OPERATIVE TREATMENT OF HARELIP.
_Period of operation—Statistics—Precautions to be adopted._
_Operation for single harelip: incisions; sutures; dressing;
after-treatment—Various plans adopted._
_Operation for double harelip: treatment of os
incisivum—extirpation or reposition; treatment of soft parts._
In discussing the period in the infant’s life when a harelip should be
operated on, it may be laid down as a general rule that the sooner an
operation is performed for the repair of the abnormal condition _per
se_ the better; but other coexistent conditions have to be taken into
consideration, such as the amount of vitality, the degree of deformity,
and its association or not with cleft palate; and these may lead us to
postpone the operation.
A low state of vitality may be due either to a general inherited
weakness, or possibly to some associated deformity in another part of
the body interfering with nutrition; or, again, simply to difficulties
attending the administration of nourishment owing to the cleft lip and
palate; for, as has been already pointed out, suction, and therefore
breast-feeding, are impossible (p. 67). The problem that the surgeon
has to solve lies in deciding to which of these causes the asthenic
condition is mainly due, and whether the infant has sufficient strength
to withstand the shock of the operation, and is in a state favorable for
the occurrence of primary union. If due to some inherited weakness, or
associated deformity elsewhere, immediate operation would be rash in
the extreme, for the child is very likely to succumb. In any such case,
careful hand-feeding is alone practicable; if a steady improvement is
manifested, the operation may be undertaken later. But if, on the other
hand, the asthenia is evidently due to the inability to take nourishment,
the child gradually getting thinner and looking half starved (as I have
seen in many cases), then the first opportunity should be taken of
closing the lip, as such treatment holds out the only prospect of saving
the child’s life. The greater the deformity, the more difficult will the
question be to decide, for with the higher degrees of malformation the
operation necessarily increases in severity. If associated with cleft
palate this should be performed as early as possible, as the closure of
the lip enables nourishment to be taken when administered in the way
indicated above (p. 67).
It would be well here to call attention to the fact that the early
closure of the lip by the insensible and yet constant pressure brought
to bear on the separated maxillæ has a most beneficial effect in
narrowing the alveolar cleft. In my own experience I can testify to
the decided diminution which has occurred in the width of many clefts
when the lip had been closed by me some years previously, the patients
having subsequently returned for operative treatment on the palate.
Passavant[66] relates a case of a child whose harelip was closed at
the age of nine weeks, and a year later the palate was found to be
approximated without further operation, so that it merely presented
a fissure. Some surgeons have attempted to gain a similar result by
prolonged compression of the maxillæ. Trendelenburg,[67] on the other
hand, casts doubt on this explanation of the narrowing of the palatal
cleft, the existence of which he fully admits, stating he has seen the
same occur in children who have not been operated on, and suggesting
that it is due to the inward growth of the bones.
Three different periods have been suggested for the operation, viz.:
(_a_) The immediate operation—within two or three weeks of birth.
(_b_) The early operation—from three weeks to six months.
(_c_) The deferred operation—from six months to two years.
Statistics do not favour the immediate operation, for although some
surgeons have obtained good results, the mortality with others has been
considerable. Thus König,[68] on the one hand, records seventy cases
operated on in the first month with but one death; whilst Hermann[69]
gives 52·4 per cent. as the mortality of the operation during the first
three months of life, and Gotthelf[70] 50 per cent. for a similar
period. The latter cannot but be considered as an extraordinarily high
death-rate, and possibly antiseptic precautions were not carefully
observed. Trendelenburg[71] reports 44 cases treated in the course of
three years with seven deaths; the infants were between three and six
months old. Fifteen were simple cases, with one death; twenty-one were
complicated, with two deaths; and eight most complex forms, with four
deaths. Only one died within a fortnight of the operation; the remainder
from intercurrent maladies. Still, however, he reckons the death-rate
during the first year of life of children operated on as 41·6 per cent.,
explaining it by malnutrition and the want of intelligent artificial
feeding. Fritzsche reckons the mortality during the first two weeks after
operation as about 5 per cent., but even this is higher than I should
consider consistent with the results of British surgery.
My own personal experience has been much more satisfactory, and the above
figures are much too high to represent my results. Out of between 300 and
400 cases treated between the fourth and eighth weeks, _i. e._ by the
early operation, I have had no death as an immediate result, but several
have died subsequently from intercurrent maladies or defective nutrition.
I attribute this success largely to the fact that I never operate upon
out-patients, but always take the precaution of carefully preparing and
watching them for a few days prior to operating. In the practice of
the late Sir W. Fergusson the one or two fatal cases which I recollect
occurred in children who were taken home immediately after the operation.
It has been claimed for the deferred operation that convulsions are
liable to ensue when an infant under six months is operated on, and also
that the interdiction of nursing impairs nutrition; but this has not been
my experience.
From a consideration of the foregoing facts, it would appear that from
the fourth week to the third month is the most favorable period for
interference, and that at which the greatest proportion of success has
been obtained.
