It should not be lost sight of that it may be preferable to cover defects with skin-grafts rather than to attempt ex traordinary feats of plastic surgery. Especially is this true of raw surfaces from which flaps have been obtained.
Tension should be avoided as far as possible, relaxation sutures often being of utility in this regard. No more sutures should be employed than are really necessary, and they should be just tight enough to draw the parts together and no tighter.
In cutting flaps, about one - third should be allowed for shrinkage.
Care must be used in twisting pellicles not to cut off the vascular supply from the body of the flap. When it is pos sible to include a blood-vessel in the pedicle, this should be clone. The bruis ing of flaps or their excessive handling must be avoided.
A certain amount of pressure on the part of the dressings is often advan tageous, but it should not be great enough to endanger the free circulation of fluids.
Artificial warmth, in the shape of fo mentations, poultices, etc., is apt to do more harm than good, and is, in general, unnecessary.
Oozing must be carefully checked, preferably without the use of ligatures. An accumulation of blood beneath a flap may seriously jeopard the success of an operation.
Hairs are readily transplanted in flaps comprising the entire thickness of the skin. This may be taken advantage of, for instance, in replacing portions of the bearded cheek from the scalp.
It is important to remember that puckers and irregularities following a plastic operation tend to smooth them selves out to a considerable extent, and what seems to be at first rather a rough piece of work may eventually become presentable. This should be no excuse, however, for careless or unsightly sur gery.
Moderate discoloration of flaps, or the appearance of blisters, may mean super ficial necrosis only, and not complete death of the flap.
In plastic surgery, dry dressings are generally preferable to moist ones.
When pedunculated flaps are used, the pedicle should not be cut until definite healing has taken place and the circular tion has become thoroughly established. This may require two or three weeks.
Even then it is usually better to wait until the tissues have contracted and smoothed themselves out as much as possible before removing the unsightly hump sometimes resulting from a twisted pedicle. It is surprising how much "time"
will often accomplish. (LEONARD FREE MAN, Assoc. Ed.) Deformities of the Lips.
Harelip.—This common deformity is due to the non-union of the mesial nasal process with the superior maxillary proc ess. It may assume various forms: (a) a mere notch in the red edge of the lip; (b) a cleft through the soft portion of the upper lip only; (c) a cleft through the lip and nostril and accompanied by cleft palate; (d) double harelip with a floating intermaxillary bone and cleft palate, a variety witnessed in one-tenth of all cases (F. J. Shepherd, Montreal Med. Jour., Jan., '99). In the latter case the intermaxillary bones usually project and are either covered by skin or con nected with the nasal septum, projecting sometimes as far as the tip of the nose. When the cleft extends into the nose there is always a simultaneous defect in the alveolar border generally involving separation of the middle and lateral in cisor teeth. Other deformities of the face, also due to defective development, are sometimes present besides harelip: congenital fissure of the cheek, eyelid, etc. Single harelip occurs most fre quently on the left side. It is often traceable to heredity.
Treatment.—Operative procedures are obviously alone of value; but the age at which these should be resorted to has given rise to considerable discussion: a fact tending to show that a fixed time, —the sixth week, the third month, etc., —as recommended by various operators, cannot be adjusted to all cases. Indeed, the resisting powers of the child are of primary importance; for, while one may easily stand the operation a few weeks after birth, another will die from shock. Doubtless the best age for operation for harelip depends on the condition of the child and the character of the deformity; should the deformity involve only the soft parts and the child be healthy, Shep herd contends that one should operate at once. In simpler cases the earlier the operation, the better. Should the child be weakly, or the fissure be double and extend through the hard parts, then the operation ought to be postponed some weeks or even mouths. From six weeks to three months is probably the proper time for operating.