CHAPTER XI. Cheiloplasty

CHEILOPLASTY

(Surgery of the Lips)

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 or compression forceps. The fenestrated oval forceps, illustrated in Fig. 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.

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.

HARELIP

A congenital defect of the upper lip caused by the lack of proper union of the maxillary, globular, and frontonasal processes in 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.

CLASSIFICATION OF HARELIP DEFORMITIES

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:

1. Median or intermaxillary cleft.

2. Single and double cleft.

3. Facial cleft.

4. Buccal cleft.

5. Mandibular cleft.

=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 and vomer bones (Engle) (see Fig. 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.

TYPES OF UNILATERAL CLEFT.]

The degrees of deformity of the soft parts in the unilateral variety are shown in Figs. 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 above its 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 the unilateral variety 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 in Fig. 152.

The bilateral form of this facial defect is rarely met with. A case reported by von Guersant is shown in Fig. 153.

=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 as macrostoma.

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

On the other hand there may exist a congenital contraction of the mouth termed microstoma. 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 OPERATIVE CORRECTION OF HARELIP

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 any rate 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.

Unilateral Labial Cleft

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 held before 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 in Figs. 155-157.

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 (see Fig. 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 upper angle of the cleft is now drawn down by its red border and the wound sutured, as shown in Fig. 159. This operation does not project a small triangle of the white skin into the vermilion border and gives excellent results.

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 (see Figs. 160-161). The latter is sutured horizontally to such part of the angular defect as has not been utilized in the median line, and also vertically as far down as its free border, as shown in 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 (see Fig. 163). The freed prolabial flaps are drawn downward, as in Fig. 164, and sutured vertically, as shown in Fig. 165. Two retention sutures are shown in the latter figure to overcome the tension of the lips post 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.

MALGAIGNE METHOD.]

=Gräfe Method.=—This method, as shown in Fig. 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 in 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 in Fig. 168. The wound made thereby is shown in Fig. 169. The inferior triangular flap of one side is utilized to restore the prolabium, the whole being sutured, as shown in Fig. 170, care being taken to make this flap of sufficient size to give stability and volume to the lower margin of the lip.

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 (see Fig. 171) allows of the bringing together the lip flaps above it. The wound is made to appear somewhat as in Fig. 172, and is sutured, as depicted in 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 (see Fig. 174), giving a wound when drawn in position, as shown in Fig. 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 in Fig. 176.

KÖNIG METHOD.]

=Maas Method.=—Maas has deviated from the above method somewhat, as is shown in Fig. 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 in Fig. 178, and the sutures are applied as in Fig. 179, with an advantage of leaving a smaller sutured wound to heal by primary union.

MAAS METHOD.]

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

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 in Fig. 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 in Fig. 184. The sutures are placed as in Fig. 185.

DIEFFENBACH METHOD.]

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

Congenital Bilateral Labial Cleft

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 (see Fig. 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 in Fig. 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.

VON ESMARCH METHOD.]

=Maas and von Langenbeck Methods.=—Maas and von Langenbeck vivify the median peninsula in square fashion, as shown in Fig. 188, and suture the fresh margins of the flaps, as shown in Fig. 189, according to 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 in Figs. 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.

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 (see Fig. 194). The two flaps are sewn to the median flap (see Fig. 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 in 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.

POST-OPERATIVE TREATMENT OF HARELIP

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 in Fig. 197, answers very well, yet adhesive plaster dressings, if carefully removed later, are most commonly used.

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.

SUPERIOR CHEILOPLASTY

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.

CLASSIFICATION OF DEFORMITIES OF UPPER LIP

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.

(c) Median 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.

OPERATIVE CORRECTION OF DEFORMITIES OF UPPER 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 in Fig. 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 in Fig. 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.

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 in Fig. 183.

=Sedillot Method.=—Sedillot also employs two rectangular flaps, but he cuts them from the region of the chin (see Fig. 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 extending downward to the limitation of the buccal fold interiorly.

The flaps are twisted into position and sutured, as shown in Fig. 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.

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 a redundancy 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.