In conclusion, whilst fully admitting that it is impossible to lay down
rules which will meet every case, and that each must be dealt with on its
own merits, I would venture to suggest the following propositions which
may be helpful as a guide to practice:
1. That, _cæteris paribus_, it is important to close the cleft in the lip
as early as possible.
2. That, under ordinary circumstances, the immediate operation is
dangerous to life, and should only be undertaken in desperate cases as a
means of saving it,[72] _i. e._ in double cleft of the lip and palate,
where suction is impossible and swallowing difficult.
3. That experience shows that the sixth week may be taken as an average
at which operations can be safely performed; but that if the child be
very weakly, it is better to defer such treatment for a few days, until
careful spoon-feeding has improved our little patient’s condition.
4. That association with cleft palate in no way invalidates the previous
propositions.
In many cases of slight cleft without alveolar complication the child is
able to take the breast, and as it is desirable to maintain this after
the lip has healed, care must be taken that the lacteal secretion is
not checked. The child is often able to suck five to seven days after
operation; during that period the mother’s milk must be drawn off by a
breast-pump when necessary, and should be given to the child by spoon.
Any mammary inflammation is thus avoided, and the child’s diet is not
changed. In many cases of severe deformity, where the child is unable
to suck from the first, an early disappearance of the milk has of
necessity entailed spoon-feeding. When such an infant is taken from home
into hospital it is well to wait for a few days before operating until
acclimatised to the change of surroundings and of diet. The general state
of health should be as satisfactory as possible, and every effort must
be made to ensure this; it is often politic to defer operation on this
account for a short period. Any aphthous condition of the mouth should
be treated by swabbing with a weak boracic solution (1-40) or by the
application of mel boracis.
Anæsthesia is now-a-days invariably employed, chloroform being the agent
used. Care must be taken by the anæsthetist to prevent any drop coming in
contact with the wound, such an occurrence being liable to interfere with
primary union.
With regard to the position of the patient, some difference of opinion
appears to exist. The practice adopted years ago and described by the
late Sir W. Fergusson in his manual[73] consisted in the surgeon and
nurse sitting opposite one another, the latter holding the child with its
head on the surgeon’s knee. To quote his own words: “A cloth should be
wrapped round the chest so as to confine the arms; a pillow-case answers
the purpose well, as the legs can then be secured by slipping the patient
into it. Then the child should be held by an assistant with its head
resting face uppermost between the surgeon’s knees; if he puts on an
apron of waterproof cloth, it will answer the double purpose of keeping
his trousers free of blood, and preventing the child’s head falling too
low; a little pressure with the thighs will enable him to keep the head
more steady.”
The majority of surgeons at the present time employ the recumbent posture
on a table, a plan which I always follow, the surgeon standing behind the
child’s head, and the anæsthetist and assistant one on either side. Some
prefer to stand at the side of the infant, with the assistant behind its
head.
OPERATION FOR SINGLE HARELIP.
For convenience of description, the operation may be divided into three
stages:
1. Detachment of the lip from the maxillæ.
2. Preparation of the edges of the cleft.
3. Union by sutures, and application of dressing.
STAGE I.—_Detachment of the Lip from the Maxillæ._
The importance of thoroughly loosening the attachment of the lip to the
maxillæ and alveoli cannot be too strongly insisted on; and although
emphasized in monographs on the subject by several authors, yet in our
ordinary surgical text-books it is but scantily noticed or not alluded
to at all. Unless this proceeding is carried out efficiently, the
tension upon the stitches subsequently inserted will be so great as to
hazard successful union, and will prevent the surgeon from obtaining a
symmetrical adaptation of the parts. In severe cases it may be necessary
to carry the knife as far as the infra-orbital foramen, and I have often
had occasion to go close up to the orbital margin to gain as much freedom
as was needful. The maxillary attachment of the ala nasi must also be
completely divided, so that the flattened and distorted nostril may be
made to correspond in shape and form to that on the opposite side. This
dissection in single harelip is mainly needed to the outer side of the
cleft, but rarely to such an extent as described above unless the cleft
be very wide.
The knife must be kept close to the bone in order to minimise bleeding,
and not unnecessarily to lacerate muscular and other structures. Sponge
pressure will readily control any hæmorrhage. Afterwards the plastic
exudation that results is useful in steadying the mask of the face, and
the temporary division of facial muscles has a like effect.
STAGE II.—_Preparation of the Edges of the Cleft._
Many different methods have been suggested and practised for the
preparation of the margins of the cleft, some of which will be noticed
in detail hereafter. It is necessary to keep clearly in view the points
to be aimed at in the operation. The mere union of the two segments of
the divided lip is not sufficient; we also require to obtain symmetry of
the nostrils, to avoid an unsightly flattening of the tip of the nose,
to have a scar almost invisible, and no notch in the lip margin; the
muco-cutaneous line or red margin, moreover, should be so united as to be
continuous.
