Millard法修复单侧唇裂的分析和研究

目的：分析阐明Millard法在修复单侧唇裂中的优点和缺陷。方法：对30例单侧唇裂的患儿，应用Millard I或Ⅱ型法修复，同时在唇红缘裂隙处作一交叉三角辨的改良，并一期复位鼻翼软骨。结果：经6个月－1年的随访，解剖复位效果满意，瘢痕隐蔽，人中完整，唇红丰满，鼻翼软骨复位良好，鼻小柱得以延长。结论：Millard法是修复单侧唇裂较为理想的方法，应用交叉三角瓣修复唇红缘，弥补了Millard法唇红缘修复方面的不足。一期鼻翼软骨钝性解剖复位效果良好，符合东方人种的特点。     

改良Millard法结合鼻唇肌肉功能重建修复单侧唇裂21例

目的:利用三维激光扫描仪分析改良Millard法结合鼻唇肌肉功能重建治疗单侧唇裂的效果。方法:选择2018年1月至12月就诊于蚌埠医学院第一附属医院整形外科接受治疗的21例单侧唇裂患者为研究对象,采用改良Millard法结合三维立体定向重建法进行修复,并利用三维扫描仪结合逆向工程软件获取5对鼻唇部指标数据进行对称性的分析。结果:21例患者术后切口均一期愈合。通过对三维面部图像的采集及鼻唇部数据的测量分析,获得鼻基底宽非对称率为0.03±0.02,鼻小柱高度非对称率为0.04±0.01,人中嵴长非对称率为0.02±0.01,唇高非对称率为0.09±0.02,唇长非对称率为0.09±0.01。鼻小柱偏斜畸形得到矫正,人中及唇部形态良好,鼻唇部健患侧对称性高。结论:运用改良Millard结合三维立体定向重建法修复单侧唇裂,术后鼻唇部外观良好,长期效果稳定,值得临床应用推广。     

Unilateral complete cleft lip repair: orthotopic positioning of skin flaps.

The ideally repaired cleft lip should provide a symmetrical Cupid's bow, philtrum, and minimal scar. In the appearance of the upper lip, the philtrum plays a key role. The most popular method for unilateral cleft lip repair is the rotation-advancement technique introduced by Millard. This technique requires the rotation of the noncleft side flap in unilateral cleft lip. As the vertical discrepancy between the peaks of Cupid's bow is increased, the scarring becomes more evident. Also, where it crosses the philtral column in the oblique extension of the upper lip, it becomes apparent for the eye to notice. Thus, many surgeons have tried to modify this technique to improve the symmetry of the philtral columns. The philtral dimple is composed of centrally located thin dense subcutaneous tissue bordered by thick loose subcutaneous tissue producing the philtral columns laterally. The aim of this surgical modification is to form a more natural looking philtrum using its original anatomical structure. The tissue defect after rotation of the noncleft side flap is filled with the C flap, not the advancement skin flap from the cleft side. The C flap helps to form the upper philtral column into a more straight appearance. The skin flaps of the cleft side and noncleft side are placed either side of the philtral column, and the skin flap from the columella is not used for the repair of the philtrum. Twenty-five patients with unilateral complete cleft lip were repaired using this technique from 1996 to 1999. Adequate alignment of the Cupid's bow and symmetric philtral appearance were obtainable.     

Repair of bilateral cleft lip: Millard's technique

The abnormal anatomy and principles of treatment of the bilateral cleft lip deformity have been presented. The Millard technique of bilateral cleft lip repair provides for a philtrum of proper width, a lip of proper height, a full-depth labial sulcus, and complete muscle continuity. Transposition of prolabium not required in the definitive lip repair into the floor of the nose permits subsequent columellar construction.     