=Estlander-Abbé Method.=—Estlander and Abbé employed a transplantation flap of triangular form taken from the lower lip to restore median defects of the upper lip, whether due to a deficiency of the latter following harelip operation or the extirpation of a malignant growth.

Where the tissues operated upon warrant such procedure this operation will give excellent results, leaving the mouth almost normal in shape and size.

The lower pedunculated flap is made by cutting directly through the entire thickness of the lip, including the prolabium at A (Fig. 203), and downward toward the median line to the point B, thence upward to the margin of the vermilion border at G, leaving the latter to form the pedicle of the flap F. The defect is freshened by either a median incision, D, E, or the ablation is made in triangular form.

The flap F is now rotated upward and sutured into the upper lip, as shown in Fig. 204. The triangular defect thus made in the lower lip is sutured along the median line.

The prolabial pedicle of the flap F is not divided until about the eighth day, when the vermilion borders of both the upper and lower lips are restored by the aid of the free stump ends, which are neatly sutured into position, as shown in Fig. 205.

ESTLANDER METHOD.]

This operation may also be used in the unilateral type of defect. It will be described in the operation of the lower lip, where it is more frequently employed than in connection with faults of the upper lip.

INFERIOR CHEILOPLASTY

Apart from harelip operation, those for the separation of the lower lip are the most common about the mouth. This is due in a great measure to the fact that malignant growths so frequently attack this part of the human economy and almost exclusively in the male. Out of sixty-one cases von Winiwarter found only one female thus affected. It has not been determined whether the habit of pipe smoking has been a factor in establishing this unequal proportion, yet it is acceded to be the fact, so much so that neoplasms of the lip in men have been commonly termed smoker’s cancer.

The ulcerative forms of syphilis and tuberculosis seem to be met with more in the lower than in the upper lip; likewise is this true of burns and acute traumatisms.

Defects in the lower lip are, therefore, due principally to the extirpation of carcinomata or other malignant growths and less frequently to the other causes mentioned.

The classification and extent of such involvement has already been referred to.

In operations intended to extirpate a growth of malignant nature the incisions should be made sufficiently distant from the neoplasm to insure of unaffected or uninvolved tissue to avoid a recurrence of the disease.

These growths appear at first in wartlike formation, becoming thicker in time, and bleeding readily upon interference. They seem to develop horizontally, and invariably in a direction toward the angle of the mouth. There is more or less involvement of the lymphatic glands, especially of the submaxillary, quite early in the attack.

An early extirpation of such growths is to be recommended, and while it is true there may be a question of primary syphilitic induration instead of the malignant variety no harm is done if the diseased area be at once excised.

This is especially true of patients beyond the thirtieth year. When such indurations occur before that age the patient may be put under a proper course of treatment to determine the nature of the infiltration for a period of three or four weeks; if this does not resolve it operative measures should be resorted to. It is to be remembered that syphilitic induration may involve the upper as frequently as the lower lip, a fact not as likely referable to cancer.

In sixty-seven cases reported from Billroth’s Clinic there were sixty-five cases of carcinoma of the lower lip and only two of the upper. Yet this proportion hardly applies to the experience of most surgeons. The age factor is not to be overlooked.

The author does not mean to claim that the differential diagnosis of these diseases is at all difficult, yet in patients beyond the admissible age early and radical treatment should not be neglected, considering what great amount of misery and suffering, not to mention disfigurement, can be overcome by prompt action.

Usually these neoplasms, when superficial, are found directly in the prolabium, are unilateral, and occupy a place midway between the angle of the mouth and the median line of the lip.

=Richerand Method.=—Very small or superficial neoplasms may be removed by lifting up the growth with a fixation forceps and cutting away the convexity so established as deeply as necessary with the half-round scissors, or the faulty area is neatly outlined in spindle form (Richerand) with the bistoury, as in Fig. 206, and then excised according to the method selected by the operator.

The wound is sutured horizontally, as shown in Fig. 207.

RICHERAND METHOD.]

