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Millard was the first to recognize that the philtral unit was present and merely malrotated in unilateral clefts5. Having made the diagnosis, he immediately developed the R-A concept: return this malpositioned anatomic unit into its normal position (the rotation flap); advance the lateral lip (the advancement flap) to fill the resultant defect.
Replace what is normal in normal position and retain it there8:

Fig.10 demonstrates the essential features of Millard's R-A repair:

Fig.10A. The complete philtral unit is marked for rotation and the lateral element is marked for advancement.

Fig.10B. The complete philtral unit has been rotated into normal position and the lateral lip is ready for advancement.

Fig.10C. The immediate postoperative result.

Fig.10D. The six week postoperative result. Note how the scar of the rotation flap imitates the normal philtral column, the alar base scar resides in the alar crease, and the remaining lip and nasal elements into more normal positions.

The R-A repair is applicable to all unilateral cleft lips, incomplete (Fig.11) as well as complete (Fig.12).

Fig. 11

Fig. 12

POOL REPAIR (is it a modified R-A or triangle flap repair?)

Pool9 recommends a "modified Millard repair" for complete clefts with tissue deficiency in the lateral element.
The modification is to "lower" the R-A repair down into the lip. First, a horizontal line is drawn 2 to 3 millimeters below the columellar crease. The rotation cut continues up to this line, in which it continues (rather than in the columellar crease) until cupid's bow is released. A lateral transposition flap then fills the rotation defect. This procedure is not a rotation-advancement modification; it is a modification of the rotation-transposition type of triangular repair. Instead of a straight line from the high point of cupid's bow into the midst of the philtrum, Pool uses a curvilinear line. From then on, it is a straightforward triangle repair. Because the lateral transposition flap is situated high in the lip (2-2.5mm below the columella) and the rotation scar does a better job of imitating the philtral column, Pool's method is the best of the triangular flap methods. However, for those preferring the unit principle in lip repair, the R-A method is clearly the procedure of choice.

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