evaluation of modified millard’s technique with premaxilla

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EvaluationofModifiedMillard’sTechniquewithPremaxillaShortening in Bilateral Labioplasty at Malahayati HospitalBandaAceh2016-2019MuhammadTaufika,MuhammadJailania*aDepartmentofPlasticReconstructiveandAestheticSurgery,FacultyofMedicineUniversitasSyiahKuala*Correspondingauthor:MuhammadJailani-DepartmentofPlasticReconstructiveandAestheticSurgery,FacultyofMedicineUniversitasSyiahKualaEmailaddress:jailani.unsyiah.co.id/[email protected]

ABSTRACT

Keywords:GenderAgeEvaluationtimeCompletebilaterallabioplastyModifiedMillard’stechniquewithpremaxillaryshortening

Introduction:CleftLipandPalate(CLP)isacongenitalabnormalityintheformofgaps in the lips,gums andpalate.This disorderoccurs due toadisruption in the first trimester ofpregnancy that causes disruptionofthe process of fetal growth and development. Surgical techniques forreconstructivesurgeryvarygreatly,butlabioplastyusingamodifiedmillardtechniquewithpremaxillaryshortening isatechniquethatweusedinthisstudywith the aim of premaxilla shortening to reduce the tension of thesuturewoundandwillreducethescarformedinBilaterallabioplastyaftersurgery.Method: This research is a cohort with a retrospective approachconducted on labioplasty patients atMalahayatiHospital inBandaAceh,whichwashandledintheperiodof2016-2019.Thesampleamountedto23respondentswhowillbeanalyzedusingthefrequencydistributiontable.Results:Fromtheresultsofthestudyfoundmalesexasmuchas60.9%,theage of patients in the age group 2 years and over asmuch as 69.6%, 6-9months evaluation time as much as 87.0%, the diagnosis of completebilateral labioplasty as much as 65.2% and good outcome in bil aterallabioplastyusingmodifiedmillardtechniquewithpremaxillashorteningasmuchas73.9%Conclusion:Fromtheoverallitcanbeconcludedthatthemajorityofmalesex is themost, the highest in the age group 2 years and above, themostevaluation time is 6-9 months, the most common diagnosis is completebilateral labiolasty and the most results on bilateral labioplasty usingmodifiedmillardtechniqueswithpremaxillaryshorteningisgoodoutcome.

abioschizis or Cleft Lip is the mostcommon case of craniofacial anomalydefects. Cleft lip with or without the

palate(CL/P)andpalate(CP)isacongenitalabnormality that occurs on the lips that canbe accompanied by abnormalities on thepalate.1 In classification, the cleft lip can hitbothsidescalledbilateral labioschizisorone

side called unilateral. Or it can also befollowed by accompanying defects such ascleftpalateandotheraccompanyingdefects.2

This research focused on the cleft lipon both sides and commonly known asbilateral labioschizis. Efforts to improvethrough surgery have been attempted withvarious techniques.Oneof them is a surgery

L

JurnalRekonstruksi&Estetik,Vol.04,No.2,July-December2019

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technique initiated by Millard (RotationAdvancement Flap). This technique isconsidered easier and can restore the lippoints toananatomicalpoint.Muscles in thecleft lip can be rotated to near normal lipmuscles.3 Repositioning the maxillary andalveolar segments into a more anatomicposition allows the surgeon to repair the lipand associated nasal deformity under moreoptimalconditions.4

But often prominent conditions arefound inbilateral labioplastypremaxilla, thiscauses difficulty for thesurgeon because thelipmusclescannotbedirectlymetorwhenitis forced there will be tension and result inloose stitches a few days later. Millardmodification technique with premaxillaryshorteningisatechniqueusedinthisstudyinordertoshortenorreducepremaxilla,sothesuture wound tension and scar formed inbilateral labioplasty after surgery would bereduced.5

