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OPTIMUM

CLEFT

TIME FOR BILATERAL

SURGERY

DISAGREEMENT
BEEN EVEN
GREATER

AS TO

THE BEST

TIME

FOR CLEFT

CLOSURE HAS THAN

WITH

REGARD TO
CLEFT

THE BILATERAL

WITH

REGARD TO

THE UNILATERAL
DIFFERENT

SOME

OF THE REASONS ARE SIMILAR


FOR EARLY

SOME

ARE

THE COMMONEST ARGUMENTS


CONCERN IMPROVEMENT
STARVATION IT
IS

CLOSURE

HAVE BEEN PARENTAL OF EMACIATION MAXILLARY

IN

SUCKING
IN

AVOIDANCE

FROM

AND REDUCTION
THAT

PREMAXILLARY CAN

AND
BE

BONE GAPS

INTERESTING

EACH OF THESE

CONTROLLED EFFECTIVELY

TODAY WITHOUT SURGERY

KEEPING
IN 1844 JOSEPH

THE

TEETH
OF JEFFERSON THOUGHTS

OUT OF
MEDICAL THE

IT

PANCOAST
HIS

COLLEGE PHILADEL
AGE
AT

PHIA

WROTE

DOWN

ABOUT

WHICH

THE

OPERATION

SHOULD

BE PERFORMED
IS

THIS

IS

POINT
AS

MOOTED BY THE OLDER WRITERS AND WHICH


TO

NOR YET SO WELL SABATIER ETC

SETTLED

TO LEAD

UNIFORMITY
TILL

IN

PRACTICE

DIONIS
ITS

LASSUS

DEFERRED THE OPERATION

THE

CHILD
ITS

HAD REACHED
PERFORMANCE

THIRD OR FOURTH YEAR

SHARP LEDRAN AND HEISTER ADVISED WEEKS AFTER BIRTH


SO INDOCILE

FROM

FEW DAYS TO

FEW

BETWEEN THE AGES OF TWO AND FOUR YEARS CHILDREN ARE FOUND WATCHED TO PULL UPON THE SUTURES
GREAT PORTION OF MODERN SURGEONS OF THE OPERATION AUTHOR AVOID TO

