Combining the Cutting and Mulliken Methods for Primary Repair of the Bilateral Cleft Lip Nose

Abstract

Adding the Mulliken approach allows alar cartilage manipulation to be performed more easily than when using the retrograde approach alone. Tip projection and alar base narrowing are facilitated using the combined technique rather than the Mulliken approach alone. Prolabial flap manipulation is safe using this combined approach, even in cases with a severely projected premaxilla. We believe that the combined approach is safe and yields better long-term results than either technique alone.

Cleft Rhinoplasty: A Surgical Technique

“…8 Because of these findings, primary cleft rhinoplasty is done by the cleft surgeon at the time of initial cleft lip repair itself. 9 This early intervention benefits the surgeon for an earlier restoration of nasal shape with the potential for more symmetric nasal growth. It is important to note that any surgery done at an early age will subsequently result in scar tissue and consequently affect future surgeries.…”

Cutting’s Technique of Bilateral Cleft Lip Repair

“…Although exposure to the LLCs is excellent with this technique, the external branches of the anterior ethmoid artery are violated by the columellar incision, compromising the blood supply to the prolabial flap. In addition, the straight line incision from the prolabium into the nostrils can cause a problematic contraction deformity [35] . Cutting subsequently developed a single-stage repair technique which incorporates a retrograde approach to the LLCs [20] .…”

“…In contrast to the previous skin paradigm techniques, McComb addressed the columellar length deficiency by bringing the LLCs into anatomic position instead of recruiting skin from the prolabium. His conceptual shift from focusing on skin rearrangement to anatomic repositioning of the nasal cartilage to increase columellar length inspired the development of the modern bilateral cleft lip repair techniques [20,[33][34][35] . McComb's two-stage operation consisted of wide exposure of the LLCs through a wide "V" incision across the base of the nasal tip.…”

“…The retrograde technique of bilateral cleft lip repair requires NAM to set the premaxilla into anatomic position, lengthen the columella, stretch the nasal lining and mold the LLCs into a convex shape in preparation for surgery. Performing the retrograde technique without NAM can result in an inadequate nasal reconstruction [35] . In cases when NAM is not possible, the retrograde approach to the nose is combined with Mulliken's nostril rim incisions [35] .…”

“…The operation was later modified by Mulliken, who eliminated the midline incision on the nose [31] . Two limitations of the Mulliken repair are the use of nostril rim incisions and failure to reposition the retro-displaced medial footplates of the nose [35] . Following the introduction of Mulliken's single-stage repair, Trott and Mohan described a single-stage procedure utilizing an extended open rhinoplasty technique to access the LLCs.…”