MaterialandMethodRetrospective reviews from all cases

ofbilateralcleft lipwereperformedbetweenSeptember 2016 and September 2019 atMalahayati Hospital. All cases were doneunder general anaesthesia with orotrachealintubation. Data retrieved from the hospitalrecordwhich then included into the analysisweresexofpatients,monthofbirth;typecleftdeformity, Bermudez Score, and evaluationoutcome. A total of 1258 patients weremanaged for cleft lip and palate deformityduring the period. 23 (2%) of these werebilateral cleft lip. There were 9 females and14males. Age of patients at time of surgeryranged between 8 and 490months. Surgicaltechnique employed was Modified Millard'swith premaxillary shortening. Surgicaloutcomewas considered satisfactory if therewere: Adequate length of the upper lip,symmetrical nostrils, reconstituted philtrumand adequate columella length. There were17 surgical interventions (73%)whichwerefoundtobesatisfactionoutof23cases.

Data collected was subjected tosimplestatisticalanalysisusingtheStatisticalPackageforSocialSciences(SPSS),SPSS®for

Windows,version25.0(SPSSInc.,Chicago,IL)statisticalsoftwarepackage.Frequenciesandmeansofthevariableswereestimated.Somepre-operative, intra operative and post-operative clinical photographs were alsoretrievedandwerepresented.

After having installed the mouth-gag on thevomerbone in frontof the centerof growth,septumnasal bone, reduction processperformedabout1cm.Figure1.ModifiedMillard’sTechnique1

1 2

3

65

7

4

1. CheiloraphyBilateralDesign2. IncisioninBilateralCheiloraphy3. Philtrumcorrection4. Musclescorrection5. MucosalSuturing6. WedgeExcision7. TheResultofCheiloraphyBilateral

Jaelani:EvaluationofModifiedMillard’s…

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Figure2.PremaxillaryShorteningSurgeryProcess1

Modified Millard Operation TechniqueswithPremakxillaryShortening

1. Mucosal incision ismademoreor less2centimeterstothebone.

2. Using a small rasparatorium, throughmucosalincisionwoundsintherightandleftelevationenough,

3. Premaxillary bonewill appear clear andenough space to do the reduction withthe knife No. 11. The bones along 1 cmare removeduntil thepremaxilla canbepushedposteriorly.

4. Premaxillashouldbefixedbyusingvicrylyarn3-0withsuturetechnique,figureof8totherightandleftAlveolar.1

Figure3.A7monthsmalewithlabioplastyusing modified millard’s technique withpremaxillashortening.1

1. Preoperativeanteriorview.2. Occlusal intra-oral view, incision

process at the edge of the premaxillabone

3. Occlusal intra-oral view, showingvomero-premaxillary suture and thesite of the wedge ostectomy of thevomerwithabonecutter.

4. Occlusal intra-oral view, showing thegapafterthewithdrawalofthewedgeosteotomizedvomer

Figure4.RepairedBilateralCleftLip13

1

2

3

4

Lips

TensionFlap

Hypertrofi

Discoloratio

Spreading

Suture


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Table1.VariableofEvaluationPostLabioplasty13

Variable of Evaluation

0 Poor

1 Fair

2 Good

Lips Form

Distance from commisura dextra to sinistra and vilmetrion thickness shows symmetrical. Perfome cupid bows looks good

Completely asymmetrical between vilmeltrion thickness, Huge discrepancy of more than 2 mm (about).

Less symmetrical, distance columella to cupid bows seems different, There is some discrepancy between about 1-2 mm.

There is not discrepancy or it is less than about 1 mm.

Tension Flap

The result after surgery makes filtrum look extracted, cupid bows not performed.

Flap looks tense and so extracted and the vilmetrion looks thin

A little tense but does not interfere with smile when smiling.

No tension, vilmetrion form not thin and not interested

Hipertrofi

Swelling in the filtrum so that the protrusion piles over the skin

Swelling was seen above the filtrum, protrusion was evident

Protrusion appears but does not interfere with vilmetrion

No visible protrusion of the collum filtrum, formed properly.

