RESULTS OF TREATMENT—AFTER-TREATMENT.
The typical result which we desire to gain after an operation for harelip
is a symmetrical appearance of lip and nose, and a normal contour and
projection of the parts as seen from the front and in profile. The
cicatrix should be practically invisible, and the red margin of the
lip continuous throughout. Unfortunately, however, in many cases these
results are not easily attainable. The tip of the nose tends to become
drawn down and depressed, especially when in double harelip the philtrum
is poorly developed, or when a mistaken attempt is made to incorporate
it between the segments of the lip. This stunted but thickened columna
encroaches on and obstructs the anterior nares, whilst in unilateral
cases the aperture on the affected side is apt to become dilated and
distended from the absence in some instances of the osseous floor, but
also from subsequent cicatricial contraction of the previously divided
bands between the cheek and maxilla. The behaviour of young cicatricial
tissue, moreover, is not always the same. In some young and feeble
children it remains vascular for a long time, and at first tends to
stretch and become more evident;[100] subsequently contracting, it may
leave an indurated cord-like ridge. In addition to this, a longitudinal
contraction takes place in direct proportion to the thickness of the
cicatrix, reducing the length of the scar and the depth of the lip, thus
bringing about the 𝖵-shaped notch in the lip margin, and assisting in the
dilatation of the nostril.
In double harelip, where the os incisivum has been removed, it has
already been mentioned that the upper lip sinks back, the lower lip
projects forwards, and the profile resulting therefrom becomes very
unsightly (Fig. 75).
[Illustration: FIG. 75.—Profile of a case of double harelip after
operation with removal of the os incisivum, showing the falling in of
the upper lip and the prominent projection of the lower. (_Coles._)]
Many of these defects may be remedied by subsequent treatment. I am
frequently in the habit of advising and practising secondary operations
for the improvement of the facial expression in young children and
adults presenting the unsatisfactory cicatrices detailed above. The
operation comprises not only the removal of scar tissue, but also the
obliteration of the 𝖵-shaped notch, elevation of the depressed nose,
and the diminution in size, if necessary, of the nasal aperture. For a
simple 𝖵-notch without other complications, I have sometimes made use of
Nélaton’s operation (Fig. 48) with most satisfactory results.
The narrowing or partial obliteration of the nostrils in double harelip
from the large size of the columna has sometimes to be remedied
subsequently. One plan which I have practised several times for reducing
the breadth of the columna is by excising a central lenticular-shaped
portion, extending nearly the whole length through its entire thickness,
and closing the gap with sutures. But a simpler method consists in paring
the edges of the columna on either side to the required dimensions,
and allowing the raw surfaces thus formed to cicatrise. The redundant
tissue should be removed on the inner or nasal aspect, so that when
cicatrisation takes place the skin is drawn round into the nares, and the
resulting scar is unobtrusive.
The falling in of the upper lip after the operation for double harelip,
when the os incisivum has been removed, can best be remedied by the
adjustment of a plate carrying the required artificial incisors, and
furnished with a central cheek-plate to restore the natural profile.
Where the lower lip projects unduly in spite of the above-mentioned
artificial adjustment, it may be requisite to reduce its size by the
removal of a 𝖵-shaped portion from its centre. This is so easily
accomplished as to need no detailed description; suffice it to say that
the greatest care is needed in the accurate application of the sutures.
I cannot conclude this portion of my subject without mentioning the
manual and mechanical aids which may be beneficially employed for the
improvement of the mobility and appearance of the face and nose after
such operations. The under-cutting of the integuments of the lip and
cheek, and the subsequent cicatrisation involved, necessarily lead to
a certain amount of rigidity of the parts. This can be remedied in a
great measure by persistent gentle manipulation of the lip and cheek,
care being taken always to press the parts towards the median line.
This should be carried out by the mother or nurse daily after due
instruction. A slight depression or collapse of the nostril on one
side can be improved by the use of an apparatus supplied by Messrs.
Hawksley, consisting of a head-band across the forehead, to which are
attached vertical stems ending in smooth bulbs, which, by rack and pinion
movement, can be so adjusted as to press the nostril into the desired
position. The apparatus can be worn at night and for a certain time
during the day.
* * * * *
The conditions which are essential to a complete success after plastic
operations for cleft palate are as follows: complete closure of the cleft
with no fistulous communication in any part of the line of union, and a
velum capable, when necessary, of being approximated to the posterior
pharyngeal wall so as to shut off the nasal cavity during speech and
deglutition. That this is not invariably attained is an undoubted fact,
and in spite of the merest shaving being removed when paring the edges of
the cleft, the velum when united is frequently so scanty as to be unable
to fulfil this condition. To remedy this, it was proposed some years ago
by the late Mr. Mason to loosen the soft palate by lateral incisions,
passing downwards and backwards through the free border, thus relaxing
the tension, and allowing it to be drawn upwards, when requisite, into
relation with the pharyngeal wall. I have adopted this plan in several
cases, but with only transient success, inasmuch as the subsequent
cicatrisation of the incisions neutralises the temporary benefit derived.
The division of the pillars of the fauces, however, is occasionally
needful and more satisfactory. This has been already alluded to (p.
127), and may either be performed at the time of the first operation, or
subsequently if found to be necessary.