If the neoplasm or defect is of a more extensive form, involving most or all of the prolabium, the entire area, including the necessary allowance of healthy structure, may be raised up by a clamp, as shown in Fig. 208, and excised. The mucous membrane from the anterior surface of the lip is then brought forward and sutured to the skin margin, as in Fig. 209. The disfigurement in this operation is surprisingly little, and the mucous membrane thus everted takes on the appearance of the vermilion border of the lip in a short time.

EXTIRPATION OF ENTIRE VERMILION BORDER.]

=Celsus Method.=—When the neoplasm has become more than superficial, or the defect or deformity involves more than the prolabium, it must be ablated by a wedge-shaped incision, the base upward including the vermilion border and the apex extending downward upon the anterior chin.

This is best performed by piercing the tissue with a sharp bistoury, the blade penetrating the mucosa, while an assistant compresses the coronary vessels with his fingers at either angle of the mouth.

The incision must be made well into the healthy tissue, or at least 1 cm. from the boundary of the defect. The incision is made, as outlined in Fig. 210, from below upward while the operator draws up the triangular mass to be removed with the fingers of his left hand. The same method is followed on the other side. The wound margins are then to be examined microscopically for any sign of malignant involvement. If there be any it should at once be removed, irrespective of the size of the wound occasioned thereby. For this reason the area excised may be so large as to prevent the ready apposition of the raw edges. Should this occur, the lip halves may be made more mobile by adding a horizontal incision continuous from the angle of the mouth outward and over the cheek, as shown in the line A, C.

A single incision for a unilateral defect and one on either side for a median excision, as shown by the lines A, C, and B, C, in the same figure.

This operation is known as the Celsus method. The parts are brought together and the sutures placed as in Fig. 211, beginning the first deeply and nearly to the mucous membrane, just below the prolabial margin, which controls the bleeding. One or two of the sutures should be made deeply to overcome the tension of the parts as far as possible.

A few fine stitches are taken in the vermilion part of the lip and several in the mucous membrane to permit of close apposition and to insure primary union. Wounds of the lips heal very well, and the defects occasioned by even extension operations which involve as much as one half of the lip soon lose their acute hideous appearance.

CELSUS METHOD WITH ADDITIONAL HORIZONTAL INCISIONS.]

=Estlander Method.=—Estlander corrects a unilateral defect by excising the neoplasm in triangular fashion, and cutting out a triangular flap from the upper and outer third of the upper lip, leaving, however, the prolabium intact, which answers for the pedicle (see Fig. 212).

This triangular flap is rotated downward, and is sutured into the opening in the lower lip, as shown in Fig. 213.

Where this method can be employed it does very well, as it overcomes the secondary defect so common with most of these operations, while a small operation may be undertaken later to correct the mouth formation if necessary.

ESTLANDER METHOD.]

=Bruns Method.=—Bruns removes the defect in quadrilateral form when the disease involves one half or more of the lower lip, as shown in Fig. 214. He encircles the mouth by two curved incisions to aid in mobilizing the edges of the wound, which he sutures, as shown in Fig. 215, leaving two crescentic wounds at either side of the mouth, which are allowed to heal by granulation.

BRUNS METHOD.]

=Buck Method.=—Buck has corrected a unilateral defect by employing the wedge-shaped incision, as shown by B, C, D in Fig. 216. After removing the triangular infected area he detaches the remaining half of the lip from the jaw as low down as its inferior border and as far back as the last molar tooth. A division of the buccal mucous membrane along the same line more readily permits of sliding the remains of the lip over to meet the raw surface opposite.

If the latter was not possible he obtained additional tissue by making a transverse incision from the angle of the mouth across the cheek to the point A, or within a fingers breadth of the muscle. A second incision is made downward from A and a little forward to the point E. This quadrilateral flap thus formed, with its upper half lined with mucous membrane is dissected up from the jaw except at its lower extremity. It is glided forward edgewise to meet the remaining half of the lip, where it is sutured into place, as shown in Fig. 217.

