CHAPTER XICHEILOPLASTY(Surgery of the Lips)

Fig. 145.Burchardt Compression Forceps.

Fig. 145.

Burchardt Compression Forceps.

This branch of plastic surgery has to do with the correction of deformities of the lips. These deformities usually involve one lip only, and are dependent upon direct traumatism, operative interference in the extirpation of malignant growths, particularly carcinomata, the correction of cicatricial disfigurement following tubercular or syphilitic ulceration or congenital faults, commonly met with in harelip.

Operations for the latter condition have usually been considered under a separate heading, but since the restorative procedures involve methods purely plastic they are included under this their proper classification.

Owing to the great number of blood vessels in the lips, it is advisable to resort to the bloodless method, where the defect to be corrected involves more than the superficial structure. This is accomplished:

1. By compressing the coronary arteries at both angles of the mouth by digital pressure, suitable clamps orcompression forceps. The fenestrated oval forceps, illustrated inFig. 145, and designed by Burchardt, or the harelip clamp of Beinl,Fig. 146, will be found to meet the purpose well, the latter having a sliding lock by which the pressure upon the tissue can be regulated to a nicety.

Fig. 146.—Beinl Harelip Clamp.

2. By clamping off the site of operation with specially made cutisector forceps. Its smooth parallel jaws should be curved outward, so that the diseased area can be fully excluded by their concavities.

3. By employing the indirect ligature of Langenbuch. This is accomplished by including the site of operation with several strong silk threads firmly tied in loops upon the skin surface, each loop including a given amount of tissue, the next encroaching upon it up to the center of this area, and so on until the entire site is rendered anemic. The advantage of this method is that with the anemia a certain amount of anesthesia is produced at the same time; a fact to be remembered when the patient is to be operated under local anesthesia, the anemia enhancing the efficacy of the latter.

A congenital defect of the upper lip caused by the lack of proper union of the maxillary, globular, and frontonasal processesin embryo. Treves states that from the buccal aspect of the maxillary process of either side the palatal processes arise, passing inward to combine with each other to form the soft palate and all of the hard palate, except the intermaxillary portion, and that from this same source are formed the cheeks, the outer or lateral parts of the upper lip, and the superior maxillary bones, while the external nose, the ethmoid, the vomer, the median portion of the upper lip, and the intermaxillary or os incisivum are derived from the frontonasal process.

The fact that these centers of development are concerned in the formation of the parts involving harelip accounts for the position of the cleft in the lip as being unilateral or bilateral, and rarely if ever median or intermaxillary.

Six varieties of harelip deformity are recognized by Rose, but herein only five classes of these will be considered, one of which, the first, is so rare that its occurrence is practically denied.

For all purposes in surgery of the face, in which cosmetic effects are sought, the author considers the following classification to answer fully:

Fig. 147.—Median Cleft.(Engle’s case.)Fig. 148.—Median Cleft with Rhinophymia.(Trendelenburg’s case.)

Fig. 147.—Median Cleft.(Engle’s case.)

Fig. 148.—Median Cleft with Rhinophymia.(Trendelenburg’s case.)

1. Median or Intermaxillary Cleft.—As has been said, the first variety of this form of lip deformity is very rarely met with. It consists of a cleft in the median third of the upper lip, more rarely associated with the absence of the intermaxillary bone and total cleft of the hard and soft palate. In fact, the entire median section may be absent with or without absence of the intermaxillary andvomer bones (Engle) (seeFig. 147). Commonly, however, the cleft involves only a part of the filtrum of the lip, although Witzel speaks of a case in which the lip assumed the form of a dog’s nose, the cleft extending upward, completely dividing the nares from one another, or the entire nose may be divided in its median line.

When the cleft involves the hard parts—that is, the intermaxillary bone and the hard palate—it is said to be total.

2. Single and Double Cleft.—The second variety in the above classification is by far the most common, and is often, therefore, termed ordinary. In this there exists either a unilateral or bilateral cleft of the lip of varying degree, depending upon the involvement of the tissue affected. It is not unusual to find fissures in these cases extending through the alveolar arch and the hard and soft palate.

This fissure or cleft is always found on one side of the median line, while in the soft palate it is median.

