Video fragment corresponding to page 20-25 (surgeon: Bart van de Ven):
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.
Illustration 5 The Millard procedure just before the closing procedure
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.
Illustration 6: A wide open cleft lip, where a Tennison-Randall is recommended because the CS is more than 2 mm shorter.
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).
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.
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.