Discoloration

Color discrepancy changes the former stitches

Color discrepancy of the former stitches due to the process of healing the wound

Discoloration is seen but does not occur in all former stitches

There is no discoloration on the stitches, the results are good


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Spreading

Widening of the stitches appears

widening of the actual stitches due to the process of healing wounds

Widening is seen but does not occur in all stitches

No widening of the stitches, better results

Suture Marks

Suture marks appear in the area of the filtrum and vilmetrion

There are visible stitches in the area of the filtrum and vilmetrion

Suture marks appear but not all stitches

No visible form of collum filtrum, suture is formed properly.

Figure5.PatientwithRepairedBilateralCleftLipafterevaluationwithin6-12month

INDICATOR ScoreLipsForm 2TensionFlap 2ScarQuality Hypertrofi 2

Discoloration 2Spreading 2SutureMarks 2

12



10

TotalScore

TotalScore



12



10

TotalScore

TotalScore

6-Month Evaluation

9-Month Evaluation


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OutcomePostLabioplasty

Thefrequencydistributionofpostlabioplastyoutcomes with the modified millardtechnique with premaxillary shortening ofbilateral labioschizispatientswhohavebeenoperated. The result obtained through poor,moderateandgoodoutcome.Table 1. Post labioplasty outcome withmodifiedmillardtechniquewithpremaxillaryshortening of bilateral completelabiopalatoschizis patients at MalahayatiHospitalBandaAceh

Outcome Post Labioplasty

Frequency (n)

Persentage (%)

Poor 0 0,0 Fair 6 26,1 Good 17 73,9

Total 23 100

Graph 1. Post labioplasty outcome withmodifiedmillardtechniquewithpremaxillaryshortening of bilateral completelabiopalatoschizis patients at MalahayatiHospitalBandaAceh

Based on table 1 and graph 1 it was foundthat the post labioplasty outcome with themodifiedmillardtechniquewithpremaxillaryshorteningofbilateralcompletepatientswasmoderateasmanyas6respondents(26.1%),Goodasmanyas17respondents(73.9%).

Age

Thefrequencydistributionofpostlabioplastypatientsbasedonage,obtainedinthisstudycanbeseenintable2andgraph2

Table2.1FrequencyDistributionofPostLabioplastyPatientsbyAgeatMalahayatiHospitalBandaAceh

Age Frequency (n) Persentage (%)

6-12 Month 4 17,4 1-2 Year 3 13,0 >2 Year 16 69,6

Total 23 100 Graph2. FrequencyDistributionofPostLabioplasty Patients by Age at MalahayatiHospitalBandaAceh

Basedon table2.1 and graph2 itwas foundthat themost post labioplasty patientswerefound at age> 2 years as many as 16respondents (69.6%), 6-12 months as manyas4respondents(17.4%),1-2yearsasmanyas3respondents(13.0%).

0

5

10

15

20

Poor Fair Good

Outcome

Outcome


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Table 2.2 Age Frequency for OutcomeDistribution of Post Labioplasty PatientsbyMalahayatiHospitalinBandaAceh

Age Outcome Total

Fair Good n % n % n %

6-12 Month 3 13.0 1 4,3 4 17,4

1-2 Month 1 4,3 2 8,7 3 13,0

>2 Month 2 8,7 14 60,9 16 69,6

Total 6 26,1 17 73,9 23 100

Basedon table2.2, itwas found that themostpostlabioplastypatientswerefoundat age> 2 years as many as 16respondents (69.6%). The resultsobtained were moderate respondents(8.7%) and good as many as 14respondents (60.9%) aged 6-12 years asmany as 4 respondents (17.4%) theresults obtained are moderate outcomesof 3 respondents (13.0%) and good asmany as 1 (4.3%) and at the age of 1-2yearsasmanyas3respondents(13,0%)the result of moderate outcome is 1respondent(4.3%)andgoodis2(8.7).Table3.1FrequencyDistributionofPostLabioplasty Patients by Gender atMalahayatiHospital,BandaAceh

Gender Frequency (n)

Persentage (%)