Most unilateral clefts of the lip will be found to be in the left outer third. They are more common in the male child.

Fig. 149.Fig. 150.Fig. 151.Types of Unilateral Cleft.

Fig. 149.Fig. 150.Fig. 151.

Types of Unilateral Cleft.

The degrees of deformity of the soft parts in the unilateral variety are shown inFigs. 149 to 151, respectively, representing the first, second, and third degrees of the cleft deformity, according to the involvement of the lip tissue. In first degree are included small notches in the prolabium only or extending upward somewhat aboveits margin, but not involving the entire lip. In the second degree both the vermilion border and the lip are divided, while in the third degree the cleft extends into the nose with an absence of part of the lip structure itself.

Since the deformity in the division under discussion is so commonly met with it will be considered fully under its operative correction.

3. Facial Cleft.—The third class of deformity includes either unilateral or bilateral fissure of the face.

In theunilateralvariety the cleft usually begins at the outer section of the upper lip, involving, as a rule, only the soft parts, extending upward and irregularly around the alæ of the nose to the inner canthus of the eye, or going even beyond the orbit and over the forehead as far as the hair line. An illustration of such a case is shown inFig. 152.

Thebilateralform of this facial defect is rarely met with. A case reported by von Guersant is shown inFig. 153.

Fig. 152.—Unilateral Facial Cleft.(Hasselmann.)Fig. 153.—Bilateral Facial Cleft.(von Guersant.)

Fig. 152.—Unilateral Facial Cleft.(Hasselmann.)

Fig. 153.—Bilateral Facial Cleft.(von Guersant.)

4. Buccal Cleft.—In the fourth variety the deformity involves the cheeks, the fissures extending from the angles of the mouth outward, causing an enlargement of this natural opening, and hence this defect is better known asmacrostoma.

It may affect one or both cheeks. The latter is elucidated inFig. 154.

Fig. 154.—Buccal Fissure with Macrostoma.

On the other hand there may exist a congenital contraction of the mouth termedmicrostoma. This defect is rarely seen, and is due to a too free union of the maxillary and mandibular processes. When observed it is usually associated with improper development of the inferior maxillary bones.

5. Mandibular Cleft.—In the fifth class the cleft is to be found in the median line of the lower lip. This fissure, though extremely rare, may involve only the soft tissue or extend to the inferior maxillary (Thorndike) and even to the tongue (Wölfler).

From what has been said of the five varieties just mentioned it can be plainly seen that the defects of the second class are the most common. Since the correction of such involves methods of an extensive technique that can be followed more or less in the restoration of any of the above, this particular subdivision will be considered fully, but only to the extent of defects of the soft parts, leaving the osteoplastic and periosteoplastic operations to be studied elsewhere.

The defects that have to do with facial and buccal clefts will be more specifically mentioned later on under Melo- and Stomatoplasty.

The correction of a harelip should be undertaken as early as the first two weeks after birth in the healthy child. If, however, the infant is considered too delicate to undergo so early an ordeal, the operation should be deferred until the third or even the fifth month. At anyrate the operation should be undertaken as early as deemed advisable, since the closure of the cleft has a desirable effect upon the ofttime overprominent intermaxillary bone, helps to approximate its lateral borders, overcomes the later depression deformity of the upper lip, aids its natural development, and permits of the child suckling the breast—an important factor in the proper nourishment, since the defect allows only of feeding with the spoon, the child being unable to grasp the nipple of the breast in this state. Furthermore, the act of phonation is practically entirely perfected by an early operation, and rarely if ever overcome when faulty phonation has been established.

The restoration of an unilateral cleft is to be performed without the use of an anesthetic. The child’s arms are fastened to its sides with several turns of a wide roller bandage. It is then seated upon the lap of the assistant, who holds its head in position, compressing the coronary arteries with his fingers at the outer sections of the upper lip at the same time. If this is impractical, proper forceps can be employed, as already mentioned. It is rarely necessary to employ the direct-ligature method heretofore referred to in this class of operations. More or less bleeding always accompanies the operation, the child usually swallowing what enters the mouth if not sponged up repeatedly.

To facilitate matters the child can be anesthetized, chloroform being used. In this case the patient is to be placed on its side, the head being fixed in a dependent position (Rose).

