By SIDNEY KAHN, M.D., and JOSEPH WINSTEN, M.D. From the Plastic Surgical Service of Dr Arthur 3?. Barsky, Mount Sinai Hospital, New York City

Transcription

1 SURGICAL APPROACHES TO THE BILATERAL CLEFT LIP PROBLEM By SIDNEY KAHN, M.D., and JOSEPH WINSTEN, M.D. From the Plastic Surgical Service of Dr Arthur 3?. Barsky, Mount Sinai Hospital, New York City INTRODUCTION THE initial result of the surgical correction of a bilateral cleft lip is usually gratifying to surgeon and parents, since a most distressing disfigurement is transformed into an immediately acceptable facies. However, as time passes, so does the first flush of enthusiasm. The lip and nose are not normal, and the abnormalities become more marked as time passes ; differential growth potentials in prolabium, lateral lip segments, vermilion, and nose lead to increasing exaggeration of initially minor deviations from normal contour. Moreover, all plastic surgeons have experienced the discouragement of gaining only minor improvements from secondary procedures. In short, the ultimate results of corrected bilateral cleft lips are far from ideal, and it is more important to stress the limitations of various procedures than to advocate any one method exclusively. We feel that a discussion of the entire problem is warranted because of recent articles describing good results with the type of operation that employs the prolabium for the entire central portion of the reconstructed lip, and implying that other procedures should be discarded. The plans for repair of double cleft lips may be divided into those that use the prolabium for the full length of the middle portion of the lip, and those that advance lateral lip flaps beneath the prolabium. In the first group there are: (I) methods in which the prolabial skin and vermilion are used for the entire middle section ; (2) methods in which prolabial skin and vermilion are used, with the addition of vermilion flaps from the lateral lip segments ; and (3) methods in which prolabial skin is used without its vermilion, and the entire vermilion is made up of tissue from the lateral flaps (Brown et al., 1947). In the second group of methods, all prolabial vermilion is inverted or discarded ; then rectangular flaps of skin and vermilion from the lateral lip segment are used to form the entire free and infraprolabial portion of the lip (Barsky, 195 ; Stenstrom, 1957). We intend to discuss the advantages and disadvantages of each method. In our clinic, under the direction of Dr Arthur J. Barsky, we have used the operation he has described, which is a modification, for use in double cleft lips, of the Hagedorn type of single cleft lip repair. We have found the immediate and ultimate results satisfactory. We do not claim that this method should be used to the exclusion of others, or that it is necessarily superior to others, but we do wish to stress its usefulness and advantages in view of the recent publications which state that lateral skin flaps (and, in some cases, lateral vermilion) should never be used to make up any part of the middle section of the lip. A problem as difficult as that presented by a double lip cleft should be approached with flexibility ; whereas one case may be better treated by one surgical method, another may not. 13