Male 14 60,9 Female 9 39,1

Total 23 100

Graph 3 Frequency Distribution of PostLabioplasty Patients by Gender atMalahayatiHospital,BandaAceh

GenderThe frequency of gender distributionpatientwith labioplasty,obtained inthisstudycanbeseenintable3andgraph3

Based on table 3.1 and graph 3 it wasfound thatmostpost labioplastypatientswere male as many as 14 respondents(60.9%) and females as many as 9respondents(39.1%).Table 3.2 Distribution of OutcomeFrequencyofPatientswithLabioplastybyGender at Malahayati Hospital, BandaAceh

Gender Outcome Total

Moderate Good n % n % n %

Male 6 26,1 8 34,8 14 60,9 Female 0 0,0 9 39,1 9 39,1

Total 6 26,1 17 73,9 23 100

Basedontable3.2 itwas foundthatpostlabioplasty patients were found most inthe male gender as many as 6respondents (26.1%) obtained moderateand good outcome as many as 8respondents (34.8%) and women asmany as 9 respondents (39.1 %) goodoutcomeisobtained.

0123456789101112131415

Male Female

Gender

Gender


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LipsForm

The frequency distribution of the lipshape of post labioplasty patientsobtainedinthisstudycanbeseenintable4andgraph4.

Table 4.1 Distribusi Frequency PasienPost Labioplasty berdasarkan BentukBibir di Rumah Sakit Malahayati BandaAceh

Bentuk Bibir Frequency (n)

Persentase (%)

Simetris 18 78,3 Tidak Simetris 5 21,7

Total 23 100

Grafik 4 Frequency Distribution of PostLabioplasty Patients based on Lip ShapeinMalahayatiHospitalBandaAceh

Based on table 4.1 and graph 4 it wasfoundthatthelipshapeoflabioplastywasfoundmostsymmetricallyasmanyas18respondents (78.3%), and asymmetricalasmanyas5respondents(21.7%).

Table 4.2 Distribution of OutcomeFrequencyofPatientswithLabioplastybyLips Form atMalahayati Hospital, BandaAceh

Lips Form

Outcome Total Fair Good

n % n % n % Symmetrical

1 4,3 4 17,4 5 21,7

Asymmetrical

5 21,8 13 56,5 18 78,3

Total 6 26.1 17 73,9 23 100

Based on table 4.2 it was found that thelipsforminpost labioplastypatientswasfoundtobemostsymmetricalasmanyas18 respondents (78.3%). symmetrical asmany as 5 respondents (21.7%) withmoderate outcome as much as 1respondent(4.3%)andgoodasmanyas4respondents(17.4%)

Table5.1FrequencyDistributionofPostLabioplastyPatientsbasedonTensionFlapatMalahayatiHospitalBandaAceh

Tension Flap Frequency (n) Persentase (%)

Tension 6 26,1 Normal 17 73,9

Total 23 100

Table 5.2 Distribution of OutcomeFrequency forLabioplastyPatientsbasedon Tension Flap at Malahayati Hospital,BandaAceh

Tension Flap Outcome Total

Fair Good n % n % n %

Tension 2 8,7 4 17,4 6 26,1 Normal 4 17,4 13 56,5 17 73,9

Total 6 26,1 17 73,9 23 100

0

5

10

15

20

Symmetrical Asymmetrical

LipsForm

LipsForm


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Graph 5 Frequency Distribution of PostLabioplasty Patients based on TensionFlapatMalahayatiHospitalBandaAceh

TensionFlapThe frequency distribution of tensionflapsinpostlabioplastypatientsobtainedin this study can be seen in table 5 andgraph5asfollows.

Based on table 5.1 and graph 5 it wasfoundthatthemostfrequenttensionflapin labioplasty was not tense as many as17 respondents (73.9%), and tense asmanyas6respondents(26.1%).