Many surgeons have endeavoured to utilise almost, if not every particle
of tissue bounding the cleft, notably Malgaigne, Nélaton, Henri, and
Giraldés; but the principal objections to this are that it leaves the
nostril wide and depressed, and the expression anything but agreeable,
whilst in some of the plans suggested the muco-cutaneous line will be
irregular. From my own experience of operations I am convinced that
better results may be obtained by a free removal of tissue, principally
from the outer or buccal half of the cleft; and in so doing the knife
should always encroach upon the affected nostril, and thus the necessary
diminution in the size of its aperture can be obtained.
Bearing in mind the tendency of scar tissue to contract in all
directions, it is obvious that the surgeon must so plan his incisions
that the united lip shall be at first slightly longer vertically than is
ultimately desired. The incisions, instead of being made parallel to the
edges of the cleft, should be curved, with their concavities facing each
other, so that when in apposition a vertical elongation may be obtained.
To avoid the formation of a 𝖵-shaped notch, a result so liable to occur,
a variety of methods of forming a _prolabium_ have been suggested and
practised. Most of these aim at the formation of a protrusion which,
exaggerated at first, will ultimately be reduced to normal dimensions by
subsequent cicatrisation. Some surgeons (_e. g._ Mirault and Giraldés)
are content with using the mucous membrane of one side only, and planting
it on a prepared surface on the other margin of the cleft; whilst
Malgaigne, Henri, and Stokes make use of labial tissue from both sides.
My usual plan of procedure is a modification of that described by Dr.
Stokes, though I have had recourse to other methods.
Great care must be taken to make the incisions clean and at right angles
to the skin. By some, however, the edges are bevelled, and when for any
reason such is thought desirable it is important to remember that each
side will need bevelling to a proportionate extent. The use of scissors
for this purpose is sometimes preferred to that of the knife, but the
difficulty of cutting cleanly appears to me much greater with scissors,
however sharp, than with a scalpel.
Various kinds of lip compressors have been suggested for controlling the
hæmorrhage from the coronary arteries during this stage of the operation;
but I agree with the majority of surgeons in considering that these are
cumbersome, and quite unnecessary when one has intelligent assistants.
The constant presence of such an instrument distorts the parts, and
prevents the operator from seeing clearly how to plan his incisions.
Nothing can be so well adapted for this purpose as the thumb and index
finger.
The usual method that I am accustomed to adopt for cases of simple
unilateral harelip is as follows:—Standing behind the patient’s head,
and my assistant holding the right side of the lip between the finger
and thumb of his right hand, so that the index finger is in the mouth,
and so holding the lip forward and inward at a sufficient distance
from the margin to enable me to remove the requisite amount of tissue
without difficulty, I enter the knife with its edge downwards either
at the apex of the cleft, or in a complete case at the margin of the
nostril as high as desirable, and cut in a curved direction downwards
until the muco-cutaneous junction is reached. The edge of the knife is
then turned so as to cut through the mucous membrane of the lip in a
direction practically at an angle of 60° to the former incision. Then
grasping the left side with my own left thumb and forefinger, and thus
making it tense, I make an exactly corresponding incision, dealing with
the muco-cutaneous margin and mucous membrane in a similar manner (Fig.
46 A). Having approximated the edges and fitted them together, we are now
ready to undertake—
[Illustration: FIG. 46 A.—Author’s method of preparing edges of cleft,
showing semilunar incision as far as red margin of lip, and oblique
upward cut on either side to form the prolabium.
FIG. 46 B.—Shows flaps in position, and the nostrils symmetrical. The
wide stitch lines represent the position of the wire sutures, the narrow
those of the catgut.]
STAGE III.—_Union by Sutures and Application of Dressing._
Many surgeons still retain the plan first introduced and figured by
Ambrose Paré[74] of uniting the edges by means of harelip pins and
figure-of-8 sutures; but this has been largely superseded by the use of
silver wire and intermediate fine sutures.
Good results undoubtedly followed the old plan of treatment, and it had
the advantage in pre-anæsthetic days of being more rapidly accomplished.
But success could not be depended on for the following reasons: it was
more difficult to adjust the edges with exactness, and the muscular
movements of the lip were liable to cause them to slip, and being hidden
by the coils of superjacent suture the displacement was undetected until
the removal of the pins. Moreover the track of the pins, especially if
they were retained beyond the fourth day, was liable to become the seat
of suppuration, and unsightly cicatrices resulted. In some instances
the pins cut their way out of the lip, leading to still more evident
cicatricial deformity, and the liability to septic infection of the wound
was of course much greater. At the same time I have no desire to detract
from the one great and acknowledged advantage of pin-transfixion and
figure-of-8 suture, viz. the steadying and accurate approximation of the
deeper parts, when efficiently inserted; but I maintain that the same
advantages can be secured by the use of silver wire as detailed below.
