PLASTIC AND COSMETIC SURGERY

[Illustration: “FATHER OF PLASTIC SURGERY.”]




                               PLASTIC AND
                             COSMETIC SURGERY

                                    BY
                      FREDERICK STRANGE KOLLE, M.D.
       FELLOW OF NEW YORK ACADEMY OF MEDICINE; MEMBER OF DEUTSCHE
     MEDEZINISCHE GESELLSCHAFT, N. Y., KINGS COUNTY HOSPITAL ALUMNI
     SOCIETY, AUTHORS’ COMMITTEE AMERICAN HEALTH LEAGUE, PHYSICIANS’
          LEGISLATURE LEAGUE ETC.; AUTHOR OF “THE X-RAYS: THEIR
       PRODUCTION AND APPLICATION,” “MEDICO-SURGICAL RADIOGRAPHY,”
               “SUBCUTANEOUS HYDROCARBON PROTHESES,” ETC.

               _WITH ONE COLORED PLATE AND FIVE HUNDRED AND
                    TWENTY-TWO ILLUSTRATIONS IN TEXT_

                              [Illustration]

                           NEW YORK AND LONDON
                         D. APPLETON AND COMPANY
                                   1911

                           COPYRIGHT, 1911, BY
                         D. APPLETON AND COMPANY

                      PRINTED AT THE APPLETON PRESS,
                            NEW YORK, U. S. A.




                                    TO

                         ALPHONZO BENJAMIN BOWERS

                   WHO KINDLED THE FIRE OF MY AMBITION
                          AND KEPT IT BURNING BY
                  HIS INTEREST AND UNTIRING APPRECIATION
                               THIS WORK IS
                         WITH HEARTFELT GRATITUDE
                                INSCRIBED




PREFACE


The object of the author has been to place before the profession a
thoroughly practical and concise treatise on plastic and cosmetic
surgery. The importance of this branch of practice is at the present
time undeniable, yet the literature on this subject is widely scattered
and scanty. It consists mostly of small, detached papers or reports
in different countries, with an occasional reference in text-books on
general surgery.

The author feels, from the numerous inquiries made him by physicians from
many parts of the world concerning methods herein described, that there
is now an actual need for an authoritative work on this subject.

Great care has been taken to select the best matter and to present
it with comprehensive illustrations every physician can readily and
confidently refer to.

Skin-grafting has been particularly gone into, as well as electrolysis
as applied to dermatology, with information as to the construction and
scientific use of apparatus involved.

To the whole has been added the practical experience and criticism of
the author, who has devoted many years to the scientific and faithful
advancement of this specialty.

                                                  FREDERICK STRANGE KOLLE.

12 EAST THIRTY-FIRST STREET, NEW YORK CITY.




CONTENTS


                                                                      PAGE

                                CHAPTER I

                                HISTORICAL

    Historical                                                           1

                               CHAPTER II

                       REQUIREMENTS FOR OPERATING

    The operating room: The walls; The floors; Skylight;
    Disinfection; Instrument cabinet; Operating table; Instrument
    table; Irrigator—Care of instruments—Preparation of the surgeon
    and assistants: Care of the hands; Gowns—Preparing the patient:
    General preparation; Preparation of the operative field              9

                               CHAPTER III

                      REQUIREMENTS DURING OPERATION

    Sponges and sponging—Sterilization of dressings: Wallace
    sterilizer; Sprague sterilizer; Sterilizing plant; Dressing
    cases; Waste cans—Sutures and sterilization: Silkworm gut and
    silk; Catgut                                                        22

                               CHAPTER IV

                          PREFERRED ANTISEPTICS

    Antiseptic solutions—Antiseptic powders                             34

                                CHAPTER V

                             WOUND DRESSINGS

    Sutured wounds—Sutureless coaptation—Granulation—Changing
    dressings—Wounds of the mucous membrane—Pedunculated
    flaps—Foreign bodies                                                43

                               CHAPTER VI

                          SECONDARY ANTISEPSIS

    Septicemia following wound infection—Gangrene—Erysipelatous
    infection                                                           52

                               CHAPTER VII

                               ANESTHETICS

    General anesthesia: Preparation for general anesthesia;
    Chloroform; Ether; Combined anesthesia; Nitrous oxid; Ethyl
    bromid; Ethyl chlorid—Local anesthesia: Ethyl chlorid; Cocain;
    Beta eucain; Liquid air; Stovain                                    58

                              CHAPTER VIII

                      PRINCIPLES OF PLASTIC SURGERY

    Incisions—Sutures—Needles—Needle holders—Methods in plastic
    operations: Stretching method; Sliding method; Twisting
    method; Implantation of pedunculated flaps by bridging;
    Transplantation of nonpedunculated flaps or skin-grafting;
    Autodermic skin-grafting; Heterodermic skin-grafting;
    Zoödermic skin-grafting—Mucous-membrane-grafting—Bone-
    grafting—Hair-transplantation                                       76

                               CHAPTER IX

                             BLEPHAROPLASTY

    Ectropion: Partial ectropion;
    Complete ectropion; Ectropion of both
    lids—Epicanthus—Canthoplasty—Ptosis—Ankyloblepharon—Wrinkled
    eyelids—Xanthelasma palpebrarum                                    103

                                CHAPTER X

                                OTOPLASTY

    Restoration of the auricle—Auricular
    protheses—Coloboma—Malformation of the lobule: Enlargement of
    the lobule; Attachment of the lobe—Malformation of the auricle:
    Microtia—Auricular Appendages—Polyotia—Malposition of the
    auricle                                                            120

                               CHAPTER XI

                              CHEILOPLASTY

    Harelip: Classification of harelip deformities; The operative
    correction of harelip; Of unilateral labial cleft; Of
    congenital bilateral labial cleft; Post-operative treatment of
    harelip—Superior cheiloplasty: Classification of deformities
    of the upper lip; Operative correction of deformities of the
    upper lip—Inferior cheiloplasty—Labial deficiency—Labial
    ectropion—Labial entropion—Vermilion deficiency                    145

                               CHAPTER XII

                              STOMATOPLASTY

    The correction of macrostoma—The correction of microstoma          192

                              CHAPTER XIII

                               MELOPLASTY

    Small and medium defects—Large defects—Employment of protheses     198

                               CHAPTER XIV

                   SUBCUTANEOUS HYDROCARBON PROTHESES

    Indications—Precautions—The advantage of the method—Untoward
    results: Intoxication; Reaction; Infection; Necrosis;
    Sloughing; Sloughing due to pressure; Subinjection;
    Hyperinjection; Air embolism; Paraffin embolism; Primary
    diffusion or extension of paraffin; Interference with
    muscular action of the wings of the nose; Escape of paraffin
    after withdrawal of needle; Solidification of paraffin in
    needle; Absorption or disintegration of the paraffin; The
    difficulty of procuring paraffin with proper melting point;
    Hypersensitiveness of skin; Redness of the skin; Secondary
    diffusion of the injected mass; Hyperplasia of the connective
    tissue following the organization of injected matter; Yellow
    appearance and thickening of the skin after organization
    of the injected mass has taken place; The breaking down of
    tissue and resultant abscess due to the pressure of the
    injected mass upon the adjacent tissue after the injection has
    become organized—The proper instruments for the subcutaneous
    injection of hydrocarbon protheses—Preparation of the site of
    operation—Preparation of the instruments for operation—The
    practical technique—Specific classification for the employment
    and indication of hydrocarbon protheses about the face—Specific
    classification for the employment and indication of hydrocarbon
    protheses about the shoulders, etc.—Specific technique for the
    correction of regional deformities about the face: Transverse
    depressions; Deficient or receding forehead; Unilateral
    deficiency; Interciliary furrow; Temporal muscular deficiency;
    Deformities of the nose; Deformities about the mouth;
    Deformities about the cheeks; Deformities about the orbit;
    Deformities about the chin; Deformities about the ear—Specific
    technique for the correction of deformities about the shoulders    209

                               CHAPTER XV

                               RHINOPLASTY

    The causes of nasal destruction—Classification of
    deformities—Surgical technique—Protheses—Nasal replanting—Nasal
    transplanting—Total rhinoplasty: Pedunculated flap method; The
    Indian or Hindu method; The French method; The Italian method;
    The combined flap method; Organic support of nasal flaps;
    Periostitic supports; Osteoperiostitic supports; Cartilaginous
    support of flap—Partial rhinoplasty; Restoration of base of
    nose; Restoration of lobule and alæ; Restoration of the alæ;
    Restoration of nasal lobule; Restoration of subseptum              339

                               CHAPTER XVI

                          COSMETIC RHINOPLASTY

    Angular nasal deformity—Correction of elevated
    lobule—Correction of bulbous lobule—Angular excision to
    correct lobule—Correction of malformations about nasal
    lobule—Deficiency of nasal lobule—Correction of widened base
    of nose—Reduction of thickness of alæ—Correction of nasal
    deviation—Undue prominence of nasal process of the superior
    maxillary                                                          448

                              CHAPTER XVII

                       ELECTROLYSIS IN DERMATOLOGY

    The electric battery—The voltage or electromotive force—Cell
    selector—Milliampèremeter—The electric current—Portable
    batteries—Electrodes—Removal of superfluous hair—Removal
    of moles or other facial growths—Telangiectasis—Removal of
    nævi—Removal of tattoo marks—The treatment of scars                470

                              CHAPTER XVIII

                         CASE RECORDING METHODS

    Photographs—Stencil record—The rubber stamp—The plaster
    cast—Preparation of photographs                                    491




LIST OF ILLUSTRATIONS

=Transcriber’s Note:= Some illustrations have been moved to where they fit
best with the surrounding text.


    FIG.                                                              PAGE

    A. Cornelius Celsus (“Father of Plastic Surgery”).       _Frontispiece_

                               HISTORICAL

      1.—Celsus incision for restoration of defect                       2

      2.—Celsus incision to relieve tension                              2

                       REQUIREMENTS FOR OPERATING

      3.—Formaldehyd disinfecting apparatus                             11

      4.—Instrument cabinet                                             12

      5.—Operating table                                                13

      6.—Instrument table                                               14

      7.—Irrigator                                                      15

      8.—Instrument sterilizer                                          16

      9.—Aseptic washstand                                              17

     10.—Von Bergman operating gown                                     19

     11.—Triffe rubber apron                                            19

                      REQUIREMENTS DURING OPERATION

     12.—Basins and rack                                                23

     13.—Willy Meyer sterilizer                                         25

     14.—Wallace sterilizer                                             25

     15.—Sprague type of sterilizer                                     26

     16.—Sterilizing plant                                              28

     17.—Dressing case                                                  29

     18.—Combination dressing case and table                            29

     19.—Waste pail                                                     30

     20.—Clark Kumol apparatus                                          32

                             WOUND DRESSING

     21, 22.—Plaster sutures                                            46

     23, 24.—Angular plaster sutures                                    46

                          SECONDARY ANTISEPSIS

     25.—Walcher dressing forceps                                       55

     26.—Toothed seizing forceps                                        55

                               ANESTHETICS

     27.—Schimmelbusch dropping bottle                                  60

     28.—Esmarch dropping bottle                                        60

     29.—Schimmelbusch folding mask                                     61

     30.—Esmarch inhaler                                                61

     31.—Allis inhaler                                                  65

     32.—Fowler inhaler                                                 65

     33.—Juillard mask                                                  66

     34.—Simplex syringe                                                72

     35.—Kolle improved Pravaz syringe                                  72

     36.—“Sub-Q” syringe                                                72

                      PRINCIPLES OF PLASTIC SURGERY

     37.—⅝ circle Haagedorn needles                                     77

     38.—Crescent curve Haagedorn needles                               77

     39.—Kersten-Mathieu needle holder                                  78

     40.—Haagedorn needle holder                                        78

     41.—Pozzi-Haagedorn needle holder                                  78

     42.—Weber-Haagedorn needle holder                                  78

     43.—Needleholder with suture carrier                               78

     44.—Celsus skin incisions                                          80

     44 _a_.—Celsus relieving incisions                                 80

     45.—Rhomboid excision                                              80

     46.—Union of rhomboid excision                                     80

     47.—Oblong excision                                                81

     48.—Coaptation of wound                                            81

     49.—Bitriangular excision                                          81

     50.—Linear coaptation                                              81

     51.—Triangular excision                                            81

     52.—Coaptation of wound                                            81

     53.—Triangular excision with relieving incisions                   82

     54.—Coaptation of wound                                            82

     55.—Square excision                                                82

     56.—Coaptation of wound                                            82

     57.—Square excision                                                82

     58.—Coaptation of flaps                                            82

     59.—Triangular excision                                            83

     60.—Coaptation of flap                                             83

     61.—Triangular excision                                            83

     62.—Coaptation of flaps                                            83

     63.—Triangular excision                                            83

     64.—Arrangement of flaps                                           83

     65.—Double triangular excision                                     84

     66.—Coaptation of wound                                            84

     67.—Tri-triangular excision                                        84

     68.—Coaptation of wound                                            84

     69.—Rectangular-bitriangular excision                              84

     70.—Coaptation of wound                                            84

     71.—Weber excision method                                          85

     72.—Coaptation of flaps                                            85

     73.—Elliptical excision                                            85

     74.—Coaptation of flaps                                            85

     75.—Triangular excision                                            86

     76.—Coaptation of flaps                                            86

     77.—Triangular excision                                            86

     78.—Coaptation of flaps                                            86

     79.—Lentenner method of excision                                   86

     80.—Coaptation of flap                                             86

     81.—Burns method of excision                                       87

     82.—Coaptation of flaps                                            87

     83.—Tagliacozza harness                                            87

     84.—Smith skin-grafting scissors                                   89

     85.—Thiersch skin-grafting razor                                   93

     86.—Thiersch folding razor                                         93

     87.—Method of cutting Thiersch graft                               94

     88.—Method of placing Thiersch graft                               95

                             BLEPHAROPLASTY

     89.—Correction of ectropion, Dieffenbach method                   104

     90 _a_ and _b_.—Correction of partial ectropion (author’s case)   104

     91, 92.—Complete ectropion, Dieffenbach method                    106

     93, 94.—Complete ectropion, Wolfe method                          107

     95, 96.—Complete ectropion, Fricke method                         108

     97, 98.—Complete ectropion, Ammon-Von Langenbeck method           109

     99, 100.—Complete ectropion, Dieffenbach-Serre method             110

    101, 102, 103.—Complete ectropion, Tripier method                  111

    104, 105.—Complete ectropion, Von Artha method                     112

    106, 107.—Epicanthus, Bull method                                  113

    108.—Probe-pointer angular scissors                                114

    109, 110, 111.—External canthoplasty                               115

    112, 113.—Blepharoplastics, author’s method                        116

    114.—Curved eye scissors                                           117

                                OTOPLASTY

    115.—Partial restoration of the auricle                            124

    116.—Correction of lobular defect                                  126

    117.—Coaptation of wound                                           126

    118, 119.—Greene method correcting coloboma                        126

    120.—Noyes’s clamp                                                 127

    121, 122.—Correction of attached lobe                              128

    123.—Restoration of auricle, Szymanowski method                    129

    124.—Auricular stump for attachment of artificial ear              130

    125.—Auricular prothesis                                           130

    126.—Auricular prothesis applied to stump                          131

    127.—Anterior view of auricular prothesis                          131

    128.—Posterior view of auricular prothesis                         131

    129, 130, 131.—Schwartze method of correction of macrotia          134

    132, 133.—Parkhill method of correction of macrotia                135

    134, 135.—Author’s method of correction of macrotia                137

    136, 137.—Author’s method of correction of macrotia                137

    138.—Monks’ method of correction of malposed ear                   139

    139, 140.—Author’s method of correction of malposed ear            140

    141, 142.—Correction of malposed auricles, author’s case
           (anterior view)                                             142

    143, 144.—Posterior view of replaced auricles                      143

                              CHEILOPLASTY

    145.—Burchardt compression forceps                                 145

    146.—Beinl harelip clamp                                           145

    147.—Median cleft, Siegel’s case                                   147

    148.—Median cleft with rhinophyma, Trendelenburg’s case            147

    149, 150, 151.—Types of unilateral labial cleft                    148

    152.—Unilateral facial cleft, Hasselmann                           149

    153.—Bilateral facial cleft, Guersant                              149

    154.—Buccal fissure with macrostoma                                150

    155, 156, 157.—Harelip correction, Nélaton method                  152

    158, 159.—Harelip correction, Fillebrown method                    153

    160, 161, 162.—Harelip correction, Von Langenbeck-Wolff-Sedillot
           method                                                      153

    163, 164, 165.—Harelip correction, Malgaigne method                154

    166, 167.—Harelip correction, Gräfe method                         154

    168, 169, 170.—Harelip correction, Mirault method                  155

    171, 172, 173.—Harelip correction, Giralde method                  155

    174, 175, 176.—Harelip correction, König method                    156

    177, 178, 179.—Harelip correction, Maas method                     156

    180, 181, 182.—Harelip correction, Haagedorn method                157

    183, 184, 185.—Harelip correction, Dieffenbach method              157

    186, 187.—Correction bilateral cleft, Von Esmarch method           159

    188, 189, 190.—Correction bilateral cleft, Maas method             159

    191, 192, 193.—Correction bilateral cleft, Haagedorn method        160

    194, 195, 196.—Correction bilateral cleft, Simon method            160

    197.—Hainsley cheek compressor                                     161

    198, 199.—Superior cheiloplasty, Bruns method                      164

    200, 201.—Superior cheiloplasty, Sedillot method                   165

    202.—Superior cheiloplasty, Buck method                            165

    203, 204, 205.—Superior cheiloplasty, Estlander method             166

    206, 207.—Inferior cheiloplasty, Richerand method                  169

    208, 209.—Extirpation of vermilion border                          169

    210, 211.—Inferior cheiloplasty, Celsus method with additional
           incisions                                                   170

    212, 213.—Inferior cheiloplasty, Estlander method                  171

    214, 215.—Inferior cheiloplasty, Bruns method                      172

    216, 217.—Inferior cheiloplasty, Buck method                       172

    218, 219.—Inferior cheiloplasty, Dieffenbach method                173

    220, 221.—Inferior cheiloplasty, Jäsche method                     174

    222, 223.—Inferior cheiloplasty, Trendelenburg method              174

    224, 225.—Inferior cheiloplasty, Bruns method                      175

    226, 227.—Inferior cheiloplasty, Bruns bilateral method            175

    228, 229, 230.—Inferior cheiloplasty, Buchanan method              176

    231, 232.—Inferior cheiloplasty, Syme method                       177

    233, 234.—Inferior cheiloplasty, Blasius method                    178

    235, 236.—Inferior cheiloplasty, Bürow method                      178

    237, 238.—Inferior cheiloplasty, von Langenbeck                    179

    239, 240.—Inferior cheiloplasty, Morgan method                     180

    241, 242.—Inferior cheiloplasty, Zeis method                       181

    243, 244.—Inferior cheiloplasty, Delpech method                    182

    245, 246.—Inferior cheiloplasty, Teale method                      185

    247, 248.—Labial ectropion, author’s method                        187

    249, 250.—Labial ectropion, author’s method                        188

                              STOMATOPLASTY

    251, 252.—Correction of Macrostoma, Dieffenbach-Von Langenbeck
           method                                                      193

    253, 254.—Correction of Macrostoma, author’s method                195

    255, 256.—Correction of Microstoma, Dieffenbach method             196

    257.—Artificial mouth, Heuter                                      196

                               MELOPLASTY

    258, 259.—Meloplasty, Serre method                                 199

    260, 261.—Correction of angle of mouth                             200

    262, 263.—Correction of extensive angle of mouth                   200

    264, 265.—Meloplasty, Kraske method                                201

    266, 267, 268.—Meloplasty, Israel method                           202

    269, 270.—Meloplasty, Bardenheuer                                  202

    271, 272, 273, 274.—Meloplasty, Bardenheuer                        203

    275, 276, 277, 278.—Meloplasty, Bardenheuer                        204

    279, 280.—Meloplasty, Staffel                                      205

    281.—Cheek prothesis after removal of sarcoma, Martin              206

    282.—Prothesis applied to face                                     207

                   SUBCUTANEOUS HYDROCARBON PROTHESES

    283.—Circulation of the head (author)                     _Facing_ 210

    284.—Eckstein insulated syringe                                    232

    285.—Quinlan paraffin heater                                       232

    286.—Author’s electrothermic paraffin heater                       244

    287.—Smith paraffin heater                                         246

    288 _a_, 288 _b_.—Microphotograph, showing fibromatosis   _Facing_ 258

    289.—Author’s drop syringe                                         265

    290.—Author’s all-metal syringe                                    266

    291.—Smith’s all-metal syringe                                     267

    292, 293.—Anterior superior third nasal deficiency and
           correction thereof                                          289

    294, 295.—Anterior median third nasal deficiency and
           correction thereof                                          292

    296, 297.—Anterior inferior third nasal deficiency and
           correction thereof                                          294

    298 _a_, 298 _b_.—Anterior superior and inferior third nasal
           deficiency and correction thereof                           301

    299, 300.—Anterior total nasal deficiency and corrections thereof  303

    301.—Untoward effect of paraffin injection about lobule and
           anterior nasal line                                         311

    302, 303.—Profile view, showing correction of antero-lateral
           deficiency about chin                                       330

    304, 305.—Frontal view, showing correction of antero-lateral
           deficiency about chin; also correction of deficiency
           of cheeks                                                   332

                               RHINOPLASTY

    306.—Deficiency of superior and middle third of nose               342

    307.—Post-ulcerative deformity of superior third of nose           342

    308.—Loss of right ala, lobule and columna                         342

    309.—Loss of lobule, inferior septum and columna                   342

    310.—Ulcerative loss of right median lateral skin of nose          343

    311.—Loss of nasal bones, partial dorsum, lobule and septum        343

    312.—Destruction of nasal bones with dorsum and lobule intact      343

    313.—Total loss of nose                                            343

    314, 315, 316.—Koomas method of rhinoplasty                        353

    317.—Graefe method of rhinoplasty                                  353

    318, 319, 320, 321.—Delpech method of rhinoplasty                  354

    322, 323.—Lisfranc method of rhinoplasty                           355

    324.—Labat method of rhinoplasty                                   356

    325.—Keegan method of rhinoplasty                                  356

    326.—Duberwitsky method of rhinoplasty                             357

    327.—Dieffenbach method of rhinoplasty                             357

    328.—Von Ammon method of rhinoplasty                               358

    329.—Auvert method of rhinoplasty                                  358

    330.—Von Langenbeck method of rhinoplasty                          359

    331, 332.—Petrali method of rhinoplasty                            360

    333.—Forque method of rhinoplasty                                  361

    334.—D’Alguie method of rhinoplasty                                361

    335.—Landreau method of rhinoplasty                                361

    336.—Von Langenbeck method of rhinoplasty                          361

    337.—Von Langenbeck method of rhinoplasty                          362

    338.—Szymanowski method of rhinoplasty                             362

    339.—Nélaton method of rhinoplasty                                 365

    340.—Heuter method of rhinoplasty                                  365

    341.—Bürow method of rhinoplasty                                   365

    342.—Szymanowski method of rhinoplasty                             366

    343, 344.—Serre method of rhinoplasty                              367

    345, 346.—Maisonneuve method of rhinoplasty                        369

    347, 348, 349.—Dieffenbach arm-flap method                         373

    350.—Szymanowski arm-flap method                                   375

    351.—Fabrizi arm-flap method                                       376

    352, 353.—Steinthal thoracic flap method                           377

    354, 355.—Volkman method of rhinoplasty                            379

    356.—Keegan method of rhinoplasty                                  380

    357, 358.—Verneuil method of rhinoplasty                           380

    359, 360.—Thiersch method of rhinoplasty                           381

    361, 362.—Helferich method of rhinoplasty                          382

    363, 364.—Sedillot method of rhinoplasty                           383

    365.—Berger arm-flap method                                        385

    366.—Berger retention apparatus                                    385

    367, 368.—Szymanowski rhinoplasty method                           386

    369.—König rhinoplasty method                                      391

    370.—Von Hacker rhinoplasty method, arrangement of frontal
           flap to allow chiseling                                     392

    371.—Von Hacker rhinoplasty method, making osteo-periostic
           support                                                     392

    372.—Von Hacker rhinoplasty method, bone-lined flap in position    392

    373, 374.—Rotter rhinoplastic method                               394

    375, 376.—Schimmelbusch frontal flap method                        395

    377, 378.—Helferich rhinoplasty method                             397

    379, 380, 381.—Krause rhinoplasty method                           399

    382.—Nélaton rhinoplasty method                                    400

    383.—Nélaton rhinoplasty method, making bony support               400

    384.—Nélaton rhinoplasty method, cutting through bony plate        401

    385.—Nélaton rhinoplasty method, disposition of frontal flap       401

    386.—Israel method, forearm flap                                   402

    387.—Israel method, position of forearm to place flap              403

    388.—Nélaton method, outlining frontal flap                        407

    389.—Nélaton method, locating cartilage strip                      408

    390.—Nélaton method, excision of cartilage strip                   409

    391.—Nélaton method, placing of cartilage strip                    410

    392.—Nélaton method, bringing down frontal flap                    411

    393.—Nélaton method, placing frontal flap                          411

    394, 395.—Steinhausen partial rhinoplasty method                   412

    396, 397.—Neumann partial rhinoplasty method                       413

    398, 399, 400.—Later Neumann partial rhinoplasty method            415

    401.—Bardenheuer method, shape of flap                             416

    402.—Bardenheuer method, disposition of flap                       416

    403.—Ollier method first step                                      417

    404.—Ollier method, second step                                    418

    405.—Ollier method, position nasal bone occupies                   418

    406.—Von Langenbeck method, first step                             419

    407.—Von Langenbeck method, showing separation and elevation of
           nose flaps                                                  419

    408.—Nélaton method, first step                                    421

    409.—Nélaton method, making lower nasal flap                       421

    410.—Nélaton method, forming base of nose                          422

    411.—Nélaton method, ultimate disposition of flap                  422

    412.—Bayer-Payr restoration of lobule, first step                  425

    413.—Bayer-Payr restoration of lobule, disposition of flaps        425

    414.—Bayer-Payr restoration of lobule, placing of pedicles
           after division                                              425

    415.—Ch. Nélaton method, attachment of forearm flap                426

    416.—Ch. Nélaton method, forearm flap in position, lateral flaps   426

    417.—Ch. Nélaton method, disposition lateral flaps                 426

    418.—Denonvillier method, making of flap for ala                   428

    419.—Denonvillier method, disposition of flap for anterior
           pedicle ala                                                 428

    420.—Denonvillier method, making of flap for ala, posterior
           pedicle                                                     428

    421.—Denonvillier method, disposition of flap for ala, posterior
           pedicle                                                     428

    422, 423.—Mutter method of restoration of ala                      429

    424, 425.—Von Langenbeck method of restoration of ala              430

    426.—Busch method of restoration of ala                            430

    427.—Dieffenbach method of restoration of ala                      431

    428.—Dupuytren method of restoration of ala                        431

    429.—Fritz-Reich method of restoration of ala                      431

    430, 431, 432, 433.—Sedillot method of restoration of ala          432

    434, 435.—Nélaton method of restoration of ala                     433

    436, 437.—Bonnet method of restoration of ala                      434

    438, 439.—Weber method of restoration of ala                       434

    440.—Thompson mucosa flap                                          435

    441, 442.—Thompson method of restoration of ala                    435

    443, 444.—Blandin method of restoration of ala                     436

    445, 446.—Von Hacker method of restoration of ala                  436

    447, 448.—Kolle method of restoration of ala                       437

    449.—Denonvillier method of restoration of ala                     438

    450, 451, 452.—Von Hacker method of restoration of ala             439

    453.—König method of restoration of ala                            440

    454, 455.—Kolle method of restoration of ala                       441

    456, 457.—Kolle method of restoration of lobule                    442

    458, 459.—Blandin method of restoration of subseptum               444

    460, 461.—Dupuytren method of restoration of subseptum             445

    462.—Serre method of restoration of subseptum                      445

    463, 464.—Dieffenbach method of restoration of subseptum           446

    465.—Heuter method of restoration of subseptum                     446

    466.—Szymanowski method of restoration of subseptum                446

    467, 468.—Szymanowski method of restoration of subseptum           447

                          COSMETIC RHINOPLASTY

    469 _a_, 469 _b_.—Monk method of correction of angular nose        450

    470, 471, 472.—Median nasal incision for angular nose              451

    473, 474.—Kolle method of lateral incision for angular nose        452

    475, 476.—Kolle chisel set                                         453

    477.—Kolle metal mallet                                            453

    478, 479.—Kolle method of correction of retroussé nose             454

    480, 481.—Kolle method of correction of broad lobule               456

    482, 483.—Kolle method of correction of elongated lobule           458

    484.—Kolle method of correction of elongated lobule and base of
           nose after excision                                         460

    485.—Kolle method of correction of elongated lobule base of alæ
           and lobule                                                  460

    486, 487.—Kolle plaster cast of lobule operation                   461

    488, 489.—Kolle plaster cast of lobule operation                   462

    490, 491.—Kolle plaster cast of lobule operation                   463

    492, 493.—Kolle plaster cast of lobule operation                   464

    494, 495.—Gensoul method of correcting broad nasal base            465

    496, 497.—Kolle method of correction of broad nasal base           465

    498, 499.—Linhardt method of reduction of thickened alæ            466

    500, 501.—Dieffenbach method of reduction of thickened nose        467

                       ELECTROLYSIS IN DERMATOLOGY

    502.—Electric wet cell                                             470

    503.—Series connection of cells                                    472

    504.—Shunt rheostat connection                                     473

    505.—Cell selector                                                 474

    506.—Cell selector and battery connection                          474

    507.—Milliampèremeter                                              475

    508.—Direct current wall plate                                     475

    509.—Wall-plate connections                                        475

    510 _a_.—Portable wet cell apparatus                               476

    510 _b_.—Portable dry cell apparatus                               477

    511.—Sponge electrode                                              478

    512.—Arm electrode                                                 478

    513, 514.—Electrolytic needle holders                              479

    515.—Interrupting current needle holder                            479

    516.—Needle holder with magnifying glass                           479

    517.—Epilating forceps                                             481

    518.—Electrolysis method for destroying growths                    483

    519.—Multiple needle electrode                                     484

    520.—Kolle electric apparatus for tattooing scars                  487

                         CASE RECORDING METHODS

    521.—Nose stencil                                                  492

    522.—Method of making nose plaster cast                            494




PLASTIC AND COSMETIC SURGERY




CHAPTER I

HISTORICAL


It seems almost incredible that at this late day so little is generally
known to the surgical profession of the beautiful and practical, not
to say grateful, art of plastic or restorative surgery, successfully
practiced even by the ancients.

The progress of the art has been much interrupted. It is only the later
methods of antisepsis, which have so greatly added to general surgery,
that have placed it firmly upon the basis of a distinct and separate art
in surgical science.

To Aulus Cornelius Celsus, a Latin physician and philosopher, supposed to
have lived in the time of Augustus, we owe the first authentic principles
of the science. He was a most prolific writer and an urgent worker. After
having introduced the Hippocratic system to the Romans he became known as
the Roman Hippocrates. His best-known work handed down to us is the “De
Medicina,” the first edition of which, divided into eight books, appeared
in Florence in 1478. The seventh and eighth volumes, designated the
“Surgical Bible,” contain much valuable data in reference to opinions and
observations of the Alexandrian School of Medicine.

In considering plastic operations about the face (Curta in auribus,
labrisque ac naribus) he writes, “Ratio curationis ejus modi est; id
quod curtatum est, in quadratum redigere; ab interoribus ejus angulis
lineas transversas incidere, quæ citeriorem partem ab ulteriore ex
toto diducant; deinda ea quæ resolvimus, in unum adducere. Si non satis
junguntur, ultra lineas, quas ante fecimus, alias dua lunatas et ad
plagam conversas immittere, quibus summa tantum cutis diducatur, sic
enim fit, ut facilius quod adducitur, segui possit, quod non vi cogendum
est, sed ita adducendum ut ex facili subsequatur; et dimissum non multum
recedat.”

Centuries elapsed before a clear understanding of the above was deduced.
Several analyses have been advanced, those of O. Weber and Malgaigne
being the most generally accepted.

As shown in Fig. 1 the method advanced is one for the restoration or
repair of an irregular defect about the face in which two transverse
incisions forming angular skin flaps, dissected from the underlying
tissue, are advanced, joining the denuded free ends.

Should there be a lack of tissue to accomplish perfect coaptation a
semilunar incision beyond either outer border is added, as shown in Fig.
2, which permits of greater traction, leaving two small quatrespheral
areas to heal over by granulation:

[Illustration: FIG. 1.—CELSUS INCISION FOR RESTORATION OF DEFECT.]

[Illustration: FIG. 2.—CELSUS INCISION TO RELIEVE TENSION.]

This is the oldest known reference to plastic surgery of times remote.

From the Orient, however, Susrata in his Ayur-Veda, the exact period of
which is unknown, discloses the use of rhinoplastic methods.

For centuries following, and throughout the middle ages, the art seems to
have waned and remained practically unknown, as far as is shown in the
literature of that period.

A revivalist first appeared about the middle of the fifteenth century
in the person of Branca, of Catania, a Sicilian surgeon, who about 1442
established a reputation of building up noses from the skin of the face
(_exore_). His son Antonius enlarged upon his methods and is said to have
utilized the integument of the arm to accomplish the same result, thus
overcoming the extensive scarring of the face following the elder’s mode.
He seems to have been the first authority employing the so-called Italian
rhinoplastic method. He is also known to have ventured, more or less,
successfully in operations about the lips and ears.

Balthazar Pavoni and Mongitore repeated these methods of operative
procedure with more or less success and the brothers Bojanis acquired
great celebrity at Naples in the art of remodeling noses.

Vincent Vianeo followed the work of the above.

But, somehow, the heroic efforts of these men dropped so much into
oblivion that Fabricius ab Aquapende, in writing of the rhinoplastic work
of the brothers Bojani, of Calabria, says: “Primi qui modum reparandi
nasum coluere, fuerunt calabri; deinde devenit ad medicos Bononienses.”

That Germany was interested at an early date is shown in the admirable
work of a chevalier of the Teutonic Order, Brother Heinrich Von
Pfohlspundt, who wrote a book on the subject entitled “Buch der Brundth
Ertznei,” with a subtitle, “Eynem eine nawe nasse zu mache.” His volume
appeared in 1460, about the time of Antonio Branca, of whose methods
he was ignorant, claiming to have learned the art from an Italian who
succored many by his skill.

Between the years of 1546 and 1599 Kaspar Tagliacozzi, Professor at
Bologna, followed the art of rhinoplasty. His pupils published a book at
Venice, describing his work in 1597, entitled “De Corturum chirurgia per
insitionem,” which established the first authentic volume in restorative
surgery. His operation for restoring the entire nose from a double
pedicle flap taken from the arm was declared famous and the operation he
then advocated still bears his name.

The great Ambroise Pare knew little of rhinoplasty except what he learned
from hearsay. As an instance, he relates in 1575 that “A gentleman named
Cadet de Saint-Thoan, who had lost his nose, for a long time wore a nose
made of silver and while being much hurt by the criticisms and taunts
of his acquaintances heard of a master in Italy who restored noses. He
went there and had his facial organ restored, and returned to the great
surprise of his friends, who marveled at the change in their formerly
silver-nosed friend.”

Now again came a century of forgetfulness, the scientific world taking no
cognizance of the work done until, suddenly, in 1794, a message came from
Poonah, India, to the effect that an East Indian peasant named Cowasjee,
a cowherd following the English army, was captured by Tippo Sahib, who
ordered the prisoner’s nose to be amputated. His wounds were dressed and
healed by English surgeons. Shortly after this the victim of this odd
mode of punishment was befriended by the Koomas, a colony of potters,
or, as others claim, a religious sect, who knew how to restore the nose
by means of a flap taken from the forehead. They operated on him and
restored his nose much to the surprise of Pennant, who reported the case
in England.

Shortly following this, and in the same year, cases of similar nature are
described in the _Gentlemen’s Magazine_ (England), and Pennant’s “Views
of Hindoostan.”

In 1811 Lynn successfully accomplished the operation in a case in
England, and in 1814 Carpue published his results in two cases
successfully operated by him by the so-called Hindoo method.

France now took up the art of rhinoplasty. Delpech introduced a
modification of the method of the Koomas in 1820, while Lisfranc
performed the first operation of this nature in Paris in 1826.

In 1816 Graefe, of Germany, took up the work of Tagliacozzi but modified
his method by diminishing the number of operations.

Bünger, of Marburg, thereupon, in 1823, successfully made a man’s nose by
taking the necessary tegument from the patient’s thigh.

A still later modification in the art of rhinoplasty was that of Larrey,
who in 1830 overcame a large loss about the lobule of the nose by taking
the flaps to restore the same from the cheeks.

Among the better advocates of reparative chirurgery were Dieffenbach,
v. Langenbeck, Ricard, v. Graefe (1816), Alliot, Blandin, Zeis, Serre,
and Joberi, while Thomas D. Mutter, in 1831, published the results he
obtained in America—his co-workers being Warren and Pancoast.

Although Le Monier, a French dentist, as early as 1764 originally
proposed closure of the cleft in the soft palate, no one attempted
to carry out his suggestion until in 1819 the elder Roux, of Paris,
performed the operation. The following year Warren, of Boston,
independently decided upon and successfully did an improved operation to
the same end.

During the years 1865-70 Joseph Lister distinguished himself in the
discovery and meritorious employment of carbolic acid as a means of
destroying, or at least arresting, infectious germ life, the principle
of which, now so fully developed, has advanced the obtainable surgical
possibilities inestimably.

The credit of first collecting data of plastic operations belongs to
Szymanowski, of Russia. In his magnificent volume of surgery (1867), he
embodies a somewhat thorough treatise on restorative surgery, leaving
the subject to be treated more fully and independently, as it should be,
to some other enthusiastic surgeon specialist. His work is the result
of careful study of such operations on the cadaver, a method much to be
recommended to the prospective or operating plastic surgeon.

Several years later, 1871, Reverdin added a valuable method to the still
incomplete art, by introducing the now well-known circular epidermal
skin grafts for covering granulating surfaces. Thiersch improved this
method in 1886 by showing that comparatively large pieces of skin could
be transplanted. Wolfe, of Glasgow, had also been successful in utilizing
fairly large skin grafts.

Krause, however, improved upon all of these methods by transplanting
large flaps of skin without detaching the subcutaneous tissue, a
procedure which causes more or less injury to the graft in other methods,
and by his method overcoming the subsequent contraction, heretofore a bad
feature when the skin-grafted area had healed.

“The results of most plastic operations have been as satisfactory as the
most sanguine could hope for or the most critical expect,” says John Eric
Erichsen.

Many important additions have been made in the past few years—the outcome
of untiring attempt and skill. Czerny replaces part of an amputated
breast with a fatty tumor taken from the region of the thigh. Glück
successfully repairs a defect in the carotid artery with the aid of a
piece of the jugular vein. Glück, Helferich, and others have advocated
implanting muscular tissue taken from the dog into muscular deficiencies
in the human, due to whatever cause.

The transplantation of a zoöneural section into a defect of a nerve in
the human was successfully accomplished by Phillippeaux and Vulpian.

Glück, who later restored a sciatic nerve in a rabbit by the
transplantation of the same nerve taken from a hen, went so far as to
restore a 5-cm. defect of the radial nerve of a patient by the employment
of a bundle of catgut fibers, fully establishing the function of the
nerve within a year’s time.

Guthrie has successfully replaced the organs and limbs of animals and has
actually transplanted the heads of two dogs.

The transplantation of a toe, to make up a part of a lost finger, is
proposed by Nicoladoni. Van Lair hints at the possibility of removing a
part or a whole organ immediately before death to repair other living
organs.

Von Hippel has successfully implanted a zoöcorneal graft from a rabbit
upon the human eye, and Copeland has taken the corneal graft from one
human and transplanted it upon the cornea of another to overcome opacity.

The transplantation of pieces of bone to overcome a defect of like tissue
has been fully investigated by Ollier, v. Bergman, J. Wolff, MacEwen,
Jakimowitsch, Riedinger, and others. They discovered that a graft of
bone, with or without its periosteum, can be made to heal into a defect
when strict antisepsis is maintained.

Von Nussbaum was the first to introduce the closing of an osseous defect
by the use of a pedunculated flap of periosteum.

Poncet and Ollier employed small tubular sections of bone, while Senn has
obtained excellent results from the use of chips of aseptic decalcified
bone.

Hahn succeeded in implanting the fibula into a defect of the tibia.

On the other hand, cavities in the bones have been successfully filled
by Dreesmann and Heydenreich with a paste of plaster made with a
five-per-cent carbolic-acid solution, and at a later period by the
employment of paraffin (Gersuny) and iodoform wax, as advocated by
Mosetig-Moorhof.

The thyroid glands taken from the sheep, it is claimed, have been
successfully implanted in the abdomen of individuals whose thyroid glands
had been lost by disease or otherwise.

Protheses of celluloid compound or gutta-percha and painted to resemble
the nose or ear have been introduced with grateful result. Metal and
glass forms have been used to replace extirpated testicles or to take the
place of the vitreous humor of the eye (Mule).

Sunken noses have been raised with metal wire, metal plates, amber, and
caoutchouc. Metal plates have been skillfully fitted into the broken bony
vault of the cranium.

Lastly comes Gersuny’s most valuable method of injecting paraffin
compounds subcutaneously for the restoration of the contour of facial
surfaces and limbs, which is rapidly taking the place of extensive
plastic transplantory and the much-objected-to metal and bone-plate
operations for building up depressed noses and other abnormal cavities.

And the end of possibilities is not yet reached. The successful plastic
surgeon has become an imitator of nature’s beauty to-day.

His skill permits of many almost unbelievable corrections of defects
that would otherwise evoke the pity and too often the aversion of the
onlooker, especially if these occur in the faces of those that have
become marred in birth or age, by accident or disease. Withal, it is a
noble, generous art, worthy of far more extensive use than it now enjoys.

The above fragmentary references include a number of plastic
possibilities. They are introduced only in the sense of general interest
to the cosmetic surgeon, the special and detailed subject matter herein
given under the various divisions have to do only with plastic and
cosmetic operations about the face.




CHAPTER II

REQUIREMENTS FOR OPERATING


THE OPERATING ROOM

The ideal operating room for the plastic surgeon need not necessarily
be large, since it requires less work to render it aseptic. Furniture
and possibly amphitheater accommodation are always a means of infection
unless scrupulously cleansed, a task of time, difficult at best.

The room should be provided with large windows, with facilities for the
introduction of the air from without. Two doors, and those well fitted,
are all the room should have—but one being used, if possible.

=The Walls.=—The walls should be of plaster, smoothly laid and well
painted, so that they may be readily washed down with antiseptic
solutions—a daily morning rule. Glass or tiled walls are much used now
and add considerably to the appearance and safety of the room, as plaster
in time will crack, while the paint, owing to the heat of sterilizers
or steam, often creeps and blisters, exposing an absorbing surface
which readily wears down, exposing parts inaccessible for even acute
cleanliness.

=The Floors.=—The floors of these rooms are now usually laid with tile
mosaic or marble or a composition resembling linoleum. The base should
be curved and all corners sloped off to improve drainage and to keep off
dust and dirt.

=Skylight.=—A skylight of metal and glass is a valuable accessory. It
should be fixed or never permitted to be opened during an operation.

=Disinfection.=—Spraying the room with an antiseptic is hardly necessary,
since all germ life descends to the floor and can best be removed by
washing with a 1-1000 bichlorid solution.