This gives freer drainage of the bleeding surfaces, the blood being sponged up with gauze sponges as required, while the vessels that are cut can be tied off with catgut ligatures as fast as they are divided.

The anesthetic can be given upon a small sponge heldbefore the nostrils. Infants should not be anesthetized, yet in older children it is almost always necessary.

A simple freshening of the edges of the defect with the bistoury, followed by suture, does not give a desired cosmetic effect, hence it is advisable to resort to methods intended to restore the lip as far as possible to its normal state.

Nélaton Method.—The simplest operation for a cleft of moderate extent not involving the nare is that of Nélaton. He divides the lip above the angle parallel with the defect with a bistoury, cutting upward, including the upper angle which allows the prolabium surmounted by a thin strip of skin to droop downward in a point.

The lower angle of the wound is then drawn downward and united lengthwise with silkworm gut sutures, giving to the prolabium a protrusion or tip, which eventually retracts and causing the lip to assume a natural aspect.

The method is shown inFigs. 155-157.

Fig. 155.Fig. 156.Fig. 157.Nélaton Method.

Fig. 155.Fig. 156.Fig. 157.

Nélaton Method.

Fillebrown Method.—Fillebrown has devised a method where the vermilion border of the lip is entirely preserved, as in the preceding operation. His method can only be employed where the cleft is not extensive. He commences his incision at the red border at the outer left line, cutting upward and inward toward the median line a short distance (seeFig. 158), then downward to the red border of the lip, then upward and outward to the right of the median line, corresponding to the incision just made to the left of the median line. The upperangle of the cleft is now drawn down by its red border and the wound sutured, as shown inFig. 159. This operation does not project a small triangle of the white skin into the vermilion border and gives excellent results.

Fig. 158.Fig. 159.Fillebrown Method.

Fig. 158.Fig. 159.

Fillebrown Method.

Von Langenbeck, Wolff, and Sedillot Methods.—The methods of von Langenbeck, Wolff, and Sedillot are somewhat similar to that of Nélaton. An incision is made slightly above the prolabium, following the angle of distortion and reaching outward to either side of the median line almost to the angle of the mouth. The raw edges corresponding to the defect are brought together by suture and a section of the prolabium is removed to overcome its overprominence, but not enough to entirely flatten the vermilion border (seeFigs. 160-161). The latter is sutured horizontally to such part of the angular defect as has not been utilized in the median line, and alsovertically as far down as its free border, as shown inFig. 162.

Fig. 160.Fig. 161.Fig. 162.Von Langenbeck-Wolff-Sedillot Method.

Fig. 160.Fig. 161.Fig. 162.

Von Langenbeck-Wolff-Sedillot Method.

Malgaigne Method.—The method of Malgaigne differs in technique in that he utilizes a semicircular incision, which is made to include the upper angle of the defect. Both ends of this incision are continued horizontally outward to a required extent (seeFig. 163). The freed prolabial flaps are drawn downward, as inFig. 164, and sutured vertically, as shown inFig. 165. Two retention sutures are shown in the latter figure to overcome the tension of the lipspost operatio.

The semicircular incision should be preferred when the defect will permit it, since the unequal lengths of the two lip halves may thereby be more uniformly approximated, while the prolabium in being crowded downward overcomes the notchlike scar so common with the vertical-incision method.

Fig. 163.Fig. 164.Fig. 165.Malgaigne Method.

Fig. 163.Fig. 164.Fig. 165.

Malgaigne Method.

Gräfe Method.—This method, as shown inFig. 166, is, therefore, to be preferred when the defect is one of the first or second degree.

The first suture is to be placed at the margin of the vermilion border and the skin, so that the unequal sides are placed in normal apposition. The parts are sutured according to the method shown inFig. 167.

Fig. 166.Fig. 167.Gräfe Method.

Fig. 166.Fig. 167.

Gräfe Method.

Mirault-Bruns Method.—An excellent method of this class is that of Mirault-Bruns. Their operation is indicated in defects of extensive degree, and usually gives excellent results. As in the former method a semicircular incision is made to include the superior angle, and two other incisions are made somewhat as shown inFig. 168. The wound made thereby is shown inFig. 169. The inferior triangular flap of one side is utilized to restore the prolabium, the whole being sutured, as shown inFig. 170, care being taken to make this flap of sufficient size to give stability and volume to the lower margin of the lip.