When harelip pins are used, the method of introduction is as follows:—The
first pin should be inserted close to the muco-cutaneous margin, and
about one centimetre from the edge of the right side of the lip, and
its point should emerge on the deep aspect of the raw surface close to
the mucous membrane. It should then be passed on through the opposite
side of the lip, entering at an exactly corresponding point on the raw
surface, and passing out through the skin of the left side at the same
distance from the edge as on the other. One or two more pins should be
similarly passed at equal distances through the other portions of the
cleft. Moderately thick unwaxed silk is now used as a figure-of-8 suture,
whilst during this the assistant presses the cheeks, and holds the lip
_in situ_. The parts should not be dragged together by this means, but
merely retained in the position to which they have been easily brought
by the pressure of the assistant’s fingers, as a result of the previous
undercutting. A separate silken thread is advisable for each pin. The
pins are now cut short by wire-nippers, and collodion painted over all.
The plan I now adopt, in common with many others, of suturing the
prepared lip is as follows:—Purified silver wire of No. 27 gauge is
carefully threaded on special wire needles. I introduce two or three
sutures by entering the needle at rather more than half a centimetre from
the margin, and bringing out the point on the raw surface close to the
mucous membrane as with the pins, taking care to pass the needle in on
the opposite side at an exactly corresponding point. The three situations
I select for these sutures are, one at the root of the nose or upper part
of the cleft; one a little above the muco-cutaneous junction; and the
third, if necessary, between the other two. In very young infants and
simple cases, only two wires are needed.
Having passed the wires and tested the accuracy of their position,
the ends are left long and unfastened lying on the cheeks, whilst the
fine catgut sutures are being adjusted. By means of small semicircular
needles, about two centimetres in diameter, held in a needle-holder,
these sutures are inserted, as near to the margin of the cleft as is
possible, consistent with their holding. The first two should be placed
one at the muco-cutaneous junction, and the other at the nostril aperture
as high as is necessary in order to bring about the approximation of the
ala nasi to the median line, and thus secure the diminution in the size
of the opening, and a symmetrical disposition of the features.[75]
As many other fine sutures as are necessary are now inserted between
these two. In regard to the mucous membrane of the lip and the formation
of the prolabium, care must be taken that the exact edges are stitched
together, as they are very liable to curl in. It will be found of great
assistance if the catgut of the first suture in the mucous membrane be
not cut short, but used as a holder to lift the lip during the passage
of the next stitch, which will fulfil the same office for the succeeding
one, and so on, until, in this way, the mucous membrane can be thoroughly
everted, and fine sutures carried through the edges on the buccal aspect.
The effect of this is most satisfactory in maintaining exact coaptation
of this part of the lip, which is so liable to be displaced when the
child is fed or cries, permitting the entrance of food or saliva which
will interfere with the progress of union. The wire stitches (sutures of
relaxation) are now fastened, and in doing so there is no necessity to
tighten them unduly; experience alone can teach the requisite amount of
tension. This completed, all traces of blood are removed from the face,
and the sutured lip carefully cleansed with a purified sponge dipped in
boracic acid lotion.
A collodion dressing is then applied in the following manner: a piece of
antiseptic gauze folded double is cut butterfly fashion, so that one wing
is fixed upon each cheek, and the uniting portion, just the width of the
lip, passes over the wound. Collodion is carried close up to, but not
over, the wound itself, which is merely covered by the bridge of gauze.
During the adjustment of the dressing, the assistant should hold the
cheeks forward, and this position must be maintained until the collodion
is firm. The contractile nature of this dressing is especially useful in
limiting to some extent the movements of the cheek.
In former days the use of Hainsby’s truss or cheek compressor was much in
vogue, with the object of relaxing, as far as possible, all tension on
the flaps; but the apparatus has now been discarded by most surgeons. The
pressure of the spring was occasionally so severe as to cause sloughing
of the cheek (as I have seen in one or two cases many years ago); or
else there was a great liability for the pads to slip out of position
during any sudden movement of the child’s head, leading to injurious
pressure on or near the wound itself. In fact, if the truss was acting
efficiently, pain and irritation to the child resulted; if it was
comfortable, it was generally useless.
One of the principal points to be attended to in the _after-treatment_
is to instruct the nurse to depress the lower lip with the index finger
for some hours after the child has recovered from the anæsthetic, and to
repeat it occasionally until it becomes accustomed to the diminished oral
aperture; otherwise the efforts to draw air through the mouth (now closed
for the first time) will tend very considerably to disturb the wounded
surfaces.[76]
Spoon food must be so administered as to allow it to touch the upper lip
as little as possible. The arms should be fixed to the side to prevent
them touching the face. In young infants constant attention day and night
is necessary, for they are very liable to roll the head from side to
side, and so bring the sutured lip in contact with the bedclothes, which
causes pain and makes the child cry, a most undesirable occurrence. The
state of the bowels should be attended to, and if constipation exist,
a small dose of grey powder with magnesia may be advisable. The silver
wire sutures should usually be taken out on the fourth day; the catgut
stitches may remain a week, or some of them until absorbed, the collodion
dressing being re-applied when necessary, and maintained for a few days
after the catgut has disappeared or been removed. Occasionally saliva
and milk soak into and under the gauze, producing a moist condition of
the skin around the freshly united wound, which may lead to eczema. The
gauze should then be left off, and the parts gently washed with warm
boracic lotion and dusted over with a mixture of equal parts of powdered
oxide of zinc and starch. In mild cases without alveolar complication
the child may be put to the breast on the fifth or sixth day, if the
condition of the wound is satisfactory. But in the severe forms, or where
the union is weak and threatens to give way, most careful spoon-feeding
and general watchfulness must be continued. In spite, however, of every
precaution, the depression of the nostril will sometimes persist or
reappear as cicatricial contraction takes place, and a slight notch in
the lip cannot be always prevented.