AND SO APT HOWEVER CLOSELY


THAT

AND DISTURB THE PROCESS OF UNION


HAVE

WITH GOOD REASON RECOMMENDED THE PERFORMANCE


AFTET

BETWEEN THE SECOND MONTH AND THE SECOND YEAT


GIVES DECIDED

BIRTH

THE

PREFERENCE TO THE PERIOD UNDER SIX

MONTHS AS WE THEN
AND ARE

THE NECESSITY OF HAVING

TO EXTRACT ANY DEFORMED TEETH

LESS LIKELY

81

BE TROUBLED

WITH

THE IRRITATION

ATTENDANT

UPON THE TEETH MAKING ON THE UNION

THEIR

WAY

THROUGH THE

GUMS

WHICH

ACTS

UNFAVORABLY

OF THE PARTS

MATTER
CONGENIAL
IN

OF

LIFE

AND DEATH

FRANCIS

MASON OF ST THOMAS HOSPITAL LONDON WROTE

1877
SOME BAD
CASES

IN

OF DOUBLE
FIRST

HARELIP

THE OPERATION

OUGHT
IN

IN

MY OPINION

TO

BE DONE WITHIN BIRTH


AS

THE
IN

THREE

MONTHS
SAVE THE

OR EVEN EARLIER
LIFE

FACT AS SOON

AFTER

POSSIBLE

ORDER TO

OF THE CHILD

MODERN IMPROVEMENTS
INGS

IN

GENERAL PEDIATRIC

CARE GAVAGE
FOR SURVIVAL

FEED

AND

ANTIBIOTICS

HAVE TAKEN THE URGENCY

OUT OF

THE SURGERY

EARLY
STILL
AS
IN
ALL

BE

SURGERY MAY THE ONLY HOPE


THERE ARE EXTENUATING SET ASIDE

OF SURGERY
RULES

CIRCUMSTANCES

UNDER ONE
IN

WHICH THE USUAL


CAN
DEAL

MUST BE WITH
THE

TEMPORARILY

SO THAT

INTELLIGENTLY

SPECIFIC

PROBLEM

FOR INSTANCE OFTEN


LIP

UNDERDEVELOPED

COUNTRIES

MULTITUDE
THAT

OF PEOPLE

OVER
IS

WHEIMS

ALL

REASON TO THE POINT

THE VALUE OF
BILATERAL WILL LIP

SINGLE

NOT
SUCK

OF GREAT CONCERN
AT THE BREAST ATE

AN

INFANT
LITTLE

WITH

CLEFT CANNOT

AND VERY

INGENUITY

BE EVOKED TO PERPERU

WHAT

TO THE PARENTS IS

FRIGHTENING

AND MONSTROUS MISTAKE


SUCH AN INFANT
IF

WITH ALMOST
OPERATED
AU

NO HOPE OF CORRECTION
AFTER BIRTH

THUS

NOR

ON

BEFORE HE LEAVES

THE HOSPITAL
THIS

MAY

NEVER

RETURN FOR AGAIN


IN

SECOND CHANCE
AREAS

HAVE WITNESSED

TRAGEDY TIME

AND

CERTAIN

OF THE ORIENT

AND THE WEST INDIES

PARENTAL
IN

CONCERN
AND BYARS
HAS IN

1947
CHILD

BROWN MCDOWELL
WITH DOUBLE PSYCHIC
CLEFT

ST LOUIS

STATED

THE

OF THE LIP

VERY DIFFICULT

FEEDING SO

PROBLEM

PRODUCES

MUCH

SHOCK TO THE PARENTS

AND

INCITES

MANY EXCLAMA
IS

RIONS OF CURIOSITY
FAIRLY SATISFACTORY

AND PITY FROM OTHERS THAT AN


RULE
IS

EARLY

CLOSURE

NECESSARY

TO

CLOSE

IT

AS

SOON

AS

POSSIBLE AFTER THE BABY WEIGHS

TEN POUNDS

82

DONALD
BILATERAL

HUNDREDS UPON HUNDREDS MACCOLLUM WHO CLOSED


CLEFTS AT

OF

BOSTON CHILDRENS HOSPITAL


TO OPERATE AT SIX

THROUGH THE

40S
OTHER

