repair of bilateral cleft lip and nose by the mulliken …...repair of bilateral cleft lip and nose...
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Repair of bilateral cleft lip and nose by the Mulliken method: a case report
Jae-Seok Lim1, Gyu-Tae Lee1, Young-Soo Jung1,2
1Department of Oral and Maxillofacial Surgery, 2Oral Science Research Center, College of Dentistry, Yonsei University, Seoul, Korea
Abstract (J Korean Assoc Oral Maxillofac Surg 2012;38:360-5)
The simultaneous surgical correction of bilateral cleft lip and nasal deformity has become a more common surgical technique that has greatly changed conventional strategies for secondary nasal correction. Mulliken has been known as one of the earliest proponents for the synchronous repair of bilateral cleft lip and nasal deformity, and he emphasized the responsibility of the treating surgeon to evaluate nasolabial growth by comparing anthropometric measurements with age-matched normal patients. Good outcomes from this surgical method have been reported in clinical cases worldwide. Herein, we describe the management of two cases of bilateral cleft repair, following the principles and methods established by Mulliken. We also provide a relevant review of the literature.
Key words: Bilateral cleft lip, Nasolabial growth, Four-dimensional change, Synchronous repair[paper submitted 2012. 2. 16 / revised 2012. 5. 9 / accepted 2012. 5. 13]
sideredtobemuchmoredifficultthantreatmentofunilateral
cleftlip3,andthesurgicaltechniquehasgraduallydeveloped
fromthestagedclosureapplyingunilateralcleftlipsurgeryto
simultaneousclosure2,4.Inthepast,attentionwasfocusedon
thelipitself,andcorrectionofnasaldeformitywaspostponed
becauseearlymanipulationofnasalcartilagewasthought
toprevent itsgrowth.Such thought,however,hasbeen
foundtobegroundlessbyresearch5,andsynchronousrepair
ofbilateralcleftlipandnosedeformitywasintroduced,in
whichtreatmentofbilateralcleftlipwasaccompaniedwith
correctionofnasaldeformity.
Mulliken isapioneerofsynchronousbilateralcleft lip
andnasaldeformityrepair.Heestablishedthefollowingfive
surgicalprinciplesin1985:1)maintenanceofsymmetry;2)
establishmentofbasicmusclecontinuity;3)propersizeand
shapeofthephiltrum;4)formationofthemediantubercle
fromthelaterallipelements;and5)primarypositionofthe
alarcartilageforconstructionofthenasaltipandcolumella.
Mullikensaiditisimportanttounderstandandapplythese
surgicalprinciplesratherthanthesurgicaltechniqueitself,
andthroughresearchongrowthmeasurementsofbilateral
cleft lippatients,healsoemphasized the importanceof
takinggrowthintoconsideration2,6.Authorsaretoreporta
caseofapplyingtheMulliken’sprinciplesandtechniquesfor
treatmentofbilateralcleftlippatients.
I. Introduction
Cleftsoflipandpalatearethemostcommondeformities
inoralandmaxillofacialarea.Althoughdifferentresearch
institutesinKoreareportedvariousincidenceratesregarding
cleftsoflipandpalate,theyaregenerallyknowntoshowan
incidenceof0.95-2.25per1,000newbornbabies1.Bilateral
cleftlip,inparticular,maybesymmetricalorasymmetrical
duetoitscomplexaspects.Itappearsinvariousformsfrom
thecaseofcleftliponlytothecaseofcleftlipaccompanied
withalveolarcleftorcleftplate.Moreover,thesizes,shapes
ofitsgrowthsegmentsandtheratiosbetweenthesegments
changealongwith thegrowthof thepatient.Therefore,
successful surgical repairofbilateral cleft lip requires
understandingof thesevariousaspectsandsuchchanges
occurringalongwiththegrowthofthepatient2.
Treatmentofbilateralcleft liphasbeenclassicallycon-
Young-Soo JungDepartment of Oral and Maxillofacial Surgery, Oral Science Research Center, College of Dentistry, Yonsei University, 50, Yonsei-ro, Seodaemun-gu, Seoul 120-752, KoreaTEL: +82-2-2228-3139 FAX: +82-2-2227-7825E-mail: [email protected]
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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CASE REPORThttp://dx.doi.org/10.5125/jkaoms.2012.38.6.360
pISSN 2234-7550·eISSN 2234-5930
Repair of bilateral cleft lip and nose by the Mulliken method: a case report
361
to immoderatedissectionandclosure ifsurgeryhadbeen
performedwithoutdealingwiththeproblemfirst.Therefore,
afterpremaxillaosteotomy,premaxillawas repositioned
backward toa favorablepositionforsurgery.(Figs.2,3)
Afterwards,surgerywasperformedintheorderofmarking,
dissection,closureandnasalcorrection.Sincethesurgeries
wereperformedaspartofourvolunteerserviceactivities
overseas,itwasunabletocarryoutalong-termobservation
ofthepatients’clinicalcoursepostoperatively.