Should it be necessary to perform an unusually extensive operation in
a private house, the room must be cleared of all furniture, pictures,
drapery, and carpet. After plugging up the crevices in the windows and
doors it should be well fumigated either with sulphur candles, as now
commonly furnished, or, better, with formaldehyd.

The superiority of formaldehyd as a disinfecting agent is now well
established. An illustration of an apparatus, largely doing away with the
difficulties and dangers encountered in the use of the older and ordinary
styles of the pressure or nonpressure type, is shown in Fig. 3. The main
difficulty with these has always been their almost inaccessibility for
cleansing purposes, and in such where this is not the case, the size of
the aperture has been made so small that the inside could not be reached.
In the pressure apparatus the tops are bolted on, making them exceedingly
difficult to remove, with the result that the necessary cleaning was not
properly attended to. The corrosive action of formaldehyd gas is such
that under these conditions any apparatus would soon become useless.

In the type shown a single clamp arrangement is used (_a_). By the
turning of the hand screw (_b_) two planed metal faces (the upper surface
of the boiler and under surface of the cover) are brought together and
sealed. When the cover (_c_) is removed the entire inside of the boiler
is in sight and can be thoroughly cleansed, which should be done each
time the apparatus is used. The pipes through which the formaldehyd gas
passes after generation are arranged so that they can be taken off and
cleaned.

[Illustration: FIG. 3.—FORMALDEHYD DISINFECTING APPARATUS.]

The gas is generated in the boiler (_d_) and passes out from the top,
down through the pipe (_e_), and from thence through a series of pipes
(_f_) underneath the boiler, which are subjected to direct heat from the
lamp (_g_). By this means the gas becomes superheated, the polymerization
of the formaldehyd is almost entirely prevented, and a dry gas is insured
and given off at the pipe (_h_).

The room should be left closed overnight and thoroughly aired thereafter.
The bare floor must then be scrubbed with hot water and soda and flushed
with a three-per-cent carbolic-acid solution.

As little furniture as possible should be found in an operating room, and
this preferably of undecorated enameled iron.

=Instrument Cabinet.=—For the instruments and dressings there should be a
dust-proof cabinet of iron and glass, such as is shown in Fig. 4.

[Illustration: FIG. 4.—INSTRUMENT CABINET.]

=Operating Table.=—The operating table should be of like construction
and as plain as possible. Its top can be padded with sterilized felt,
protected from moisture by rubber sheets. A surgical chair of plain
construction might suffice, inasmuch as most plastic operations cover but
a small area and are usually about the head and often performed under
local anesthesia. A chair with head rest is much more comfortable, adding
much to the moral and physical comfort of the then conscious patient. A
very desirable chair is shown in Fig. 5.

[Illustration: FIG. 5.—OPERATING TABLE.]

=Instrument Table.=—An instrument table, such as is shown in the next
illustration, is quite necessary, upon which dressings and instruments
are laid during operation. In this the frame is of white enameled iron
and the top and shelf of plate glass.

[Illustration: FIG. 6.—INSTRUMENT TABLE.]

=Irrigator.=—An irrigator is often of service, especially in washing
out the fine pieces of bone resulting from chiseling or drilling. In
skin-grafting it may be used with sterilized three-per-cent salt solution
as described later. The best irrigators are those of germ-proof or
ground-glass stopper type. They are suspended from the wall by means of
an iron bracket or pulley service or placed upon a movable enameled stand
as shown in Fig. 7.

Irritating antiseptic solutions are to be avoided, their especial
indication will be found under antiseptic care of wounds.


CARE OF INSTRUMENTS

[Illustration: FIG. 7.—IRRIGATOR.]

All instruments should be of modern make, devoid of clefts or grooves,
and having separating locks when possible. Wooden or ivory handles
should be entirely discarded. They should first be rendered free of
dirt or dried blood by scrubbing briskly with a stiff nailbrush and hot
water; then dried and placed in the sterilizer. The immersed instruments
are boiled for five or ten minutes. There are many of such sterilizing
apparatuses to be obtained, all made on the same plan, however, and
consist of a copper or brass box and cover well nickel plated. Folding
legs are placed beneath. A perforated tray is placed within for the
immersion of instruments. An alcohol lamp with asbestos wick furnishes
the heat.

One per cent of carbonate of soda added to the water prevents them from
rusting. The simple subjection of instruments to carbolic-acid solutions
or antiseptics of like nature is useless. (Gärtner, Kümmel, Gutch,
Redard, and Davidsohn.)

From the sterilizer the instruments are placed in a glass tray containing
a one-per-cent lysol solution. Knives, needles, and scissors should be
immersed in a tray with alcohol, as a great number of antiseptics destroy
their cutting edges. Glass or porcelain trays are best for this purpose.
A sterilized towel being placed in the bottom of each for the better
placing of instruments.

After operation all instruments should again be scrubbed with soap and
hot water, immersed a moment in boiling water or a jet of live steam,
dried with an aseptic cloth, and returned to the case.

A very effectual means of rendering instruments sterile is to place them
in a metal box and bake them in the ordinary oven (200° F.) for one hour.

To preserve needles Dawbarn advises keeping them in a saturated solution
of washing soda. Albolene has an unpleasant oiliness, but is otherwise
good. Calcium chlorid in absolute alcohol is efficacious, but expensive.
All rust accumulating on instruments must be carefully removed with fine
emery cloth; this, however, is unnecessary if the soda solution is used
as previously mentioned. It is well to occasionally dip the instruments
(holding them with an artery forceps) into boiling water as they are used
during operation.

[Illustration: FIG. 8.—INSTRUMENT STERILIZER.]


PREPARATION OF THE SURGEON AND ASSISTANTS


CARE OF THE HANDS

The hands of the surgeon and his assistants must always be thoroughly
prepared before operation or dressing a wound. The mere immersion of the
hands into an antiseptic solution is not sufficient to remove germ life.
The oily secretions of the skin and its folds, as well as the cleft about
the nails and the nails themselves, are common carriers of infection and
are cleansed only by the vigorous method of scrubbing with soap and water
and then rendered aseptic by the use of proper media.

The aseptic hospital washstand, as shown in Fig. 9, will be found an
ideal piece of furniture; it has a frame constructed of wrought iron,
white enameled. The top is of one-inch polished plate glass, with two
twelve-inch holes.

[Illustration: FIG. 9.—ASEPTIC WASHSTAND.]

The entire stand can be moved away from the wall, to permit of thorough
cleaning of basins, supply pipes, etc. The basins are the best annealed
glass, and are supported by nickel-plated traps, with connections for
vent pipes. The water supply is controlled by foot valves, which enable
the operator to draw either cold, medium, or hot water at will. The waste
is also controlled by a foot valve, as shown.

The systematic law of cleansing the hands should be insisted upon at all
times. Rules for the method followed might be displayed in abbreviated
form in the operating room by glass or enameled signs hung on the wall
over the basin and reading as follows:


    +----------------------------------------------------------+
    |                        YOUR HANDS                        |
    |                                                          |
    |   I. Clean nails.                                        |
    |  II. Scrub with very hot water and soap for five minutes.|
    | III. Wipe in sterile towel.                              |
    |  IV. Brush with eighty per cent alcohol.                 |
    |   V. Dip into antiseptic solution.                       |
    +----------------------------------------------------------+

Green soap is commonly used and is to be preferred to powdered or cake
soap. The powder cakes and clogs the container in damp weather, while
the latter collects impurities from the air. Synol soap, also liquid,
is perhaps the most ideal, a two per cent solution of which forms an
excellent lavage for cleaning instruments, as well as washing down
furniture in the operating room.

The brushes to be used are of the common wooden-back, hard-bristle make,
which can be boiled without injury. There should be several of these,
marked on their backs as desired, so that one brush can be used for
the one purpose only. In cleansing the hands, the forearms, and even
the elbows, should be similarly treated. After scrubbing with soap, as
directed, they are to be rinsed, dried with a sterilized towel, again
scrubbed with alcohol, and then dipped or flushed with a bichlorid
solution.


GOWNS

No woolen garments should be allowed to come in contact with the site of
the operation, nor is it well to allow such material in the operating
room while working.

Freshly laundered linen gowns of Von Bergman’s pattern, reaching to the
shoes, should be worn. They should contain half sleeves and be buttoned
on the back. See Fig. 10. These may be sterilized in the steam sterilizer
or washed in one-per-cent soda solution. When soiled or blood-stained
they should be relaundered.

The operator may substitute the gown with a rubber apron of the Triffe
pattern, reaching as high as the collar, but continuous washing quickly
ruins them. See Fig. 11.

[Illustration: FIG. 10.—VON BERGMAN OPERATING GOWN.]

[Illustration: FIG. 11.—TRIFFE RUBBER APRON.]


PREPARING THE PATIENT


GENERAL PREPARATION

The patient for all plastic operations should be carefully examined as to
general health and past history. His healing powers should be at their
best, as much depends on primary union. If he presents a syphilitic
history, it is well to place him under treatment, for a time, at least,
before an operation is undertaken. The bowels should be regular. Sulphate
of magnesium should be given each morning, before breakfast, for at
least two days prior to operating, while his general condition may be
improved by the employment of bitter and alterative tonics. Nux vomica
with tinct. cinchonæ com., associated with essence of pepsin aromat.,
or lactopeptone, are very useful. This treatment is also carried on for
several days, _post operatio_.

The success of an operation depends, first, upon the selection of the
case; second, the selection of the method employed, and, third, upon the
hygiene under which the patient undergoes convalescence. The patient
must be given to understand, in many cases, that it is often necessary
to reoperate, even to the extent of seven or eight operations, to bring
about the desired result. The first result obtained with many cosmetic
operations is not at all gratifying to the patient, and unless this is
explained to him beforehand he may become discouraged awaiting the next
operation and disappear, thus losing the opportunity of being pleased
finally, while the surgeon is misunderstood and underestimated by
narrow-minded judges and the ever-willing friendly advisers and critics—a
consummation much to be avoided.


PREPARATION OF THE OPERATIVE FIELD

The part to be operated upon should first be closely shaven. The oily
secretions of the area are next rubbed off with an absorbent cotton
sponge saturated with alcohol or ether. Next, the skin is washed with hot
water and soap or three-per-cent synol suds, then rinsed, and finally
rendered aseptic with a bichlorid solution.

If the operation is to be done about the face a rubber cap is so adjusted
as to cover the hair. If this is not obtainable sterilized bandages can
be employed.

In operations about mucous membranes, as in the nose and mouth, the parts
must be cleaned at short intervals with a solution of permanganate of
potash or boric acid. The teeth must be cleansed with antiseptic soap,
tartar is scraped off, and the mouth rinsed with a proper disinfectant.
The corrosive sublimate, or carbolated solutions, owing to their toxic
qualities, cannot be used. The preparation of wounds for reoperation, or
where an operation is secondary to injury, is referred to later.

All clothing about the site of operation should be removed and rubber
cloth placed to surround the field and cover the clothing. This should be
covered again with sterilized towels. Everything that touches the patient
after this has been done should be aseptic; indeed, hands employed during
operation must be immersed from time to time in 1-500 bichlorid solution,
and allowed to remain wet.




CHAPTER III

REQUIREMENTS DURING OPERATION


SPONGES AND SPONGING

Natural or sea sponges are now little used in surgery, owing to their
peculiar cellular construction. They invite and readily retain spores and
germs, are difficult to clean, and require almost constant attention to
be at all safe.

Many methods for rendering these sponges aseptic have been proposed, but
at best the life of such a sponge is short and hardly pays for the labor
and time expended. The absorbing power of a sponge is, of course, its
essential quality. For plastic operations sterilized absorbent cotton
made into small balls answers every purpose. These puffs of cotton are
covered with gauze to prevent the fraying out of the fibers. To further
improve them, their centers may be made up of cellulose or wood fiber.
When an absorbent cotton sponge is moistened and squeezed out it does
not answer as well, since its absorbing qualities are much reduced; the
addition of the other material overcomes this.

A much-used and inexpensive sponge having great absorbing power is made
in the form of a small compress of sterilized gauze held together with
one or two stitches of thread. All of the above sponges are sterilized
with the needed dressings and are burned after use. When removed from the
sterilizer they are placed in a suitable basin containing six per cent
sterilized salt water. It is well to place the receptacle close by the
assistant who is to sponge. An enameled iron basin rack, as shown in
Fig. 12, answers the purpose best.

[Illustration: FIG. 12.—BASINS AND RACK.]

The soiled sponges are thrown into a lower empty basin or one placed
at the operator’s feet. As they are removed from the solution they are
squeezed as dry as possible and pressed upon, rather than wiped across,
the operative field. It must be remembered that the surgeon’s work must
not be hampered by slow or inefficient sponging, and that this procedure
must be quick and timely. It is well for the assistant to become
accustomed to the habit of the operator.

The best assistant is one who has acquired a methodical and regular
manipulation, a result dependent upon constant individual association;
such a one is practically invaluable for the skillful performance of
plastic surgery. He becomes not only familiar with the one thing, but
cultivates a ready knowledge of the arrest of hemorrhage by digital
compression when hemostatic forceps would hinder the ease of work,
besides cultivating a happy manner of holding retractors or spreading the
edges of the incisions with the free hand. As in most of these operations
hemorrhage cannot be controlled by the so-called bloodless method. The
assistant must control the constant oozing by the gentle pressure of the
sponge quickly applied at short intervals. When the sponges are squeezed
out in salt solution, as hot as the hand will bear comfortably, capillary
oozing is more readily overcome.


STERILIZATION OF DRESSINGS

All dressings to be used in covering wounds, _post operatio_, or
otherwise, must be as scrupulously clean and free from infection as the
hands and the instruments of the operator. This is done by means of
sterilization by dry heat or steam under pressure. For all minor cases,
small apparatuses only are needed. They are usually made of copper,
often nickel-plated, and so constructed as to contain a lower perforated
instrument tray and another, placed above it, for dressings. The two
are fitted into an outer copper receptacle with snugly fitting cover. A
folding stand is furnished upon which this arrangement is placed, and an
alcohol lamp with asbestos wick furnishes the heating power. The lower
tray is covered with water which, by boiling, fills the upper compartment
with steam evenly distributed and with sufficient pressure to accomplish
sterilization in from thirty to sixty minutes. Metal hooks are provided
with which the trays can be removed. A complete and compact outfit, as
designed by Willy Meyer, is shown in Fig. 13.

In the above sterilizer, or in those of similar type, there is naturally
more or less saturation of the dressings and the possibility, in the
event of the entire conversion of the water contained therein into steam,
of injuring the instruments by excessive heat. To overcome this defect
the Wallace sterilizer may be advantageously employed.

[Illustration: FIG. 13.—WILLY MEYER STERILIZER.]

[Illustration: FIG. 14.—WALLACE STERILIZER.]

=Wallace Sterilizer.=—Its chief feature is the addition of a reservoir
fitting with the separated sterilizer into the outer body. See Fig. 14.
This reservoir automatically regulates the water and steam supply. It is
filled with water and inserted into the compartment provided for and
adjoining the sterilizer. Through an opening in the bottom the water is
permitted to escape into the sterilizer until the bottom of the latter
is covered to a depth of ⅛ inch. As the heat is applied from the alcohol
lamp this film of water is rapidly converted into steam.

The dressings arranged in the large tray are placed in the sterilizer
and the supply of steam is maintained through the constant and steady
flow of water from the reservoir, which compensates the evaporation in
the sterilizer. In about twenty minutes the formation of steam in the
top of the reservoir exerts sufficient pressure to force all the boiling
water from the reservoir into the sterilizer to the depth of about 1½
inches. The tray of instruments is now inserted and the process continued
for another ten minutes. Much less heat is required with this apparatus
than with those of ordinary type, while sterilization can be continued
uninterruptedly for one and one half hours, if need be.

=Sprague Sterilizer.=—The most perfect sterilizer is that of the Sprague
type, in which a dry chamber is surrounded by steam under pressure. The
apparatus is shown in Fig. 15.

[Illustration: FIG. 15.—SPRAGUE TYPE OF STERILIZER.]

Its cylindrical chamber is surrounded by two heavy copper shells, the
space between which is occupied by the water. This compartment is
entirely shut off from the sterilizing chamber, and as the steam is
generated, the inner, or sterilizing, chamber becomes heated to a degree
nearly equal to that of the steam in the surrounding cylinder; this
prevents any condensation of steam taking place in the dressings. By
opening the lever-handled valve at the bottom of the sterilizer in the
rear, and the valve to the right, on top of the sterilizer, and allowing
them to remain open for a space of four or five minutes, a vacuum is
formed in the sterilizing chamber. These two valves are then closed, the
lower one first, and the steam from the outer cylinder is allowed to
enter the chamber, by opening the left valve on top.

The contents should be allowed to sterilize for twenty or twenty-five
minutes under a pressure of fifteen pounds. Then close the steam-supply
valve; open the vacuum valve (right) and the lever-handled valve at the
bottom; leave these open about the same time as in creating a vacuum at
the beginning of the process; close both valves, then open the air-filter
valve on the door, in order to break the vacuum; the door can then be
opened and the dressings be taken out dry and absolutely sterile.

The steam-safety valve on this sterilizer is set at seventeen pounds, but
it can easily be regulated should a higher or lower pressure be desired.
The door used on this apparatus has no packing of rubber or other soft
material which wears or shrinks in time, a steam-tight joint being
formed by the bringing together of two plane metal faces on the door and
sterilizer head. The door hinge is so made that these parts are bound to
come together properly, without the use of excessive caution. Springs
on such doors are liable to get out of order or need replacing, and are
avoided in this apparatus. All that is necessary to lock or unlock the
door is to turn the large hand wheel on the front; the locking levers
then work automatically. These sterilizers are arranged for both gas and
steam heat.

=Sterilizing Plant.=—For the ideal operating room the entire sterilizing
plant can be had in combined form, as shown in Fig. 16. It consists of
a dry-heat dressing apparatus, just described, water and instrument
sterilizers, all mounted on a white enameled, tubular, wrought-iron
frame. The chamber of the dressing sterilizer is 8½ by 19 inches. The
water sterilizer has a capacity of six gallons in each tank and is
fitted with natural stone filters, thermometer, water gauge, safety
valve, etc. The size of the instrument sterilizer is 8 by 15 inches and
6 inches deep, with two trays. Each apparatus in the above can be used
independently of the other, all being arranged for gas-heating.

[Illustration: FIG. 16.—STERILIZING PLANT.]

=Dressing Cases.=—All dressings should be sterilized immediately before
operation, and not laid away for later use, as often done. As the aseptic
material is taken from the sterilizer it is to be placed in glass cases
provided therefor, from which they are removed, as needed, during the
operation.

A simple glass case, as shown in Fig. 17, may be used, or, better still,
the same can be obtained in combination with an instrument table, as
shown in Fig. 18.

[Illustration: FIG. 17.—DRESSING CASE.]

[Illustration: FIG. 18.—COMBINATION DRESSING CASE AND TABLE.]

=Waste Cans.=—All soiled dressings and sponges should be immediately
thrown into an enameled iron pail furnished for the purpose. At no time
must soiled dressings or sponges be thrown upon the floor, where they are
walked over, soiling the floor and, by drying, contaminating the air of
the room. Cans for this purpose are made of steel, enameled, of the form
shown in Fig. 19.

The contents of the can must be taken from the room after each operation
and burned. The can should be flushed with carbolic solution, and
returned to the operating room.

[Illustration: FIG. 19.—WASTE CAN.]


SUTURES AND STERILIZATION

(_Ligatures_)

=Silkworm Gut and Silk.=—In plastic surgery silkworm gut and silk are
used extensively. Rarely is ordinary catgut resorted to, because it is
absorbed before thorough union takes place, besides being a source of
infection, either primarily from imperfect sterilization or by taking
it up from the secretions of the deeper layer of skin not affected by
external antiseptics.

The sterilization of silk is accomplished by boiling it for one hour in
a 1-20 carbolic solution and then keeping it in a 1-50 similar solution
(Czerny). Or it may be boiled in water for one hour and retained in a
1-1,000 alcoholic solution of corrosive sublimate. Ordinarily it may,
however, be simply subjected to boiling and steamed in the autocleve.
Silkworm gut is treated in the same manner. It has greater tensile
strength than silk, and for that reason the thinner varieties are to be
preferred to ordinary silk.

=Catgut.=—It is far more difficult to prepare catgut, but, since it is
necessary for ligation, the following methods may be considered best:

The commercial catgut as made from the intestines of sheep, is wound
snugly upon a rod of glass and thoroughly brushed with soft soap and hot
water. It is then rinsed free of soap, wound upon small glass spools,
and placed for forty-eight hours in a one-per-cent alcoholic bichlorid
solution, composed of bichlorid of mercury, 10 parts; alcohol, 800 parts;
distilled water, 200 parts. The turbid fluid produced by first immersion
is changed. Before using, the spools are placed in a glass vessel contain
containing a 1-2,000 sublimate alcohol (Schaffer), made up as follows:

    Bichlorid of mercury      gr. vj;
    Alcohol                   ℥x;
    Distilled water           ℥iiss.

These glass cases are obtainable for the purpose and contain a second
perforated compartment for the ligatures passing through rubber valves
placed into the openings (Haagedorn).

Catgut is generally prepared by soaking in oil of juniper for one
week and then retaining it in absolute alcohol (Kocher), or a 1-1,000
alcoholic sublimate solution.

Another method for strengthening catgut, as well as to prevent its too
rapid absorption, is to chromatize it. This is done as follows:

The catgut is placed in sulphuric ether for forty-eight hours, then
treated for another forty-eight hours in a ten-per-cent solution
of carbolized glycerin, followed by a five-hour subjection to a
five-per-cent aqueous solution of chromic acid (Lister). It is allowed
to remain in the latter forty-eight hours, then placed in an antiseptic,
dry, tightly closed receptacle, and finally soaked in 1-20 carbolic
solution before using.

The _formaldehyd method_ of Kossman is to immerse the gut in formaldehyd
for twenty-four hours, then washing with a solution of chlorid and
carbonate of sodium and retaining it in the same solution. The catgut in
this procedure swells and its strength is much impaired in this way.

Any of the above methods are not above criticism, however, rigid as they
may seem, bacterial growths having been obtained with nearly all of them.

The _dry-air method_ (Boeckman, Reverdin) is reliable, but the subjection
of catgut to dry air at a temperature of 303° F. for two hours results in
making it tender and less pliable.

[Illustration: FIG. 20.—CLARK KUMOL APPARATUS.]

The _Kumol method_ (Kronig) is considered the most reliable, even under
the severest tests. This mode of sterilization is accomplished as
follows: A specially devised apparatus of brass, with a cast-bronze top,
both thoroughly nickel-plated, is used. The apparatus of J. G. Clark, as
shown in Fig. 20, will be found excellent. The kumol is retained in a
seamless cylinder, 8 by 8 inches, which is surrounded on the sides and
bottom by a sand bath; the flame, impinging on the bottom, heats the
sand, thereby insuring an even heat to the inner or sterilizing cylinder.
The catgut, in rings, is placed in a perforated basket hanging in the
cylinder, which can be raised or lowered at will; after drying for two
hours at 80° C., the basket is dropped, and the catgut immersed in the
kumol, at 155° C., for one hour; the kumol is then drawn off through a
long rubber tube, and the catgut dried at 100° C., for two hours; it is
then transferred to sterile glass tubes plugged with cotton.

_Prepared catgut_ of the various sizes can now, however, be purchased in
the market, and that offered by the better firms of chemists is quite
reliable and may be safely used for all plastic surgery about the face.
It is supplied in glass tubes, either in given lengths, as in the Fowler
type, in which the hermetically sealed tube is U-shaped or on glass
spools placed in glass tubes, not sealed, but closed by a rubber cap,
through which the desired length of ligature is drawn and then cut off.




CHAPTER IV

PREFERRED ANTISEPTICS


ANTISEPTIC SOLUTIONS

These are solutions used for the destruction of and to arrest the
progress of microörganisms that have found their way into wounds—the
cause of sepsis, as exhibited by fever, suppuration, and putrefaction.
These preparations are called antiseptics and are used to render parts
aseptic. They vary much in their destructive power, effect on tissue, and
toxic properties. The reader is referred to a work on bacteriology for
the specific knowledge of such on germ life.

The antiseptic treatment of wounds was founded by Joseph Lister, 1865-70,
then called Listerism. His one chemical agent to accomplish this was
carbolic acid, but many such and more effective agents have been added
since that time, all differing in their specific properties and each
having, for the same reason, its particular use.

The following group of antiseptics has been chosen with a view of giving
the best selection, to which the author has added a short description of
each, so that the surgeon may choose one or the other, as the occasion
may demand. As a rule, an operator cultivates the use of a certain line
of antisepsis, especially in this branch of surgery, experience being the
best guide; yet it is hoped he may find certain aid from those referred
to, their particular use being pointed out from time to time, as the
author has had occasion to prefer one or the other.

=Alcohol= (_absolute_).—This is a well-known antiseptic, but, because of
its ready evaporation, is especially used for the hands, as described,
and to cover sharp-edged instruments after sterilization.

=Aluminum Acetate= (_Bürow_, _H. Maas_).—A powerful, nontoxic antiseptic.
Is used only in two- to five-per-cent solution. According to Primer,
it arrests the development of schizomycetes, and in twenty-four hours
destroys their propagation. It readily removes offensive odors of wounds;
its great objections are that it injures the instruments, and, because
of its astringent nature, roughens the skin of the hands. This, however,
makes it particularly useful for sponging to arrest capillary oozing.

=Boric Acid= (_Lister_).—Not a powerful, but nonirritating, antiseptic.
For this reason it is used extensively in cleansing mucous membranes,
and, when associated with salicylic acid, as in the well-known Thiersch
solutions, composed of salicylic acid, 2 gms.; boric acid, 12 gms.;
water, 1,000 gms., is much used in skin-grafting operations. It is
not very soluble in cold, but readily in hot, water and alcohol. The
saturated solution is prepared by adding ℥j to the pint of boiling water.

=Benzoic Acid.=—Nonirritating, moderate antiseptic (Kraske); is prepared
in 1-250 solutions. Soluble in hot water and alcohol, but sparingly in
cold water.

=Carbolic Acid= (_Phenylic Acid_).—Not a powerful, but a much-used
antiseptic. The purest acid should be used. It appears as a colorless
crystalline solid, liquefied by the addition of five per cent water. If
more water is added the solution becomes turbid, clearing when 1-2,000 is
reached.

It is readily soluble in glycerin, alcohol, ether, and the fixed volatile
oils. Solutions in alcohol and oils have no antiseptic effect (Koch). The
1-20 aqueous solution is recommended by Lister.

The aqueous solutions used in surgery are 1-20 and 1-40. The weaker
is used for the operator’s hands, to cover instruments, as already
mentioned, and to impregnate sponges. The stronger solution is used
for the carbolic spray, to cleanse the unbroken skin about the site of
operation, and to disinfect wounds. Either solution, when applied to an
open wound, whitens the raw surface, coagulates the albumen, and causes
considerable irritation, which subsides quickly and is followed by
numbness.

Such solutions, by virtue of their irritant nature, increase the serous
discharge from a wound for about twenty-four hours, for which proper
drainage must be provided, as by its collection it would add to the
danger by increasing inflammation and suppuration, and, by absorption,
even produce toxic effect generally.

When a cold solution is used it should be prepared by vigorous stirring
to separate the globules of the acid. Hot water insures perfect
distribution. After an infected wound is washed with it, the solution
should not again be used, nor should any of the acid be permitted to
remain in the spaces about the wound. It will be found that many patients
cannot tolerate such dressings, and that others must be substituted.

Large surfaces should never be exposed to carbolic solutions, because
the skin absorbs them readily, followed by untoward results. Dangerous
symptoms have been known to result from the internal administration of
seven drops of the acid, and fatal termination has followed its use as a
surgical dressing (Bartley).

Mild acid poisoning is first noted in the urine, which turns olive green.
If the agent is continued, the urine appears dark and turns almost black
on standing. The coloring is due to the presence of indican. If the
absorption is not prevented beyond this there is dull frontal aching,
tinnitus aurium, dizziness, fainting, severe and uncontrollable vomiting.
Untoward symptoms are noted by albuminuria, total absence of sulphates in
the urine, a contracted and inactive pupil, elevation of temperature,
unconsciousness, muscular contraction, and death.

The treatment consists in immediately removing the cause and employing
another antiseptic. Support the patient with stimulants, freely given.
Cracked ice and brandy to allay the vomiting. Small doses of sodium
sulphate, frequently repeated, as a means of converting the acid into
nonpoisonous sulphocarbolate (Bauman). Albumen and milk internally.
Magnesium sulphate, five per cent.

=Chromic Anhydrid.=—Improperly called chromic acid. Made by adding one
and one half parts sulphuric acid, c. p., to one part of concentrated
solution of dichromate of potash. Appears in saffron-colored crystals.
It acts as a caustic upon tissue, and, although a splendid antiseptic,
cannot be used for such purposes, but is well adapted for the preparation
of catgut, as mentioned.

=Creolin.=—Is an antiseptic prepared from coal by dry distillation, and
is used to stimulate granulations, being much more powerful than carbolic
acid. It is nonirritant and practically nontoxic. Used in two-per-cent
aqueous solutions, in which it appears as a turbid but effective mixture.
It is well suited for cleansing the hands, a five-per-cent solution
having none of the irritating or anesthetic effect of carbolic acid.
Owing to the opacity of the aqueous solution, it is not suitable for the
immersion of instruments for operation.

=Eucalyptol= (_W. Schultz_).—A nonpoisonous volatile oil of considerable
antiseptic power. Soluble in alcohol, and used in three-per-cent
solution. It is claimed to quickly reduce the temperature in a wound. It
was much used by Lister on gauze dressings, the formula of which is given
elsewhere.

=Glycerin.=—It is said to have certain antiseptic power, but is used
principally as a staple solvent of carbolic and boric acid. Soluble in
all proportions in water and alcohol.

=Hydrargyrum Bichloratum Corrosivum= (_v. Bergman_, _Schede_, _Buchholz_,
_Billroth_, _R. Koch_).—The most valuable and effective, although the
most toxic of all antiseptics. It appears as a white crystalline powder.
A 1-50,000 watery solution is efficacious as a germicide (Koch; anthrax
bacilli killed by 1-20,000 solution). Albumen decomposes the bichlorid,
forming a white insoluble precipitate, albuminate of mercury. The same
effect takes place in aqueous solutions allowed to stand for a time—the
resultant being either calomel or metallic mercury. The addition of
sodium or ammonium chlorid or a weak acid, such as tartaric, prevents
this. As much sodium as of the sublimate, weight for weight, should be
used (Koch). When tartaric acid is used for this purpose, five times the
weight of the sublimate is employed.

For all surgical purposes, except in irrigation, solutions of 1-500 and
1-1,000 are used. For the sterilization of wounds and during operations a
1-3,000 is employed.

For the ready preparation of such solutions sublimate tablets can be
obtained, properly mixed with one of the above-named salts. The dyed
tablets are to be preferred, to prevent error on the part of the user.
Tablets containing 1 gm. sublimate, 1 gm. sodium chlorid, and colored
with eosin, are advocated by Angerer.

As metallic substances immediately decompose the bichlorid in solution,
instruments cannot be placed in it, nor may it be kept in metallic
vessels, glass being preferred.

Alcoholic solutions of sublimate are used to cover catgut, silk, and
rubber drainage tubes.

Since sublimate is extremely toxic, great care must be used to prevent
its absorption or retention in wounds. A strong solution must immediately
be followed by a weaker one.

Toxic symptoms resemble arsenic poisoning very much, and are ushered in
by an acute irritation of the wound, especially if moist sublimated gauze
has been used, vertigo, and vomiting. The mucous membrane of the mouth
becomes affected, followed by salivation and bleeding from the gums.
There may be intestinal hemorrhage and an inflammation of the entire
intestinal tract and kidneys, increasing in severity and resulting in
death.

The early symptoms must be at once met by removal of the cause. Albumen
and milk should be given internally, with stimulants as needed. The mouth
is to be rinsed out at frequent intervals with a saturated solution of
chlorate of potash.

=Hydrogen Peroxid= (_Love_).—A powerful nontoxic antiseptic. It is used
in five- to fifty-per-cent aqueous solutions, and is most efficacious in
suppurating wounds, in which it destroys the microörganisms of pus. It
foams actively when brought in contact with the latter, and is said to
render a wound aseptic by one or two applications. A standard preparation
of known strength must be obtained, however, to get good results.

=Iodin.=—A very powerful nonirritating antiseptic. Used especially for
washing wounds. The proper solution is made by mixing two drams of the
tincture (℥j iodin to ℥Oj alcohol) with one pint of warm water (Bryant).
The one-per-cent solution of the trichlorid is equal in its effectiveness
to a four-per-cent carbolic solution (Langenbuch).

=Lysol.=—Very similar to creolin, both in composition and effect. Is
nontoxic, and employed in two-per-cent aqueous solution. Appears as a
soapy liquid, and forms a clear solution with water.

=Potassium Permanganate.=—An active disinfectant, quickly destroying the
odor of decomposition, and for that reason is splendid for the washing
out of foul wounds. It is nonpoisonous, and has moderate antiseptic
power—the five-per-cent solution killing resting spores. Its effect is
limited to a short time only, as the secretions from a wound decompose
and precipitate it into an inactive form. It is employed in aqueous
solution, differing in color from light ruby to dark brown; that is,
1-1,000 to 1-100. The solution, known as Condy’s Fluid, has a strength of
1-1,000.

=Salicylic Acid.=—A derivative of carbolic acid, and an effective
nonirritating antiseptic. It is only slightly soluble in cold water,
1-300. When combined with boric acid, it becomes more soluble. This
antiseptic cannot be used for instruments, however, as it corrodes them.
Its other objections are that it evaporates quickly from dressings and
that it is expensive.

=Sodium Chlorid.=—Is a common agent used for the irrigation of putrid
wounds in two-per-cent solution. For irrigation during aseptic operation
and for covering sterilized sponges it is used in eight-per-cent solution
(v. Esmarch). This corresponding to the normal salt solution. Its use in
connection with corrosive-sublimate solutions (Maas) has been referred to.

=Thymol= (_Rancke_, _Bouillon_, _Paquel_).—The aromatic principle of
thyme. Efficient as an antiseptic in 1-1,000 aqueous solution. It has a
pleasant odor, and is nonirritant and nontoxic. Exhibited in colorless
crystals. An excellent solution is prepared as follows:

    ℞ Thymol           20 parts
      Alcohol          10   ”
      Glycerin         20   ”
      Aquæ          1,000   ”

It is used especially in washing out cavities where carbolic acid cannot
be employed, and for cleansing mucous membranes preparatory to operation.

=Zinc Chlorid= (_Morgan_, _Bardeleben_, _Billroth_).—Extensively used
as an antiseptic, especially in the oral cavity, where, by sealing the
lymph spaces with a plastic exudate, it hinders the absorption of septic
matter. It is only slightly antiseptic, however, in ten-per-cent aqueous
solution. Zinc chlorid represents the active agent in Burnett’s fluid.
May be effectively employed in the proportions of from twenty to forty
grains to the ounce of water. Care must be exercised to prevent its
retention in alveolar tissue, since it may occasion serious sloughing. As
a cleansing agent for infected wounds it is of great value, although the
sulphocarbolate of zinc may be preferred, as it is less irritating and
less toxic.

=Peroxoles.=—Beck has introduced a group of preparations, known as
peroxoles; liquid antiseptics containing a solution of hydrogen peroxid
in combination with other disinfectants. The preparations are composed of
from thirty-three to thirty-eight per cent alcohol, about three per cent
of hydrogen peroxid, and one per cent of thymol, menthol, or camphor,
the name given them being according to the last ingredient—thymosol,
menthosol, or camphorosol. The association with these disinfectants
greatly increases the antiseptic power of hydrogen peroxid. Aqueous
solutions containing ten per cent of the peroxoles are usually employed.
These correspond to a one-per-cent solution of mercuric chlorid, and
possess a more energetic action than five per cent carbolic acid.


ANTISEPTIC POWDERS

=Aristol= (_Dithymol Di-iodid_) (_Eichhoff_).—Reddish-brown powder
containing forty per cent iodin. Soluble in ether, chloroform, and fatty
oils, sparingly in alcohol. Must be kept in dark glass bottles. Is
incompatible with corrosive solutions. Used externally as iodoform.

=Dermatol= (_Bismuth Subgallate_).—An odorless yellow insoluble powder,
containing fifty-three per cent Bi₂O₃.

=Iodol= (_Tetraido Pyrol_) (_Kalle_).—A light grayish-brown powder,
containing eighty-nine per cent iodid. Slightly soluble in water, soluble
in alcohol and chloroform. Its action is very similar to iodoform, and
has taken its place to a great extent, first, because it is odorless, and
secondly, because any quantity used exerts no toxic effect (Wolfenden).
It is dusted upon the wound. Its action is due to the liberation of
iodin, which acts upon the albuminous elements, and the ozone set free
oxidizes the products of decomposition. It has a slight escharotic
effect, forming a thin crust over the surface to which it is applied,
thus effectually remaining in constant contact with it. That it is
quickly absorbed is shown by its presence in the saliva and the urine.

=Orthoform= (_Methyl Ester of Meta-Amido-Para-Oxybenzoic
Acid_).—Nonpoisonous, white, odorless powder of moderate antiseptic
power, and well suited for wounds involving mucous membranes. It has a
decided anesthetic effect, lasting for several hours upon painful wound
surfaces.

=Iodoform= (_Formyl Iodid_, _Féréol_).—A lemon-yellow crystalline powder
of penetrating, saffronlike odor. Contains ninety-seven per cent iodin.
Insoluble in water, but forms solution with alcohol, ether, chloroform,
and the fixed volatile oils. Has a decided stimulating effect on wounds
by preventing putrefaction and deodorization (Mikulicz). Its antiseptic
value has been much discussed, but practically it has found favor with
the majority of surgeons. According to research, iodoform is a powerful
antiseptic, from the fact that the product of its decomposition in
the presence of germ life renders the ptomains in a wound inert, thus
preventing suppuration, or at least checking the absorption of such,
which is often a serious matter in infected wounds. It is not sterile,
and may contain ptomains which in themselves would produce pus, but as
associated with the iodoform do not occasion it.




CHAPTER V

WOUND DRESSINGS


The dressing or treatment of wounds, considered herein, embodies
particularly that practiced by the surgeon in the performance of plastic
operations.

The elasticity of the skin is especially serviceable in bringing about
desirable restorative results, but, owing to its extreme vascularity
and the infrequent supply of venous valves, as in the face, there
is considerable danger of infection, with rapidly spreading septic
inflammation.

=Sutured Wounds.=—Before the wound is closed all hemorrhage must be
arrested, either by catgut ligature, in exceptional cases, and by torsion
or pressure, as generally practiced. Gauze sponges dipped into hot
sterilized solution are most suitable for the latter purpose.

The edges of the wound must be coapted perfectly by cutaneous sutures
of sterilized silk of suitable thickness. Formaldehyd catgut is often
used because of its limited absorption. Ordinary catgut should not be
employed, as its early absorption interferes with obtaining the proper
union, and by becoming softened invites sepsis.

The wound, if small, may be powdered over with any of the antiseptic
powders, such as aristol or iodol. It must be remembered that such
powders form a hard crust with the serous oozing of wounds, which, by
reason of pressure from the dressing applied over it, is very liable to
separate the edges of the wound, thus increasing the width of the scar, a
very important factor in facial surgery.

Where perfect apposition has been made, the dusting powders may be used
and a covering of Lister’s protective silk plaster placed over it. The
edge of the strips of plaster must be incised at distances of about ⅛
inch, so as to snugly take on the curvature of the parts and at the same
time thoroughly seal over the area to prevent subsequent contamination.

The plaster is made of taffeta silk, preferably of flesh color, coated on
one side with copal varnish and a mixture prepared as follows:

    ℞ Dextrin            ʒj;
      Starch             ʒij;
      Carbolic acid      ℥ij.

When applied, it should be moistened with an antiseptic solution only.
This can be applied only to dry surfaces, however, and should be rarely
used, since subsequent hemorrhage or oozing will raise the plasters,
inviting sepsis.

It is better, however, in all cases to employ several layers of an
antiseptic gauze, such as fifteen-per-cent iodoform or boric-acid gauze
to cover the wound, and back it with absorbent cotton, over which a
bandage or the silk protective is applied to retain it. The gauze absorbs
the secretions, at the same time rendering them harmless.

At no time should cotton be placed next to the wound, as it forms a hard
mass with the secretions, the removal of which requires enough force to
injure or hazard the union of a new wound. Nor should a plaster dressing
be pulled off without thoroughly moistening it first, withdrawing the
various layers one by one. The gauze, when moistened, readily leaves the
wound without injurious traction. An excellent dressing for small, dry
wounds, and one that causes little tension, is collodium, or, better,
iodoform-collodium painted over the surface. The latter may be prepared
as follows;

    ℞ Iodoformum        5j;
      Collodium         5x.
                     [Küster.]

To this may be added oil of turpentine or castor oil, which permits of
greater flexibility. Boric lint, applied wet, is also good. It must be
moistened thoroughly before removal. Larger wounds should be dusted over
with one of the powders mentioned and covered with folds of gauze and
absorbent cotton, held in place with gauze bandages.

Such dressings are allowed to remain until the sutures are taken out,
unless there is sign of soiling. As these secretions readily decompose,
it is best to remove the cotton and upper layers of gauze and renew them
every day, or as often as is necessary. The wound, in this way, is not
disturbed whatever, and the antiseptic properties of the lower fold of
gauze is sufficient to keep the wound surface clean.

In most superficial wounds it is best to remove the sutures at the end of
forty-eight hours, unless there are reasons for retaining them longer,
as the coapted surfaces are then sufficiently united to permit of other
dressings, such as aseptic plaster, now extensively used. Before these
are applied the skin is washed with alcohol or ether to assure a dry
surface to facilitate adhesion.

Sutures drawn as stated leave no possibility of stitch scars and reduce
the occurrence of possible stitch abscess to a minimum. As there is
always slight oozing following their removal, aristol or iodol may be
powdered over them before applying the plasters. This brings us to the
rather late question of sutureless coaptation of superficial incisions.

=Sutureless Coaptation.=—This method, first practically demonstrated by
_Bretz_, may be used with considerable advantage in wounds about the
face, and overcomes the strain of individual sutures, besides avoiding
the possibilities of stitch infection.

[Illustration: FIG. 21. FIG. 22.

PLASTER SUTURES.]

The method involves the proper placing of strips of plaster at either
or opposite ends of the wound. The distance between the incision and
the edge of the plaster must not be less than ¼ inch or more, according
to the length of the wound and its position. In place of the strips of
rubber adhesive plaster, the aseptic Z. O. plaster should be substituted
to overcome the objections of the infections therefrom.

[Illustration: FIG. 23. FIG. 24.

ANGULAR PLASTER SUTURES.]

The inner edges of the plasters are raised slightly, and interrupted
sutures are inserted through them instead of the skin (see Fig. 21).
They are then tied as shown in Fig. 22. In angular incisions the plasters
are cut as desired to insure perfect coaptation, as in Figs. 23 and 24.
The advantages of this method, besides those already mentioned, are that
the wound is always open for inspection and permits of free drainage.
If thought best, a small strip of iodoform gauze may be placed over the
threads or even under them, if there is little tension.

Since the introduction of the aseptic Z. O. (Lilienthal) strips, the
above method may be discarded as unnecessary and requiring too much
time for their application. Strips of the antiseptic plaster are placed
across the wound at right angles, or, if the surface be a curved one,
obliquely to the wound. The plasters are furnished in strips of the width
desired, packed in two germ-proof envelopes. They are extremely adhesive
to dry surfaces. Besides being aseptic, they are slightly antiseptic and
nonirritating. The strips are placed in position, leaving an open space
between them while the assistant brings the edges of the wound into
position.

