Sutures are best made of fine silver wire or of black silk, as the ordinary silk is usually too absorbent, and permits infection of the stitch holes. These sutures are introduced with any one of a variety of needles devised for the purpose. A complicated needle is not necessary for this purpose, for with an adequate needle holder even the ordinary needles can be used. Silver wire may be fed directly into the needle or through a hollow needle devised for the purpose, or sutures of silk may be passed, by which a wire suture is pulled after them.
Great assistance can be obtained from packing strips of gauze between the flaps and the bone from which they have been detached. These may be inserted for pressure effect and prevention of hemorrhage during the operation, and later may be substituted by smaller packing of antiseptic gauze left for the purpose of helping to minimize tension, flaps being crowded toward each other by their use.
Fig. 468
Fig. 469
Uranoplasty, showing incisions. (Tillmanns).
Staphylorrhaphy, sutures placed. (König.)
The parts being approximated and the wound suitably tamponed it is necessary to keep the patient as quiet as possible. Young infants tend to keep up a constant sucking motion with the tongue, which may interfere with the quietude of the palate. Small doses of bromide or chloral may be administered either by the mouth or rectum, for every effort at crying, coughing, or vomiting tends to make a stress upon the line of sutures. Vomiting immediately after the operation is not necessarily serious, and yet should be avoided. Patients sufficiently old to talk should be cautioned not to converse. Water is better for the patient than milk, as the latter does not allay thirst so well and may form curds. Most of the nourishment for the next few days should be administered by the rectum, giving only water through the mouth. Children should be watched continuously lest they get fingers or toys into their mouths, and fretfulness should be guarded against. Thread sutures should only be removed with scissors and forceps after the expiration of five or six days. A useless suture is a foreign body which does more harm than good. When lead plates are used with strong wire sutures they should remain from two to four weeks. In young or undisciplined children it may be necessary to give an anesthetic for removal of the sutures. The tampons or pledgets of gauze should be removed from day to day. An antiseptic mouth-wash or spray should be frequently used.
The two results most desired are prevention of passage of food from the mouth to the nose, which is always commensurate with the success of the operation itself, and improvement in speech and voice. The earlier the closure the more natural the voice. Patients in adolescence or adult life rarely note much gain in this respect, while those operated in early childhood may learn to talk almost perfectly.