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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 3  |  Page : 178-183

Use of combination of Millard and Pfeifer incision technique for treatment of unilateral complete cleft of lip: A report of two cases


1 Department of Oral and Maxillofacial Surgery, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India
2 Private Practitioner, Kalol, Gujarat, India

Date of Web Publication22-Aug-2016

Correspondence Address:
Rajeev Pandey
School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh
India
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DOI: 10.4103/0976-433X.188806

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  Abstract 

Cleft lip and palate is one of the most common congenital deformities of the head and neck region. The prevalence of cleft lip and palate depends on racial, ethnic, geographic origin, and socioeconomic status. It is estimated that isolated cleft lip occurs in 20–30%, cleft lip along with palate occur in 35.50% and isolated palate in 30–45% of cases. It affects the psychological, social, and mental well-being. It is considered as a social stigma and has poor acceptance with a negative perception. These patients require a multidisciplinary approach and aged specific treatment plan. Early repair of cleft lip is advocated for making the child acceptable to the parents and relatives as well as to the society. It also helps in the feeding of the child. There are various techniques for repair of the complete unilateral cleft lip. Almost all techniques continue to leave behind some amount of dissatisfaction. Even today most of the surgeons like to use Millard's technique or its modifications. Here, we present two cases of a newly developed technique utilizing both Millard and Pfeifer incision. For assessment of the success of the technique, we evaluated the vermilion match, lip length, nasal symmetry, white roll match, and postoperative scar after 6 months of primary lip closure. At 6th month follow-up, we found the overall result was average for both the cases. (minor deformities which can be corrected by lip revision procedure). As this technique is based on the principle of rotation and elongation, we found that this technique allowed tension free closure of the cleft lip even when both the patients had a wide cleft of the lip. This technique addresses the overall anatomy of cleft lip including nasal region. The incision marking is such that rhinoseptoplasty and alar cinch suturing can be done without making any new incision.

Keywords: Millard's incision, Pfeifer incision, unilateral complete cleft lip


How to cite this article:
Pandey R, Bhagat N, Gupta R, Khatri A. Use of combination of Millard and Pfeifer incision technique for treatment of unilateral complete cleft of lip: A report of two cases. SRM J Res Dent Sci 2016;7:178-83

How to cite this URL:
Pandey R, Bhagat N, Gupta R, Khatri A. Use of combination of Millard and Pfeifer incision technique for treatment of unilateral complete cleft of lip: A report of two cases. SRM J Res Dent Sci [serial online] 2016 [cited 2019 Jun 26];7:178-83. Available from: http://www.srmjrds.in/text.asp?2016/7/3/178/188806


  Introduction Top


Historical reference to cleft lip goes back to the era of Greek Physician Hippocrates. Chinese physicians were credited as first to repair cleft lip deformity around 390 A.D.[1] Cleft lip and palate is a major craniofacial problem affecting 1 in every 500–1000 births worldwide.[2] According to the WHO, every 2 min, cleft child is born somewhere in the world.[3] In India, about 32,000 cleft children are born every year.[4] The etiology of cleft lip and palate is very complex. Many factors have been attributed including genetic and environmental factors. Other causes include defect in vascular supply in the region involved, alternation in tongue size, intoxication with substances such as alcohol, drugs, toxins, and sometimes infection. The commonly used classification system for cleft lip and palate is the striped Y classification, developed in 1958 and later modified by Kernahan.[5]

The facial deformity due to cleft lip and palate includes high asymmetry of face, lack of continuity of perioral musculature, anomalous position of underlying osseous structures, nasal cartilages, and nasal asymmetry.[6] Therefore, the primary goal of treatment of cleft lip is to obtain both esthetic and functional corrections of the nasolabial region to correct the deformity and helps in progressive and balances development of mid face.

Therefore, the basic aim of a unilateral cleft lip repair should be to achieve a lip length on the cleft side matching that on the normal side, an inconspicuous residual scar that does not cross anatomic boundaries, an adequate Cupid's bow width, perfect white roll match, and accurate nasal symmetry.[7] Many techniques have been used for repair of cleft lip, and each of them has their advantages and disadvantages. Most of the techniques utilize three basic methods: Straight line, rotation advancement, and triangular flap technique.