Where there is tension of the parts this method is not to be employed.
The wound may be dusted as when sutured and dressed in the same manner.
The plasters are removed about the sixth day _by drawing the ends of
the strips toward the wound_. Their second application is unnecessary,
regular dressings being substituted.

From the above it must not be inferred that all plastic wounds are
amenable to the above methods, because many require specific treatment,
as later described.

=Granulation.=—Wounds left open for granulation should be dusted over
with some stimulating antiseptic powder, such as aristol or boric acid,
and then covered with iodoform or borated gauze. The granulating surface
must be gently washed with a mild solution of peroxid.

Prolific hypertrophic granulations, that jut out over the surface, are
touched with a lunar caustic point, avoiding the epithelial edge of the
wound, where it causes considerable pain. Pale and loose granular points
should be scraped away with the sharp spoon curette to hasten better
growth.

If the skin edges are thickened and curled upon themselves, it may be
best to curette or to reduce them by cauterization, so stimulating
epitheliar spreading. Sterile gauze is then loosely laid upon the
surface, backed with a highly absorbing material, such at charpie
cotton (Burns), wood wool, and poplar sawdust, retained in gauze bags
(Porter). The absorbing layer should be light and pervious to the air,
to facilitate not only free absorption, but ready evaporation of the
secretions.

=Changing Dressings.=—All dressings must be absolutely sterile and all
precautions, as primarily carried out, must be followed in changing them.

It is rather infrequent to use permanent dressings in plastic surgery,
but where the wound appears aseptic, with a dry serous crust over the
line of healing, it should not be disturbed except for mechanical
reasons. The latter are caused by the coagulated mixture of the wound
secretion and the antiseptic powder used, often aggravated by the median
knotting of sutures or the careless disposition of the loose suture ends.
Not too much can be said of carefully folding the free silk suture ends
at right angles to the incisions. The ends, moistened subcutaneously,
are very liable to take on septic infection and communicate it to the
wound—crowded into the very wound. When becoming embodied in the coagula
of serum and antiseptic powder it prevents, by pressure, perfect union,
causing a wider scar at such point, as well as endangering the asepsis
of the wound by being pulled off accidentally, thus tearing it open and
bringing on hemorrhage.

The appearance of the resulting scar in facial surgery is often of as
much importance to the patient as the operation itself, therefore, all
care should be exercised in bringing about the very best result.

For this reason, a patient in poor health should not be operated upon,
and any erosion of the skin about the seat of operation should be
thoroughly healed before attempting plastic work. Aristol dusted on an
abrasion will heal it quickly.

If hemorrhage follows the dressings of a wound, the dressing should be
removed and the hemorrhage controlled by pressure, unless severe, and
be redressed. Moist blood decomposes readily and is a source of early
infection, unless careful drainage under antisepsis is established. At no
time should any part of the wound be unnecessarily exposed directly to
the air. For small wounds, silk protective plaster may be used to cover
the gauze dressing, while sterile gauze bandages should keep dressings of
large area in place.

Bandages, when changed, should be cut away with the aid of the
Lazarewitch angular bandage scissors and not be unwound. It is quicker
and the undue pulling of such, when glued by secretions, is liable to
disturb the healing of wounds and even result in the tearing out of
sutures.

The patient should never be intrusted to dress wounds himself. In cases
where the dressings cannot be changed frequently proper precautions for
drainage and comfort must be observed. The temperature of the patient
should be taken twice daily; any elevation thereof may indicate septic
infection and demand immediate attention.

When a portion of the ear, nose, or lip has been severed by injury, the
part may be put back into place and held by sutures and aseptic Z. O.
strips, powdered with aristol and properly dressed. Union usually takes
place, even in the most unexpected cases. None but incised wounds of
such nature should be covered hermetically with collodium or plaster,
as bruised surfaces so often in this kind of injury require perfect
drainage. The retention of secretions produces infection, generally
resulting in the entire loss of the part.

=Wounds of the Mucous Membrane.=—Wounds of the mucous membrane should be
carefully drained and cleansed freely at frequent intervals, especially
those about the mouth. Wounds of the cheek, if including the mucous
membrane, should be especially cared for, as there is here the increased
danger of infections from the secretions of the mouth.

=Pedunculated Flaps.=—When pedunculated flaps are left free of other
attachment, for reasons later mentioned, they must be dressed as
granulating wounds. Here it becomes necessary to support the loose
piece of skin in such a way as to overcome circulatory obliteration.
Unnecessary handling is always to be avoided. The following method has
been used with the best results by the author.

The flap is not dressed until all hemorrhage has ceased. A small pad
of sterilized or borated absorbent cotton is covered lightly with
ten-per-cent iodoform gauze—cigarette fashion. The surface of this roll
drain is powdered well with aristol or iodol and it is gently placed
beneath the flap so that it rests easily upon the same. A second and
somewhat larger pad or roll of like construction is placed next to the
skin surface of the flap. This is held in position by silk protective
plaster or several layers of gauze bandage, gently, though snugly,
applied.

The flap thus dressed should not be subjected to pressure, often
requiring considerable care on the part of the patient, especially during
the night. Undue pressure will induce sloughing and must be avoided, even
at the expense of comfort to the patient.

This dressing may be changed the second day, when the flap will appear
anemic. Signs of discoloration indicate gangrene, which is difficult to
overcome. In a short time the skin takes on a pale pink color, which
indicates a reëstablishment of circulation, and granulations begin to
show themselves on the reverse side, which, as they multiply, soon
thicken the flap sufficiently for the purpose desired.

The dressings are continued, as begun, if there be no indication for
interference, although the granulations may be stimulated if too
inactive. Gently irritating the granular surface with a 1-3,000 sublimate
solution, although rarely permitted by most surgeons, does no harm; in
fact, it is to be recommended before reapplying the dry dressing.

In removing the dressings the edges of the flap will be found to adhere
to the gauze; this may be gently lifted with the tenaculum, after
previous softening with a weak solution of hydrogen peroxid.

Pus (laudable) is the natural secretion from these flaps. Whatever
remains on the surface is easily removed by an antiseptic solution,
whereupon the powder is again dusted upon the part. When the flap has
thickened sufficiently it may be covered by skin grafts, but this is
rarely done until it has been properly implanted into the area for which
it was intended and only then when union between its sutured borders has
taken place. Ofttimes one part of a flap is left unattached, as, for
instance, the outer border of the ear, with the object of developing
a greater thickness. This must be cauterized along the edge with the
caustic pencil, keeping the granulations within the desired limit until
the opposite layer of skin has either cicatrized with it or has been
grafted near it for the same purpose. The surface is then antiseptically
treated, as any granulating surface, except as otherwise indicated.

=Foreign Bodies.=—Especial care must be exercised with wounds into which
foreign bodies have been implanted. Under favorable conditions many are
kindly received by the tissues, but often these rebel and even with
the greatest of care in dressing such wounds will often result in the
necessity for removal of the substance. Individual cases of such nature
are fully referred to later.




CHAPTER VI

SECONDARY ANTISEPSIS


SEPTICEMIA FOLLOWING WOUND INFECTION

=Symptoms.=—After operations performed under the most thorough aseptic or
antiseptic procedure, wound fever, more or less marked, may be expected.
It develops a few hours after operation and subsides in twenty-four
or forty-eight hours. If, however, the wound has not been properly
rendered aseptic, or in which there is reason for irritation or tension,
more serious symptoms may develop about the second or third day. These
symptoms increase with the amount of infection in the wound and result
in septicemia, or septic intoxication, the outcome of the absorption of
ptomains—the product of tissue decomposition.

Inflammatory fever is marked by a sudden rise in temperature, 100° to
103° F., with a full, strong, and rapid pulse, headache, anorexia, coated
tongue, constipation and diminished secretion. If the infection is severe
delirium comes on.

If the symptoms are not relieved promptly the indications of septicemia
assert themselves with an increasing temperature, between 102° and 104°
F., with a rapid compressible pulse gradually becoming weaker. The
respirations are rapid and shallow. The tongue becomes dry and discolored
and the teeth are covered with sordes.

The restlessness disappears and apathy, somnolence, and a low type of
delirium takes its place. Vomiting occurs. There may be a profuse
diarrhea and the urine is passed involuntarily. In other words,
septicemia is but an aggravated continuance of inflammatory fever;
untoward symptoms may come on early, and death may result within
forty-eight hours.

On inspection, the infected wound appears highly inflamed, there is
increasing swelling, with more or less pain in the part. The edges of the
wound appear pale and everted. Serous oozing comes from the wound. If
sloughing is to occur from tension or low vitality of the parts the area
becomes discolored, assuming at first a pale green color, which turns
into bluish brown—and, lastly, brown.

=Treatment.=—The treatment of such wounds is to immediately relieve all
tension by withdrawing the sutures. Flush the wound with peroxid solution
and irrigate thoroughly with a 1-3,000 bichlorid solution, leaving the
wound open for a free drainage.

Then apply iodoform gauze over the wound and change the dressings as
often as is deemed necessary—two or three times a day. In severe cases
open the wound thoroughly, even by further incision, clean out the
contents of the wound, such as foreign matter, bloodclots, exudate, or
perhaps pieces of bone that may have been overlooked, using a small,
sharp spoon curette for the purpose. See that the deeper recesses of the
wound, especially in those about the nasal bones, are thoroughly gone
over.

Next irrigate the wound with a 1-1,000 bichlorid solution. Carbolic
solutions to be of use in the severer cases, are too irritating and
cause an increase of the secretions, hence they are not to be used.
Furthermore, their toxic property is not desirable and ofttimes are not
well borne by the patient.

The wound is now loosely filled (not packed) with iodoform gauze to
permit of perfect drainage. Aseptic absorbent cotton may be placed over
this.

It is not advisable to bring the edges of the wound together; the main
object is to overcome the spread of infection and the toxic absorption of
the wound product.

When the symptoms are severe moist dressings, in the form of compresses
dipped into 1-3,000 bichlorid, are to be preferred, changing them every
hour.

Internally it becomes necessary to reduce the temperature and to overcome
the toxemia.

For the temperature quinin is the best agent. In milder cases it can
be given in tonic doses, associated with antifebrin, with or without
morphin, to quiet the patient. In severe forms quinin must be pushed,
giving as much as twenty grains at a dose, to be repeated as necessary.
A saline purge, magnesium sulphate in full doses, is useful to eliminate
the ptomains.

The strength of the patient must be supported by the free use of
stimulants and frequent small quantities of nutritious food. Milk with
whisky is excellent. Peptonoids and beef juice are given several times in
the day.

Favorable symptoms are heralded by the lowering of the temperature, the
abatement of toxic symptoms, the reduction of the edema, and the deep
redness, as well as the softening of the hard and painful edematous walls
of the wound, followed by the breaking down of more or less tissue with
the production of pus.


GANGRENE

Gangrene in these cases is often due to undue bruising or pressure on
the parts during operation, and otherwise to the tension of sutures. It
is best to allow the gangrenous mass to remain, keeping it aseptic by
antiseptic measures, as it is often found that only the superficial layer
and the edge or edges of the wound have suffered.

As demarcation is well established the gangrenous portions may be removed
with the dressing or small seizing forceps. _Walcher’s_ pattern of a
dressing forceps is shown in Fig. 25, a toothed seizing forceps being
represented in Fig. 26.

[Illustration: FIG. 25.—WALCHER DRESSING FORCEPS.]

[Illustration: FIG. 26.—TOOTHED SEIZING FORCEPS.]

The wound from now on may be at first subjected to a rather strong
aqueous solution of hydrogen peroxid, fifty per cent, followed by the
same sublimate solution used throughout.

Iodoform gauze dressing, with or without dusting of iodoform or iodol, is
continued with the purpose of draining the pus secretion thrown off by
the granulating tissue which soon begins to fill the wound, as well as to
exert its antiseptic and stimulating influence upon the granulations.

Lazy or glassy granulations are removed with the curette as they appear,
or a cauterant, in the form of a nitrate-of-silver stick. Gradually the
new tissue contracts, the epidermal edges begin to fold over the surface.

Dry dressing, in the form of aristol or boric acid, may then be used, to
produce ultimate healing under an aseptic scab, or lint moistened with
two-per-cent salicylic oil or boric vaselin is placed upon the wound. A
formula of the latter is made up as follows:

    Boric acid    3 parts
    Vaselin       5   ”
    Paraffin     10   ”

A desirable boric-acid oil for the same purpose is composed of:

    Boric acid    3 parts
    Cera alba     4   ”
    Ol. oliva    20   ”

The latter must be changed daily until cicatrization has been established.

If it is more desirable to cover the granulating area by means of skin
grafts it may be accomplished readily, as later described. This is
usually resorted to when there has been loss of tissue from the result of
sloughing, although a sliding-flap operation may overcome the defect to a
nicety; this is especially true of wounds about the anterior nasal border.

If the resulting cicatrice is no larger than the gaping wound it may be
excised, the skin at either side is undermined and the edges are brought
together, as was originally intended.


ERYSIPELATOUS INFECTION

It sometimes happens that a wound takes on erysipelatous infection. It is
usually of the simple variety, although the cellulo-cutaneous variety is
not rare.

=Causes.=—The predisposing causes are septic infection, lowered vitality,
resulting from alcoholism, poor hygiene, and nephritis. The exciting
cause has been accredited to the erysipelo-coccus of _Fehleisen_, which
is found chiefly in the more superficial channels of the corium and
appearing in chain groups as seen microscopically.

=Symptoms.=—The symptoms locally are the peculiar rosy rash, rapidly
spreading out from the wound with well-defined margins. The affected part
appears smooth and edematous and is slightly raised above the surface,
the patient complains of stiffness and burning pain in the part. Often
vesicles form on the affected part.

The temperature rises suddenly to 102° to 103° F., there is nausea and
vomiting.

=Treatment.=—The wound in such cases must be treated as described in
inflammatory fever. Internally the usual remedies are given. A local
application of sixty-per-cent ichthyol ointment, covered with salicylated
cotton, serves best. The skin may be incised in various places, washed
with an antiseptic (sublimate solution 1-1,000) and the serous exudation
pressed out with the sterilized hand, after which the above ointment is
applied under absorbent cotton (Glück).

Antithermic remedies, as obtained by the application of certain
alkaloids, such as cocain, spartein, solanin, helleborin, have been
successfully used by Guimard and Geley.

Spartein is especially claimed to exert a happy influence.

Lately a product under the name of antiphlogistin has been used locally
with excellent results and its use is to be commended even in local wound
inflammation.

If the subcutaneous tissue is affected and the surface indicates the
breaking down of tissue, hot antiseptic applications are advisable or
the skin is incised down to the deep fascia at such places and iodoform
gauze is packed into the wound for several hours. Constant antiseptic
irrigation is then established by means of drainage tubes inserted
into the various incised places, which are connected to an irrigating
apparatus, so that the antiseptic may reach all parts of the infected
area.

Nontoxic solutions are indicated in this event; of these, hydrogen
dioxid, three per cent, and boric acid, nine per cent, are most suitable.
The solution is allowed to trickle gently through the wound and is led
off by open tubes, that may be connected in such way as to empty into a
receptacle placed beneath the bed.




CHAPTER VII

ANESTHETICS


Anesthesia of the human may be accomplished in two ways: first, by the
employment of a general anesthetic, and, secondly, by the local use of a
narcotic agent.

It is not the intention of the writer to dilate upon the nature and use
of anesthetics, as their value and indication has been fully exploited.
A concise review of these agents, however, will meet with the approval
of the special surgeon, inasmuch as they have their particular use in
individual cases. Local anesthesia is undoubtedly the most extensively
employed, in the performance of the average plastic operation, yet in
certain cases it is contra-indicated, and it is to further the proper
selection of such that the following may be of value.


GENERAL ANESTHESIA

It must be understood that general anesthesia has its many advantages and
equally its disadvantages. It necessitates the early preparation of the
patient and a thorough physical examination as to the state of lungs,
heart, and kidneys. Patients having cardiac affections or serious lesions
within the lungs should be given the safest anesthetic obtainable; in
fact, if the operation can possibly be done by local administration, it
should be.

It is to be remembered that in a majority of these cases the operation
is undertaken to remedy a deformity, however caused, one that is not
necessarily serious to health, and it would indeed be unwise to place
such a body in jeopardy or to take undue chances if they can be avoided.
Ofttimes several operations, a few weeks apart, must be done and the
frequent repetition of a general anesthetic might impair the health of
the patient—a condition not associated with local anesthesia.

Neurotic subjects often insist upon the use of chloroform and the surgeon
is frequently tempted to administer it, but little objection should be
found with local narcosis, where it can be employed.


PREPARATION FOR GENERAL ANESTHESIA

The patient must not be allowed food at least six hours prior to
operation. In neurotic and anemic subjects a full dose of strong wine
or whisky should be given half an hour before operation. Habitual
drinkers should be given one quarter grain morphin sulphate. All movable
artificial teeth, or other foreign bodies, must be removed from the
mouth. Observe the laws of asepsis as heretofore described. Loosen the
clothing of the patient about the neck and chest. Only a single garment
should be worn during the time of operation—a loose, sterilized night
robe, as it may be necessary to move the patient about, and too much or
tight clothing might prove to be dangerous in the delay occasioned by its
removal.

The operating room should never be cold enough to chill a patient so
prepared. Hot-water bottles or a warm pack can be placed between or
about the limbs to equalize the external circulation. This is especially
necessary when chloroform is administered, as this lowers the temperature
of the body. Have the bowels and bladder emptied. Choose the early part
of the day for operations of some length, because the stomach is then
empty and vomiting with resultant gastric disturbance will be lessened or
entirely avoided. The anesthetizer should be experienced and attend to
his duty implicitly. He must at all times watch the patient, take note
of the pulse, pupils, and respiration. Close by he must have a mouth-gag,
tongue forceps, long-handled sponge holders, containing dry absorbent
cotton sponges, and a basin in case of emesis.

He should quietly instruct the patient how to breathe and at first assure
him, and as narcosis comes on command him to do what is necessary. No
desultory or detracting conversation should be permitted. A small but
efficient faradic apparatus must be within call of the administrator.
Sterile vaselin should be smeared about the nose and mouth to prevent
skin irritation.


CHLOROFORM

(_Guthrie_) The pure product must be used. It is a colorless, mobile
liquid, having an ethereal odor and sweet to the taste. It should not
affect litmus or turn brown with sulphuric acid or give a precipitate
with nitrate of silver. If there is emphysema of the lungs, bronchitis,
or renal disease, chloroform is to be preferred to ether, also in
operations about the oral cavity. Children bear chloroform narcosis
better than adults.

[Illustration: FIG. 27.—SCHIMMELBUSCH DROPPING BOTTLE.]

[Illustration: FIG. 28.—ESMARCH DROPPING BOTTLE.]

Chloroform first affects the brain, then the sensory tract of the spinal
cord, then the motor tract, followed by an involvement of the sensory
path of the medulla, paralyzing the respiratory centers, while cardiac
syncope may come on at any time during narcosis. Death may be either
due to respiratory or cardiac failure, often from both. To overcome this
the anesthetic should not be crowded, nor should the apparatus be held
too close to the mouth of the patient. The best method of giving it is
by means of the dropping bottle of Schimmelbusch (Fig. 27) or that of
Esmarch (Fig. 28) and a simple mask or apparatus.

[Illustration: FIG. 29.—SCHIMMELBUSCH IMPROVED FOLDING MASK.]

[Illustration: FIG. 30.—ESMARCH INHALER.]

The wire frame affair, to be covered with a fold of muslin, designed by
Schimmelbusch, is perhaps the best (Fig. 29). Another splendid inhaler is
that of the Leiter improvement of the Esmarch folding frame (Fig. 30).

A folded towel, crumpled or pinned into a hollow oval form, may be
substituted for the above.

Begin by pouring about thirty drops upon the inhaler, gradually bringing
it nearer from a distance of six inches to the mouth and nostrils of the
patient; then continue by letting one drop fall upon the apparatus every
five or ten seconds until the patient is thoroughly anesthetized; then
use one drop about every ten seconds, although it might be necessary
to push this quantity at certain moments of the operation. To obtain
complete anesthesia by this method takes about ten minutes. The vapor
should be thoroughly mixed with air in the proportion of ninety-five
per cent of air to five per cent of the vapor. The amount administered
during operation can rarely be determined, because of the uneven
respiration of the patient, who takes more during frequent inspiration
than during ordinary breathing. By all means do not let the chloroform
trickle upon the skin or into the eyes, as it causes considerable
irritation.

The respirations are at first full and deep, soon becoming shallow and
rapid. At first the pulse is slightly stronger and fuller than the
normal, but it soon loses its strength and volume and becomes more rapid.
The pupils are at first dilated, and as narcosis is induced, contract.
Should they contract after this, during operation, it is a danger signal
not to be neglected. Death may come on suddenly.

If the patient struggles violently under early anesthesia, as is often
seen in alcoholics and athletes, it is not advisable to push the
chloroform nor should total muscular relaxation be effected. The arrest
of reflex movement is all that is required.

As the reflex action of the cornea disappears last of all, the
anesthetizer can use this as a guide during further administration to
avoid all danger. This is accomplished by gently touching the cornea with
the index finger, raising the eyelid with the third finger.

Chloroform lowers the body temperature, due undoubtedly to its aiding
in the dissipation of heat and by reason of its effect on the nervous
mechanism of heat production. It is rapidly eliminated by both the lungs
and the kidneys, because of its high volatility, and as little is given,
the irritation to these organs is not as great, volume for volume, as
with ether.

In case of asphyxia the lower jaw must be pushed far forward, the tongue
be drawn forward with forceps, and the head extended and lowered, by
raising the feet off the table. Cold water should be dashed over the face
and chest. Slapping the chest with a wet towel and vigorously rubbing
with hot cloths or brushing the palms and soles. Brandy and water, one
to two parts, can be introduced into the rectum, or faradization of the
nasal mucous membrane can be tried. These means failing, artificial
respiration (Sylvester’s method) must be resorted to. This being of no
avail, tracheotomy must be done.

If the patient is induced to vomit, he should immediately be turned on
his side to prevent the indrawing of the ejected matter into the lungs.
After it has ceased, thoroughly wipe out the mouth with a long-handled
sponge. The anesthetic must now be crowded slightly to overcome the
irritation of the mucous membrane of the stomach. Often during the early
stage of anesthesia the patient stops breathing, which must be overcome
by slapping the chest or by two or three forceful downward movements on
the epigastrium.

If the face of the patient takes on a sudden change of color or breathes
heavily the anesthetic should be withdrawn for a few moments, until the
symptoms abate. If the mucus collects about the glottis it is liable to
cause respiratory difficulty and must be swabbed out. If the inversion of
the patient does not relieve syncope and the methods already mentioned
fail to relieve, injections of normal salt solution into the median
basilic vein must be employed as a last means.


ETHER

(_Jackson, Morton._) Sulphuric ether is used in the pure form, free from
alcohol and water. It should be a colorless, volatile, mobile, and highly
inflammable liquid, having a peculiar penetrating odor. As its vapor is
much heavier than air, and owing to its combustible nature, lights about
the room should always be placed above the patient. Often its vapor is
ignited by the careless use of the electro-cautery.

Ether for anesthesia should not affect blue litmus. It should not give
a blue color to ignited copper sulphate—the test for the presence of
water. Alcohol is indicated when it turns red by adding fuchsin.

Ether is less toxic than chloroform, therefore it requires a greater
quantity to induce narcosis.

If properly administered it is by far safer than chloroform, Ollier,
of Lyons, reporting only one fatality directly due to its employment
in four thousand patients. If the anesthetic is crowded cyanosis with
jugular pulsation is noted—the signs of inefficient oxygen and cardiac
distention. In most recorded cases of death there were complications
of a nephritic pulmonary nature. Ether should not be used where there
is bronchitis, gastritis, or peritonitis, owing to its irritant effect
on mucous membranes, nor in nephritis, aneurysm, or advanced atheroma.
The movements of the diaphragm must be constantly watched as it is the
first to become paralyzed when anesthesia is carried too far. The same
care must be observed with the pupil for cerebral and the pulse for
cardiac signs. Before giving this anesthetic the same preparations as for
chloroform narcosis should be observed. The stomach should be empty, the
nose and mouth smeared with vaselin, and the eyes protected with a towel.

At first the patient is given the ether with a considerable mixture of
air, which should be lessened gradually. Coughing comes on quite often,
which is overcome by increasing the ether. Soon there comes a state
of respiratory forgetfulness. This is caused by the irritation of the
trigeminal and vagal nerves (Hare). This is corrected by dashing ether
upon the epigastrium or by sudden and repeated pressure at this point.
There is also choking and struggling, the face becoming suffused and red
and there is an injection of the conjunctiva. As the ether is pushed
the patient becomes quiet, followed by a second seizure of struggling,
so intense, that force must often be employed to hold him on the table.
With this there are the various attacks of laughing, crying, singing,
or yelling—a semiconscious exhibition of the state of the mind of the
individual.

As anesthesia progresses relaxation takes place and the time for
operation is at hand. Often the throat fills with mucus, owing to the
irritant effect of the vapor on the mucous membranes. This must be wiped
out with the sponges.

If vomiting occurs the head of the patient is turned to one side until
relieved. The mouth should be cleansed thoroughly thereafter to prevent
the contents getting into the lungs and causing bronchial irritation and
often broncho-pneumonia. If the patient gets too little air, shown by
laryngeal stertor, frequent and feeble pulse, livid face or pallor, tonic
spasm, thoracic breathing with fixed diaphragm, and drawing in of the
abdominal walls with inspiration, the ether should be let up and the jaw
pushed forward by placing the fingers under the rami. The tongue should
be drawn forward, as already described, and such methods be used as have
been mentioned in connection with asphyxia in chloroform narcosis. The
pupils fixed in dilatation is indicative of immediate danger.

Strychnin and digitalis should be given hypodermically or the intravenous
use of ammonia may be employed. If the stertorous breathing is due to
mechanical causes, not to too much ether, the hypodermic use of ether
will bring about reflex respiratory movement by reason of the local pain
and irritation thus produced.

[Illustration: FIG. 31.—ALLIS INHALER.]

[Illustration: FIG. 32.—FOWLER INHALER.]

[Illustration: FIG. 33.—JUILLARD MASK.]

The anesthetic may be administered with the aid of various masks
or inhalers. Simplicity of construction is to be preferred to more
complicated apparatuses. The aseptic metal inhaler of Allis (Fig. 31) or
the folding form of the same modified by Fowler (Fig. 32), are much used
in the United States, while the Juillard mask—a metal frame covered with
several thicknesses of gauze—is used abroad. (See Fig. 33.)

It is to be remembered that in operations about the face ether anesthesia
is not practicable, owing to the repeated lifting of the mask which
allows the patient too much air. It can only be given by specially
constructed inhaling devices, which are more easily used with chloroform
or the mixed anesthetics. Their specific use and construction will be
referred to later.


COMBINED ANESTHESIA

It is often desirable to get the patient as quickly as possible under
anesthesia and still overcome the depleting effects of chloroform
narcosis. A common method to accomplish this is to give chloroform to the
point of relaxation and with a change of inhaler continue with ether.
In this way anesthesia can be kept up safely a long time with a minimum
amount of ether. There are, however, a number of mixtures used in place
of this interchange of anesthesia, all having their particular merit.
Some of the best known are:

=Alcohol-Chloroform-Ether= (_A. C. E. Mixture, English Formula_,
1:2:3).—This induces rapid anesthesia without the danger of syncope or
the other objections to chloroform or ether when used alone.

=Chloroform-Ether-Alcohol=, in the proportion of 3:1:1, and known as
Billroth’s mixture, is extensively used in the same way.

=Chloroform-Ether.=—This mixture, in equal proportions, is known as
Tillman’s mixture, and has been employed by many well-known surgeons.


NITROUS OXID

Nitrous oxid, as advocated by Sir Humphrey Davy, is a safe product,
but the anesthesia produced thereby is of too short duration to be of
practical value in plastic surgery. Its employment is resorted to only
for such operations as the opening of abscesses or the removal of small
cysts, etc.


ETHYL BROMID

While ethyl bromid is a product that cannot be said to be absolutely
safe, Terrier, of Paris, has used it largely to induce anesthesia,
following it up with chloroform. It should be given freely with deep
inspiration, the sixth inhalation producing total loss of consciousness.
A moment after complete muscular relaxation is attained, with congestion
of the face and dilated pupil. The average time necessary to accomplish
this is about one minute, in which about three to five grams are used.
In this way the stage of excitement is overcome and immediate narcosis
is obtained. As the chloroform is substituted it must be given fairly
strong, reducing it gradually. The facial congestion slowly diminishes
and the pupillary dilation gives way to contraction. About sixteen grams
of chloroform are required to keep up anesthesia for fifteen minutes. The
after-effects of chloroform are entirely overcome by the above method.


ETHYL CHLORID

Hawley, in reviewing the use of ethyl chlorid as a general anesthetic
in minor operations, states that after several years of more or less
constant use of ethyl chlorid, both in clinical and private practice, he
has still to see the first case in which it has caused him the slightest
uneasiness. The following precautions in its administration should be
observed: (1) The patient should be prepared as for chloroform or ether;
(2) whatever mask is used, it should fit the face snugly; (3) a graduated
tube with a large aperture should be used; (4) the anesthetic should be
well supplied with air and as little given as possible; (5) care should
be taken not to present it at first in too large a quantity; frequently
a dram is quite sufficient for short operations; (6) the patient should
rest a while after its administration, as faintness sometimes supervenes;
(7) a mask should be used which does not receive the drug close to the
patient’s face, otherwise one is liable to either freeze the face of
the patient or to cause asphyxia by the moisture from the expired air
freezing on the gauze in the mask, and thus preventing the free passage
of air to the patient.

The use of ethyl chlorid has the following advantages: (1) Safety in
administering; (2) ease of administration; (3) it rapidly produces
surgical anesthesia; (4) it can be used where chloroform or ether
would be contra-indicated; (5) the patient can be kept in any position
during anesthesia, upright or prone; (6) no cyanosis need occur during
administration; (7) the patient recovers promptly without after-effects;
(8) it is inexpensive; (9) it can be used for a long or short operation
with equal success; (10) it is especially useful as a preliminary to
other anesthetics, decreasing the time required for the production of
anesthesia and avoiding shock and discomfort to the patient.


LOCAL ANESTHESIA


ETHYL CHLORID

Ethyl chlorid is a colorless, mobile liquid, which boils at 52° F. This
is furnished in thirty- and sixty-gram glass tubes, sealed with a metal
screw cap or spraying device. As this cap is removed the liquid in the
tube begins to boil, owing to the temperature of the room, or, better,
the operator’s hand, and a fine vapor spray is ejected from the opening.

The tube end is held from six to eight inches from the part to be
anesthetized. Immediately the skin is frosted over and the lanugo hairs
become covered with snow. The skin turns white and becomes slightly
elevated, appearing to be thickened; at the same time the patient feels a
stinging pain in the area. This may be overcome greatly by first smearing
the part with sterile vaselin. In a few moments the skin is frozen and
rendered antalgic, and operations of short duration can be performed. The
only disadvantage with this method is that the part to be operated on is
frozen stiff, hence the skin cannot be neatly dissected away from the
subcutaneous tissue as under other local anesthesia, nor can the tissues
be moved about as readily, as in the case with flap operations, owing to
this stiffness.

The parts thaw out quickly with a returning sensitiveness, and it may
be necessary to apply the spray repeatedly until the operation has been
completed. If _elastic constriction_ can be employed, the antalgic effect
is more quickly produced and more lasting.

As the parts thaw out there is considerable prickling, which can be
mitigated by applying sponges soaked in hot sterilized water. More or
less redness of the skin will be noted even for some time after the
operation.


COCAIN

(_Methylbenzoylecgonin_)

(Gädeke, Nieman, Bennett, Koller.) Cocain is the alkaloid derived from
several varieties of _Erythroxylon coca_. It should appear as a permanent
white crystalline powder in colorless prisms or flaky leaflets. The salt
used for anesthetic purposes is the hydrochlorid; it is soluble in 0.4
part water, 2.6 parts alcohol, 18.5 parts of chloroform, and insoluble in
ether.

Locally applied on mucous membranes and open wounds, it exerts an
analgesic effect, but not of the unbroken skin. Punctures or abrasions
are necessary to permit of absorption in this event. When locally applied
it paralyzes the peripheral sensory nerves, and at first blanches the
parts by reason of its active contraction on the arterioles, which is
soon followed by marked congestion.

Krymoff has made extensive experiments to determine the anesthetic
effects of cocain solutions sterilized in various ways. He claims that
the best results in minor surgery are obtained with the one-per-cent
solution pasteurized at 60° C. for three hours. The same solution
pasteurized at 80° C. for two hours or at 120° C. for fifteen minutes
gave results far less satisfactory.

While the pasteurized solutions accomplished an anesthesia lasting from
one to two hours, sterilized solutions (boiled at 100° C.) overcame pain
only for a period between twenty and thirty minutes.

Pasteurized solutions have the advantage of being sterile and do
not decompose as the boiled solutions would. The pasteurization is
accomplished as follows: The necessary amount of cocain is dissolved in
sterilized water. The solution is put into a sterilized glass bulb,
which is sealed hermetically and subjected to a temperature of 60° C. for
three hours.

Since cocain is a nerve poison, its systemic absorption must be avoided.
The constitutional effects of a given amount injected about the head,
face, and neck are more marked than when injected in other parts of the
body or extremities. This is due to two causes: a more rapid absorption
and the proximity to the brain (Ricketts). For this reason less cocain
should be used and the blood vessels be avoided.

Idiosyncrasy influences greatly these toxic effects. In neurotic patients
of irritable and impressionable type the hypodermic use of this agent has
especially induced serious syncope. Very serious symptoms and even death
have been caused by its local use (⅛ grain hypodermically).

Untoward effects are manifested by nausea, vertigo, emesis, syncope,
followed by clonic convulsions, delirium, and death.

Cocain first stimulates, then paralyzes, the pneumogastric nerve; the
respiration is first accelerated, and then paralyzed, death being due to
failure of respiration.

Should these symptoms occur, the patient should be placed on his back
with the head low. Amyl nitrate inhalations act as the antidote and
reduce the cerebral anemia (Feinberg). Morphin or caffein is to be
given hypodermically, or the former is associated with potassium bromid
internally.

To overcome the toxic qualities of the anesthetic it may be combined with
morphin in solution, Schleich’s solution being well known. It is composed
as follows:

    Cocain murias        0.1
    Morph. sulph.        0.025
    Sodium chlor.        0.2
    Aquæ sterilis.     100.0

Gauthier suggests the addition of one drop of a one-per-cent solution
of nitroglycerin to the quantity injected and repeated to prevent the
unfavorable after effects.

Solutions of cocain are to be made up fresh each day, as they become
moldy on standing. They cannot be sterilized, for the reason that a
temperature of 213° F. renders them useless. The solution is most active
at 50° F. (Costa).

For hypodermic purposes two- to ten-per-cent solutions are employed, the
four per cent being more generally used, not more than 0.1 gram of the
agent being introduced (Hänel, ano).

[Illustration: FIG. 34.—SIMPLEX SYRINGE.]

[Illustration: FIG. 35.—KOLLE IMPROVED PRAVAZ SYRINGE.]

[Illustration: FIG. 36.—“SUB-Q” SYRINGE.]

For the introduction of the solution the ordinary Pravaz syringe can be
used, a modification of which being known as the “Simplex” (Fig. 34). It
is a glass instrument, without screw threads within the needle base, and
has a sterilizable fiber piston. The only disadvantage offered by this
syringe is the lack of finger rests. The author has added a removable
nickel-plated sleeve with finger rings to slip over the glass barrel, as
shown in Fig. 35. The advantage of this modification will be appreciated
when injections are made into dense or cicatricial tissue where
considerable pressure is necessary for the introduction of the solution.

Another excellent syringe for the purpose is the metal-cased instrument
known as the “Sub-Q” (Fig. 36); the barrel and piston in this are of
glass, an asbestos packing being wound over the piston head.

Metal needles with large thread or smooth ends are employed. As the
asbestos packing contracts in drying, the piston should be removed from
the barrel and cleansed immediately after use, and not be introduced into
the barrel until both the asbestos windings and the inside of the barrel
have been moistened with warm sterile water. This precaution prevents the
cracking of the instrument through undue pressure exerted on the end of
the piston rod at the time of use.

To render the primary introduction of the needle painless the area might
be sprayed for a moment with ethyl chlorid. After carefully preparing the
site of operation, the subcutaneous injections are made in a somewhat
oval or circular manner, the first infiltration of the cocain rendering
the succeeding points analgesic.

It will be noted that the skin becomes whitened and is raised in little
tumors, with the point of puncture as a center. The various punctures
are so placed that the borders of these tumors meet, the entire site
becoming edematous. If by constriction the part can be rendered ischemic,
the analgesic effect is prolonged, reducing the systemic absorption to a
minimum.

The subsequent nausea often following may be promptly overcome by the use
of a mixture of creosote, four drops in limewater. For mucous surfaces
the anesthetic may be applied with absorbent cotton and allowed to remain
about five minutes. In deeper wounds than those involving skin, deeper
injections must be made.

The effect of the anesthetic as above employed is practically immediate,
and the operation can proceed at once. Its duration is from fifteen to
twenty minutes for subcutaneous surgery, but where the deeper structures
are involved subsequent injections must be made to control the pain.


BETA EUCAIN

(_Benzoylvinyldiacetonalkamin_)

(Merling, Vinci.) White powder, soluble in 33 parts of water. While the
effects of eucain are immediate and produce anesthesia as thoroughly as
cocain, it has the objection of producing local hyperemia and increased
edema of the parts injected. This often interferes with the successful
outcome of the first operation, as will be later shown. The advantage
over cocain, however, is that a solution of eucain can be sterilized by
boiling without reducing its usefulness, which in itself is an item,
since both are expensive, and if we must prepare a cocain solution fresh
for each day we must discard all that has not been used, while with
eucain the same preparation can be safely used over and over, after
proper sterilization.

The two- and three-per-cent solutions are most employed to the extent of
from 10 to 60 minims. Its subcutaneous effect is immediate, lasting from
ten to twenty-five minutes. When applied locally to mucous membranes, the
five-per-cent solutions are used.

Principally it may be said that eucain does not exhibit the toxic
properties of cocain, the author having employed it in over 5,000 cases
with no untoward effect.


LIQUID AIR

Liquid air is suggested as a means of local anesthesia by A. C. White. He
recommends its intermittent application instead of freezing the part as
with ethyl chlorid. It is sprayed on the parts and produces immediately
anemia and insensitiveness. There is no hemorrhage during its use, so
that dressings may be applied before the parts assume their circulatory
function; an advantage of considerable value in plastic surgery. No
untoward results follow its use.


STOVAIN

(_Benzoyl-ethyl-dimethylamin-opropanol hydrochlorid_)

(Fourneau.) This is the latest preparation advocated for local
anesthesia. It is a synthetic product, derived from tertiary amyl
alcohol. It is less toxic than cocain, and has been used more or less in
the past years experimentally, but the consensus of opinion seems to be
against its use. Jennesco has used it extensively in conjunction with
strychnin in spinal anesthesia, but the surgeon in general has not taken
kindly to it. In plastic surgery, as used locally, it has been little
employed, eucain being the most serviceable for the purpose.




CHAPTER VIII

PRINCIPLES OF PLASTIC SURGERY


Plastic surgery is resorted to in covering defects of the skin due to
congenital or traumatic malformation, injuries, burns, the removal of
neoplasms, or the ulcerative processes of disease. Furthermore, it can be
employed cosmetically for the rebuilding of organs, whole or in part, or
for their reduction when abnormally developed. This applies particularly
to the nose, ears, and lips, wherein it may involve either the skin alone
or the mucous membranes, or all the tissue making up the parts operated
on.

=Incisions.=—The incisions in plastic surgery are to be made obliquely
into the skin rather than at right angles to the surface, the former
permitting of better apposition, and undoubtedly causing less epidermal
scar. The incisions include the skin only, except when otherwise stated.

=Sutures.=—Sutures should be placed not more than ¼ of an inch apart and
be made to include the skin only, unless it is deemed advisable to employ
deeper ones to relieve undue traction, which often results in suture
scars and ofttimes tissue loss, necessitating further operation. The
latter may be obviated by placing every other stitch at greater distance
from the free edge of the skin, that is, into the undissected border.

Intracutaneous sutures may also be employed, but these are rarely, if
ever, necessary if the apposition has been properly accomplished. To
relieve tension, harelip pins are also used, as later described. Catgut
of such size as would be suitable because of its ready absorption is not
to be employed for skin suturing, fine twisted silk or selected horsehair
being the best material.

Formaldehyd catgut can be used if it is desirable; its fine strands
withstand absorption to a greater degree than the ordinary.

[Illustration: FIG. 37.—⅝ CIRCLE HAAGEDORN NEEDLES.]

[Illustration: FIG. 38.—CRESCENT CURVE HAAGEDORN NEEDLES.]

_Needles._—Very fine, flat, round-eye needles, such as Haagedorn’s,
Nos. 12 to 15, ½ or ⅝ circle, are the most serviceable in skin work, as
they incise the skin in penetrating and leave an elongated slit, which
heals readily, rarely leaving a needle scar. The selection of needles,
however, must be left to the operator, many preferring the one variety to
the other. Split-eye needles are quite convenient, but they break more
readily, and while they work best with fine silk, this is more readily
withdrawn from the eye at undesirable times. For very delicate work the
needles mentioned are the best.

_Needle Holders._—Inasmuch as the needles used in plastic operations are
very small and fine, proper needle holders must be used. The requisitions
are that the jaw be long, narrow, of soft copper, and that they have an
automatic lock attachment. Plain needle holders may be used, but at times
the locking device is very necessary and saves time. The most serviceable
of this class are the Kersten modification of Mathieu, an uncomplicated
holder of merit (Fig. 39), and the small Haagedorn, five-inch narrow-jaw
holder (Fig. 40), or the holders taking similar needles, as shown
in Figs. 41 and 42, known as Pozzi’s and Weber’s modifications,
respectively.

[Illustration: FIG. 39.—KERSTEN-MATHIEU NEEDLE HOLDER.]

[Illustration: FIG. 40.—HAAGEDORN NEEDLE HOLDER.]

[Illustration: FIG. 41.—POZZI-HAAGEDORN NEEDLE HOLDER, 5 IN.]

[Illustration: FIG. 42.—WEBER-HAAGEDORN NEEDLE HOLDER, 6 IN.]

[Illustration: FIG. 43.—NEEDLE WITH SUTURE CARRIER.]

Holders with cup jaws serrated at different angles are of no value,
unless other needles are used with them, as they invariably break the
flat ones.

To overcome the necessity of rethreading or the use of many needles,
the very ingenious holder with ligature carrier can be used, especially
where the surgeon does not care to sew with a long, free thread. The silk
can be sterilized on the metal spool separately and inserted within the
handle of the holder, as shown in Fig. 43.


METHODS IN PLASTIC OPERATIONS

THERE ARE FIVE DISTINCTIVE METHODS EMPLOYED IN PERFORMING PLASTIC
OPERATIONS:

    I. Stretching of the margins of the skin.

    II. Sliding flaps of adjacent skin.

    III. Twisting pedunculated flaps.

    IV. Implantation of pedunculated flaps by bridging.

    V. Transplantation of nonpedunculated flaps or skin grafting.

This classification differs from that heretofore generally given in the
meager literature on the subject, but the author believes his arrangement
to be more scientifically exact as well as simpler for recording and
history purposes.