To cover the triangular raw space occasioned by the sliding forward of the flap A, B, C, E, another transverse incision is made through the skin continuing the line A, D, Fig. 217, to the extent of one inch. The skin is then dissected up as far as this incision will allow and is stretched forward until the edge meets the outer skin margin of the quadrilateral flap, to which it is sutured. A later operation for the restoration of the mouth has to be made.

BUCK METHOD.]

=Dieffenbach Method.=—Dieffenbach’s method is very similar to the above, but is applicable only to cases where the entire lower lip is involved and is extirpated (see Fig. 218). The wound is sutured as in Fig. 219. The secondary wounds are either sutured as in Buck’s method or they are covered immediately by Thiersch grafts (author’s method).

Dieffenbach allowed these secondary wounds to heal by granulation.

DIEFFENBACH METHOD.]

=Jäsche Method.=—Jäsche’s method is to be preferred to that of the foregoing author. After a cuneiform excision of the defect he adds two curved incisions extending downward at either side to insure mobility of the parts, as shown in Fig. 220.

In bringing the wound together, as shown in Fig. 221, he overcomes the large secondary defects of the operation last considered by suturing the skin margins.

JÄSCHE METHOD.]

=Trendelenburg Method.=—Trendelenburg has modified the method of Jäsche by shortening the curve of the cheek incisions so that their outer borders were made to lie anterior to the facial artery (see Fig. 222), the parts being approximated and sutured, as shown in Fig. 223.

To obtain sufficient mucous membrane to cover the superior margin of the two flaps when brought together he made the cheek incision only down to the mucosa, dissected up the latter a short distance from the upper part of the cheek, and divided it about one half centimetre above the line of the external incision. This flap of mucous membrane on either side was used to line the lip in place of the prolabium.

TRENDELENBURG METHOD.]

=Bruns Method.=—Bruns excises the defect when not involving the whole lip in quadrilateral form, and takes up a flap from the anterior region of the chin to cover it, as shown in Fig. 224.

This flap is rotated upward into the wound made, and is sutured in place, as shown in Fig. 225. The secondary wound is brought together by suture.

BRUNS METHOD.]

In cases where the entire lip is removed he cuts two square flaps from the upper anterior region of the cheeks extending as far upward as the alæ of the nose (see Fig. 226).

He rotates these flaps into the open wounds and sutures them into place, as shown in Fig. 227.

The border of the lip is lined with the mucous membrane of the cheek flaps then brought down. If the latter has become too stretched longitudinally, he relieves it at its base by transverse incisions.

BRUNS BILATERAL METHOD.]

=Buchanan Method.=—Buchanan’s method consists of removing the diseased area by an elliptical incision A, B, A. A second oblique incision B, C, and a third of the same obliquity B, C, is made downward and outward upon the anterior chin. From the points C, C, two curved incisions parallel to the upper incision A, B, A, and equal to their lengths, are made to the points D, D, as shown in Fig. 228.

The latter incisions provide two flaps, as shown in Fig. 229. They are dissected off from their attachment to the lower jaw and raised upward so that their upper line B is raised on a level with the former margin of the lip A, A.

The oblique margins C, B, C are thus brought together vertically and sutured in the median line. The mucous membrane is brought from within outward and stitched to the skin margin.

The operation leaves two triangular wounds, which are to be healed by granulation. The result of the rotation and apposition of the flaps is shown in Fig. 230.

BUCHANAN METHOD.]

=Syme Method.=—Syme removes the affected area in triangular fashion, and from the apex of the wounds carries two curved and sweeping incisions downward from the anterior chin and beneath, terminating at the angles of the jaw (see Fig. 231).

These two large flaps are dissected from their attachment to the jaw and are slid upward until the sides of the triangular wound are raised to a horizontal line corresponding to the superior border of the lower lip, when the flaps are sutured vertically upon the anterior chin and to the triangular island of undisturbed tissue underneath the chin, as shown in Fig. 232.

The advantage of this operation is that no secondary wounds are left to granulate, the whole healing by primary union.

SYME METHOD.]

=Blasius Method.=—The method of Blasius is very similar to the foregoing, except that this author does not carry his two curved incisions as far downward and backward (see Fig. 233).