榫卯型口轮匝肌肌瓣修复单侧唇裂术后继发人中嵴畸形

目的探讨榫卯型口轮匝肌肌瓣修复单侧唇裂术后继发人中嵴畸形的疗效。方法 2009年1月-2011年8月,收治43例单侧唇裂修复术后继发人中嵴畸形患者。男23例,女20例;年龄18～31岁,平均23.6岁。左侧26例,右侧17例。唇裂采用MillardⅠ式修复15例,MillardⅡ式修复28例。唇裂修复术至此次手术时间为15～30年,平均21.7年。术中切取双侧口轮匝肌肌瓣,水平分成上、下两层;双侧下层肌瓣相互重叠缝合,上层肌瓣形成榫卯型结构,缝合于皮下。结果术后患者切口均Ⅰ期愈合。40例患者获随访,随访时间6～34个月,平均13.4个月。双侧人中嵴隆起、对称,人中凹形态接近正常,上唇动态效果满意。术后6个月38例明显改善,2例改善不明显。结论榫卯型口轮匝肌肌瓣手术操作简便,修复单侧唇裂术后继发人中嵴畸形能较好恢复解剖结构,术后获得良好上唇外形和功能。     

The V.L.S. classification for secondary deformities in the unilateral cleft lip: clinical application.

Results obtained in 70 cleft lip and palate patients who were assessed using the V.L.S. classification are presented. Of these 70 patients, 24 (34%) had had a Millard repair, 13 (19%) a straight line repair, and 33 (47%) had had a repair incorporating a Z-plasty. Both the Millard repair and the Z-plasty repair were associated with a lip of equal height in 54% of patients, whilst in the straight line repair group, 69% of patients had lips of equal height. A long lip was more often associated with the Z-plasty type repair group (27%) of patients, and short lips were more associated with Millard type repair (33%), and straight line repair (31%). Irrespective of the technique used, a notch at the site of the scar was the most common defect found at the vermilion. Wideness and irregularity were the most common unaesthetic features of the scar.     

The cleft lateral lip element: do traditional markings result in secondary deformities?

In cleft surgery, two methods have traditionally been used to mark the height of cupid's bow on the lateral lip element. One technique measures the distance from the oral commissure to the height of cupid's bow on the noncleft side, and transposes this distance onto the cleft-side lateral lip element. The second technique marks the height of cupid's bow on the cleft-side lateral lip element where the white roll disappears. The authors believe these techniques may result in deformities of residual cleft tissue in the repair. Marking the height of cupid's bow on the cleft-side lateral lip element, just before the attenuation of lip fullness, can prevent this deformity. A retrospective study yielded a series of 17 patients with secondary deformities of residual cleft tissue in their repair. The method used to mark the lateral lip element was determined by chart review. Patients then underwent secondary surgery with excision of residual cleft tissue, and repair using the initial technique. A random group of primary cleft patients, repaired using the authors' technique for marking the lateral lip element, was likewise evaluated for the presence of residual cleft tissue in the repair. Of the 17 cases of secondary deformities, 14 were unilateral and 3 were bilateral. Among the unilateral cases, seven were repaired with a triangular flap and seven by rotation advancement. The bilateral cases were repaired using the modified Millard technique. The lateral lip element was marked using cessation of the white roll in 8 patients, and the commissure to the height the of cupid's bow in 2 patients, whereas in 7 patients the method was unreported. Using the authors' technique, both "controls" repaired primarily and cases repaired secondarily resulted in no redundant cleft tissue. Average follow-up was 11 months (range, 1-41 months). The authors think that traditional markings for establishing the height of cupid's bow on the cleft lateral lip element may result in residual cleft tissue in the repair. This deformity can be prevented by marking the height of cupid's bow on the cleft lateral lip element just before the attenuation of lip fullness.     

