Beyond Fifty Years of Millard’s Rotation-Advancement Technique in Cleft Lip Closure: Are There Many “Millards”?

In 1955, Millard developed the concept of rotation-advancement flap to treat cleft lip. Almost 6 decades later, it remains the most popular technique worldwide. Since the technique evolved and Millard published many technical variations, we decided to ask 10 experienced cleft surgeons how they would mark Millard’s 7 points in two unilateral cleft lip patient photos and compared the results. In both pictures, points 1 and 2 were marked identically among surgeons. Points 3 were located adjacent to each other, but not coincident, and the largest distances between points 3 were 4.95？mm and 4.03？mm on pictures 1 and 2, respectively. Similar patterns were obtained for points 4, eight of them were adjacent, and the greatest distance between the points was 4.39？mm. Points 5 had the most divergence between the points among evaluators, which were responsible for the different shapes of the C-flap. Points 6 also had dissimilar markings, and such difference accounts for varying resection areas among evaluators. The largest distances observed were 11.66？mm and 7？mm on pictures 1 and 2, respectively. In summary, much has changed since Millard’s initial procedure, but his basic principles have survived the inexorable test of time, proving that his idea has found place among the greatest concepts of modern plastic surgery. 1. Introduction In 1955, Millard developed the concept of rotation-advancement flap to treat cleft lip, which became the most popular technique worldwide [1]. Many other authors published their variations of the original Millard technique [2]. The procedure consists of a lateral flap advancement into the upper lip combined with downward rotation of the medial segment, preserving the philtrum. After that, the author published 41 indexed papers and several book chapters [3–10]. In 1976, Millard published the “trilogy” entitled Cleft Craft: The evolution of its surgery, which eventually became instrumental in facial cleft treatment [11]. We reviewed these articles to identify the evolution of the technique described by Ralph Millard Junior [1, 3–10] and compared its variation among 10 well-known cleft surgeons. 2. Methods We carried out a systematic review of all indexed articles published by Millard since 1957. In addition, two photographs (picture 1 and picture 2) of patients with unilateral cleft lip were sent to 10 well-known Brazilian craniofacial surgeons, and we asked them to draw on them Millard’s markings (Figures 1 and 2). They were asked to mark the seven standard points on the pictures and to draw the flaps afterwards. Point 1 was placed in