If there be any difficulty experienced in accomplishing this, owing to the presence of cicatricial thickening of the parts, the latter must be excised in gutterlike fashion (author), and the mucous membrane be freed from its attachment until it comes into place readily. Care should be especially exercised in lining the angles of the newly formed mouth. The subsequent contraction of the rima oris following the above operation is prevented only by lining the angle with mucous membrane, healing into place by first intention. [Illustration: FIG. 255. FIG. 256. DIEFFENBACH METHOD.] =Rose Method.=—Rose advises sewing a small triangular flap of mucous membrane into each angle to overcome the contraction. =Heuter Method.=—Heuter employs an artificial mouth of hard rubber tubing of a size corresponding to the new mouth made in the form shown in Fig. 257. This ring is forced into the oral opening and the patient is instructed to wear it for some weeks after the operation or until the tissues have become softened and elongated and will no longer retain it. [Illustration: FIG. 257.—ARTIFICIAL MOUTH. (Heuter.)] =Nonoperative Treatment.=—Smaller operations about the mucosa alone are of no avail to correct this deformity, but where the contraction of the oral orifice is moderate and of recent origin, exercising the mouth and stretching the angles forcibly may help to overcome the deformity to a great extent. Smaller deformities due to contraction usually subside after a time from the normal use of the mouth. The hypodermic injection of a solution of thiosanimin or fibrolysin (Mendel) are of import in cases where an operation cannot be undertaken. Their use is more fully described in a later chapter. CHAPTER XIII MELOPLASTY (_Surgery of the Cheeks_) This branch of surgery has to do with the reconstruction or restoration of the cheek following the excision of scars or the extirpation of malignant growths. The procedure is also recognized as genioplasty. SMALL AND MEDIUM DEFECTS Where the defect occasioned by the ablation is of small extent, the free and somewhat undermined margins of the wound, which should be made in elliptical form, are neatly brought together with several retention sutures alternating with superficial sutures of fine twisted silk. If deeper structure than the skin be involved, the diseased area should be carefully removed even to the limitation of the buccal mucous membrane, the soft parts detached from the mucous membrane to render them mobile, and the wound brought together by suture. Care must be exercised so that the tension of the suture does not create a new deformity, such as blepharal ectropium, distortion of the rima oris or the alæ of the nose. If there is enough mucous membrane after the excision of the diseased area, Oberst advocates closing the defect with two pedunculated flaps made each from the mucous membrane of the cheek and of the lip.