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.