2 14 BRITISH JOURNAL OF PLASTIC SURGERY SURGICAL TECHNIQUE The description of the method of repair that we generally favour is here reproduced from Dr A. J. Barsky's textbook (195 o) with some modifications (Fig. I, A). As in all cleft lip repair procedures, it is essential that measurements be accurately planned and checked before the operation is undertaken. Light finger tension is made upon the prolabium, holding it down to see how long it will be when sutured to lateral tissue under slight tension. A measurement is taken from the base of the columella to the border of the vermilion and an amount (known as cd) is added to make the lip the desired length. (We agree with LeMesurier (1955) that the normal lip at age of 3 months, or when the child is IO to 12 lb., is ~- to ½ in.) Take points a on the lateral side of the cleft close to the point of the ala, that is, the point where the ala joins the lip. Locate a low enough so the ala will rotate up well; if it is not low enough, the nostril will not be circular enough ; it cannot be made lower later in the operation, for this would encroach on length ab. Proper rotation of the ala may result in a kinking or buckling of the nostril rim. This buckling rounds itself out within a few months after operation. Points a' are located at the base of the columella at the mucocntaneous junction (both points a' must be equidistant from the midline). Points b' are located equidistant from the midline at the mucocutaneous junction at the points where it curves and changes its vertical direction to a horizontal one. The point c' is on the midline at the intersection of the midline with the line b'b' or slightly below it at the vermilion border. The point b is located On the lateral side of the cleft so that the distance ab equals distance a'b'. The direction of ab depends upon the length of lip desired ; its distance from the mucocutaneous junction should be such that cb is greater than cd, since the flap of lateral tissue (bcd) which will be rotated inferior to the prolabium is to be rectangular, rather than square ; this is explained below. Point c is taken along ab so that bc equals b'c'. The distance cd equals the distance from c' to the future vermilion border of the philtrum. This length was determined as the first planning step above, and it is achieved by inclining line ab so that c is as far from the vermilion as required to make cd the planned length. The first step in the operation is the insertion of the tongue suture. An incision is then made on each side in the mucobuccal fold, extending forwards into the crease between the vermilion border and the alveolar process on the lateral side of the cleft. The incision should be continued in the lining of the nose between the upper and lower lateral cartilages. Now with a rounded double-edged scissors the lip, the base of the ala, the skin over the lower lateral cartilage, and the cheek are undermined as extensively as may be necessary to permit mobilisation of the lip and ala. This procedure is repeated on the opposite side. A pointed knife blade enters at point a and passes through the thickness of the lip down to point b. Line cd is next incised. The incision is then continued up from d, leaving all vermilion attached to flap bcd, and flap acd is left attached by a pedicle to the nasal ala. An incision is then made along the lille a'b'c'b'a' extending down to, but not through, the mucosa. The skin and vermilion peripheral to the incision in the prolabium is thinned out slightly and everted to add to the mucosal lining of the lip, if necessary, later in the operation (Fig. I, B). The first skin suture unites a and a' and as much of the flap acd is used as necessary to form the nasal threshold and floor of the vestibule (Fig. i, c). The

3 SURGICAL APPROACHES TO THE BILATERAL CLEFT LIP PROBLEM 15 intersection of the vermilion border with the line cd is carefully approximated. We generally then place very fine catgut sutures uniting the muscle at key points (it is often very difficult to find any tissue on the prolabial side to hold these sutures). Skin silk sutures then bring points b to b' and points c to c' at the midline, and additional sutures approximate all skin margins. The two vermilion flaps are held criss-cross one on top of the other, while a V-shaped incision is made in one to receive a properly trimmed flap from the other. This produces the zigzag A B FI~. I A, See text (Surgical Technique) for details of measurements and markings. Note that bcd is a rectangular flap (be is longer than cd; compare Fig. 8). B, Incisions made. Note traction suture on everted prolabial vermilion to use as flap to fill out lining of lip. C, Repaired lip ; everted prolabial mucosal flap to be sutured into lip mucosal surface if necessary. suture line of the vermilion. Excess mucosa of the prolabium is then excised. If there is any insufficiency of the lateral vermilion and mucosa, a portion of the everted vermilion of the lateral and inferior borders of the prolabium is used to fill out the mucosal surface of the repaired lip (Fig. I, c). Traction on the sutures inserted in the vermilion aids in everting the entire lip to permit suturing of the mucous membrane. A steel retaining suture is passed through one ala, across the floor of the nostril, through the septum, across the floor of the other nostril, and out the other ala ; it is fled over two perforated lead plates, curved and moulded to fit the alar-labial crease on each side. A Logan bow is applied. DISCUSSION CRITIQUE OF VARIOUS OPERATIVE TECHNIQUES The Premaxilla.--A most important point of discussion in the total repair of bilateral cleft lip is the handling of the premaxiua. In complete bilateral clefts this bone is invariably in a much more rostral position than is normal. When the bilateral cleft is complete on one side and incomplete on the other, there is a premaxillary protrusion and horizontal rotation towards the incomplete side (Fig. 2, A). In bilateral incomplete clefts there may or may not be some protrusion. Woo (1949) found from embryologic studies that the premaxilla develops from two pairs of ossification centres : the principal pair forms above the primordia of the lateral incisors, extends upwards and forms, with the maxilla, the frontal process ; it also extends backwards as the palatine process to join with the lateral maxilla:. The other pair makes up the infravomerine centre which arises in the