I. STRETCHING METHOD

In the stretching method the defect is neatly excised, so as to freshen
the margins to be brought together. It may be necessary, if the defect
is too large for free apposition, to dissect the skin away from the
underlying tissue to render it more movable and to overcome tension. The
shape of the incision depends largely upon the nature of the defect and
must be made with a view of leaving as little scar as possible. Where the
defect is somewhat _linear_, or elongated, an elliptical incision (_A_)
is made, as in Fig. 44, and, if necessary because of too great tension,
the skin is undermined sufficiently to allow the parts to come together;
if this cannot be done readily, two semilunar incisions (_b_, _b_) must
be added. This will allow of ready coaptation. The wound is then brought
together with an interrupted suture, appearing as in Fig. 44_a_, the
semilunar spaces being allowed to heal by granulation.

[Illustration: FIG. 44.

CELSUS INCISIONS.]

[Illustration: FIG. 44_a_.

CELSUS RELIEVING INCISIONS.]

In excisions in small rhomboidal form, the skin is merely dissected up
and around the wound, the same as in Fig. 45, and the wound is sutured in
linear form, as shown in Fig. 46.

[Illustration: FIG. 45.

RHOMBOID EXCISION.]

[Illustration: FIG. 46.

UNION OF RHOMBOID EXCISION.]

If the defect is oblong in form, the angles are brought together wholly,
leaving a small surface to granulate, as in Fig. 47, or they are drawn
toward the center, leaving the remainder of the parallel lines to be
sutured, as shown in Fig. 48.

[Illustration: FIG. 47.

OBLONG EXCISION.]

[Illustration: FIG. 48.

COAPTATION OF SAME.]

Another method of overcoming a smaller defect of similar form is to
excise a small triangular portion of skin at either side of the oblong,
as in Fig. 49, and then with or without dissection bringing the margins
together in linear form, as in Fig. 50.

[Illustration: FIG. 49.

BITRIANGULAR EXCISION.]

[Illustration: FIG. 50.

LINEAR COAPTATION.]

Likewise can a triangular fault be brought together by sewing in the
greater angles and making a linear wound of the remaining part, as in
Figs. 51 and 52.

[Illustration: FIG. 51.

TRIANGULAR EXCISION.]

[Illustration: FIG. 52.

COAPTATION OF WOUND.]

Again, a triangular defect may be remedied by adding a smaller triangle
at each end involving healthy skin, utilizing, if need be, the relieving
incisions, as in Figs. 53 and 54.

[Illustration: FIG. 53.

TRIANGULAR EXCISION WITH RELIEVING INCISION.]

[Illustration: FIG. 54.

COAPTATION OF WOUND.]


II. SLIDING METHOD

Following the principle of Celsus, as mentioned on page 8, defects can be
overcome in various ways. The incisions may be straight or curved, and
one or more flaps of skin are raised, slid, and sutured over the part to
be covered. The simplest form is the covering of a square, as shown in
Figs. 55 and 56.

[Illustration: FIG. 55.

SQUARE EXCISION.]

[Illustration: FIG. 56.

COAPTATION OF WOUND.]

If the square be too large for the above method, the incisions can be
carried to the other side and above or below the defect, as shown in
Figs. 57 and 58.

[Illustration: FIG. 57.

SQUARE EXCISION.]

[Illustration: FIG. 58.

COAPTATION OF FLAPS.]

For triangular areas the curved incisions can be made, as in Fig. 59,
rotating the flap into place, as shown in Fig. 60.

[Illustration: FIG. 59.

TRIANGULAR EXCISION.]

[Illustration: FIG. 60.

COAPTATION OF FLAP.]

Or bilateral flaps may be utilized by straight incisions, stretched and
sewn, as in Figs. 61 and 62.

[Illustration: FIG. 61.

TRIANGULAR EXCISION.]

[Illustration: FIG. 62.

COAPTATION OF FLAPS.]

Again, two curved incisions are made to obtain rotating flaps, Fig. 63,
and sewn, as shown in Fig. 64.

[Illustration: FIG. 63.

TRIANGULAR EXCISION.]

[Illustration: FIG. 64.

ARRANGEMENT OF FLAPS.]

Bürow introduced a method for closing over defects by sliding flaps
in which he utilized the mobility of skin obtained by the excision
of triangles of healthy skin. The results are exceedingly good, but,
unfortunately, the sacrifice of skin affects its general use, inasmuch as
patients can afford but little loss of healthy skin; besides, there is
the objection of added scarring. The closing of a triangular defect by
this method is shown in Figs. 65 and 66, in which _a_ is the triangular
defect and _b_ the triangle of healthy skin excised. The skin about the
incisions is dissected up and the flaps are sutured into position, as
shown in Fig. 66.

[Illustration: FIG. 65.

DOUBLE TRIANGULAR EXCISION.]

[Illustration: FIG. 66.

COAPTATION OF WOUND.]

Where the triangular defect has a wide base, bilateral triangular
sections of skin are removed (Fig. 67), and the flaps are coapted, as in
Fig. 68.

[Illustration: FIG. 67.

TRI-TRIANGULAR EXCISION.]

[Illustration: FIG. 68.

COAPTATION OF WOUND.]

Through the sacrifice of two triangles a large oblong or square defect
may be covered, the excisions being shown in Fig. 69 and the suturing in
Fig. 70.

[Illustration: FIG. 69.

RECTANGULAR-BITRIANGULAR EXCISION.]

[Illustration: FIG. 70.

COAPTATION OF WOUND.]


III. TWISTING METHOD

Although in several of the above methods the flaps are rotated and
slightly twisted, the following are only classified with those under this
division.

Where an elliptical defect is to be obliterated the curved incision shown
in Fig. 71 can be satisfactorily employed, leaving but a small area to
granulate over. The suturing is depicted in Fig. 72.

[Illustration: FIG. 71.

WEBER METHOD.]

[Illustration: FIG. 72.

COAPTATION OF FLAPS.]

In this the twisting of the flaps is but little, while in the following,
in which the defect is of similar shape, the twisting is more apparent;
so much so, that a fold at the root of the flap may be induced to some
extent. The excision and incisions are shown in Fig. 73, and the method
of bringing the parts together in Fig. 74, leaving a small area for
granulation.

[Illustration: FIG. 73.

ELLIPTICAL EXCISION.]

[Illustration: FIG. 74.

COAPTATION OF FLAPS.]

Considerable twisting of flaps is shown in covering triangular parts in
Figs. 75 and 76.

[Illustration: FIG. 75.

TRIANGULAR EXCISION.]

[Illustration: FIG. 76.

COAPTATION OF FLAPS.]

In this only a small surface is left to granulate over, while in the
following the parts are entirely covered. The excision and incisions are
shown in Fig. 77, and the method of approximation and suturing in Fig. 78.

[Illustration: FIG. 77.

TRIANGULAR EXCISION.]

[Illustration: FIG. 78.

COAPTATION OF FLAPS.]

In covering a square area considerable twisting must be resorted to, as
shown in Figs. 79 and 80, leaving a portion to granulate.

[Illustration: FIG. 79.

LENTENNER METHOD.]

[Illustration: FIG. 80.

COAPTATION OF FLAP.]

Where the area is irregular and formed somewhat as in Fig. 81, bilateral
incisions are made and the flaps twisted into place and sewn, as in Fig.
82.

[Illustration: FIG. 81.

BURNS METHOD.]

[Illustration: FIG. 82.

COAPTATION OF FLAPS.]


IV. IMPLANTATION OF PEDUNCULATED FLAPS BY BRIDGING

In this method the flap to be utilized in covering a defect is taken from
a distant part of the body, as, for instance, from the arm. The flap
thus taken at first remains attached at its distal end to the tissue of
the arm by a pedicle, which is not severed until a circulation has been
established between the flap and the part of the human economy to which
its free end has been attached by suture, the arm being held in position
in the meantime by a suitable contrivance, as shown in Fig. 83.

[Illustration: FIG. 83.—TAGLIACOZZA HARNESS.]

These pedunculated flaps, bridging over space, may likewise be taken from
the forearm, the hand, or the thoracic region.

When thoracic flaps are used they may be directly sewn at their free ends
to the part to be covered, as, for instance, in the forearm or arm, or
they are stitched to the forearm to be later transferred to another part
of the body after their circulation had become established.

The various methods of the employment of these bridging flaps will be
taken up individually in their respective places farther on.


V. TRANSPLANTATION OF NONPEDUNCULATED FLAPS OR SKIN-GRAFTING

Where there is loss of skin due to injury or operative procedure the
parts may heal by granulation, but as this requires much time, and the
consequent cicatrice causes considerable deformity, the granulating or
freshly made wounds are covered with so-called detached skin flaps or
grafts, when the former methods of plastic surgery cannot be followed.

The methods employed in skin-grafting may be classified as: 1,
autodermic; 2, heterodermic; 3, zoödermic.

    1. _Autodermic_, when the grafts are taken from the tissue of
    the patient.

    2. _Heterodermic_, when the grafts for the patient are taken
    from other persons.

    3. _Zoödermic_, when the grafts for the patient are taken from
    the lower species.

The former two classes may for convenience be again subdivided into

    1. (_a_) Auto-epidermic.
       (_b_) Autodermic.

    2. (_c_) Hetero-epidermic.
       (_d_) Heterodermic.

The third class will permit of a great many subdivisions, too numerous to
mention, each taking its name from the source of the graft.


_1. Autodermic Skin-grafting_

=a. Auto-epidermic Skin-grafting.=—The method of covering granulation
areas with small circular pieces of detached skin, pin grafts, was first
advocated by J. Reverdin in 1870. The Reverdin method is applicable to
healthy granulating surfaces only. The small lentil-form skin grafts
are obtained from the arm or other suitable part of the body by raising
the superficial layer of the skin with a tenaculum hook and cutting the
conelike elevation off with delicate scissors. The grafts thus obtained
contain the epiderm and corium and a slight base of the Malpighian layer.
They are immediately transferred, without handling, to the granulating
surface and fixed by the gentle pressure of the hook point.

The skin may be transfixed with an ordinary sewing needle and the
graft cut away with a delicate flat knife or razor blade, or scissors
especially designed for the purpose may be used. (See Fig. 84.)

[Illustration: FIG. 84.—SMITH SKIN GRAFTING SCISSORS.]

A number of these grafts are often needed to cover a defect, in which
case they are placed side by side upon the surface with a little space
between their borders. Several such operations may be necessary, as many
of the grafts are liable to die from malnutrition, pressure, or defective
cutting.

The granulating surface to be covered in this manner must first be
cleansed with a weak sublimate solution, followed by a sterilized
normal salt solution. When an ulcerated or denuded surface requires
skin-grafting, the best time to begin is as soon as there is evidence
of the formation of new skin at the edges of the wound; in other words,
when reparative action is becoming established. This does not apply to
surfaces just denuded over healthy areas for plastic purposes, which
should be grafted immediately.

The grafts, having been placed, are covered with a layer of very thin
protective silk, or gutta percha, over which a soft gauze or cotton
dressing may be applied, borated absorbent cotton being most suitable.

_Thiersch_ recommends the use of gauze compresses saturated in the normal
salt solution, which are changed each day.

Another method of covering the grafts is to use perforated silk or small
strips of the same material, which permit the dressings to absorb the
excretions from the wound and also allow of the free use of either weak
antiseptic or sterile salt solutions.

The use of silk or rubber prevents the adhesion of the grafts, which
would otherwise be torn away by the removal of dressings, although
iodoform gauze answers the purpose very well. It can be safely lifted by
first thoroughly wetting it with the normal salt solution.

Strips of tinfoil, first rendered aseptic by immersion in a 1-1,000
sublimate solution and then dipped into sterilized oil or two-per-cent
salicylized oil, have been recommended by _Socin_. Goldbeaters’ skin has
also been advocated.

A method that has proved of great value in America is that of
skin-grafting in blood. In this method the grafted site is covered with
perforated protective silk or rubber tissue, covered with a thin layer of
absorbent cotton, or, better, several folds of sterilized gauze, which is
kept wet constantly with bovinine. The latter undoubtedly is the means of
keeping life in the grafts by supplying the necessary nutrition until the
grafts have formed vascular connection, have become firmly adherent, and
begin to spread or grow out at their edges.

The living grafts remain as pale islets of skin, which throw out thin
epidermal films that meet and grow thicker, until finally the interjoined
grafts assume all the functions of normal skin.

It is often necessary to reduce or scarify the edges of the healthy skin
that has become thickened where the grafts meet it. This is permissible
only when the grafts have become firm and thrive, and may be accomplished
by the careful and intelligent use of pure carbolic acid applied with a
wooden pick, or by the employment of a stick of fused nitrate of silver,
care being taken not to come in contact or to allow the cauterant to
touch directly or in solution the new skin.

=b. Autodermic Skin-grafting.=—Larger pieces of skin may be excised from
selected parts of the body, preferably the outer side of the arm, and
utilized to cover the entire defect. The piece of skin is cut about one
third larger than the size and shape of the area to be covered. This
method was first introduced by _R. Wolfe_ in 1876, and gives splendid
results. He advises removing all subcutaneous adipose tissue from the
graft by gently cutting it away with fine scissors or the razor, and then
loosely suturing the flap to the skin surrounding the denuded defect.

Granulating surfaces must first be freed of their loose superficial
layers with a sharp curette and the bleeding controlled by
sponge-pressure before the flaps are placed. The edges of the wound made
by the excision of the flap are simply sewn together, or one of the
plastic methods may be used to accomplish the same. Unfortunately these
flaps, if they thrive, contract, leaving uncovered spaces, which must be
treated separately or allowed to granulate. The dressing in this case is
the same as in the Reverdin process.

_F. Krause_, of Altoona (1896), advocates the use of freed flaps from
which the subcutaneous adipose tissue has not been removed, holding that
in the healing of such there is less contraction to follow. The success
in both of the above methods depends upon an early vascular connection,
as considerable nutrition is necessary to supply their want. The blood
dressing has aided much in bringing about a happy result. The latter is
continued in the manner described for about ten or twelve days, when the
grafts may be allowed to depend upon their own circulatory supply. The
parts must, in the meantime, be kept at rest and all undue pressure is to
be avoided.

These grafts, while becoming organized, change in color more or less from
a light gray to a bluish gray and shed off their epitheliar layers, while
the _cutis vera_ remains, rebuilding its squamous covering eventually and
leaving the surface quite normal.

At times small points of the flap, where subjected to undue pressure or
interference, will turn dark and break down, sloughing away and leaving
the granulating surface exposed. These areas are, however, soon recovered
by skin cells being thrown out from the infral edges of the graft. Often
the use of the nitrate-of-silver stick, applied gently at various tardy
points, will hasten the process of repair.

The most satisfactory results in skin-grafting are those obtained by
the method introduced by _Ollier_, of Lyons, in 1872, and perfected by
_Thiersch_, of Leipzig, 1874. His method is now almost entirely used
for covering large defects. The grafts can be applied over connective
tissue, periosteum, bone, and even adipose tissue. The grafts consist of
very thin strips of skin taken from the extensor surface of the arm or
the anterior region of the thigh, after thorough antiseptic preparation.
They should be taken from the patient in preference to those of other
individuals or the new-dead or freshly amputated parts.

Granulating surfaces are scraped clean of their superficial or loose
layer, while fresh wounds may be covered at once or a few days after
having been made, antiseptic compresses being used in the meantime.
Hemorrhage is controlled at the time of grafting by sponge-pressure or
torsion of the small vessels.

In this, as in the former method, it is desirable that the surface to be
covered be free from loose tissue and dry (_Garre_).

For the removal of the strips the Thiersch razor is to be used. It is
concave on its upper side and plane below, the blade being bent at an
angle to the handle (Fig. 85). Folding razors of the same type can be
procured; their advantage lies in having a protecting case when not in
use.

[Illustration: FIG. 85.—THIERSCH RAZOR.]

Slide fixation locks are a valuable addition to the latter, as they hold
the blade in place when open. See Fig. 86.

[Illustration: FIG. 86.—FOLDING RAZOR.]

The site from which the graft is to be taken is first thoroughly scrubbed
and washed, then cleansed with an antiseptic solution. The skin of the
anterior surface of the arm or upper thigh is usually chosen. The skin of
the part is made tense with the left hand, while the point of beginning
is slightly raised by the assistant with the aid of a tenaculum hook. The
razor, dipped into sterile salt solution, is now taken in the right hand
and by quick sawing movements, the plane side being placed next to the
limb, a strip of skin is detached (Fig. 87), which, as it is cut, glides
in folds upon the concave side of the razor.

[Illustration: FIG. 87.—METHOD OF CUTTING THIERSCH GRAFT.]

The uppermost layer of the skin is removed, including epidermis, the
Malpighian and papillary layers, as well as a small portion of the
stroma. _Hübscher_ includes only the epidermis and the upper portion of
the papillary layer, with equal success.

The length and width of the strips so removed must be made according to
the defect to be covered. Their width may be made as much as two inches
and their length not to exceed four inches.

The collected strip of skin, still on the razor, is now brought to the
place of grafting and, with the point of a needle placed at its farther
end, is slid off upon the part to be covered and allowed to fall in place
by the gentle backward withdrawal of the razor blade, as shown in Fig.
88.

[Illustration: FIG. 88.—METHOD OF PLACING THIERSCH GRAFTS.]

The graft may be smoothed out with the needle held flatwise or be stroked
down gently, so that its fresh surface makes contact with every portion
of the part covered, a precaution the author considers important to
obtain the best results.

If the defect is large, and where several grafts are needed, the second
flap thus obtained is made to slightly overlap the one already placed,
and so on. The free, or distal, ends of the flaps are made to slightly
overlap the skin or that of a graft placed endwise to it. Every part of
the wound should be covered.

As soon as this has been accomplished the strips are powdered over
with iodol or aristol or protected with some antiseptic gauze (boric
or iodoform), or covered with strips of lint smeared with borated
petrolatum, over which light, teased-out pieces of sterilized cotton are
placed. A gauze bandage may be utilized to hold all in place.

It is quite necessary to have the part kept at rest so as not to displace
the skin-graft arrangement. If the antiseptic powder has been used
the dressings need not be disturbed for a week or ten days, but the
petrolatum dressing must be changed every third day, care being observed
not to disturb the grafts.

Perhaps the best success is obtained by the aid of perforated rubber
tissue, covered with gauze dressing, constantly kept wet with bovinine
for ten days.

In healing, parts of the grafts may die, leaving small areas to
granulate over, but ordinarily the cicatrization resulting therefrom
is indeed slight. From the observations of E. Fisher, it seems that
the most successful results are obtained when the grafts are taken and
transplanted under the bloodless method of Von Esmarch.


_2. Heterodermic Skin-grafting_

=c. Hetero-epidermic Skin-grafting.=—A novel method of covering wounds
with skin is advocated by Z. J. Lusk, of Warsaw, N. Y., 1895, in which
small squares of epithelium, previously prepared, are placed upon the
granulating surface, over which a dressing of sterilized gauze is placed,
saturated with a mixture of balsam of Peru, ʒj, and ol. Ricini, ℥j, and
covered with several layers of sterilized absorbent cotton. The dressing
is allowed to remain undisturbed until the tenth or twelfth day, unless
there is an accumulation of pus.

The advantage of this method is that the epidermal layers can be
collected at random from various patients who present themselves with
blistered surfaces—the result of burns—or where the skin has been raised
by some blistering process for counterirritative reasons.

This loose skin is collected and spread upon a glass plate and sterilized
in warm boric-acid solution, then allowed to dry in this position to
prevent curling, and, when dry, cut into desirable sizes and laid away
for future use.

=d. Heterodermic Skin-grafting.=—In this mode of skin-grafting the
pieces of skin are taken from freshly amputated limbs of one patient or
from any selected part of the body of the newly dead, and placed upon
the defects to be covered in another patient. These grafts have been
successfully employed even after ninety-six hours had elapsed between
the time of amputation or the death of a person and the taking of the
skin-grafts.

The method employed is as follows: The site of the amputated member or
dead body from which the skin is to be taken is thoroughly cleansed, as
in the Thiersch method. Pieces of the skin, including the subcutaneous
tissue, but no fat, are cut from the cleansed parts. These sections are
cut into smaller pieces, about one inch square (_Hartman_ and _Weirick_),
and placed upon the granulating surface to be covered, leaving
one-half-inch wide interval between each piece.

The grafts are then covered with overlapping narrow strips of rubber
tissue, over which a normal saline dressing is applied. The outer
dressing is composed of gauze saturated with the same solution. These
dressings are changed every twenty-four hours.

The grafts will soon be found to adhere, showing a pinkish color in about
six days; those showing a tendency to undergo gangrene or a laziness of
attachment at this time are removed.

In about two weeks the epitheliar surfaces of these grafts are thrown
off, as with other grafts already mentioned, and shortly thereafter a
new, deep-pink epithelium is formed, the ends of the grafts throw out
epitheliar cells, which soon coalesce with those of the neighboring
grafts, eventually taking on the normal appearance and vitality of skin.


_3. Zoödermic Skin-grafting_

The advantage of using zoödermic grafts is that the patient is saved the
ordeal of general anesthesia and the secondary wound occasioned by the
removal of the graft, which necessarily leaves more or less of a scar.

The grafts for this purpose may be taken from freshly killed animals,
such as dogs, rabbits, frogs, kittens, etc.

The best results, in the estimation of the author, are obtained by the
use of the skin taken from the abdominal region of dogs.

The method for preparing these grafts is to kill a healthy animal,
thoroughly cleansing the skin of the abdomen, as already described in the
taking of any graft.

The entire abdominal surface is neatly shaved under antiseptic
precautions and the skin is dissected off in one piece, leaving the
subcutaneous tissue. It is then placed in a warm boric-acid solution and
cut into small pieces, say one or two inches square, according to the
size of the defect to be covered.

These pieces are placed upon the granulating surface and firmly pressed
into place, so that they are in close contact throughout their area.
Other pieces are placed quite near or even in contact with the edge of
the first, and so on, until the space is entirely covered. Boric-acid
dressing of any desired form is placed over them and superimposed by
loose gauze and bandage.

The dressing should be left undisturbed for at least forty-eight
hours, and then be gently removed and renewed. The utmost care should
be exercised with the dressings, since here lies the success of the
whole result. The blood dressings have given excellent results in cases
undertaken by the author, and should be resorted to whenever practicable.
The method has already been fully described, and does not differ in the
event of employing zoödermic grafts.

When boric-acid dressings are used, they should be changed every day
after the first dressing has been removed, so that the behavior of the
grafts can be closely watched.

Lazy grafts and those showing signs of sloughing should be removed at
once, and granulations crowding through the grafts should be snipped off
with a fine scissors, as they are liable to destroy the life of a graft
by pressure or by crowding it away from its bed of nourishment.

As in dermic grafts, the upper layers of these plaques will be thrown
off, giving at times the appearance of total sloughing, yet on
interference the deeper layers will be found to be intact and healthy.
The dressings should be continued until the grafts have not only
established their circulation, but until their edges have firmly united
and the surface has taken on a dull reddish color, which eventually fades
to a shade somewhat paler than the normal skin. The hairs that have been
carried over with the grafts at first seem to thrive, but eventually drop
out, leaving the surface bare. Spots of color so often observed in the
skin of the bellies of dogs also disappear from the grafts, leaving their
color uniform.

Amat, in 1895, claims that good results in skin-grafting are obtained by
substituting the epidermal pin grafts with the film or inner-shell lining
membrane of the fresh hen’s egg. For this purpose as fresh an egg as can
be obtained is used. It is broken along the horizontal axis. A delicate
forceps is now made to grasp the free membrane found at the air chamber
of the enlarged end of the egg. The inner lining is drawn away from the
shell in pieces four or five millimeters long; these pieces are cut with
a fine scissors into equal lengths and placed with the point of the
scissors to the granulating surface to be covered, in the same way as the
Reverdin grafts. Amat covered the grafts with tinfoil, over which were
placed several lays of carbolized gauze. The dressings were changed every
three or four days.

The skin of the frog has successfully been implanted upon granulating
surfaces by Baratoux and Dobousquet-Laborderie. They observed that the
peculiar pigmented mottling of the skin disappeared about the tenth day,
and that the grafts gradually took on the appearance of human skin
thereafter.

The best results in this method are obtained with the skin taken from the
back of the frog in preference to that of the belly or legs. This skin is
cut into pieces about one fourth inch square, which are placed upon the
granulating surface in rows, each graft being separate from its neighbor
by a space of half an inch.

At the end of forty-eight hours the plaques of skin will have adhered to
the granulating surface. At the end of five days they lose their original
color and send out cells of epithelium to each neighboring square.

The dressing to be applied over the flaps should consist of borated
vaselin, one dram to the ounce, which is smeared upon strips of sterile
gauze, over which loose gauze is placed, held in place by a roller
bandage.

The skin, once organized, is very thin, as a rule, and requires more or
less care for some time after.


_General Remarks_

The skin of the grafted area will always present a different appearance
from that of the healthy skin, both as to color, which is always paler,
and in texture. The grafted portion is usually slightly elevated above
the healthy skin, giving it an edematous look.

It has been found that skin grafts taken from the negro take more
successfully than those from the white race. White skin flaps placed upon
the negro do not meet with much success. In this event, however, the
newly grafted skin soon takes on the color peculiar to the negro and vice
versa (Thiersch).

The investigations of Karg seem to show that the pigmentation of skin is
not secreted in the rete, but is carried to it by wandering cells arising
from the deeper layer. Von Altmann has discovered certain cell granules,
termed by him bioblasts, which he believes are responsible for the
production of the pigmentary deposits under peculiar influences of the
blood.


MUCOUS-MEMBRANE-GRAFTING

The grafting of mucous membrane, both from the animal and man, has been
accomplished by Wölfler. His methods are particularly applicable to the
restoration of the conjunctiva, mucous membrane of the cheek, etc. Under
certain circumstances pedunculated skin flaps have been folded inward to
serve as the mucous membrane by Gersuny. When mucous-membrane flaps were
taken from the animal, the conjunctiva of the rabbit has been preferred.

Under peculiar circumstances, though rarely, mucous-membrane flaps may be
utilized to cover denuded skin areas. The mucous membrane, in such cases,
in about ten days takes on the appearance of the skin.

Ofttimes, when it is impossible to obtain foreign mucous membrane, grafts
may be taken from the inner surface of the lips of the patient. These
grafts answer exceedingly well for conjunctival restorations, while the
wound occasioned by their removal is closed by suture or allowed to heal
by itself, if not too large, under boric-acid antisepsis.


BONE-GRAFTING

Bone-grafting, as followed by MacEwen, Ollier, Poncet, and Adamkierwicz,
has been more or less successful. Their methods have been often employed
in plastic facial surgery, as will be shown later. Their methods were
later improved by Senn, who advocated chips of decalcified bone in place
of bone taken from young or new-born animals, from which the bones under
ossification have been utilized.

Glück’s method of introducing pieces of ivory into bone defects may be of
interest, but is applicable only to long bone implantations. The success
of his method has yet to be practically demonstrated. Zahn and Fisher
have used various foreign substances to overcome bone defects, but these
do not interest the cosmetic surgeon to any extent, since other methods
have been proved to give better results. These, however, belong to the
subject of subcutaneous prothesis, and must be considered separately
thereunder.


HAIR-TRANSPLANTATION

It may be of interest to know that Schweininger and v. Nussbaum have
attempted to graft hairs upon granulating tissue by sprinkling the hairs,
with their attached roots, upon the surface to be covered. If any of
these lived and attached themselves the root sheath formed a scar center,
and the hair dropped out after several days.




CHAPTER IX

BLEPHAROPLASTY

(_Surgery of the Eyelids_)


Plastic operations about the eyelids are necessitated by and for:

    I. Direct injury causing the loss of a part, one or both lids.

    II. Loss of tissue following excision of tumor.

    III. Loss of tissue, the result of gangrene or ulceration.

    IV. Injuries due to burn or acid wounds.

    V. The healing and cicatrization following lupus.

    VI. The cicatrization following inflammatory lesions of the
    orbital borders, especially those of the supra-orbital ridge.
    Since the upper lid lies below the supra-orbital ridge, the
    above cause is rarely met with.

    VII. For the removal of redundant tissue.

The result of the above causes leads to eversion of the lid (ectropion).
There may be cicatricial contraction of the conjunctiva leading to
ectropion, however, but its correction is not strictly of a plastic
nature and belongs principally to the oculist surgeon, and will therefore
not be referred to herein.


ECTROPION

Ectropion is not uncommon, and involves the lower lid only in the great
majority of cases. It may be partial or complete, according to the
extent of cicatricial changes in the skin.

[Illustration: FIG. 89.—DIEFFENBACH METHOD.]


PARTIAL ECTROPION

For the correction of partial ectropion a V-shaped incision is made on
the lid with the base of the triangle, including the maximum eversion, as
in Fig. 89, _a_.

[Illustration: FIG. 90_a_.—CORRECTION OF PARTIAL ECTROPION. (Author’s
case.)]

The incisions are made downward from the tarsal border, just below the
lashes, and converge to a point. The flap included therein is carefully
dissected up, dividing all the scar adhesions, and is pushed upward
until the tarsal border at the seat of the defect is overcorrected
in this position. The incisions are united with No. 1 twisted-silk
structures to form the letter Y, as shown in Fig. 89, _b_.

As the lid has usually become elongated from prolonged eversion, a small,
triangular piece of skin may be excised at the outer end of the lid, with
its base turned upward. In bringing the two sides together in linear
form, horizontal traction is made along the tarsal line, which aids much
in bringing about the desired result.

In the case shown in Fig. 90_a_ the ectropion was the result of the
application of nitric acid or caustic potash for the removal of a nevus.
It was corrected by the method just described, the result being shown in
Fig. 90_b_.

[Illustration: FIG. 90_b_.—CORRECTION OF PARTIAL ECTROPION. (Author’s
case.)]


COMPLETE ECTROPION

=Dieffenbach Method.=—In complete ectropion the entire lid between the
canthi is included in the V-shaped incision just mentioned (Fig. 91) and
the flap is sutured as shown in Fig. 92.

In crowding up the detached flap the palpebral border must be
overcorrected, since the contractions following union will reduce the
effect even to the extent of necessitating later minor operations.

[Illustration: FIG. 91. FIG. 92.

COMPLETE ECTROPION, DIEFFENBACH METHOD.]

To prevent this contraction the palpebral fissure may be united after the
correction is made by fine sutures, which are removed in several weeks
(Plessing). This is rather uncomfortable for the patient, but there is
no question as to the efficacy of the method. A shield can be worn over
the eye operated upon after the incisions have united until the lids are
separated. This relieves the discomfort of the patient to some extent,
while the constant conscious strain to open the eye is greatly overcome
by the mere knowledge of the presence of the shield.

If the position, or the extent of the deformity, does not permit of the
Dieffenbach method, the following may be employed:

=Wolfe Method.=—An incision is made parallel to the tarsal border just
below the lashes. The scar tissue is then excised. The palpebral fissure
is closed by several sutures, as already described, thus drawing up the
everted portion and bringing the lids together and causing a large, open
wound (Fig. 93).

After the hemorrhage has been controlled a piece of skin about one third
larger than the defect is taken from the arm or temporal region of the
patient. Next its reverse side is freed of all adipose tissue. It is then
laid upon the freshly made open wound, covering it completely, and held
in place by numerous fine silk sutures fixing it along the wound margin,
as shown in Fig. 94.

[Illustration: FIG. 93. FIG. 94.

WOLFE METHOD.]

There is more or less contraction of the flap, although primary union
takes place. Less contraction of the flap is obtained in the Wolfe method
when the subcutaneous fat is not removed, as mentioned above (Hirschberg).

=Thiersch Skin-grafting Method.=—To somewhat overcome the contraction
of the single-graft operation of Wolfe, the Thiersch skin-grafting
method may be resorted to as already described. Better results have
been obtained with this method. The graft should be placed parallel to
the tarsal border. A number of Reverdin grafts can be taken from the
temporal region, just below the hair line, and used to cover the wound.
These small grafts must be placed quite close together to obtain the best
result (Von Wecker). Immobility of the lid is, of course, necessary,
and the temporary fixation of the lid must be accomplished as already
described. Contraction in this, as in any other skin-grafting methods,
is to be looked for and remedied later by minor plastic operations.

=Fricke’s Method.=—The best results in blepharoplasty, after the
extirpation of tumors, are undoubtedly obtained by Fricke’s method. A
flap is obtained from the temporal region, with its base in line with
the inferior border of the defect to be covered. The flap must be cut to
about twice the size of the bared surface, because of the contraction
that follows in healing, and also to permit of covering the defect in its
longest diameter when twisted. The flap should be taken from the tissues
at the outer angle of the eye and cut in the curved form depicted in Fig.
95 to overcome its distortion as much as possible in twisting. It is
twisted upon its pedicle at an angle of 90° and sutured into the defect,
as shown in Fig. 96.

[Illustration: FIG. 95. FIG. 96.

FRICKE METHOD.]

The lids are temporarily sewed together, thus stretching the defect
fully into which the flap is to be sutured. The pedicle is severed after
thorough circulation in the flap has been established.

Owing to the free movement of the skin over the temporal fascia, the
wound formed by the incision of the flap can be entirely closed by a
single line of interrupted sutures.

=Ammon and Von Langenbeck Method.=—A very similar method, especially
devised for the correction of extensive ectropion of the lower lid, is
that in which the pedunculated flap is taken from the latter aspect of
the cheek.

A curved incision is made just below the tarsal border, freely loosening
the attached conjunctiva in this manner. The cicatricial tissue or other
cause of the defect is thoroughly excised and the lids fixed together by
suture.

The wound is then fully exposed. A curved incision, as shown in Fig. 97,
is now made, with its base in line with the superior line of the raw
surface. It is carefully dissected up and twisted into position and held
by suture (Fig. 98).

[Illustration: FIG. 97. FIG. 98.

AMMON-VON LANGENBECK METHOD.]

The sides of the wound made by the excision of the flap are brought
together by an interrupted suture.

The skin of the cheek is liable to contract more readily than that from
the temporal region, because it is thicker. Again, it is less suitable
for grafting because of its subcutaneous layer of adipose tissue.

=Dieffenbach-Serre Method.=—Where the defect is too large to be covered
with any of the preceding methods, as is often the case following the
extirpation of carcinomata, a rhomboid flap can be utilized as shown in
Fig. 99.

The extirpation incision is made in the form of a V. The faulty tissue
or scar is removed, care being exercised to retain as much of the
conjunctiva as possible. A rhomboid flap is then taken from the lateral
aspect of the cheek and slid over the defect and sutured into place, as
shown in Fig. 100.

[Illustration: FIG. 99. FIG. 100.

DIEFFENBACH-SERRE METHOD.]

The objection to this method is that the extensive contraction following
the healing of the wound made by the raising of the flap causes the
lid to be drawn outward. This wound is usually allowed to heal by
granulation, but it is better to place Thiersch grafts over the area
which cannot be closed by suture, either immediately or as soon as a
good granulating surface has been obtained and the sutured portions have
become healed.

The outer or free margin of the conjunctiva is sutured to the upper
free border of the rhomboid flap or enough of the flap should be at
first provided by incision to warrant the turning in of its superior or
palpebral border after it is slid into place.

In such case, however, it is best to provide mucous-membrane grafts from
the lip of the patient to overcome the loss of conjunctiva (Wolfer).

Because of the splendid success obtained with temporal flaps it is better
to follow the method of Fricke in the above operation, changing the shape
of the flap to suit the form of the defect to be covered.

=Tripier Method.=—For the restoration of an entire lid the method of
Tripier is to be advocated. A bridge flap with both ends attached is
taken from the healthy eyelid (Fig. 101). It is obtained by making the
curved inferior incision in a line with the superior border of the tarsal
cartilage, and the superior incision parallel to the first at a distance
depending upon the size of the defect to be covered. The flap thus formed
should include some of the fibers of the orbicularis muscles detached
from the tarsal cartilage, making it really musculo-cutaneous.

[Illustration: FIG. 101. FIG. 102. FIG. 103.

TRIPIER METHOD.]

This bridge or musculo-cutaneous flap, attached at both ends, is then
gently drawn forward with a tenaculum and slid downward over the upper
lid upon the defect of the lower lid, and there retained by interrupted
silk sutures (Fig. 102), the superior margin of the bridge flap being
sutured to the conjunctival fold freed by the previous extirpation of the
lower lid.

The retention of the fibers of the orbicularis palpebrarum in the flap
covering the defects is intended to take the place of the part of muscle
destroyed by the incision of the faulty tissue in the lower lid, and
enables the patient to open and close the lid almost as well as in the
normal state.

The margins of the wound made by the removal of the flap are snugly
brought together and heal without the least discomfort to the patient,
inasmuch as the skin covering the lid is quite loose and elastic (Fig.
103).

=Von Artha Method.=—It sometimes happens that by the extirpation of
tumors part of both eyelids has to be removed. To restore such defect the
following method may be followed:

Two sickle-shaped flaps are raised from the skin bordering the outer
margins of the primary incision, according to Von Artha, and sliding them
about so as to reform the canthus of the palpebral fissure (Figs. 104 and
105).

[Illustration: FIG. 104. FIG. 105.

VON ARTHA METHOD.]

This method leaves little if any secondary effect, its immediate success
depending upon the preservance of the conjunctiva at the time of
extirpation.

As will be seen, the foregoing method only included operations about the
lower lid. The majority of these operations are required only for the
lower lid; where defects of the upper lid are to be corrected the flaps
and incisions mentioned must be made to correspond to the defect, while
in the V-Y method the incision must be inverted.


ECTROPION OF BOTH LIDS

In the case of ectropion of both lids the palpebral tissue may be
sutured for a period of several months with certain benefit, if no other
operations can be decided upon. Or the method may be combined with any
other plastic operation deemed serviceable for its correction. In most
defects of the upper lid, however, if they are not too extensive, the
loose skin of the lid itself can be utilized by sliding flap methods to
cover the defect (Kolle).


EPICANTHUS

This condition, in which a fold of skin stretches across from the inner
end of the brow to the side of the nose covering the inner canthus, is
met with principally in children. It usually disappears later in life. It
may remain, however, owing to nondevelopment of the nasal bridge and is
often met with in the colored races.

=Bull Method.=—This defect may be corrected by the excision of an
elliptical piece of skin from the anterior aspect of the bridge of the
nose, and sewing the wound together with interrupted fine silk sutures,
as shown in Figs. 106 and 107.

[Illustration: FIG. 106. FIG. 107.

BULL METHOD.]

=Paraffin Injection.=—As the above operation leaves a linear scar on the
anterior nasal line, the author has found it much better to correct the
defect by building up the nasal bridge, or the entire anterior nasal
line by the subcutaneous injection of one of the paraffin compounds,
thus overcoming both the epicanthus and the nasal deformity. In fourteen
cases, two Japanese and the rest negroes, the author has obtained
excellent and permanent results.

The process herein referred to was first suggested in a general way by
Gersuny, and has been extensively and successfully utilized in many
ways, especially in this country. A special chapter is given to the
method elsewhere.

Following the injection of the substance employed there is slight
swelling for a few days, which may or may not involve the eyelids. This
disappears about the second or third day. The injected material becomes
organized in two or three weeks’ time and gives no further trouble to the
patient.

If the patient complains of a dull pain or soreness in the area thus
operated upon, the application of cold extract of hamamelis is to be
applied on little squares of sterilized gauze, which usually relieves the
discomfort in a few hours.


CANTHOPLASTY

Canthoplasty involves the lengthening of the palpebral fissure at the
external canthus. The canthus is divided outward to the extent designed
with a pair of angular scissors, probe pointed (Fig. 108), and to the
extent as shown in Fig. 109.

[Illustration: FIG. 108.—PROBE-POINTED ANGULAR SCISSORS.]

The contiguous ocular conjunctiva is dissected (Fig. 110) up and attached
to the newly made skin margin with silk sutures to prevent its reunion,
one suture uniting the angle of the wound with the raised tip of
conjunctiva (Fig. 111).

The sutures are allowed to remain about five days. Traction with the
fingers should be made several times each day to thoroughly separate the
wound and to prevent the contraction of the conjunctival triangle, which
would offset entirely the object of the operation. As a rule the fine
silk sutures heal out of the mucodermal margins owing to the softening
of the tissue through the increased lachrymal secretion caused by the
irritation of their presence and the resultant reaction following the
operation.

[Illustration: FIG. 109. FIG. 110. FIG. 111.

EXTERNAL CANTHOPLASTY.]

A slight regional conjunctivitis usually follows this operation, yielding
readily to simple treatment, often requiring no special care but the
hygiene of secondary-wound antisepsis.


PTOSIS

This is a drooping of the upper eyelid, due to congenital or paralytic
causes. It may be unilateral or bilateral.

Apart from internal and proper external electrical and other treatment
the simplest surgical method to be employed is to remove an elliptical
piece of skin from the eyelid and to suture the margins of the wound
together. Care should be taken not to take out too much tissue, as this
would involve inability to close the lid.


ANKYLOBLEPHARON

A condition in which the two lid margins are united by cicatricial
adhesion. These should be removed and the margin of the lids be rebuilt
by any of the methods suggested if possible. Mucous-membrane flaps are
naturally to be preferred.


WRINKLED EYELIDS

A common condition after middle life, when not due to other causes than
normal changes in the skin and subcutaneous tissue. Edematous pressure
due to disease is a common factor.

The wrinkling may be marked or slight.

To correct the condition is to remove the redundant or baggy tissue by
excision, as massage in any form accomplishes little if any benefit. The
shape of the incision should be made to include the loose tissue and
varied somewhat, as shown in Figs. 112 and 113.

[Illustration: FIG. 112. FIG. 113.

BLEPHAROPLASTIES, AUTHOR’S METHOD.]

The superior line of incision in operations of the lower lid should be
made as close to the tarsal line as is practical, so as to show as little
of the resulting scar as possible. The best distance is about an eighth
of an inch below the tarsal cartilage fold. Accuracy in making the
superior line of the incision is furthered by outlining the flap to be
removed with a very fine bistoury.

In operations about the upper lid a somewhat widened elliptical piece of
skin is excised with its inferior margin about one fourth to one half
inch above the tarsal line, so as to allow the line of union to lie above
it and within the curved fold when the eye is open.

[Illustration: FIG. 114.—CURVED EYE SCISSORS.]

For the excision it will be found best to use a fine pair of curved eye
scissors, beginning the incision by raising the skin at the outer canthus
with a fixation forceps or tenaculum.

Another guide to outline the necessary amount of tissue to be removed
is to mark the area, prior to operation, with India ink or an indelible
pencil. The parts can then be snipped away readily without fear of
causing ectropion. There is usually very little bleeding, and in most
cases the tissue is exceedingly thin.

The margins of the wound are brought together with very fine twisted
silk, using the continuous suture preferably on account of the ease with
which it can be removed.

The wound is then powdered with a suitable antiseptic powder and covered
with antiseptic adhesive silk plaster moistened with an antiseptic. The
form of the plaster should be of suitable shape, not too wide, and nicked
so as to permit of proper application.

There is more or less edema following the operation, associated with
or without discoloration, which disappears usually without treatment
in forty-eight hours. It is advisable to administer a saline laxative
each morning following the operation for several days. Small doses of
magnesium sulphate answer the purpose very well.

The sutures are withdrawn in from twenty-four to forty-eight hours
after having been carefully softened with warm boric-acid solution, or
a ten-per-cent peroxid-of-hydrogen aqueous solution. The early removal
of the sutures prevents stitch cicatrices. The part is again powdered as
before and covered with the adhesive silk plaster, which answers both
purposes of protection and splinting.

