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https://doi.org/10.15644/asc51/1/8

Modifikacija klizno-rotirajućeg režnja napravljenog 1950. godine

Predrag Knežević ; Stomatološki fakultet Sveučilišta u Zagrebu – Zavod za oralnu i maksilofacijalnu kirurgiju Kliničke bolnice Dubrava, Zagreb, Hrvatska
Marko Vuletić   ORCID icon orcid.org/0000-0002-8750-7212 ; Privatna ordinacija, Sisak, Hrvatska
Igor Blivajs ; Zavod za oralnu i maksilofacijalnu kirurgiju Kliničke bolnice Dubrava, Zagreb, Hrvatska
Emil Dediol ; Stomatološki fakultet Sveučilišta u Zagrebu – Zavod za oralnu i maksilofacijalnu kirurgiju Kliničke bolnice Dubrava, Zagreb, Hrvatska
Darko Macan ; Stomatološki fakultet Sveučilišta u Zagrebu – Zavod za oralnu i maksilofacijalnu kirurgiju Kliničke bolnice Dubrava, Zagreb, Hrvatska
Mišo Virag ; Medicinski fakultet Sveučilišta u Zagrebu – Zavod za oralnu i maksilofacijalnu kirurgiju Kliničke bolnice Dubrava, Zagreb, Hrvatska

Puni tekst: hrvatski, pdf (488 KB) str. 60-64 preuzimanja: 194* citiraj
APA 6th Edition
Knežević, P., Vuletić, M., Blivajs, I., Dediol, E., Macan, D. i Virag, M. (2017). Modifikacija klizno-rotirajućeg režnja napravljenog 1950. godine. Acta stomatologica Croatica, 51 (1), 60-64. https://doi.org/10.15644/asc51/1/8
MLA 8th Edition
Knežević, Predrag, et al. "Modifikacija klizno-rotirajućeg režnja napravljenog 1950. godine." Acta stomatologica Croatica, vol. 51, br. 1, 2017, str. 60-64. https://doi.org/10.15644/asc51/1/8. Citirano 14.05.2021.
Chicago 17th Edition
Knežević, Predrag, Marko Vuletić, Igor Blivajs, Emil Dediol, Darko Macan i Mišo Virag. "Modifikacija klizno-rotirajućeg režnja napravljenog 1950. godine." Acta stomatologica Croatica 51, br. 1 (2017): 60-64. https://doi.org/10.15644/asc51/1/8
Harvard
Knežević, P., et al. (2017). 'Modifikacija klizno-rotirajućeg režnja napravljenog 1950. godine', Acta stomatologica Croatica, 51(1), str. 60-64. https://doi.org/10.15644/asc51/1/8
Vancouver
Knežević P, Vuletić M, Blivajs I, Dediol E, Macan D, Virag M. Modifikacija klizno-rotirajućeg režnja napravljenog 1950. godine. Acta stomatologica Croatica [Internet]. 2017 [pristupljeno 14.05.2021.];51(1):60-64. https://doi.org/10.15644/asc51/1/8
IEEE
P. Knežević, M. Vuletić, I. Blivajs, E. Dediol, D. Macan i M. Virag, "Modifikacija klizno-rotirajućeg režnja napravljenog 1950. godine", Acta stomatologica Croatica, vol.51, br. 1, str. 60-64, 2017. [Online]. https://doi.org/10.15644/asc51/1/8
Puni tekst: engleski, pdf (488 KB) str. 60-64 preuzimanja: 177* citiraj
APA 6th Edition
Knežević, P., Vuletić, M., Blivajs, I., Dediol, E., Macan, D. i Virag, M. (2017). The Modification of Rotation - Advancement Flap Made in 1950. Acta stomatologica Croatica, 51 (1), 60-64. https://doi.org/10.15644/asc51/1/8
MLA 8th Edition
Knežević, Predrag, et al. "The Modification of Rotation - Advancement Flap Made in 1950." Acta stomatologica Croatica, vol. 51, br. 1, 2017, str. 60-64. https://doi.org/10.15644/asc51/1/8. Citirano 14.05.2021.
Chicago 17th Edition
Knežević, Predrag, Marko Vuletić, Igor Blivajs, Emil Dediol, Darko Macan i Mišo Virag. "The Modification of Rotation - Advancement Flap Made in 1950." Acta stomatologica Croatica 51, br. 1 (2017): 60-64. https://doi.org/10.15644/asc51/1/8
Harvard
Knežević, P., et al. (2017). 'The Modification of Rotation - Advancement Flap Made in 1950', Acta stomatologica Croatica, 51(1), str. 60-64. https://doi.org/10.15644/asc51/1/8
Vancouver
Knežević P, Vuletić M, Blivajs I, Dediol E, Macan D, Virag M. The Modification of Rotation - Advancement Flap Made in 1950. Acta stomatologica Croatica [Internet]. 2017 [pristupljeno 14.05.2021.];51(1):60-64. https://doi.org/10.15644/asc51/1/8
IEEE
P. Knežević, M. Vuletić, I. Blivajs, E. Dediol, D. Macan i M. Virag, "The Modification of Rotation - Advancement Flap Made in 1950", Acta stomatologica Croatica, vol.51, br. 1, str. 60-64, 2017. [Online]. https://doi.org/10.15644/asc51/1/8