4 16 BRITISH JOURNAL OF PLASTIC SURGERY tenth week and unites with the medial portion of the palatine process of the premaxilla. Complete unilateral or bilateral clefts of the palate occur at the site of this suture. This entire palatine process (including the infravomerine) normally grows backwards to lie under and support the anterior extremity of the vomer. Shortly before ten weeks, the maxilla extends forwards to embrace the premaxilla on both sides. By the end of the third month the whole premaxilla is covered on FIG. 2 A, Bilateral cleft lip, complete on left, incomplete on right. B, Note rotation of premaxilla towards incomplete side. C, Repair. Premaxilla not set back. D, Note prolabial convexity, due to shape of underlying premaxilla. its anterior surface by the maxilla proper. It seems logical, then, that the embrace of the maxilla retains the premaxilla in its normal position in spite of the forward growth pressure of the anterior end of the vomer. When this " retaining wall" is absent on one side, that side of the premaxilla will respond to the pressure from the vomer and be thrust forwards with some rotation (Fig. 2). Where both maxillm do not clasp the premaxilla, as in a bilateral complete cleft, the entire premaxilla is displaced forwards. In unilateral complete clefts, this phenomenon is almost always seen ; the portion of the alveolar arch medial to the cleft protrudes beyond the natural alveolar arch line.

5 surgical APPROACHES TO THE BILATERAL CLEFT LIP PROBLEM 17 In a bilateral cleft the decision to reposition the premaxilla to form a more normal-appearing alveolar arch depends on the degree of protrusion and on the surgeon's expen'ence. Most surgeons allow themselves some leeway. Slaughter and Brodie (I949).and Adams and Adams (I953) do not set back the premaxilla in any case, believing that surgical repositioning may lead to cessation of growth FIG. 3 A, Bilateral complete cleft lip. B, PremaxiUa set back. C, Lip repaired ; no attempt made to place premaxilla between lateral alveolar segments. D, Final result. Note small flaps of lateral lip tissue inferior to prolabium. of the premaxilla, while the tension of the repaired lip will gradually push the premaxilla back into good position anyway. However, while this is true, the septum will generally buckle, obstructing the nasal airways. We thus do not agree with the opinion that the premaxilla should never be set back if the lateral lip segments can be brought up to meet it. Rather we feel that the premaxilla should be recessed if it protrudes enough to cause tension on the future suture line. If properly performed, no growth retardation of the nose, nor instability of the central section of the lip, will result (Fig. 3). We set back about 5 per cent. of the cases. Since the repositioning operation involves the anterior portion of the vomer only, and leaves an adequate blood supply to the premaxilla, the procedure has IB

6 I8 BRITISH JOURNAL OF PLASTIC SURGERY no serious drawbacks. Also, because the lip pressure method on the premaxiua may cause buckling of the septum, the surgical repositioning procedure seems a preferable alternative. In the case in Fig. 4 the premaxilla has grown normally in the three years after the repositioning procedure. What better evidence of Fio. 4 X-rays in case of complete bilateral cleft lip with protruding premaxilla. A, Septum deviated, with attached premaxiua. B, Premaxilla protruding, side view. C, One month after premaxilla set back ; two Kirschner wires. D, Three years after repositioning of premaxilla. Clinically, premaxilla has continued normal growth, is fixed and stable ; two central incisors are of normal size and alignment. viability can there be than the presence of two central incisors of normal size and position? In cases where the premaxiua is at no point in contact with the lateral palatal processes, repair of the cleft lip without repositioning of the premaxilla results in a medial collapse of the alveolar arch, requiring prolonged orthodontic treatment and occasionally radical surgery upon the maxilla to separate the two alveolar segments and leave room for the premaxilla. The repositioning operation in use to-day involves a submucosal excision of a quadrilateral piece of vomer, an incision in the septal cartilage parallel to the