The two semilunar flaps are made from the tissue of the anterior chin and slid upward, and sutured in the median line and to the intermedian spur of undisturbed tissue, as in Fig. 234.

BLASIUS METHOD.]

=Bürow Method.=—Bürow, who favors the excisions of two triangles of healthy tissue in restoring an entire loss of the lower lip, proceeds by ablating the diseased area in triangular form. From the angles of the mouth he cuts two transverse incisions, upon which he outlines two triangles, as in Fig. 235.

The tissue included in these triangles is removed entirely, an unnecessary loss and one unwarrantable, but he saves the mucosa of these excised portions with which he lines the upper margin of the newly formed lip.

The freed lateral chin flaps he slides forward so that their oblique borders meet vertically in the median line, where they are sutured.

The triangular wounds in the cheeks are by this sliding process obliterated, and their raw edges are sutured vertically, as shown in Fig. 236.

BÜROW METHOD.]

=Von Langenbeck Method.=—Von Langenbeck, contrary to the double-flap methods, uses only one flap, with a lateral pedicle from the anterior chin.

After a semilunar excision of the diseased area, he cuts obliquely downward upon the anterior chin, then rounds his incision and continues it along, just above the margin of the chin, gradually cutting upward until its extremity is obliquely opposite to the angle of the mouth, as in Fig. 237.

The flap thus formed will be seen to have a pedicle at this point. It is dissected away from its mucous attachment and is rotated upward, jumping it over the triangular spur, which has also been mobilized by a sliding dissection.

The flap is sutured into position, as shown in Fig. 238. Unfortunately, the flap does not permit of lining the raw margin of the wound with mucous membrane turned outward from within, hence it is best to take sufficient of the mucous membrane from the cheeks to accomplish this, or the vermilion border of the upper lip may be carefully cut away from the lip at its outer sections just above the prolabial line, and elongated by stretching upon the raw surface of the under lip, to which it is sutured.

VON LANGENBECK METHOD.]

=Morgan Method.=—For an extensive loss of the lower lip Morgan operates in the following manner:

After a thorough elliptical extirpation of the diseased area, he makes a curved incision in the tissue under the chin, conforming in its curvature to the incision made below the diseased area of the lip (see Fig. 239). The length of this incision is about twelve centimeters.

This bridging flap is carefully dissected up from its basement membrane. Any infected glandular tissue encountered in the meantime is removed thoroughly.

The whole bridge of tissue is now crowded upward, until it displaces the defect in the lip. It is sutured on either side, as shown in Fig. 240, to hold it in position.

Several sutures are introduced along its inferior margin, to tie it to the tissue of the anterior jaw border and to prevent its sliding downward.

Strips of borated gauze are laid into the fold between the raw surface of the flap and the jaw.

The secondary elliptical submental wound is drawn together by suture as far as possible; the remaining raw surface is either allowed to heal by granulation or is covered immediately with Thiersch grafts (Wölfler, Regnier).

The objection experienced with the method just considered is found in the difficulty with which the bridge flap is carried upward over the prominence of the jawbone. It is very essential, therefore, to give as much freeness to this flap as possible, a fact necessitating considerable injury to the flap by handling and cutting, although the result of the operation, if carefully done, is excellent; the lip, owing to its solid form and undisturbed mucous membrane, does not contract as readily as with the average lip operation, and consequent ectropion is overcome to a great extent.

MORGAN METHOD.]

=Zeis Method.=—To overcome the difficulty of sliding this bridgelike flap, Zeis advocates ablating the diseased area in quadrilateral form and forming the lip of unbroken tissue by making the flap two-tailed (see Fig. 241), each flap meeting anteriorly in a bridge of tissue sufficiently wide to permit of the formation of the required lower lip and extending obliquely downward and backward upon the submental surface, having their pedicles as far back and upon the neck as is necessary to allow the two-tailed flap to move forward into position.

The parts are slid into position and sutured, as shown in Fig. 242.

Unfortunately the tissue of the neck is not very thick, nor is it well nourished, factors that do not make it very satisfactory for cheiloplastic purposes.

