients. This can be explained by the fact that in case of incomplete cleft lip, the initial deformity is already less to begin, thus giving a better outcome. Also nostril floor and alar cartilage are better improved in Millard technique.
On evaluating the PSS score at different interval follow ups, it was observed that the esthetic outcome is better in early period than later. This result can be attributed to the fact that in Millard procedure, the vertical scar is a mirror image of the opposite philtral ridge, hence gives a better appearance early on, but as the scar matures, it contracts leading to vermilion notching and scar hypertrophy and shortening which account for worsening of esthetical score later on. Willams  compared the Millard and LeMesurier's methods of lip repair by allocating scoring points to the various features, using 10-point assessment divided into nose and lip category each carrying fifty points and found that Millard technique had a statistically significant better outcome than LeMesurier in case of incomplete cleft lip deformity. They also showed higher grades of improvement in nostril floor and alar cartilage in incomplete cleft lip repaired by Millard technique. Our study is consistent with the findings of the study as it also shows that, in case of incomplete cleft lip, Millard technique has statistically significant better esthetic outcome. Holtmann and Wray  have compared triangular (Randall Tennison) and rotation-advancement (Millard) technique for unilateral cleft lip repair (both complete and incomplete) by 12-point assessment of nose and lip, with excellent (12) to poor (0), each component's score from 3 to 0 points and found that degree of improvement in nasal deformity was greater in triangular, i.e., Randall Tennison repair, indicating it being better study, however this could also be attributed to the fact that preoperative nasal deformity in these cases was statistically significant more as compared to rotation-advancement (Millard) technique. They also stated that patients with triangular repair had greater secondary deformities and greater number of secondary surgeries (twice) as compared to rotation-advancement technique, although lip scar hypertrophy was much more in rotational advancement as compared to triangular technique. Overall, they found no statistically major difference in early results among both the techniques.
Amaratunga  compared Millard and LeMesurier's technique for repair of complete unilateral cleft lip by linear measurements of height and width of certain important features of the lip and nose to assess the symmetry. They found that nostril height is better with Millard's technique, vermilion symmetry was better with LeMesurier's technique, philtral height tends to be short with Millard's method due to the straight scar undergoing contraction, and lips tend to be long in LeMesurier's method. In our study, we found that long-term outcome was good despite an excellent short-term early outcome which can be attributed to the lip scar hypertrophy and short philtral height due to straight scar undergoing contracture, thus our findings corroborate with those seen in the above-stated study.
In a study, Chowdri et al. comparing the two techniques of cleft lip repair, it was found that there was no statistically significant difference with regard to symmetry of lip, although patients treated with Millard's technique had short lips as compared to Randall Tennison's technique with long lips postoperatively. Overall, there was no statistical difference in the outcome of the two techniques for either lip or nose segment or combined. The score was statistically significant better for incomplete clefts compared with complete clefts following repair. Our study too concluded that incomplete cleft lip had better esthetic outcome using Millard's technique which was statistically significant. Twenty-three patients with a unilateral complete cleft were photographed by a standardized method before repair by Xing et al., 7 days and 12 months postoperatively. Lips on the cleft side were measured and compared with the opposite side. They concluded that severity of the initial deformity does not relate to the outcome, and primary repair of the cleft lip is crucial in maintaining labial symmetry 1 year after operation. Our study too has similarities to this study since they also used photographic evaluation, but in contrast, we found that severity of the preoperative deformity has an inverse relation to outcome. Reddy et al. studied 796 patients in a study divided into two groups, each group of slightly <400 patients. They used either a modified Millard or Pfeifer wavy line incision, both in conjunction with functional repair of the underlying tissues as described by Delaire. Soft tissue measurements of the lip and nose were recorded preoperatively. They found that one technique was as good as the other and concluded that the technique for closure of the underlying tissues is probably of more importance.
Cline et al. conducted a retrospective study, in which two senior board-certified surgeons used different surgical techniques for the unilateral cleft lip: The philtral ridge and rotation-advancement repairs and analyzed the pre- and post-operative photographs of consecutive patients who underwent repair performed by each surgeon between 2003 and 2009. Using Adobe Photoshop imaging software, facial points on the cleft and noncleft sides were measured, including height and symmetry of Cupid's bow, width, and height of the nasal vestibule, height of the vermilion, and alar base position. Ratios of cleft side to noncleft side measurements were calculated to standardize comparisons between patients. The symmetry of each lip repair was graded subjectively by health-care professionals and the general public. There were no differences in preoperative ratios between the two techniques with the exception of a wider cleft nasal vestibule in the rotation-advancement group (P = 0.04) and there were no statistically significant differences in postoperative measures or subjective analysis of symmetry between the groups.
Santhosh et al. conducted a study of 18 patients who received primary unilateral cleft lip repair by using two different designs of skin incision (modified Millard's incision and Delaire's functional method techniques) and compared the outcomes by analyzing postoperative assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, nostril symmetry, and appearance of the alar dome and base. They concluded that lip length improvement was better in case of modified Millard's incision.
| Conclusions|| |
In this study, based on the above grading, it is concluded that the mean ISS scoring of overall unilateral cleft lip patients in each group was found to be severe, with complete and incomplete cleft lip patients having severe and moderate deformity, respectively. The overall esthetic appearance of unilateral cleft lip patients (severe ISS) showed that Millard repair had excellent outcome on early follow-up, although there was a good esthetic outcome in long-term follow-up. The esthetic outcome of complete (severe ISS) and incomplete (moderate ISS) cleft lip patients when repaired with Millard methods showed better outcome in incomplete unilateral cleft lip patients with excellent esthetic outcome. The severity of the preoperative deformity (e.g., complete cleft lip) has an effect on the outcome of the repair, with more severe deformity having less better results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]