1. Flap marking
Thephiltralflapwasdesignedtobealittlebiconcaveand
II. Case Report
WevisitedHanoiNationalHospitalofOdonto-Stomatology
in2009and2011,andthesameoperatorperformedsurgery
ontwobilateralcleft lipandnosepatientsonthebasisof
Mulliken’sprinciplesandtechniques.Thefirstpatientwas
an18-month-oldmale,whowasobservedtohaveprotrusive
premaxilla because early surgical repair hadnot been
performed.(Fig.1.A)Thesecondpatientwasan8-month-
oldmale,whodidnothavesevereprotrudingpremaxilla.
(Fig.1.B)Inthecaseofthefirstpatient,itwasdifficultto
restorealveolarridgecontinuityduetoprotrusivepremaxilla,
excessivesofttissuetensionwouldhavebeenexpecteddue
Fig. 1. Preoperative clinical photograph. A. 18 months child with protrusive premaxilla. B. 6 months child without protrusive premaxilla.Jae-Seok Lim et al: Repair of bilateral cleft lip and nose by the Mulliken method: a case report. J Korean Assoc Oral Maxillofac Surg 2012
Fig. 2. Intraoperative clinical photograph (18 months child). A. Osteotome was applied to posterior of epiphysial line. B. Premaxillary osteotomy was done.Jae-Seok Lim et al: Repair of bilateral cleft lip and nose by the Mulliken method: a case report. J Korean Assoc Oral Maxillofac Surg 2012
J Korean Assoc Oral Maxillofac Surg 2012;38:360-5
362
2. Dissection
Thephiltral flapwas incisedupto thedermis, thenthe
piecesofskinonitssideweredeepithelized,andthenthe
remainingprolabiallipskinwasexcised.Thephiltralflap,
includingthesubdermalsoft tissue,waselevatedfromthe
premaxilla to thecaudal septum.Analarbase flapwas
formedbyincisingthelateralwhiteline-vermilion-mucosal
flap,andabundleoforbicularisorismuscleswasdissected
fromthelaterallabialelements.(Fig.5)
3. Closure
Thealveolarridgeonbothsidesofthecleftwasincised
verticallyandthenclosedbyraisingthegingivomucoperiosteal
itsendtobedart-shapedbecauseofthetendencyofcicatrix
tobulgeoutwardlaterontheedgesofitsbothsides.Along
narrowstripwasdesignedonbothsidesofthephiltralflap
fordeepithelization,whichwasthenperformedinorderto
formaphiltralridgebyplacingitbelowthelaterallabialflap.
ThepeaksoftheCupid’sbowtobeformedwereplacedon
thelateral labialelements.Analarbaseflapwasdesigned
on theupper junctionof the lateral labialelements.The
medialedgesof the lateral labialelementsweredesigned
alongrightabovethevermilion-cutaneousline.(Fig.4)The
secondpatienthadaleftnostrilsill,butsincethesillwas
unnecessaryforadvancementofthealarbaseflap,anincision
linewasalsoestablishedonit.(Fig.4.B)
Fig. 3. Surgical repositioning of premaxilla (18 months child). A. Protrusive premaxilla was observed. B. Premaxilla was moved backward.Jae-Seok Lim et al: Repair of bilateral cleft lip and nose by the Mulliken method: a case report. J Korean Assoc Oral Maxillofac Surg 2012
Fig. 4. Marking. A. 18 months child. B. 6 months child.Jae-Seok Lim et al: Repair of bilateral cleft lip and nose by the Mulliken method: a case report. J Korean Assoc Oral Maxillofac Surg 2012
Fig. 5. Dissection of the orbicularis oris muscle and elevation of flap.Jae-Seok Lim et al: Repair of bilateral cleft lip and nose by the Mulliken method: a case report. J Korean Assoc Oral Maxillofac Surg 2012
Repair of bilateral cleft lip and nose by the Mulliken method: a case report
363
4. Nasal correction
Thebilateralalarcartilagewasexposedbyincisingthe
bilateralnostrilrim.Interdormalmattresssuturewasperfor-
medonthegenuasofthebilateralalarcartilageaswellason
itsmiddlecruses,andthenthesuturedgenuasandthesutured
middlecrusesweresuturedtotheupperlateralcartilageatthe
lateralsideofgenuaandatthelateralcrusrespectively.The
alarwidthwasnarrowedto25mmorbelowbypositioning
thecinchsutureoneachalarbase.(Fig.6)Anostrilsillwas
constructedbycuttingandrefiningtheendofanalarbaseflap
andthenrotatingitinward,thussuturingittotheendofthe
skinonbothsidesofthecolumellarbase.Thedermisofeach
alarbaseflapwassuturedtotheperiosteumofthepremaxilla
andtheorbicularisorismuscle,thusforminganormalcymal
shapeofthelateralsillandloweringthepositionofthealar
base.Thiscouldminimizethenostrilsbeingliftedduringthe
patient’ssmilebystimulatingthedepressoralaenasimuscle.
