This surgical tutorial illustrates the steps in Millard unilateral cleft lip repair.

Mark the trough (nadir) of cupid’s bow. You may evert the lip and look at the frenulum as another midline reference.

Mark the peak of cupid’s bow on the non-cleft side. You will see this peak at the lower aspect of the philtral column.

Measure the distance between the two aforementioned points and transpose to create the other peak of cupid’s bow.

The wet-dry border on the vermilion is marked perpendicular to each point that was marked on the white roll.

Mark midline at the columellar base.

Mark the height of philtral columns at the columellar base.

Measure lip height differential. The cleft side lip shortening will be lengthened in this technique by 1) the Mohler columellar back cut, 2) the curvilinear Rose-Thompson effect, and 3) the cutaneous back cut.

The rotation back cut is designed 1.5mm below the columella on the lip. This back cut begins on the cleft side philtral column and extends transversely towards but not onto the non-cleft philtrum. Mark this with a dot on each philtral column.

Mark the base of the C-flap at the level of the columella on the cutaneous-mucosal border.

The C-flap can be seen here.

Mark each alar base. Care is taken to put these markings at the same anatomic point – the cleft side alar base is significantly distorted and can easily be mis-marked.

Mark this point on the lateral lip element. It is chosen where the white roll has its full thickness and where the vermillion has near full substance.

Mark the superomedial corner of the lateral lip element.

Mark the base of the L-flap.

Mark the wet-dry border on each side. A narrowing of the dry vermillion is typically noted on the medial lip element. This will be augmented with a triangle from the lateral lip.

This height difference can be see here.

Based on the difference in height of the dry vermillion on the medial lip element, design a vermillion triangle with a base that wide at the wet-dry junction on the lateral lip.

The vermillion markings can be seen here.

The M-flap from the medial lip element and the L-flap from the lateral lip element are small mucosal flaps that will be used for lining. Mark the most distal aspect of each flap on the wet vermillion directly below the medial peak of cupid’s bow and Noordhoff’s point.

Incision design from the markings can be seen here.