Many of these defects may be remedied by subsequent treatment. I am frequently in the habit of advising and practising secondary operations for the improvement of the facial expression in young children and adults presenting the unsatisfactory cicatrices detailed above. The operation comprises not only the removal of scar tissue, but also the obliteration of the 𝖵-shaped notch, elevation of the depressed nose, and the diminution in size, if necessary, of the nasal aperture. For a simple 𝖵-notch without other complications, I have sometimes made use of Nélaton’s operation ([Fig. 48]) with most satisfactory results.
The narrowing or partial obliteration of the nostrils in double harelip from the large size of the columna has sometimes to be remedied subsequently. One plan which I have practised several times for reducing the breadth of the columna is by excising a central lenticular-shaped portion, extending nearly the whole length through its entire thickness, and closing the gap with sutures. But a simpler method consists in paring the edges of the columna on either side to the required dimensions, and allowing the raw surfaces thus formed to cicatrise. The redundant tissue should be removed on the inner or nasal aspect, so that when cicatrisation takes place the skin is drawn round into the nares, and the resulting scar is unobtrusive.
The falling in of the upper lip after the operation for double harelip, when the os incisivum has been removed, can best be remedied by the adjustment of a plate carrying the required artificial incisors, and furnished with a central cheek-plate to restore the natural profile. Where the lower lip projects unduly in spite of the above-mentioned artificial adjustment, it may be requisite to reduce its size by the removal of a 𝖵-shaped portion from its centre. This is so easily accomplished as to need no detailed description; suffice it to say that the greatest care is needed in the accurate application of the sutures.
I cannot conclude this portion of my subject without mentioning the manual and mechanical aids which may be beneficially employed for the improvement of the mobility and appearance of the face and nose after such operations. The under-cutting of the integuments of the lip and cheek, and the subsequent cicatrisation involved, necessarily lead to a certain amount of rigidity of the parts. This can be remedied in a great measure by persistent gentle manipulation of the lip and cheek, care being taken always to press the parts towards the median line. This should be carried out by the mother or nurse daily after due instruction. A slight depression or collapse of the nostril on one side can be improved by the use of an apparatus supplied by Messrs. Hawksley, consisting of a head-band across the forehead, to which are attached vertical stems ending in smooth bulbs, which, by rack and pinion movement, can be so adjusted as to press the nostril into the desired position. The apparatus can be worn at night and for a certain time during the day.
The conditions which are essential to a complete success after plastic operations for cleft palate are as follows: complete closure of the cleft with no fistulous communication in any part of the line of union, and a velum capable, when necessary, of being approximated to the posterior pharyngeal wall so as to shut off the nasal cavity during speech and deglutition. That this is not invariably attained is an undoubted fact, and in spite of the merest shaving being removed when paring the edges of the cleft, the velum when united is frequently so scanty as to be unable to fulfil this condition. To remedy this, it was proposed some years ago by the late Mr. Mason to loosen the soft palate by lateral incisions, passing downwards and backwards through the free border, thus relaxing the tension, and allowing it to be drawn upwards, when requisite, into relation with the pharyngeal wall. I have adopted this plan in several cases, but with only transient success, inasmuch as the subsequent cicatrisation of the incisions neutralises the temporary benefit derived. The division of the pillars of the fauces, however, is occasionally needful and more satisfactory. This has been already alluded to ([p. 127]), and may either be performed at the time of the first operation, or subsequently if found to be necessary.
Even in cases where the tissue is abundant, and the united velum loose and moveable, the immediate effect on the speech is not always satisfactory. The other advantages of the operation (e. g. exclusion of nasal mucus from the mouth, prevention of regurgitation of fluids through the nose, improvement in taste and smell, and the psychical effects) are immediately apparent; but speech is a more complicated proceeding, and the first result of the operation is often to dislocate the mechanism which the patient had formerly made use of in its production, and hence, as has been often noticed, speech and voice may be temporarily deteriorated, even after a successful operation. This is a disappointment both to the patient and friends unless they have been previously warned. A subsequent thorough educational course at the hands of a professional voice-trainer, if possible, is therefore most important.
In some instances tension of the velum is no doubt the cause of the persistent nasal twang, but in many others habit is the principal factor, and this can alone be got rid of by a suitable education. The reluctance to breathe through the mouth, and the unwillingness to open it sufficiently during articulation, are conditions very liable to persist after operation. Such patients also speak too rapidly and run the words into one another, the velum evidently not being under control. The most difficult letters to pronounce are t, b, d, k, g, s, z, and l. The best means of dealing with the defective breathing is to make the patient undergo a course of “respiratory gymnastics.” Thus he should be made to practise deep abdominal breathing with the mouth wide open; he should stand in front of a looking-glass, and breathe with his mouth open and his tongue voluntarily depressed. He should next repeatedly exercise the movements of his tongue and lower jaw; this is often productive of great improvement in the facial expression. These exercises should be followed up by others directed to the improvement of speech. The distinct production of the various vowels and consonants and of all the sound combinations must be a matter of daily practice. He should be made to speak and read aloud according to the recognised laws of elocution, and by so doing obtain proper modulation of the voice and fluency of speech. Compression of the nasal apertures during these exercises is also advantageous.
The physical condition of the hard palate after the operation of uranoplasty is a subject of considerable interest. Langenbeck[101] claimed that a new formation of bone really occurred about three or four weeks after the operation, and attained in time considerable solidity. From experiments, however, by M. Marmy on the palates of dogs, doubt was thrown on the correctness of this assertion; and M. Ollier, so well known as an authority on subperiosteal work, declares that “if there may be doubt as to the ossification, all must admit that it forms a very resisting surface, which has the strength and takes the place of bone.” Opportunities for post-mortem investigation do not seem to have been taken advantage of for deciding this question; but clinical experience seems to indicate that no new bone is actually formed, the central portion of the palate consisting merely of dense fibro-cicatricial tissue covered with mucous membrane. In operating after a lapse of several years for the closure of oval apertures in the hard palate in patients in whom a previous operation had been but partially successful, I have never found osseous tissue, either when paring the margins or when detaching the flaps through lateral incisions.