It will be convenient to append here a description of some of the better
known methods of operating on unilateral harelip, with a few words of
criticism on each.
* * * * *
1. _Graefe’s method_ is applicable only to incomplete clefts in the soft
tissues. He prepares the edges by an arch-like incision (Figs. 47 A and
B), and brings them together with the muco-cutaneous margin even. It will
be seen that a notch must necessarily result (in spite of the successful
appearance in the picture which I have borrowed) from cutting the red
margin of the lip in this manner.
[Illustration: FIG. 47.—Graefe’s operation. The completed lip is an
impossible diagram of the result of such a section.]
2. _Nélaton’s method_ (Figs. 48 A and B).—In this no tissue is removed,
but the margin is freed by a semicircular incision skirting the cleft
and extending through the whole thickness of the lip. The centre of the
fissure is then drawn down, and the opening thus created is brought
together laterally so as to cause the lower portion to protrude as a
prolabium. It is only suitable for very mild cases of harelip where the
nostril is not involved, and has been adopted in the secondary treatment
of the 𝖵-shaped notches, the results of previous operations. It will
be noted, however, that the prolabium in this case consists mainly
of cutaneous tissue, and that there must necessarily be an unsightly
break in the red margin of the lip, which makes it a most undesirable
proceeding.
[Illustration: FIG. 48.—Nélaton’s operation. No tissue removed, but the
loosened margin pulled down and sutured.]
3. _Malgaigne’s operation_ (Figs. 49 A and B) was suggested for
unilateral harelip where the fissure does not extend into the nostril.
No tissue is removed, but flaps are turned down from the apex of the
cleft on either side, the incision stopping at the red margin of the
lip. Knife or scissors may be used. The flaps are drawn down and united
to form a prolabium, whilst the raw surfaces, necessarily left above,
are united from side to side. The same objection applies to this as to
Nélaton’s operation, viz. the break in the red margin of the lip caused
by the interposition of integument.
[Illustration: FIG. 49.—Malgaigne’s operation. No tissue removed; cleft
margins turned down to form a prolabium.]
4. _Giraldés’_[77] _or the mortise operation_ (Figs. 50 A and B) is a
somewhat complicated proceeding. Taking a left-sided unilateral cleft for
illustration, a flap (_a_) is cut on the right side from below upwards,
starting from the muco-cutaneous junction, and remaining attached by
its base to the root of the nose. The portion of red lip margin below
this is removed by an oblique incision (_c_), and so prepared for
receiving a flap from the other side. On the left side of the cleft,
a flap (_b_) is made by cutting from the ala nasi downwards to the
muco-cutaneous junction, leaving it attached below; and in addition
a transverse incision outwards is made from the same starting-point,
skirting the nostril if necessary. The right-hand flap (_a_) is turned up
and implanted along the opening made by the transverse incision, whilst
the left-hand flap (_b_) is turned down and implanted on the oblique raw
surface (_c_). It will then be easy to approximate the surfaces _d_ and
_e_ together as indicated in the figured diagrams. I have not practised
this identical operation as described above, because of the objection
there is to the left-hand flap, which contains skin at its upper part,
being introduced into the red margin of the lip.
[Illustration: FIG. 50.—Giraldés’ or the mortise operation.]
5. _Mirault’s operation_ (Figs. 51 A and B) consists in entirely removing
the inner margin of the cleft, whilst on the outer side a flap is turned
down by cutting from above downwards, commencing at or near the apex and
extending to the junction of the middle and lower thirds where it remains
attached. Care must be taken to make this flap sufficiently thick. It is
then carried horizontally across the cleft and applied to the opposite
margin, and the raw surfaces sutured together. The same objection may
be raised to this as to some of the above-mentioned operations, viz.
the implantation of integumental tissue in the continuity of the mucous
membrane of the lip, resulting probably in an irregularity of the red
margin.
[Illustration: FIG. 51.—Mirault’s operation. Outer side of cleft margin
implanted on prepared surface of inner side.]
6. _König’s operation_ is more satisfactory, and not unlike the one I
usually employ (Fig. 46). It consists in paring both margins of the
cleft, and in then forming two small prolabial flaps by horizontal
incisions parallel to the lip margin.
7. _Stokes’s operation._—In this a prolabium is formed by tissue from
both sides of the cleft by means of incisions skirting the red margin of
the lip, as seen in the drawing (Fig. 52, _ab_, _a′b′_). The upper part
of the cleft is not completely pared on either side, but the knife is
only carried three quarters of the way through the thickness of the lip,
the mucous membrane remaining intact. These partially dissected flaps are
turned back, and the edges of the skin brought into apposition, whilst
the prolabial flaps are drawn downward and outward. As regards the latter
part of this proceeding, it will be seen that my own plan is much the
same, but the necessity for leaving the tissue at the back of the lip
does not appear to possess any advantage commensurate with the greater
difficulty that its presence entails in the accurate adaptation of the
flaps.
