02 자음 Consonants
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1) 자음 1 Consonants 1
(1)
발음하기
Pronunciation
Listen and repeat. furniture
(2) 쓰기 Writing
to go
I/my/me roe deer song
leg/bridge shoe two pieces duck radio
Write each of the following vowels in the correct stroke order.
we/our/us
(3) 음절 Syllables
Combine vowels and consonants to construct syllables in the following chart. For the syllables below, consonants are located on the left or the top, and vowels are either on the right or below.
Vowels
Consonants
A single vowel can constitute a syllable by itself but then its shape does not qualify as a valid syllable. The solution is to append in front of the vowel. This signifies that syllable has no consonant, as in the word , and when used in this way it is silent.
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(4)
연습 Practice
Listen and repeat the words below.
1) there older sister
2) where to go out (from a place)
3) country to get off (a vehicle)
2)
자음
1 Consonants 2
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(1) 발음하기 Pronunciation
Listen and repeat.
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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.
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
F . 177. F . 178. F . 179.
M M
F . 180. F . 181. F . 182. H M .
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.
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.
F . 183. F . 184. F . 185. D M
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 mucousmembrane 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.
186 F 187
V E M .
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.
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
F
F . 188. F . 189. F . 190.
M M
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.
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.
F . 191. F . 192. F . 193. H M .
F 194 F 195 F 196
S M .
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.
P - T H
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
F 197 —H C C
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.
U L
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.
C
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.
O C D U L
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.
B M
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 mucousmembrane 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.
F . 200. F . 201.
S M
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. F 202 B M
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
F . 203. F . 204. F . 205.
E M
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.
F 206 F 207
R M .
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.
F . 208. F . 209.
E E V B
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.
F . 210. F . 211.
C M A H I
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.
212. F . 213.
E M
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.
F . 214. F . 215.
B M .
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
F .
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.
F . 216. F . 217.
B M
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.
F . 218. F . 219.
D M
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.