Fig. 168.Fig. 169.Fig. 170.Mirault Method.

Fig. 168.Fig. 169.Fig. 170.

Mirault Method.

Giralde Method.—This method is intended for defects of the third degree. A vertical incision frees the vermilion border on one side, while an angular cut on the opposite side (seeFig. 171) allows of the bringing together the lip flaps above it. The wound is made to appear somewhat as inFig. 172, and is sutured, as depicted inFig. 173.

Fig. 171.Fig. 172.Fig. 173.Giralde Method.

Fig. 171.Fig. 172.Fig. 173.

Giralde Method.

König Method.—König advocates two vertical incisions which dispose of the cicatrized borders of the defect. A slanting incision is added at both sides to free the prolabium (seeFig. 174), giving a wound when drawn in position, as shown inFig. 175. In suturing the wound the vermilion border flaps are turned downward as much as possible to restore the contour of the prolabium. The sutures are placed as shown inFig. 176.

Fig. 174.Fig. 175.Fig. 176.König Method.

Fig. 174.Fig. 175.Fig. 176.

König Method.

Maas Method.—Maas has deviated from the above method somewhat, as is shown inFig. 177, by making one of the prolabial flaps much larger than the other. His operation is applicable to defects of maximum extent. The lip wounds are thereby made to appear as inFig. 178, and the sutures are applied as inFig. 179, with an advantage of leaving a smaller sutured wound to heal by primary union.

Fig. 177.Fig. 178.Fig. 179.Maas Method.

Fig. 177.Fig. 178.Fig. 179.

Maas Method.

Haagedorn Method.—Haagedorn’s method does not differ much from the above. The incisions are shown inFig. 180, the appearance of the freed margins inFig. 181, andthe sutured wound inFig. 182. The prolabial flaps are somewhat alike in size in this operation, in which it differs only in the method just considered.

Fig. 180.Fig. 181.Fig. 182.Haagedorn Method.

Fig. 180.Fig. 181.Fig. 182.

Haagedorn Method.

Geuzmer Method.—Geuzmer so incised the cicatrized defect that a small prolabial flap is formed from the median border and a larger one from the lateral, the very opposite of the Haagedorn technique.

Dieffenbach Method.—To facilitate the mobility of the lip flaps, Dieffenbach has added two additional incisions on either side of the nose, in circular fashion, encircling the alæ of the nose, as shown inFig. 183. This procedure is hardly ever necessary in harelip, and truly applies to the restoration of a considerable loss of tissue of the upper lip occasioned by the extirpation of cancerous growths, although clefts of the median variety might be corrected thereby.

The wound thus formed appears as inFig. 184. The sutures are placed as inFig. 185.

Fig. 183.Fig. 184.Fig. 185.Dieffenbach Method.

Fig. 183.Fig. 184.Fig. 185.

Dieffenbach Method.

Instead of the semicircular incisions a horizontal incision on either side of the cleft may be made just belowthe nose with the same object in view, the wound being sutured in angular form similar to the method of Nélaton.

The occurrence of bilateral cleft of the lip is much rarer than the variety just described. According to Fahrenbach, out of 210 cases he found only 59 of some degree of the bilateral form.

The degrees of deformity have already been mentioned.

The correction of these types of fissure is very similar to that of the single cleft variety except that the operations for the latter are simply duplicated on the opposite side.

Particularly is this true in cases of the first degree, while in the severer forms, modifications of such methods as have been described must be resorted to, according to the nature and extent of the defect.

It must always be the object of the surgeon to save as much of the presenting tissues as is possible, to avoid traction on the tissues and to overcome the consequent thinning out of the entire upper lip or the flattening so often seen in the lips of these patients.

The correction of this flattening of the lip following operations for the restoration of the lip will be considered later.

The following operations for the correction of bilateral cleft may be regarded as fundamental:

Von Esmarch Method.—Von Esmarch advocates an incision circling the central peninsula just sufficient to remove the bordering cicatrix. Both lateral borders are vivified along the limit of the vermilion borders (seeFig. 186). He advises suturing the mucous-membrane flaps which he retroverts to form a basement membrane, upon this he slides the skin flaps, and sutures them as shown inFig. 187.