(Fig.7)
Ifalarcartilageisproperlypositioned,therewillclearly
beextraskininthesofttriangle.Theextraskinwasexcised
togetherwiththeremainingskinonthelateralsideof the
columella.Crescenticexcisionwasextendedtothetopand
middleof thecolumella,passing the incision lineon the
nostriledge.Moreover,alateralvestibularwebappearsinside
thenose.Thiswebwasincisedbylenstypeincisionalongthe
intercartilaginousline,afterwhichitwassutured.(Fig.7)
Aftercompletionofnasalcorrection,thelastskinclosure
wasperformed.Theendofthephiltralflapwasplacedinside
andsuturedtothemuscularlayerinordertoformaphiltral
ridgebyhaving thephiltral flapsettledown.(Fig.8)The
flap.Theanteriorwallof thegingivolabial sulcuswas
shortenedbyexcisingandrefining thevermilion-mucosa
remaininginpremaxilla.Theremainingmucousmembraneof
thepremaxillawasmadetobeaflap,whichwasthensutured
totheperiosteumoftheanteriornasalspine,thusachieving
formationoftheposteriorwalloftheanteriorgingivolabial
sulcus.Byadvancingthelaterallabialelementfullyinward,
medialmucosalflapsweremadetoformtheanteriorwallof
thecentralgingivolabialsulcusandtheposterioraspectofthe
upperlip.Theorbicularisorismusclesweresuturedfromthe
bottomtothetop.Theparsperipheralis,thetopclosure,was
suturedtotheperiosteumoftheanteriornasalspine.(Fig.5)
Themediantuberclewasformedusingtheremainingportion
ofthelaterallip.Thelastskinclosurewasperformedafter
nasalcorrection.
Fig. 6. Narrowing interalar dimension with cinch suture.Jae-Seok Lim et al: Repair of bilateral cleft lip and nose by the Mulliken method: a case report. J Korean Assoc Oral Maxillofac Surg 2012
Fig. 7. Inferior view after suturing. A. 18 months child. Cymal trim was done at superior edge of lateral labial flap. B. 6 months child.Jae-Seok Lim et al: Repair of bilateral cleft lip and nose by the Mulliken method: a case report. J Korean Assoc Oral Maxillofac Surg 2012
J Korean Assoc Oral Maxillofac Surg 2012;38:360-5
364
Aspremaxillaryosteotomywasperformedintheposterior
partoftheepiphyseallineandthesurgicalrepositioningof
thepremaxilla tookplacewithoutanyparticularfixation,
wethinkthegrowthofthebabypatient’smidfacewouldbe
inhibitedonlyslightly.
Itisnecessarytounderstandthenasalandlabialshapeofa
normalbabyforcorrectionofbilateralcleftlip,butonlythree-
dimensionalunderstanding isnotsufficient.Thesurgeon
mustbeawareof thechanges thatwouldappearduring
thenormalgrowthandevenbeable topredictdistortions
occurring in the patientwho had underwent surgery.
Accordingly,it isnecessarytoperformfourth-dimensional
treatmentbytakingchangesingrowthintoconsideration.
Mullikenetal.10confirmedthatthereisacorrelationbetween
thethree-dimensionalsizeimmediatelyafterthesurgeryand
thegrowthspeedbygrowthobservationofbilateralcleft
lippatientswhohadunderwentsurgery. Inotherwords,
thefast-growingpartswouldgrowtobe longerorwider
whereastheslow-growingpartswoulddeformtobeshorter.
