# Cleft Lip > Cleft lip for NEET-SS Plastic Surgery: rule of tens, Millard rotation-advancement, Tennison repair, bilateral clefts, nasal deformity and secondary revision. - Canonical URL: https://prepelephant.com/topics/neet-ss/plastic-surgery/cleft-lip-ss - Exam / course: NEET-SS · Subject: Plastic Surgery - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Cleft Lip", PrepElephant, https://prepelephant.com/topics/neet-ss/plastic-surgery/cleft-lip-ss ## Direct answer Ten weeks of age, ten pounds and ten grams per decilitre of haemoglobin — the rule of tens — is the classical green light for cleft lip repair, most often by Millard's rotation-advancement, which rotates the medial lip element down to restore vertical length and advances the lateral element across, placing the final scar along the future philtral column. The Tennison-Randall lower triangular flap achieves the same lengthening with a measured zigzag in the lower third. Whatever the diagram, the operation is a muscle repair: the aberrant orbicularis oris fibres that insert into the alar base and septum must be freed and reconstituted as a continuous sphincter, or the lip looks repaired but works badly. ## What you must remember - Rule of tens: about 10 weeks old, about 10 pounds, haemoglobin 10 g/dL — an anaesthesia fitness guide rather than a law. - Unilateral cleft lip is classically commoner on the left, by roughly two to one. - Complete versus incomplete: the incomplete cleft retains Simonart's band, a skin bridge at the nostril floor; the complete cleft runs through lip, alar floor and alveolus. - Millard rotation-advancement components: the rotation flap with its back-cut, the lateral advancement flap, and the C-flap that fills the defect above and builds the nostril sill. - Tennison-Randall: a lower-lip triangular flap with the zigzag in the lower third; length is set by a measured template — precise but hard to adjust intraoperatively. - The cleft lip nose: alar dome displaced inferolaterally, alar base posterior and wide, columella deviated to the non-cleft side; primary rhinoplasty (McComb, Tajima reverse-U) is increasingly done at lip repair. - Presurgical preparation: nasoalveolar moulding or lip adhesion to align wide complete clefts before repair. - Bilateral cleft lip: one or two stages; the prolabium forms the philtrum and columella base, vermilion and muscle come from the lateral elements, and muscle must cross behind the prolabium. - Secondary deformities: the whistle deformity of notched vermilion, a short or long lip, widened scars — revised after growth. ## Marking a Millard repair Mark before infiltrating local anaesthetic, because adrenaline blanches and distorts the landmarks. On the medial element, identify the two peaks of the cupid's bow — the cleft-side peak is set to match the normal peak — and the base of the columella. The rotation incision drops from the cleft-side peak along the intended philtral column to the columella base, where the back-cut is added medially until the cupid's bow rotates level; the back-cut is the genius of the design — length is adjusted on the table rather than measured beforehand. On the lateral element, the advancement incision follows the nostril floor down the cleft margin, freeing the flap off the maxilla to advance across. The C-flap, taken from the cleft margin above the rotation, rotates into the back-cut defect, lengthening the columella and building the nostril sill. Then the decisive step: orbicularis oris is freed from its abnormal insertion into the alar base and septum and sutured as a real sphincter, after which the skin is closed in layers and the nose addressed with defining sutures on the displaced dome. ## Where the viva goes next "Why rotation-advancement rather than a straight line?" — because straight-line closures contract and shorten, notching the lip, and the Millard design hides the scar along the philtral column where a scar belongs; the Tennison answers the same problem with a measured triangle, at the cost of a visible zigzag. Expect the Simonart's band definition, and the left-sided predominance question. The bilateral cleft leads to the prolabium question — it becomes the philtrum and columellar base, while vermilion, white roll and muscle are borrowed from the lateral elements. Nasal questions follow the lip: describe the displaced dome and deviated columella, and know that primary nasal correction at the time of lip repair, once feared for growth, is now mainstream. ## Frequently asked questions ### What are the components of the rule of tens? Age about ten weeks, weight about ten pounds, haemoglobin about ten grams per decilitre, with freedom from active infection — the classical fitness threshold for cleft lip anaesthesia; units adjust for individual infants. ### What is Simonart's band? The bridge of skin across the nostril floor in an incomplete cleft lip; its presence defines incompleteness and predicts a less severe alar deformity. ### Where does the C-flap go in a Millard repair? Into the defect above the rotated medial element, at the columella base — lengthening the columella and constructing the nostril sill; without it the rotation shortens the medial lip. ### Why is the final scar placed along the philtral column? Because the philtral column is a natural aesthetic boundary where a scar mimics normal anatomy; scars placed on convex surfaces or across the lip's vertical lines widen and contract. ### What is a whistle deformity and how is it revised? Notching and deficiency of the vermilion, usually from lost muscle bulk or mismatch at the original closure. Revision re-aligns the vermilion flaps or augments the free border with a local mucosal flap after growth stabilises.