The best results are obtained when the lip is sufficiently detached from the jaw by deep incisions beginning at the duplicature of the mucous membrane. This insures the necessary mobility, and is considered by him the most important step in the operation.

Fig. 186.Fig. 187.Von Esmarch Method.

Fig. 186.Fig. 187.

Von Esmarch Method.

Maas and von Langenbeck Methods.—Maas and von Langenbeck vivify the median peninsula in square fashion, as shown inFig. 188, and suture the fresh margins of the flaps, as shown inFig. 189, according toFig. 190.

Fig. 188.Fig. 189.Fig. 190.Maas Method.

Fig. 188.Fig. 189.Fig. 190.

Maas Method.

Haagedorn Method.—Haagedorn’s method is very similar to the above except that in cutting square the inferior border of the median portion he fashions it into a triangular form, with the object of giving to the prolabium the tiplike prominence found in the normal lip, and also avoiding the cicatricial notch obtained with the direct suturing of the vermilion border on a line with its inferior limitation. The various steps of his method are shown inFigs. 191, 192, 193.

If there be considerable absence of lip tissue he advises making two lateral incisions sufficient to overcome the tension on the parts. These secondary wounds are allowed to heal by granulation.

Fig. 191.Fig. 192.Fig. 193.Haagedorn Method.

Fig. 191.Fig. 192.Fig. 193.

Haagedorn Method.

Simon Method.—Simon utilizes two curved lateral incisions encircling the alæ of the nose. This permits of a ready juxtaposition of the lateral flaps (seeFig. 194). The two flaps are sewn to the median flap (seeFig. 195) and are allowed to heal into place, the secondary wounds healing by granulation.

When this has been accomplished, a later operation is undertaken to correct the prolabial border, the incision for which and the disposition of the suture are shown inFig. 196.

Fig. 194.Fig. 195.Fig. 196.Simon Method.

Fig. 194.Fig. 195.Fig. 196.

Simon Method.

This operation is useful only in older children, and has the disadvantage of requiring a secondary interference. The results are not as good as those obtained with the operations mentioned previously, leaving, besides, a disfiguring cicatrix at either border of the alæ, a serious objection, especially to the cosmetic surgeon.

When the operation has been performed in the infant the wound is simply kept clean by the local use of warm boric-acid solutions and the mouth is cleansed from time to time by wiping it out with a piece of gauze dipped into the solution.

Children do not bear dressings of any kind well, although Heath employs strips of adhesive plaster to draw the cheeks together to relieve tension on the sutures.

To keep the child from tearing or picking at the wound Littlewood advises fixing both elbows in the extended position with a few turns of a plaster-of-Paris bandage.

Everything should be done to keep the child quiet, as crying often results in separating the wounds. This is accomplished by giving it milk immediately after the operation. The mother must ply herself closely in soothing the child by carrying it about, rocking, and feeding it.

The feeding should be done with the spoon. Dark-colored stools containing swallowed blood will be passed in the first twenty-four hours; to facilitate this a mild laxative, such as sirup of rhei, can be given.

In older children a compressor can be applied to the head. That of Hainsley, shown inFig. 197, answers very well, yet adhesive plaster dressings, if carefully removed later, are most commonly used.

Fig. 197.—Hainsley Cheek Compressor.

The sutures may be removed as early as the sixth day,but it is best to release the wound sutures about this time, and leave the tension sutures for two or three days later.

It often happens that the entire wound has not healed by primary union, if this occurs and sufficient union has taken place in part of the lip, the wound should be allowed to heal by granulation.

Should the entire wound separate on the removal of the sutures, the operator may attempt to secure healing of the wound by applying a secondary suture to bring the granulating surfaces together, although little is gained by this procedure as a rule.

If reoperation becomes necessary, it should not be undertaken before six weeks or more have elapsed. At any rate not before the lip tissues have returned to their normal state. Inflamed tissues do not retain sutures well.

It usually becomes necessary to perform small cosmetic operations after the healing of harelip wounds. Those should not be undertaken until the child is of such age as to insure a perfect result.