7 surgical APPROACHES TO THE BILATERAL CLEFT LIP PROBLEM 19 vomer extending towards the tip of the nose, and careful fixation of the reapproximated vomer by wires or pins. A single pin applied through the premaxilla and into the vomer will not usually suffice to keep the premaxilla solid against the forward pressure of the constant tongue activity. A second diverging pin is needed for complete fixation. It is directed either into the lateral palate or into the vomer at a different angle from the first pin. The older wedge excisions or oblique vomer sections are rarely practised to-day. Wedge excision causes a lingual rotation of the premaxilla with subsequent abnormal tooth alignment. Oblique section of the vomer causes narrowing of the nasal passages due to the overriding of the two fragments of the septum. Several significant modifications in the repositioning operation have been described. Hufflnan and Lierle (1949) reposition the premaxilla and, at the same operation, attach the already elevated vomerine flaps to medially incised palatal flaps, thus performing at the same session the first stage of a palatal repair. While this modification achieves two goals with one operation, it is our experience that such a procedure could be performed in very few cases ; we have rarely seen, in these infants, a vomer large or wide enough to yield two mucosal flaps which could be attached to the lateral palatal flaps without great tension, or occlusion of the nasal airway. The most definitive repositioning operation requires bone-to-bone contact of the premaxilla and the lateral maxillary segments, as well as reapproximation of the cut ends of the vomer. The raising of mucosal flaps from both sides of the premaxilla and lateral alveolar ridges (a total of eight flaps) gives the potentially best repair. However, the difficulty of raising and suturing tiny flaps from irregular surfaces, in very narrow spaces, and the invariable sacrifice of tooth buds, have discouraged us. In the last six cases where this has been done, only two cases could be considered surgically satisfactory. Now we feel that perhaps the most physiological approach from a long-term standpoint is, as Vaughan (1946) points out, to reapproximate the alveolar arch by shortening the vomer but not manipulating the mucosal surfaces of the alveolus. If closure of the remaining slit-like fistulm proves necessary, this can be done more easily at a later date and on the larger palate. The Prolabium.mThe proper use of the prolabium is the principal point of debate in the discussion of methods of bilateral cleft lip repair. The question is, should the prolabium (with or without its vermilion tissue) be used as the entire philtrum, or should the prolabium make up only the upper portion of the philtrum (in which case lateral lip tissue is brought beneath the prolabium (the Hagedorn-Barsky procedure)). The most widespread criticism of the Hagedorn type of operation is that it results in too long a lip in a vertical direction, and too tight a lip horizontally. Adams and Adams (1953) feel that this is due to a pulling downwards of the lip over a bulging premaxiua. This is a possibility. However, in the cases where the premaxilla is not protruded, or has been repositioned prior to lip closure, this result is not inevitable (Figs. 5, 6, and 7). It seems to us, on examining the presentations of writers who feel that the Hagedorn-Barsky method yields too long a lip, that they have chosen for their illustrations cases in which square flaps of lateral tissue were employed. Use of such flaps is a technical plarming error, and it may follow if one adapts the unilateral Hagedorn-LeMesurier technique to bilateral lip repair without modification. In repairing a unilateral complete cleft

8 20 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 5 A, Before surgery. B, C, Premaxilla repositioned ; no attempt to set it back too far. D, After lip closure. Associated cranio-facial anomalies. E, F, Twenty-seven months later. Note desirable concavity of philtrum.