50S AND
SURGEONS

60S

WAS CONTENT

POUNDS MOST

HAVE FOLLOWED
STRIKE

THE

10POUND

STANDARD OF

BROWN

FEW
AS THEIR

DEFORMITIES

PARENTS
LIP

WITH THE SAME SHOCK AND SHAME


ARE

SEVERE

BILATERAL

CLEFT

DOES THEY
SURGERY

ALMOST

FRANTIC

IN

EFFORTS TO HAVE

CORRECTIVE

STARTED

IMMEDIATELY

FOR

THE

SAKE

OF

THE

CHILD
IF

PARENTAL

CONCERN

MUST BE

SECONDARY

CONSIDERATION EXPLAINED
IS

USUALLY

THE REASONS FOR POSTPONEMENT ARE KINDLY WILLING


TO WAIT

THE PARENTS ARE QUITE

WHATEVER
DIFFERENT

INTERVAL

SUGGESTED
DIFFERENT

THEY

WILL

GET

DIFFERENT

TIMES

AND

REASONS

FROM

SURGEONS

FOR EARLY
CLAIRE
FIRST

MOLDING

ACTION
BILATERAL CLEFTS IN

STRAITH

OF DETROIT
LIFE

USED TO CLOSE HIS

THE

WEEKS OF COUPLE OF
AS HE

SO THAT THE MUSCLE BAND COULD RESTRAIN

THE PREMAXILLA

SAID
OSSIFIED

BEFORE THE PREMAXILLA

AND VOMER HAD


EARLY

ENOUGH TO
THAT

RESIST

DISPLACEMCNR

HE

FELT

SO STRONGLY ABOUT LOCAL

CLOSURE

AS LATE AS

1950

HE WAS

USING

ANESTHESIA TO BYPASS THE DANGERS OF NONENDOTRACHEAL

GENERAL ANESTHESIA MULTITUDE


CLOSURE

OF SURGEONS THROUGH THE YEARS HAVE LOOKED PHYSIOLOGICAL


RESTRAINING

TO LIP

AS THE CREATION OF

BAND WAYNE
COHORTS

SLAUGHTER BRODIE ACTION


STRAITH SIDE

WHO TRAINED
ALL

WITH

STRAITH

AND
III

HIS

CHICAGO

AND PRUZANSKY
AFTER LIP

HAVE CONFIDENCE SLAUGHTER


CLEFTS

THE MOLDING MUSCLE OPERATE


AS EARLY AS

CLOSURE

DID

NOT

BUT POSTPONED BILATERAL


SEVERAL

MONTH
SIDE

OR TWO FOR THE

FIRST

AND

MONTHS

FOR

THE SECOND

EVIDENTLY
BILATERAL

FEELING

AN URGENCY TO OPERATE EARLY THE PREMAXILLA OF CARACAS

ON COMPLICATED

CLEFTS TO

RESTRAIN

WITHOUT SECTION OF THE


IN

SEPTUM
SURGICAL

BARROS

SAINTPASTEUR

1964

REPORTED

HIS

TIMING

AFTER BLOOD STUDIES

OF COAGULATION

AND BLEEDING
ANESTHESIA
SIDE SIDE

TIME
FOR

RED BLOOD

COUNT AND HEMOGLOBIN


OF THE LIP

HE USED LOCAL
PALATE

VEAU
THE

CLOSURE
FIRST

AND

ANTERIOR BIRTH

ON ONE

DURING

36

HOURS FOLLOWING

AND ON THE SECOND


PALATE

16 TO 30 DAYS LATER

AT 15 MONTHS THE

POSTERIOR

WAS CLOSED

AND THE

LIP

CORRECTED SECONDARILY

83

FARA AND SMAHEL OF PRAGUE HAVE


BELIEVE THAT

MORE ETHEREAL

CONCERN THEY
OF THE

POSTEMBRYONIC

MESENCHYMAL
LATERAL LIP

PENETRATION HAS

PROLABIUM
CHANCE
IF

FROM THE
IS

ELEMENTS

BETTER

THE LIP

CLOSURE

CARRIED

OUT DURING

THE EARLY

MONTHS

EMERGENCY NO LONGER
IN
BILATERAL CLEFTS

THE SOONER THE LIP