ZEIS METHOD.]

=Delpech Method.=—Delpech has utilized the skin of the anterior neck region in the following manner: He ablates the extensive diseased area, as shown in Fig. 243, and dissects up an inverted triangular pedunculated flap of skin from the hyoidean region of the neck, having its raw surfaces brought face to face at its distal extremity sufficiently to line the newly formed lip with skin which eventually would take on the function of mucous membrane.

The whole flap was now rotated upward on an arc of 180° and sutured into the labial defect, as shown in Fig. 244.

The large wound of the neck was readily drawn together by suture, leaving only a small triangular space to heal by granulation.

As has been mentioned, the skin of the neck is not adaptable for this purpose, not only because of its poor nourishment and extreme thinness, but because a flap made therefrom is devoid of muscular structure, contracts easily, and is devoid of a mucous-membrane prolabium, the greatest objection being in the resultant contraction of the lip so formed, which usually constitutes so high a degree of ectropion of the lip as to allow the saliva to escape from the mouth.

Apart from the ingenuity of the method it has no practical value, for the reasons given.

DELPECH METHOD.]

=Larger Method.=—Larger restores two thirds of the lower lip after the ablation of an epithelioma, as follows:

1. An incision is made from the union of the left third with the right two thirds of the upper lip, directed toward the alæ of the nose and including the entire thickness of the lip, the cul-de-sac, and the buccal mucous membrane.

2. A second incision is made from the upper extremity of the first incision downward from the nasolabial fold to a point on the cheek a little below and to the left of the left labial commissure. The flap being turned down, is sutured by its three edges to the lip of the quadrangular breach, after the lower edges of the flap has been freshened; this border being formed by the mucous membrane of the upper lip, the membrane is destroyed in order to permit of the edge being sutured to the horizontal branch of the loss of substance. The upper lip is then sutured vertically to the cheek.

=Guinard Method.=—Guinard modifies the above method by making the operation bilateral and symmetrical instead of unilateral, thus giving marked facial symmetry; the mucous membrane forming the free edge of the upper lip, instead of being destroyed, is dissected, turned over, and is sutured in a groove in front of the maxillary in such a way as to reconstitute the buccal vestibule; the mucous membrane of the deep surface of the lip is sutured to the skin by eversion in order to form a new mucous border.

With the above modification of the Larger method a considerable loss of substance can be restored, the new lip being constructed of normal tissue of the lip lined with mucous membrane retaining the saliva. Naturally the secondary deformity, while great, is one that only changes the physiognomy, leaving the face symmetrical with slight cicatrices.

=Berger Method.=—Berger advocates replacing a large loss of skin from the lower lip, the result of burns, lupus, or syphilitic ulceration, by employing a pedunculated flap made from the arm.

The free borders of the flap are sutured into the defect and the arm is bandaged to the head in the proper position. The pedicle on the arm is not divided until the flap has become thoroughly reunited, which is at the end of eight to twelve days.

He dissects up and divides the free border of the mucosa until it is free from its attachments to fibers of the orbicularis muscle. This he utilizes in lining the flap.

The flap taken from the arm may be made large enough to cover the entire anterior aspect of the chin.

When the mucosa has been destroyed partially he advises releasing whatever remains of the mucous membrane, either as it may be, and loosening it so as to inclose the buccal orifice. He slides a flap taken from the subhyoid region to reconstruct the lip over this, or resorts to the Italian method just described.

LABIAL DEFICIENCY

Where the lip structure has become flattened and thinned as a result of tension following the exsection of a part of the lip, as in harelip, or the ablation of malignant growths, operations may be undertaken to give the tissue a better cosmetic appearance.

Estlander’s operation, described on page 171, gives, perhaps, the best results in these cases, but the objection to this procedure to make up the deficiency in the other, and often necessitating a later stomatoplasty to overcome the oval shortening occasioned by the rearrangement of the prolabium. This, of course, is a matter of little consequence where the primary fault is due to the ulcerative inroads of syphilis or the cicatricial contraction following burns. At any rate, the triangular flap implantation method is to be preferred to any other cutting procedure.