Rad u XML formatu

Sažetak
Rane tehnike zatvaranja rascjepa usne uključuju linearnu ili druge oblike geometrijskih linija (trokutasta ili četvrtasta zatvaranja). Prekretnica u operaciji rascjepa usana počela je 1955. godine kada je, na Prvom međunarodnom kongresu za plastičnu kirurgiju u Stockholmu, dr. Millard predstavio svoju metodu – klizno-rotirajuću tehniku ili režanj. Danas tu tehniku diljem svijeta, s modifikacijama ili
bez njih, primjenjuje više od 85 posto kirurga za rascjepe. predstavljamo pacijenta s potpunim jednostranim rascjepom usne i nepca koji je operiran prije šezdeset i pet godina. Ožiljak na usni sličan je klizno-rotirajućoj liniji. Plastiku usne obavio je profesor Šercer 1950., pet godina prije Millardove publikacije. Profesor Ante Šercer međunarodno je poznat otorinolaringolog iz Hrvatske. Ističe se njegov značajan doprinos operaciji velofaringealne insuficijencije i plastičnoj kirurgiji nosa i uha.

Ključne riječi
rascjep usne; ožiljak; kirurški režanj; operativna tehnika; plastična kirurgija

Hrčak ID: 177497

URI
https://hrcak.srce.hr/177497

▼ Article Information



Introduction

The early techniques of cleft lip repair involved a straight-line or some kind of geometric line (triangular, quadrangular closure). In 1843, Malgaigne described the cleft lip closure method with local flaps and that year was considered to be the beginning of plastic surgery of the cleft lip. The following year, Mirault modified Malgaigne's technique with a lateral flap across the cleft. All future methods of cleft lip closure have been based on Mirault's principle (1). The first straight line lip repair was performed by Ambroise Pare in 1568. W. Rose advocated curved incision, which included paired incision design that extended from the nasal floor to the vermilion border in 1879. In 1945, LeMesurier reintroduced the geometric lip repair technique, based on Hagerdon's description from 1892, of a laterally based quadrangular lip flap. The Tennison flap repair, which included a triangular flap from the inferior part of the lateral lip, was modified by Randall in 1959 (1, 2).

