• Saeed Ashraf Cheema
  • Muhammad Asim
  • Awais Ahmad


Background: Surgery for unilateral cleft lip repair has evolved over centuries. Many studies givedetailed inside to this process of evolution of various techniques and their modifications. Objectiveswere to compare linear repair of Millard rotation advancement technique and triangular flap techniqueof Nordhoff, at vermilion in unilateral cleft lip repair. Methods: This cross-sectional analytical studywas conducted at Departments of Plastic Surgery, Services Institute of Medical Sciences, and WAPDATeaching Hospital Complex, Lahore form Jan 2004 to Dec 2011. Patients presenting with unilateralcleft lip deformity were included in the study. In the early part of the study (2004–2008), only Millardlinear repair at vermilion was the routine practice. Last consecutive 40 cases repaired with thistechnique during this period were selected for the study. From 2009 to 2011 the unilateral cases wereoperated with Nordhoff triangular flap repair. A group of 40 consecutive cases repaired with thistechnique was also selected for the study. In both groups, the postoperative period exceeded one year.Results were compared for the presence of notch on repaired vermilion area. Results: Notch was absentin 29 cases (72%) treated with Millard Technique whereas Noordhoff Technique Group showed ahigher number of 34 cases (85%). On other extreme, a notch of more than 1 mm was evident in twocases (5%) of Millard technique only and Noordhoff technique did not show this wide notch atvermilion. Similarly, two subgroups of 0.5 mm notch and 0.5–1 mm notch had a slightly highernumber of cases in group dealt with Millard technique (5 and 4 cases respectively) as compared tocases dealt by Noordhoff technique (3 cases in each subgroup). Conclusion: Nordhoff triangular flaprepair at vermilion reduces the chances of notching to minimum due to break in the linear repair invermilion and also helps in reconstructing a symmetrical vermilion by bringing in the vermilion fromlateral to medial segment.Keywords: Flap repair, cleft lip, congenital


Demke CJ, Tatum SA. Analysis and evolution of rotation

principles in unilateral cleft lip repair. J Plast Reconstr Aesthet

Surg 2011;64:313–8.

Adenwalla HS, Narayanan PV. Primary unilateral cleft lip

repair. Indian J Plast Surg 2009;42(Suppl):S62–S70.

Millard DR Jr. A primary camouflage of the unilateral hare

look. In: Skoog T, (Ed). Transactions of the International

Society of Plastic Surgeons, First Congress, Stockholm. 1955.

Baltimore: Williams and Wilkins; 1957. p. 160–6.

Sitzman TJ, Girotto JA, Marcus JR. Current surgical practices

in cleft care: unilateral cleft lip repair. Plast Reconstr Surg


Mitsukawa N, Hosaka Y. Secondary correction of deformities

of the vermilion with exposed oral mucosa after cleft lip repair.

J Craniofac Surg 2008;19(5):1370–3.

Lee SW, Kim MH, Baek RM. Correction of secondary

vermilion notching deformity in unilateral cleft lip patients:

complete revision of two errors. J Craniomaxillofac Surg


Noordhoff MS. The surgical technique for the unilateral cleft

lip-nasal deformity, Taipei, Taiwan: Noordhoff Craniofacial

Foundation; 1997. p. 6–53.

Narayanan PV, Adenwalla HS. Notch-free vermillion after

unilateral cleft lip repair: The Charles Pinto centre protocol.

Indian J Plast Surg 2008:41(2):167–70.

Jan SN, Khan FA, Ansari HH, Hanif A, Bajwa A. Reducing the

vermilion notch in primary lip repairs. Z plasty versus the

Noordhoff triangular flap. J Coll Physicians Surg Pak


Bardach J, Noordhoff MS. Correction of secondary unilateral

cleft lip deformities. In: Bardach J, Salyer KE, (Eds). Surgical

techniques in cleft lip and palates. St Louis: Mosby; 1991. p. 60.

Smith JD, Burnsted RM, (Eds). Paediatrics facial plastic and

reconstructive surgery. New York: Raven Press; 1993.

Patel IA, Hall PN. Free dermis fat graft to correct the whistle

deformity in patients with cleft lip. Br J Plast Surg


Nakajima T, Yoshimura Y. Early repair of unilateral cleft lip

employing a small triangular flap method and primary nasal

correction. Br J Plast Surg 1993;46:616–8.

Nakajima T, Yoshimura Y, Yoneda K. Primary repair of an

incomplete unilateral cleft lip: avoiding an elongated lip and

achieving a straight suture line. Br J Plast Surg 1998;51:511–6.

Nakajima T, Tamada I, Miyamoto J. Nagasao T, Hikosaka M.

Straight line repair of unilateral cleft lip: new operative method

based on 25 years experience. J Plast Reconstr Aesthet Surg


Fisher DM. Unilateral cleft lip repair: an anatomical subunit

approximation technique. Plast Reconstr Surg 2005;116:61–71.

Bailey BJ, Jhonson JT. Cleft lip and palate: evaluation and

treatment of the primary deformity. In: Newlands SD, Calhoun

KH, (Eds). Head and neck surgery-otolaryngology.

Philadelphia: Lipponcot. William & Wilkins; 2003. p. 1327.

Fernades DB, Hudson DA. The modified z-plasty for unilateral

cleft lip repair. Br J Plast Surg 1994;46:676–80.

Noordhoff MS, Chen PK. Unilateral cheiloplasty. In: Mathes

ST, (Ed). Plastic Surgery. Vol. 4. Philadelphia: WB Saunders;

p. 192.



Most read articles by the same author(s)