Thesurgerymustmakethefast-growingpartssmallerand
theslow-growingpartsslightlybiggerthannormal.Farkas
etal.11mentionedintheirgrowthresearchinnormalwhite
peoplethatnasaltipprotrusionandcolumellarlengthgrow
slowlywhilereportingthatallthelabialpartsgrowfast,thus
reaching90%ofanadult’slabialpartssizebytheageof5
years.Alsointhetwocases,surgerywasperformedbased
onthesegrounds,thusnarrowingthenasalwidthtobe25
mmorbelowandincreasingthecolumellarlength.Sincelips
growfastexceptthemediantubercle,thepatient’slipswere
formedtobeshorterandnarroweronanoverallbasis.(Fig.8)
It isknown that therearevariousmethodsofprimary
heightofthelaterallipwasmodifiedbycuttingandrefining
thetopedgeofthelaterallabialflapintheformofacymal
curveatthealar-labialjunction.(Fig.8.A)
III. Discussion
Thesuitabletimeforperformingprimarycheiloplastyon
bilateralcompletecleftlippatientsmaybevariableaccording
to literatures,but it isgenerallyperformedbetween3 to
6monthsafterbirth7.Incasesofprotrusivepremaxilla, it
isnecessary to treat it surgicallyornonsurgicallybefore
primarycheiloplasty.Sothetimingofprimarycheiloplasty
maybeadjustedaccordingtothepriorsurgicalornonsurgical
treatmentof theprotrusivepremaxilla.Protrusionof the
premaxillaisaphenomenonappearingduetotheabnormal
growthof theboneunder the influenceof thestrengthof
stickingoutthetonguelocatedinthebilateralcleftliptogether
withtheabnormalmuscularstrengthoftheorbicularisoris
muscleswhicharenotcontinuousdueto thecleft lip8. In
thefirstcase,surgicalrepositioningofthepremaxillawas
performedon the first18-month-oldpatient (Fig.1.A)
becauseitwasimpossibletoachieveaprimaryrepairwithout
treatingthepremaxillafirst.Surgicalrepositioningof the
premaxillaisrecommendedfor6to8-year-oldpatientsrather
thanyoungerpatientsbecausesurgical repositioningmay
hamperthegrowthofthemidface9.Inthefirstcase,however,
premaxillaryosteotomywasperformedonthepatientduring
thecourseofprimarycorrectionofcleftlipandnasaldeformity
despitehisageof18monthsbecauseneitherperiodical
observationofhisclinicalcoursenoruseofanorthopedic
appliancewaspossibleduetoeconomiccircumstances.(Fig.2)
Fig. 8. Frontal view after suturing. A. 18 months child. B. 6 months child. Jae-Seok Lim et al: Repair of bilateral cleft lip and nose by the Mulliken method: a case report. J Korean Assoc Oral Maxillofac Surg 2012
Repair of bilateral cleft lip and nose by the Mulliken method: a case report
365
patientswerealsoorientalpeopleinthiscase,weappliedthe
modifiedthree-dimensionalpositiontothesurgicaloperation.
Theprinciplesoftheprimarycorrectionofbilateralcleft
lipandnasaldeformityhadbeenestablished,andthesurgical
techniqueisgraduallydeveloping.TheMullikenmethodisa
four-dimensionaltreatmenttakinggrowthintoconsideration,
andgoodresultsarebeingreportedbothinKoreaandabroad
throughthissurgicalmethod6,16.Wehopethiscasereportbe
helpfulfororalandmaxillofacialsurgeonsinapplyingthe
Mulliken’streatmentmethodintheirsurgicaloperations.
References
1. BaikHS,KeemJH,KimDJ.Theprevalenceofcleft lipand/orcleftpalateinKoreanmaleadult.KoreanJOrthod2001;31:63-9.
2. MullikenJB.Bilateralcleftlip.ClinPlastSurg2004;31:209-20.3. BrownJB,McDowellF,ByarsLT.Doublecleftsofthelip.Surg
GynecolObstet1947;85:20-9.4. MillardDR.Bilateral cleft lip andaprimary forked flap: a
preliminaryreport.PlastReconstrSurg1967;39:59-65.5. SalyerKE.Primarycorrectionoftheunilateralcleftlipnose:a15-
yearexperience.PlastReconstrSurg1986;77:558-68.6. MullikenJB.Bilateralcompletecleftlipandnasaldeformity:an
anthropometricanalysisofstaged tosynchronousrepair.PlastReconstrSurg1995;96:9-23.