Basedon table5.2, itwas found that thetension flap in post labioplasty patientswas found to be the least tense of 17respondents (73.9%). The moderateoutcomewas4respondents(17.4%)andgood was 13 respondents (56.5%) andtense asmanyas6 respondents (26.1%)

with moderate outcome as much as 2respondents(8.7%)andgoodasmanyas4respondents(17.4%)

6.ScarQuality

The quality of the scar using thebermudes score in post labioplastypatients can be seen in table 6.1 andgraph6

Table6.1FrequencyDistributionofScarQuality of Post Labioplasty Patients inMalahayatiHospitalBandaAceh

Scar Quality

Frequency (n)

Persentage (%)

Poor 0 0 Fair 6 26,1 Good 17 73,9

Total 23 100

Graph 6 Frequency Distribution of ScarQuality in Post Labioplasty Patients atMalahayatiHospitalBandaAceh

Based on table 6.1 and graph 6, it wasfound that the quality of scars in postlabioplasty patients was found to be atgood 17 respondents (73.9%), and 6respondents(26.1%)fair.

Table 6.2 Distribution of FrequencyOutcomeofLabioplastyPatientsbasedonScar Quality at Malahayati Hospital,BandaAceh

Scar Quality

Outcome Total Fair Good

n % n % n % Fair 3 13,1 3 13,0 6 26,1 Good 3 13,1 14 60,9 17 73,9

Total 6 26,1 17 73,9 23 100

Basedon table6.2, itwas found that thequalityofscarinpostlabioplastypatientswasfoundtobeatmostgoodasmanyas

0

5

10

15

20

Tension Normal

TensionFlap

TensionFlap

0

5

10

15

20

Poor Fair Good

ScarQuality

ScarQuality


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17 respondents (73.9%) obtained fairoutcome results as many as 3respondents (13.1%) and good as manyas 14 respondents (60.9%) and fair asmanyas6respondents(26.1%)withfairoutcomes as many as 3 respondents(13.1%) and good as many as 3respondents(13.1%).

Result

The follow-up period rangedbetween6and12months.Weexaminedthe shape of the lips, tension flaps alongwith an assessment of the quality of thescar using Bermudez Score. None of thepatientshadanymajorcomplication,suchaslossofthepremaxillaforanyischemicepisode or vascular compromise of thepremaxilla or skin dehiscence of the lip.During followup, it was noted that thepremaxilla was minimally mobile in allpatients.17of23patientsachievedgoodliprepairand6ofthemhadfairresults,inall cases with adequate muscle repair,with excellent lip symmetry, prolabiumandCupidbowsandgoodscars.Nofistulawas found. Evaluation such as speech isrecommended for the next research toassess the possibility of hypernasal orarticulation disorders. However, asexpected, it has not been recommendedbecause there are should need anyimprovements to the palate and also theeffectsofpostoperativetreatmentitself.

DiscussionTreatmentasearlyaspossibleisthebestcourse of surgery because surgical scarsarelessvisibleaftersurgeryininfants.7Inaddition, bone tissue and soft cartilagecanbeformedininfantsmakecorrectioneasier with surgery, and normal oral

function can be formed after the lipstructurehasbeenrepairedanatomically. Premaxilla protrusion incomplete bilateral labioschizis can beseenat10weeksgestationalage.8Growthof the anterior septum and anteriorvomero-premaxillary is uncontrolled,combined with a lack of continuity ofbone and soft tissue, and impairedbalancebetweenoralmusclesandtongueis thought to result in deformity inbilateral premaxilla.9 Uncontrolledgrowth in the premaxilla can result insignificant functional problems such astheabsenceofproperanteriorocclusion,lateral mobility of the premaxillarysegment and labial oronasal orisnasalfistula or palate causing a problem thatresults in disruption of speech andcleanliness mouth.1 Repair of bilateralcleft lip with prominent premaxillaremains one of the most challengingproblems for surgeons. To ourknowledge,therearereportsofone-stagesurgery with premaxillary shortening orvomerine ostectomy to repair completebilateral labioschizis with protrudingpremaxilla.10 Followed by premaxillashortening or vomerine ostectomy,followed by gingivoperiosteoplastybecome a technique to achieve adequatestability of the premaxilla in its newposition, so that it can close the alveolargap bilaterally, followed by sewing theorbiculus muscle then using modifiedMillard technique to repair the lips.Primarynasalcorrectionisnotperformedbecause it increasestheriskofdamagingthe philtrum and premaxillavascularization that has been performedsurgery.11 The possibility of displacedpremaxilla is very possible. treatmentalone is not possible. On the other hand,surgical repositioning is technically