9 surgical APPROACHES TO THE BILATERAL CLEFT LIP PROBLEM 21 lip (Fig. 8), the lateral flap must be quadrilateral, that is, bc must equal cd ; this makes cd longer than we advise for double clefts. As a matter of fact, in single clefts the wider the cleft, the longer must the line cd be. However, in double clefts (as described above under Surgical Technique), although bc must equal FIG. 6 Long-term follow-up. (Courtesy of Dr A. 37. Barsky.) A, Incomplete bilateral cleft lip. B, After repair. C, Seventeen years later. Lip not too long. Good vermilion match and symmetry. FIG. 7 Long-term follow-up. (Courtesy of Dr A..7. Barsky.) A, Complete bilateral cleft lip with protruding premaxilla. B, Four years after repair. C, Thirteen years after repair. Frolabium has grown, but not excessively. b'c', cd may be as long or as short as required to make the lip of proper length, and cd does not necessarily equal be. Thus, the flap bed is rectangular in double lip repairs, not quadrilateral as in single lip repairs ; it may be long and narrow, and excessive lip length will be avoided (see Fig. I). The length cd is determined by the length of the prolabium ; i.e., the longer the prolabium, the shorter is cd. Huffman and Lierle (1949) feel that the bilateral Hagedorn-type procedure

10 22 BRITISH JOURNAL OF PLASTIC SURGERY causes the flat, broad nasal tip and extremely short columella so often seen after surgery. It was formerly common for the prolabium to be used in part or in its entirety to elongate the invariably short columella. To-day this is universally condemned. The prolabium is part of the lip, not of the nose (Stark and Ehrmann, I958). Methods of repair that push the prolabium up into the columella and unite lateral lip segments to make up the entire phikrum are not advised. However, one would suspect that, where the prolabium is used as the entire philtrum, the vertical pull on the tip of the nose would be greater than where lateral elements are brought inferior to the prolabium. In the best of cases the tip of the nose is pulled down because bilateral cleft lip patients have short columellas. When the prolabium is used for the entire philtrum, this short columella may be accentuated FIG. 8 Markings for repair of single hare lip, for comparison with Fig. I, A. square (bc equals cd). See text (p. 19) for significance. Flap bcd is and the tip of the nose pulled down even tighter, causing flaring of the aloe (Cronin, I957). The truth may be that the broad nasal tip and short columella are not by-products of any particular operation, but rather are more the sequelae of the tissue stresses and strains of the deformity itself. The bilateral Hagedorn-Barsky operation sacrifices more horizontal tissue than does the procedure which uses prolabium for full philtrum. However, the amount of horizontal tissue lost when the flaps are fashioned is equal only to the combined vertical dimensions of the two lateral flaps, usually 2 to 3 ram. each (length cd). The sacrifice of lateral tissue is just as acceptable as in the Hagedorn-LeMesurier operation for unilateral cleft lip. The tissue can well be spared in the upper portion of the lip, near the nose, while there is need for the tissue in the lower portion of the lip, where fullness is desirable. The post-operative tightness or flatness of the lip is mainly a result of the rigid bony framework of the premaxilla. Cronln (1957) states that the prolabial portion of the philtrum often bulges forwards in the bilateral Hagedorn type of operation. It is certainly true that this is seen frequently ; however, in such cases the prolabium is relatively large and is closely applied or adherent to the anterior surface of the premaxilla over most of its extent, with only a shallow gingivo-labial sulcus. Thus the prolabium is convex because it takes the form of the underlying convex premaxilla. This convexity is evident pre-operatively as well as post-operatively (Figs. 2 and 9). Scar contracture and hypertrophy of the scar may be a factor in the mtiology of this prolabial bulge, but there is no consistent relationship. The scar hypertrophy involutes (Fig. IO) and yet the convex bulge may persist, although it generally disappears in time. Neither bulging of the prolabium nor scar hypertrophy is

11 surgical APPROACHES TO THE BILATERAL CLEFT LIP PROBLEM 2 3 Fig. 9.--One year after repair of bilateral hare lip. One view to illustrate a pleasing profile in spite of some convexity of philtrurn. As in Fig. 2, D, this convexity is governed by the shape of the underlying premaxilla. FIG. 9 FIG. IO A, Bilateral incomplete cleft lip. B, Six months after repair. Note scar hypertrophy. Also illustrates excellent match of vermilion tissue of the two lateral lip segments. C, One year after repair. Scar hypertrophy has involuted. D, Lip is not too long, and profile contour is pleasing. (PremaxiUa was not convex.)