7. PreciousDS,GooddayRH,MorrisonAD,DavisBR.Cleftlipandpalate:areviewfordentists.JCanDentAssoc2001;67:668-73.
8. FigueroaAA,ReisbergDJ,Polley JW,CohenM. Intraoral-appliancemodificationtoretractthepremaxillainpatientswithbilateralcleftlip.CleftPalateCraniofacJ1996;33:497-500.
9. PadwaBL,SonisA,BagheriS,MullikenJB.Childrenwithrepairedbilateralcleftlip/palate:effectofageatpremaxillaryosteotomyonfacialgrowth.PlastReconstrSurg1999;104:1261-9.
10. MullikenJB,BurvinR,FarkasLG.Repairofbilateralcompletecleftlip:intraoperativenasolabialanthropometry.PlastReconstrSurg2001;107:307-14.
11. FarkasLG,PosnickJC,HreczkoTM,PronGE.Growthpatternsofthenasolabialregion:amorphometricstudy.CleftPalateCraniofacJ1992;29:318-24.
12. MullikenJB.Principlesandtechniquesofbilateralcompletecleftliprepair.PlastReconstrSurg1985;75:477-87.
13. MillardDRJr.Columella lengtheningbya forked flap.PlastReconstrSurgTransplantBull1958;22:454-7.
14. CroninTD.Lengtheningcolumellabyuseofskinfromnasalfloorandalae.PlastReconstrSurgTransplantBull1958;21:417-26.
15. McCombH.Primaryrepairofthebilateralcleftlipnose:a15-yearreviewandanewtreatmentplan.PlastReconstrSurg1990;86:882-9.
16. KimSK,LeeJH,LeeKC,ParkJM.Mullikenmethodofbilateralcleft liprepair:anthropometricevaluation.PlastReconstrSurg2005;116:1243-51.
cheiloplastyforbilateralcleftlip,butnoneofthemisperfect.
Traditionalmethods,inparticular,involvepullingthemedial
cruraofthenosebackwardanddownward,thuscausingthe
columella tobeshorter12.Becauseof these limitationsof
surgicalmethods,mostsurgeonsperformprimarycorrection
whilekeeping inmindsecondarysurgery forcolumellar
lengthening.Millard13 andCronin14 stored some forked
flapsintheinferiorpartofthenasalsillduringtheprimary
surgeryand thenused themin thesecondarysurgery. In
1990,however,McComb15reportedunaestheticresultssuch
asnasal tip lengthening,unnaturalnostrils,andexcessive
lengtheningof thecolumella in their retrospectivestudy
of thetwo-stagesurgeryfor15years.Mullikenalsoused
the two-stagesurgeryfornasalcorrection initially.After
understanding,however,thatthenoseofabilateralcleftlip
andnosepatientjustlooksshortbutisnotreallyshort,he
startedtoperformnasalcorrectionwithoutanyadditional
tissue transplant. Inaddition,heestablished thepresent
surgicalproceduresafterstoppingnasaltipverticalincision
inordertominimizecicatrixes.Hereportedthatasaresultof
retrospectivecomparisonofhissurgicalprocedures,thetwo-
stagesurgeryandtheone-stagesurgerygenerallyshowed
similarresults.Alsointhetwocases,nasalcorrectionwas
performedafteranapproach throughthenostrilmarginal
incisionwithoutusingthenasaltipverticalincisionapproach.
(Fig.7)
Inprimarycorrectionofcleftlipandnasaldeformityusing
theMullikenmethod, the three-dimensionalpositionwas
determinedbasedonthegrowthofwhitepeople.Mulliken
proposedthatthelengthofthephiltralflapbe6-8mm,that
thedistancebetweenthepeakofCupid’sbowbe3-4mm,
andthatitshouldbe2mmatthecolumellar-labialjunction.
Kimetal.16,however,announcedthebilateralcleftlipsurgery
performedonsomeKoreansusing theMullikenmethod,
alsomentioningthenecessityofsomemodificationinthe
three-dimensionalpositionduetothetendencyofKoreans
havingfewertissuesthanwhitepeople.Theyproposedthat
thelengthofthephiltralflapbeaslongaspossible,thatthe
distancebetweenthepeakofCupid’sbowbe5mm,andthat
itshouldbe3mmatthecolumellar-labialjunction.Sincethe