CLINICAL NOTE. Long-Term Results in the Bilateral Cleft Lip Repair by Mulliken s Method

CLINICAL NOTE Long-Term Results in the Bilateral Cleft Lip Repair by Mulliken s Method Seok-Kwun Kim, MD, PhD, Myung-Hoon Kim, MD, Yong-Seok Kwon, MD, and Keun-Cheol Lee, MD, PhD Purpose: To evaluate long-term results in the bilateral cleft lip repair by Mulliken s method, using anthropometric measurements, we assessed the growth of the nose and upper lip after the operation by comparing with those from 30 children without bilateral cleft lip. Materials and Methods: Forty-four patients had their bilateral cleft lip and nasal deformity repaired simultaneously by Mulliken s method during the period from July 1997 to December 2007. Of these patients, 15 patients had bilateral complete cleft lip, 17 patients had bilateral incomplete cleft lip, and 12 patients had a mixed type of complete and incomplete bilateral cleft lip. To follow up on the growth of the lips and nose after the operation, the following 6 anthropometric measurements were analyzed: nasal tip protrusion, nasal width, columellar length, upper lip height, cutaneous lip height, and vermilion mucosa height. Results: In most patients, nasal length, nasal tip projection, columellar length, and upper lip shape were appropriate. Nasal tip protrusion, nasal width, upper lip height, and vermilion-mucosal height were within normal limit. However, columellar length and cutaneous lip height were relatively shorter than the average values of children without bilateral cleft lip. Conclusions: By performing Mulliken s method, we can achieve natural lip and nasal shape, harmonious Cupid s bow, appropriate nasal projection, and natural philtrum. Key Words: Bilateral cleft lip, Mulliken, anthropometric analysis (J Craniofac Surg 2009;20: 1455Y1461) There are no other congenital deformities than bilateral cleft lip nose that demand the surgeon s imaginary capability in surgical techniques. Brown et al 1 reported that the correction of bilateral cleft lip nose is twice as difficult as unilateral cleft lip nose; however, the outcome is only half as good. Nonetheless, the correction of bilateral cleft lip has been improved continuously in the past few decades, and thus, the outcome became comparable to unilateral cleft lip nose, even better in some patients. In unilateral cleft lip, it is not easy to correct the cleft side to be symmetrical to the opposite side; on the other hand, in bilateral cleft lip, something should be created from From the Department of Plastic and Reconstructive Surgery, Dong-A University School of Medicine, Busan, South Korea. Received April 20, 2009. Accepted for publication April 30, 2009. Address correspondence and reprint requests to Dr Seok-Kwun Kim, Department of Plastic and Reconstructive Surgery, Dong-A University School of Medicine, #1,3Ga, Dongdaesin-Dong, Seo-Gu, Busan, 602-715, South Korea; E-mail: sgkim1@dau.ac.kr Copyright * 2009 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3181af15c5 nothing, and thus, particularly, it is easier to construct the symmetrical philtrum. In Mulliken s study, 2 the principle of the correction of bilateral cleft lip has been established, and at the same time, a new technique has been developed. Influenced by Brown et al, he pointed out that the cleft lip has four-dimensional problems, which described the change over the patients growth after surgery, and that surgeons whose mind is only two-dimensional (not threedimensional) should overcome four-dimensional problems and modify the techniques by establishing the principle of surgery through the meticulous analyses of cases not only performed by themselves but also by others. The repair of bilateral cleft lips was developed from the method of correcting one side first followed by the other side 3 to the method of the synchronous repair of both sides, 2,4Y7 and the preferential first repair of cleft lips rather than of nasal deformity was performed. The correction of nasal deformity was postponed until the patient s growth to a certain level because of the possibility that the early surgery might delay nasal growth; however, numerous surgeons simultaneously performed nasal correction at the time of the repair of unilateral cleft lip, and it is not proven that early correction of the deviated septum might affect nasal growth. 