Cleft Lip and Palate
The history of cleft lip and palate surgery dates back to 390 BC when, for the first time, a cleft lip was closed successfully in China. Although the Egyptians and Greeks developed techniques to a remarkable degree, no descriptions of cleft operations have survived. In the Middle Ages, operations on cleft lip were described several times, and numerous descriptions of cleft lip repairs are found in European literature from the 13th to the 17th centuries, all of which fundamentally involve freshening of the cleft edges and suturing them together, with the adjunct of various dressings and salves to promote healing and combat infection. However, a successful operation on a cleft palate did not occur until 1816. This can be explained in part by the fact that cleft palates were thought to be secondary to syphilis, but also because without anesthetic, this operation was extremely painful and difficult. Gräfe and Roux published the first satisfactory result, followed by the French surgeon Veau. At the same time, other surgeons started to publish successful results by building upon the success and techniques of the others. It is because of all this past work that today’s cleft lip and palate surgeries are both predictable and, more importantly, safe.
Mémoire sur la staphyloraphie [Memoir of staphylorraphy].
Philibert Joseph Roux. Paris: Bechet, Migneret, 1825.
Philibert Joseph Roux was a French surgeon during the first half of the 19th century. He was trained as a military surgeon and moved to Paris, where he befriended the famous French anatomist and pathologist Xavier Bichat. In Paris he succeeded Guillaume Dupuytren as the chief surgeon at Hôtel-Dieu de Paris. Although a skilled military surgeon, he is best remembered for his work in plastic surgery, being credited for performing among the first staphylorrhaphies, the surgical repair of a cleft palate. He was also a skilled gynecologic surgeon, being credited as the first surgeon to suture a ruptured female perineum. In this work or memoir, Roux details the surgical repair of a cleft palate, where the roof of an infant’s mouth remains open or patent. He improved upon the recent earlier works of cleft palate repair as performed by von Gräfe.
“On an Operation for the Cure of Natural Fissure of Soft Palate.”
John Collins Warren. American Journal of the Medical Sciences 3, no. 5 (1828).
John Collins Warren was an American surgeon during the first half of the 19th century. He was very involved in academic medicine, being not only the founder of the New England Journal of Medicine but also the first dean of Harvard Medical School and the third president of the American Medical Association. Warren was also involved in two of the earlier cases of anesthesia. In 1845 he was involved in the failed use of nitrous oxide by the dentist Horace Wells. And in 1846, again at Massachusetts General Hospital, he removed a tumor from his patient’s neck where Wells’s competitor William Morton used ether for the first time to ease the pain from a surgical procedure. This second time, the ten-minute procedure was an anesthetic success. (Warren and Morton championed the use of sulphuric ether for surgical operations.) This work describes the first American procedure for the repair of the soft palate without any direct knowledge by Warren of Roux’s description published in France three years earlier.
Chirurgischer Atlas [Surgical atlas].
Victor von Bruns. Tubingen: H. Laupp’schen, 1854.
Victor von Bruns was a German surgeon in the 19th century and a founding member of the German Society of Surgery. He is most known for his work in plastic surgery and laryngology. He gained fame with his elegant reconstructions of the lip and cheek following trauma or surgical resections for disease and cancer. He also popularized the usage of absorbent cotton dressings, which has since become normal operating practice in the treatment of wounds. In this surgical atlas, von Bruns discusses many surgeries of the head and neck. The illustrations are both exquisite and detailed.
Die Uranoplastik mittelst Ablösung des mucös-periostalen Gaumenϋberzuges [The uranoplasty by the medial detachment of the muco-periosteum of the palate].
Bernhard von Langenbeck. Berlin: August Hirschwald, 1862.
Bernhard von Langenbeck was not only known for his nasal surgery but his cleft palate surgery as well. In fact, the von Langenbeck repair still is used today for correction of the cleft palate. Cleft palate affects almost every function of the face except vision. There are different techniques based on the child’s condition, but correction of the hard and soft palate remains mandatory, usually before the age of one year. In this publication, von Langenbeck describes his technique for the repair of the soft palate in the child.
Beitrage zur plastischen Chirurgie [Contributions to plastic surgery].
Gustav Simon. Prague: Carl Reichenecker, 1867.
Gustav Simon was a 19th-century German surgeon. He was a military surgeon who served in reserve hospitals during the Franco-Prussian War. Simon was a well-rounded surgeon, not only performing plastic surgery but the other disciplines of orthopedics and gynecology. His military background afforded him the opportunity to publish a book informed by his early experiences on gunshot wounds. In this publication, Simon discusses his technique of preserving the cupid’s bow (an important anatomic landmark of the upper lip) in the surgical repair of the cleft lip. This was the first known report detailing this preservation. Other sentinel articles appear in this publication as well.
La clinica operativa [The operating clinic].
Edoardo Bassini. Genoa: Sordo-Muti, 1878.
