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.