The resulting cicatrization is so surprisingly little as to be almost
invisible in the great majority of cases. In patients of blond complexion
the redness of the scar disappears as early as three weeks, but is more
prolonged in persons of darker type. It is not advisable to do both upper
and lower eyelids in one operation to avoid the discomfort of the edema
which usually follows.

In rare instances there appears a hypertrophy of the scar line, which is
best treated with strips of thiosinamin plaster mull, twenty per cent,
applied nightly and removed the next morning. If irritation results the
plasters should be discontinued for a day or two.


XANTHELASMA PALPEBRARUM

A yellow discoloration of irregular patchlike formation in the skin of
the lids, usually about the region of the inner canthus.

The condition may involve both upper and lower lids symmetrically. The
patches are generally slightly elevated and vary in size. They make their
appearance usually late in life, and are due to the infiltration of the
deeper layers of the skin with groups of cells overburdened with fat.

They are best removed by excision, following the method of the preceding
operation. There may or may not be a recurrence of the disease at an
indefinite period, when the tissue must again be removed.


_Remarks_

All of the above operations in blepharoplasty can be done under
local anesthesia, using either the two- or three-per-cent cocain or,
preferably, Beta-eucain solutions.

About ten minutes after each operation a sharp stinging sensation is
experienced in the eyelid operated upon, which lasts for almost an hour
or more, and indicates nothing alarming except the absorption of the
anesthetic and a return to the normal state. A sponge dipped into cold
sterile water relieves the parts considerably at the time.

It is advisable to inform the patients of this symptom beforehand to
avoid unnecessary alarm on their part. Patients are easily frightened
when cutting operations around the eye are undertaken, and should be
apprised of what is to be done, and what to expect, especially when the
operation has been done as a purely cosmetic one.

After the sutures are removed the patient is instructed to allow the
plasters to remain until they fall off, which occurs usually in about
two days, unless there be reasons for dressings for discharges due to
infection, the result of carelessness in operating.

Should at any time, from carelessness or accident, the wound be torn
open, the parts need only be brought together with adhesive silk plaster.
Healing will go on, giving practically as good a result as with the
suture. Bardeleben does not suture these wounds at all, yet the author
believes it a safeguard and a psychological necessity in most cosmetic
cases.




CHAPTER X

OTOPLASTY

(_Surgery of the Ear_)


This branch of surgery has to do with the corrective and restorative
operations of and about the external ear.

Traumatisms of the auricle, owing to the exposed position of that organ,
are frequently met with and are commonly the result of stab wounds,
direct blows, shot wounds, and human bites, especially in Spaniards and
Italians, who follow this queer kind of revenge upon one another.

Such wounds of the ear may involve only part of or the whole of the
auricle. Loss of auricular substance may also be the results of gangrene
following freezing or the direct result of burns.

Fracture of the cartilage of the ear is exceedingly rare (Schwartze).

Where the injury is one of incision or laceration without loss of
the part, the site should be cleansed gently but thoroughly with a
boric-acid solution, and the free torn edges brought together with fine
silk sutures. If the cartilage projects unduly into the line of union
it should be trimmed away with a fine pair of scissors (Roser). Wounds
of such character usually heal well, even if the pieces hang loosely by
threads of skin, a linear indent of cicatricial tissue usually marking
the traumatic separation of the cartilage.

In the negro where razor cuts about the ear are often seen, a
hypertrophic scar or keloid is liable to result, even to the extent of
involving the punctures of the suturing needle.

It is advisable to save all that is left of the injured member, even if
entirely severed, with the hope of obtaining union, since the rebuilding
of even part of an ear is by no means an easy matter, owing to the
complicated formation of the cartilaginous frame.

Wounds about the meatus are liable to result in stenosis, which should
be guarded against by packing of small strips of gauze or in the case
of loss of substance immediately about the orifice by the employment
of a sliding flap taken from the skin of the vicinity or by the
transplantation of a nonpedunculated skin flap taken from some other part
of the body and sewn into place.


RESTORATION OF THE AURICLE

If a loss of substance of the auricle cannot be avoided, the surgeon must
rely upon otoplastic means to make up the deficiency.

For the best cosmetic defects it is desirable to have as much of the
cartilage remaining as possible. The stump of the ear is freshened at its
outer margin with the bistoury and the frontal skin carefully dissected
away from the cartilage to the extent of a quarter inch.

A flap, one third larger than the defect to be supplied, is now outlined
on the skin back of the ear in such a way that the flap included therein
will not be subjected to too much torsion.

This flap must necessarily vary in shape and size, according to the
nature of the deformity to be corrected. It may even extend into the hair
of the scalp over the squamoparietal region of the head or a part of the
neck laterally and below the ear.

This flap, after careful estimation as to size, should be dissected up
freely down to the periosteum, leaving a bridge of tissue at the point
where the least resistance will be caused after its free end has been
sutured to the remains of the ear.

The free flap is stitched to the stump with several silk sutures.
After bleeding has been controlled, a few layers of borated gauze are
introduced under the flap to prevent its reattachment and to encourage
its thickening, and the entire site of the operation dusted over with
an antiseptic powder, and covered with loose folds of sterile gauze. A
bandage can be lightly applied over the whole to keep the parts in place.

The success of union of the flap depends upon the immobility of the
parts while healing is taking place. The patient is to rest at night in
a semirecumbent position with the head held down firmly on the uninjured
side with the aid of a tight-fitting linen cap made for the purpose and
tied by attached tails of the same material to the bed in such a way that
the head cannot be turned during sleep, yet allowing of more or less
movement in either direction, never enough, however, to cause tension
in the flap. During the day the patient should be on his feet as usual,
since the operation is hardly severe enough to compel absolute rest.

As soon as the union of the flap to the ear has been established, which
is about the eighth day, the sutures are carefully removed to avoid
irritation, but the pedicle of the flap is not to be severed until
the tenth or fifteenth day, when satisfactory circulation has been
established.

The flap when severed will shrink more or less, but will be seen to be
somewhat thicker than when dissected up in the primary operation.

Nothing should be done for a few days hereafter except to keep the
granulating surfaces of the flap and back of the ear aseptically clean
and healthy.

As soon as the flap loses its pale color and takes on a pinkish glow it
may be deemed safe to cover the granulating or secondary wound on the
head with grafts of skin, using whatever method most suitable for the
purpose. The transplantation of a single flap of skin taken from the
anterior border of the arm is perhaps productive of the best result.

To assure of success the graft may be healed under the blood dressing;
the methods for which have been fully described heretofore.

Once the secondary wound is healed the surgeon’s attention must be given
to the flap attached to the stump. By the aid of the judicious use of the
nitrate-of-silver pencil certain parts of this flap may be stimulated to
become thickened.

The upper or outer border of the flap should be taken under operation
first to form the new helix of the ear. This can be done by making
several incisions along its free edge and gently turning backward these
small flaps so that their raw surfaces face that of the flap.

This procedure, if neatly done, will eventually give a thickened border
to the superior rim.

Should the flap have been cut large enough to permit of lining its entire
back this can be done, but care must be exercised not to cause a too
abrupt folding over of the same, as gangrene is likely to result. The
more slowly this freshening is accomplished the better will the result be
eventually.

If, however, this flap will not permit of autolining, and its raw surface
presents a healthy granulated appearance, recourse may be had to the
transplantation of a flap from the arm upon it and fastened to the
denuded edges of the aural flap.

As soon as healing has been established a number of delicate, often
complicated incisions are made in the newly formed part of the ear to
give it proper shape and size.

Kuhnt has obtained excellent results in a case where he employed a flap
from the back of the ear, combined with two pedunculated tongue-shaped
flaps taken from the cheek above and the neck below, which he twisted
about back of the flap of the newly formed ear, so that their epidermal
surfaces faced its raw surface with the object of giving greater
thickness to the ear at that point.

At best, however, the restoration of an entire ear may be considered
impracticable, and only in such cases where the greater part of the ear
remains can cosmetic results be looked for.

In the illustration shown the author restored the upper third of the ear
shown above the line drawn obliquely across the ear. Seventeen delicate
operations were necessary to obtain the result (see Fig. 115).

[Illustration: FIG. 115.—PARTIAL RESTORATION OF THE AURICLE. (Author’s
case.)]

Where the loss of substance is not too great and along the helix of the
ear, a flap can be taken from the back of the ear, leaving it attached at
its cicatrized union with the primary wound, and sliding this flap upward
or outward until the defect of the helix is overcorrected to allow for
contraction and suturing the flap in its new position.

The secondary wound if too large to permit of direct union with sutures
may at once be covered with a flap taken from the anterior border of the
arm, or, if preferred, from the inner aspect of the calf of the leg. The
wound occasioned by the removal of the graft can easily be closed by
suture, leaving simply a linear scar of little consequence. Usually such
defects of the rim can be hidden by the combing of the hair, especially
in women.


AURICULAR PROTHESES

When the injury has resulted in complete loss of the organ or so much of
it that its remaining stump will not permit of otoplasty, protheses or
artificial ears or parts of ears may be employed to render the patient
less unsightly. These protheses are usually made of aluminum, papier
maché, or rubber, and painted to match the good ear. They are attached
with a special kind of gum, termed zinc-leim, which makers of such
protheses furnish, or are held by metal springs, which are inserted
under strips or bridges of skin surgically created for the purpose. The
esthetic effect is surprisingly good in most cases.


COLOBOMA

A very common injury observed in women is laceration of the lobule of
the ear or ears, generally due to the wearing of heavy earrings, which
gradually cut their way through the tissues. Coloboma may be occasioned
by the forcible tearing out of the earrings; it has also been found to be
congenital in rare cases.

The simplest method for correcting this deformity is to cut away both
cicatrized edges of the defect by the aid of the angular scissors,
exposing fully the width of the lobular tissue on both sides (Fig. 116),
as the cicatricial edges are likely to be thinner than the lobule proper,
and if brought together would leave a depression along the line of union.
The freshened cut surfaces are brought together with fine silk sutures,
an inferior one being taken in the outer border, so as to establish
perfect coaptation at this point (Fig. 117).

The objection to the above operation is that invariably owing to the
resultant contraction a notch is formed at the union of the angles of the
freshened wound. To avoid this the operation shown in Fig. 118 is to be
employed (Greene).

[Illustration: FIG. 116.—CORRECTION OF LOBULAR DEFECT.]

[Illustration: FIG. 117.—COAPTATION OF WOUND.]

[Illustration: FIG. 118. FIG. 119.

GREENE METHOD.]

The bistoury is thrust through the lobule at the point _A_ and an
incision is made to follow at a little distance the defect along the line
_D_. This frees the cicatrix except at the pedicle _A_. A transverse
incision is now made above the point _A_ corresponding to the curved
exsection of the opposite side except for a thin strip of tissue _B_.
This delicate little flap is preserved and severed a short distance
beyond.

The raw edges when now brought in apposition will assume the form in Fig.
119. The wound is sutured as in the simpler operation.

[Illustration: FIG. 120.—NOYES’S CLAMP.]

These operations are best performed under local anesthesia, the
two-per-cent eucain being preferred. There is practically little
bleeding, but even this may be avoided by applying a large Noyes’
compression clamp with its angular arms so placed as to include the
entire lobule (Fig. 120).


MALFORMATION OF THE LOBULE

There may be an enlargement of or an absence of the lobule.


ENLARGEMENT OF THE LOBULE

In the enlargement of the lobule the operation last described may be
resorted to, making the now supposed coloboma the triangular amount
of tissue to be removed. It will be found that the upper curve of the
incisions must be carried much higher in cases of this kind, furthermore,
that they should define a sharper angle at this point.

The simple exsection of a triangular piece of the lobule and suturing
is commonly practiced, with the objection of the notch previously
referred to. This operation is very quickly done, and if care be taken in
bringing the raw surfaces together neatly a splendid result is attained,
especially if the incisions are made obliquely to the plane of the skin.


ATTACHMENT OF THE LOBE

There may be a shortening of the lobule, or, as is more frequently seen,
the attachment of the inner lateral border of the lobe to the skin
opposite.

This attachment of the lobe has been alleged by criminologists to be
a mark of the degenerate. If this be so it can scarcely apply to the
Japanese, in whom it is found as a racial fact.

As the defect is often objected to by patients its correction may be
considered briefly.

An incision is made in the inferior auricle and in the skin below it, as
shown by the dotted lines in Fig. 121, removing the triangular piece of
tissue included therein.

[Illustration: FIG. 121. FIG. 122.

CORRECTION OF ATTACHED LOBE.]

The wound is then sutured with fine silk, as shown in Fig. 122, and
allowed to heal. The result is very gratifying in most cases.


MALFORMATION OF THE AURICLE

Malformations of the ear are due to the arrest of development, termed
microtia, excessive development, or macrotia, and malposition.


MICROTIA

The total absence of the auricular appendage is quite rare. One or
the other part of the ear is usually found, either partially or fully
developed, giving to the ear an irregular rolled-up appearance. This
defect may be unilateral or bilateral.

It may be associated with congenital fistula (_Fistula auris congenita_),
varying in length from one fourth to one inch, and secreting a serouslike
fluid. These fistulæ are usually found anteriorly and above the tragus,
the lobule, or more rarely at the crus helix, or even behind the ear.
Sometimes these fistulæ communicate with the middle ear or even the
esophagus. They are due to imperfect development _in utero_. In microtia
little can be done surgically, since the malformation is usually so
pronounced as to exclude all methods of restoration.

Szymanowski advises making an ear from the skin immediately back of the
auditory canal if present, making the incisions of the shape shown in
Fig. 123.

[Illustration: FIG. 123.—RESTORATION OF AURICLE, SZYMANOWSKI METHOD.]

The flap included in these incisions is dissected up and doubled on
itself posteriorly. The doubled flap thus formed is brought forward and
placed as near into the linear position as the ear should have. The
flap is then sutured through and through to make the raw surfaces heal
together. The secondary wound and the treatment of the flap are carried
out as already referred to under restoration of the auricle.

Several later delicate operations are done to add to the shape of the
newly made organ, but at best the effect is far from even good.

In the case of Mr. B., illustrated in Fig. 124, an attempt was made to
enlarge the somewhat elastic roll of tissue corresponding to the helix
by several injections of paraffin. The result proved to be anything but
satisfactory; in fact, the prominence of the malformed upper ear was made
more evident, and painful when subjected to pressure, so that the patient
was compelled to refrain from lying on that side of the head.

[Illustration: FIG. 124.—AURICULAR STUMP FOR ATTACHMENT OF ARTIFICIAL
EAR.]

[Illustration: FIG. 125.—AURICULAR PROTHESIS.]

There had been also congenital atresia of the auditory meatus, which
had been operated for, leaving a hair-lined opening, leading down to a
useless middle ear, a condition sometimes associated with microtia.

In presenting himself to the author for operation it was decided that
the otoplastic methods for the restoration of the ear were out of the
question, as is usually the fact in these cases.

The hard mass of tissue referred to and corresponding to the helix
was reduced considerably, so that the stump obtained was soft and
pliable, with not only the object of overcoming the sensitiveness
and inconvenience of the part, but to obtain as good a base for the
attachment of an artificial ear as possible (see Fig. 124).

[Illustration: FIG. 126.—AURICULAR PROTHESIS APPLIED TO STUMP.]

[Illustration: FIG. 127.—ANTERIOR VIEW OF AURICULAR PROTHESIS.]

[Illustration: FIG. 128.—POSTERIOR VIEW OF AURICULAR PROTHESIS.]

The author advises a complete amputation of such underdeveloped ears,
since a better and firmer seat of attachment is offered thereby to the
prothesis to be worn over it, at the same time giving the artificial
organ a better position in reference to its normal relation to the face.
An irregular stump makes this more or less difficult, as in the case just
referred to, but even these patients are loath to part with an irregular
ugly mass of tissue they consider themselves thankful to be born with.

The auricular prothesis used in this case is shown in Fig. 125, and its
position and appearance when placed on the stump is shown in Fig. 126.

Another, showing both anterior and posterior surfaces, is given in Figs.
127 and 128.

The fistular conditions mentioned should be thoroughly dissected out
and healed from the bottom when practical by antiseptic gauze packing.
Those involving the middle ear require special treatment that cannot be
included under plastic procedure.


MACROTIA

Abnormal enlargement of the ear is often found in the idiot, but is
commonly seen as a hereditary defect in many without having the least
relation to the mental development of the person. These conditions occur
more frequently in men than in women.

Enlargement always depends upon overdevelopment of the cartilaginous
structure of the auricle, and may also be the result of direct violence,
the result of blows upon the organ, as in prize fighters, football
players, and other athletes.

Following violence the auricle undergoes either an acute or chronic
hypertrophy of the chondrium, resulting in the condition known as the
“cauliflower ear.”

Again, there may be hematoma occasioned by direct violence, termed
othematoma traumaticum, or a spontaneous development of such hematoma
without any appreciable injury, as found in the insane. In the latter
form the disease appears suddenly without warning or inflammatory
manifestations, the hematoma reaching its full size in three or four
days, after which a passive resolution in the form of absorption of
the tumor takes place associated more or less with an organization of
the blood mass, and leaving the auricular appendage unduly enlarged,
distorted, and thickened, with here and there islands of seemingly
detached or displaced cartilage firmly adherent to the overlying skin.

Early in these cases much can be done by the application of external
medication, depletion, and pressure bandage, and the removal of the
effusion producing the swelling and lying between the perichondrium and
the cartilage, by the introduction of a trocar cannula or by incision, as
may be required.

The union between cartilage and perichondrium is always slow, requiring
about three weeks in the traumatic variety and often months in the
noninflammatory form.

Be the enlargement due to whatever cause, the patient not infrequently
presents himself for a correction of the deformity.

The slightest of such deformities is a tiplike enlargement of the outer
and upper angle of the helix, most commonly unilateral. This has been
termed “_fox ear_.”

In this condition there is more or less loss of the curl of the helix,
with flattening beginning well down in the fossa, extending upward, and
terminating in a triangular cartilaginous tip resembling the ear of an
animal, hence the name.

The correction of this fault is quite simple. An incision somewhat
larger than the base of the cartilaginous triangle is made under a local
anesthetic about one fourth inch below and back of the line corresponding
to the superior border of the helix. The cartilage is exposed through
this incision and excised with a fine curved scissors without wounding
the anterior skin of the helix, and the incision neatly sutured, leaving
the now redundant skin to contract.

In this manner the fault is corrected without any appreciable scar.

The sutures can be removed in three or four days.

In the correction of macrotia various surgical methods may be employed,
yet none can be emphasized, as exclusively indicated, inasmuch as the
enlargements may involve one or the other part of the pinna.

The greatest fault with most of these ears lies in the overdevelopment of
the triangular antihelix or that area lying posterior to the fossa of the
antihelix and the fossa of the helix, although in many cases the greatest
malformation is found in the concha itself.

The following methods for operation are therefore given not so much for
their individual merit, but to act as a guide in the selection of an
appropriate election or modification for specific cases.

=Schwartze Method.=—Schwartze advises and has obtained excellent results
by removing a long elliptical piece of the entire thickness of the pinna,
including both skin and cartilage, from the fossa of the helix, followed
by the excision of a triangular section with its base corresponding
to the outer border of the helix and its apex terminating well in the
concavity of the concha. The scheme of procedure is shown in Figs. 129
and 130. The raw edges are brought together by fine silk sutures, which
are made to pass directly through the cartilage, and tied carefully to
prevent any change of the transfixed parts, which would mar the result
of the operation more or less and necessitate further interference. The
arrangement of the sutures and the disposition of the parts are shown in
Fig. 131.

[Illustration: FIG. 129. FIG. 130. FIG. 131.

SCHWARTZE METHOD.]

=Parkhill Method.=—Parkhill advises a semilunar incision from the fossa
of the helix with a rhomboidal exsection of the helix, as shown in Fig.
132, and suturing the parts, as shown in Fig. 133.

[Illustration: FIG. 132. FIG. 133.

PARKHILL METHOD.]

The tonguelike ends of the semilunar incisions must, of course, vary
in length, according to the amount of tissue necessary to remove to
facilitate accurate juxtaposition of the newly designed flaps.

=Author’s Method.=—The latter operation is most successful where the
upper part of the pinna is unusually flat. It does not correct this
flatness, however, which is often an objection, hence the author suggests
excising a section of the entire thickness of the ear from the fossa
somewhat in the form shown in Fig. 134, curving the two deeper invading
incisions, so that when the parts are brought together a concavity will
be given the antihelix, as in the natural auricle.

[Illustration: FIG. 134. FIG. 135.

AUTHOR’S METHOD.]

The rearrangement of the parts in this event is shown in Fig. 135. The
only objection to the above may be found in the two linear scars across
the antihelix entirely overcome by the Parkhill operation, wherein the
line of union falls just below the rim of the helix and into the groove
commonly found there, yet any of these scars shows little in well-done
operations and when union takes place by first intention.

There will always appear a notchlike depression where the newly cut ends
of the helix are brought together, owing to the cicatrix involving the
space between the cartilaginous borders.

Inasmuch as this notch necessarily shows the most prominent part of the
ear, the author advocates the following method in which the notch is
brought anterior to the fossa of the antihelix; in other words, near to
the point of the union of the helix with the skin of the face about on a
line with the superior border of the zygomatic process; a point where the
hair is in close proximity with the ear and where the scar can be more
easily covered.

The form of incision is somewhat sickle shaped, the upper curvature of
the incision following the inferior border of the helix and extending
well into the fossa of the helix, as shown in Fig. 136. Where the
antihelix is particularly large a triangular section may be removed, as
shown at _A_, with a corresponding shortening of the helix flap at _B_.
The latter gives more contour to the ear as well.

[Illustration: FIG. 136. FIG. 137.

AUTHOR’S METHOD.]

The parts are brought together and sewn into position, as shown in Fig.
137.


AURICULAR APPENDAGES

Small nipplelike projections of skin or elongated tumefactions of
connective tissue are sometimes found about the tragus, the lobule, or
on the neck. They are easily removed by encompassing their bases with an
elliptical incision and amputating them a little below the level of the
skin and suturing the wound in linear form.


POLYOTIA

Auricular appendages may contain small pieces of cartilage or resemble
crudely the auricle in miniature. This condition is termed polyotia. One
or more of these supernumerary ears may be found anterior or posterior to
the true ear or even below it on the skin of the neck.

In the case reported by Wilde there were four ears, the two abnormal ones
being situated on the neck at either side. Langer has reported a similar
case. The condition may be unilateral or bilateral.

This congenital malformation is corrected by simple amputation, as
described under minor auricular appendages.


MALPOSITION OF THE AURICLE

The most common deformity met with in ears is undue prominence. The
ears stand out from the head at an obtuse angle, often lopping forward
and downward, giving the patient a stupid appearance. This condition is
usually inherited, but may be acquired during childhood by the careless
wearing of caps that crowd the pinnæ forward and away from the head. The
habit of ear-pulling is also said to be a cause, also the faulty position
of the head during sleep. The deformity is usually bilateral, but in the
majority of cases one ear usually projects more than the other.

Where the deformity is recognized during infancy the ears should
be simply bandaged to the head with a suitable bandage or ear cap,
procurable for that purpose with the hope that the cartilages may thus be
influenced during their period of hardening and growth.

Invariably these patients are seen too late, and operative procedures
alone will restore the ears to their normal position.

The earlier in life such an operation is performed the more satisfactory
is the result, inasmuch as the cartilage of the ear is more pliable, and
hence more susceptible of readjustment; moreover, the operation when done
early in life necessitates only the removal of an elliptical piece of
skin from the back of the ear, according to Monks, and suturing of the
wound, as shown in Fig. 138.

[Illustration: FIG. 138.—MONKS’ METHOD.]

The elliptical form of the incision must, however, be changed according
to the varied prominence of various parts of the ear. When the ear lops
forward, it should be broader above and narrower below, and _vice versa_
in the event when the concha is overprominent.

When the patient is less than fourteen or fifteen years of age a general
anesthetic should be employed, but in older patients the operation can be
easily undertaken under local use of two-per-cent eucain solution.

=Author’s Method.=—The method followed by the author is to thoroughly
anesthetize the back of the ear, the patient lying in a recumbent
position with the head to one side, sufficient to place the ear to be
operated upon in as convenient position for operation as is possible. A
rubber cap is drawn over the head to cover the hair.

An incision is now made along the whole of the back of the ear as far
down as the sulcus, where the retro-aural integument joins that of the
neck.

The incision should involve the skin only, and vary from three fourths to
one half an inch from the outer border.

At once the blood will ooze from the line of incision. The operator now
presses the ear backward on the bare skin of the head, leaving an imprint
of the bleeding line on the skin there.

A second incision is made along this line, giving the total outlining
incision a heart-shaped form, as shown in Fig. 139.

The skin within this area is now dissected up quickly. There will be
more or less bleeding from the post-auricular vessels, which can easily
be controlled by sponge pressure, or with one or two artery forceps
of the mosquito-bill pattern. The wound should be large enough to
overcorrect the fault, as the ear springs out more or less when healed.

Sutures are now introduced. When necessary one or two catgut sutures are
taken through the concha, not going through the anterior skin, however,
and the deeper tissue back of the ear and tied. These hold the cartilage
in place.

[Illustration: FIG. 139.—AUTHOR’S METHOD.

FIG. 140.—CARTILAGE TO BE REMOVED. (Author’s method.)]

For the coaptation of the skin the continuous suture is to be preferred,
but when the cartilage suture is employed it will be found impracticable,
owing to the close position of the ear to the head. In that event
interrupted sutures must be placed, as shown in the Monks operation, and
tied after the cartilage has been fixed as described.

Where it is deemed necessary to fix the cartilage in this way, the author
advises to remove an elongated elliptical piece of the concha, as shown
in Fig. 140.

This is neatly done by outlining the section with the scalpel, and
excising it with the aid of a fine pair of scissors, half rounded; the
operator holding the index finger of the left hand in the depression of
the concha anteriorly as a guide to avoid injuring the skin.

After the elliptical exsection a linear incision with the scissors may be
made both superiorly and inferiorly to further mobilize the springy shell
of the ear, which will then be found to fall easily into place.

The bleeding in the latter method is more severe, since the posterior
auricular arteries and the auricular branch of the occipital have to be
severed, yet ligation is rarely necessary.

The interrupted suture may now be applied, varying the site of puncture
as below or above its fellow puncture, as made necessary by the droop of
the ear, with the object of shifting it into a normal position; or in
other words, by raising or lowering it upon tightening the sutures.

The continuous suture is to be preferred, however, when the cartilage has
been removed as described, since the ear has now become quite mobile and
is easily placed in position.

When the removal of these sutures, which should be of Nos. 5 or 6 twisted
silk, is considered, one can comprehend the advisability of this form of
wound closure.

The ear will now appear to lie quite close to the head, compared with the
original position, as shown in Figs. 141 and 142.

The patient is now turned so as to present the other ear, a pad of gauze
and absorbent cotton being placed under the ear operated on for comfort’s
sake.

The second ear is operated as was the first, the operator having taken
note of the form and size of the incision of the ear just finished.

Both ears sutured, the wounds are cleansed thoroughly, though gently,
with fifty-per-cent peroxid of hydrogen and dried and dusted over with
aristol powder.

[Illustration: FIG. 141. FIG. 142.

CORRECTION OF MALPOSED AURICLES. (Author’s case.)]

A pad of gauze is placed over each ear and a bandage applied around the
head to protect the wounds and retain the ears, care being taken not to
tighten too tightly, as this occasions great pain and possible pressure
erosion of the skin.

The dressing should be changed on the second day, as there is usually
some soiling of the dressings at the lower angles of the wounds. They are
again powdered, using the pulverflator preferably, and rebandaged.

The ears will be found to lie very close to the head at this time, if
the operation has been properly done. Anteriorly in the skin of the
concha and corresponding to the line of cartilage exsection will be found
a crease more or less discolored, according to the severity of injury
occasioned by the operation.

This should give the surgeon no concern, as the fold will accommodate
itself in a few days. There may be a persistence of the fold for some
time, however, which, if desirable, can be corrected by a small secondary
operation at a later date. The author has never experienced the need of
such, however.

The patient at this time usually bemoans the position of his ears, and
should be assured beforehand what was expected, and that the condition is
only temporary.

The dressings after this can be repeated every second or third day, as
may be required, although these wounds heal surprisingly well.

Moist dressings are to be avoided at all times, they soften the edges of
the wound and prevent primary union.

[Illustration: FIG. 143. FIG. 144.

POSTERIOR VIEW OF REPLACED AURICLES.]

The sutures are removed on the ninth or tenth day, whereafter the patient
may be allowed to go without the head bandage, but is strictly instructed
to replace it at night with a band of muslin three inches wide, snugly
pinned around the head to prevent the ears from being injured or torn
away from their new attachment by sudden movements during sleep. This
bandage should be worn at night for at least a month.

When only a part of the ear is overprominent the operation undertaken
should in the main be according to the methods just described, the
incisions being changed in extent accordingly.

In the illustrations above, Figs. 143 and 144, are shown the posterior
view of the ears before and after operation. At no time should the ears
be placed too closely to the head, as is often peculiarly requested by
the patient, as it gives an unnatural appearance and predisposes toward
the collection of filth in the sulcuses that is hard to remove. The
distance from the head to the outer rim of the ear should be about half
an inch at its widest part.




CHAPTER XI

CHEILOPLASTY

(_Surgery of the Lips_)


[Illustration: FIG. 145.

BURCHARDT COMPRESSION FORCEPS.]

This branch of plastic surgery has to do with the correction of
deformities of the lips. These deformities usually involve one lip
only, and are dependent upon direct traumatism, operative interference
in the extirpation of malignant growths, particularly carcinomata,
the correction of cicatricial disfigurement following tubercular or
syphilitic ulceration or congenital faults, commonly met with in harelip.

Operations for the latter condition have usually been considered under a
separate heading, but since the restorative procedures involve methods
purely plastic they are included under this their proper classification.

Owing to the great number of blood vessels in the lips, it is advisable
to resort to the bloodless method, where the defect to be corrected
involves more than the superficial structure. This is accomplished:

1. By compressing the coronary arteries at both angles of the mouth
by digital pressure, suitable clamps or compression forceps. The
fenestrated oval forceps, illustrated in Fig. 145, and designed by
Burchardt, or the harelip clamp of Beinl, Fig. 146, will be found to meet
the purpose well, the latter having a sliding lock by which the pressure
upon the tissue can be regulated to a nicety.

[Illustration: FIG. 146.—BEINL HARELIP CLAMP.]

2. By clamping off the site of operation with specially made cutisector
forceps. Its smooth parallel jaws should be curved outward, so that the
diseased area can be fully excluded by their concavities.

3. By employing the indirect ligature of Langenbuch. This is accomplished
by including the site of operation with several strong silk threads
firmly tied in loops upon the skin surface, each loop including a given
amount of tissue, the next encroaching upon it up to the center of this
area, and so on until the entire site is rendered anemic. The advantage
of this method is that with the anemia a certain amount of anesthesia is
produced at the same time; a fact to be remembered when the patient is to
be operated under local anesthesia, the anemia enhancing the efficacy of
the latter.


HARELIP

A congenital defect of the upper lip caused by the lack of proper union
of the maxillary, globular, and frontonasal processes _in embryo_. Treves
states that from the buccal aspect of the maxillary process of either
side the palatal processes arise, passing inward to combine with each
other to form the soft palate and all of the hard palate, except the
intermaxillary portion, and that from this same source are formed the
cheeks, the outer or lateral parts of the upper lip, and the superior
maxillary bones, while the external nose, the ethmoid, the vomer, the
median portion of the upper lip, and the intermaxillary or os incisivum
are derived from the frontonasal process.

The fact that these centers of development are concerned in the formation
of the parts involving harelip accounts for the position of the cleft in
the lip as being unilateral or bilateral, and rarely if ever median or
intermaxillary.


CLASSIFICATION OF HARELIP DEFORMITIES

Six varieties of harelip deformity are recognized by Rose, but herein
only five classes of these will be considered, one of which, the first,
is so rare that its occurrence is practically denied.

For all purposes in surgery of the face, in which cosmetic effects are
sought, the author considers the following classification to answer fully:

    1. Median or intermaxillary cleft.

    2. Single and double cleft.

    3. Facial cleft.

    4. Buccal cleft.

    5. Mandibular cleft.

[Illustration: FIG. 147.—MEDIAN CLEFT. (Engle’s case.)]

[Illustration: FIG. 148.—MEDIAN CLEFT WITH RHINOPHYMIA. (Trendelenburg’s
case.)]

=1. Median or Intermaxillary Cleft.=—As has been said, the first variety
of this form of lip deformity is very rarely met with. It consists of a
cleft in the median third of the upper lip, more rarely associated with
the absence of the intermaxillary bone and total cleft of the hard and
soft palate. In fact, the entire median section may be absent with or
without absence of the intermaxillary and vomer bones (Engle) (see Fig.
147). Commonly, however, the cleft involves only a part of the filtrum of
the lip, although Witzel speaks of a case in which the lip assumed the
form of a dog’s nose, the cleft extending upward, completely dividing the
nares from one another, or the entire nose may be divided in its median
line.

When the cleft involves the hard parts—that is, the intermaxillary bone
and the hard palate—it is said to be total.

=2. Single and Double Cleft.=—The second variety in the above
classification is by far the most common, and is often, therefore, termed
ordinary. In this there exists either a unilateral or bilateral cleft of
the lip of varying degree, depending upon the involvement of the tissue
affected. It is not unusual to find fissures in these cases extending
through the alveolar arch and the hard and soft palate.

This fissure or cleft is always found on one side of the median line,
while in the soft palate it is median.

Most unilateral clefts of the lip will be found to be in the left outer
third. They are more common in the male child.

[Illustration: FIG. 149. FIG. 150. FIG. 151.

TYPES OF UNILATERAL CLEFT.]

The degrees of deformity of the soft parts in the unilateral variety are
shown in Figs. 149 to 151, respectively, representing the first, second,
and third degrees of the cleft deformity, according to the involvement
of the lip tissue. In first degree are included small notches in the
prolabium only or extending upward somewhat above its margin, but not
involving the entire lip. In the second degree both the vermilion border
and the lip are divided, while in the third degree the cleft extends into
the nose with an absence of part of the lip structure itself.

Since the deformity in the division under discussion is so commonly met
with it will be considered fully under its operative correction.

=3. Facial Cleft.=—The third class of deformity includes either
unilateral or bilateral fissure of the face.

In the _unilateral_ variety the cleft usually begins at the outer section
of the upper lip, involving, as a rule, only the soft parts, extending
upward and irregularly around the alæ of the nose to the inner canthus of
the eye, or going even beyond the orbit and over the forehead as far as
the hair line. An illustration of such a case is shown in Fig. 152.

The _bilateral_ form of this facial defect is rarely met with. A case
reported by von Guersant is shown in Fig. 153.

[Illustration: FIG. 152.—UNILATERAL FACIAL CLEFT. (Hasselmann.)]

[Illustration: FIG. 153.—BILATERAL FACIAL CLEFT. (von Guersant.)]

=4. Buccal Cleft.=—In the fourth variety the deformity involves the
cheeks, the fissures extending from the angles of the mouth outward,
causing an enlargement of this natural opening, and hence this defect is
better known as _macrostoma_.

It may affect one or both cheeks. The latter is elucidated in Fig. 154.

[Illustration: FIG. 154.—BUCCAL FISSURE WITH MACROSTOMA.]

On the other hand there may exist a congenital contraction of the mouth
termed _microstoma_. This defect is rarely seen, and is due to a too free
union of the maxillary and mandibular processes. When observed it is
usually associated with improper development of the inferior maxillary
bones.

=5. Mandibular Cleft.=—In the fifth class the cleft is to be found in
the median line of the lower lip. This fissure, though extremely rare,
may involve only the soft tissue or extend to the inferior maxillary
(Thorndike) and even to the tongue (Wölfler).

From what has been said of the five varieties just mentioned it can be
plainly seen that the defects of the second class are the most common.
Since the correction of such involves methods of an extensive technique
that can be followed more or less in the restoration of any of the
above, this particular subdivision will be considered fully, but only to
the extent of defects of the soft parts, leaving the osteoplastic and
periosteoplastic operations to be studied elsewhere.

The defects that have to do with facial and buccal clefts will be more
specifically mentioned later on under Melo- and Stomatoplasty.


THE OPERATIVE CORRECTION OF HARELIP

The correction of a harelip should be undertaken as early as the first
two weeks after birth in the healthy child. If, however, the infant is
considered too delicate to undergo so early an ordeal, the operation
should be deferred until the third or even the fifth month. At any
rate the operation should be undertaken as early as deemed advisable,
since the closure of the cleft has a desirable effect upon the ofttime
overprominent intermaxillary bone, helps to approximate its lateral
borders, overcomes the later depression deformity of the upper lip, aids
its natural development, and permits of the child suckling the breast—an
important factor in the proper nourishment, since the defect allows
only of feeding with the spoon, the child being unable to grasp the
nipple of the breast in this state. Furthermore, the act of phonation is
practically entirely perfected by an early operation, and rarely if ever
overcome when faulty phonation has been established.


_Unilateral Labial Cleft_

The restoration of an unilateral cleft is to be performed without the
use of an anesthetic. The child’s arms are fastened to its sides with
several turns of a wide roller bandage. It is then seated upon the lap of
the assistant, who holds its head in position, compressing the coronary
arteries with his fingers at the outer sections of the upper lip at the
same time. If this is impractical, proper forceps can be employed, as
already mentioned. It is rarely necessary to employ the direct-ligature
method heretofore referred to in this class of operations. More or less
bleeding always accompanies the operation, the child usually swallowing
what enters the mouth if not sponged up repeatedly.

To facilitate matters the child can be anesthetized, chloroform being
used. In this case the patient is to be placed on its side, the head
being fixed in a dependent position (Rose).

This gives freer drainage of the bleeding surfaces, the blood being
sponged up with gauze sponges as required, while the vessels that are cut
can be tied off with catgut ligatures as fast as they are divided.

The anesthetic can be given upon a small sponge held before the
nostrils. Infants should not be anesthetized, yet in older children it is
almost always necessary.

A simple freshening of the edges of the defect with the bistoury,
followed by suture, does not give a desired cosmetic effect, hence it
is advisable to resort to methods intended to restore the lip as far as
possible to its normal state.

=Nélaton Method.=—The simplest operation for a cleft of moderate extent
not involving the nare is that of Nélaton. He divides the lip above the
angle parallel with the defect with a bistoury, cutting upward, including
the upper angle which allows the prolabium surmounted by a thin strip of
skin to droop downward in a point.

The lower angle of the wound is then drawn downward and united lengthwise
with silkworm gut sutures, giving to the prolabium a protrusion or tip,
which eventually retracts and causing the lip to assume a natural aspect.

The method is shown in Figs. 155-157.

[Illustration: FIG. 155. FIG. 156. FIG. 157.

NÉLATON METHOD.]

=Fillebrown Method.=—Fillebrown has devised a method where the vermilion
border of the lip is entirely preserved, as in the preceding operation.
His method can only be employed where the cleft is not extensive. He
commences his incision at the red border at the outer left line, cutting
upward and inward toward the median line a short distance (see Fig. 158),
then downward to the red border of the lip, then upward and outward to
the right of the median line, corresponding to the incision just made to
the left of the median line. The upper angle of the cleft is now drawn
down by its red border and the wound sutured, as shown in Fig. 159. This
operation does not project a small triangle of the white skin into the
vermilion border and gives excellent results.

[Illustration: FIG. 158. FIG. 159.

FILLEBROWN METHOD.]

=Von Langenbeck, Wolff, and Sedillot Methods.=—The methods of von
Langenbeck, Wolff, and Sedillot are somewhat similar to that of Nélaton.
An incision is made slightly above the prolabium, following the angle of
distortion and reaching outward to either side of the median line almost
to the angle of the mouth. The raw edges corresponding to the defect are
brought together by suture and a section of the prolabium is removed
to overcome its overprominence, but not enough to entirely flatten the
vermilion border (see Figs. 160-161). The latter is sutured horizontally
to such part of the angular defect as has not been utilized in the median
line, and also vertically as far down as its free border, as shown in
Fig. 162.

[Illustration: FIG. 160. FIG. 161. FIG. 162.

VON LANGENBECK-WOLFF-SEDILLOT METHOD.]

=Malgaigne Method.=—The method of Malgaigne differs in technique in
that he utilizes a semicircular incision, which is made to include the
upper angle of the defect. Both ends of this incision are continued
horizontally outward to a required extent (see Fig. 163). The freed
prolabial flaps are drawn downward, as in Fig. 164, and sutured
vertically, as shown in Fig. 165. Two retention sutures are shown in the
latter figure to overcome the tension of the lips _post operatio_.

The semicircular incision should be preferred when the defect will permit
it, since the unequal lengths of the two lip halves may thereby be more
uniformly approximated, while the prolabium in being crowded downward
overcomes the notchlike scar so common with the vertical-incision method.

[Illustration: FIG. 163. FIG. 164. FIG. 165.

MALGAIGNE METHOD.]

=Gräfe Method.=—This method, as shown in Fig. 166, is, therefore, to be
preferred when the defect is one of the first or second degree.

The first suture is to be placed at the margin of the vermilion border
and the skin, so that the unequal sides are placed in normal apposition.
The parts are sutured according to the method shown in Fig. 167.

[Illustration: FIG. 166. FIG. 167.

GRÄFE METHOD.]

=Mirault-Bruns Method.=—An excellent method of this class is that of
Mirault-Bruns. Their operation is indicated in defects of extensive
degree, and usually gives excellent results. As in the former method a
semicircular incision is made to include the superior angle, and two
other incisions are made somewhat as shown in Fig. 168. The wound made
thereby is shown in Fig. 169. The inferior triangular flap of one side is
utilized to restore the prolabium, the whole being sutured, as shown in
Fig. 170, care being taken to make this flap of sufficient size to give
stability and volume to the lower margin of the lip.

[Illustration: FIG. 168. FIG. 169. FIG. 170.

MIRAULT METHOD.]

=Giralde Method.=—This method is intended for defects of the third
degree. A vertical incision frees the vermilion border on one side, while
an angular cut on the opposite side (see Fig. 171) allows of the bringing
together the lip flaps above it. The wound is made to appear somewhat as
in Fig. 172, and is sutured, as depicted in Fig. 173.

[Illustration: FIG. 171. FIG. 172. FIG. 173.

GIRALDE METHOD.]

=König Method.=—König advocates two vertical incisions which dispose of
the cicatrized borders of the defect. A slanting incision is added at
both sides to free the prolabium (see Fig. 174), giving a wound when
drawn in position, as shown in Fig. 175. In suturing the wound the
vermilion border flaps are turned downward as much as possible to restore
the contour of the prolabium. The sutures are placed as shown in Fig. 176.

[Illustration: FIG. 174. FIG. 175. FIG. 176.

KÖNIG METHOD.]

=Maas Method.=—Maas has deviated from the above method somewhat, as is
shown in Fig. 177, by making one of the prolabial flaps much larger than
the other. His operation is applicable to defects of maximum extent. The
lip wounds are thereby made to appear as in Fig. 178, and the sutures are
applied as in Fig. 179, with an advantage of leaving a smaller sutured
wound to heal by primary union.

[Illustration: FIG. 177. FIG. 178. FIG. 179.

MAAS METHOD.]

=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.

[Illustration: FIG. 180. FIG. 181. FIG. 182.

HAAGEDORN METHOD.]

=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
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.

[Illustration: FIG. 183. FIG. 184. FIG. 185.

DIEFFENBACH METHOD.]

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.

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 mucous-membrane 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.

[Illustration: FIG. 186. FIG. 187.

VON ESMARCH METHOD.]

=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.

[Illustration: FIG. 188. FIG. 189. FIG. 190.

MAAS METHOD.]

=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 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.

[Illustration: FIG. 191. FIG. 192. FIG. 193.