No single technique is perfect and associated with one or more complications; also most of the times, a surgeons decision to use a certain technique dependent on his or her training and exposure to the various techniques.[6]

Now a days, many surgeons have started to use combination of two or more techniques to utilize the advantages of both and minimize the complications. In this case series, we have used combination of both Millard and Pfeifer incisions called as Afroze technique for repair of unilateral complete cleft lip.[8] Afroze technique is a recent technique for treatment of cleft lip based on a Milliard incision on the noncleft side and a Pfeifer incision on the cleft side utilizing the advantages of both techniques.


  technique Top


Markings

On noncleft side, following points are marked: Point 1: Highest point on the white roll, Point 2: Deepest point on the white roll, and Point 3: It is marked on the white roll at distance equal to the distance between Point 1 and Point 2 [Figure 1].
Figure 1: Points for incision marking

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On cleft side: Only one point is marked called as Point 4: It is the highest point on the white roll [Figure 1].

Millard incision was marked on the noncleft side extending from Point 3 [Figure 2].
Figure 2: Incision marking

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Pfeifer incision was marked on the cleft side extending from Point 4 [Figure 2].

On both sides, the incision marking was extended to the vermilion and continued medially to meet the previous incision marking.

The sterile mucosa was removed and on the cleft side, extensive dissection is carried out to relieve all the abnormal attachments from the piriform rim, ala, lateral aspect of the nose, infraorbital, and malar regions. On the noncleft side, a minimal dissection is done to relieve the abnormal attachments from anterior nasal spine and the columella [Figure 3].
Figure 3: Dissection of tissues on cleft and non cleft sides

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Septoplasty along with perioplasty was performed. Cinch suture was placed, and nasal sill was sutured. After that orbicularis oris muscle was sutured to its counterpart, first at the vermillion below the white roll then going higher up till the alar region. Finally, skin suturing was done. This was done by joining Point 3 on the Cupid's bow to Point 4 on the cleft side white roll. The C flap was essentially horizontally positioned, resulting in a horizontal scar. The downward rotation of the C flap causes a V-shaped defect in front of the columella, which was filled with the distal V flap of the Pfeifer wave. Vermilion mucosa was sutured using vertical mattress sutures to get eversion [Figure 4] and [Figure 5].
Figure 4: Mobilization of flap from non cleft side (C flap) and cleft side (V flap)

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Figure 5: Skin and vermilion suturing

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  Case Reports Top


Case report 1

A 4-month-old male baby reported to our department with cleft of lip and palate. He was the first baby of the couple by a normal vaginal delivery. There was no familial history of cleft lip and palate in the family. The baby was diagnosed with unilateral complete cleft of lip, alveolus, hard and soft palate of right side [Figure 6].
Figure 6: Case 1: Unilateral complete cleft of lip, alveolus, hard and soft palate of right side

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The age-specific surgical and nonsurgical treatment plan was explained to the parents. The baby was operated for cleft lip by Afroze incision, and suture removal was done after 10 days. After 6 months, the lip of the baby was reevaluated for the esthetic and functional outcome.

On evaluating the lip, the length of the lip was shorter by 3 mm on the cleft side when compared to the noncleft side which had led to a mismatch in the white roll. The Cupids bow form was not distorted much, and scar appearance was acceptable. The vermilion fullness was acceptable [Figure 7].
Figure 7: Case 1: Post operative result after 6 months

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On evaluating the nose, there was gross nasal asymmetry between the cleft and noncleft sides. Only positive finding was that nasal septum was in the midline.

These minor deformities were explained to the parents, and this patient will require minor lip and nose revision at a later stage.

Case report 2

A 6-month-old male baby reported to our department with cleft of lip and palate. He was the first baby of the couple by a normal vaginal delivery. There was no familial history of cleft lip and palate in the family. The baby was diagnosed with unilateral complete cleft of lip, alveolus, hard and soft palate of right side [Figure 8].
Figure 8: Case 2: Unilateral complete cleft of lip, alveolus, hard and soft palate of right side

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The age-specific surgical and nonsurgical treatment plan was explained to the parents. The baby was operated for cleft lip by Afroze incision, and suture removal was done after 10 days. After 6 months, the lip of the baby was reevaluated for the esthetic and functional outcome.