[Illustration: FIG. 52.—Stokes’s operation. Prolabium formed by flaps
_ab_, _a′b′_ from each side; margins of cleft partially detached, and
flaps K B _ab_, K B _a′b′_ turned backwards to increase breadth of raw
surface. (_Mason._)]
8. _Collis’s operation_[78] (Figs. 53 A and B).—This proceeding is
somewhat similar to Stokes’s as regards the utilisation of every portion
of the soft tissues. On the inner side the knife is carried along the
margin of the cleft (_a b_), but stops short at the mucous membrane,
allowing this portion to be turned, as on a hinge, backwards to increase
the thickness of the raw surface. On the outer side a prolabial flap (_e
f_) is made from above downwards, starting at the centre of the margin,
whilst the rest is turned upwards to form a flap attached above (_c d_).
This latter is then drawn across and adapted to the upper part of the
inner margin with its apex upwards, whilst the lower flap is drawn across
and implanted on the lower portion with its apex downwards. In actual
practice this is complicated and tedious, but the principal objection to
it as well as to Stokes’s operation lies in the fact that there is no
provision for restoring the shape of a distorted nostril.
[Illustration: FIG. 53.—Collis’s operation. No tissue removed. Inner
margin is pared by incision _a b_, but left attached by mucous membrane,
and hinged backwards. Outer margin is transfixed, and flaps _c d_ and _e
f_ are cut; _c d_ is turned up and attached to _a g_; _e f_ is turned
down and attached to _b h_. (_Mason._)]
In the severer forms of harelip, where either the cleft is broad or the
nostril much flattened, other modifications may be necessary; such, for
instance, as that practised by Dieffenbach, the essential principle of
which consists in making additional incisions horizontally below, and
even skirting around the ala nasi, with the object of so loosening the
tissues as to bring them more readily into apposition. I have never
practised this, and cannot help thinking that the difficulty often
experienced in bringing a flattened nostril into position would be rather
increased than otherwise. Free undercutting of the cheek tissue will
probably be found much more efficacious.
In alveolar harelip with projection of either segment of the alveolus
it may be necessary to excise the projecting portion, or to reduce its
bulk in order to prevent undue tension on the flaps. In many it is
sufficient merely to excise the milk tooth, whilst in others a part of
the bony margin may need removal with cutting pliers. Any such step, when
obviously necessary, should be carried out as a preliminary operation.
OPERATIVE TREATMENT OF DOUBLE HARELIP.
This subject naturally resolves itself into the discussion of two points,
viz. the method of treatment of the os incisivum, and that of the soft
parts.
The treatment of the os incisivum has given rise to considerable
discussion, and the practice of various surgeons differs greatly. Whilst
some, especially on the Continent, have advocated its retention, others,
particularly of the English school, have just as strongly urged its
extirpation. One thing is plain; if the bone is to be retained steps must
be taken to restore it to a normal position. It will be well to describe
_seriatim_ the different plans of treatment which have been suggested,
and subsequently to discuss their relative value.
The oldest and simplest method consists in the complete removal of the
bone, or, as it is sometimes called, the operation of Franco.[79]
This should be always undertaken as a preliminary step a week or two
prior to dealing with the soft parts, and is effected in the following
manner:—The central portion of the upper lip, together with all the
available tissue which can be turned up, is first dissected away from the
bone and left attached to the columna nasi. The mucous membrane behind
the projection is then incised transversely to allow of the introduction
of a pair of cutting pliers, by which the separation of the bone from
the vomer is effected. Smart bleeding from the anterior palatine vessels
frequently occurs, and may require a touch of the cautery to stay it. No
after-treatment is necessary, as the stump rapidly cicatrises. The child
should be well fed up in view of the subsequent operation upon the soft
parts.
Where the os incisivum is retained, the following methods for its
treatment have been adopted:
1. Gradual and continuous backward pressure by means of a bandage
(Desault). In this plan the bandage requires constant attention to keep
it sufficiently tight; and it is very doubtful whether much effect can
be thus produced, especially when only applied, as in Desault’s cases,
for from ten to eighteen days. The use of elastic tension by means
of india-rubber has been also recommended (Thiersch). The effect of
such treatment will be to bend the vomer in proportion to the amount
of repression; but much pain must always be produced by this process,
and the vitality of the central part of the upper lip may be seriously
impaired.
It would appear from Desault’s writings that he only advised this
proceeding in cases where the projection of the bone was slight, and
where there was a certain amount of mobility owing to the median septum
being soft and cartilaginous, conditions which do not often obtain; and
certainly statistics do not show any large number of cases treated.
Where, however, the projection is but slight, and the vomer not too
strong and hypertrophied, this plan deserves a trial prior to undertaking
more serious steps.
