title: Combining the Cutting and Mulliken methods for primary repair of the bilateral cleft lip nose.
abstract: BACKGROUND
  Since 1990, primary bilateral cleft nasal reconstruction has been focused on placing the lower lateral cartilages into normal anatomical position. Of the four major techniques in this class, the Cutting (i.e., retrograde) method and the Mulliken method have been most successful. The retrograde method makes no external nasal incisions, but requires either preoperative or postoperative nasal molding to achieve maximum benefit. Mulliken's technique does not require molding, but leaves the footplates of the medial crura in the depression above the projecting premaxilla associated with the diminutive anterior nasal spine. Leaving the footplates in place also prevents adequate approximation of the alar bases. In this article, the two methods are combined to achieve the benefits of both.
  
  
  METHODS
  We report our experience with the retrograde nasal approach associated with marginal rim incisions (Mulliken method) in a series of 25 consecutive bilateral cleft lip cases simultaneous with lip repair. We performed a retrograde approach through membranous septum incisions elevating a prolabial-columellar flap. To facilitate alar cartilage manipulation we added bilateral marginal rim incisions. Nasal width, columella length and width, tip projection, and nasolabial angle were analyzed after a minimum of 2 years after surgery. These were compared with a normal, age-matched, control group. We also examined nostril symmetry and marginal nostril scars.
  
  
  RESULTS
  Columellar length was not statistically significantly different from that of the control group (p = 0.122442). Nasal width, columellar width, tip projection, and nasolabial angle were all significantly greater in the cleft group than normal (p < 0.001). No hypertrophied scars were found associated with the marginal rim scar.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Luis Calvo Mackenna Hospital, University of Chile, School of Medicine, Santiago, Chile. cmorovic@cmet.net
authors.forename: Carmen Gloria
authors.initials: CG
authors.lastname: Morovic
authors.forename: Court
authors.initials: C
authors.lastname: Cutting
mesh_terms: D002971:Cleft Lip / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009300:Nasal Septum / Q000601:surgery; D009666:Nose / Q000601:surgery*; D019647:Oral Surgical Procedures / Q000379:methods*; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000098:blood supply