On evaluating the lip, the length of the lip was shorter by 2 mm on the cleft side when compared to the noncleft side which had led to a mismatch in the white roll. The Cupids bow form was not distorted much, and scar appearance was acceptable. The vermilion fullness was acceptable [Figure 9].
Figure 9: Case 2: Post operative result after 6 months

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On evaluating the nose, the nasal anatomy was symmetrical, and nasal septum was in the midline.

These minor deformities were explained to the parents, and this patient may require minor lip and nose revision at a later stage.


  Discussion Top


Repair of unilateral cleft lip is a challenging procedure which requires skilful expertise. The ideal requirements of a lip repair are: Perfectly matching white roll, minimal scar, lip length on cleft and noncleft sides should be same, perfect Cupids bow form and a symmetrical nose. In general, a single surgical technique usually cannot fulfill the ideal lip repair requirement criteria, and in most cases, cleft lip repairs require secondary operations in an attempt to achieve this goal. A full understanding of all the anatomical elements involved in the cleft deformity by the surgeon is necessary for the improvement of surgical methods and every attempt should be made to restore the normality of the tissues involved in the cleft, in particular, the underlying musculature, rather than just confining activities to the overlying skin. The designing of the skin incision is also an important esthetic consideration, and every attempt should be made for improvement in the designs for attaining good esthetic outcomes.

Historically, earlier incisions were straight line, broken line, or flap design based. These incisions were poorly designed or had poor outcomes. In the 1950s, several new incisions were designed to counter these shortcomings. Few of them worth mentioning are: Tennison utilized a triangular flap and Petit and Psaume designed a superiorly based flap.[9],[10] A combination of the superior and inferior flap was given by Trauner and Skoog.[11],[12] This technique was later modified by Malek.[13] These designs had mixed outcomes. They had complex incision marking designs and had strict patient selection criteria. Some of them did not address the complete cleft morphology, mainly the nasal structure.

In Europe, the two most commonly used incisions patterns are Millard and Pfeifer. Millard technique is based on rotation and advancement of local tissues, whereas Pfeifer is a straight line closure technique.[1],[14]

In Millard repair, a rotation flap is created on the noncleft side coupled with an advancement flap on the cleft side. This technique represents a significant advanced method overcoming the limitations of previously described techniques. It also laid down the foundation for other techniques, e.g., Delaire, Mulliken, and Martinez Perez.[15]

Pfeifer technique is based on the concept of morphological order.[16] A measurement of the noncleft side is translated to the cleft side with the help of flexible wire.

In this case report, we have used a recently developed technique known as Afroze incision. Afroze incision is a combination of two incisions: Millard incision on the noncleft side and Pfeifer incision on the cleft side. This new design variant uses the advantages of both Millard and Pfeifer incisions. On the noncleft side, the Millard's incision helps in rotation and Pfeifer on the cleft side helps in lengthening. By its nature, the more waves incorporated in the incision, the greater the height of the lip. Because of this there is no tension during closure of the cleft lip. The postoperative scar is essentially horizontal in nature, and the contracture of the scar occurs horizontally rather than vertically. There is also no pressure on the Cupid's bow for the same reason. This helps in better scar which is less hypertrophic and within the boundaries of anatomical structures.[17] The Millard incision on the noncleft side also used to perform primary septorhinoplasty through the same incision along with perioplasty. Pfeifer incision helps in the proper exposure of ala nasalis, and hence, cinch suture can be placed more accurately. These factors help in better esthetic outcome in the nasal region in Afroze incision.[16]

Studies have been done to compare Afroze incision with other incisions. These studies have shown that Afroze incision has better outcomes in overall esthetic and functional outcome.[18]

This is because of the fact that this technique allows tension free closure of the underlying tissues.[6] Another study had shown that Afroze incision could be used in all types of complete unilateral lip regardless of the width of cleft.[8] We also found this technique much simpler in incision marking and perform. Overall result in the two cases was average. Minor deformities if present can be reviewed and can be addressed when the patient is 4–5 years old. Other advantages of this technique include: No measurements are required, less operative time, can be used in almost all types of cleft lip and can be used for month babies to adult cleft lip has been reported. The problems which are reported in using this incision are: In wide clefts, an extensive elevation of facial tissue mask is required. In some cases, there is a danger of necrosis of the rotated flap from the noncleft side. Problems of nasal stenosis and perichondritis have been also reported.