HAAGEDORN METHOD.]

=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.

[Illustration: FIG. 194. FIG. 195. FIG. 196.

SIMON METHOD.]

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.


POST-OPERATIVE TREATMENT OF HARELIP

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.

[Illustration: FIG. 197.—HAINSLEY CHEEK COMPRESSOR.]

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 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.


CLASSIFICATION OF DEFORMITIES OF UPPER LIP

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. 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.


OPERATIVE CORRECTION OF DEFORMITIES OF UPPER LIP

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.

[Illustration: FIG. 198. FIG. 199.

BRUNS METHOD.]

=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 mucous-membrane 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.

[Illustration: FIG. 200. FIG. 201.

SEDILLOT METHOD.]

=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.

[Illustration: FIG. 202.—BUCK METHOD.]

=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.

[Illustration: FIG. 203. FIG. 204. FIG. 205.

ESTLANDER METHOD.]

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.

[Illustration: FIG. 206. FIG. 207.

RICHERAND METHOD.]

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.

[Illustration: FIG. 208. FIG. 209.

EXTIRPATION OF ENTIRE VERMILION BORDER.]

=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.

[Illustration: FIG. 210. FIG. 211.

CELSUS METHOD WITH ADDITIONAL HORIZONTAL INCISIONS.]

=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.

[Illustration: FIG. 212. FIG. 213.

ESTLANDER METHOD.]

=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.

[Illustration: FIG. 214. FIG. 215.

BRUNS METHOD.]

=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 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.

[Illustration: FIG. 216. FIG. 217.

BUCK METHOD.]

=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.

[Illustration: FIG. 218. FIG. 219.

DIEFFENBACH METHOD.]

=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.

[Illustration: FIG. 220. FIG. 221.

JÄSCHE METHOD.]

=Trendelenburg Method.=—Trendelenburg has modified the method of Jäsche
by shortening the curve of the cheek incisions so that their outer
borders were made to lie anterior to the facial artery (see Fig. 222),
the parts being approximated and sutured, as shown in Fig. 223.

To obtain sufficient mucous membrane to cover the superior margin of the
two flaps when brought together he made the cheek incision only down to
the mucosa, dissected up the latter a short distance from the upper part
of the cheek, and divided it about one half centimetre above the line of
the external incision. This flap of mucous membrane on either side was
used to line the lip in place of the prolabium.

[Illustration: FIG. 222. FIG. 223.

TRENDELENBURG METHOD.]

=Bruns Method.=—Bruns excises the defect when not involving the whole lip
in quadrilateral form, and takes up a flap from the anterior region of
the chin to cover it, as shown in Fig. 224.

This flap is rotated upward into the wound made, and is sutured in place,
as shown in Fig. 225. The secondary wound is brought together by suture.

[Illustration: FIG. 224. FIG. 225.

BRUNS METHOD.]

In cases where the entire lip is removed he cuts two square flaps from
the upper anterior region of the cheeks extending as far upward as the
alæ of the nose (see Fig. 226).

He rotates these flaps into the open wounds and sutures them into place,
as shown in Fig. 227.

The border of the lip is lined with the mucous membrane of the cheek
flaps then brought down. If the latter has become too stretched
longitudinally, he relieves it at its base by transverse incisions.

[Illustration: FIG. 226. FIG. 227.

BRUNS BILATERAL METHOD.]

=Buchanan Method.=—Buchanan’s method consists of removing the diseased
area by an elliptical incision _A_, _B_, _A_. A second oblique incision
_B_, _C_, and a third of the same obliquity _B_, _C_, is made downward
and outward upon the anterior chin. From the points _C_, _C_, two curved
incisions parallel to the upper incision _A_, _B_, _A_, and equal to
their lengths, are made to the points _D_, _D_, as shown in Fig. 228.

The latter incisions provide two flaps, as shown in Fig. 229. They are
dissected off from their attachment to the lower jaw and raised upward so
that their upper line _B_ is raised on a level with the former margin of
the lip _A_, _A_.

The oblique margins _C_, _B_, _C_ are thus brought together vertically
and sutured in the median line. The mucous membrane is brought from
within outward and stitched to the skin margin.

The operation leaves two triangular wounds, which are to be healed by
granulation. The result of the rotation and apposition of the flaps is
shown in Fig. 230.

[Illustration: FIG. 228. FIG. 229. FIG. 230.

BUCHANAN METHOD.]

=Syme Method.=—Syme removes the affected area in triangular fashion, and
from the apex of the wounds carries two curved and sweeping incisions
downward from the anterior chin and beneath, terminating at the angles of
the jaw (see Fig. 231).

These two large flaps are dissected from their attachment to the jaw and
are slid upward until the sides of the triangular wound are raised to a
horizontal line corresponding to the superior border of the lower lip,
when the flaps are sutured vertically upon the anterior chin and to the
triangular island of undisturbed tissue underneath the chin, as shown in
Fig. 232.

The advantage of this operation is that no secondary wounds are left to
granulate, the whole healing by primary union.

[Illustration: FIG. 231. FIG. 232.

SYME METHOD.]

=Blasius Method.=—The method of Blasius is very similar to the foregoing,
except that this author does not carry his two curved incisions as far
downward and backward (see Fig. 233).

The two semilunar flaps are made from the tissue of the anterior chin
and slid upward, and sutured in the median line and to the intermedian
spur of undisturbed tissue, as in Fig. 234.

[Illustration: FIG. 233. FIG. 234.

BLASIUS METHOD.]

=Bürow Method.=—Bürow, who favors the excisions of two triangles of
healthy tissue in restoring an entire loss of the lower lip, proceeds
by ablating the diseased area in triangular form. From the angles of
the mouth he cuts two transverse incisions, upon which he outlines two
triangles, as in Fig. 235.

The tissue included in these triangles is removed entirely, an
unnecessary loss and one unwarrantable, but he saves the mucosa of these
excised portions with which he lines the upper margin of the newly formed
lip.

The freed lateral chin flaps he slides forward so that their oblique
borders meet vertically in the median line, where they are sutured.

The triangular wounds in the cheeks are by this sliding process
obliterated, and their raw edges are sutured vertically, as shown in Fig.
236.

[Illustration: FIG. 235. FIG. 236.

BÜROW METHOD.]

=Von Langenbeck Method.=—Von Langenbeck, contrary to the double-flap
methods, uses only one flap, with a lateral pedicle from the anterior
chin.

After a semilunar excision of the diseased area, he cuts obliquely
downward upon the anterior chin, then rounds his incision and continues
it along, just above the margin of the chin, gradually cutting upward
until its extremity is obliquely opposite to the angle of the mouth, as
in Fig. 237.

The flap thus formed will be seen to have a pedicle at this point. It is
dissected away from its mucous attachment and is rotated upward, jumping
it over the triangular spur, which has also been mobilized by a sliding
dissection.

The flap is sutured into position, as shown in Fig. 238. Unfortunately,
the flap does not permit of lining the raw margin of the wound with
mucous membrane turned outward from within, hence it is best to take
sufficient of the mucous membrane from the cheeks to accomplish this, or
the vermilion border of the upper lip may be carefully cut away from the
lip at its outer sections just above the prolabial line, and elongated by
stretching upon the raw surface of the under lip, to which it is sutured.

[Illustration: FIG. 237. FIG. 238.

VON LANGENBECK METHOD.]

=Morgan Method.=—For an extensive loss of the lower lip Morgan operates
in the following manner:

After a thorough elliptical extirpation of the diseased area, he makes a
curved incision in the tissue under the chin, conforming in its curvature
to the incision made below the diseased area of the lip (see Fig. 239).
The length of this incision is about twelve centimeters.

This bridging flap is carefully dissected up from its basement membrane.
Any infected glandular tissue encountered in the meantime is removed
thoroughly.

The whole bridge of tissue is now crowded upward, until it displaces the
defect in the lip. It is sutured on either side, as shown in Fig. 240, to
hold it in position.

Several sutures are introduced along its inferior margin, to tie it to
the tissue of the anterior jaw border and to prevent its sliding downward.

Strips of borated gauze are laid into the fold between the raw surface of
the flap and the jaw.

The secondary elliptical submental wound is drawn together by suture as
far as possible; the remaining raw surface is either allowed to heal by
granulation or is covered immediately with Thiersch grafts (Wölfler,
Regnier).

The objection experienced with the method just considered is found in
the difficulty with which the bridge flap is carried upward over the
prominence of the jawbone. It is very essential, therefore, to give as
much freeness to this flap as possible, a fact necessitating considerable
injury to the flap by handling and cutting, although the result of the
operation, if carefully done, is excellent; the lip, owing to its solid
form and undisturbed mucous membrane, does not contract as readily as
with the average lip operation, and consequent ectropion is overcome to a
great extent.

[Illustration: FIG. 239. FIG. 240.

MORGAN METHOD.]

=Zeis Method.=—To overcome the difficulty of sliding this bridgelike
flap, Zeis advocates ablating the diseased area in quadrilateral form
and forming the lip of unbroken tissue by making the flap two-tailed
(see Fig. 241), each flap meeting anteriorly in a bridge of tissue
sufficiently wide to permit of the formation of the required lower lip
and extending obliquely downward and backward upon the submental surface,
having their pedicles as far back and upon the neck as is necessary to
allow the two-tailed flap to move forward into position.

The parts are slid into position and sutured, as shown in Fig. 242.

Unfortunately the tissue of the neck is not very thick, nor is it
well nourished, factors that do not make it very satisfactory for
cheiloplastic purposes.

[Illustration: FIG. 241. FIG. 242.

ZEIS METHOD.]

=Delpech Method.=—Delpech has utilized the skin of the anterior neck
region in the following manner: He ablates the extensive diseased area,
as shown in Fig. 243, and dissects up an inverted triangular pedunculated
flap of skin from the hyoidean region of the neck, having its raw
surfaces brought face to face at its distal extremity sufficiently to
line the newly formed lip with skin which eventually would take on the
function of mucous membrane.

The whole flap was now rotated upward on an arc of 180° and sutured into
the labial defect, as shown in Fig. 244.

The large wound of the neck was readily drawn together by suture, leaving
only a small triangular space to heal by granulation.

As has been mentioned, the skin of the neck is not adaptable for this
purpose, not only because of its poor nourishment and extreme thinness,
but because a flap made therefrom is devoid of muscular structure,
contracts easily, and is devoid of a mucous-membrane prolabium, the
greatest objection being in the resultant contraction of the lip so
formed, which usually constitutes so high a degree of ectropion of the
lip as to allow the saliva to escape from the mouth.

Apart from the ingenuity of the method it has no practical value, for the
reasons given.

[Illustration: FIG. 243. FIG. 244.

DELPECH METHOD.]

=Larger Method.=—Larger restores two thirds of the lower lip after the
ablation of an epithelioma, as follows:

1. An incision is made from the union of the left third with the right
two thirds of the upper lip, directed toward the alæ of the nose and
including the entire thickness of the lip, the _cul-de-sac_, and the
buccal mucous membrane.

2. A second incision is made from the upper extremity of the first
incision downward from the nasolabial fold to a point on the cheek
a little below and to the left of the left labial commissure. The
flap being turned down, is sutured by its three edges to the lip of
the quadrangular breach, after the lower edges of the flap has been
freshened; this border being formed by the mucous membrane of the upper
lip, the membrane is destroyed in order to permit of the edge being
sutured to the horizontal branch of the loss of substance. The upper lip
is then sutured vertically to the cheek.

=Guinard Method.=—Guinard modifies the above method by making the
operation bilateral and symmetrical instead of unilateral, thus giving
marked facial symmetry; the mucous membrane forming the free edge of
the upper lip, instead of being destroyed, is dissected, turned over,
and is sutured in a groove in front of the maxillary in such a way as
to reconstitute the buccal vestibule; the mucous membrane of the deep
surface of the lip is sutured to the skin by eversion in order to form a
new mucous border.

With the above modification of the Larger method a considerable loss of
substance can be restored, the new lip being constructed of normal tissue
of the lip lined with mucous membrane retaining the saliva. Naturally
the secondary deformity, while great, is one that only changes the
physiognomy, leaving the face symmetrical with slight cicatrices.

=Berger Method.=—Berger advocates replacing a large loss of skin from
the lower lip, the result of burns, lupus, or syphilitic ulceration, by
employing a pedunculated flap made from the arm.

The free borders of the flap are sutured into the defect and the arm is
bandaged to the head in the proper position. The pedicle on the arm is
not divided until the flap has become thoroughly reunited, which is at
the end of eight to twelve days.

He dissects up and divides the free border of the mucosa until it is
free from its attachments to fibers of the orbicularis muscle. This he
utilizes in lining the flap.

The flap taken from the arm may be made large enough to cover the entire
anterior aspect of the chin.

When the mucosa has been destroyed partially he advises releasing
whatever remains of the mucous membrane, either as it may be, and
loosening it so as to inclose the buccal orifice. He slides a flap taken
from the subhyoid region to reconstruct the lip over this, or resorts to
the Italian method just described.


LABIAL DEFICIENCY

Where the lip structure has become flattened and thinned as a result of
tension following the exsection of a part of the lip, as in harelip, or
the ablation of malignant growths, operations may be undertaken to give
the tissue a better cosmetic appearance.

Estlander’s operation, described on page 171, gives, perhaps, the
best results in these cases, but the objection to this procedure to
make up the deficiency in the other, and often necessitating a later
stomatoplasty to overcome the oval shortening occasioned by the
rearrangement of the prolabium. This, of course, is a matter of little
consequence where the primary fault is due to the ulcerative inroads of
syphilis or the cicatricial contraction following burns. At any rate,
the triangular flap implantation method is to be preferred to any other
cutting procedure.

In simple cases where a triangular ablation has caused the flattening the
defect can be overcome to a great extent by employing the subcutaneous
method of Gersuny.

=Author’s Method.=—The author recommends a subcutaneous division of the
scar line in cases permitting such procedure prior to the injection of
the tissues. This is accomplished with a fine tenotome, which requires
only the making of a small opening in the skin through which the filling
can be introduced. A single suture may be made through the lips of the
wound, which is tied immediately after the filling has been introduced
to avoid the displacement or pressing out of the injected mass at this
point, which is sure to result if the suture be introduced after the
injection.

A secondary filling may be found to be necessary subsequently to obtain
the desired cosmetic result. The process of subcutaneous filling is fully
considered in Chapter XIV.

When the lower lip is extremely flattened by the tension of cicatricial
contraction of burn wounds of the mental region with more or less
ectropion of the lip.

=Teale Method.=—Teale advocates the following method:

Two cheek flaps are formed by making a curved outward and upward incision
upon either cheek, terminating at the second molar tooth of the upper jaw
and corresponding to the lines _A_, _A_, in Fig. 245. These terminate
anteriorly in two vertical incisions about three quarters of an inch
long, made through the entire lip structure down to the bone on a line
with the canine teeth.

The upper extremity of the two vertical incisions are united with a
horizontal incision through the thinned-out or everted prolabium.

The two cheek flaps are dissected off from the bone, the mucous membrane
uniting them to the alocoli being freely divided.

A base surface is made along the alocolar border of the median portion of
the lip between the upper extremities of the two vertical incisions first
made.

The flaps _A_, _A_ are then brought together so that their vertical
margins meet at the median line, where they are sutured. A few fine
sutures are taken through the vermilion border.

A secondary wound, _C_, _C_, at either side is thus occasioned (Fig.
246), which can at once be covered with Thiersch grafts or is allowed to
heal by granulation.

[Illustration: FIG. 245. FIG. 246.

TEALE METHOD.]

Where the deficiency is due to cicatricial contractions of the submental
tissue the latter must be divided horizontally from one healthy border to
the other, the parts freed well from all subcutaneous adhesions in the
cellular structure. The head should be forcibly raised and a flap of skin
be placed into the elliptical wound thus formed either by the rotation of
a pedunculated neck or thorax skin flap or the implantation of Wölfler or
Thiersch grafts.

Carefully keeping the head in an extended position during the healing in
of these grafts will overcome the primary defect, unless the lip itself,
too, has become tied down, when the bridge flap method of Morgan or Zeis
can be undertaken in conjunction with the skin-grafting method to correct
the fault.


LABIAL ECTROPION

Eversion of the lip may be due to cicatricial contraction of ulcerative
wounds, burns, and traumatisms of the skin, or it may be hereditary. In
the latter case the entire lip structure is more or less overdeveloped,
as in the negro, especially in the lower lip, so that the thickened lip
droops forward and downward. This condition is termed macrocheila.

Ectropion of the lower lip is more common than in the upper lip. The
defect may be slight and only of cosmetic importance or it may be so
extensive as to permit an overflow of the saliva from the mouth.

When the cause of deformity is due to a cicatrix of the skin, as often
met with in the lower lip, a flap should be neatly raised by a V
incision, as with ectropium of the lower lid on page 104, and the wound
sewed in the Y form (Dieffenbach).

In cases of severer form the cicatrix is removed by an elliptical
incision, the lip returned to its natural position, and a pedunculated
flap of skin is taken up from the chin or the cheek which is rotated into
the wound, or a skin graft is implanted into the area by the Wölfler
method and sutured to the free margins of the skin, or the Thiersch
method may be employed.

In hereditary cases of mild form or partial ectropion the author
advocates making two vertical incisions in the mucous membrane, half an
inch long, one half inch distant from the median line of the lip, and
suturing them horizontally, as shown in Figs. 247 and 248.

[Illustration: FIG. 247. FIG. 248.

AUTHOR’S METHOD.]

In some cases the ectropion, whether partial or more or less general, is
caused by protrusion of the teeth either of the upper or lower jaw; more
commonly of the alveolar structure of the superior maxillary bone. In
such cases a cosmetic operation on the mucosa will do little to restore
the deformity. Such cases should be corrected primarily by a surgeon
dentist, the teeth being forced back into place by proper metal springs
or splints—a tedious process requiring from six months to two years’ time.

If, after the teeth have been brought back to the normal bite, the
lip still shows an abnormal contour, the surgeon may restore this by
several small incisions in the mucosa, as above advised, at the various
protruding points of the lip.

When the simple vertical-line incisions sutured horizontally will not
accomplish the result, the excision of small triangles or elliptical
pieces of the mucosa may be made, bringing the distal edges of the
wounds together horizontally with silk sutures, which are found best for
suturing wounds about the buccal cavity.

The same methods as above given apply to the correction of upper-lip
deformities.

Where the fault is too great to be overcome by this method, the author
advocates removing an elliptical or diamond-shaped piece of the lip
from the inner surface or mucosa, the whole length of the lip and wide
enough to correct the fault, as shown in Fig. 249, and bringing together
the margins by an interrupted suture, as in Fig. 250. This is the most
satisfactory method to restore either the upper or lower lip to normal
position. The resulting cicatrix of the mucous membrane offers no
objection whatever, and soon becomes obliterated.

[Illustration: FIG. 249. FIG. 250.

AUTHOR’S METHOD.]

If the operator feels justified to remove a triangular piece, with its
base upward, in case of the lower lip, and _vice versa_, from the whole
thickness of the lip he can do so, but the operation has the objection
of leaving a noticeable vertical scar in the skin and a notch in the
vermilion border.

The former can of course be materially hidden by the mustache or beard in
man.


LABIAL ENTROPION

While labial inversion is in most cases caused by the removal of tissue
from the inner or whole lip structure due to disease or other causes, it
may nevertheless be met with in hereditary instances. The condition is
termed microcheila.

It is more common in the upper lip, perhaps because of the frequency of
harelip corrections undertaken with that part of the mouth, but it may
involve both lips or be partial in one or both lips; in the latter case
often the result of the habit of talking, chewing, or laughing with one
side of the mouth, in which the active side is the normal and the passive
side the one showing a lack of development.

In the latter case daily facial gymnastics should be advised, and such
teeth as need attention to permit of the use of the side favored should
be restored to usefulness—the loss or uselessness of teeth in the earlier
days of puberty often causing the deformity. The correction of such
defect has in view to widen the lip structure, and the best method to
follow is the suturing of one or more horizontal incisions in a vertical
direction, these incisions depending in number upon the extent of the
lack of tissue, whether total or partial. This, of course, overcomes
only the rolling in of the vermilion border, and does not in cases of
the extensive variety overcome the deformity. In such cases an incision
is made through and along the entire mucosa half an inch below the
vermilion border. The incision should be made deep enough to permit of
free movement of the upper section of the lip, which is drawn up by an
assistant, while a flap of mucosa, either pedunculated or free and taken
from the inner side of the cheek in the near vicinity to the lip, is
sutured into the opening thus made by traction.

If a pedunculated flap is employed, it should be cut in such a way that
the twisting or rotation of its pedicle will not be too abrupt, and thus
cause gangrene.

The secondary wound is sutured with silk and heals quite readily under
proper hygienic care (see matter on mucous-membrane grafting, page 101).

If, for traumatic reasons, a more extensive operation involving the whole
lip structure is indicated, one of the harelip operations heretofore
given will answer the best purpose.


VERMILION DEFICIENCY

The cosmetic surgeon is often called upon to correct the vermilion
borders of the lips, the usual fault being a lack of sufficient of the
delicate membrane to give an artistic appearance or form to the mouth,
and in some rare cases the absence of the so-called “Cupid’s Bow” of the
upper lip.

Surgical means are of little avail to correct or beautify such fault, and
the cosmetic operator must resort to other means. The only practicable
method at hand is the careful tattooing of the skin with rose pigment
introduced into the skin, preferably with an electric instrument made for
that purpose. The hand-tattooing method is slow, irregular at best, and
much more painful because of this.

The part to be tattooed is first outlined and then tattooed in linear
fashion parallel to the vermilion border presenting, working upward to
the peripheral line. The color applied should be pale rose at the first
sitting, to be gone over after healing has taken place, and repeated even
thereafter until the desired shade has been attained.

The method and instruments involved in the above and the tattooing of
scar tissue is fully described in a later chapter.




CHAPTER XII

STOMATOPLASTY

(_Surgery of the Mouth_)


This branch of surgery has to do with the plastic restoration of the oral
orifice. Operations of this kind are required to enlarge a contracted
mouth, termed microstoma, whether the same be due to congenital origin or
to cicatricial contraction after operative interference about this origin.

Stomatoplasty may also be needed to rebuild an abnormally enlarged mouth,
termed macrostoma, which has already been described on page 149.


THE CORRECTION OF MACROSTOMA

The operative methods to correct the latter need little mention, since
there is usually sufficient tissue present from which the orifice can be
properly formed.

The simplest method is to excise the borders of the enlarged mouth or
buccal clefts, whether unilateral or bilateral, and to bring the raw
edges together by suture. These sutures should be made nearly through the
muscular walls of the cheek and at sufficient distance from the edges of
the wounds to avoid tearing through.

When the cleft is of sufficient length to warrant tension sutures, they
may be employed, alternating with superficial sutures to neatly coapt the
skin surfaces.

The mucous membrane should also be sutured with fine silk to insure
a perfect closure of the parts, and to avoid, as far as possible,
intra-oral infection.

When possible the vermilion borders of the lips should be neatly brought
out to the angles of the mouth, where they should be sutured one to the
other somewhat diagonally. This will tend to give the angles a normal
appearance and shape.

=Dieffenbach-Von Langenbeck Method.=—It is not unusual after the
extirpation of a malignant growth that a greater part of the prolabium
has been sacrificed in either of the lips. In this event the vermilion
border must be carefully and neatly trimmed away from the healthy lip,
leaving a median attachment (see Fig. 251).

The two strips of prolabium will be found to stretch easily. They are
utilized to line the entire denuded raw surface and are held in position
by a number of fine silk sutures, as shown in Fig. 252.

[Illustration: FIG. 251. FIG. 252.

DIEFFENBACH-VON LANGENBECK METHOD.]

Accessory mobilizing incisions, as shown in the above figures, may be
necessary to contract the oral orifice sufficiently to permit of such
a prolabial grafting, especially where a greater part of the vermilion
border has been destroyed. These extra incisions are not necessary when
only a small part of the latter is lost; a partial unilateral dissection
in that case would suffice to restore the part.

This prolabial lining of the mouth gives it a puckered and contracted
appearance for a time only, because the parts soon stretch, while oral
gymnastics will help much in restoring its size and usefulness.

The objection to the above method is the danger of partial or total
gangrene of that part of the prolabium which has been dissected up and
stitched to line the mouth as a result of lack of nutrition or to the
bruising or rough handling of the delicate strips during the operation.

=Tripier Method.=—Tripier refashions the prolabium of the mouth by means
of a mucous strip taken from the inner surface of the lip. This strip is
left attached at both ends, forming a bridge flap of mucous membrane, the
pedicles of the ends giving nourishment to the whole. The bridging strip
is slipped into place and is sutured to the outer skin by its superior
border, so as to restore the normal appearance and thickness of the lip.

Antisepsis must be carried out scrupulously and a strip of iodoform gauze
be placed between the lips operated upon and the gum. In forty-six cases
operated upon by this method forty-two were successful, while in two of
the unsuccessful cases there was partial gangrene of the flap.

=Macrostoma and Overdevelopment of the Lips.=—In the cosmetic correction
of macrostoma there may be an overdevelopment of one or both lips as
well as the wide oral fissure. In such cases the lip structures is to be
reduced by the methods heretofore given, before shortening of the mouth
line is undertaken, because of the greater freedom allowed the surgeon to
correct the deformity.

If possible the operation at the oral angles above referred to should be
avoided because of a certain amount of scarring of the skin at either
side of the mouth and the resultant stiffness of the parts due to the
surgical interference; therefore, when practicable, or when the deformity
is of moderate extent, the angles of the mouth should be advanced toward
the median vertical of the lips. In such case it is best to do such
operations before any labial corrections are undertaken.

=Author’s Method.=—The method advised by the author is the employment of
the Dieffenbach procedure as follows:

A V-shaped incision, its apex pointing inward and its distal ends a half
inch from the prolabial line, is made quite deep through the mucosa and
muscular tissue, as shown in Fig. 253. The part included in the V is now
drawn toward the median line of the lip, causing the wound to gape. The
latter is then sutured with deep and superficial silk sutures in the form
of a Y, as shown in Fig. 254. The same operation is repeated at the other
angle of the mouth.

[Illustration: FIG. 253. FIG. 254.

AUTHOR’S METHOD.]


THE CORRECTION OF MICROSTOMA

When the oral orifice has become lessened, as is frequently the result of
cicatricial contraction following ulcerations or operative interference,
but which may, too, occur congenitally, the condition is termed
microstoma.

=Dieffenbach Method.=—Dieffenbach advocates the following operation for
the correction of this abnormality:

Two lateral incisions are made outward from the mouth across the cheeks
and through their entire thickness, extending in length a little beyond
the intended angle of the mouth (see Fig. 255). The mucous membrane from
within is brought forward and is sutured superiorly and inferiorly to the
skin with fine silk sutures.

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.

In cases where the whole thickness of the cheek is involved the cheek
can be incised from the angle of the mouth as far as the border of the
masseter muscle down to the adipose layer. A part of the fatty tissue
is exsected and pushed aside, the thumb of the operator being introduced
into the buccal cavity and pressed outward against the cheek to determine
the position and extent of the pathological involvement. The diseased
area is cut out with curved scissors, going well into the healthy tissues.

The wound is then brought together by suture while the defect of the
mucous membrane is tamponed for four or five days, when it can be covered
with Thiersch grafts. The latter in a short time takes on the appearance
of mucous membrane and overcomes the contraction of the ordinary sutured
wound (Edward-Albert).

=Serre Method.=—For still larger defects Serre makes the ablation in
rectangular form, as shown at _A_, Fig. 258, and forms a longer flap of
rectangular form from the tissue of the cheek and neck. This flap he
dissects off from the margin of the maxillary bone to give it the proper
mobility. The flap is drawn upward and sutured, as in Fig. 259.

There is little retraction experienced in this method, and answers well
for defects of medium extent.

[Illustration: FIG. 258. FIG. 259.

SERRE METHOD.]


LARGE DEFECTS

In larger defects the flaps to be utilized in overcoming the deformity
must be taken from the cheek above as well as the anterior chin, as shown
in Figs. 260 and 261.

[Illustration: FIG. 260. FIG. 261.

CORRECTION OF ANGLE OF MOUTH.]

Another method is to cut the two flaps as in Fig. 262.

These flaps are made of the entire thickness of the cheek tissue, and are
slid down into position and sutured or approximated, as in Fig. 263.

[Illustration: FIG. 262. FIG. 263.

CORRECTION OF EXTENSIVE DEFECT AT ANGLE OF MOUTH.]

As a rule the excised mucous membrane subsequently prevents a free
opening of the mouth added to by the contraction of the flaps themselves.

To overcome this a flap of skin with its epidermal surface turned inward
is sutured into the defect, as will be shown presently, or a pedunculated
flap formed at the wound surface before its transplantation into the
defect may be covered with skin grafts (Thiersch).

=Bayer Method.=—Bayer has successfully utilized a large flap from the
mucous membrane of the palate and covered it externally with a flap of
skin taken from the submaxillary region.

=Kraske Method.=—Kraske forms the flap to be turned into the defect
of the tissue immediately surrounding it, as shown in Fig. 264. This
flap may heal into position, even though its pedicle is made up only of
subcutaneous tissue, according to Gersuny.

The epidermal surface of such flap is made to form the inner or mucous
surface of the repaired cheek (see Fig. 265), while its external surface
and the secondary wound are covered with Thiersch grafts, at one and the
same sitting.

The only difficulty experienced in the case with men is that the bearded
surface of this inturned flap offers considerable discomfort to the
patient, although in the majority of cases the skin thus inverted soon
takes on the appearance of the mucosa, the objectionable hairs falling
out and the hair follicles becoming obliterated.

[Illustration: FIG. 264. FIG. 265.

KRASKE METHOD.]

=Israel Method.=—To overcome the above objection Israel makes his flaps
from the skin of the side of the neck, the flap being elongated and
attached at its upper end, as in Fig. 266.

This flap he turns upward into the defects with its epidermal surface
facing inward and sutures it into place, as shown in Fig. 267, leaving
the outer surface to granulate over and thicken on the sutured margins
to heal into place. This requires from fourteen to seventeen days, when
the pedicle is severed and the lower or freed portion of the flap is
brought forward. The granulation of the entire surface is scraped off and
the free end of the flap is turned over upon itself, as it were, and its
margins sutured to the descended skin margin, as in Fig. 268.

[Illustration: FIG. 266. FIG. 267. FIG. 268.

ISRAEL METHOD.]

=Bardenheuer Method.=—Bardenheuer has given this subject a great deal of
attention, and advocates the use of the skin of the forehead for closing
these buccal or oral defects. The skin of the forehead is without hair,
is well nourished, and has little adipose tissue underlying it, facts
that make it especially useful for these operations. The skin surface he
turns into the mouth cavity, while the outer or raw surface is covered
with a pedunculated skin flap taken from the region of the intramaxillary
region.

The secondary wounds of the forehead and below the jaw should be covered
with Thiersch grafts at the same sitting.

The best cosmetic results are obtained by correcting the entire defect at
one sitting, as the subsequent contraction of the flaps do not allow of
it in successive operations.

The apposition of the raw surfaces of the flap from the forehead and
that of the cheek or chin greatly increases their vitality and overcomes
markedly the cicatricial contraction.

The pedicle of the forehead flap is cut apart about the fourteenth day
and replaced.

In the case depicted in Fig. 269 a large portion of the cheek and the
whole upper and a part of the lower lip had to be removed. A large flap
taken from the forehead that turned into the defect (see Fig. 270), and
a flap taken from the intramaxillary region, were brought over the major
and lower portion of its raw and outer surface.

[Illustration: FIG. 269. FIG. 270.

BARDENHEUER METHOD.]

In Figs. 271, 272, and 273 the various steps of the same operation are
more fully shown, including the placing of the Thiersch grafts and the
replacing of the pedicle in Fig. 274.

[Illustration: FIG. 271. FIG. 272. FIG. 273. FIG. 274.

BARDENHEUER METHOD.]

A still more extensive restoration of the cheek is shown in Figs. 275,
276, and 277, and the position of the skin grafts and replaced flap
pedicles in Fig. 278.

[Illustration: FIG. 275. FIG. 276. FIG. 277. FIG. 278.

BARDENHEUER METHOD.]

=Staffel Method.=—Staffel has also utilized pedunculated flaps taken from
the forehead to correct defects of the cheeks and mouth.

His method of procedure in an aggravated case resulting from mercurial
stomatitis with resultant cicatricial trismus is shown in Figs. 279 and
280.

Two pedunculated forehead flaps were employed in the above case as well
as two flaps each attached by a broad pedicle from the skin under the
chin Tripier fashion, and although the patient thus operated upon was
only five years of age, an excellent result was obtained.

[Illustration: FIG. 279. FIG. 280.

STAFFEL METHOD.]


EMPLOYMENT OF PROTHESES

When the defect of the cheek due to the removal of a greater part of its
structure is so large as to frustrate all attempts at its correction we
may resort to the employment of protheses made for the purpose.

In Fig. 281 a case of Morris is shown following the removal of a myeloid
sarcoma involving a greater part of the upper cheek, the eye, and the
palate. The operator had a prothesis constructed by Hayman, which
provided not only an artificial cheek, but also an eye and the palate.

[Illustration: FIG. 281.—CHEEK PROTHESIS, AFTER REMOVAL OF SARCOMA.
(_British Medical Journal._)]

How excellently this has been accomplished is depicted in Fig. 282. This
prothetic contrivance not only improved the patient’s appearance, but
also enabled him to speak intelligibly, which had been impossible, owing
to the absence of a greater part of the soft palate.

[Illustration: FIG. 282.—PROTHESIS APPLIED TO FACE. (_British Medical
Journal._)]

Hayman describes what he did as follows:

“I obtained a model of the mouth, after which an ordinary plate was
made, then a special obturator to correct the palatine defect. With the
obturator in position a model of the remaining hollow was taken, and
from this a silver plate was struck, which filled accurately into the
hollow and under the right ala of the nose; a small tongue of silver was
adjusted over the bridge of the nose, and on to this the spectacles were
subsequently soldered. An artificial cheek and eye were then modeled in
wax to match the other side of the face. A second silver plate was struck
upon a metal cast taken from the model, soldered to the inner plate as a
cover is fixed to a box. An artificial eye was then fixed to the plate
in the proper situation, and the face portion painted flesh-color and
japanned. In order to keep the mask in position, a strong wire, fixed to
the posterior edge of the artificial cheek, passes around the right ear,
and the ear pieces of the spectacles are joined behind the head by an
elastic band.”

[Illustration: FIG. 283.—CIRCULATION OF THE HEAD.

    A, Supra-Orbital Vein.
    B, Supra Palpebral Vein.
    C, Angular Vein.
    D, Nasal Vein.
    E, Facial Vein.
    F, Temporal Vein.
    G, Ext.-Jugular Vein.
    H, Post-Auricular Vein.
    I, Occipital Vein.
    J, Post-Ext.-Jugular Vein.
    K, Sup. Labial Vein.
    L, Inf. Labial Vein.
    M, Transverse Facial Vein.
    N, Communicating Br. Ophtal Vein.
    O, Angular Artery.
    P, Ant. Temporal Artery.
    Q, Post Temporal Artery.
    R, Sup. Coronary Artery.]




CHAPTER XIV

SUBCUTANEOUS HYDROCARBON PROTHESES


Although the subcutaneous employment of oil and liquefied paraffin has
been known for some years, particularly by Corning, who refers to his
use of solidifying oils in surgery in an article published in 1891, no
actual application for prothetic purposes was made until 1900, when
Gersuny first advocated the method. In his published report he says that,
“if vaselin, which at the temperature of the body has the consistency
of ointment, be liquefied by heat and by the means of a Pravaz syringe
is injected into dilatable tissue of the human body, there is produced,
at the site where the injection is made, a tumefaction whose volume
corresponds to the quantity of vaselin injected. The reaction which
results from the procedure is insignificant and the mass appears to rest
without change where injected.”

This subcutaneous method of vaselin injection he employed in the case of
a young girl to correct a saddle or depressed nose. The operation was
purely a cosmetic one, and was performed on May 8, 1900, with a very
satisfactory result.

From the time of the appearance of Gersuny’s paper, “Ueber eine Subcutane
Prothese,” a number of operators, such as Halban, von Frisch, Kapsammer,
Delangre, Rohmer, Stein, and others, began to follow the method with
gratifying results.

Pfannenstiel, shortly after, claimed that the injection of vaselin was
not wholly without danger, and that pulmonary embolism had been observed
by him subsequent to its use. Moszkowicz denied the possibilities of
such danger, although at this date it is quite evident that there are
many objections to the sole use of sterile vaselin for all subcutaneous
cosmetic purposes where such protheses might be indicated.

Eckstein, on July 24, 1901, rehearses these objections and advocates the
use of “Hart paraffin,” or paraffin with a melting point of 57-60° C.
(140° F.). His method was taken up by Brœckært, Baratoux, Brindel, Watson
Cheyne, Walker Downie, Leonard Hill, Lake, Scanes Spicer, Karewski, and
other prominent surgeons abroad, and by Parker, Harmon Smith, Hamilton,
Quinlan, Connell, and others in the United States.

Drs. Lynch and Heath were the first American physicians to place
themselves on record in the employment of the method of Gersuny for the
correction of nasal deformities.

Each of the operators employing the now so-called Gersuny method
advanced their individual ideas and improvements in the art, and those
of distinctive merit will be considered later by the author, who has
employed both methods from the time of their incipiency.

The method of procedure in the injection of vaselin or paraffin is
practically similar, except for the various ways in which the paraffin of
different melting points is rendered liquid.


INDICATIONS

The indications for the protheses of either method are the same,
except where the author advocates the use of either one or the other
or a combination of the two from an experience with over five hundred
personally conducted cases.

The advantages of the Gersuny method is that the operation is practically
painless, causes no scar if properly performed, and corrects a deformity
that could not be overcome otherwise in some cases, while in others it
would entail not only difficult surgical interferences, but subsequently
unsightly cicatrices that would render them more objectional than the
very defects which were intended to be corrected.

This is particularly true in the cosmetic correction of depressions about
the forehead resulting from direct violence or frontal sinus operations,
for obliterating habit furrows, or frowns, between the eyebrows;
also to restore the symmetry of the face in hollows of the cheek due
to the removal of malignant growths, the maxillæ, or when caused by
facial hemiatrophy or a congenital or long-acquired sinking in of the
cheeks; while it may also be employed with excellent result to prevent
post-operative adhesions about the face after mastoid operations and even
to restore the form of the breast after operation for malignant disease
and the raising of smallpox pits.

Numerous other uses may be mentioned, such as elevating an undue
depression at the root of the nose, raising sunken furrows below the
eyes, obliterating nasolabial folds, angular droops about the chin,
rebuilding weak or pronounced oval or peaked chins, filling hollows about
the neck and shoulders, and in fact anywhere about the body to restore
the contour.

In correcting the deformities of the nose, whether congenital or
acquired, this method has met an urgent and most useful demand, so much
so that many rhinoplastic operations of extensive delicacy have been
thrown aside for this simpler, rapid, and gratifying means of surgery.

Not only has it been employed to restore the nasal line in saddle noses,
but also in many other deformities of that organ which do not require the
removal of superabundant tissue.

According to the appended classification of nasal deformities, given by
Roe, it will be seen that many faults of that organ may be overcome by
the method.

                                           { Concave.
                {               { Vertical { Convex.
                { Bony Portion  {
                {               { Lateral  { Spatulated.
                {                          { Defected.
    Deformities {
    of the nose {                          { Excessive or Deficient Tissue.
                {               { Tip      { Deviation from Median Line.
                { Cartilaginous {
                { Portion       { Wings    { Collapsed.
                {                          { Expanded.

From the above arrangement, and taking each division separately, the
author enumerates the applicability of the subcutaneous prothesis, adding
such as are not included in the above.

    1. Vertical concavity. An overmarked depression at the site of
    the bony structure and about the root of the nose.

    2. Lateral deficiency of form about the root of the nose
    extending downward as far as the inferior borders of the nasal
    bones.

    3. Median anterior vertical concavity or saddle nose involving
    the middle third, otherwise the inferior and superior sections.

    4. Deviations of the cartilaginous structure about the middle
    third of the nose, either unilateral or bilateral.

    5. Deviation of the lobule.

    6. Deficiency of the lobule.

    7. Lobular cleft.

    8. Subseptal cleft.

    9. Collapsed alæ, unilateral or bilateral.

    10. Retraction of subseptum.

In these ten subdivisions much can be done to bring about a normal
appearance of the nose.


PRECAUTIONS

In selecting a case for subcutaneous injection the operator must well
consider the methods to be employed, his successes with such methods,
the importance and gravity of the operation, the condition of the
patient, the extent of the deformity, the peculiarity of the patient and,
particularly, the state of mind of the patient.

While at this date of the use of this method of beautifying parts of
the human face we may feel certain of the happy outcome of an operation
undertaken by the operator, he must not lose sight of the hypercritical
person upon whom the work is to be done; even with an outcome gratifying
in the extreme from a surgical standpoint, the patient will insist, and
that in eighty per cent of all cases, to still further improve them in
spite of the fact that a normal appearance has been attained, often
leading the operator into doing what he should not do, and eventually
undoing his own excellent efforts.

The author does not mean to imply this as a weakness on the part of the
surgeon, but cannot impress too deeply upon him the unreasonable demands
of a person insanely bent upon having the alabaster cheek ideal of the
poets, the nose of a Venus, the chin of an Apollo, the neck of swanlike
form, etc.

The patient believes it lies in the power of the cosmetic surgeon to
do with their malformations as a sculptor would model in clay and will
insist upon gaining their ideal beyond all reason.

Let the author warn the operator against the “beauty cranks,” especially
of those who are just about to engage in great theatrical ventures,
circus performances, or “acts,” and very desirable marriages. These are
patients who are not only difficult to deal with, but the first to harm
the hard-earned, well-deserved reputation of the surgeon and to drag
him into courts for reimbursement for all kinds of damages, especially
backed up by events, losses, and sufferings largely imaginable and
untrue, and ofttimes entirely impossible.

In all cosmetic surgery this branch is the most dangerous from that
point of view; therefore the operator should take his case well in
hand, proceed with an unshakable determination and give the patient to
understand his position, even to explaining what disappointments there
might be and what dangers, if any, he might look forward to. The author
believes it no unjust demand to have an agreement made with the one to be
treated in which these matters are fully considered. Such an arrangement
will save him much worry and will tend in the majority of cases to keep
his patient satisfied.

On the other hand, the operator should not undertake to do an operation
of a cosmetic nature unless he has a fundamental and practical experience
of long standing in this branch of surgery, and is ready at all times to
cope with such post-operative conditions as are likely to arise, which
will be described later.

The author has on various occasions been asked to correct the most
hideous malformations of parts of the face, particularly the nose, in
which surgeons of high standing, both here and abroad, had injected
paraffin in liquid form, usually under a general anesthetic, the most
remarkable being that of a hospital orderly in the United States service,
who had been subjected to not only one of such injections to correct
a saddle nose under chloroform anesthesia, but to three distinctive
operations, with the result of a permanent disfigurement, bettered only
by a succession of excisions at different parts of the nose.

Apropos of such cases it may be timely to state that a general
anesthetic for the performance of a prothetic injection operation is
never justifiable and should be considered a lack of knowledge on the
part of the operator, unless its use be advised by another surgeon in
consultation.

The greatest mistake made with this so-called “filling method” has been a
desire on the part of the patient or the operator, or both, to complete
the work too quickly. Unscrupulous operators have restored a saddle nose
or the contour of the cheeks in a few minutes, when it is an established
fact that the work should be done slowly, giving time for the injections
to accommodate themselves and to organize before others are attempted.
This is not only true of fillings about the cheeks and shoulders, but
also of injections about the nose and forehead.