8,9 In addition, because of the nasal deformity during the growing period, patients could not mingle with their peers, and thus, psychologic and social problems may intervene. In the condition that patients grow to the degree that the deformity becomes severe, it would be difficult to correct at later times, and thus, the trend is to correct the cleft lip and nasal deformity simultaneously. In the initial period, Mulliken also corrected bilateral cleft lip as 2 stages; however, with several years of experiences and technical improvement, the early correction of nasal deformity simultaneously with cleft lip correction allowed for the reduction of additional surgery. The characteristic of Mulliken technique is that a narrow flap is made in the prolabium for philtral reconstruction, and for the early simultaneous repair of cleft lip and nasal deformity, the following 5 principles are based: the formation of symmetry, the primary muscle continuity, the appropriate prolabial size and shape, the formation of the medial tubercle from the vermillion mucosa of the lateral labium, and the repositioning of the alar cartilage for the reformation of the nasal tip and the columella. In patients with bilateral cleft lip repaired by the application of Mulliken s technique, we compared the growth level of the nose and the upper labium after surgery with those in children without bilateral cleft lip by performing anthropometric measurements on the nasal tip projection, the nasal width, the columellar length, the cutaneous lip height, the vermilion-mucosal height, and the upper lip height before surgery, 1 year after surgery, and 3, 5, and 7 years after to evaluate the long-term outcome of this technique. PATIENTS AND METHODS On 44 patients who had simultaneous correction of bilateral cleft lip and nasal deformity from June 1997 to December 2007 using Mulliken s technique, we performed the long-term follow-up The Journal of Craniofacial Surgery & Volume 20, Number 5, September 2009 1455

Kim et al The Journal of Craniofacial Surgery & Volume 20, Number 5, September 2009 observation, from 1 year to 10 years. Among them, bilateral complete-type cleft lip was found 15 patients, incomplete type was in 17 patients, and the mixed type (complete and incomplete) was in 12 patients. In 7 patients with severe collapse of the alveolar segments, an active Latham orthodontic appliance was used before the definitive repair. At 5 to 6 weeks after birth, the appliance was prepared, applied, and adjusted for approximately 3 months, and subsequently, when the alveolar cleft became well aligned and close, definitive repair was performed. In 9 patients with wide maxillary gap and without excessive protrusion, lip adhesion was performed before the definitive repair. At the time of surgery (definitive repair of bilateral cleft lip), the mean age of patients was 3.8 months. Preoperative Design For the application of Mulliken s technique, at our institute, his original method was slightly modified to make the size of the philtral flap slightly bigger to improve the blood flow of the flap because his small-sized philtral flap resulted in a high postsurgical tension. The length of the philtral flap was not limited to 6 to 7 mm, made as long as possible, the width of peak to peak of Cupid s bow was widened from a range of 3 to 4 mm to a range of 5 to 6 mm, and the width of the base at the columellar-labial junction was made somewhat wider, from a range of 2.0 to 2.5 mm to a range of 3 to 4 mm. In Asians, the vertical incision of the nose may leave a remarkable scar and it should be avoided if possible; the alar cartilage was repositioned only by the alar rim incision. The excision of the excess tissue of the nasal soft triangle and the nasal vestibular web was also minimized (Fig. 1). Operative Technique Under general anesthesia, local infiltration was done on the nose, the lateral lip, and the prolabium with lidocaine containing epinephrine diluted to 1:100,000; a philtral prolabial flap was incised along the marking and raised, and the bilateral lip incision was made for the flap. Then, by incising the vermilion, Cupid s bow and vermilion tubercle were made. The prolabial mucosa was not used for the vermillion, but