[Illustration: FIG. 64.—Shows effect of drawing stitches together when needles cutting parallel to the edge of the cleft have been used, resulting in an oval opening at the site of each needle puncture.] [Illustration: FIG. 65.—Contrasts the effect produced when needles cutting at right angles to the cleft margin are used. There is no tendency to opening up of the needle tracks, but rather to close them.] With reference to the _sutures_, many different materials have been employed, such as silk, silkworm gut, catgut, horsehair, and fine silver wire. For many reasons the silver wire is to be preferred; it can be more easily and accurately adjusted to the required degree of tension, and has no tendency to slip; catgut and horsehair are often so springy that the knots are liable to come unfastened. Silver wire is less irritating, and therefore can be left for an almost indefinite period _in situ_; it is incapable of absorbing septic material, and is insoluble in the tissues. The method of introducing the wire stitches is described later (p. 119); the wire twister (Fig. 66) will be found useful for the purpose of regulating their tension. [Illustration: FIG. 66. Wire twister (_Maw_).] The thickness of the wire used must vary directly with the delicacy or otherwise of the palatal tissues; the thinner the palate, the finer the wire, and _vice versâ_. In different portions of the same palate, wires of varying thicknesses have often to be used. The principal varieties that I make use of are Nos. 30 and 32 on the ordinary wire gauge. Whichever is used, it should be uniformly and well annealed, otherwise it is liable to break whilst being twisted, and does not straighten out on removal. In the region of the uvula it is better to employ some softer material, such as fine silk or catgut, as the projection of the ends of the wire has a tendency to irritate the back of the tongue and cause coughing and nausea. A narrow straight probe-pointed bistoury may be needed to extend the lateral incisions into the soft palate, in order to relieve lateral tension. THE OPERATION. It will be convenient first to describe in detail the technique of the operation in a typical case of combined cleft of the hard and soft palate, _i. e._ the operations of uranoplasty and staphyloraphy combined, and subsequently indicate the modifications necessary under special circumstances.