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recommended to prevent disruption ofthepremaxillablood supply.A two-stageprocedureisrecommendedinsubsequentstudies.12 Premaxilla shortening, incombination with correction of lip slits,hasalsobeenreportedtobesuccessfulincertaincases,especially inolderpatients.This procedure allows closure of largefistulas (increasing the likelihood ofsuccessful lip reconstruction withouttensionontheskinofthelips),facilitatingoverjetandoverbitecorrection.12 Evaluation by assessing theshape of the lips, tension flaps and scarquality becomes an important correctionfor the surgeon to be a reference inconducting further operations.Researchers use a modified scoringsystem in cases of bilateral labioschiziscomplete with premaxillary shortening.Theneedforstandardizationinassessingthe results of labioplasty is veryimportant to improve health services byan organization, hospital or medicalexpert so that it gives betterrecommendations and actions forlabioplastyinthefuture.13

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(2002) Tehnik Pembedahan Celah Bibir danLangit-langit,Jakarta:SagungSeto.

2. TolarovaMMet al. Pediatric Cleft Lip andPalate.Medscape;2018

3. Burt JD, Byrd HS. Cleft lip: unilateral primarydeformities. Plas. Reconstr. Surg. 2000; 105(3):1043-55.

4. Meara JG, Andrew BT, Ridgway EB, RaisolsadatMA, Hiradfar M. Unilateral cleft lip and nasalrepair: techniques and principles. Iran J. Pediatr.2011;21:129-38

5. Millard,D.R.(1976)CleftCraftandARhinoplastyTetralogy Vol 1 The Unilateral Deformity,Miami:AmericanPublishingAssociation.

6. ZayedEF,AyadW,MoustafaWA,El-ShishtawyAH.Unilateralcleftliprepair:Experiencewithmillardtechnique and introduction to the concept ofjunctional zones repair. Egypt J. Plast. Reconstr.Surg.2012;36:109-18.

7. DesaiS.Primaryliprepairinnewbornbabies.In:KehrerB,etal.,eds,LongTermTreatmentinCleftLip and Palate Bern .Stuttgart, Vienna: HansHuberPublishers;1981.pp.248–53.

8. NaryananRK,HussainSA,MurukesanS,MurthyJ.Synchronous palatal closure and premaxillarysetback in older childrenwith bilateral completecleft of lip and palate. Plast Reconstr Surg.2006;117:527–31.

9. LathamRA,DeatonTG,CalabreseCT.Aquestionofthe role of the vomer in the growth of thepremaxillarysegment.CleftPalateJ.1975;12:351–55.

10. Murthy J. Primary bilateral cleft lip repair withmanagement of premaxilla without preoperativeorthopedics.JCraniofacSurg.2009;20:1719–22.

11. Fakih-Gomez N, Sanchez-Sanchez M, Iglesias-MartinF,Garcia-Perla-GarciaA,Belmonte-CaroR,Gonzalez-Perez LM. Repair of complete bilateralcleft lip with severely protruding premaxillaperforming a premaxillary setback and vomerineostectomy in one stage surgery. Med Oral PatolOralCirBucal.2015Jul1;20(4):e500-7

12. Abbott MM, Meara JG. Nasoalveolar molding incleft care: is it efficacious? Plast Reconstr Surg.2012;130:659–66.

13. BermudezL.,LizarragaA.OperationSmile:HowToMeasure Its Success. Annals Of Plastic SurgerySeptember2011,Volume67,Issue3,Pp205-208.

evaluation of modified millard’s technique with premaxilla

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