a portion was used to form the inside of the lip. Through the alar rim incision, the displaced cartilage was introduced, avoiding the vertical incision of the nasal tip. If the premaxilla and the lateral maxilla segments became well aligned by Latham orthodontic appliance before surgery, the nostril floor and subsequent alveolar cleft were closed by elevating a periodontomucosal flap. The lateral lip was advanced to the medial site, the labial sulci were sutured, and the orbicularis oris muscles were approximated FIGURE 1. Left, Markings for simultaneous repair of bilateral complete cleft lip and nasal deformity. Dislocated alar cartilages are dissected by rim incision. Right, After closure of alveolar cleft and nasal floor, apposition of orbicularis oris muscle to caudal septum at anterior nasal spine. Drawings adapted from Mulliken. 14 1456 FIGURE 2. Upper left, Apposition of splayed alar domes. Inset shows left alar cartilage secured to ipsilateral upper lateral cartilage and corresponding mattress suture, before being tied, through right nasal cartilage. Upper right, Insertion of alar base cinching suture and trimming tip of alar base flaps. Lower left, Minimal excision of redundant curtain in nasal soft triangles and trimming of superior border of lateral lip element in cyma curve. Lower right, Completed simultaneous nasolabial correction. Drawings adapted from Mulliken. 14 with each other. The uppermost area of the orbicularis oris muscle was closed with the periosteum of the anterior nasal spine (Fig. 1). The central vermilion tubercle was constructed with the bilateral vermilion-mucosal flap. Generally, these procedures were completed before nasal repair. Through the alar rim incision of one side, a pair of 5-0 prolene sutures on both alar cartilage was tied together and suspended to the upper lateral cartilage, so that configuration of both alar could be symmetrical. The alar base was trimmed, joined, and approximated to the upper area of each orbicularis oris of the same side. After repositioning of the alar cartilage, redundant nasal skin in a soft triangle was excised in a crescent fashion. If a mucocutaneous fold was formed in the lateral vestibules owing to the medial transposition of the alar base, this vestibular webbing deformity was excised in a crescent shape. The superior edge of the lateral labial flap was trimmed properly as a semicircular shape. In a such manner, the tendency of the high locating alar was alleviated, and the unnatural long lateral lip was shortened (Fig. 2). Anthropometric Measurements After surgery, to evaluate the growth of the lips and the nose, 3 types of anthropometric measurements on the nose were adopted: (1) subnasale-pronasale (sn-prn), (2) alare-alare (al-al), and (3) subnasale-columella (sn-c) were measured by applying a sliding Vernier caliper (E-Base Measuring Tools, Taiwan). On the upper lip, 3 types, namely, (1) subnasale-labiale superius (sn-ls), (2) labiale superius-stomion (ls-sto), and (3) subnasale-stomion (sn-sto; Fig. 3) were measured, and the growth of the lip and the nose was examined, comparing with the mean value of 30 children without bilateral cleft lip of the same age. * 2009 Mutaz B. Habal, MD

The Journal of Craniofacial Surgery & Volume 20, Number 5, September 2009 Mulliken in Bilateral Cleft Lip Repair FIGURE 3. Anthropometric markings. Nasal: nasal tip projection (subnasale-pronasale, sn-prn), nasal width (alare-alare, al-al), and columella length (subnasale-columella, sn-c). Labial: cutaneous lip height (subnasale-labiale superius, sn-ls), vermilion-mucosal height (labiale superius-stomion, ls-sto), and total upper lip height (subnasale-stomion, sn-sto). Statistical Analyses All values are presented as mean (SD). The SPSS for Windows 14.0 software package (SPSS Inc, Chicago, IL) was used for the statistical analyses of the data. Variance among the groups was determined by one-way analysis of variance test, and the groups were compared with each other using Tukey B and Duncan tests. The results were assessed in 95% confidence intervals and considered significant when P G 0.05. RESULTS The nasal anthropometric data are shown in Table 1, and the labial anthropometric findings are shown in Table 2. The mean lengths of the nasal tip protrusion