SPECIAL

MUSCLES CAN BE JOINED

ACROSS

THE GAPS THE BETTER YET SURGERY

DEVICES
FITTED

TAKE THE URGENCY OUT OF THE RUBBER TUBE

AN

ASEPTO SYRINGE

WITH
OF THE INFANTS CAN

EXTENSION WITH THE

W1I
INFANT

PLACCD OVER ONE SIDE IN BOLT UPRIGHT


TRACTION

TONGUE AND
FEEDING HEADCAP THIS

POSITION

FACILITATE TO

REMARKABLY RUBBER BAND


CAN
TAKES

WHEN

ATTACHED

BE

EFFECTIVE

IN

RESTRAINING

THE PROJECTING

PREMAXILLA

THE PRESSURE OFF THE NEED FOR EARLY SURGERY THE PATIENT
IS

WHICH

NOW CAN

BE POSTPONED UNTIL

REALLY

READY

PROCRASTINATION
THERE
YEARS ARE THOSE

RECONSIDERED
POSTPONE SURGERY CONSCIENTIOUSLY OVERREACTION
FOR TO

WHOWOULD
IS

AND YEARS THIS

PROBABLY SURGEONS

SOPHISTICATED

THE FACT THAT FOR CENTURIES


RESORTED TO DRASTIC ALVEOLAR

OBSESSED WITH CLOSING THE HOLE EVENTUALLY DENTISTS FACING PROTEST

PROCEDURES DISTORTIONS

UNTIL

UNBELIEVABLE

STARTED

AN ANTISURGERY

BOTH SURGEONS AND


THE

DENTISTS

TURNED TO UNOPERATED OF MEXICO DEFORMITY

ADULT CLEFTS FOR


THAT IN

ANSWER ORTIZMONASTERIO
CLEFTS THE ORIGINAL

FOUND

ADULTS

WITH UNTREATED

DID NOT INCREASE DURING

THE NATURAL PROCESS OF


BETTER

GROWTH PITANGUY
THESE CASES

OF BRAZIL

WENT HIM ONE


WITH AGING

BY CLAIMING
HIS FINDINGS

THAT

ACTUALLY IN

IMPROVED

AND HAD

CONFIRMED
IN

BY INNIS

NORTH BORNEO AND


IS

MESTRE JESUS AND SUBRELNY


BY THE UNOPERATED
IT IS

PUERTO RICO
CLEFT

THE SAME

SUGGESTED

ADULT

BILATERAL

SHOWN HERE
MOST

SEEN IN

JA

MAICA
TIES

GENERALLY ACCEPTED
THAT

HOWEVER IN
SUFFER

CIVILIZED

SOCIE
LEFT

EVEN BY DENTISTS
FACIAL

PATIENTS

MORE FROM BEING


WAITING

WITH UNCORRECTED
BLE

CLEFTS

THROUGH CHILDHOOD

POSSI

IMPROVEMENT

THAN FROM HAVING

THEM

CLOSED EARLIER

BY

MOD

ERN ATRAUMATIC

METHODS

84

IN 1965 SKOOG OF SWEDEN ADDED EMERGENCY BUT

AGREED THAT

CLEFT LIP

SURGERY

IS

NOT AN

SURGEONS
ITSELF UTILIZE
IS

MAY

DIFFER

CONCERNING
ISSUE

THAT SPECIFIC
AS

AGE FOR SURGERY


IS

BUT THIS

IN

NOT AN IMPORTANT
THE EXISTING

LONG AS REPAIR

CARRIED

OUT EARLY ENOUGH TO


THE

GROWTH FACTORS FOR GRADUAL


IS

CORRECTION

OF

DEFORMITY
IN

THIS

AA

PRINCIPLE COMPLETE

OF RECONSTRUCTIVE SURGERY
BILATERAL CLEFT

ESPECIALLY

IMPORTANT

THE

CASE OF

OF THE

LIP

AND ALVEOLUS

AN

EARLY

CONFLICT

THE BILATERAL ALTHOUGH MOST MODERN SURGEONS BEGIN OPERATING ON CLEFT LIP BETWEEN THE EARLY WEEKS AND THE THIRD MONTH OF AGE IT
IS