12 BRITISH JOURNAL OF PLASTIC SURGERY FIG. I I A, B, C, Bilateral hare lip previously repaired by using prolabium and its vermilion for entire central portion of lip. Illustrates convexity of prolabium and inadequacy of vermilion. D, E, Eight weeks after revision according to Barsky-Hagedorn technique ; rectangular lateral lip flaps and vermilion advanced to replace prolabial vermilion. Improved fullness and match of vermilion under philtrurn. Patient still to have release and advancement of columella. Fig. i2.~bilaterai cleft lip previously repaired by using prolabium and its vermilion for entire central portion of lip. Note inadequacy of vermilion. Also, scar hypertrophy can occur with this type of repair as well as with any other. FIG. I2

13 surgical APPROACHES TO THE BILATERAL CLEFT LIP PROBLEM 2 5 restricted to cases operated upon by this method. The patients in Figs. 9 and IO had the primary repair performed by the alternate method and the first displayed a convex prolabium while the second shows evident scar hypertrophy. FIG. 13 A, Wide complete bilateral cleft lip. B, Ink line outlines protruding premaxilla. C, D, After repositioning of premaxilla. E, After repair of lip. Note good fullness and match of two vermilion segments without interposition of prolabial vermilion. Use of Prolabial Vermilion.--0f course, if lateral lip skin is brought inferior to the prolabium, the prolabial vermilion is discarded except for that portion which is everted to fill out the mucosal surface. The use of this everted flap (as described under Surgical Technique) (see Fig. I) avoids any tendency to notching that occurs if vermilion flaps from the lateral segments are inadequate (Figs. II and 12). The use of this tucked-back flap usually makes it unnecessary to pull the lateral vermilion too tight. When the prolabial skin is used for the entire philtrum, prolabial vermilion may or may not be used for the central red tissue. When it is not so used, then the formation of the vermilion and mucosal portions of the lip is the same as in the Hagedorn-Barsky method. However, most advocates of the use of prolabium for the entire philtrum do use all or part of the vermilion of the prolabium. We