Millard Ⅱ式手术矫正单侧唇裂术后继发畸形的分析

目的 分析Millard Ⅱ式手术矫正单侧唇裂术后继发唇鼻畸形的优点与手术要点.方法 2003年3月至2004年9月,对42例单侧唇裂术后继发畸形患者采用Millard Ⅱ式手术矫正,同时松解患侧鼻翼软骨与皮肤的粘连,应用埋没导引针悬吊鼻翼软骨,或切断其内侧脚后上提与对侧鼻翼软骨内侧脚缝合.结果 所有患者术后切口愈合良好.随访3～6个月,患侧鼻小柱延长,两侧鼻孔对称,人中嵴对称,唇弓形态好,无瘢痕增生.结论 Millard Ⅱ式手术是矫正单侧唇裂术后继发畸形的理想术式,同时松解、悬吊患侧鼻翼软骨能够更好地矫正鼻畸形.     

Correction of the bilateral complete cleft lip: transformation to a unilateral incomplete cleft lip closure

The complete lip alveolus and cleft palate is the most difficult of all bilateral clefts to treat because of the deformity of and tissue insufficiency in the prolabium. A bilateral concomitant procedure is impractical for treatment of this condition because of the problems that have to be resolved postoperatively, including a short columella, a lack of philtrum, labial horizontal and vertical insufficiency, and vermilion and alveolar vestibulum insufficiency. A two-stage procedure called the transformation method has been developed to circumvent these problems, and the authors present it here. With this method one side is closed completely using the maximum amount of tissue available. Concomitantly, incomplete closure is performed on the other side. The result at the end of the first stage of the procedure is a condition approximating unilateral incomplete closure. The results were obtained from 6 patients who underwent complete bilateral closure and were followed for at least 2 years with satisfactory results.     

A long term subjective and objective assessment of the scar in unilateral cleft lip repairs using the Millard technique without revisional surgery.

The aim of unilateral cleft lip repair is to achieve a functional and aesthetically acceptable upper lip scar. Many techniques have been described but do not fulfil the basic aesthetic criteria. This series assessed the long term results from a subjective and objective point of view in a group of 20 patients who only had the initial repair, as described by Millard, without further revisional surgery. Surgery was undertaken at approximately 3 months of age and no secondary procedures were performed thereafter. The analysis related essentially to the residual scar. Patients were assessed subjectively and objectively by means of questionnaires. A control group (n = 20) of normal patients, of similar age, male to female ratio and of similar racial distribution was selected for comparison of the Cupid's bow. No patients were unhappy with the middle part of the scar, however, the upper and lower thirds created more concern. The complaints in the upper part of the scar were related to an unattractive scar crossing the base of the columella. The complaints relating to the lower part of the scar were related to peaking of the vermilion skin junction and notching of the lip margin. The most striking features that were noted from the objective evaluation were: 1. Virtually all patients had scar transgression of normal anatomical boundaries in the upper part of the lip. 2. There was a very high incidence of peaking (65%) and notching (45%) in this study group. 3. Cupid's bow to horizontal lip length ratio was greater in most patients as compared to normal. The study shows that the upper part of the scar close to the nose is problematic both from a subjective and objective point of view. In addition, the ratio of Cupid's bow to the overall lip length seems to be large.     

单侧唇裂手术前后唇鼻部外观变化的数据分析

目的获得单侧唇裂患儿术前唇鼻形态的数据资料,根据唇鼻畸形特征设计手术修复方案,通过术后临床观察,评价手术效果。方法单侧唇裂患儿85例,分为单侧完全性唇裂组、单侧不完全性唇裂组。术前、术后6个月分别测量裂隙两侧唇长、唇高、人中嵴高度、鼻底宽度和鼻小柱高度,采用配对t检验来比较各组患儿裂隙两侧测量值的差异。结果单侧唇裂患儿术前裂隙两侧唇鼻部各项参数均有统计学意义（P〈0．01）;短期术后随访表明,两组1岁以内患儿在健一患侧唇长和鼻底宽度方面具有统计学意义（P〈0．01）,裂隙侧唇长较健侧小,鼻底宽度较健侧大。完全性唇裂组患儿术后半年患侧鼻小柱高度小于健侧。1～2岁患儿在健一患侧唇长、唇高、人中嵴高度、鼻底宽度和鼻小柱高度方面差异无统计学意义。结论测量单侧唇裂患儿唇长、唇高、鼻底宽度、鼻小柱高度和人中嵴高度,对术前手术设计和术后对称性评估有很大的帮助。短期随访表明,1岁以内单侧唇裂患儿患侧唇长变短,鼻底增宽,在今后的唇裂修复中,需要通过改进手术方法来解决。     

