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Landmarks

Illustration 13:

Nasal and vermillion border landmarks for the Tennison-Randall design.

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Nasal landmarks

Landmark 5 and 13
Illustration 14

First mark the end of the medial crus of the lower lateral cartilage. This landmark is considered the columellar base. The German name for this landmark is famous: ‘Naseneingangschwelle’. This is landmark (5) on the non-cleft side and landmark (13) on the cleft side.
Marking landmark 13 at the end of the medial crus of the lower lateral cartilage.

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Landmark 4 and 10

Mark the alar bases as landmarks (4) and (10). These landmarks are found at the end of the light reflection on the nostrils. It is most important that both landmarks are in a comparable position right to left, otherwise your measurements are meaningless. These four landmarks are made close to the cartilage in order to allow for maximum rotation of the alar base.

Vermillion border landmarks

Landmark 2, 3 and 1

Landmark (2) is the top of the Cupid’s bow on the healthy side and is easy to locate. Therefore it is tattooed right away.

Landmark (3) is the end of the white roll on the NCS, it represents the other end of the Cupid’s bow. Landmark 3 is tattooed as well.

Landmark (1) is chosen as the middle of (2) and (3). It represents the middle of the Cupid’s bow.

 

Landmark 8

On the lateral or cleft side (CS) we still need to establish the peak of the Cupid’s bow. This is landmark (8) and is the end of the white roll on the CS. The distance between the commissure on the non-cleft side and the Cupid’s bow landmark (6)-(2) is measured and transferred to the cleft side. Almost universally the available distance (7)-(8) is shorter. This gives an idea of the amount of shortening of the lip on the CS.

Note on landmark 8
Shorter means that the lip at the end of operation will be shorter on the CS. This is not so obvious or disturbing on first sight and tends to fade away during life. What on the other hand is obviously disturbing is a Cupid’s bow to high or a nostril to low. This catches the attention right away.

 

Landmark 3’ and 8’

On both sides of the cleft landmarks (3) and (8) are the paring peaks of the Cupid’s bow and they are marked twice: One landmark is marked just above the white roll (3 and 8) and one landmark is perpendicular to the white roll just in the red lip (3’ and 8’). The distance between both upper and lower landmarks is on average 1,5 mm. It is most important that this little distance is equal on both sides. These four cardinal landmarks should stay clearly visible during the whole surgery. Suturing these landmarks at the end of the procedure will create the new Cupid’s bow top with a close to normal white roll, in a continuous mode and without steps.

Skin triangle landmarks

Illustration 15:
Measurements for the triangular design.

The distance from landmark (5) to (2) should finally become the lip length on the cleft-side too. Since length (13)-(3) is ‘x’ shorter than (5)-(2), ‘x’ must be added to establish equal length. We bring this in as a triangular skin flap from the cleft side with a base of ‘x’. This triangular skin flap, after incision, will be brought in via a deep incision from (3) to (12’), thus splitting (3). Later, the upper half of (3) will be sutured to (11), the lower half to (8). This reconstructs the lip with a normal contoured Cupid’s bow and a zigzag scar line, which also prevents vertical scar contracture.

…End of the preview of this chapter

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Extract: Unilateral Cleft lip: choice between Tennison-Randall and Millard procedure

Two basic techniques are universally in use for unilateral cleft lip closure: the Tennison-Randall procedure and the Millard procedure. Both techniques re­cognize the importance of repositioning the lip muscle (orbicularis oris) in a correct anatomic orientation that results in an aesthetic as well as a functional improvement.

The popularity of the triangular flap technique (Tennison-Randall) diminished in the 1970 to 1980s with the gaining popularity of the Millard procedure. However the triangular flap again gained popularity with widespread practice in many highly regarded institutions. So, both techniques must be considered essential in the armamentarium of the cleft surgeon.

