wound which can be brought together by stitches should be undermined and sutured, so as to diminish the area requiring grafting. The wound is not touched for four or five days, when the stitches may be taken out. The plug of gauze should be changed once or twice a day. The pins may be left in situ for three or four weeks. At the end of about four weeks, the pedicle of the flap should be divided at the root of the nose and the parts there pared and sutured: the rest of the pedicle is then turned upwards and replaced in the wound on the forehead. Subsequently some small plastic operations may be required to improve the shape of the nose thus formed or to cut away redundant tissue. If the columella has not been fashioned with the forehead flap, it can be formed afterwards from the upper lip. A narrow strip of the middle line of the upper lip is isolated by vertical incisions beginning just below the aperture of the nares on each side and carried downwards through the entire thickness of the lip to the free margins. This small portion is turned upwards, the frenum being divided, and its free end is refreshed and stitched to the tip of the nose. The new columella will have its cutaneous surface looking backwards while the mucous surface is external. Nasal plugs are introduced on each side in order to keep the parts in position, and the divided upper lip is sutured in the middle line after short lateral cuts have been made on each side beneath the nose, so as to allow the upper part of the lip to slide in below the new columella (see Fig. 238). The Tagliacotian method.-This plan, although successful in some cases, is unsatisfactory on the whole, and entails great inconvenience and the use of special apparatus. In it the arm is fixed to the forehead so that the elbow comes opposite the nose, and a large flap is then fashioned from the skin over the biceps and made to cover the defect in the nose. The arm must be kept in this position for about four weeks before the pedicle of the flap can be divided. The position, however, is so irksome that few patients will submit to it, while the new nose is even more apt to shrink than the one formed by a flap from the forehead; the only advantage of the method is the avoidance of extra scarring about the face or forehead. Fig. 239 will illustrate sufficiently the position of the arm and the mode of attachment of the flap. CHAPTER XLII. HARE-LIP AND CLEFT PALATE. IT is best to consider these two deformities together, as they are commonly associated, and the treatment of the one condition is often preliminary to that of the other. HARE-LIP. Hare-lip is a gap or cleft in the upper lip of congenital origin, resulting from failure in the union of its component parts. It is usually unilateral, and generally on the left side, although it may be on the right. It is not uncommonly bilateral (double hare-lip), and it may or may not be accompanied by cleft palate. The defect in the lip varies in extent from a mere notch in the red line to a wide cleft extending upwards into the nostril. In the latter case there is generally also a cleft of the alveolar margin and of the palate, and in addition the nostril on the affected side is unduly widened. When the cleft only affects the red line, the rest of the lip may be normal, but even then the nostril on that side is often broader than on the other. When the gap is wide and there is an extensive cleft in the palate, the edge of the cleft in the lip on one or both sides is bound down to the alveolus by a broad fold of mucous membrane. When the cleft is bilateral, the intervening portion of the lip, which is called the prolabium, lies over the pre-maxillary bone; this is of variable size, and there is a gap between it and the superior maxilla on both sides. The central portion of the lip may be quite small, and the columella rudimentary, so that the tip of the nose is bound down to this central portion and the nose itself is flattened. The pre-maxillary bone is usually tilted forwards and attached to the septum nasi; in bad cases, in which the prolabium is quite small, it may be only connected with the columna nasi. TREATMENT.-The first question which arises in the treatment of hare-lip, whether alone or in conjunction with cleft palate, is the age at which the operation should be performed. It may be said that the sooner the operation for hare-lip is performed the better is the result both from the point of view of appearance and also of the development of the parts and the general nutrition of the child. Two points, however, must be taken into consideration in determining this question, namely, the strength of the child and its ability to stand the necessary loss of blood, and the presence of any septic condition about the mouth and nose, such as coryza, snuffles, or aphthous stomatitis. If the child is feeble, the loss of blood at the operation may be sufficient to cause a fatal result, and, apart from that, there is considerable liability to septic infection. As regards the second point, any septic condition of the mouth or nose is particularly prone to lead to septic inflammation of the wound, and thus endanger union. In the absence of these unfavourable conditions. primary union almost invariably occurs, and therefore the age at which uncomplicated hare-lip may be operated upon depends, to a large extent, on the size of the gap. In simple cases the operation may be done a few weeks or even a few days after birth. If, on the other hand, the cleft is wide, extends up into the nostril, and entails a long operation and a free separation of the soft parts from the bone with considerable loss of blood, it may be advisable to delay the operation for some weeks, unless the child is losing ground from inability to take food