Primary closure of harelip

ABSTRACTS

OF CURREST

1009

LITERATURE

epithelial or lymphoepithelial origin are of a higher degree of malignancy than most cancers of the mouth, and, therefore, besides direct extension to neighboring tissues such as the tonsillar pillars, floor of the mouth, base of the tongue, pharyngeal wall, and extrinsic larynx, they almost invariably show neck metastases. Most advanced intraoral cancers thus involve, besides the site of origin, the adjacent structures or the lymph nodes of the neck, or both. Therapeutically, both the primary locus and the secondary nodes must be considered carefully from a surigcal and radiological point of view to obtain the highest rate of cure and the greatest degree of palliation. The palliative care of the patient with advanced cancer of the mouth is the obligation of the surgeon in those cases in which surgery is the treatment of choice. The task of the radiologist is not complete with the administration of roentgen rays and radium, but includes repeated examination, daily removal of slough, frequent packing of ulcers, institution of a proper dietary regime, relief of radiation reactions, and whatever contributes to the control of infection and the alleviation of the patient’s suffering.

DISEASES Unilateral

Hyperplasia

(Oslo).

Acta

OF THE MANDIBULAR

of the Mandibular

odont. Scandinav.

Condyle.

8: 44, January,

JOINT

R. Wang-horderud

and S. Lossius

1948.

This i.s a case report describing unilateral hyperplasia of the mandibular condyle in thre’e patients 24, 25, and 26 years old, respectively, one male, and two female. Each of them had noticed asymmetry of the face several years before examination by the authors. X-ray examination revealed considerable enlargement of the condyle on one side as well as elongation of the ramus. Upon resection of the enlarged condyle, microscopic examination revealed in all cases hyalins cartilage in different parts beneath the precartilaginous layer a’s well as in several places of the bone. In addition to these three severe cases, some minor changes have been seen in the condyle of other patients with slight asymmetry of the face. The authors believe that hyperplasia of the mandibular condyle may exist more often than usually believed. R. F. S. De

d’acrylique en chirurgie maxillofaciale specialement dans le de I’ankylose temporo-maxillaire (The Use of Acrylic Inclusions in Maxillofacial Surgery, Especially in the Surgical Treatment of Ankylosis of the Temporomandibular Joint). G. Maurel (Paris). La Rev. Odontologique 70: 1.51, 1948.

l’empoli

des inclusions

traitement

chirurgical

The author reviews the various procedures for the surgical treatment of mandibular ankg-losis and recommends on the basis of three reported cases (one bilateral, two unilateral) the inclusion of either an acrylic condyle or a rectangular perforated piece constructed in, advance. The acrylic prosthe’sis has on ‘the lower border a groove by means of which it rides on the resected area of the ascending ramus to prevent lateral displaceThough in the British maxillofaeial centers the enthusiasm for this method has ment. greatly diminished, because in :several cases the pro’sthesis had to be removed, the author feels encouraged by the postoperative observation (one year) of his results. He feels the method should be given due consideration. K. H. T.

P:LASTIC

PROCEDURES

Kilray P, Blair Primary Closure of Harelip. Gynec. & Obst. 86: 502, April, 1948. The attempted do’s and the don’t’s

and Robert

R. Robinson,

Editorial,

Surg.,

closure of congenital lip clefts dates back to surgical dawn, and the that guide us today had been well established in the first half of the

SOlO

QUARTERLY

REVlIiW

OB LlTERhTC’RE

past century; but with the distracting introduction of anesthesia and the control of sepsis, these gains were mostly lost in the latter half of the same century and largely neglected during the first quarter of the present. It is temptingly easy to freshen and unite the cleft borders, but that it takes skill and real study of each individual case to obtain an acceptable result has been rather commonly overlooked. In this type of surgery the margin between success and failure is narrow, pitfalls are numerous, and luck, if any, is mostly bad. Further, the area is always in evidence, and, ironically, it is the poor results that attract attention while the factor of an excellent outcome must content himself with the silent flattery of nonrecognition. We now see children reared in utter ignorance of an early correction. The primary aim of any operative plan is to retain free breathing and produce a symmetrical lip and nose of natural appearance without too evident suture marks or other scars. Undue transverse shortening, verticai overlength, or both, asymmetry of the lip or vermilion, or failure to correct vestibular distortions are the more common faults of planning or execution that make for the unpleasing result. With any congenital lip cleft, partial or complete, there is some actual deficiency of lip tissue, but most of the spread of a complete cleft is due to tissue displacement. The first operative move, to be undertaken only after sufficient study, checked by the use of measuring dividers, is to ink in the pattern of cuts that will determine the contour of the nascent lip and nose. Previous study will have also estimated the amount of lip, cheek, and nasal mobilization needed to permit soft tissue adjustments without undue tension. In a primary operation this i,s made available by simple undermining, the extent of which is determined by the needs of the individual case. The infant’s condition and related circumstances are apt to dictate the operative when; the operat,or’s fancy and the extent of involvement will largely determine the how. As a general rule, the earlier the simpler. IJip closure in the first two days of life makes possible exhibition of an apparently normal infant two weeks later which is a great comfort to a mother who has by then weathered the first shock. Barring this very early closure, simpler operations will still suffice any time between two weeks and two years later, as circumstances dictate, without resorting to the more extreme measures. In the baby with partial cleft the undermining might be quite limited, but for a widespread opening in one of similar age the complete cheek mobilization might extend the full depth of the maxilla and up to the orbital border on the cleft side, somewhat less on Also, corresponding liberation of the ala, plus undermining between the skin the other. and lower lateral cartilage through a transverse intranasal incision made along the upper edge of the lower cartilage, and in addition some slight trimming of the alar borderanteriorly might be needed to raise it. all of this is to insure proper airway and contour. In early childhood the unoperated upon or maladjusted lip can develop a definite displacement of the ala which dema.nds repositioning droop as well a#s increased backward by completely separating the two halves of the eolumella, free undermining of the skin over and beyond the upper lateral cartilage, with removal also of a triangular piece of It will take all of this, and maybe skin and cartilage from just above the alar border. This new molding is maintained by more, to raise the slumped ala to its proper position. suturing. In adolescence faulty or nonapproximation may have caused lateral divergence of the nose from the cleft side which, if sufficiently disfiguring, may require complete subcutaneous chisel or saw mobilization and mass fixation with transtissue wiring of the freed nasal spine to an upper molar tooth, this to be retained for four to six weeks. The aforementioned progressive complexities emphasize the advantages of early correction. There are four merging types of classic single harelip: the partial soft tissue cleft, the complete soft tissue cleft, the complete lip cleft involving also the alveolar process, and the very wide complete cleft of lip and palate. The first of these can be the mo,st complicated by a smalI transverse refractory because of sparsity of excess vermilion, nostril, while the wide open cleft is vermilion-lined and the ala is stretched. Regarding the alveolar or the complete bony cleft: in the vast majority of cases the separated