The First International Congress of Plastic Surgery in Stockholm in 1955 marked a turning point in cleft lip surgery when doctor Millard presented his technique: the rotation-advancement flaps. At the beginning of his clinical career, Millard used
LeMesurier method but he was not entirely satisfied with the results. Ralph Millard developed the rotation-advancement technique by operating the children with cleft lip during his military service in the Korean War. The design of rotation-advancement flap is based on a curved line (rotation) on the non-cleft side in order to balance the lip height discrepancy. With this technique a more symmetrical lip height, philtral column width and nasal base symmetry can be achieved. The symmetrical curved line is made on the cleft side with small extension beneath the nasal alla in order to achieve the access to the nose (2, 3).

No other technique has withstood the test of time like Millard's innovative principle (4). The technique is anatomically logical; it permits individual modifications, therefore, it can be adapted to each form of cleft lip. The type of scar and the patient’s skin dictate the treatment of the scar. Sometimes, the postoperative scar needs to be corrected. However, surgery is performed to fix the scar in cases where the scar does not respond to other noninvasive applications. Today the technique (Figure 1), with or without some modifications, is used by more than 85% of cleft surgeons around the world (5).

Figure 1 The original rotation-advancement design conceived by D. Ralph Millard in
Korea and presented at the First International Congress of Plastic Surgery
in Stockholm in 1955 (10)
ASC_51(1)_60-64-f1

Case report

Was Ralph Millard the first surgeon to describe this technique?

We present a case of the patient with complete unilateral cleft lip and palate who underwent surgery in 1950, which had happened five years before the Millard's publication.

Recently, the patient was hospitalized at our emergency department due to zygomatic fracture. It was obvious that he had undergone the cleft lip and palate surgery. The bone cleft was also seen on MSCT scan when the fracture was diagnosed (Figure 2).

Figure 2 MSCT scan of the patient
ASC_51(1)_60-64-f2

The scar on his lip was visible and it was similar to the rotation advancement line. The scar was hidden in the philtrum of the lip, and the line was curved on the medial side of the lip. It also seemed that the rotation was extended below the base of the columella. There was a clearly visible scar below the alla nasi of the cleft side which could form the advancement flap. Cheiloplasty was performed by Professor Šercer. We are enclosing a few photos which show the line of incision (Figure 3, 4).

Figure 3 Scar of the lip
ASC_51(1)_60-64-f3
Figure 4 Drawing of rotation advancement line
ASC_51(1)_60-64-f4

The patient was born on July 5 in 1950 and he underwent the surgery when he was six months old. The surgery was performed by professor Šercer at “Sestre Milosrdnice Hospital” in Zagreb. We tried to get his medical records from the ENT Department, but they seemed to be lost. Yet, the time of the surgery and the surgeon were well known.

Discussion

After Millard's presentation of the rotation advancement technique there were some concerns about the shortness of the lip. Millard later changed the technique with the back-cut to enable more rotation and length of the medial flap. The rotation advancement technique has been followed with some modifications which have been made by numerous cleft surgeons. Extended incision in the columella, insertion of small skin triangle on the non-cleft side for the elongation of the lip on the cleft side or some other small geometric modification on the line of rotation or some changes in subalar incision on the cleft side are some of them. Two flaps (rotation and advancement) as it was described in the original Millard’s publication in 1955 serve as basis for all further modification techniques.

Professor Ante Šercer was born in 1896 and he passed away in 1968. He was one of the founders of othorinolaringology in Croatia. Soon after completion of his medical studies in Prague (Czech Republic) and Graz (Austria), he attended the specialized courses in Othorinolaringology in Zagreb, Vienna and Prague. Having returned to his homeland, he worked at the ENT Department University Clinic in Zagreb from 1920 to 1945, and from 1929 he was head of department.

Today, in Croatia, the name of professor Šercer is a synonym for a leading figure in the field of medicine, teaching and research. In 1936/37 and in 1943/45, he was director of “The Sestre Milosrdnice Hospital” in Zagreb. He was head of Department of Ear, Nose and Throat Diseases (ENT) in 1946 which was transformed into a University Clinic in 1964. He was also a founder of the scientific Institute for the Study and Protection of Ear and Respiratory Organs. Šercer was the first Croatian clinician with international reputation for interpretation of the formation of nasal septum deviation and otosclerosis. Also, he discovered the nasothoracicle reflex. He was a leading surgeon in plastic and reconstructive surgery of the nose and ear not only in Croatia but also in this part of Europe (6).

