On harelip and cleft palate

by William Rose

Another method that I have recently employed with partial success consisted in reflecting a flap of mucous membrane from the back of the upper lip, and turning it down into the gap, fixing it laterally to the refreshed margins by fine wire sutures. Even if complete union does not take place, the portion thus reflected forms a point d’appui for later plastic interference.

It has also occurred to me to try the effect of cutting through the alveolar process immediately external to the canine tooth; that is, instead of detaching the palatal flap anteriorly to continue the lateral incision forward through the bony alveolus and after partially detaching this to prise it towards the median line. This proceeding is practically a modification of Fergusson’s osteoplasty, but differs from it inasmuch as there is little fear of necrosis on account of the spongy and vascular state of the alveolus. In the performance of it, after the palatal flaps have been detached by the raspatory, I incise the gum vertically along the line indicated, that is, continuing the lateral incision forward external to the canine tooth; a notch is then made with a small saw, and a chisel inserted cuts through and sufficiently detaches the portion of the alveolar process contiguous to the palate. The edges are now carefully freshened, and, if necessary, on the bevel, so as to allow for the slight rotation which occurs in drawing them together. Sutures are passed through the soft tissues deep enough to gain a firm hold of the flaps, so that when twisted they do not cut their way out in spite of the traction which is exercised. Care must be taken to pass the stitches in such a manner as to prevent undue rotation of the detached portions, otherwise the raw edges will not come into proper contact. Having at present given this plan but a limited trial, I do not wish to speak too confidently in its favour. Should such operative proceedings fail, an obturator should be fitted to the aperture.

Many other methods have been from time to time suggested as accessories to the ordinary operations of uranoplasty and staphyloraphy, and some of these need a cursory notice. Passavant stitched the halves of the velum to the posterior pharyngeal wall by an operation, known as “staphylo-pharyngoraphy.” Schönbein and Trendelenburg suggested “staphyloplasty” as an improvement, i. e. taking a flap of mucous membrane from the posterior pharyngeal wall and stitching this to the hinder wall of the velum. Both these operations aimed at totally shutting off the nose from the mouth; but in practice this was found to be not only uncomfortable, but also injurious. Smell and hearing were both interfered with, and breathing could only be carried on through the mouth; actual inflammatory troubles followed, which necessitated the communication being reopened.

Von Mosetig Moorhof attempted to improve upon these operations by allowing a fistula to remain at the position of the anterior palatine canal, which could be filled with an obturator by day to prevent the objectional nasal twang, and at night could be left open for breathing purposes.

Still more heroic are the operations which have been undertaken for the closure of palatal clefts by tissue taken from the face. Only three such cases, are, I believe, on record and of these two were for acquired deformities, and but one was for a congenital deficiency.

Blasius operated in a case where both the nose and the palate had been destroyed, by dissecting up a flap from the forehead attached to a long pedicle. This he easily twisted down into the mouth owing to the absence of the nose, and stitched into the gap. Success, however, did not follow from the drying effect of the double current of air. The same method was tried on the cadaver by Nussbaum, who demonstrated the possibility of drawing the flap through a slit in the nostril into the mouth and fixing it there; but he never had the opportunity of operating upon the living subject.

Professor Thiersch in 1868 successfully closed a hole in the hard palate, the result of a gunshot injury. He chiselled away the alveolar process, and turned in through this a flap consisting of the whole thickness of the cheek, its base being close to the nose.

Rotter records a third instance.[96] It was in a case of very wide right-sided harelip with cleft palate, in which Langenbeck’s operation had been successfully performed in so far as union in the middle line was concerned but the left palatine process was so nearly vertical that a lateral cleft half an inch in breadth resulted. This was repaired by a modification of Blasius’ operation. A long cutaneo-periosteal flap was taken from the forehead; the raw under-surface was grafted and allowed to heal entirely before being placed in situ. To accomplish this it was merely necessary to draw it through the still unclosed harelip to pare the edges of the flap and of the cleft, and to fix with sutures the former within the latter. When united firmly, the pedicle was divided, and the harelip closed. A good result followed, and was maintained two years later.

Such procedures can only be necessary in exceptional cases. Permanent scarring of the face is always to be regretted, and Langenbeck’s method or some slight modification of it, carefully and skillfully carried out, should meet nearly all contingencies. There is an instance recorded by Wolff[97] where the whole of the right-sided flap in a case of uranoplasty became gangrenous, leaving a wide opening which, however, was successfully closed subsequently by a repetition of the same process.