before operation were 4.6, 5.1, and 4.9 mm in complete, incomplete, and mixed types of bilateral cleft lip, respectively (Figs. 4Y6). After the operation, the values were changed to 7.9, 8.1, and 8.2 mm for each type at 1 year; 11.0, 11.8, and 11.6 mm at 3 years; 12.0, 12.8, and 12.6 mm at 5 years; and 13.1, 13.6, and 13.6 mm at 7 years. The results are closer to the normal value of 14.2 mm by the age of 7 years (P = 0.737). The nasal widths before operation were 35.3, 33.8, and 34.8 mm for each group (P = 0.00). After the operation, the widths at 7 years decreased to 33.1, 31.7, and 32.8 mm in each group, which were closer to the normal values (P = 0.540), although somewhat wider than the normal value of 31.6 mm. The columellar lengths before operation were as short as 2.1, 2.5, and 2.2 mm in each group. After operation, the lengths were 3.1, 3.5, and 3.2 mm at 1 year; 4.3, 4.9, and 4.5 mm at 3 years; 5.9, 6.5, and 6.0 mm at 5 years (P = 0.004); and 6.9, 7.2, and 6.5 mm at 7 years. The columellar lengths at 7 years were a bit shorter than the normal values but showed adequate growing tendency compared with the normal value of 8.0 mm (P = 0.067). The upper lip heights before operation were 7.1, 7.7, and 7.5 mm in each group. After operation, the heights were increased to 18.8, 19.2, and 19.2 mm at 7 years, which were pretty close to the normal value (P = 0.682), although a little shorter than normal height of 19.9 mm. The vermilion-mucosal heights before operation were 3.1, 3.7, and 3.5 mm. After operation, the heights were increased to 9.1, 9.2, and 9.2 mm at 7 years. The results showed a tendency close to the normal value of 9.7 mm (P = 0.609). The cutaneous lip heights of 5.3, 5.9, and 5.5 mm before operation were increased to 11.2, 12.8, and 12.5 mm at 7 years, which were underdeveloped compared with the normal value of 14.2 mm. Most patients showed adequate growth of the nasal tip protrusion, of the nasal width without any evidence of growth retardation since early nasal correction. However, the columellar lengths were slightly shorter than the normal values. The upper lip height and vermilion-mucosal height showed near normal growth. Cutaneous lip heights were underdeveloped compared with the normal value. The symmetry of the lip and nose and the natural shape of the philtrum were well maintained. Through the early synchronous correction of nasal deformity with cleft lip repair by using Mulliken s method in bilateral cleft lip surgery, the lip and TABLE 1. Three Nasal Anthropometric Measurements for Bilateral Cleft Lip Children Compared With Age-Matched Averages of 30 Korean Children Without Bilateral Cleft Lip Type Preoperatively 1-y 3-y 5-y 7-y Nasal tip protrusion (sn-prn), mm Complete 4.6 (1.84) 7.9 (1.59) 11.0 (2.92) 12.0 (2.63) 13.1 (2.99) Incomplete 5.1 (1.53) 8.1 (1.78) 11.8 (3.37) 12.8 (3.00) 13.6 (2.22) Mixed 4.9 (1.04) 8.2 (1.53) 11.6 (2.13) 12.6 (1.78) 13.6 (1.45) Normal 7.3 (2.39) 8.5 (2.16) 12.4 (3.31) 13.4 (3.08) 14.1 (2.73) Nasal width (al-al), mm Complete 35.3 (2.53) 30.3 (2.86) 31.6 (2.15) 32.6 (3.81) 33.1 (3.1) Incomplete 33.8 (2.97) 28.8 (4.40) 30.1 (3.50) 31.1 (4.17) 31.7 (2.90) Mixed 34.8 (5.30) 29.8 (5.83) 31.1 (4.05) 32.0 (3.85) 32.8 (3.00) Normal 26.8 (3.06) 27.3 (2.86) 29.5 (3.63) 31.3 (3.33) 31.6 (3.46) Columella length (sn-c), mm Complete 2.1 (0.33) 3.1 (0.64) 4.3 (0.91) 5.9 (0.78) 6.9 (1.68) Incomplete 2.5 (0.50) 3.5 (0.57) 4.9 (0.94) 6.5 (0.99) 7.2 (0.98) Mixed 2.2 (0.48) 3.2 (0.67) 4.5 (0.88) 6.0 (0.38) 6.5 (1.01) Normal 4.0 (0.96) 4.5 (0.80) 6.1 (1.23) 7.2 (1.12) 8 (1.32) All values are expressed as mean (SD). * 2009 Mutaz B. Habal, MD 1457

Kim et al The Journal of Craniofacial Surgery & Volume 20, Number 5, September 2009 TABLE 2. Three Labial Anthropometric Measurements for Bilateral Cleft Lip Children Compared With Age-Matched Averages of 30 Korean Children Without Bilateral Cleft Lip Type Preoperatively 1-y 3-y 5-y 7-y Upper lip height (sn-sto), mm Complete (N = 15) 7.1 (1.27) 13.0 (1.44) 14.4 (2.29) 17.0 (2.94) 18.8 (1.65) Incomplete (N = 17) 7.7 (1.25) 13.5 (1.76) 15.3 (1.93) 17.4 (2.16) 19.2 (2.35) Mixed (N = 12) 7.5 (1.01) 13.2 (1.51) 15.0 (1.60) 17.3 (1.88) 19.2 (1.79) Normal (N = 30) 13.0 (2.16) 15.0 (2.45) 17.7 (1.98) 18.7 (2.36) 19.9 (3.31) Cutaneous lip height (sn-ls), mm