On harelip and cleft palate

by William Rose

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]).

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.

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.

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.)

CHAPTER VI.
OPERATIVE TREATMENT OF CLEFT PALATE.

Period of operation.—Preparation of patient.—Anæsthesia.—Duties of the assistant.—Instruments.—Description of uranoplasty; of staphyloraphy.—After-treatment.—Complications.—Modifications of operation.

The period of life at which an operation can be safely undertaken for Cleft Palate is a matter which demands careful consideration. Before the introduction of anæsthesia the assent of the patient was required, and therefore the operation was seldom performed before the age of puberty. With the aid of chloroform this is obviated, and we can now operate at an earlier period; undoubtedly as regards the subsequent power of articulation the earlier the operation is performed the better. On the other hand, the palatal tissue in infant life is so delicate, and the cavity of the mouth so small that a plastic operation is attended with more than usual difficulty. Further it is almost impossible to keep an infant sufficiently quiet to allow of primary union, as it is constantly interfering with the stitches by pushing the tongue against the wound, and sucking the edges apart. Statistics of results, moreover, tend to prove that such operations conducted on young infants are not only directly dangerous to life, but also indirectly, by depressing the general vitality and increasing the liability to subsequent disease. Thus Ehrmann[86] records ten cases operated on under two years of age with two deaths, two failures, and six cures, which latter he considers due to the fact that the children were fed after the operation by œsophageal tubes passed through a protective plate of hardened rubber so as to prevent interference with the sutures. Of these six cases cured, only one was living after four years had elapsed, and in this the soft palate only had been closed. He considers that the loss of blood, and the shock of the prolonged operation or operations interfered in a serious manner with the vitality of the patients. These are, perhaps, somewhat scanty facts to argue from, but they tend to show that there is a greater risk associated with operations performed at an early period of life, although we have the authority of many well known surgeons for attempting them. Thus Billroth has operated at the age of four weeks, Roye of Lausanne at eight days; but my own experience is certainly in favour of deferring operation until the child is at least three years old, or as soon after that period as possible if it is at all of a tractable disposition; the moral control at this age is usually sufficient for our purpose.

As to whether the whole cleft should be dealt with at one operation or not, the practice of surgeons differs considerably; and indeed each case needs to be decided upon its own merits. Where the cleft merely involves the soft palate, or possibly extends but for a short distance into the hard, one operation will usually suffice; but in extreme cases of complete cleft of the hard and soft palate with wide separation of the edges, it may be advisable to deal at different times with the hard and soft, some preferring to close the hard at the first operation, and others the soft. This must depend upon the surgeon’s confidence in himself and in his patient. Personally I always prefer, if practicable, to obtain union in the hard palate at the first operation; then if after taking the necessary steps for loosening the muco-periosteal flaps the parts appear to come easily together, the edges of the whole cleft can be pared, and the whole process completed at one sitting. I cannot too strongly insist on the paramount importance of obtaining firm union in the anterior part of the palate, for if the smallest opening be left in that situation, distinctness of speech in after-life will be seriously impaired.