He published scientific papers on cleft surgery in 1943 while he was using the techniques which were known at that time (7). His contribution to surgical management of velopharyngeal insufficiency and plastic surgery of the nose and ear is significant but probably not sufficiently associated with his name. He was an open rhinoplasty surgery pioneer (decortication) (8).

The book on plastic surgery of the nose, which was written by professor Šercer in 1962, should be emphasized as his most important work. It was written in German (9). He initiated and was the editor in chief of a Croatian medical Encyclopedia, which was one of the first books of that kind in the world (6).

Conclusion

There are three basic techniques for unilateral cleft lip repair: straight line, geometric line and rotation advancement technique. The revolutionary rotation-advancement procedure for cleft lip repair is an original and excellent technique developed by the American surgeon Ralph Millard. Today, the rotation advancement technique is one of the most widely used methods. Our case report deals with postoperative cleft lip of the patient operated by the Croatian ENT specialist Ante Šercer almost five years before Millard’s publication. It is not easy to explain the surgical technique used in this case since it was based on the postoperative scar which had been made sixty-five years before this surgery. Yet, if the scar line is carefully analyzed, it can be observed that Šercer’s technique is very similar to the rotation advancement method.

References

1 

Salyer KE, Marchac A, Cheng MS. Unilateral Cleft Lip/Nose Repair. In: Losee, JE; Kirschner RE - editors. Comprehensive Cleft Care. Columbus: The Mc Graw Hill Companies; 2009. p. 23-32.

2 

Tollefson TT, Sykes JM. Cleft Lip Repair: Unilateral. In: Goudy, SL; Tollefson, TT - editors. Complete Cleft Care – Cleft and Velopharyngeal Insufficiency Treatment in Children. Stuttgart: Thieme Verlagsgruppe; 2015. p. 37-62.

3 

Allen GC, Banks CA, Boss EF. Cleft Lip Repair: Unilateral. In: Goudy, S; Tollefson, T - editors. Complete Cleft Care. Stuttgart: Thieme Verlagsgruppe; 2015. p. 37-9.

4 

Stal S, Brown RH, Higuera S, Hollier LH Jr, Byrd HS, Cutting CB, et al. Fifty years of the Millard rotation-advancement: looking back and moving forward. Plast Reconstr Surg. 2009 Apr;123(4):1364–77. DOI: http://dx.doi.org/10.1097/PRS.0b013e31819e26a5 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/19337105

5 

Knežević P, Grgurević L, Uglešić V, Grgurević J. Modified Millard’s technique in operations for unilateral cleft lip. J Plast Surg Hand Surg. 2012 Oct;46(5):326–9. DOI: http://dx.doi.org/10.3109/2000656X.2012.713573 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22931135

6 

Padovan I. Život i djela Ante Šercera. Zagreb: Nakladni zavod Globus; 1997. p. 17.

7 

Šercer A. Beitrage zur Technik der Lippen-Kiefer-Gaumenspaltenoperationen. Archiv fur O.N. Kehlkopfheilkunde. 1943;153(3-4):319–42.

8 

Šercer A. La decortication du nez et sa valeur pour la chirurgie cosmetique. Rev Laryngol Otol Rhinol (Bord). 1957 Mar-Apr;78(3-4):161–8. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/13442220

9 

Šercer A, Mundnich K. – editors. Plastiche Operationen an der Nase und an der Ohrmuschel. Stuttgart: G. Thieme; 1962. p. 55-311.

10 

Randall P, Jackson O. A Short History of Cleft Lip and Cleft Palate. In: Losee, JE; Kirschner, RE - editors. Comprehensive Cleft Care. Columbus: The McGraw-Hill Companies; 2009. p. 194.


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