Eschweiler particularly emphasizes the advocacy of oft-repeated
injections, and the author recommends such rule without reserve or
deviation.


THE ADVANTAGE OF THE METHOD

As has been said, the advantage of the Gersuny method over other
procedures is that it can be undertaken practically without pain, that it
is quick, bloodless, leaves no scar, and is harmless except under such
conditions as will be referred to under a separate heading.

While the method entails only the pain of a pin prick a local anesthesia
may be employed to overcome this, but never a general anesthetic. The
ethyl-chloride spray, except at very small points of the skin, is not
to be recommended because it freezes and consequently hardens the
very tissue which should be flexible, the operation being undertaken
the moment the needle is inserted and lasting only a few seconds. The
hypodermic use of a two-per-cent solution of cocain, or better Eucain β,
can be employed, but the author sees no advantage in it, as the hyperemic
engorgement following its use obliterates, to a certain degree, the
actual extent of the deformity.

It is desirable to obtain the best result to have the skin above the
part as free as possible. When closely adherent it should be freed by
the careful use of a delicate tenotome, inserted at the point where the
injection is to be made, the same opening being used for the introduction
of the needle of the syringe. If this opening has been made too large
a fine suture of silk should be employed to bring the lips of the
wound together before the injection is made; the needle point, being
knife-edged, will not disturb the apposition and will tend to retain the
filling if no undue pressure is used, as in the case of hyperinjection.


UNTOWARD RESULTS

Connell has tabulated the difficulties and dangers met with in this work
as follows:

    1. Toxic absorption.

    2. Marked inflammatory reaction.

    3. Loss of tissue, due to infection and abscess formation.

    4. Pressure necrosis, caused by hyperinjection.

    5. Sloughing of tissue as a result of the heat of paraffin.

    6. Injection into very dense or inelastic structures, or where
    scar tissue is firmly attached to the underlying and adjacent
    parts.

    7. Subinjection of too small an amount of paraffin with an
    insufficient correction of the deformity.

    8. Hyperinjection with overcorrection of deformity.

    9. Air embolism.

    10. Paraffin embolism.

    11. Primary diffusion or extension of paraffin (when first
    introduced) into adjacent normal structures.

    12. Interference with muscular action of the nose.

    13. Escape of paraffin after the withdrawal of the needle or
    primary elimination.

    14. Solidification of the paraffin in the needle, which renders
    the injection difficult and causes injudicious expedition on
    the part of the operator.

    15. Absorption or disintegration of the paraffin.

    16. The difficulty of procuring paraffin at the proper melting
    point.

    17. Hypersensitiveness of the skin over the injected area.

    18. Redness of the skin over the injected area.

    To those the author would add:

    19. Secondary diffusion of the injected mass.

    20. Hyperplasia of the connective tissue following the
    organization of the injected matter.

    21. A yellow appearance and thickening of the skin after
    organization of the injected mass.

    22. The breaking down of tissue and the resulting abscess due
    to the pressure of the injected mass upon the adjacent tissue
    after the injection has become organized.

Each of the above subdivisions may be advantageously considered
individually, to wit:

=1. Intoxication.=—The danger of intoxication may truly be said to be
more so due to the unclean or unsterilized matter injected than to
the absorption following its employment, although Meyer has claimed
untoward symptoms found in his experiments from absorption of injections
of vaselin in the animal. Taddie and Delain, Stubenrath, Straume,
Sobieranski, and Dunbar have corroborated this claim. They injected
paraffin of various melting points in the lower animals and observed
results therefrom, among which were loss of hair, a reduction of eighteen
per cent in the body weight in two months and death.

Stein and Harmon Smith refute these conditions and remarked neither
systemic nor local untoward results from such injections when paraffin of
higher melting points were used.

Jukuff claims that no toxic symptoms resulting from the absorption of
paraffin injected into tissues are shown, unless the amount be equal to
ten per cent of the weight of the animal. To have this apply to the human
as much as ten to fifteen pounds would have to be injected—an amount
never required in operations of this nature.

While it cannot be denied that the injected mass becomes more or less
absorbed in from two to three months and is replaced by connective
tissue, it may be definitely stated that no toxic symptoms are caused
directly thereby, except by the employment of an impure product.

=2. Reaction.=—The reaction following a properly made injection is of a
mild inflammatory character. Considerable inflammation points to some
fault in the technique or impurity of the injection. More or less edema
of the site and its adjacent area may be noted, associated with slight
or marked discoloration and pain of variable degree. The normal reaction
following the injection is temporary and does not necessitate treatment
or confinement of the patient, who can resume the duties of life fifteen
hours after the operation.

=3. Infection.=—The cause of infection cannot be said to be due to
anything but surgical uncleanliness, as it is with any surgical
undertaking, and can be overcome by the same means.

The material injected should be thoroughly sterilized by boiling before
using. Brœckært suggests combining an antiseptic with the paraffin and
has used guiaform, a combination of formic aldehyde and guiacol in a
proportion of five to ten per cent; yet this is of little value when we
consider how readily these hydrocarbons can be rendered sterile at high
temperatures.

=4. Necrosis.=—Death of tissue may follow an injection of paraffin when
too much pressure has been applied, or when too much has been injected
into the tissue, cutting off the blood supply, or when the injection has
been made into the skin instead of beneath it. Again, constitutional
disease, such as diabetes or Bright’s disease, may superinduce the
breaking down of the tissue.

Hyperinjection should and can be avoided by the use of the proper
instrument with which the required amount is graduated to a nicety. At no
time should an injection be crowded into a dense tissue or where the skin
is closely adherent, nor carried so far as to create a blanching of the
skin. By carefully injecting the mass this danger should be overcome.

Dense or bound-down areas of skin should be loosened and freed, as has
already been mentioned.

If care be exercised and small amounts be injected, in preference to
overcoming the defect in one sitting, pressure effects are entirely
overcome.

The circulation in the skin over the site of injection should be normal
immediately after the operation has been performed, determined by
observing the reaction in the color of the skin after delicate digital
pressure.

=5. Sloughing.=—That sloughing of the skin should be occasioned by
the high temperature of the paraffin injected is a condition entirely
inexcusable. Paraffin of high melting points 58° to 65° C., or the
so-called “Hart paraffin” employed by Wolff, liquefying at from 57°
to 60° C., are to be used with caution. The author doubts whether the
temperature of the paraffin at the time of injection, even in the latter
method, is ever beyond 54° C. even if the thermometer registers 60° C. in
the liquefying, hot-water bath.

By the time it has been drawn into the syringe, which has been heated
by dipping into hot water, and the moment it is injected it has lost
several degrees in heat.

It would not be permissible to inject a molten mass of a temperature
so high as to scar or burn the tissues, and the best results of most
operators have been obtained with such of the paraffin group that become
liquefied at a temperature of not over 45° C. (112° F.).

The claim of Eckstein, that paraffins of low melting points are more
likely to be absorbed, has not been substantiated in actual practice,
since we now know that any and all of these injections, irrespective of
their melting points, are absorbed in time, giving place to connective
tissue, and that rarely, if ever, is there a true and complete
encapsulation or encystment of the mass thus introduced. Even the hard
paraffins are split up in time into minute pearllike particles which
are displaced by the growth of tissue arising from the presence of the
foreign substance. This is true even in those cases in which the author
has introduced by surgical means solid paraffin plates in the cold state.

=6. Sloughing Due to Pressure.=—When an injection is forced into a dense
or firmly bound-down tissue, as into the body of a thickened cicatrix, or
about the point of the nose or the subseptum of the nose without first
dissecting off the skin above the subcutaneous layers, an acute anemia is
at once marked, followed by inflammation and gangrene.

By injecting sterile water into the area thus loosened with the knife a
good idea of the thoroughness of the dissection and the possibility of
building up the part to be corrected is obtained, yet in these cases the
author has always found more or less difficulty in keeping the injected
mass in place for the reason that the divided surfaces tend to unite
at their peripheral borders, crowding the mass upward or to one side
or diffusing it in such a way that the result has been anything but
satisfactory.

To overcome this it is advisable to inject a smaller quantity than
necessary to entirely correct the defect, to mold it out flat and to
allow it to organize before more is introduced.

=7. Subinjection.=—Insufficient injection leading to an undercorrection
of the defect is a far more desirable condition than hyperinjection,
and is easily corrected by a repetition of the treatment, even to a
third sitting, until the desired result is obtained. Following this rule
will give far better results, as has been said, than to be compelled to
remove a part of the filling and some of the connective tissue which has
resulted therefrom.

=8. Hyperinjection.=—The injection of too much vaselin or paraffin is one
of the most common faults found with operators. In the first instance a
tumefaction of the site results which with the production of the tissue
which takes the place of part of the filling makes the result very
unsatisfactory and requires one or more cutting operations to reduce it.
A peculiar fact with these hyperplastic growths is that even though they
may be reduced with the knife to a normal size they seem to redevelop
again and again, giving both surgeon and patient great concern.

This, in the opinion of the author, is due to the binding down of the
marginal borders, which, in the event of partial extirpation, are not
injured sufficiently to displace them and that they unite again in their
former position. To overcome this it is found best to excise the entire
filling much beyond the margins and to apply pressure over the area until
perfect union has taken place.

This is best accomplished with a disk of aluminium, bent to conform to
the shape of the part operated, lined with sterilized lint and fixed over
the site by strips of Z. O. plaster.

While the hyperinjection of vaselin is not as objectionable as that of
paraffin, because of the more ready accommodation and absorption of
the mass, it nevertheless leads to diffusion of the material, owing to
its softer consistency and consequent greater facility in seeking fine
avenues of escape, paraffin having the advantage of cooling upon itself
_en masse_, leaving little to escape into undesirable channels after it
has once been molded and set.

Vasserman cites a case in which gangrene of the bridge of the nose
resulted after an injection of 2.05 c.c. of vaselin.

However, when these faults occur they are errors of technique, and should
be avoided, as has been mentioned heretofore.

The removal of such hyperinjected masses by the aid of paraffin solvents,
such as benzine, ether, chloroform, or xycol, applied to the skin above
the filling, has proved a failure, nor will heat used externally in the
same manner remedy evil.

What is left to the operator is to open the skin and, with a small, sharp
spoon curette, remove the mass early, before it has become organized,
or to excise the new connective tissue and the broken-down filling, as
mentioned.

When, however, the tumefaction resulting from such hyperinjection is not
extensive, as is often found about the chin and at the root of the nose,
the secondary deformity can be materially, if not entirely, remedied by
electrolysis. A needle or brooch of certain hardness is to be employed,
connected with the negative pole of a continuous current apparatus. From
twelve to twenty milliampères are required. The process is similar to
that used with the destruction of hair, nævi, or moles on the face. The
needle should puncture the entire tumor or penetrate its maximum diameter
and be charged with the current for two or three minutes. Several of such
punctures should be made at each sitting, the latter being repeated as
often as is deemed necessary by the operator. The reaction which follows
this procedure is of little moment, and these sittings can be undertaken
every three or four days.

While this method is liable to leave little punctuate scars at the sites
where the needle is introduced, it is nevertheless more satisfactory than
the linear scar made with the knife, to the use of which the patient
may, on the other hand, object, not to speak of the difficulty and
unsatisfactory results usually obtained therewith.

=9. Air Embolism.=—The fault of introducing air under the skin with the
syringe at the time of injection can only be the result of flagrant
negligence. Every physician should know enough to hold the syringe in an
erect or vertical position, and to expel the air above the solution in
his syringe, as is done with any hypodermic injection.

Air embolisms are also occasioned by a careless filling of the syringe
with the hydrocarbon in a cold state, as the material is now generally
used, and while the dangers of such emboli are very much exaggerated they
should not be permitted, when by the pouring in of the liquefied material
the syringe can be filled evenly.

Practically there is no harm done by the injection of air under the
skin, yet it elevates the skin at the site of the defect and hinders the
surgeon in accomplishing the best results.

These emboli cause a bulging up of the skin for the time being and may
occasion more or less pain to the patient, which passes away in ten or
twelve hours, leaving the parts as injected except for such reactionary
symptoms or edema, already referred to.

=10. Paraffin Embolism.=—The creation of an embolism is invariably due to
an injection of the foreign substance directly into a blood vessel. This
condition is one of the most objectionable, if not the most dangerous,
factor associated with the subcutaneous injection of any foreign matter,
be it a liquid substance, as, for instance, an oil; many cases have been
placed on record where they have been observed after the introduction of
even paraffin of high melting points, when introduced under the skin in
hot liquid state. Consequently the use of vaselin liquefied by the aid of
heat is especially liable to give rise to such condition.

Pfannenstiel cites a case wherein he injected paraffin in which the
patient was at once attacked with violent coughing, and for three days
exhibited symptoms of grave nature, such as pain in side, intense
dyspnea, acceleration of the pulse, hyperthermia, cyanosis of the
face, hemoptysis, violent cephalalgia, and vomiting—all indications of
pulmonary and cerebral embolism. The injection in this case was one of
30 c.c. of paraffin, with a melting point of 45° C. The symptoms as
mentioned continued for about one week, gradually subsiding, and followed
by recovery.

Kapsammer has also noticed such symptoms. Leiser, after injecting vaselin
to correct a saddle nose, noted an immediate collapse of the patient,
which was obviated only by the hypodermic use of ether and the resort
to artificial respiration. When the patient returned to consciousness,
he was found to be entirely blind in the right eye, the eye before the
operation having been known to show only a pronounced astigmatism.

Kofman cites the loss of a patient from the injection of 10 c.c. of
paraffin for vaginal prolapsis. Moskowicz observed two cases of pulmonary
embolism treated in the same manner, stating that an alarming dyspnea
continued for several hours.

Especially have cases in which the injections of paraffin were made
submucously for the correction of atrophic coryza shown embolic
tendencies. This is especially true when paraffins of high melting points
have been employed, as in the case of Pfannenstiel, in which instance
the condition of the mass permitted of freer absorption or the high
temperature caused a coagulation of the blood in the veins, leading to
thrombosis and embolism, and when the amount of such an injection is so
large as to prevent cooling and hardening in the normal space of time
added to the quantity and associated at the same time with consequent
pressure, predisposing to absorption or dissemination, especially if the
injection be made into the parenchymatous instead of the subcutaneous
tissue.

Comstock, in his experience on animals, states that “in all cases in
which paraffin was used at 102° F. the animals died within two weeks’
time, hence the specimens at that temperature are limited (death being by
thrombosis). In all other cases with the higher melting point, 110° F.,
no unpleasant results were experienced.”

Hurd and Holden have observed a patient who had previously undergone two
injections of paraffin for the correction of a depression in the upper
part of the nose. A third injection was advised and made under the same
conditions as the first, except that no cocain anesthesia was employed,
the paraffin being at same temperature as before.

The moment the injection was made complete blindness in the right eye
resulted, while a small ecchymotic spot appeared at the site of the
needle insertion in the skin. Half an hour later an examination of
the eye showed the right pupil dilated and inactive light stimulus,
the patient being unable to distinguish light from darkness.
Ophthalmoscopically the lower branch of the central retinal artery and
its subdivisions were found to be empty and in a state of collapse,
evidenced by their pale appearance. The upper branch of the same vessel
was found to be poorly filled.

The authors endeavored to remove the embolism to a collateral branch of
the artery by the use of amyl nitrate, digitalis, and pressure on the
globe of the eye, with no effect. Some hours later edema of the retina
appeared, followed by permanent loss of sight. The same authors have
observed several cases of pulmonary embolism result from the injection of
paraffin.

It is also a fact that injections of the nature being considered, while
not causing immediate embolism, may do so as a result of phlebitis,
caused by a direct injection into the vein or over or upon it in such a
way as to cause irritation.

Mintz reports a third case of amaurosis following a paraffin injection.
The latter was made to correct a saddle deformity caused by syphilis.
Three minutes after the injection the patient complained of pain in the
left eye, which was followed by total blindness, vomiting, and a pulse
of 48. Several days later there appeared symptoms of venous congestion
in the orbit, paralysis of the ocular muscles, corneal cloudiness,
and exophthalmos, a small gangrenous spot appeared at the site of the
injection.

Brœckært observed a case of facial phlebitis, followed by pulmonary
infarction. Brindel cites a case in which he observed a hard line of
considerable extent and painful to the touch, extending from the inner
angle of the eye to the angle of the eye, where it deviated toward the
root of the nose and terminated at the origin of the eyebrow.

De Cazeneuve made an injection, and on the following day noted that the
right cheek had increased considerably in size with an elevation of
temperature in the part. Two days after, under the right eye and to the
right of the nose, the whole cheek was red, hot, and much distended,
giving the skin a glazed appearance. Palpation was extremely painful. A
hard line could be made out, extending from the inner angle of the eye
outward and downward under the lower eyelid and terminating in the center
of the edematous cheek. The phlebitis in this case resulted without the
development of an embolism.

After a careful study of the causes of such embolisms we come to the
conclusion:

1. That the injected mass should not be heated above a certain melting
point.

2. That hyperinjection should at all times be avoided, particularly with
paraffins of high melting points.

3. That the injection should be made subcutaneously not into
parenchymatous tissues, and

4. That a puncture of a vein or the introduction of the injected mass
into a vein should be avoided.

In the consideration of the first two causes the author advocates using
injections of low melting points only at all times; in fact, from his
experience with over two thousand subcutaneous injections, he relies
entirely upon such paraffins or hydrocarbon mixtures as are semisolid at
70° F., appearing as a white cylindrical thread from the needle of the
syringe as pressure is applied.

With such a preparation and a careful introduction of the needle, as
described later, and with the injection of an amount much less than that
needed to correct the deformity and proper digital compression on the
blood vessels and about the site of the injection embolism is practically
impossible.

The avoidance in the third instance is self-evident, and it is to the
fourth fault and cause that we must pay particular attention.

Stein says that all that is necessary to avoid puncturing a vein is to
first introduce the needle alone under the skin and to attach the syringe
only when it is found no flow of blood results from the puncture thus
made.

Freeman and the author add to this by advocating the use of a somewhat
blunt-pointed needle instead of the extremely sharply pointed knife-edged
needles usually furnished with syringes intended for this purpose.

=11. Primary Diffusion or Extension of Paraffin.=—The spreading of
paraffin into normal tissues about the site to be corrected by prothetic
injection is a fault due principally to a careless use of the syringe.
The employments of an improper syringe in which the amount to be injected
cannot be graduated or controlled will be considered later—the result
with such being hyperinjection. In this event, when the anterior line
of the nose is to be restored, the mass is liable to find its way into
the loose areolar tissue of the infra-orbital region; in correcting
a nasolabial furrow the mass is pushed upward or is forced into the
tissue of the cheek above it, aggravating the trouble; in obliterating a
frown it travels upward toward the margin of the scalp, giving a median
prominence to the forehead that is found to be very difficult to correct;
in injections about the mouth the mass moves down upon the chin or
accumulates at the angle of the jaw; in correcting the creases beneath
the chin it seeks the sides of the neck, even traveling to the superior
border of the clavicle at its sternal third. Many other forms of such
diffusions can be mentioned directly due to primary diffusion the result
of hyperinjection.

Enough has been said of the danger of hyperinjection, yet even with a
proper amount of the injected mass this distention may be observed. To
avoid this the operator, or his assistant, should compress the margins
of the site of the injection with his fingers firmly applied, as, for
instance, in the injection of the root of the nose pressure should be
made at both inner canthi and over the tissue just above the root of the
nose and beneath the finger tips.

Downie advocates the use of celloidin in the correction of a saddle nose
as follows: He paints a band of celloidin or collodion down each side of
the nose, limited by the line of junction with the cheeks, and another
band across the root of the nose. These painted on bands he allows to
dry and contract for fifteen minutes before undertaking the injection.

The contraction of these bands prevents to a certain extent the spreading
or extension of the liquid paraffin into the cellular tissue about the
eyes, yet experienced digital pressure is at all times to be preferred.

If a liquid paraffin or hydrocarbon mixture or vaselin is used, the
immediate use of ice cloths applied to the part as digital pressure is
removed, is advisable to aid in the rapid hardening or setting of the
injected mass before the tension of the tissues over and about it might
influence it. With semisolid injection this is not necessary, except
in the subsequent treatment, as will be considered later, because the
mass, unless of too soft a consistency, as, for instance, vaselin, will
practically remain as injected and molded.

Vaselin when injected into tissue where there is tension would naturally
be forced out of position and shape, and should not be used except in
combination with a paraffin of a melting power high enough to give the
proper consistency to the former.

=12. Interference with Muscular Action of the Wings of the Nose.=—That
nasal respiration may be encroached upon as a result of injecting
paraffin about the nose has been observed by Alter. He points out that
during nasal inspiration there is a tendency for the alæ to contract
upon themselves or to move inward, decreasing the lumen of the orifice,
and that in the normal state this movement is counteracted by the action
of dilator muscles of the alæ—that is, the dilator naris anterioris,
the pyramidalis nasi, and the levator labii superioris alæque nasi—and
that this muscular action is interfered with owing to the pressure of
the paraffin upon these delicate structures, and resulting in more or
less permanent collapse or indrawing of the alæ during inspiration. He
observed considerable interference with inspiration in a case cited in
which an injection of paraffin had been made.

To avoid undue pressure upon the structures referred to, it is advised to
have an assistant place a thumb into each nostril and the index fingers
without and above the alæ in such way that the tips of the fingers may
be enabled to exert the necessary pressure over the injected mass into
these structures, and to maintain this pressure until the mass has been
properly molded and set. Connell advises inserting the little fingers
into the nostril to prevent an encroachment on the lumen of the nasal
canal.

The above applies particularly to those cases where injections are made
into the anterior lower or lateral third of the nose, as, for instance,
in overcoming slight depressions in the anterior line, immediately above
the lobule or in a low unilateral deviation of the nose.

=13. Escape of Paraffin after Withdrawal of Needle.=—When the injected
mass employed is of a semisolid consistency, as heretofore advised, it is
hardly possible for the mass to be forced out through the opening of the
skin made by the introduction and withdrawal of the needle, unless there
be an unwarrantable immobility of the skin above the site to be injected.
The latter should be corrected before injection.

The mass after having been molded in the shape desired may be further
hardened and set by the application of ice cloths or spraying with
ether before the needle is withdrawn from the skin, yet this is hardly
necessary, and the author advises against the practice for the reason
that pressure of the needle prevents proper and free molding of the mass
and renders the tissue liable to further injury by scraping its point to
and fro subcutaneously, adding to the extent of the wound and the dangers
of infection and repair.

The skin immediately around the needle hole, after withdrawal of the
needle, may be gently smoothed out with the dull rounded metal handle end
of the bistoury to free the interdermal canal of any foreign matter.

The skin about the needle hole is then gently washed with a
fifty-per-cent solution of hydrogen peroxid, dried with a sterile cotton
sponge and the opening sealed with a drop of collodion. Subsequent
treatment of the parts will be considered later.

=14. Solidification of Paraffin in Needle.=—This occurs only when
paraffins of high melting points are employed in liquid form in the
syringe, and is due to the rapid cooling of the paraffin in the small
metallic cannulæ, or needle, wherein it sets more readily, since the
volume contained therein is very small, often not more than two or three
drops.

This cooling establishes a pluglike formation in the distal end of the
needle, which prevents a proper use of the syringe, often breakage, and
when suddenly liberated by an extra pressure on the piston rod causes a
rapid discharge of the contents of the syringe to an extent not desired
with the result of hyperinjection.

This fault was one of the most annoying in the early days of such
injections when syringes of ordinary pattern, such as the Pravaz, or
those built like the ordinary hypodermic, were used. It was not unusual
to have the paraffin cool in the needle so quickly between the latter
in the flame of an alcohol lamp that the syringe became unmanageable
and broke in the hands of the operator. Since that time new and more
useful syringes have been introduced by various operators which overcome
this difficulty, yet with them, too, come the employment of semisolid
paraffins or mixtures thereof. Yet, as some authors insist upon using
paraffins of high melting points, it may be well to rehearse their
methods of overcoming this annoying intraneedle solidification.

Eckstein surrounds the syringe and needle shaft, except the tip of
the needle, with a rubber tubing, as shown in Fig. 284, to act as an
insulator, and thus, for a time at least, keep the preparation liquid.
Before filling the syringe he heats it by several immersions in and
internal washings of hot sterile water. To prevent the paraffin from
setting in the exposed tip of the needle he draws into the filled syringe
a few drops of hot water, which are injected into the tissues, causing no
objection to the method.

[Illustration: FIG. 284.—ECKSTEIN METHOD OF INSULATING NEEDLE AND
SYRINGE.]

Paget and Harmon Smith warm the needle in hot sterilized or even boiling
water. Previous to this Smith cools the contents of the syringe drawn
into it at a temperature of 120° F. by immersing the latter in a bath of
sterilized water at a temperature of 80° F.

From the above it will be noted that Smith advocates using the injections
in semisolid state being ejected in a thin, cylindrical thread. A syringe
of special construction, as referred to later, is, of course, required
for such work.

Quinlan has invented a so-called paraffin heater, as shown in Fig. 285,
in which the paraffin is kept in solution by the syringe being surrounded
by a continuous flow of hot water. A plain and very objectionable syringe
is shown in the illustration, and while the preparation in the syringe
is thus kept in a liquid state the solidification in the needle is not
overcome.

[Illustration: FIG. 285.—QUINLAN PARAFFIN HEATER.]

Downie winds fine platinum wire about the needle through which he passes
the current from a storage battery to keep the needle hot, yet such an
arrangement is obviously difficult of manipulation, and when paraffins of
high melting points are employed it is quite likely that a plug is formed
in the exposed point of the needle.

Karewski has introduced a syringe having a jacket through which hot water
is allowed to circulate, while similar instruments have been originated
by Pflugh and De Cazeneuve. None of these overcome the difficulty in
question.

Viollet went even further by inventing a syringe surrounded with a coil
of resistance wire, heated by an electrical current, and Delangre, Ewald,
and Moszkowicz use special thermophorm sleeves over the syringe proper;
all, however, offering the same objection in the exposure of a part
of the needle in which temperature of the liquid must necessarily be
lowered, or be low enough to cause plugging, the very fault for which all
these modifications have incidentally been urged, as the greater amount
of paraffin in the syringe itself is as a rule large enough to retain
sufficient heat to permit of its ejection, if the injection is made as
expeditiously as possible.

The objection of the setting of the paraffin in the barrel of the syringe
has never hampered any operator, the difficulty in these instances
having been entirely due to the obstruction offered its ejection by the
threadlike plug obstructing the metal cannula before it; the barrel,
being glass, retains its temperature more readily than the thin metal
needle, hence the difficulty.

That all prothetic preparation of the nature in hand should be placed in
the barrel of the instrument in liquid form is essential, in that the
syringe is thus filled to its required height evenly, and devoid of air
spaces, yet in the light of the best and most successful results the
mass should be allowed to cool and be ejected in semisolid state from a
specially constructed instrument, to be described later.

With such method it is impossible to have an occlusion of the needle
at any time, and the objection of sudden outbursts of unknown and
undesirable quantities of the mass is entirely overcome.

=15. Absorption or Disintegration of the Paraffin.=—The question of
the ultimate disposition of paraffin, injected subcutaneously for any
purpose, has been an extensive one in which many operators have taken
part.

Gersuny at first claimed an encapsulation for the injected mass of
vaselin, which he states was not taken up by the lymphatics, but remained
_in situ_ as an inert, nonirritating body. Shortly after it was shown
that the encapsulated mass soon became ramified by newly formed, fine
bands of connective tissue, which developed more and more in the part
until the entire mass had become displaced by this tissue with an
eventual consistency of cartilage.

Eckstein claims that at first a capsule of new connective tissue incloses
the injected mass (Hart paraffin) a few days after the latter is
injected, which can be easily stripped away from the encapsulated matter
several weeks or months after, showing a smooth inner wall, the encysting
capsule showing a decided lack of blood vessels, proving histologically
its relation to the structure of cicatricial formation.

In this Eckstein is undoubtedly mistaken. He objects to the ultimate
replacement with connective tissue for the vaselin process of Gersuny,
when in reality we have begun to realize that such result will follow any
hydrocarbon subcutaneous injection unless the latter be made in small
quantity into parts of the body which are in constant motion.

The latter is shown with injections of paraffin made into or about the
nasolabial fold. The tumor is so small as to be hardly felt by the
palpating finger, but soon takes on larger proportions, evidencing an
encapsulation of some extent or less independent of the encysted mass.
That this is true can be ascertained by incising these little hard tumors
when the contents can be readily pressed out or evacuated, the mass
appearing practically as injected months before.

The same result is shown by Harmon Smith, who made an injection of
paraffin (110° F.) into the peritoneal cavity of a rabbit which was
killed twenty-two days later. On examination no sign of inflammation of
the peritoneum was found—a fact that seems to prove the nontoxic effect
of paraffin—nor were there evidences of the formation of adhesions. The
mass had become rounded, had traveled about the abdominal cavity, and was
found lodged between the liver and the diaphragm.

Comstock, with his experiences of injections of paraffins at high melting
points, found that the harder paraffins do not become encysted, but
become a part of the new tissue, which belief is corroborated by Downie,
who introduced paraffin into a carcinomatous breast. Upon subsequent
amputation and microscopic examination there was shown an intimate
connection between the ramified site of the injection and the surrounding
tissue. The same results have been noted by Jukuff.

Smith found that, in trying to remove an injected mass of paraffin
several months after introduction, the greater part of the mass had
become so thoroughly imbedded in the meshes of the newly formed
connective tissue that it was practically impossible to remove it without
including a considerable portion of the connective tissue as well.

Stein claims also that the paraffin is absorbed, little by little, as
it is replaced by the new connective tissue, no matter what the melting
point of the introduced paraffin might have been. The mass grows smaller
to a degree, according to the amount injected; finally, at the end of
a month or more, the entire mass is replaced by a tissue perceptibly
analogous to cartilage.

Freeman, like Eckstein, claims that encystment of the paraffin occurs
soon after the injection, much like that following a bullet or other
foreign body in the tissues, but, unlike the latter author, that a
limited amount of the connective tissue also penetrates the mass, which
is speedily converted into a solid cartilagelike body.

Wendel believes entirely in the encystment theory, while Hertel, in
specimens removed twelve to fifteen months after injection of paraffin
with a melting point of 100° F., found a wall of round cells under
various states of inflammation surrounding the masses with fibers of
connective tissue traversing the latter. In the various histological
findings he argues that the greater the tissue surface exposed to the
injected foreign body the greater the irritation, and the larger the
smooth paraffin mass the less the reaction; in other words, small masses
of the injected mass cause a higher rate of tissue formation, while the
larger masses have a tendency to encystment merely. He also believes that
the harder paraffins require a greater length of time to become absorbed,
and that during such time of resorption new connective-tissue growth is
established, continuing to the time of its complete disappearance.

Comstock, after thorough and extensive investigation with the injection
of paraffins of various melting points made at varying times after the
injection of such procedures, concludes definitely that, “In paraffin we
have a substance that will fill in spaces of lost tissue, and not remain
entirely a capsulated foreign body, but become a bridgework, and, in
fact, a part of the new tissue.”

Wenzel, after an unsuccessful attempt to overcome a laparocele by the
injection of paraffin, a year later performed a radical operation of the
parts. The excised tissue at the site of the injection showed deposits
of the broken-up mass of paraffin, each being enveloped by a capsule of
connective tissue without any signs of ramifying bands, and hence decided
against the belief of the resultant tissue formation.

Eschweiler, the latest authority on the above question, after examining
microscopically a portion of paraffin-injected tissue that had been
carried “_in situ_” on the bridge of the nose for about one year, concurs
absolutely with the connective-tissue replacement belief.

From the foregoing it may be definitely accepted that while there may be
an encapsulation or encystment of the injected mass, be it what it may so
long as it belongs to the paraffin group, there is always a ramification
of the mass by the formation of the strands of new connective tissue
which eventually in a month or more, according to the amount of the mass,
develops to a size corresponding to the latter or even beyond the size
of the latter, as will be mentioned later, and that in all cases the
paraffin is ultimately and almost, if not completely, crowded out of the
area occupied by the injection, and that its disappearance is accountable
to absorption.

This absorption, following such an injection, is productive of no harm
to the human economy, and the new tissue caused to be formed by such
injection truly enhances the cosmetic and surgical value of the method
inasmuch as an encapsulated mass of paraffin is liable to displacement,
spreading, and irregularities, should it be subjected at any time to
external violence.

Such violence, again, would lead to the irritation and inflammation of
such cyst wall, causing an undue crowding upon the parts injected and
possible gangrene of that part of the wall upon which such pressure was
brought to bear, leading to unsightly attachment and ultimate contraction
of the skin where bound down by the inflammation, or even evacuation by
the absorption of gangrenous material and resultant abscess.

That this absorption or disintegration of paraffin is of no consequence
may be proven by all the early cases in which such injections were used.
Gersuny’s first case, having been done May, 1899, shows no diminution of
the prothetic site at the end of two years. The same may be said of the
hundreds of cases done by other operators.

The greater question in the mind of the author is what will be the
ultimate behavior of this new connective tissue.

That the development of this new connective tissue is gradual has been
mentioned, some authors claiming a complete replacement of the mass
at the end of a month, others from two or three months. Morton says
that four months’ time is required before the mass is, more or less,
completely removed and replaced by organized tissue. The author believes,
however, that the length of time necessary for this replacement not only
varies, proportionately with the amount of paraffin injected, but that it
differs in each case, and markedly with some patients in which the growth
or developments of the new tissue did not cease for months and even a
year after such injection. This corresponds truly to a hyperplasia, and
will be considered later.

Time alone will show the ultimate behavior of this new tissue, and while
it is reasonable to argue that this newly organized tissue could cause
no untoward results, it must be determined whether this tissue will not
undergo atrophy and contract, or become susceptible to other changes in
time. It is a new tissue practically, and as yet we know nothing of its
idiosyncrasies, although its histological nature is determined.

We do not know that irritations, such as surgical interference, will
cause it to take on new growth, as evidenced by the attempts of
extirpation of unaccountable overcorrections obtained with injections
made early in the time of the employment of the Gersuny method, in which
the parts practically grew back to their former size or became even
larger. This may be accounted for by the fact that most, if not all, of
the connective tissue was not removed or points to an active nucleus or
several such centers which were not destroyed.

That the growth is not limited by the size of the mass injected is the
author’s belief; in other words, the replacement of the new tissue is not
proportionate to the injection, but that other forces, such as adjacent
tissue pressure and presence and outer influences, as, for instance, the
daily massage of the parts with the hands, have much to do with the final
amount of tissue caused to be developed by the initial stimulus of the
injection. Nothing further or definite, however, has been written on this
supposition.

=16. The Difficulty of Procuring Paraffin with the Proper Melting
Point.=—This should not prove an objection to the method, since operators
can procure pure and sterilized paraffins of the various melting points
from any reliable chemical house.

What the operator should determine first of all is the kind of paraffin
he intends to use for subcutaneous injection.

The selection of paraffin of a certain melting point should be influenced
by what he has read on the subject, as given by authorities of wide
experience.

A few cases do not suffice from which to draw conclusions; it is only
from a great number of similar operations that a definite form or
preparation of paraffin can be decided on.

From the following authorities is shown a variance in the melting points
of the preparations used, but by a glance it may be noted that the
first division of men, from numbers 1 to 10 inclusive, use paraffins of
melting points very near to each other; the latter group, from 11 to 13
inclusive, employ those of the higher melting points.

The former group may, therefore, be said to utilize the paraffins of
lower melting points.

                            GROUP I

    1.         Gersuny          36-40° C.   97-104°    F.
    2.         Moskowicz        36-40° C.   97-104°    F.
    3.         Parker                       102°       F.
    4.         Freeman          40° C.      104°       F.
    5.         A. E. Comstock               107°       F.
    6.         Walker Downie                104-108°   F.
    7.         A. W. Morton                 109°       F.
    8.         Harmon Smith                 110°       F.
    9.         Stephen Paget                108-115°   F.
    10.        Pfannenstiel                 115°       F.

                            GROUP II

    11.        Brœckært         56° C.      133°       F.
    12.        Eckstein         56-58° C.   133-136°   F.
    13.        Karewski         57-60° C.   134-140°   F.

From a glance of the first group the variance of the temperature of
melting points is not a great one, practically lying between 102°
and 115° approximately. When we consider the actual difference in
the employing practicability and the effect upon the tissue there is
practically little, if any, difference. The only difference between these
authorities is that some employ their preparation in liquefied form,
through the application of heat, while the others employ it in the cold
or semisolid form. The choice of such method, from what has already been
said, should unreservedly be the employment of a paraffin in the cold or
semisolid form at a mean temperature of about 110° F.

This choice would fall upon any one of the paraffins used by the
authorities given in Group I.

The objections to the “Hart paraffins” of melting points given in Group
II have been sufficiently shown in preceding paragraphs, although a few
pointed objections from the various surgeons may not be out of place here
to offset the claims and advocacies of those employing the preparation
in liquid form at higher temperatures than 110° F.

Paget says: “I am absolutely sure now that Eckstein’s paraffin is without
any real advantage. It is very difficult to handle; it sets very rapidly;
it causes a great deal of swelling and some inflammation, and may even
produce some discoloration of the skin, and it yields no better results
than does Pfannenstiel’s paraffin, which melts at 110° F.”

Again he says: “The best paraffin is that which has a melting point
somewhere between 108° and 115° F. When the paraffin has to stand heavy
and immediate pressure, the higher melting point is preferable.”

He had up to the date of the latter extract operated upon forty-three
cases of deformed noses and “in no case was there embolism, sloughing of
the skin, or wandering of paraffin.”

Paget, however, employs the paraffin in liquefied form, and allows cold
water to trickle over the nose while the injection is molded into form.
Of this later.

Comstock says, “Paraffin must be used where it will be at all time above
the body temperature,” and further that, “in selecting the melting
temperature for surgical uses, it should be that from 106° to 107° F.,
the best for use in subcutaneous injections, for the reason that it gives
a substance firm enough to hold very well its form, especially when
confined by the surrounding tissue, and at the same time with a melting
point out of the reach of the system at all times.”

From this we are given to understand that he uses his preparation in cold
form entirely when injecting, but of the melting point mentioned.

The author can see no advantage in using any paraffins of low temperature
melting points in liquid form. Here is the very factor of causing
embolism reintroduced. Surely a liquid of any kind injected into a
blood vessel will give cause for trouble, even if the temperature of
the setting of such a paraffin be high or low. The employment of the
paraffins of a melting point above 120° F. in cold form is difficult, if
not impossible, even with the latest pattern of screw syringe which is
quite true, but there is no need of using such paraffin nor any liquefied
paraffin, since any such preparation of about the melting point of
110° F. will serve every purpose overcoming all the objections of the
advocates of those using any other.

If a vessel be injected and filled with any paraffin preparation there is
danger of phlebitis and thrombosis; the only possible way to overcome it
is not to puncture the vessel.

While a preparation injected cold can be more easily governed from
without by digital pressure or guidance, what can be said for a hot
seething preparation introduced under great pressure?

Furthermore, when paraffin is injected in liquid form, especially when
so rendered by a temperature necessarily even higher than the actual
melting point, there is danger of searing the entire site intended for
injection—a condition inducive to no good and a burning of the skin where
the necessary superheated needle enters it, causing a punctate scar, more
or less painful during the time required to heal the wound.

With the later knowledge that small amounts should be injected, and that
such injections should be repeated, it being known that such method
facilitates the production of new connective tissue, may we not draw the
conclusion that the result obtained by the injection depends not upon the
injection _per se_, but the resultant of that injection—namely, tissue
production, and that this tissue production is the outcome of a stimulus
in the form of that injection?

There has not appeared an authority who has claimed otherwise for
injections of paraffin hot or cold, while it is true that the use of
liquefied paraffins at high temperatures have caused all sorts of
untoward results, while those of lower melting points in similar form
have not escaped objections.

The author has used the cold-injection method in over three hundred
nose cases without a single case of sloughing, embolism, or death, and
in no case was there secondary diffusion or hyperinjection. The only
fault has been the desire on the part of the patient to be finished too
quickly, which usually leads to a result not as satisfactory as when the
injections are made sufficiently far enough apart to allow the formation
of organized tissue at the site of injection.

Gersuny’s preparation of paraffin, particularly useful for the
cold-injection method, is made as follows: A certain amount of cold
paraffin, melting at about 120° F., and white cosmolin or vaselin,
melting at about 100° F., are mixed by being heated to liquefaction. The
bulb of a clinical thermometer is then coated with the cooled mixture of
paraffin, which is then placed into a hot-water bath, the temperature
of which is gradually raised until the paraffin melts and floats upon
the surface of the water. The water is then allowed to cool and its
temperature noted just as the oil-like liquid paraffin begins to look
opaque, which marks the melting-temperature point of the mixture.

Should this be found to be too high more vaselin is added, or _vice
versa_, until the desired quantity of both is known.

This method of preparation is, however, a tedious and awkward one, and
can be readily improved upon by mixing certain known quantities of the
one with the other after the first experiment.

The author recommends the following formula for the preparation of a
mixed paraffin, which he has found serviceable and satisfactory for use
with cold-process injections and employed by him for the last four years.

    ℞ Paraffin (plate, sterile)     ʒij;
      Vaselin alba (sterile)        ℥ij.

The two are placed into a porcelain receptacle and melted in a hot-water
bath to the boiling point, then thoroughly mixed by stirring with a glass
rod and poured into test tubes of appropriate size and allowed to cool.
Each tube is sealed properly with a close-fitting rubber cork, which may
be coated with a liquid paraffin without, including the neck of the tube,
and put away for later use.

Since 1905 the author has used an electrothermic heating device in which
the paraffin mixture is prepared. The apparatus is made up of a metal pot
set into a resistance coil, and is shown in Fig. 286.

[Illustration: FIG. 286.—AUTHOR’S ELECTROTHERMIC PARAFFIN HEATER.]

This instrument overcomes the complications of the water bath and burning
or browning of the paraffin mixture, so commonly found with ordinary
methods, the temperature of the resistance coil within the heating
chamber being controlled by a small rheostat at will.

Before using, the contents of each test tube thus prepared are reheated
to sterilization and poured into the barrel of the syringe to two thirds
of its length, the piston introduced and screwed down into position; the
syringe being placed to one side until its contents have been cooled, or
the entire instrument is immersed in sterilized water at about 70° F.
until the paraffin mixture has set or becomes uniform in consistency,
which takes about five minutes.

Upon screwing down the piston the mass will be found to issue from the
needle as a white, cylindrical thread, and is ready for use in this form.

Harmon Smith has had such a paraffin prepared which has a melting
point of 110° F. This can be purchased in the market in sterile sealed
tubes ready for use. The contents of these tubes should, however, be
resterilized at the time of employment.

The same author prepares this paraffin of 110° F. melting point by mixing
sufficient petroleum jelly (evidently white vaselin) with the commercial
paraffin melting at about 120° F. to bring the melting point down to 110°
F. He claims that making such a mixture is a difficult matter, since a
plate of paraffin will have various melting points, one corner melting at
120° and the opposite as high as 140° F. He advises having the mixture
accurately prepared in large quantities and dispensing it in test tubes
of one-half ounce capacity, as now found on the market. The mixture is
poured in hot liquid form into these test tubes, which are then sealed
with wax and placed on a sand bath, whose temperature is raised to 300°
F. to insure sterilization.

The latter author has devised a neat paraffin heater, shown in Fig. 287.

[Illustration: FIG. 287.—SMITH PARAFFIN HEATER.]