INTERESTING

TO STUDY

THE TWO EXTREMES

OF THIS

TIMING

AS

EX

PRESSED IN LIP

TWO BOOKS STARKS 1968


BY

CLEFT PALATE

AND THE 1971

CLEFT

AND

PALATE

GRABB

ROSENSTEIN

AND BZOCH

MATTER OF WEEKS

DEHAAN
FIRST

FOR STARK
LIFE

ADMITTED

AVOIDING

THE OPERATION
PERINATAL

DURING

THE BUT

24

HOURS OF

BECAUSE OF THE HIGH THE EARLY WEEKS

MORTALITY

ADVOCATED

CLOSURE

IN

THE VERY YOUNG INFANT WHO


RESISTANCE TO

STILL

HAS IMMUNITY

FROM THE MOTHER AND HIGH


ANESTHESIA

INFECTION

TOLERATES

SURGERY WELL AND REQUIRES MINIMAL

HE

MENTIONED

OTHER ADVANTAGES

SUCH

AS

SOLVING

THE
AS

SUCKING DETERRENT

PROBLEM PROTECTION
TO RESPIRATORY ORIS TRACT

OF THE NASOPHARYNGEAL
INFECTIONS

MUCOSA

AND

EARLY

UNION OF THE
ORTHODONTIC
CITED

ORBICULARIS

MUSCULATURE

TO ACT AS

BIOLOGICAL

BAND ON THE
AN EXAMPLE
BILATERAL CLEFT

PREMAXILLARY

AND MAXILLARY

SEGMENTS DEHAAN

OF POSTPONING LIP INFANT

SURGERY IN
PATIENT

4POUND
ONLY

PREMATURE
TO AM

THE

TINY

NOT

FAILED

GAIN

WEIGHT

BUT

DEVELOPED

AN

UPPER

RESPIRATORY

INFECTION
HIS TOTAL

TWO AND ONEHALF

WEEKS WITH

LOSS OF

ONEEIGHTH OF

BODY WEIGHT CORRECTIVE PROMPT

LIP SURGERY AT SEVEN

AND ONEHALF WEEKS WAS FOLLOWED BY

GAIN

DEHAAN CONCLUDED

IN

RETROSPECT DEFERRING SURGERY BECAUSE OF PREMATURITY COLLEAGUES AGREE

WAS

MISTAKE

AS

OUR

PEDIATRIC

85

DEHAAN
FOR INCREASE

ALSO STRIKES IN

DOWN THE ARGUMENT


OF THE LIP
TO

THAT

ONE SHOULD WAIT


CLOSURE

THE SIZE

FACILITATE

WE HAVE
LIP

NOT FOUND THIS

TO BE TRUE
IS

AND
EASIER

IN

FACT FEEL THAT THE SLIGHTLY

LONGER

AT THE AGE OF

MONTHS

NO

TO CORRECT

OR MONTHS RAY BRAUER


LIP FOR

GRABB

ET

AL

CITED

THE

COMMON CAUSES

DELAYING

CLOSURE

PROTRUDING

PREMAXILLA

COLLAPSE OF THE LATERAL PALARAL SUCH AS CONGENITAL

SEGMENTS THE PRESENCE


OF THE HEART

OF OTHER CONGENITAL ANOMALIES

DEFORMITY

AND

POOR GENERAL NUTRITION


BABIES WITH POOR GENERAL
STATUS
IS

NUTRITION

SIMPLY

FAIL

TO THRIVE

AND UNTIL

THE

GENERAL NUTRITIONAL DELAYED

ONE OF STEADY IMPROVEMENT

SURGERY SHOULD BE

BRAUER

CONCLUDED
UNTIL THE CHILD TO THIS

TODAY MOST SURGEONS PREFER TO WAIT


WEIGHS
SUFFICIENT AT LEAST

IS

MONTHS OLD AND


ALLOWS TIME
FOR

12

POUNDS BEFORE STARTING LIP

REPAIR
LIP

DEVELOPMENT OF THE PROLABIAL AND AND EXECUTION


OF THE

LATERAL

SEGMENTS

AND MAKES
THIS

BOTH PLANNING
MAXILLARY

SURGERY EASIER

DURING

PERIOD

ORTHOPEDIC

PROCEDURES

CAN BE USED

BIT

OF BOTH

IN

1970

RUSSIAN

HANDBOOK
INSTITUTE IN BILATERAL STATED CLEFTS

KOLESOV OF THE
IN

MOSCOW
PRI

MEDICALSTOMATOLOGICAL

REFERENCE TO THE

MARY
IN THE

LIP

OPERATION

FIRST

STAGE ONLY ONE SIDE OF THE CLEFT

IS

CLOSED THE

FIRST

STAGE IN

MOST
OF

CHILDREN CAN BE CARRIED OUR WHILE THE CLEFT


IS

THEY ARE IN THE NURSERY

THE

OTHER SIDE

CLOSED AFTER

TWO TO TWO AND ONEHALF MONTHS

THE

PRELIMINARY

LIP

ADHESION
OF CREATING
IT IS

THE SIMPLE QUICK


MINOR SOME

BLOODLESS PROCEDURE
ACROSS

PRELIMINARY
TO ACHIEVE

LIP ATTACHMENT BENEFITS

THE CLEFT MAKES THIS


IT

POSSIBLE

QUITE
ITS

EARLY

OF COURSE

THE APPEAL
LIES

OF

THE

ADHESION AND

REAL

VALUE

WOULD SEEM

IN

ITS

EARLY

USE
FOR

BENGT JOHANSON AND

EMPLOYED THE PRELIMINARY

ADHESION

86

VARIOUS PRIMARY MANIPULATION PRELIMINARY


TO BE
LIP

REASONS BUT BOTH OF US ENJOYED SOME PREMAXILLARY

