Cleft-Lip Craft

There were no serious casualties one day in mid-1954, so 34-year-old Captain David Ralph Millard Jr., assigned to a 1st Marine Division medical unit in South Korea, had time at day's end to ponder one aspect of his chosen specialty: plastic surgery. Among the Korean youngsters around the base were many with cleft lips. Dr. Millard set a series of photographs of them on an easel, and while studying them he dozed off. He awoke with a start, looked at them from a new direction, and then the inspiration came: what he (and generations of surgeons before him) had failed to notice was that one aspect of the abnormality was that normal features were present but at an unnatural angle. What he had to do, Millard reasoned, was to move the misplaced features down, put them in proper alignment, then fill the remaining triangular gap with tissue shifted from the opposite side of the cleft.

Many cleft lips show the defect only on one side, some are in the middle, and some affect both sides. Millard wanted to work first on a simple, unilateral case. As a boy in North Carolina, he had been a rodeo fan and had learned to twirl a lariat. So during some friendly horseplay, he literally lassoed a ten-year-old Korean boy and lollipopped him into the medical hut. (His parents could not be reached for approval.) When the stitches were removed, the result was so good that the boy became a walking, talking testimonial to Millard's wondrous surgery.

Harelip Repairs. Soon Millard was operating on cleft-lip youngsters from all over Korea, often in freezing temperatures, with no electric power and an assistant holding a flashlight. The Millard simplified technique produced a more natural appearance than others previously used for unilateral cleft lip; it was so successful that after Millard reported his results, it was widely adopted and now accounts for a major proportion of all one-side harelip repairs.

Harelips and cleft palates, in one form or another, afflict one in about every 750 newborn children, or 5,000 a year in the U.S. alone. That they develop early in fetal life is clear, but beyond that no one knows the exact cause. It may be a genetic defect, the result of maternal malnutrition or infection, drugs, or a combination of these. Whatever the cause, as fetal tissues grow and form the lips, mouth and palate, something inhibits normal development. The result is a twisted, often grotesque distortion of the nose and a gaping cleft in the upper lip, and sometimes the palate.

Millard's experience with the unilateral deformity has been so deep and extensive that he has compiled it in a large volume: Cleft Craft (Little, Brown), which weighs 7 Ibs. and lists at $85. Even with that fiscal bite, Millard expects to lose money: his 10% royalty will not cover the original costs of research and illustration. Volume II, on bilateral and rare cleft-lip deformities, is already at the publisher's. Millard is also at work on alveolar and palatal deformities for Volume III.

His present book traces records of cleft lips to figurines almost 2,000 years old and surgical attempts to correct them back to early Christian times. About A.D. 950, according to Millard, a Saxon surgeon wrote in The Leech-Book of Bald: "Pound mastic very small, add the white of an egg and mingle as thou dost vermilion, cut with a knife the false edges of the lip, sew fast with silk, then smear without and within with the salve, ere the silk rot." As recently as 1926, St. Louis Surgeon Vilray Blair was so fond of horsehair for sutures that he kept a white horse near a local hospital to ensure his supply.

Millard graduated from Harvard Medical School in 1944 and soon fell under the spell of the great New Zealand-born plastic surgeon, Sir Harold Gillies, with whom he was co-author of The Principles and Art of Plastic Surgery. Millard has been at the University of Miami School of Medicine for the past 20 years. He is so aggressively innovative that some colleagues find him abrasive, but all respect his skill and anyone who can heft Cleft Craft will admire his scholarship. Millard is an outspoken proponent of reconstruction of the breast after mastectomy and at the center of controversies in that field. He also performs purely cosmetic surgery such as nose bobbing, and there is a two-year waiting list for Miami matrons who want face lifts. The doctor refuses to disclose his fees for these. "That's where the money is," he admits. But for many of his cleft patients there is no charge.

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