ABSTRACTS

OF CURRENT

1011

LITER,ATURE

borders will be quickly drawn -together, with slight overlapping, after any sort of lip closure. This narrowing of the bony cleft is helpful to the subsequent palate closure, but it leaves an opening in the upper fornix to be closed at the time of the staphylorrhaphy or later. Very rarely is the bone resistant to the lip pressure. Forceful approximation of the bosny cleft borders is a mutilating practice condemned by writer,s of the early nineteenth century, revived by dentists in the doldrums of the nineties, but happily now almost extinct. There are two general plans of closing the lip-nose cleft, each capable of special modification. The earliest is the Husson-Rose plan which eliminates the straight or convex cleft b’orders by angular or curved excisions which when sutured push upward and downward in a straight line. The length of the line will depend upon the depth of the excision, but thi.s procedure is apt to give too long a lip. The second plan, more difficult but more adaptable, is best represented by Mirault’s presentation published in 1844. It consists in turning an angular flap taken from the upper pa,rt of one side of the cleft across the defect and uniting it to the denuded opposite border. Regardless of the type of excision for the tissues that are to be sutured to a vertical line, the vertical part should be beveled so the tension will be on the deep-holding sutures with no strain on the superficial ones. In that way, possibly with the help of a little radium, unsightly scars can usually be prevented. The lip closure of complete double cleft of lip and palate is done in two steps. At the first step closure is accomplished by adjusting the widespread alae and suturing the upper part of the Rose or Mira,ult sectioned lateral lip fragments to corresponding areas of the denuded prolabium. So far the procedures are similar. Lower down, in the Rose type the prolabium is trimmed to a point, but in the Mirault plan it is cut squarely across if the lip flaps are to interdigitate, or to a blunt point if the Aaps are to be trimmed to abut in the midline. The cheek-ala undermining for the aforementioned is greater than in the single cleft for there is no appreciable length to the columella, and the premaxilla stands well forward of the maxillae. The septum is not to be shortened at this stage. Doing so might risk letting the premaxilla drift back between the maxillae, which is ruinous to both incisor occlusion and to facial contour. push-back done at the hard palate closure will have Second step: the premaxilla caused definite nasal snubbing. Correction of this consists in raising a superficial trifoil flap from the lip, in conjunction with the separation of the short columella from the septum; a far forward transverse cut across the septum will then permit the nasal tip to be advanced and leave a correspanding triangular defect in the septum; suturing the lateral leaves of the trifoil into the septal defect on each side and closing the lip defects will restore continuity to the advancement. The doubt clefts may be mirror images, or either cleft might fall into one of the four types mentioned previously. In the complete double cleft the premaxilla will be found at the top of the nose. If there is :any attachment between the maxilla and premaxilla on either side, no matter how slight, the central mass will diverge in that direction. A bilateral attachment, no matter how attenuated, will restrain the forward movement of the mass. There are few primary instances of harelip in which an acceptable result cannot bc attained in from one to three operative steps; there are still fewer in which the original possibilities can be attained after a bungled start. Ueber

dile operative

Treatment Sohweiz. lower

Behandlung

of Traumatic Monatschr.

traumatischer

Defects

Unterlippen-Kinnschaden

of the! Lower Lip

Surgical

J. KGhler.

f. Zahnb. 58: 252, 1948.

Clinical experience in plastic surgery for the restoration of traumatic lip and the chin suggests to the author a case classification into four 1. Wounds of without mandibular

(The

and the Chin).

soft tissues of the chin excluding the lower lip, fracture, mostly without opening to the oral cavity.

defects groups: with

of the or