  Conclusion Top


Afroze incision is a recent technique based on the concept of morphofunctional rearrangement of cleft tissues. Wide cleft of lip can be easily managed because of incorporation of rotation as well as elongation features in the incision design. Minor deformities were seen after 6 months of follow-up which shows that cleft surgery is a skilful technique and associated with the learning curve. Both of our cases were wide cleft lip, and postoperative healing was uneventful with minimal scar. Furthermore, in both the case, the cleft side maxilla was hypoplastic and retruded. After 6 months follow-up, we found that the hypoplastic maxilla had developed well, and the retrusion was missing. Changes were seen in the complete facial region proving the morphofunctional concept.

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

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Millard DR Jr. The unilateral deformity. Cleft Craft: The Evolution of its Surgery. Vol. 1. Boston: Little, Brown and Co.; 1976.  Back to cited text no. 1
    
2.
Cooper ME, Ratay JS, Marazita ML. Asian oral-facial cleft birth prevalence. Cleft Palate Craniofac J 2006;43:580-9.  Back to cited text no. 2
    
3.
WHO. Global Strategies to Reduce the Health Care Burden of Craniofacial Anomalies. Report of WHO Meetings on International Collaborative Research on Craniofacial Anomalies: Geneva, Switzerland; 2000.  Back to cited text no. 3
    
4.
Reddy SG, Reddy LV, Reddy RR. Developing and standardizing a center to treat cleft and craniofacial anomalies in a developing country like India. J Craniofac Surg 2009;20 Suppl 2:1664-7.  Back to cited text no. 4
    
5.
Kernahan DA. The striped Y-a symbolic classification for cleft lip and palate. Plast Reconstr Surg 1971;47:469-70.  Back to cited text no. 5
    
6.
Reddy GS, Webb RM, Reddy RR, Reddy LV, Thomas P, Markus AF. Choice of incision for primary repair of unilateral complete cleft lip: A comparative study of outcomes in 796 patients. Plast Reconstr Surg 2008;121:932-40.  Back to cited text no. 6
    
7.
Markus AF, Delaire J. Functional primary closure of cleft lip. Br J Oral Maxillofac Surg 1993;31:281-91.  Back to cited text no. 7
    
8.
Reddy GS, Reddy RR, Pagaria N, Berge S. Afroze incision for functional cheiloseptoplasty. J Craniofac Surg 2009;20 Suppl 2:1733-6.  Back to cited text no. 8
    
9.
Tennison CW. The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg 1952;9:115-20.  Back to cited text no. 9
    
10.
Petit PP, Psaume J. The treatment of cleft lip. Paris: Masson and Co; 1962.  Back to cited text no. 10
    
11.
Trauner R. The surgery of the lip split. Fortschr Kiefer Gesichtschir 1950;1:1.  Back to cited text no. 11
    
12.
Skoog T. Skoog's method of repair of unilateral and bilateral cleft lip. Cleft Lip and Palate. Boston: Little, Brown; 1970. p. 288-304.  Back to cited text no. 12
    
13.
Malek R. Initial treatment of cleft lip and palate. Chir Pediatr 1983;24:256-67.  Back to cited text no. 13
    
14.
Millard DR Jr. Complete unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull 1960;25:595-605.  Back to cited text no. 14
    
15.
Mulliken JB, Martínez-Pérez D. The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: Technical variations and analysis of results. Plast Reconstr Surg 1999;104:1247-60.  Back to cited text no. 15
    
16.
Pfeifer G. Morphology of the formation of cleft as a basis for treatment. In: Schuchardt K, editor. Treatment of Patients with Cleft Lip, Alveolus and Palate: 2nd International Symposium, Hamburg. Stuttgart: Thieme; 1964.  Back to cited text no. 16
    
17.
Gosla-Reddy S, Nagy K, Mommaerts MY, Reddy RR, Bronkhorst EM, Prasad R, et al. Primary septoplasty in the repair of unilateral complete cleft lip and palate. Plast Reconstr Surg 2011;127:761-7.  Back to cited text no. 17
    
18.
Reddy SG, Reddy RR, Bronkhorst EM, Prasad R, Kuijpers Jagtman AM, Bergé S. Comparison of three incisions to repair complete unilateral cleft lip. Plast Reconstr Surg 2010;125:1208-16.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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