Plastic operations for the reconstruction of the upper lip are not met with often in surgery, except in connection with the various forms of harelip. When the latter is not the cause, deficiencies of the upper lip are due to the ulcerative forms of syphilis, and are occasioned by the ablation of epithelioma and carcinoma or the result of burns or lupus. Rarely the surgeon will meet with such a defect caused by dog bite or other traumatisms due to direct violence, as in railroad or automobile accidents.

Berger has classified three degrees of this deformity, according to its severity, to wit:

1. The skin only is destroyed and the mucosa remains.

2. The mucosa has been partially destroyed with the skin, but a part of the free border of the lip remains and is attached to the cicatrix.

3. All the parts which make up the lip have been destroyed, and there remains neither skin, mucosa, muscles, nor the prolabium.

The loss of substance of varying degree may involve either of the outer thirds or the median position of the lip, or its entire structure. For a more explicit classification the author divided these defects into:

(a) Unilateral defect of the first, second, or third degree.

(b) Bilateral defect of the first, second, or third degree.

(d) Total loss of upper lip.

This same classification applies to the defects of the lower lip.

When the deformity is either of the first or second degree, one or the other of the operations for the restoration of congenital cleft just considered may be employed. When these are impracticable other methods must be resorted to.

Bruns Method.—Bruns advocates making two lateral flaps from the cheeks, as shown inFig. 198. He preserves the inferior margin of these flaps, which contain a cicatricial border which must take the place of the prolabium. This border can, however, be made up of the vermilion border of the lower lip, as shown later in the performance of stomatoplasty, to establish a better cosmetic effect.

The rectangular cheek flaps are sutured, as inFig. 199, leaving two small triangular wounds at either side of the alæ to heal by granulation.

The cheek flaps referred to must be dissected up from the bone, and be rendered as mobile as possible for a successful issue.

Fig. 198.Fig. 199.Bruns Method.

Fig. 198.Fig. 199.

Bruns Method.

Dieffenbach Method.—The method of Dieffenbach is very similar to the above. It has been described on page 157. In this the lateral flaps are made by two curved incisions encircling the alæ of the nose. Should these be insufficient, two other curved incisions are added, as shown by the dotted lines inFig. 183.

Sedillot Method.—Sedillot also employs two rectangular flaps, but he cuts them from the region of the chin (seeFig. 200).

The advantage of this method lies in the fact that these flaps are lined throughout with mucous membrane, as the incisions are made entirely through the tissues involved, beginning at the angle of the mouth and extendingdownward to the limitation of the buccal fold interiorly.

The flaps are twisted into position and sutured, as shown inFig. 201. The mucous membrane of the inferior border is dissected up to a required extent and turned outward and stitched to the skin margin without to provide the prolabium. This is an important matter not only for cosmetic reasons, but especially because such mucous-membrane lining overcomes to a great degree the objectionable cicatricial contraction of this free border.

In certain cases the mucous-membrane grafts of Wölfler may be employed to cover the raw edge of these newly made lips, or the Thiersch method of skin-grafting might be employed with the same object.

Where the defect is unilateral, as is usually the case, a single cheek or chin flap need only be employed, and this lined with mucous membrane.

Fig. 200.Fig. 201.Sedillot Method.

Fig. 200.Fig. 201.

Sedillot Method.

Buck Method.—Buck, in such unilateral defects, employs an interolateral rectangular flap. It contains a part of the lower lip and its vermilion border. This flap is twisted upward, so that its outer and free end comes in apposition at or near the median line as may be, with the remaining half of the upper lip.

This half of the lip is freely liberated by dividing the buccal mucous membrane along the reflecting fold. Should the vermilion border be contracted upward along the median cicatricial line it is carefully cut away from the lip proper down to its normal margin. This strip is retained until the flap taken from the under lip is brought into position, when it is neatly sutured to the prolabium thus brought into apposition. If there be aredundancy of the freed prolabium after the median sutures have been applied it is cut away.

The secondary defect in the cheek caused by the rotation of the flap is closed by suturing the raw surfaces together.

The resulting mouth will be much smaller than normal, having a puckered appearance. A secondary operation, mentioned later, is employed to correct this.

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