In simple cases where a triangular ablation has caused the flattening the defect can be overcome to a great extent by employing the subcutaneous method of Gersuny.

=Author’s Method.=—The author recommends a subcutaneous division of the scar line in cases permitting such procedure prior to the injection of the tissues. This is accomplished with a fine tenotome, which requires only the making of a small opening in the skin through which the filling can be introduced. A single suture may be made through the lips of the wound, which is tied immediately after the filling has been introduced to avoid the displacement or pressing out of the injected mass at this point, which is sure to result if the suture be introduced after the injection.

A secondary filling may be found to be necessary subsequently to obtain the desired cosmetic result. The process of subcutaneous filling is fully considered in Chapter XIV.

When the lower lip is extremely flattened by the tension of cicatricial contraction of burn wounds of the mental region with more or less ectropion of the lip.

=Teale Method.=—Teale advocates the following method:

Two cheek flaps are formed by making a curved outward and upward incision upon either cheek, terminating at the second molar tooth of the upper jaw and corresponding to the lines A, A, in Fig. 245. These terminate anteriorly in two vertical incisions about three quarters of an inch long, made through the entire lip structure down to the bone on a line with the canine teeth.

The upper extremity of the two vertical incisions are united with a horizontal incision through the thinned-out or everted prolabium.

The two cheek flaps are dissected off from the bone, the mucous membrane uniting them to the alocoli being freely divided.

A base surface is made along the alocolar border of the median portion of the lip between the upper extremities of the two vertical incisions first made.

The flaps A, A are then brought together so that their vertical margins meet at the median line, where they are sutured. A few fine sutures are taken through the vermilion border.

A secondary wound, C, C, at either side is thus occasioned (Fig. 246), which can at once be covered with Thiersch grafts or is allowed to heal by granulation.

TEALE METHOD.]

Where the deficiency is due to cicatricial contractions of the submental tissue the latter must be divided horizontally from one healthy border to the other, the parts freed well from all subcutaneous adhesions in the cellular structure. The head should be forcibly raised and a flap of skin be placed into the elliptical wound thus formed either by the rotation of a pedunculated neck or thorax skin flap or the implantation of Wölfler or Thiersch grafts.

Carefully keeping the head in an extended position during the healing in of these grafts will overcome the primary defect, unless the lip itself, too, has become tied down, when the bridge flap method of Morgan or Zeis can be undertaken in conjunction with the skin-grafting method to correct the fault.

LABIAL ECTROPION

Eversion of the lip may be due to cicatricial contraction of ulcerative wounds, burns, and traumatisms of the skin, or it may be hereditary. In the latter case the entire lip structure is more or less overdeveloped, as in the negro, especially in the lower lip, so that the thickened lip droops forward and downward. This condition is termed macrocheila.

Ectropion of the lower lip is more common than in the upper lip. The defect may be slight and only of cosmetic importance or it may be so extensive as to permit an overflow of the saliva from the mouth.

When the cause of deformity is due to a cicatrix of the skin, as often met with in the lower lip, a flap should be neatly raised by a V incision, as with ectropium of the lower lid on page 104, and the wound sewed in the Y form (Dieffenbach).

In cases of severer form the cicatrix is removed by an elliptical incision, the lip returned to its natural position, and a pedunculated flap of skin is taken up from the chin or the cheek which is rotated into the wound, or a skin graft is implanted into the area by the Wölfler method and sutured to the free margins of the skin, or the Thiersch method may be employed.

In hereditary cases of mild form or partial ectropion the author advocates making two vertical incisions in the mucous membrane, half an inch long, one half inch distant from the median line of the lip, and suturing them horizontally, as shown in Figs. 247 and 248.

AUTHOR’S METHOD.]

In some cases the ectropion, whether partial or more or less general, is caused by protrusion of the teeth either of the upper or lower jaw; more commonly of the alveolar structure of the superior maxillary bone. In such cases a cosmetic operation on the mucosa will do little to restore the deformity. Such cases should be corrected primarily by a surgeon dentist, the teeth being forced back into place by proper metal springs or splints—a tedious process requiring from six months to two years’ time.