14 26 BRITISH JOURNAL OF PLASTIC SURGERY do not feel that this is an advantage. Close attention to the photographs in the recent articles advocating its use reveal a definite difference in the contour and appearance of prolabial vermilion from that of lateral vermilion. The prolabial vermilion is generally thinner and shorter, and its plane has a different inclination ; thus the junction of the vermilion from the two sources is obvious (see Fig. II). In addition, when the prolabial vermilion makes up all the central vermilion, bilateral notching (the "whistle deformity ") is a common sequela (Crickelair and Hickey, 1957). Good fullness and match of the two lateral segments can be achieved without the interposition of prolabial vermilion (Figs. IO and 13). In fairness, it must be admitted that no method of lip reconstruction ensures adequacy of vermilion tissue (particularly in cases of incomplete bilateral cleft lips) ; notching deformities may be unavoidable. There is always enough skin for the skin flaps (a good portion of skin is actually discarded) ; the vermilion is the tissue likely to be deficient. Staging the Operations.--Huffman and Lierle (I949), Cronin (1957), Vaughan (I946), Schnltz (1946, I947), and Brown et al. (1947) replace the premaxilla when necessary as a separate preliminary stage in most cases. Matt_hews (I952), when he deems repositioning of the premaxiua necessary (in extreme cases), does so with a one-side lip closure as a first stage at age 4 months. In the United States the tendency is to do the first stage at an earlier time whether the criterion be age, absolute weight, or weight curve. Marcks et al (1957) reposition the premaxilla and close one side of the cleft lip in the first stage in early infancy. Slaughter and Brodie (I949), Adams and Adams (I953), and Huffman and Lierle (1949) usually close one side of the lip as a separate stage. The repair of the two sides of a bilateral cleft lip separately has some drawbacks. There are two anmsthesias for an infant with all the attending morbidity ; unequal lateral pressure is exerted on the yielding premaxilla and vomer ; there is perhaps less precision in making the lip symmetrical. Our own policy has been to await a definite upward trend in weight, or in the case of a very small infant the attainment of 3,ooo g. in weight in a normal upward weight trend. The lip closure is carried out in one stage as described above (Surgical Technique). If repositioning of the premaxilla is first required, the lip closure follows in about six weeks. Although we have not yet had the opportunity and courage to do so, we feel that perhaps the best overall plan for the correction of a bilateral cleft lip with protruding premaxilla would be a single operation embodying a simple repositionlng procedure with simultaneous closure of the bilateral cleft lip. CONCLUSION We have presented some advantages of the Hagedorn-Barsky method of reconstruction of bilateral cleft lips ; in this method the vertical length of the repaired lip is made up of prolabial skin, small rectangular lateral skin flaps brought inferior to the prolabium, and vermilion flaps from the lateral segments ; prolabial vermilion is used only to fill out the posterior aspect of the lip. This paper is presented at this time because of the recent publication of a number of articles stating that this type of repair should be abandoned. We make no claim that this procedure is fool-proof, or should be used exclusively. Plastic surgery (or any

15 surgical APPROACHES TO THE BILATERAL CLEFT LIP PROBLEM 2 7 type of surgery for that matter) should be flexible and versatile enough to vary a technical procedure according to the individual conditions each case presents. When the prolabium is small, and its vermilion inadequate, the Hagedorn-Barsky procedure is certainly indicated; when the reverse is true, prolabium and its vermilion may be used for the entire central lip segment ; intermediate conditions will call for the use of varying amounts of tissue from the different lip elements. In the attack upon this most difficult surgical problem, only considered judgment and careful planning of each case will achieve the best results. REFERENCES ADAMS, W. M., and ADAMS, L. H. (1953). Plast. reeonstr. Surg., 12~ 225. ]]ARSKY, A. J. (195o). " Principles and Practice of Plastic Surgery," p Baltimore : Williams & Wilkins. BROWN, J. B., MCDOWELL, F., and BYARS, L. T. (1947)- Surg. Gynee. Obstet., 85, 2o. CRICKELAIR, G. F., and HIClr2y, M. J. (1957). Surg. Gynec. Obstet., xo4, 759. CRONIIq, T. D. (1957). Plast. reconstr. Surg., 19, 389. HUFFMAN, W. C., and LIERLE, D. M. (1949). Plast. reconstr. Surg., 4, 489 LEMESURIER, A. B. (1955). Plast. reconstr. Surg., x6, 422. MARCKS, K. M., TREVASKIS, A. E., and PAYNE, i. J. (I957). Plast. reeonstr. Surg., x9, 4Ol. MATTHEWS, D. N. (1952). Brit. ft. plast. Surg., 5, 77. SCHIJLTZ, L. W. (1946). Plast. reconstr. Surg., I, 338. (1947). Dent. Digest, 53, 122. SLAUGHTER, W. B., and BRODIE, A. G. (1949). Plast. reconstr. Surg., 4, 311. STARK, R. B., and EI-IRMANN, N. A. (1958). Plast. reeonstr. Surg., 2I, 177. STENSTROM, S. (1957)- Plast. reconstr. Surg., x9, 25o. VAUGHAN, H. S. (1946). Plast. reconstr. Surg., x, 24o. Woo, Ju-KANG (1949). Anat. Rec., io5, 737-