Complete 5.3 (0.7) 7.0 (0.96) 9.4 (1.52) 10.4 (1.29) 11.2 (1.50) Incomplete 5.9 (1.19) 7.5 (1.25) 10.3 (1.80) 11.8 (1.71) 12.8 (1.56) Mixed 5.5 (0.99) 7.2 (1.52) 9.9 (0.92) 11.3 (1.34) 12.5 (1.77) Normal 9.0 (1.38) 9.0 (1.44) 11.7 (1.76) 12.9 (1.71) 14.2 (1.81) Vermilion mucosal height (ls-sto), mm Complete 3.1 (0.91) 5.2 (0.97) 6.0 (1.29) 7.8 (1.00) 9.1 (1.63) Incomplete 3.7 (0.39) 5.9 (1.05) 6.9 (1.08) 8.0 (1.35) 9.2 (1.74) Mixed 3.5 (0.58) 5.7 (1.02) 6.3 (1.40) 7.9 (0.73) 9.2 (1.2) Normal 5.6 (1.34) 6.0 (1.31) 6.5 (0.97) 8.1 (1.17) 9.7 (1.48) All values are expressed as mean (SD). FIGURE 4. Upper panels, A 2-month-old infant with bilateral incomplete cleft lip. Middle panels, Appearance of the patient at age 3 years. Lower panels, Appearance at age 7 years postoperatively. Normal nasolabial anthropometric values, except for slightly wide nasal width. 1458 FIGURE 5. Upper left, A 2-month-old infant with bilateral asymmetric (complete/incomplete) cleft lip. Upper right, Frontal view immediately after operation. Middle panels, Appearance at age 5 years after operation. Lower panels, Appearance at age 7 years after operation. Normal nasolabial anthropometric values, except for slightly short columellar length. * 2009 Mutaz B. Habal, MD

The Journal of Craniofacial Surgery & Volume 20, Number 5, September 2009 Mulliken in Bilateral Cleft Lip Repair FIGURE 6. Upper left, A 1-month-old infant with bilateral complete cleft lip. Premaxillary-maxillary segments aligned with a Latham orthodontic appliance. Synchronous nasolabial repair done at age 4 months. Middle panels, Frontal and submental views at age 5 years. Lower panels, Appearance at age 8 years. Normal nasolabial anthropometric values, except for slightly short columella. nose grew naturally with a good Cupid s bow shape. The vermilion and tubercle were adequate, along with acceptable nasal tip protrusion, columella, and nostril shape and size. DISCUSSION In bilateral cleft lip, similar to unilateral one, the anatomic characteristic of facial deformity is manifested very diversely depending on the level of the initial embryological failure and on the level of abnormal growth after birth. 10 Therefore, it is well known that maximal effectiveness could be obtained by recognizing the level of fetal failure through the accurate presurgical evaluation. The anatomic deformity of bilateral complete cleft lip is influenced by the defect of tissues developed from the mesoderm, such as skeleton and muscles, and, eventually, has the mechanism similar to the anatomic deformity of unilateral cleft lip. In the nasal deformity of bilateral complete cleft lip, the nasal septum and nasal bone are positioned as straight without deviation. Nonetheless, if the periodontal tissue of any one side was adhered or if a Simonart band was present, it would show a pattern similar to unilateral cleft lip. The deformity of the alar cartilage of bilateral cleft lip shows a pattern similar to unilateral cleft lip, but the flaring and buckling of the lateral angle of the nasal cartilage appear to be more severe. 11 In comparison with unilateral cleft lip, the characteristic of bilateral cleft lip is that the columella tends to be short. This is because the alar cartilage is flared widely. Consequently, fibrous adipose tissues are present excessively between the nasal tip and the alar cartilage, forming the blunt nasal tip. 12,13 Embryologically, complete bilateral cleft lip is caused by the failure of the mesodermal reinforcement of both maxillary processes, and the migration of nasofrontal process seems to be normal. In incomplete bilateral cleft lip, muscular fibers are detected in the prolabium, which suggests the partial migration of muscles. There are intrinsic and extrinsic factors determining the morphologic characteristic of bilateral cleft lip. 14 The intrinsic factors are the wide and bifid nasal tip with a horizontally oriented nostril axis and short columella. The alar cartilage not only shows hypoplasia but is also caudally rotated, and subluxated from the upper lateral cartilage. The genu is widened, and the tissue of the alar margin is hypoplastic. These intrinsic factors result in primary deformity. The extrinsic factors are the secondary change coming from cleft lip repair. If the bilateral cleft lip is corrected by conventional methods, the medial crus of the alar cartilage is pulled inferoposteriorly making the columella shorter. If the lateral labial segment is fixated without shortening, despite the fact that the vertical length of the lateral labial segment is long, the ala and the * 2009 Mutaz B. Habal, MD 1459

