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.