2. Forcible repression of the incisive bone by seizing the projecting
tubercle at its extremity and violently forcing it back, fracturing the
bony processes which support it. This proceeding, which was introduced
by Gensoul of Lyons, rests on the theoretical hope of simply fracturing
its pedicle at its narrowest part without giving rise to much hæmorrhage,
or to laceration of the mucous membrane. But anatomical facts are
opposed to such a probability. The vomer, we know, is usually thick and
hypertrophied in these cases, and the line of fracture will probably be
far back, and may very possibly extend to the cribriform plate of the
ethmoid and base of the skull. The mucous membrane, moreover, is liable
to be severely lacerated and the hæmorrhage considerable; Sédillot[80]
sums up the proceeding as “peu sûre, difficile toujours, et impossible
souvent.” But few cases of success are recorded, and from its uncertainty
one may dismiss it as unscientific and unjustifiable.
3. Repression after excision of a wedge-shaped piece of the vomerine
plate immediately behind the os incisivum (Blandin’s method).[81] This
only applies to cases of complete double cleft where the vomer is
unattached to either palatal segment. Using strong scissors, M. Blandin
cut out a 𝖵-shaped portion of the vomer, the anterior incision being
vertical and the posterior oblique. The median tubercle could then be
easily replaced. The great objection to this method, however, is the
severe hæmorrhage which is liable to ensue from the divided anterior
palatine arteries, and, in fact, M. Richet reported three cases in
the ‘Société de Chirurgerie,’ in 1856, in which he had performed this
operation, and all with fatal results.
A much better plan is that which was suggested, in order to avoid such
mishaps, by Bardeleben.[82] He incises the mucous membrane along the
lower border of the nasal septum behind the os incisivum, and then strips
up the mucous membrane and periosteum by means of a narrow-bladed
raspatory. The septum may be either divided with cutting pliers and
the projection thus reduced, or being grasped by a pair of sequestrum
forceps, the blades of which are protected by gutta percha, may be
diminished in length by being forcibly twisted upon itself. The effect
of either of these proceedings will be to cause the two portions of the
vomer to overlap, a matter of little consequence, whilst the operation
being subperiosteal, but slight hæmorrhage occurs. The results of this
method of treatment seem to have been fairly satisfactory.
The late Mr. Butcher[83] designed certain ingenious instruments for
“cutting through the projecting pieces in complicated harelip without
dividing the soft parts,” or interfering with the vascular supply from
behind previous to bending them back.
By whatever method the median tubercle has been replaced, it is always
advisable to operate at the same time on the soft parts, as the united
lip is the best splint for steadying the bone in its new position and
giving it as good a chance as possible for becoming fixed. To assist this
fixation various plans have been adopted, but with very partial success,
_e. g._ the lateral aspects of the cleft and the os incisivum have been
freely pared in order to obtain firm adhesions of the raw surfaces, and
even silver wires have been passed, a proceeding somewhat detrimental to
the developing teeth.
Langenbeck,[84] after paring the edges of the prominent tubercle and of
the maxilla, transfixed the parts with a harelip pin after replacement
into position, and I have myself tried the same plan, but with
indifferent success.
In discussing the relative merits of these two forms of treatment,
extirpation or reposition, it must be remembered that the latter is
practically impossible in adults or in patients rather older than the
usual infants operated on, for the os incisivum will in such be larger
and more bulky than usual, and the palatine cleft having become narrower,
the space into which the bone has to be repressed is much smaller than
usual. The advantages claimed for reposition are the following:
1. The profile view of the face is much improved by retaining the normal
shape of the alveolar border, and the appearance, especially when the
mouth is open, as in laughing or yawning, is more pleasant.
2. The normal contour and size of the upper jaw is maintained, preventing
the patient from becoming so obviously “underhung” as is commonly the
case after extirpation.
3. The patient retains his own teeth, and is able to use them better than
any artificial appliances.
But such advantages are more theoretical than practical, as the following
facts will show.
The os incisivum in its new position is admittedly never very firm, and
usually has considerable mobility, and hence its use in bearing the
incisors is considerably discounted. Moreover the position of these
teeth is such that they are both useless and unornamental; for from the
rotary movement by means of which reposition is effected, the teeth will
generally erupt obliquely backwards; they are in addition often small and
decayed. Although it may be desirable to maintain the normal contour of
the jaw, we must assert that the presence of the incisive bone between
the anterior portions of the maxillæ is by no means an unmixed good, as
its wedge-like action interferes materially with the subsequent narrowing
of the palatine cleft, and so renders the later operation for the cure of
this defect more serious and difficult.
Again, it has been already pointed out that it is desirable to complete
the operation on the lip simultaneously with the reposition of the
median projection; the effect of this more serious step is manifestly to
increase the shock to the little patient, who is probably not in the most
vigorous condition of health from its inability to take nutriment in the
usual way, and at any rate renders the occurrence of primary union less
likely. This fact may perhaps explain the much higher death-rate after
operation amongst German surgeons than in this country. The prominent
condition of the under lip (Fig. 75, p. 147) can be remedied later on
by excising a 𝖵-shaped portion from its centre, resulting in marked
improvement to the facial expression, especially in patients operated on
after infancy.
