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—
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.
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.
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.
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.
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.
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.
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.
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.