Tennison-Randall procedure

The Tennison-Randall procedure is known as a geometrical design requiring exact pre-surgical measurements. Once the basic principles of cleft lip repair are fully understood the operation is fairly straightforward and should lead to pleasing surgical results. The operation is done strictly on mathematical principles and measurements. There is little room for surgical flexibility and artistry. This is most of the time and for most of us an advantage since errors in surgical artistic licence are common and never far away.

An important advantage of the Tennison-Randall procedure is the lip lengthening effect between the alar base and the Cupid’s bow on the affected side (distance 8-10).

 

Illustration 4
The lip lengthening effect of the Tennison-Randall procedure on the lateral side of the cleft.

The disadvantage however is the disturbance of the aesthetic unit of the CS philtrum column in the lower third. This is a violation of a known anatomic subunit, but not always that obvious. The philtrum dimple has a tendency to be more flat in the classical Tennison. This is no longer the case if the basket-weave method of interlacing the orbicular muscle is used.

Millard procedure

The Millard procedure is known as the rotation-advancement technique. It is a more flexible technique – cut as you go – but needs more experience and artistry.

The advantage of this technique is that it camouflages the violation of the philtrum column near the nose.

The disadvantage however is that one can easily get a vertical scar contracture with vermilion notching of the lip or lowering of the alar base. Horizontal scar contracture provokes a tendency towards a small nostril. Excessive narrowing of the nostril is never far from reality and the surgeon should simply aim for a slightly larger nostril on the cleft side.

In most articles you will find that pre-surgical measurements are less important in the Millard procedure. But small mistakes in judgement, even by excellent surgeons, can quickly translate into irreversible cosmetic concerns. Therefore we think that measurements are equally as important in the Millard technique as in the Tennison-Randall technique.

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Illustration 5
The Millard procedure just before the closing procedure.

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Illustration 6
A wide open cleft lip, where a Tennison-Randall is recommended because the CS is more than 2 mm shorter.

The Choice

Roughly speaking, we use the Millard technique for the partial cleft and the Tennison-Randall for the wide open clefts.
The ultimate decision comes from measuring the distance between the alar base and the end of the white roll on the cleft side (CS). Compare this distance with the non-cleft side (NCS). Most often you will see that the CS is smaller. If the distance on the cleft side (8-10) is more than 2-3mm shorter than on the NCS (4-2), we use the Tennison-Randall technique. If it’s less than 2 mm shorter, we use the Millard procedure.

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Illustration 7
A partial cleft, where a Millard procedure is re­commended because the CS is less than 2 mm shorter.

The reason is as follows: if the difference is more than 2-3 mm—like in most complete clefts—you need to find a way to compensate because if the lengthening is not properly realized the operation will end up with vertical discrepancies in the lip architecture that catch attention right away. The Tennison-Randall compensates by bringing in a triangle of extra tissue. The Millard lengthens the lip medial by straightening a curved incision. But laterally the lip is not lengthened. The alar base will be positioned too low, or the Cupid’s bow will be pulled up (Lazarus DD and co.; “Repair of unilateral cleft lip: a comparison of five techniques” in Ann Plast Surg, 1998, Dec;41(6):587-94).

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Illustration 8
Alar base on the operated side (10) is too low after a Millard operation. A Tennison-Randall would have been a better choice.

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Illustration 9
The Cupid’s bow is pulled upwards on the operated side after a Millard operation. A Tennison-Randall would have been a better choice.

In the Millard procedure, the only way to sail around is to place the end of the white roll on the CS (8) more laterally. This shortens the lip horizontally on the cleft side, but small differences in lip width do not show as obviously as even the most subtle asymmetry in the lip height. But there are aesthetical limits to how lateral one can go.

Sometimes however the difference is less than 2-3 mm—like in most partial clefts. The length of the alar base to the end of white roll is comparable to the other side, and sometimes even longer and more voluminous.

The Tennison-Randall technique then creates a too long lip on the affected side, since you bring in a triangle of extra tissue. The Millard technique perfectly suits these cases.

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