Kim et al The Journal of Craniofacial Surgery & Volume 20, Number 5, September 2009 1460 lateral crus of the alar cartilage will be cephalad displaced. As a result, the alar dome will get curved, and the space between the genu will get wider, causing reposition of the deformity more difficult in later times. In the repair of lip deformity, numerous techniques have also been introduced, with their own advantages and shortcomings. In bilateral lip repair, most investigators postponed the time of correction of nasal deformity and focused on the technique of lengthening the columella. The methods that bring tissues to the columella are 2 types. One method is to bring the tissues from the upper lip, the representative method of which is the fork flap technique described by Millard. 15 The other method is to move the nasal dorsum, alar margin, and nasal floor tissues to the columella, the representative of which the is method of Cronin. 16 Such methods leave a scar across the columella-labial junction, and the scar surrounds the prolabium, and thus, the prolabium becomes protruded rather than depressed. Besides, because of the fork flap, the columella-labial angle may be acute, more severe by the accompanied scar. 17 McComb 18 reported a 15-year review after cleft lip correction using a fork flap; it not only showed the nasal columella being too long but also showed the following shortcomings: the nasal tip was still wide, the nostril was a bit big and its shape was not natural, and the columellar base was caudally displaced. Therefore, the fork flaps were no longer used. After presurgical maxillary orthodontic treatment, as the first stage, he performed cleft lip repair by alar cartilage lifting suture through the bird wing incision on the nasal tip and lip adhesion. One month later, he did cleft lip repair by raising the prolabium from the premaxilla as the second-stage operation. Mulliken also applied a staged correction initially; at later times, he corrected bilateral cleft lip and nose synchronously. He described the development of his own surgical techniques into 3 phases. 17 During the first phase (1980Y1986), he was not completely free from Millard s method. Therefore, the tines of the forked flap were banked below the sills, and during the second-stage repair, the tines of forked flap were trimmed and transposed intranasally into the intercartilagenous incision. In addition, through vertical incision of the nasal tip, the splayed domes were sutured to one another and suspended to contralateral or ipsilateral upper lateral cartilage. 2 Afterward, Mulliken improved his own technique continuously and found that the tines of the banked fork flap were not required for the construction of the columella; thus, he trimmed the tines. This period was the second phase (1987). During the third phase (1988Y 1992), not only that a fork flap was not created but also that the remaining prolabial tissues that were not used for the construction of the columella were begun to be resected. Therefore, single-stage synchronous bilateral nasolabial repair including the construction of the columella could be performed. 14,17 Afterward, the technique has been improved continuously, and the vertical incision was discontinued to avoid a nasal tip scar that had been problems previously, and with the accumulation of experiences, the alar cartilage could be repositioned only by extended alar rim incision; consequently, the nasal tip and the columella could be constructed better. 19,20 The characteristic of Mulliken s method is to reposition the alar cartilage without a fork flap and thus to lengthen the nasal columella. In bilateral cleft lip, because of the medial angle and dome of dislocated alar cartilage, the nasal columella appears to be short, 21 but the skin is not insufficient, and thus, it is not required to borrow tissues from the lip or the nose. 13 Therefore, by repositioning of the appropriate anatomic sites through the suspending suture of the domal segment of the alar cartilage, the columella could be of normal length. He emphasized the importance of the apposition of both genua, elevation of the lateral dome, and the fixation of the genu to the same side of the upper lateral cartilages. 