HARELIP AND CLEFT PALATE.*

G. B. NEW, M. D., Mayo Clinic, Rochester, Minn.

Harelip and cleft palate are congenital malformations due to the failure of union of the parts that form the lip and the palate. The palate is formed from the globular and the maxillary processes of the mandibular arch; the lip is formed from the globular, the lateral nasal, and the maxillary processes. While several theories have been advanced for the lack of fusion of these parts no definite cause seems to be known.

Heredity may have some bearing on the condition since in a small percentage of cases a hereditary tendency to deformities is noted in families. Sometimes a parent and child are deformed and, again, different children in the same family may have harelip and cleft palate. In 14 per cent of the cases of harelip and cleft palate seen in the Mayo Clinic there is a family history of the occurrence of the condition. In 4 per cent a brother or sister has a harelip or cleft palate and in 10 per cent the parents or ancestors have been so deformed. In one family three children had harelip and cleft palate.

Many types of both harelip and cleft palate are seen. The lip may be fissured on one or both sides, and there are all grades of deformity. In a slight deformity the musculature of the lip may be thinned out, a groove being

formed from the nostril to the vermilion border with a slight notch in the lip, or there may be a complete unilateral harelip with flattening on one side of the nostril and separation of the alveolar process. The double complete harelip presents a marked deformity in which the nostrils are flattened. The filtrum and the premaxilla extend forward and are attached to the

tip of the nose. The palate also may vary in the type and in the extent of the cleft. The alveolar process may be notched or the cleft may extend completely through the hard and soft palates; the uvula may be bifid or the soft palate may be cleft. The parts of the palate The parts of the palate

*Read before the Southern Minnesota Medical Association, Faribault, Minnesota, July 24, 1917.

may be widely separated as seen in a double cleft palate.

The age at which the child with a harelip and cleft palate should be operated on and the operation which should be done first, are much debated questions among the various men performing these operations. Moreover there are many types of operations for these deformities. I will not attempt, at this time, to discuss the advantages and disadvantages of different methods, but I will describe the procedure which, with slight minor modifications from time to time, has been employed for many years at the Mayo Clinic.

We prefer to close the lip first when the child is between three and four months old, if he is gaining weight and doing well. Children are operated on earlier than this, but results are not so satisfactory. From three or four days to a week before the operation the child should be fed with a spoon or dropper to accustom it to this method of feeding, since of course, after the operation, it is not allowed to nurse from the bottle or the breast. When there is a cleft of the alveolar process, as in the complete single harelip, the lip is brought together over it, but no attempt is made to approximate the alveolar process. The same procedure is used in the treatment of the premaxilla. In a case of double harelip the lip is brought together over the premaxilla and its normal rounded appearance is maintained. If the alveolar process is forced back in the single harelip or if the premaxilla is removed in the double harelip or a and the premaxilla forced back, the lip will be wedge-shaped piece is taken out of the vomer flattened and it will be almost impossible to correct the deformity. When united, the lip gradually presses back the alveolar process or premaxilla into its normal position, giving the normal rounded contour to the face and the correct alinement to the teeth.

A satisfactory cosmetic result is obtained only when the nostril has been shaped to correspond to the normal side. To do this the noslittle smaller than seems tril should be made best at the time of the operation, since the cartilage tends to spread a little within a few days. It is also essential that a line drawn underneath the alae of both nostrils shall be at right angles to the mid-line of the face. The ver

milion border must present a continuous line without a notch and there must be as little scarring as possible on the outside of the lip. To prevent the scarring it is best to avoid tension sutures which pass through the skin on the outside of the lip. The lip and cheek on both sides. should be well freed from the underlying bone so they will fall together readily without tension.

The time for closing the palate is when the child is from a year to a year and a half old,

before it has begun to talk. Many operations are performed much later, however, with quite good functional results. Adults from 20 to 30 years of age have had their palates closed, and the functional results have been very good. If the lip has been approximated at the proper age the alveolar process will have become approximated; the cleft of the rest of the palate will thus be narrowed and made easier to close.

The edge-to-edge approximation or the Langenbeck operation is the operation of choice for

the closure of cleft palate. With this method as much of the palate is approximated as may be accomplished without tension at one operation, the remainder being closed later either by an edge-to edge method or by turning a flap. Failures are frequently due to the attempt to close too much of the palate at one time; in such cases tearing out of the stitches results. When the palate begins to pull out with tension, the tear may often extend into the part of the palate that would otherwise have held together. It is sometimes possible to close a soft palate with the edge-to-edge approximation method, but the hard palate may require a flap operation. We do

not like to use the flap method primarily except in certain wide clefts, usually double clefts that cannot be closed satisfactorily in any other

way.

It would seem that the most important factor necessary to success in operations on cleft palate is a thorough knowledge of the blood supply. In making the lateral incisions it is essential that they be made as close as possible to the teeth or to the alveolar process, so that the main branches of the great palatine artery may not be injured. These are not the long lateral incisions to which the term is usually applied but are just long enough to admit the palate elevator for elevating the palate. It is also necessary to thoroughly free the muco-periosteal flaps. In doing this the posterior margin of the hard palate must be freed from the soft palate so that the two portions of the palate may be approximated without tension.

In closing a cleft of the soft palate the same principles hold good as are used in closing the complete cleft palate. Also in these cases the posterior margin of the hard palate should be freed from the soft palate.

Technic of Harelip Operation.

The child is anesthetized with ether by the drop method, and is kept asleep with chloroform administered on a gauze sponge. Older children are given ether vapor through a cannula at the side of the mouth.

In operating on the single harelip a point is selected on the median portion of the lip at the vermilion border where the lip should join the opposite portion. The location of this point depends on the type of the lip as regards its thickness and the amount of tissue present, and on the experience of the operator. A small nick is made with a knife in the skin at this point. Calipers are then used to measure the distance from here to just inside the ala of the nose on the same side. This distance fixed, one point of the caliper is placed just inside the ala of the nose on the outer side and the other point at the vermilion border. In this way the points of the vermillion border which are to be approximated are definitely fixed and the two margins to be approximated are made the same length. Thompson, I believe, was the first to suggest the use of the calipers for the purpose of meas