To my own mind the disadvantages of the retention of the incisive bone so
clearly outweigh the _prima-facie_ advantages, that in my practice I have
followed the usual course adopted by the majority of British surgeons
in removing the bone at the earliest opportunity. By this removal the
operation on the lip can be more successfully accomplished, and as
regards the profile effect the later introduction of a dental plate with
artificial incisors will greatly improve the appearance, and enable the
patient to bite in a satisfactory manner, far more so, in fact, than with
the mobile os incisivum.
After removal of the bone and union of the lip, the approximation of
the maxillæ to one another has been repeatedly observed and accurately
noted. Whether this is due to the insensible pressure of the united
lip or to increased osseous development is a matter of but slight
importance; probably both agents contribute to this desirable effect.
If, however, the maxillæ are considerably drawn together, the “bite” or
dental adjustment between the upper and lower jaws becomes uneven, _i.
e._ the upper teeth fall within the lower so that during mastication,
side-to-side movements of the mandible, as seen in horses and cows,
become needful.
After the child has recovered from this preliminary operation of
extirpation of the incisive bone, and the raw surface left by its
removal has cicatrised, the soft parts of the lip are then dealt with.
This cannot be well undertaken before the tenth to the fourteenth day.
The operation, so far as the lateral segments are concerned, should be
carried out according to the principles enunciated for the single harelip
operation. A free detachment of the lip from the maxillæ by undercutting
should be the first step, and this must be accomplished thoroughly
in these bilateral cases. The edges will then require preparation by
curved incisions made from above downwards as far as the muco-cutaneous
junction, and then prolabial flaps are formed by cutting upwards and
inwards at an angle of 60° to the preceding (Fig. 54 A).
[Illustration: FIG. 54.—Author’s incisions for double harelip. The
central tubercle is pared in a 𝖵-shaped manner, and the lateral segments
by curved incisions from above down to the muco-cutaneous junction,
and then obliquely upwards and inwards. Only the apex of the central
portion is included in the completed lip. The long cross lines represent
the position of the wire stitches, and the short ones of the catgut
sutures.[85]]
The treatment of the central part of the upper lip demands special
notice. In the first place it is quite evident that to attempt to
draw it down to any extent between the flaps would have the effect of
depressing the point of the nose and producing an unsightly lateral
dilatation of the nostrils, for it must be remembered that this stunted
portion of tissue represents in most cases not only the central part of
the lip, but also the columna nasi. Very commonly there is but little
more tissue than will suffice to form a columna. Though thus deficient
in length it is often broader than is necessary, and may subsequently
require further operative treatment to reduce it to a shapely size (p.
148); otherwise it encroaches too much upon the nostrils, and is very
unsightly. Consequently it is only the extremity of this philtrum which
needs preparation, and this is effected by cutting it into a 𝖵-shape,
the raw margins thus exposed being carefully implanted between the edges
of the lateral flaps at the upper part (Fig. 54 A). Wire stitches are
now passed; the upper one should traverse the apex of the 𝖵, and other
fine catgut sutures should be used for accurately adjusting this central
portion. The outer segments can then be brought together in the median
line in the manner previously described in the operation for unilateral
harelip (Fig. 54 B).
Several other operations have been suggested, and notable amongst
them are those of Sédillot and Mr. Thomas Smith. The former devised a
cheiloplastic method of remedying this double deformity, the incisions
for which are shown in the accompanying engraving (Fig. 55). Flaps _aa_
consisting of the outer margins of the clefts are turned down to form
the red border of the completed lip, and united in the middle line,
whilst oblique incisions are made upwards and outwards to free the outer
segments. The central tubercle is pared, leaving raw surfaces (_b′b′_),
to which are applied by suture the surfaces (_bb_) made by the oblique
incisions. I cannot but think that the objections stated above to a
similar plan suggested for single harelip are equally valid as regards
this method (p. 91), viz. that the nasal distortion is less easily
remedied by this plan than by the free under-cutting of the segments
which I invariably practise.
[Illustration: FIG. 55.—Sédillot’s operation for double harelip. _a a._
Prolabial flaps to form red margin of lip by union in middle line. _b b._
Incisions below alæ nasi to permit approximation of the above. _b′ b′._
Incisions in sides of central tubercle. (_Mason._)]
The latter operation (T. Smith’s, Fig. 56) is only adapted to those rare
cases where the soft tissues of the central tubercle are abundant. He
turns down marginal flaps from this central part and implants them on
prepared surfaces of the outer segments. The apex of the philtrum thus
forms the central part of the united lip; hence there must not only
be a tendency to depression of the point of the nose, but also great
probability of a decided notch subsequently manifesting itself in the
median line, when cicatrisation is complete.
[Illustration: FIG. 56.—T. Smith’s operation for double harelip. The
outer segments are pared and the parings removed. Prolabial flaps are
turned down from the sides of the central tubercle. Evidently it can only
be of use where the soft tissues are abundant. (_Mason._)]