properly. In severe. forms, in which the cleft is wide and the whole depth of the lip and the palate are involved, there is considerable difficulty in feeding the child. In such cases, therefore, the sooner the operation is done the better, provided that the child is not emaciated. If it is, careful spoon-feeding must be persisted in until the general health is so much improved that the operation can be performed with a reasonable chance of success. The milk must be placed in the mouth in small quantities slowly and. intermittently, and sufficient time allowed for the child to swallow one spoonful before the next is given. In these cases-and especially when there is a double hare-lip, which is always accompanied by cleft palateit is of the greatest importance to unite the lip as soon as possible in order to remedy the severe deformity and thereby render the proper feeding of the child possible. When cleft palate complicates hare-lip, the question has to be considered whether the operations for uniting the hare-lip and the cleft palate should be done at the same time or separately. It is a generally accepted rule, and one with which we agree, that the hare-lip, at any rate, should be closed as soon as possible, whether the operation on the palate be deferred to a later period or not. This is advisable, because the development of the parts improves directly the lip is united, the cleft in the palateand especially in the alveolus-tends to diminish, and the nutrition of the child becomes better. It is advised by some that the operation on the palate should precede that on the lip and that the former should be done at quite an early age, from a few days upwards. The principal reason for the first of these recommendations is that the gap in the lip gives the surgeon freer access, and this is no doubt a point of considerable importance when the small size of the parts is borne in mind. This question is discussed in connection. with the subject of cleft palate. The chief essential in operating on hare-lip is to repair the cleft so that no notch is left after operation, and so that the red line of the lip is united accurately. In performing the operation two of the points already referred to must be especially borne in mind, namely, that the edges of the cleft are bound down to the gum, and that the nostril on the affected side is broader than on the other. We shall consider the following cases separately: Those in which the cleft does not extend into the nostril; those in which the cleft does extend into the nostril; those in which this extension into the nostril is FIG. 240.-OPERATION FOR SIMPLE HARE-LIP WITHOUT WIDENING OF THE NOSTRIL. When the cleft is pared, as shown in A, and the edges are brought together, the slight downward projection seen in B occurs at the free margin of the lip, associated with cleft of the alveolus and, perhaps, of the palate as well ; and double hare-lip. 1. Of an Incomplete Cleft in the lip.-The closure of the gap in these cases is usually a comparatively simple matter. The attachment of the lip to the alveolus must be freed, if present, and the gap pared so as to leave a concave surface on each side. If the nostril is not wider than normal and the structures above the apex of the cleft are of natural thickness, the knife is entered just above the apex of the cleft and the curved incision shown in Fig. 240, A, is made through the whole thickness of the lip on each side. When the two cut surfaces are brought together in the middle line, there will be a projection downwards of the red line (see Fig. 240, B), which is afterwards obliterated by the contraction of the vertical scar. The stitches are inserted so as to bring the red line on the two sides into accurate apposition. The sutures in the mucous membrane should be of fine catgut, but at the red line and at the centre of the vertical wound it is better to use silkworm-gut going through nearly the whole thickness of the lip. One or two intermediate stitches of fine horse-hair will be needed to complete the union. In many cases the nostril may be unduly broad, although the cleft does not extend into it, and it will be necessary to remedy this also. Under these circumstances, the concave incision should be carried vertically upwards from the apex of the cleft into the nostril on each side and the ala freely detached from the bone. The narrow vertical strip of the whole thickness of the lip included between the two vertical incisions FIG. 241.-OPERATION FOR SIMPLE HARE-LIP WITH WIDENING OF THE NOSTKIL. The removal of the portion between the incisions shown in A allows the width of the nostril to be reduced. is then removed, so that the nostril is restored to its proper shape when the resulting wound is sutured (see Fig. 241). It is very important to insert one stitch within the nostril at the upper end of the incision. 2. Of a Complete Cleft of the lip. Many operations are employed for complete clefts of the lip; we shall only describe those that we usually employ. A B C FIG. 242.-MIRAULT'S OPERATION FOR HARE-LIP. The steps of the operation are described in the text. Undue widening of the nostril is corrected by carrying the incision well up into it, as shown in the figure. When there is a complete cleft of the lip without deformity of the alveolus, the first step in the operation is to detach the margins of the cleft from the gum on both sides; this must be continued upwards until the upper border of the lip on the affected side is separated from the bony nostril. The ala of the nose on the same side is then widely detached and the cheek sufficiently freed to allow the margins of the cleft to be approximated without any tension. The edges of the cleft are then pared in the following manner: A narrow, sharp-bladed knife |