Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology

Abstract

Background Cleft lip repair is essential to restoring physiologic function and ensuring social and psychological well-being in children with orofacial clefts. It is important to critically study various techniques to understand the elements of the lip and nasal repair that contribute to favorable results. Here, we use eye-tracking technology to evaluate how viewers analyze images of cleft lips repaired by the Fisher, Millard, or Mohler techniques. Methods Thirty viewers were shown 5 images without deformity and 5 images each of unilateral cleft lips repaired by the Fisher, Millard, or Mohler techniques. Viewers assessed the esthetic quality of images on a Likert scale while eye-tracking technology analyzed their gaze patterns. Results Of the 3 repair techniques, viewers found Fisher repairs most esthetically pleasing (mean ± standard error, 6.91 ± 0.13). Mohler repairs were next most attractive at (6.47 ± 0.13), followed by Millard repairs at (5.60 ± 0.14). The proportion of time spent in fixed gaze on the nose and upper lip was greatest for Millard repairs (58.3% ± 0.4%) and least for Fisher repairs (51.9% ± 0.5%). Viewers fixated most frequently on the nose and upper lip in Millard repairs (83.2% ± 0.5%) and least frequently in Fisher repairs (75.3% ± 0.5%). When examining the Millard compared with Fisher and Mohler repairs, viewers spent more time and fixations on the ipsilateral lip, nose, and repair scar than on the contralateral lip. Conclusions The esthetics of the Fisher repair appear to be favored as measured by Likert scores and gaze data. Eye-tracking technology may be a useful tool to assess outcomes in plastic surgery.

The role of scar massage in cleft lip surgery

“…6,7,10 Our study found a statistically significant improvement in scar scores when the Fisher's technique of cleft lip repair was used. The results are in keeping with other evidence previously described by Kwong and colleagues 18 and Mittermiller and colleagues. 19 Further limitations include the retrospective nature of this study and reliance on parents' recall.…”

Improvements in Cleft Lip Aesthetics with the Fisher Repair Compared to the Mohler Repair

“…Another study published recently by Kwong et al 12 used eye-tracking technology to compare rotation-advancement repairs to the anatomic subunit repair. The study presented data suggesting that viewers from multiple levels of training found cleft lips repaired with the Fisher technique to be more aesthetically pleasing than those repaired with Mohler or Millard techniques.…”

“…This outcome further supports our data, which suggests that superior aesthetic outcomes can be achieved with the Fisher technique for cleft lip repair. The study by Kwong et al 12 offers a more objective evaluation of cleft lip repair outcomes, but it does not have a complete sample of all consecutive cleft lip repairs performed by the senior author. This study uses surgeon revision rates as a proxy for the quality of surgical outcome.…”

Comparative study between fisher anatomical subunit approximation technique and millard rotation- advancement technique in unilateral cleft lip repair

“…Kwong et al in 2019 performed a comparative study between Fisher, Millard, and Mohler techniques of cleft lip repair surgery and assessed the results using eye-tracking technology; and concluded that Fisher repairs were the best esthetically, then Mohler repairs and finally Millard repairs [23].…”