On harelip and cleft palate

by William Rose

Stage 3. Passage and tightening of sutures.

Stage 4. Relief of lateral tension.

Stage I.—Incision and Detachment of Muco-periosteal Flaps.

The patient being thoroughly anæsthetised, and the mouth held open by the gag, the surgeon, standing on the right side of the patient, commences by making a lateral incision, preferably on that side of the cleft which is opposite to the gag; it facilitates matters to shift the gag to the opposite side of the mouth when the second incision is made. These incisions should commence a little internal and opposite to the last molar tooth ([Fig. 67 A]), and should be carried forward parallel to the alveolar margin to a point immediately behind the lateral incisor, terminating a little anterior to the apex of the cleft, if the alveolus be intact. The knife should be held so that the incision is always perpendicular to the varying planes of the mucous membrane, in order to prevent the edge from being bevelled, which may seriously impair its nutrition. All the structures should be cleanly divided down to the bone.

Fig. 67a.—Diagram to indicate the extent of the incisions in Langenbeck’s operation. The thick black lines show the primary incision; the thick dotted lines the extension backwards of the same to relieve any lateral tension (made after the insertion of the stitches); the thin dotted lines indicate approximately the position of the free posterior border of the bony palate.

Fig. 67b.—Shows the position of the sutures and the condition of the parts at the close of the operation.

Hæmorrhage, even to a considerable amount, naturally follows, and this should be checked by pressure with purified sponges; it will be much more serious should the palatine arteries be included in the line of incision. The distribution of the anterior and posterior palatine arteries is so variable, and their pulsation so rarely to be felt beforehand, that it is not always possible to avoid wounding one or other of them. Should this occur, it is important that the vessel be completely divided, as a buttonhole in it will cause severe and protracted hæmorrhage. During the bleeding the patient’s head should be turned on one side and lowered, so as to allow the blood to run freely out of the mouth and not into the throat.

Whilst the assistant is staunching the hæmorrhage, the operator can introduce the raspatories through the openings thus made, and working them from without inwards, separate the whole of the muco-periosteal tissue. To effect this, different shapes of instruments will be required in order to follow the curves of the palatal segments, and those devised by Mr. Durham will be found most useful ([Fig. 60]). In loosening the flaps anteriorly, the advantage of the double-curved raspatory ([Fig. 68]) will be obvious. As the point of the raspatory reaches the inner free margin of the palatal segment, the separation of the muco-periosteal flap should be completed by the protrusion of the instrument into the cleft at the junction of the buccal and nasal mucous membranes. This is more readily accomplished if the edges have been previously pared; but it is better to postpone this step until the flaps have been detached, as the raw edges are less liable to be bruised by the sponging, and with the flaps loosened the margin can be pared with greater accuracy. In cases where the vomer is attached to one free edge of the palate ([Fig. 11]) the junction of the nasal and buccal mucous membrane should be incised to prevent its being lacerated by the raspatory.

The attachment of the soft structures to the hamular process and back of the hard palate must be freely and fully divided. This is a most important and delicate part of the operation, and as the structures are here extremely thin, great care must be exercised. Should this separation be incomplete, the lateral incision cannot be carried down into the soft palate, and the flaps will not come into proper apposition. It may be attained by the use of a sharp cutting raspatory kept close to the bone, and as regards the hamular process, by a narrow probe-pointed bistoury, or a pair of curved scissors. The introduction of the left forefinger into the incision is of great assistance in effecting this with precision and thoroughness.