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.