Even in cases where the tissue is abundant, and the united velum
loose and moveable, the immediate effect on the speech is not always
satisfactory. The other advantages of the operation (_e. g._ exclusion
of nasal mucus from the mouth, prevention of regurgitation of fluids
through the nose, improvement in taste and smell, and the psychical
effects) are immediately apparent; but speech is a more complicated
proceeding, and the first result of the operation is often to dislocate
the mechanism which the patient had formerly made use of in its
production, and hence, as has been often noticed, speech and voice may
be temporarily deteriorated, even after a successful operation. This is
a disappointment both to the patient and friends unless they have been
previously warned. A subsequent thorough educational course at the hands
of a professional voice-trainer, if possible, is therefore most important.
In some instances tension of the velum is no doubt the cause of the
persistent nasal twang, but in many others habit is the principal
factor, and this can alone be got rid of by a suitable education. The
reluctance to breathe through the mouth, and the unwillingness to open it
sufficiently during articulation, are conditions very liable to persist
after operation. Such patients also speak too rapidly and run the words
into one another, the velum evidently not being under control. The most
difficult letters to pronounce are _t_, _b_, _d_, _k_, _g_, _s_, _z_, and
_l_. The best means of dealing with the defective breathing is to make
the patient undergo a course of “respiratory gymnastics.” Thus he should
be made to practise deep abdominal breathing with the mouth wide open; he
should stand in front of a looking-glass, and breathe with his mouth open
and his tongue voluntarily depressed. He should next repeatedly exercise
the movements of his tongue and lower jaw; this is often productive of
great improvement in the facial expression. These exercises should be
followed up by others directed to the improvement of speech. The distinct
production of the various vowels and consonants and of all the sound
combinations must be a matter of daily practice. He should be made to
speak and read aloud according to the recognised laws of elocution,
and by so doing obtain proper modulation of the voice and fluency of
speech. Compression of the nasal apertures during these exercises is also
advantageous.
The physical condition of the hard palate after the operation of
uranoplasty is a subject of considerable interest. Langenbeck[101]
claimed that a new formation of bone really occurred about three or four
weeks after the operation, and attained in time considerable solidity.
From experiments, however, by M. Marmy on the palates of dogs, doubt
was thrown on the correctness of this assertion; and M. Ollier, so well
known as an authority on subperiosteal work, declares that “if there may
be doubt as to the ossification, all must admit that it forms a very
resisting surface, which has the strength and takes the place of bone.”
Opportunities for post-mortem investigation do not seem to have been
taken advantage of for deciding this question; but clinical experience
seems to indicate that no new bone is actually formed, the central
portion of the palate consisting merely of dense fibro-cicatricial tissue
covered with mucous membrane. In operating after a lapse of several years
for the closure of oval apertures in the hard palate in patients in whom
a previous operation had been but partially successful, I have never
found osseous tissue, either when paring the margins or when detaching
the flaps through lateral incisions.
The shape and size of the alveolar arch are sometimes considerably
affected as an after result of uranoplasty. It would appear that in the
young the contraction of the cicatrix between the palatal segments and of
the new tissue in the lateral openings exercises a narrowing influence
on the transverse diameter. The alveolar borders approach one another,
and this approximation is most marked at the level of the first or second
bicuspids, and indeed is so great occasionally as to produce an obvious
incurvation of the alveolar ridge. M. Ehrmann of Paris, has investigated
many instances of this change, and from his work[102] the figures
mentioned below are obtained.
In one case a child was operated on for total cleft at three and a half
years. Six months later the following measurements were taken:
Transverse interval between canines 13 mms.
” ” 1st molars 18 ”
” ” 2nd ” 26 ”
At twenty-three years of age the following were the measurements:
Transverse interval between canines 7 mms.
” ” 1st premolars 13 ”
” ” 2nd ” 19 ”
” ” 1st molars 23 ”
” ” 2nd ” 32 ”
The alveoli here formed a reversed 𝖵, and when the patient spoke, the
tongue was more or less protruded. In another case, operated on at five
years of age for the palate defect, a double harelip having been treated
at an earlier date, the measurements were—
At 5 years. At 6 years. At 11 years.
Intervals between canines 23 mms. 19 mms. 12 mms.
” 1st premolars 27 ” 24 ” 14 ”
” 2nd ” 32 ” 27 ” 19 ”
” 1st molars — — 23 ”
This result is more frequently seen in the severer forms of cleft palate
associated with double harelip, especially where the os incisivum has
been removed. Extreme youth increases the tendency to the production of
these deformities, which may become troublesome, not only by interfering
with the size of the buccal cavity, and so causing protrusion of
the tongue during speech, but also by interfering with the “bite,”
necessitating lateral movement of the jaw during mastication.
In one of Ehrmann’s cases an actual increase of the interdental diameters
was found; this was one in which Fergusson’s osteoplasty had been
performed with complete success; possibly the formation of new bone from
the callus produced led to this, or it may have been merely an evidence
of normal growth. The measurements were as follows:
At 3 years. At 11 years.
Intervals between canines 24 mms. 26 mms.
” 1st premolars 26 ” 29 ”
” 2nd premolars 29 ” 32 ”
” 1st molars — 34 ”