Edoardo Bassini was an Italian surgeon during the latter half of the 19th and early 20th centuries. Like most military surgeons, he was a member of the Italian unification movement. During the war he was injured and taken prisoner. After his release and recovery, he traveled through Europe, where he studied under great European surgeons and doctors of that time including Billroth, von Langenbeck, and Lister, honing his skills. He is most well known for his description of hernia repair and is also credited for the use of eucalyptus and carbolic acid in the post-operative care of surgical patients. In this work, Bassini discusses and describes both the medical and surgical treatment of various diseases and afflictions.
“Über eine Modification der Hasenscharten Operation” [On a modification of the hare lip operation].
Walter Hagedorn. In Tageblatt der 57. Versammlung deutscher Naturforscher und Aerzte, Magdeburg. Leipzig: Breitkopf & Hartel, 1884.
Werner Hagedorn was a 19th-century German surgeon. He studied in Berlin under von Langenbeck. While in Germany he was responsible for introducing the Listerian technique of antisepsis to his Magdeburg-Allstadt hospital. He was also a surgical instrument innovator, developing both the Hagedorn needle holder and the Hagedorn needle for surgery. This publication reports on Hagedorn’s performing the basis for most of the early repair of a unilateral cleft lip (a cleft or hare lip on one side of the child’s upper lip as opposed to the bilateral cleft lip, which involves both sides). Variations of his repair are still in use today.
Pamphlets on palatoplastie [palatoplasty].
Jules Ehrmann. Paris: Masson, 1897.
Jules Amédée Ehrmann was a French surgeon during most of the 19th century. These surgical pamphlets discuss case reports of cleft palate repair. The publications were meant for the oral surgical and plastic surgical practitioners of that time. Ehrmann published frequently on the topic of palatoplasty.
“A New Principle in the Surgical Treatment of ‘Congenital Cleft Palate,’ and Its Mechanical Counterpart.”
Harold Gillies and William Fry. British Medical Journal 1 (1921).
Sir Harold Gillies was a 20th-century surgeon trained in otorhinolaryngology, who originally hailed from New Zealand. He has widely been regarded as the father of modern-day plastic surgery. After the start of World War I he joined the Royal Army Medical Corps and rapidly became interested in the management and repair of facial war wounds. Because of the new weaponry developed for the war and the fact that new techniques in facial reconstruction were evolving, more hospitals were needed. Gillies founded the Queen Mary’s Hospital in Sidcup, London, where many techniques in both plastic surgery and facial reconstructive surgery were developed. Sir William Kelsey Fry was a 20th-century dental surgeon in World War I and a key figure in the development and advancement of oral and maxillofacial surgery. This collaboration between plastic surgeon and dental surgeon was very important in the rehabilitation of soldiers with massive facial wounds that were both destructive and disfiguring. In this work, both Gillies and Fry describe a new principle in the operation of a cleft palate. It is an important piece in that the combined expertise of both surgeons was utilized and both the maxillofacial and dental components were addressed.
Overcoming Cleft Palate Speech.
Edna Young. Minneapolis: Hill-Young School, 1928.
Edna Young was a 20th-century speech pathologist. She was known for her work in the moto-kinesthetic method, a version of motor speech therapy. She herself had speech problems stemming from a severe malocclusion. She had been a school teacher before transitioning to speech therapy. In this work on the correction of cleft palate speech, Young reviews the principles for overcoming speech pathology that arises particularly from a child born with a cleft palate. Children born with a cleft palate have their speech affected because of the inability to form a seal on the roof of their mouths; as such, the loss of air produces different sounds that must be overcome. Speech pathology plays a crucial role in the rehabilitation of the cleft palate patient.
Division palatine [Palatine division].
Victor Veau. Paris: Masson, 1931.
Victor Veau was an early 20th-century French plastic surgeon. He was one of the foremost surgeons performing surgery on the cleft palate. Having performed hundreds upon hundreds of cases, he modified and improved upon the works of his predecessors, including von Langenbeck, with very high success rates. He repaired the clefts much more anatomically, leading to this high rate of success. He also believed in a collaborative approach to the success of cleft palate repair that incorporated the use of a speech pathologist in the post-operative care of his patients. In this massive volume, Veau discusses his cleft palate repair; numerous illustrations and phonetic parts written by his speech pathologist, Miss Borel, supplement the text.
“A Method of Cutting and Suturing the Lip in the Treatment of Complete Unilateral Clefts.”
Arthur Le Mesurier. Plastic and Reconstructive Surgery 4 (1949).
Arthur Le Mesurier was a 20th-century pediatric surgeon who was surgical chief at the Hospital for Sick Children in Toronto, Canada. While there he worked with children born with cleft lip and palate. Previously, the restoration of the cupid’s bow on a cleft repair was still challenging many surgeons. Building upon Hagedorn’s method of lip repair, Le Mesurier was the first to attempt reconstruction of the cupid’s bow on the vermilion of the upper lip. Before this, the repair of the cleft lip was not natural-appearing and was excessively scarred. The success of his technique was not long lived, however, as many other surgeons during the 20th century further developed surgical techniques to improve upon both the function and form of cleft lip repair.