17 After alar cartilage securing sutures, he analyzed such results anthropometrically and found that the nasal columellar length and the nasal tip protrusion were normal. 17 Actually, even if the nasal tip protrusion grew normally, around at the age of 5 years, it grows only to approximately two thirds of adults 22 ; hence, even if the nasal tip protrusion was not satisfactory, it is not a big problem. The authors found some problems with Mulliken s method performed on Korean children with bilateral complete cleft lip, so we modified his method. The prolabial philtral flaps were made wider to minimize tension and improve blood supply; thus, a hypertrophic scar can be prevented. Instead of limiting the size of the prolabial philtral flap to 6 to 7 mm, it was made as long as possible because the prolabium of the cleft lip of Asian patients is inherently short. The width of peak to peak of Cupid s bow was made widely from a range of 3 to 4 mm to a range of 5 to 6 mm and the width of the base at the columella-labial junction was modified from a range of 2.0 to 2.5 mm to a range of 3 to 4 mm. The redundant skin from the soft triangle of the nose was either not excised or minimally excised. The vestibular web of the nose was excised in a crescent form. Before correcting the bilateral cleft lip, the knowledge on the anatomy of normal lip and nose is required to understand the threedimensional aspect of the size and shape of cleft lip nose. Mulliken 20 reported that four-dimensional understanding of changes according to growth should be conceptualized, and at the same time, the potential deformity should be predicted. Summarizing the growth feature of the lip of white children without bilateral cleft lip between 1 and 18 years, other nasolabial anthropometric values except for the columella length (sn-c) and nasal tip protrusion (sn-prn) showed a fast-growing feature, and thus, at the age of 5 years, it became more than two thirds of adults. What matters is that the deformity of bilateral cleft lip correlated greatly to the growth rate. 19,20 In other words, the nasolabial components with fast-growing feature become too long or too short after correction (nasal length, alar width), and the nasolabial components with slow-growing feature become short after correction (columellar length, nasal tip protrusion). Therefore, anticipating the four-dimensional cleft lip nasal changes that would occur after correction, the operator can control the degree of correction during surgery. However, as the vermillion-mucosal height (ls-sto) has an exceptional feature, although it was a fast-growing feature, the growth rate could not be maintained until childhood. Therefore, vermilion central tubercle (vermillion-mucosal height) has to be designed as maximally as possible because the incision shown is difficult to anticipate until later childhood. In the author s results, the columellar length was maintained to be slightly short after correction until 7 years afterward, and the nasal tip protrusion was shown to be short after correction in comparison with the normal value, but it did not show a great difference from 1 year after surgery. According to the follow-up study after operation, nasal tip protrusion, nasal width, vermilion-mucosal height, and upper lip height were adequate compared with the normal values. The symmetry of the lip and the nose was well maintained. The vermilion tubercle was adequately formed along with the natural shape of philtrum. However, columellar length and cutaneous lip height were a bit shorter than the normal values. And because of the excessive elevation of the nasal tip in the cephalic direction, the nasolabial angle became too large. This finding was also reported in Mulliken s result. Trott and Mohan 23 tried caudal advancement of the nasal tip by suturing the soft tissue between the lobule and the alar dome and by pulling the skin of the nasal base caudally. But once the cartilage suture is done, cephalic displacement of the nasal tip will be an unavoidable problem. Cutting et al 24 reported the same finding in patients who underwent presurgical nasoalveolar molding combined with 1-stage lip, nose, and alveolus repair. The previous Mulliken method had the disadvantage of vermilion getting excessively long, although the overall upper lip height is normal. 13 In the author s * 2009 Mutaz B. Habal, MD