FROM OUR ADHESIONS


ALVEOLAR

CELESNIK

IN

1962

PROPOSED

AND

NASAL

FLOOR CLOSURE AT FOUR

MONTHS OF AGE AND


DEFINITIVE AT
FIRST

FOLLOWED WITH

PROSTHODONTIC
SIX

MANIPULATION
LATER

SOONER THAN SURGERY NO

MONTHS

RANDALL

ENTHUSIASTIC

AND NOW MORE


BUT NOT UNTIL

SELECTIVE

USES PRELIMINARY SIX

ADHESION
IN

IN

TWO

THREE

AND

STAGES

MONTHS OF AGE
LIP

BILATERAL

CLEFTS

WALKER AND COLLITO

APPROXIMATED

CLEFT EDGES

WITHOUT

UNDERMINING ON
BUT WITH

CONSERVATIVE

COMBINATION OF ADHESIONCLOSURE SEGMENTS


FEAR THAT

GOOD MOLDING
ALL

OF THE MAXILLARY ADHESIONS


LED

EVIDENTLY

OF THESE

AND THE

SURGERY WILL

STUNT MAXILLARY

GROWTH

ONE AUSTRIAN
TO PROPOSE

SURGEON
IN

HOLLMANN
SEQUENCE
SINCE FLAPS

OF THE UNIVERSITY OPERATIONS WITH

OF VIENNA
VARIATION IN

1973

OF

TIMING

THAT

HE HAS USED

1967
FROM

AT

ONE WEEK OF AGE HE CREATES


LIP

AN ADHESION

WITH MUCOSAL
INFERIOR

THE LATERAL VERMILION

SEGMENTS SUTURED
LETS THIS

UNDER THE

PROLABIUM

AND
SOFT

STIMULATE

TISSUE

GROWTH OF THE

LABIAL

STUMPS

IN

THE

CLEFTED

AREA

AT ONE
AGE
IS

YEAR

THE SOFT PALATE


CLOSURE

IS

CLOSED

AND NOT

UNTIL

TWO

YEARS

OF

THE DEFINITIVE

OF THE LIP

ACCOMPLISHED

PRIME

TIME
VERY SEVERELY PROTRUDING PREMAXILLA

IN THE RARE CASE WITH CANNOT BE POSITIONED SCREW RETRACTION

WHICH

PROPERLY BY RUBBER BAND TRACTION

OR COAXIAL

AN ADHESION

MAY

BE THE BEST

PRELIMINARY

MA
LL

NEUVER AND CAN BE EXECUTED AT THE TIME


IN

OF SOFT PALATE
TO BYPASS DEFINITIVE

CLOSURE YET THE ADHESION CLOSURE IN

MOST COMPLETE

BILATERAL

CLEFTS

PREFER

AND ACHIEVE

THE EARLIEST

PRACTICAL

ONESTAGE
ACROSS

ORDER TO CREATE AN INTACT THE RUBBER BAND TRACTION

MUSCLE BAND FROM


TO

BOTH

CLEFTS AS

SOON

AS

HEADCAP

HAS REDUCED

THE PROJEC OPERATION


IS IS

NON

OF THE PREMAXILLA
POSSIBLE AT ONE

REASONABLE DEGREE THIS


OR EARLIER FEEL THAT

USUALLY

MONTH

PROVIDED

THE BABY

WELL

AND GAINING
NEED BE
BILATERAL

WEIGHT

DO NOT

MUSGRAVES
10

EERULE OF IN

10
IN

ENFORCED WITH
CLEFTS

REGARD TO THE

POUNDS

WEIGHT
CITED

BUT HIS OTHER STANDARDS ARE ESSENTIAL

AS

YEARS

87

AGO BY OXFORDS PROFESSOR KILNER AND NO EVIDENCE


ENSURING HEALING OF

AT LEAST

10 GIN

OF HEMOGLOBIN
ARE ESSENTIAL TO

UPPER

RESPIRATORY

INFECTION

SMOOTH POSTOPERATIVE

COURSE WITH

OPTIMUM WOUND

TRIPLE
AT THE TIME

ACTION
OF BILATERAL
ORITIS LIP

CLOSURE
CLEFT

TWO OTHER
PALATE

ASPECTS ALSO

OF THE CLEFT TREATED

SYNDROME
USUALLY SUCTION

MEDIA
THE

AND

ARE

AS

INDICATED OF FLUID THEN

ENT
AND
AS

ACTIONS

OF BILATERAL

MYRINGOTOMY
OUT
IS

AND

INSERTION

OF TUBES ARE CARRIED

MOUTH
CLOSED AS

GAG

IS

INSERTED

MUCH

SOFT

PALATE

CLEFT

POSSIBLE BY SIMPLE

EDGE SPLITTING

AND APPROXIMATING WITH SUTURES


PROVIDES
AT

EARLY MUSCLE CLOSURE OF THE VELUM


CLEFT

THE BACK OF THE


THAT

THE SAME

MOLDING

CONTRACTING

MUSCLE ACTION
WILL

THE

LIP

CLOSURE ACHIEVES DISUSE BE AVOIDED


EARLY

UP

FRONT
THERE

NOT

ONLY

THE

VELAR

ATROPHY

OF

BUT

MUST BE

BENEFICIAL

EFFECTS

FROM THE

COORDINATION

OF VELAR

AND PHARYNGEAL BEING QUICK


LIP

MUSCULATURE THUS AND BLOODLESS AND


ARE

THESE TWO ADDITIONAL TAKING SO


LITTLE

PROCEDURES

TIME

FROM THE PRIMARY


ASSETS THAT

OPERATION ACCRUE

MORE

THAN JUSTIFIED

BY THE

EVENTUALLY

88