If, after the teeth have been brought back to the normal bite, the lip still shows an abnormal contour, the surgeon may restore this by several small incisions in the mucosa, as above advised, at the various protruding points of the lip.

When the simple vertical-line incisions sutured horizontally will not accomplish the result, the excision of small triangles or elliptical pieces of the mucosa may be made, bringing the distal edges of the wounds together horizontally with silk sutures, which are found best for suturing wounds about the buccal cavity.

The same methods as above given apply to the correction of upper-lip deformities.

Where the fault is too great to be overcome by this method, the author advocates removing an elliptical or diamond-shaped piece of the lip from the inner surface or mucosa, the whole length of the lip and wide enough to correct the fault, as shown in Fig. 249, and bringing together the margins by an interrupted suture, as in Fig. 250. This is the most satisfactory method to restore either the upper or lower lip to normal position. The resulting cicatrix of the mucous membrane offers no objection whatever, and soon becomes obliterated.

AUTHOR’S METHOD.]

If the operator feels justified to remove a triangular piece, with its base upward, in case of the lower lip, and vice versa, from the whole thickness of the lip he can do so, but the operation has the objection of leaving a noticeable vertical scar in the skin and a notch in the vermilion border.

The former can of course be materially hidden by the mustache or beard in man.

LABIAL ENTROPION

While labial inversion is in most cases caused by the removal of tissue from the inner or whole lip structure due to disease or other causes, it may nevertheless be met with in hereditary instances. The condition is termed microcheila.

It is more common in the upper lip, perhaps because of the frequency of harelip corrections undertaken with that part of the mouth, but it may involve both lips or be partial in one or both lips; in the latter case often the result of the habit of talking, chewing, or laughing with one side of the mouth, in which the active side is the normal and the passive side the one showing a lack of development.

In the latter case daily facial gymnastics should be advised, and such teeth as need attention to permit of the use of the side favored should be restored to usefulness—the loss or uselessness of teeth in the earlier days of puberty often causing the deformity. The correction of such defect has in view to widen the lip structure, and the best method to follow is the suturing of one or more horizontal incisions in a vertical direction, these incisions depending in number upon the extent of the lack of tissue, whether total or partial. This, of course, overcomes only the rolling in of the vermilion border, and does not in cases of the extensive variety overcome the deformity. In such cases an incision is made through and along the entire mucosa half an inch below the vermilion border. The incision should be made deep enough to permit of free movement of the upper section of the lip, which is drawn up by an assistant, while a flap of mucosa, either pedunculated or free and taken from the inner side of the cheek in the near vicinity to the lip, is sutured into the opening thus made by traction.

If a pedunculated flap is employed, it should be cut in such a way that the twisting or rotation of its pedicle will not be too abrupt, and thus cause gangrene.

The secondary wound is sutured with silk and heals quite readily under proper hygienic care (see matter on mucous-membrane grafting, page 101).

If, for traumatic reasons, a more extensive operation involving the whole lip structure is indicated, one of the harelip operations heretofore given will answer the best purpose.

VERMILION DEFICIENCY

The cosmetic surgeon is often called upon to correct the vermilion borders of the lips, the usual fault being a lack of sufficient of the delicate membrane to give an artistic appearance or form to the mouth, and in some rare cases the absence of the so-called “Cupid’s Bow” of the upper lip.

Surgical means are of little avail to correct or beautify such fault, and the cosmetic operator must resort to other means. The only practicable method at hand is the careful tattooing of the skin with rose pigment introduced into the skin, preferably with an electric instrument made for that purpose. The hand-tattooing method is slow, irregular at best, and much more painful because of this.

The part to be tattooed is first outlined and then tattooed in linear fashion parallel to the vermilion border presenting, working upward to the peripheral line. The color applied should be pale rose at the first sitting, to be gone over after healing has taken place, and repeated even thereafter until the desired shade has been attained.

The method and instruments involved in the above and the tattooing of scar tissue is fully described in a later chapter.