改良Millard术式矫正单侧唇裂继发畸形

目的:对Millard术式进行改进以常规用于矫正单侧唇裂继发畸形。方法:在矫治单侧唇裂继发畸形时,常规应用仿Millard术式,并结合上唇瘢痕组织瓣,对所有唇、鼻畸形进行解剖复位。结果:应用本法共矫治单侧唇裂继发畸形58例,皮瓣全部成活,矫治畸形效果良好。结论:根据唇裂继发畸形的特点改进Millard术式,形成了与唇裂修复术不同的唇裂继发畸形矫治术专用术式。     

Repair of the unilateral cleft lip/nose deformity

Successful surgical repair of the unilateral cleft lip and nose deformity, defined as normal orbicularis oris function and near-perfect symmetry of the repaired lip and nose, demands that the surgeon possess complete understanding of the embryology and anatomy of the midfacial defects. The surgical approach to repair of the unilateral cleft lip/nose should place great emphasis on achieving symmetry, not only with the lip segments but also perhaps even more importantly with the nasal tip. The reconstruction should recreate an intact fully functional orbicularis oris muscle across the cleft and camouflage the scar optimally. We have found that modification of the Millard rotation-advancement flap technique, with particular attention to the primary nasal repair, provides the best outcomes. In patients who have undergone primary repair of the lip and/or nose deformity, secondary rhinoplasty is generally required, regardless of the technique used at the primary repair. The degree of nasal deformity, however, is less severe following primary repair of the asymmetric nasal tip. We have found that the sliding flap cheliorhinoplasty, Wang's modification of the Vissarionov technique, provides excellent results for most secondary cleft rhinoplasties.     

Cleft lip repair by soft-tissue expansion.

I report herein a newly devised method of cleft lip repair that involves the expansion of cheek skin by tissue expander and transferring the scar from the philtrum to the nasolabial fold, or reducing a broad scar to a finer and less conspicuous one without leaving tension. The method, having been applied in three patients with good results, is thereby recommended for patients with severe cleft lip deformity wherein a tight lip is present.     

The contour lines of the upper lip and a revised method of cleft lip repair

Many techniques for cleft lip repair have been reported, but these techniques do not consider the contour lines of the upper lip and, in fact, destroy them. The upper lip has complicated contour lines including the vermilion free margin, vermilion border, upper lip horizontal groove (upper lip groove), philtrum (dimple and columns), nostril sills, and nasolabial grooves. Incision lines should be designed so that the postoperative scars do not cross these contour lines. We feel that our incision lines and postoperative scars provide better aesthetic results and diminish hypertrophic scar formation.     

唇裂的鼻小柱侧面皮瓣修复法

为唇裂患者塑造一个正常唇的美好形态,改进现在常用的手术对人中嵴,人中窝和朱缘弓这三种个重要美容结构的塑造中的缺欠,使修复后的嘎满,松动。方法在鼻小柱裂面形成一个矩形瓣,将其与人中一起垂直下降,被充裂侧唇人中的长度不 和保持朱缘弓在下降的正常位。     

Modification of Reichert's technique based on natural landmarks and individual designs for unilateral repair of cleft lip.

We present a new technique for repair of unilateral cleft lip used in 230 patients. This is a modification of Reichert's technique for unilateral cleft lip repair. It is based in three concepts: form, severity, and natural landmarks of the lip. All the incisions are placed on natural landmarks, between the aesthetic subunits of the upper lip. The incision for rotation of the philtrum is designed to imitate the column of the philtrum on the normal side with good aesthetic result. We do not use a subnasal incision on the lateral side. Since 1996, we have used this technique in 230 unilateral cleft lip repairs. We obtained a good functional and aesthetic result in the nose and upper lip. Our failure rate was 14%. We describe Reichert's modified technique, named the Reichert-Millard's technique, with good aesthetic results (fewer scars and more individual designs than traditional techniques) for repair of the lip and nose in patients with unilateral cleft lip.     