The Journal of Craniofacial Surgery & Volume 20, Number 5, September 2009 Mulliken in Bilateral Cleft Lip Repair patients, the cutaneous lip height was slightly shorter than the normal value, but the vermilion and overall upper lip height turned out to be normal. In the author s recent correction of nasal deformity, the space between the cephalic margins of the domal segment of the medial angle and between caudal margins of foot plate segment was gathered to turn the alar cartilage into the most normal anatomic shape possible. This method is expected to make the shape of the nose more natural. When performing cleft lip correction after active presurgical orthodontic Latham appliance and lip adhesion, alveolar cleft correction by gingivoperiosteoplasty can help with normal and harmonious growth. REFERENCES 1. Brown JB, McDowell F, Byars LT. Double clefts of the lip. Surg Gynecol Obstet 1947;85:20 2. Mulliken JB. Principles and techniques of bilateral complete cleft lip repair. Plast Reconstr Surg 1985;75:477Y487 3. Bauer TB, Trusler HM, Tondra JM. Changing concepts in the management of bilateral cleft lip deformities. Plast Reconstr Surg 1995;24:321Y332 4. Veau V. Division palatine. In: McCarthy JG, eds. Plastic Surgery. Philadelphia: WB Saunders; 1990, p.2663 5. Tennison CW. The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg (1946) 1952;9:115Y120 6. Millard DR Jr. Bilateral cleft lip and primary forked flap: a preliminary report. Plast Reconstr Surg 1967;39:59Y65 7. Manchester WM. The repair of double cleft as part of an integrated program. Plast Reconstr Surg 1970;45:207Y216 8. McComb H. Primary correction of unilateral cleft lip nasal deformity: a 10-year review. Plast Reconstr Surg 1985;75:791Y797 9. Salyer KE. Primary correction of the unilateral cleft lip nose: a 15-year experience. Plast Reconstr Surg 1986;77:558Y566 10. Veau V, Politzer G. Embryologic du becde-lievere Le Palais primaire. Ann Anat Pathol Anat Norm Med-Chir 1936;13:275 11. McComb H. Primary repair of the bilateral cleft lip nose. Br J Plast Surg 1975;55:596Y601 12. Potter J. The nasal tip in bilateral hare tip. Br J Plast Surg 1968;21:173Y179 13. Steinstrom SJ, Oberg TRH. The nasal deformity in unilateral cleft lip. Plast Reconstr Surg Transplant Bull 1961;28:295Y305 14. Mulliken JB. Correction of the bilateral cleft lip nasal deformity: evaluation of a surgical concept. Cleft Palate Craniofac J 1992; 29:540Y545 15. Millard DR Jr. Columella lengthening by a forked flap. Plast Reconstr Surg Transplant Bull 1958;22:454Y457 16. Cronin TD. Lengthening columella by use of skin from nasal floor and alae. Plast Reconstr Surg Transplant Bull 1958;21:417Y426 17. Mulliken JB. Bilateral complete cleft lip and nasal deformity: an anthropometric analysis of staged to synchronous repair. Plast Reconstr Surg 1995;96:9Y23 18. McComb H. Primary repair of the bilateral cleft lip nose a: 15-year review and a new treatment plan. Plast Reconstr Surg 1990;86:882Y889 19. Mulliken JB, Burvin R, Farkas LG. Repair of bilateral complete cleft lip: Intraoperative anthropometry. Plast Reconstr Surg 2001;107:307Y314 20. Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plast Reconstr Surg 2001;108:181Y184 21. Sheen JH. Middle crus: the missing link in alar cartilage anatomy. Perspect Plast Surg 1991;5:31 22. Farkas LG, Posnick JC, Hreczko TM, et al. Growth Patterns of the nasolabial region: a morphometric study. Cleft Palate Craniofac J 1992;29:318Y324 23. Trott JA, Mohan N. A preliminary report on one stage open tip rhinoplasty at the time of lip repair in bilateral cleft lip and palate: the alar setar experience. Br J Plast Surg 1993;46:215Y222 24. Cutting C, Grayson B, Brecht L, et al. Presurgical columellar elongation and primary retrograde nasal reconstruction in one stage bilateral cleft lip and nose repair. Plast Reconstr Surg 1998;101:630Y639 * 2009 Mutaz B. Habal, MD 1461