鼻前庭矩形瓣法单侧唇裂修复术

目的：探讨鼻前庭矩形瓣法修复单侧唇裂的临床可行性，评价该方法的优越性。方法：应用遵循整形外科原则的鼻前庭矩形瓣法对80例单侧唇裂患者行立体三维修复。术后对外观及功能进行评价。结果：所有病例均Ⅰ期愈合。随访6个月～3年，除3例患儿红唇唇珠欠丰满，2例患侧鼻翼扁塌，2例切口有轻微瘢痕增长外，其余病例静态、动态效果良好。所有病例患侧唇峰均下降充分，两侧唇峰对称，人中形态好，人中嵴的形态接近正常。修复后的上唇更为丰满、松动，红唇丰满，唇珠明显。结论：应用鼻前庭矩形瓣法进行单侧唇裂的立体三维修复，符合整形外科原则，且不牺牲人中部位的组织及破坏了人中嵴、人中窝等重要美容结构。手术效果良好，值得推广应用。     

Straight line repair of unilateral cleft lip: new operative method based on 25 years experience.

The resultant scar in the primary repair of unilateral cleft lip should ideally be straight and the mirror image of the philtrum on the non-cleft side. In 1993, we reported a new operative technique for unilateral cleft lip, in which we designed a straight line for the incision on the white lip. In order to produce the nostril floor, we used the white lip tissue in the area between the alar base and alveolus at the cleft side as a flap. We also used a small triangular flap above the white skin roll to prevent Cupid's peak from being drawn up. Unlike the rotation-advancement method, our technique does not leave a transverse scar at the alar base. Instead, it leaves a scar only along the line coincident with the natural philtral ridge. However, during observations of our patients, we noticed that the small triangular flap designed to be 1.5mm tended to become a conspicuous angular scar as the patients grew older. In addition, drooping of Cupid's peak on the cleft side was often observed with this small triangular flap. To make it less conspicuous, we made some modifications to the small flap above the white skin roll. With this new technique, we designed a semi-circular flap (1.5 x 3mm) above the white skin roll, instead of the small triangular flap. The suture line of our refined procedure draws a gentle curve, which looks almost straight because of skin elasticity. Moreover, the semi-circular flap causes less drooping of the upper lip than the triangular flap. We believe that revising the shape of the small flap on the white skin roll greatly improves patients' appearance. In this report, we present our refined techniques of primary repair of unilateral cleft lip.     

Post-burn philtrum restoration

One of the consequences of face burn is upper lip deformation with philtrum injury. The philtrum's absence poses severe cosmetic defects. A literature review shows no effective developed technique which allows the surgeon to restore the upper lip and the philtrum in a single-stage procedure. The article presents a new method for burn-damaged philtrum restoration. Two scar stripes are deliberately left in place above the upper lip where the normal philtral ridges should be. The width of these two stripes (ridges) should be around 4 mm. The upper lip scars, lateral both ridges and between them, are excised forming the philtral dimple. The wound is covered with a split thickness skin graft. Two U-shaped sutures are led through the skin graft, both scar stripes and deeper through the underlying tissues between stripes. A bolster is plunged between the ridges in order to fill the dimple and is fixed by the tie-over dressing with tension. The skin transplant lying laterally to the ridges is covered with a separate tie-over dressing. The bolster is being kept in place for the duration of 7 days. As a result, the scar ridges preserve their height and the dimple keeps its depth. Good long-time follow-up results (up to 7 years) were observed in all 18 patients. In most cases the dimple can be slightly smoothed with time. The suggested method of philtrum restoration is an important component of the burned upper lip reconstruction as part of the post-burn facial resurfacing.