Of this he says: “To insure still further the sterilization of the
paraffin, I have devised a tin (nickle-plated) receptacle supported
on an attached tripod, which raises the bottom an inch from any plane
surface on which it is placed, and is closed with a detachable lid. This
arrangement prevents the paraffin from burning or browning. Into this
I pour the paraffin from the test tube, after melting, and place this
receptacle into a sterilizer, or any ordinary boiler—surround it almost
entirely with water and then boil. After I have boiled it for a few
minutes I remove the receptacle and permit it to cool until the paraffin
therein is about 120° F. I then draw it up into the syringe, which has
been sterilized in the same boiler with the paraffin. When sufficient is
withdrawn, I evacuate the air bubbles from the syringe by pressing the
piston upward and run my set screw into place. Some two or three minutes
are now allowed for the paraffin to assume equal consistency throughout
and to cool down to a semisolid state. When the paraffin reaches this
consistency it may be kept many hours ready for use, at the temperature
of the room, if only the precaution to warm the needle is taken each time
before attempting the injection.”

=17. Hypersensitiveness of the Skin.=—A permanent hypersensitiveness of
the skin over the site of a subcutaneous paraffin injection has never
been definitely shown. While it is true there is some pain and feeling
of stress and fullness over and about such area, immediately after the
operation, this has subsided in about twenty-four hours in the average
case, except in those where a very hot liquid paraffin and of large
amount has been injected, when several days are required to overcome
these symptoms.

Smith claims a numbness over the site of the injected area which soon
passes away, but this is perhaps more a feeling of fullness rather than
one of anesthesia.

The author has observed, however, in several cases a period of extreme
discomfort, fullness and cephalalgia in cases of subcutaneous injections
about the root of the nose. Peculiarly these attacks appear only after
the filling has become organized; that is, after the connective tissue
has displaced the paraffin. The secondary tumor in such cases appears
to be slightly larger superiorly than the original size at the time of
injection.

The irregularity of these attacks, with edema of the forehead and slight
puffing of the upper eyelids, points to a disturbance of the circulation
and is undoubtedly due to pressure on the angular vessels, and the
venous arch across the root of the nose. The symptoms usually appear in
the early morning and moderate toward night, reappearing again the next
morning or not again until the next attack, which may be expected at any
time.

This condition of affairs is an unfortunate one, since we cannot look to
the avoidance of the trouble nor foresee it at the time of operation.
In one case the symptoms did not develop until nearly two years after
the injection was made and became so troublesome that the only relief
had was by opening the skin of the nose laterally and excising as much
as seemed necessary of the newly formed connective tissue with a fine
pair of curved scissors. None of the injected matter was discovered
except two fine scalelike disks of glistening paraffin of a diameter
of one sixteenth inch. These were evidently all that remained of the
injected mass, and were undoubtedly held in the innermost meshes of the
new tissue. Immediate relief followed the operation, but no appreciable
difference in the size of the tumor could be noticed.

Cold applications or ice cloths relieve the temporary pain following an
injection of paraffin, but in most cases this is rarely necessary except
in extremely nervous and expectant patients.

On the whole the author believes the secondary neuroses and circulatory
difficulties are now practically overcome by the more conservative use
of the matter to be injected, coupled with a repetition of the injection
of smaller amounts at each sitting and not repeating the same until the
first has become organized.

=18. Redness of the Skin.=—Redness of the skin following an injection of
the nature under consideration was one of the early objections made by
various operators.

That redness, more or less permanent, has been found in many cases in
which these injections were made is true, but such redness was found
particularly when the injections were those of liquid paraffin of high
melting points and in which the operator was overzealous in bringing
about an absolute correction of a deformity, with the result that when
the paraffin had been molded and set, it was generally pinched or shaped
up or outward, thus causing a great deal of pressure upon the circulatory
vessels of the skin.

The redness in such cases did not appear until several days after the
operation, becoming worse gradually instead of better even in spite of
the efforts to reduce it by external applications. Not unusually, in the
permanent cases, distended capillaries can be seen in the skin resembling
the condition in acne rosacea chronica, especially when the injection had
been made to correct a saddle nose.

Smith says: “Redness is present in a good many cases. I have seen a case
in which the redness lasted over a year, but it gradually disappeared.
There seems to be a tendency on the part of nature to take care of a
foreign body, and I think the reënforcement of connective tissue that
grows into this mass requires an increased blood supply, and later, when
the blood supply is no longer necessary, the redness will disappear.”

The latter is true where the hyperemia is either acute or subacute, but
in chronic cases where the capillaries have become distended and show
plainly there is little to be hoped through the effort of nature.

Eckstein, the advocate of “Hart-paraffin” method of high melting point,
states that a redness of the parts develops a few days after the
injection that disappears after a time, but that this redness is more
marked and of longer duration when the injections are made intracutaneous
instead of subcutaneous.

These injections should be made subcutaneous in all cases, and there is
no excuse for deviating from this method.

With the use of semisolid and cold paraffin mixtures, as heretofore
advocated, redness rarely if ever follows the injection unless undue
pressure has been made, in which case necrosis is more liable to follow
unless the adjacent tissue will gradually allow the mass to become
relieved by a change in form and position.

Such subsequent hyperemias are not now as common as when the injections
were at first attempted, and the author may say freely that they never
occur when the proper method and material is used.

Paget says: “In a few cases—but only in a few—some reddening of the skin
has followed the injection, and in a few this has been very slow to fade.

“The few referred to are of a record of twenty-two nasal cases, but no
data is given whether the operator used paraffin of high or low melting
points. F. Connell found that redness in that case continued for a year,
diminishing very little in that time. It appeared on the second time
after the operation for a correction of a saddle nose, and remained
stationary for about one month. Twenty drops of paraffin were injected.
It very gradually increased, so gradually, in fact, that there is still
a distinct reddened area over the bridge of the nose. On pressure this
redness will disappear, but returns immediately after the removal of
the pressure. A few dilated and tortuous capillaries course their way
over the area. The condition is still present fourteen months after the
injection.

“There has been practically no change or decrease in the redness during
the last six or seven months, it is not as marked as it was during the
first few months, but still requires the profuse application of face
powder in order to prevent her nose from being conspicuously red.”

The above case has been cited because it is typical of such condition,
and while the amount as stated was quite small, one is almost nonplussed
for an explanation of the result, yet it undoubtedly must have been
due to a close attachment of the skin to the underlying structures,
necessitating pressure, which is known to cause it.

However, it is possible to have such redness develop weeks or months
after the injections are made. In such cases it is not due to the primary
pressure of the injection, but to that of the newly developed tissue
which has taken its place, but which is slightly overdeveloped for the
same unaccountable reason already referred to.

Almost every surgeon who has used this method of restoring the contour of
parts of the face has observed redness, more or less permanent, follow
the method used, but in most cases liquid paraffin of high melting points
had been forced into the tissues at great pressure.

In one case, that of a southern operator, the entire tip of the nose had
become injected by primary diffusion or direct filling.

It became inflamed immediately after, and some weeks later, when the
swelling had subsided, the lobule was found to be very hard, tense, and
extremely red. Two years after the author saw this case, and the tip
of the nose still appeared like a red cherry with numerous capillaries
showing over its area, while the rest of the nose, although much
broadened by secondary displacement of the paraffin, was natural in color.

This proves that as the pressure was relieved by absorption and
displacement, the tissue took on a normal appearance, whereas in the
lobule of the nose, where there was no relief from the pressure, nature
could do nothing to relieve the inevitable result.

In cases where the redness is suspected it may not be too late, a day or
two after the injection, to remold the mass into such form as to relieve
the acute tension.

If the redness develops early, cold applications of an antiseptic nature
or ice cloths can be used to advantage. Antiphlogistin or other similar
preparations applied externally give good results.

Later ichthyol, twenty-five-per-cent solution, may be applied; acetate
of alumen in saturated solution seems to do well. Some operators
apply hydrogen peroxid, but it gives only temporary benefit. When the
capillaries have become distended and the redness is practically chronic
the vessels should be destroyed with a fine electric needle, using about
20 milliampères—direct current.

Sometimes when the redness is acute and seems to persist depletion of
the part does some good. This is done by nicking the skin here and there
with a fine bistoury and allowing the part to bleed freely. Care should
be taken not to puncture the skin too deeply, so as not to allow the
injected mass to escape.

In some cases it is allowable to open the filled cavity early and remove
enough of the filling to overcome the difficulty, injecting later, after
the filling has become organized, to make up the deficiency.

When the redness is secondary—that is, when it develops after the
connective tissue has replaced the paraffin—it is best to open up the
part and excise enough of the tissue to overcome the pressure.

In a case where the author injected for a deep furrow in the forehead
with a cold semisolid paraffin mixture, a secondary redness developed
three months after the injection had been made, no redness having been
noticed in the meantime. There was more or less swelling for two or three
weeks, undoubtedly due to pressure phlebitis, which eventually subsided.

The redness in this case was only reduced by an excision of the tissue
causing the trouble. The result was satisfactory.

=19. Secondary Diffusion of the Injected Mass.=—This is a condition
that no operator can foretell, although it might be caused by a primary
diffusion due to hyperinjection of so small an extent that it escaped the
surgeon’s attention at the time.

Again, a site injected may at the time of operation present all the
indications of a satisfactory result—that is, the tissues at the place
of operation and its immediate vicinity appear perfectly loose and
elastic; the injection being made easily and the contour of the defect
being remedied either partially or entirely as the operator may desire;
there being no mechanical anemia post-operatio, and no decided effort
on the part of the tissues to cause primary elimination after the
withdrawal of the needle; yet it is possible that, by such an injection,
sufficient pressure may be caused upon some of the blood vessels within
the limitations of the injection as to cause a decided reaction a few
hours after the operation, as evidenced by a swelling, too great for the
disturbance occasioned, and associated with all the signs of a fairly
active inflammation.

It is possible that such a reaction may cause a displacement or
diffusion, post-primary, of the mass injected, especially if the mass be
merely vaselin or a mixture of vaselin and paraffin at a melting point
too low for the purpose. Nevertheless, it is practically impossible to
foresee such result and the operator can only use the same care as with
any or all such injections.

It is possible, when the reaction is too marked, to mitigate, to a great
extent, this diffusion of the injected mass, by using such methods as
reduce the inflammatory symptoms.

As a rule, these cases exhibit considerable ecchymosis after this active
reaction has subsided, lasting from one to two weeks.

Secondary diffusion, as the author uses the term, signifies an extension
of the injected mass beyond the intended area. This may occur in two or
three weeks or be proportionate to the activity of the production of
fibrous connective tissue that is supplanting the mass.

Leonard Hill has reported a case in which he injected vaselin to
correct a saddle nose for æsthetic or cosmetic reasons. The result was
very satisfactory to both operator and patient, and continued so for
nearly twelve months, when secondary diffusion of the mass began to be
noticeable. Eventually the diffusion became so great in the upper eyelids
as to close both eyes completely.

The worst case of such secondary diffusion the author has ever heard
of or seen came to his attention early this year. The patient had been
subjected to a subcutaneous injection of oils for the cosmetic correction
of an abnormal deepening of the inner clavicular notch. The injected
mixture, as far as the author could learn, was made up of sweet almond,
peanut, and olive oils with two others that had been forgotten. Her
physician had made two injections several days apart with a satisfactory
result. The reaction was trifling and the parts returned to the normal in
two weeks.

Five months later the part injected became tender to the touch and began
to enlarge daily. With the increase in size a gradual inflammation
involved the whole lower region of the anterior region about the root
of the neck. Various applications were made to the part to reduce the
inflammation, but at the end of ten days a region of skin that had
indicated the pointing of an abscess burst, allowing the escape of about
eight ounces of pus. Under the most careful surgical attention this
discharge continued for about three months, until under the influence
of gauze packing the wound was made to heal from the bottom, leaving
an ugly irregular scar at the site of the opening. With the healing of
this fistular wound, however, the size of the tumor did not diminish
whatever, but continued to grow until, at the present time, one and
one half years after the injections had been made, the size of this
peculiar hyperplastic growth of ovate form measures nearly five inches
across its horizontal diameter and three and one half inches through
the vertical. It is closely adherent to the overlying thickened skin,
which has undergone a yellow pigmentary change to be considered in the
next text subdivision. The tumor is hard, painless, and freely movable
beyond the limitation of its skin attachment and rests upon the sternal
thirds of the clavicles, extending upward and forward with evidences of
traction on the whole anterior skin of the neck. Laryngoscopy discloses
nothing abnormal. The deformity is hideous, and necessitates a mode of
dress to conceal it. The patient has not as yet been operated on for the
extirpation of the growth, owing to her present physical condition, the
result of melancholia.

Scanes-Spicer injected some vaselin to correct a saddle nose with
satisfactory immediate result, but after several days the upper lids
became slightly edematous, and soon after a small hard lump, the size of
a grain of shot, was felt in the left upper lid.

Harmon Smith observed a secondary diffusion in two cases in which the
abnormality in one occurred on the side of the nose and in the other at
the inner canthus following the course of the angular vein.

While in the foregoing cases the difficulty may have been overcome by
using the cold, semisolid paraffin mixture and reducing the amount
injected, it is questionable if the diffusion could thus have been
entirely overcome.

The author points to the fact that undoubtedly this fault is observed
more when the tissues at the side of the nose, or about the alæ, are
injected, and that the cause here is one of an unequal pressure of the
parts—the skin more or less bound down above and the ungiving cartilage
below.

In such cases great care should be exercised in the amount injected,
and if, after introducing the needle, the tissue be found to be unduly
adherent and inelastic, to withdraw the needle and with a fine tenotome
divide or dissect up the skin before the mass is injected. At no time
would an operator be justified to inject more than ten drops of the mass,
at a single operation, into the parts referred to.

As already mentioned, there is not only danger of diffusion of the mass
in such region of the nose, including the lobule and the subseptum, but
there is a special danger of gangrene from pressure where the tissues are
less supportative than where muscular tissue or greater mobility of the
skin is found.

After the immediate attempts to reduce a reactive inflammation, nothing
can be done to overcome secondary diffusion except excision of the amount
not wanted. This should not be undertaken until at least three months
after the time of injection.

The mass of connective tissue must be entirely excised as thoroughly as
possible, and slightly beyond the border of the abnormal elevation. A
sharp curette is practically of no use for this purpose, and only wounds
the skin, and by reason of retentive shreds of tissue may cause infective
inflammation.

The opening into the skin should be made with a fine bistoury, the skin
be dissected off from the elevated connective tissue, and the latter
extirpated by dipping cuts of a fine small, sharp-pointed, half-rounded
scissors. The operation can be done neatly and painlessly under eucain
anesthesia.

The wound may be sutured with fine silk or be allowed to unite of its own
accord.

It is advisable to supply a small pressure dressing, made of a circular
gauze pad, over the site to assure of the best union between the
dissected or undersurface of the skin and the floor of the wound.

Dry dressings are to be preferred, since moisture would tend to soften
the skin and permit it to crawl, which would not improve the ultimate
result.

=20. Hyperplasia of the Connective Tissue following the Organization of
the Injected Matter.=—The overproduction of connective tissue replacing
the injected mass is rarely observed, yet a few cases have been noted.

Sebileau has reported a true case of diffuse fibromatosis following an
injection of paraffin. This not only included the site of the injection,
but extended to the surrounding or adjacent tissue, making the secondary
defect much more disfiguring than the first.

The author has observed in one case of hyperplasia following the
correction of a saddle nose, that the area injected presented no unusual
appearance for six months, when the nose at its middle third began to
enlarge slowly until it resembled a marked Roman shape, the enlargement
extending laterally and as far down as the nasogenian furrows at the end
of nine months.

The injection used was a cold, semisolid paraffin mixture, and only
sufficient to barely correct the defect was injected, the skin being
thoroughly flexible at the time of operation.

No reason can, therefore, be given for this unusual result, except,
perhaps, a peculiar idiosyncrasy of the tissues, that may be compared,
somewhat, with the external tissue changes in hypertrophic or keloidal
scars, especially noted in the wounds of negroes—a condition for which
we have, as yet, found no attributable cause.

While we cannot definitely prevent such a result, following an injection
of a hydrocarbon, we may at least be sure that hyperinjection is not the
cause.

The hyperplasia as exhibited in these cases is one of true fibromatosis.
The microscopical examination may show the retention of paraffin in
small, round, pearllike masses lying in cells of varying size, but with
specimens of such tissue removed after a number of years’ standing does
not show the paraffin _in situ_.

In a specimen taken from a chin five years after the injection of
paraffin the Lederle Laboratory makes the following report accompanied by
microphotographs of sections taken from the fibromatous area as shown in
Figs. 288_a_ and 288_b_:

“ANATOMIC DIAGNOSIS.—The specimen consists of several pale, tough masses
of tissue removed from the chin covered on the outside by normal skin.

“HISTOLOGIC DIAGNOSIS.—The various layers of the epidermis—i. e., the
strata corneum, lucidum, and granulosum—are unthickened and practically
normal. In the corium the papillary and reticular layers are apparently
normal, showing no thickening nor round-cell infiltration.

“The glandular elements in this area and the hair follicles appear normal.

“Toward the deeper layers and the subcutaneous connective tissues appear
isolated areas of round-cell infiltration separated by masses of fibrous
connective tissue, much of which is of new formation, as indicated by the
nucleated character of the elongated cells. There are areas of diffuse
round-cell infiltration.

“In this portion of the corium there is also to be found a large
number of vacuolated areas varying very greatly in size, and which are
surrounded by membranous fibrous-tissue elements, much of which is
likewise of new formation, as indicated by the character of its cells.

“These vacuoles doubtless represent the areas containing the masses of
paraffin which have been split up by the new formation of fibrous tissue.
Between the vacuolated areas can be seen actual infiltration by true fat
cells.

“In many spots the fibrous-tissue formation has proceeded to the point of
thick bands containing but few nucleated cells. Fig. 288_a_, which is a
photomicrograph of this portion of the section, shows these changes.

“In one of the foci of round-cell infiltration which have been surrounded
and invaded by bands of new fibrous tissue there are numerous giant cells
of the so-called ‘foreign-body’ type. This is shown in Fig. 288_b_.

[Illustration: FIG. 288_a_.—MICROPHOTOGRAPH SHOWING FIBROMATOSIS. × 40.]

[Illustration: FIG. 288_b_.—MICROPHOTOGRAPH SHOWING FIBROMATOSIS. × 40.]

“SUMMARY.—_Histological Diagnosis._—Diffuse fibromatories with fatty
infiltration and giant-cell formation in a vacuolated area produced by
paraffin injection.”

Once the hyperplasia is established the surgeon must simply wait until he
believes the activity of the abnormal growth has subsided and then remove
the superabundant tissue with the knife.

With another case, in which the patient was operated on by another
surgeon, the author was called upon to remove the growth. A part of the
coarse, yellowish pale and cartilagelike tissue was excised, sufficient
to restore the parts to a normal contour. After an uneventful recovery
the patient went away, greatly pleased, only to return in six months,
presenting a similar condition as before the extirpation.

A second operation was done, this time more extensively, the entire
yellowish connective tissue being removed by the aid of a long median
incision on the anterior aspect of the nose.

The wound healed readily and showed very little scar, and the patient was
discharged. One year after the last operation the nose was still normal
in appearance and the growth had not reappeared.

From this it is deemed absolutely necessary to remove practically all of
the newly formed tissue to warrant a nonrecurrence of the fibromatosis.

=21. A Yellow Appearance and Thickening of the Skin after Organization
of the Injected Mass Has Taken Place.=—This condition of the skin is
evidenced some time after the injected mass has become organized,
beginning about the sixth month after the time of injection. It has been
especially noticed with the hard paraffin fillings of the nose, but also
with other injections, even of the lowest melting points, about the
sternoclavicular regions of the neck.

The skin becomes at first streaked with a superficial and irregularly
defined patch of red, the forerunning indication of the size of the
ultimate pathological change. The red color subsides slowly, leaving the
area pale, which thereafter gradually thickens, taking on the appearance
of a light yellow stain in the skin.

Practically opposite to the condition in xanthalasma, where the yellow
area is slightly elevated and occurs in the loose tissue of the eyelids.

The cause seems to be a degenerative change in the skin dependent on
pressure upon its underlying tissues. Evidently the pressure of an
overproduction of the connective tissue which has sprung up to replace
the injected mass.

Seemingly the cause is due to an injection being made too close to the
derma where the latter is bound down to the subcutaneous tissue, or a
desire on the part of the surgeon to prevent an injection into the deeper
areolar tissue, especially when the injection is made in the vicinity of
the larger blood vessels, for fear of causing embolisms or phlebitis.

Excluding the use of hard paraffin for such injection, the operator
should be sufficiently experienced to use these injections properly and
without fear, and at all times avoid injecting into the skin instead of
subcutaneously.

Making the puncture first and observing if blood flows freely or
trickles from the detached needle will assure the operator into what
tissues he has thrust his needle.

Should active bleeding follow the puncture, he should withdraw the
needle and wait to inject the site at a later sitting, using the same
precaution; at no time should he be in doubt as to the absolute placing
of the injected mass.

When the injections are done about the lower neck or shoulders great
care must be exercised to avoid the blood vessels, and small quantities
be only injected to prevent reactions that may cause phlebitis of these
vessels; furthermore, the injected mass must be carefully molded to
prevent the formation of uneven elevations or lumps. Without doubt an
injection into one of the blood vessels of the neck would mean certain
death.

Kofman lost a patient by pulmonary embolism twenty-four hours after an
injection of 10 c.c. of paraffin. How many punctures he made to inject
this amount is not stated, but certain it must be that he introduced part
of the mass directly into some blood vessel.

The author advises, when injecting about the neck, to use a stout,
dull-pointed needle introduced under local ethyl chloride anesthesia and
to elevate the tissue with the needle as the injection is made. In this
way the operator can observe the behavior or placing of the injected
mass, at the same time stretching the skin to permit of the injection
without encroaching upon the blood vessels. The mass is immediately
molded after each injection. The further question of the practical method
of making these injections will be fully considered later.

If, however, the pigmentation under consideration has taken place,
electrolysis with a fine needle may be resorted to, with the object of
whitening the discoloration by producing scar tissue, in the form of
punctations, in the discolored area.

While the numerous white spots so caused are objectionable, they are
better borne by patients than the pigmented appearance. A thorough
needling of the spot in this way eventually brings about an improvement,
and if, for æsthetic reasons, the patient objects to the unsightliness of
the result thus obtained, the white area may be carefully tattooed with
an appropriate color to match the rest of the skin of the face or neck.

If the pigmented area is not too large, it can be excised with the knife
and the healthy skin be brought together with a fine silk suture, thus
leaving a thin linear scar which can be dealt with as the punctate scar
area, if desired; the electrolysis being a painful procedure at all
times, since sufficient milliampères must be used to cause scar-tissue
formation, which is between 20 to 30 milliampères in such cases.

=22. The Breaking Down of Tissue and Resultant Abscess Due to the
Pressure of the Injected Mass upon the Adjacent Tissue after the
Injection Has Become Organized.=—The above result is particularly
noticeable when the injections have been made into the cheek or the
breast. It is understood that the suppurative changes under consideration
herein are not attributable to imperfect sterilization of the injected
matter, although it is possible, and perhaps is the cause in fifty per
cent of the suppurative elimination of the infected mass from the cheek,
that a nucleus of infection is carried into the tissues and is held in
suspense for a time, because of its imbedment in a neutral media that
does not readily permit of bacteriological propagation, but eventually
this nucleus must come in contact with tissue which it can affect, and
only then may its infection be taken up.

The author believes that such secondary affections are accountable to
pressure effects upon the blood vessels or glandular structure, as in the
case of breast injections, the new connective tissue causing a lack of
nourishment in the part or gland, and a resultant breaking down of the
tissue, directly influenced in some instances by external violence.

Tuffier reports the elimination of paraffin injected into the breast
several weeks after the injection. If this elimination had been caused
by primary infection an acute reaction would have taken place at least
within forty-eight hours, ending in abscess shortly after.

A case which came to the author’s attention was that of a lady who had
been operated upon for the correction of a saddle nose three months
before. The result had been satisfactory. The day previous to consulting
the author she had injured her nose in an automobile accident. The nose
was much swollen, very painful, and red over the entire upper and middle
third. The use of external cold did not relieve the condition much, and
on the fourth day the skin broke open at one point, allowing pieces of
the paraffin to escape. Immediate relief followed, the wound healed with
a marked sinking of the middle third of the nose. After three weeks the
nose was again injected with no further untoward symptoms, the result
being satisfactory for two years past.

In this case undoubtedly the exciting cause was directly due to violence,
which may be the forerunner in many of such cases, but there is a number
of such eliminations directly due to a breaking down of the tissue from
internal pressure alone.

There is no way to overcome this difficulty, except to await the definite
formation of the abscess and then to puncture the skin directly over the
soft fluctuating area and to drain the cavity.

Once relieved, the condition quickly subsides, leaving a certain amount
of loss of contour, which can, however, be corrected several weeks after
by a secondary injection.

When the abscess occurs in the cheek it is not advisable to open
interiorly, but to make the puncture through the skin, on account of
the danger of infection from the buccal cavity and of the imperfect
evacuation thus attained.

A trocar and cannula of proper size will be found to be the most
suitable, the parts being gently manipulated to evacuate the contents of
the abscess.

Aspiration can also be resorted to, but for the breast a small linear
incision, made under local anesthesia at the most dependent point, best
answers the purpose.

A small gauze strip drain may be employed for a few days to insure of
perfect drainage in the latter case, the wound being brought together
eventually by a delicate cosmetic operation if desirable.


THE PROPER INSTRUMENTS FOR THE SUBCUTANEOUS INJECTION OF HYDROCARBON
PROTHESES

Although Gersuny advocated the use of a Pravaz syringe for injecting the
liquefied vaselin mixture for prothetic purposes, it was soon found that
such an instrument was practically useless, especially when the parts to
be injected offered more or less resistance to the introduction of the
foreign matter.

Other operators, following the advice of Eckstein, who advised the
employment of “Hart paraffin” of high melting point liquefied by heat,
raised the objection that the metal needle became so easily obstructed by
the rapid setting of the paraffin in its distal end that the great force
necessary to eject the contents of the syringe usually resulted in a
breakage of the glass barrel in the hands of the operator, or, as in some
types of the syringe, a separation of needle and syringe at the point
where the former was slipped upon the ground point of the latter, with
the annoyance of the paraffin squirting over the faces of both patient
and operator.

Eckstein tells us how to overcome the first difficulty with this same
style of syringe as used by him. He covers the syringe with a rubber
insulating sleeve and draws several drops of hot, sterilized water into
the needle to overcome the plugging up of the latter; an illustration of
his syringe has been shown on page 232. Mention has also been made of the
various methods used to overcome this difficulty by other operators.

It was presently found that such an instrument was not only impractical,
but also a detriment to procuring desirable results, the paraffin
solution shooting out suddenly, in some instances causing hyperinjection,
and at other times emerging so slowly that it required unusual force on
the part of the operator—a painful procedure for delicate hands, inasmuch
as the fingers only can be applied to operate the instrument.

With the object of overcoming this uncertainty of the amount of the
injection and the unnecessary exertion to inject any given quantity, as
well as to establish enough _vice à tergo_ to keep the needle free from
plugging up with cooling paraffin, various operators devised instruments,
all having practically similar points of mechanical merit and usefulness.
The required necessities being to invent a syringe which would have a
known capacity, a piston under control of the operator at all times, and
metallic needles of proper lumen, to prevent the solidification of the
liquid paraffin, screwed to the syringe to prevent loosening.

With the object of overcoming these difficulties the author devised a
syringe which was made for him by Tiemann & Co., early in 1902. He begs
to introduce the same here, as a type similar to which most operators
have built their special instrument.

The syringe at that time consisted of a glass barrel, of a size to hold
6 c.c. of liquefied paraffin. At either end of the barrel tube were
placed metal ends, the distal one containing a cap with a screw thread to
receive the needle, the upper cap being threaded to receive a check nut
through its center and on its outer surface, on opposite sides to each
other, two metallic rings to accommodate the thumb and forefinger. The
center of the check nut was double threaded to receive the piston rod,
the piston or plunger being held in place by two, upper and lower, washer
nuts, the lower being threaded to receive a small rod passing through the
bored-out center of the piston rod, and which ended in a check nut, in
the handle, threaded upon the outer or manual end of the piston rod, in
such a way that the fiber or asbestos piston washer could be tightened
and loosened at will.

The syringe permitted of being used as an ordinary syringe by unscrewing
the cap check nut or be made into a screw drop syringe by screwing the
same nut into place. By turning the handle end of the piston rod the
contents of the syringe were forced out smoothly and evenly in any
quantity desired.

With the later employment of the cold, semisolid preparation of vaselin
and paraffin, as heretofore considered, it was found necessary to
reënforce this syringe, so that the greater pressure necessary to
eliminate the wormlike thread of hydrocarbon would not force off the
lower cap or break the barrel of the syringe at its needle end.

This was done for the author by the Kny-Scheerer Company, December 6,
1902, when metallic strips were added to opposite sides of the glass
barrel connecting the lower with the upper cap.

The instrument as then made is shown in Fig. 289.

[Illustration: FIG. 289.—AUTHOR’S DROP SYRINGE.]

At the same time the same firm made the author a syringe entirely of
metal, similar in construction, except that the barrel was made larger in
diameter and shorter in proportion to bring the instrument near to the
seat of operation. The regulating washer rod was not needed, since in
this instrument no washers were required, the piston head being made of
solid metal throughout and the rod being soldered to the plunger, thus
overcoming any objectionable fault in sterilization.

This type of syringe was found to be most suitable for the cold,
semisolid injections, and is of the type now universally used except for
the slight modifications of the various operators. It is illustrated in
Fig. 290.

[Illustration: FIG. 290.—AUTHOR’S ALL-METAL DROP SYRINGE.]

Since there were no objections to making the barrel large enough to
permit of injections, such as are required for restoring the contour
of the cheek and the neck and shoulder, it was made to contain 10 c.c.
working capacity, overcoming the necessity of constant refilling, when
comparatively large injections had to be made—a fact worth remembering
from a practical standpoint, although two or three of these syringes,
specially prepared for each patient, might be found desirable by some
operators. Yet the simplicity and ready facility with which this
instrument can be used and refilled renders it useful and sufficient for
performing operations of this nature to any judicious extent.

Syringes holding small quantities of the paraffin mixture are found to be
a nuisance.

The following operators employ syringes of the capacity given:

    Brœckært     3 c.c.       50 mm.
    Eckstein     5 c.c.       80 mm.
    Freeman      5.6 c.c.     90 mm.
    Downie      10 c.c.      150 mm.

The instrument employed by Brœckært, holding less than one dram, would be
of little use except to correct very slight deformities about the brow or
nose, or dressing up or completing the contour of parts previously filled
by larger injections.

Another syringe similar in type to the author’s, but of a capacity of 5.6
c.c., was introduced by Harmon Smith.

The principles of the syringe are alike, but the style of handles, two
flat metal bars at opposite sides, offers no objection when comparatively
hard mixtures of paraffin and vaselin are used.

While operating the syringe the narrow blades are brought in contact with
the soft flexor sides of the thumb and forefinger, indenting the flesh
deeply, and with the least unexpected move on the part of the patient
permitting it to slip out of the grasp of the surgeon. Its incapacity for
large injections also offers some objection, but for correcting smaller
defects it is both practical and compact. It is illustrated in Fig. 291.

[Illustration: FIG. 291.—SMITH ALL-METAL DROP SYRINGE.]

It is obvious that with the screw drop type of syringe the cold semisolid
paraffin mixture contained in its barrel is always under the full command
of the operator, nor can there be a plugging of the needle, since the
great force that can be exerted with a turn of the piston handle would
free it, even if the mixture were of a comparatively high melting point,
although the force to be applied would naturally increase in proportion
to the hardness of the mass within the syringe.

The turning of the screw piston forces out the contents of the syringe
in the form of a white thread of a diameter equal to the diameter of the
lumen of the needle.

To facilitate this ejection, the needles should be of ample diameter, not
over one inch long and having knife-edged points. Longer needles are not
necessary, and only add to the force required to turn the screw handle.

Curved needles, used by some operators, are never needed, and the author
does not see how they could be applied at any time in preference to the
straight.

As much of the paraffin mixture can be forced out of the syringe as may
be desired by screwing the piston down into the barrel.

The piston rod may be graduated in five- or ten-drop divisions, but the
operator rarely ever refers to the scale. He judges the amount required
by the elevation of the tissues brought about by the presence of the
paraffin thus forced under the tissue. Experience soon teaches him the
amounts necessary or judicious in each case, always remembering that it
is better to do a second and later injection than to hyperinject.

The entire instrument being of metal permits it to be sterilized as
readily and in the same manner as any other metallic instrument.

It is understood that the syringe must be taken apart for sterilization
at all times.

Lubrication, to facilitate operation, is never required, since the nature
of the mixture used in the syringe answers this purpose in every way.

Owing to the greater amount of metal in the solid piston itself, the
latter is very likely to expand under dry heat sterilization or boiling,
so much so that for a moment it cannot be introduced within the barrel.
This can be quickly overcome by dipping it into cold sterile water or
absolute alcohol, which brings about its contraction.

After using, the syringe should be emptied entirely, unscrewed and
sterilized, and placed in the metal case furnished for it. A screw cap is
furnished to take the place of the needle when not in use.

The method of filling and using the syringe will be considered later.


PREPARATION OF THE SITE OF OPERATION

The same surgical precautions should be observed when a paraffin
injection is to be undertaken, as with a minor surgical operation.

It is hardly found necessary to prepare the site of operation the day
before, nor need the patient be detained for such time for the purpose of
making him ready.

With careful observance of ordinary surgical technique, both as to
surgeon and patient, all of this class of operations can be performed in
any physician’s office, providing that both instruments and the mass to
be injected have been rendered sterile.

Especial care should be given to the operator’s hands, for with these he
not only handles the instruments, but must also mold the mass injected,
thus frequently coming in contact with the needle opening or openings
made in the skin.

When injections are to be made in the cheeks of the patient, the mouth
should be prepared by cleansing the teeth thoroughly and washing out the
buccal cavity with warm boric acid or hydrogen peroxid solution, or any
of the preparations of the Listerine composition.

This rinsing should be continued every few minutes for at least ten
minutes before the operation is undertaken.

This is necessary, as the surgeon must introduce his finger into the
mouth and behind the cheek to mold out the mass injected subcutaneously,
and infection could easily be introduced by his fingers during this
procedure.

Externally a generous field of the operation is scrubbed with a brush
dipped into green soap and water.

The skin is then thoroughly washed with gauze sponges steeped in absolute
alcohol, followed with spongings with a 1-5,000 solution of bichlorid
of mercury. The whole surface is then wiped off with a sponge dipped in
ether and covered for the time being with a pad of sterilized gauze until
the operator is ready to proceed with the operation.


PREPARATION OF THE INSTRUMENTS FOR OPERATION

The manner of preparing the necessary mixture of paraffin has been
described on page 244. After such preparation, the mixture, still hot,
may be poured into test tubes, which are sealed and put away for further
use, each tube holding just enough to fill the syringe two thirds full.

When a syringe is to be filled, one of the tubes is opened and the
contents are again boiled over a spirit flame, or simply liquefied and
poured into one of the types of heaters already described for the same
purpose of resterilization.

From the test tubes or the heater, the boiling mixture may be drawn up
into the sterilized syringe to the required amount or it may be poured
into the opened piston screw cap end.

In the latter event the ready cooling of the mixture as it enters the
needle will permit it to be retained in the barrel, or the needle may be
immersed in sterile water as the paraffin is poured into the syringe, yet
even if a few drops escape from the needle in the former method, no harm
is done, as such loss amounts to nothing and helps to eventually fill the
syringe evenly and free of air.

If the mixture is drawn up into the barrel to the required height, more
or less air enters, which must be removed by turning the syringe, needle
up, and screwing up the piston rod until either the liquid or cylindrical
thread of the cooled mixture appears.

If the mixture is poured into the syringe the piston is slowly pressed
into the barrel, thus allowing the air to escape along its sides if
the mixture is set, or if warm the syringe is turned up and the piston
screwed into place. As this is done the few drops of cooled paraffin
will be forced from the needle before the air is exhausted. The screw is
turned until the paraffin emerges evenly from the needle.

The syringe must now be laid aside, or placed in sterile water of the
temperature of the room, to allow the liquid within to set evenly and
become uniform in consistency.

The operator will follow what method he pleases in filling his syringe,
but at no time should he fill it with the cooled product with a spatula,
or other such means, as he is sure to fill it unevenly in this way,
incorporating a number of air spaces. The air issues from time to time
during an operation with sudden sputtering outbursts, that not only tend
to annoy the patient, but also to frighten him—the shock being unusual
and unexpected, while the air thus forced into the subcutaneous tissues
puffs out the parts and interferes with a perception of the proper amount
to be injected and adds to the danger of air embolisms.

Slipshod methods are inexcusable, and should not be tolerated. The
best results possible should be given the patient, and only from the
best results obtained with the best care can the most reliable data be
attained, all helping to fix the reliability, efficacy, and exactitude of
this branch of cosmetic surgery.


THE PRACTICAL TECHNIQUE

The field of operation and the instruments having been properly prepared,
as described, the _modus operandi_ must next be considered.

Since the various parts of the face to be injected demand specific
procedure, they will be considered somewhat individually hereafter,
whereas the general technique, applicable in as far as the method of
injection is concerned and applying similarly in all cases, may tersely
be first taken up.

Various and noted surgeons point out that these subcutaneous injections
should be made under general anesthesia, i. e., ether, while others
consider the hypodermic use of cocaine or Eucain β solution in one to
four per cent necessary to accomplish good results.

The author considers the method in the first case objectionable both as
to patient and operator, entailing much discomfort to the one operated
on and demanding an unnecessary waste of time for the etherizing and
recovery. Likewise is the employment of a local anesthetic not indicated
or demanded, since the operation to be undertaken necessitates only the
pain associated with the prick of the needle through the skin.

The objection to etherization is obvious, while the hypodermic employment
of any local anesthetic, by the very fact of its presence of volume and
its physiological action upon the tissue, tends to interfere with the
proper injection of the parts by reason of temporary swelling of the
parts, not caused by the later injections of the prothetic mass.

If in nervous irritable patients an anesthetic is required to allay fear
it is best to use the ethyl-chlorid spray upon the skin sufficiently
to overcome the sharp sting of the needle insertion. For this purpose
the ether spray is used only to the point of blanching the skin, and no
longer.

This mode of procedure is especially useful when a number of injections
are to be made, as in the rounding out of a cheek or of the shoulders, in
which the contour cannot be restored from one point of injection, as will
hereinafter be described.

The patient, being now in readiness, the skin over the area is lifted or
pinched up with the fingers of the left hand of the operator as a guide
to its mobility and to steady the part.

The point of the needle is now forced through the skin and into the
subcutaneous tissue at a point along the periphery of the deformity and
pushed a little beyond the center of the cavity to be filled.

The elevation of the skin is in the meantime partly kept up with the
needle itself, while the syringe is grasped with the freed hand, the
thumb and forefinger of the right hand being placed upon the handle of
the screw or piston rod, which they must rotate to force the semisolid
mass from the instrument.

Before beginning the injection an assistant is instructed to press
with his fingers the tissue about the margin of the defect to prevent
the filling from becoming misplaced or being forced into undesirable
channels, especially if the skin over the defect is found to be thick and
inelastic.

The screw handle is now rotated evenly and slowly, discharging the mass
to be injected, which will soon be evidenced by the rise of the skin over
the depression to be corrected.

Only sufficient of the mass must be injected to fairly correct, never to
overcorrect, the defect.

Experience alone will assure the surgeon when this point has been
attained, since he cannot immediately judge the necessary amount
injected, as it will appear as a round or irregular lump under the skin,
until it has been molded or worked out into shape.

Owing to the pressure exerted upon the contents of the syringe, which
will continue to emerge from the needle for a time, the needle is left
in place for a few seconds before withdrawal, so that the needle canal
through the skin will not become filled with the semisolid mixture.

Such blocking up of the opening causes a cystic development or
enlargement about the opening in the skin by this backing up or
exuding, ofttimes crowding itself in between the layers of the skin and
necessitating later removal with the knife. If not this fault it tends to
keep the wound open unnecessarily after the operation, preventing healing
and permitting the escape of a certain amount of the injected mass, if a
mixture of low melting point has been utilized.

The needle, having been allowed to remain as advised, is now withdrawn.
The tip of one finger is placed over the opening in the skin and held
there gently, but firmly, while the mass is molded into the shape
required or desired with the fingers of the right hand.

If it now appears that the injection is insufficient the needle may again
be introduced through the same opening and more is injected, remembering,
however, that if the correction is quite normal no more should be added
for several days, or until the injected mass has become organized, which
should take place in about three weeks.

If it is found that the skin over the defect is inflexible and bound
down, it will be found advisable to sever or dissect subcutaneously
the adhesions that bind it down with the use of a fine tenotome or a
spear-headed paracentesis knife.

This may be done two or three days before the parts are injected to
assure the surgeon of an absolute cleanliness of the wound.

Mayo advocates the injection of a saline solution into subcutaneous
wounds thus made as a guide to the extent of dissection and to further
loosen the tissues.

When the parts, thus loosened, show little tendency to bleed, the author
advocates immediate injection, as the waiting for several days permits
the throwing out of new connective-tissue cells that interfere to a
certain extent with the proper injection of the part.

It is with such wounds that secondary elimination is most likely to take
place, especially if “Hart paraffin” or paraffin of a high melting point
has been employed.

This is undoubtedly due to the healing down and contraction of the
margins of the wound, which seems to progress more and more, encroaching
eventually upon the hard mass and ending in inflammation of the overlying
skin and ultimate elimination. With injections of softer consistency
this is less frequent and, in fact, may be entirely overcome by limiting
the amount of the injection at the first sitting, relying upon a full
correction for later operations, when the periphery of the wound has
become more or less influenced by the presence of the neutral mass
between the wounded surfaces.

The subcutaneous dissection referred to must, of course, be done under
local anesthesia, preferably the Schleich mixture or a one-per-cent
solution of Eucain β.

The injection of the paraffin, or hydrocarbon mixture, in semisolid
form, having been made and properly molded into shape, is set or fixed
by spraying the part with ether or by the application of sterile ice
cloths. When liquid paraffin has been injected it will be noted that the
paraffin in setting contracts upon itself considerably, leaving less of a
correction than anticipated.

The needle opening in the skin is next washed off with a
twenty-five-per-cent solution of hydrogen peroxid and closed over with a
drop of collodion.

The patient may then be discharged for the time being, with the
instruction to apply ice cloths to the part for at least twelve hours to
reduce, as far as possible, the reactive resultant inflammation.

On the third day the collodion patch may be removed and replaced with
isinglass adhesive plaster applied with an antiseptic solution. The
latter is allowed to remain on the skin until it falls off.


SPECIFIC CLASSIFICATION FOR THE EMPLOYMENT AND INDICATION OF HYDROCARBON
PROTHESES ABOUT THE FACE

Reference has been made heretofore to the general indications for which
subcutaneous injections of paraffin or its compounds may be employed.
With the object of systematizing such indications and to further
bring out the practicability and judicious use of the method under
consideration the author submits the following tabulated arrangement,
with the hope that it may lead to a more concise and better knowledge of
the possibilities within the reach of the plastic or cosmetic surgeon.

The face will be considered in such grand divisions as are easily and
readily understood, the defects of each part being shown under its
distinctive regional heading.


DEFORMITIES ABOUT THE FOREHEAD

    Transverse Depressions                     { Punctate.
                                               { Linear.
    Deficient or Receding Forehead:
      (Exhibition of Undue Superciliary Ridges.)

                  Unilateral Deficiency        { Surgical (Frontal Sinus).
                                               { Traumatic.

                  Interciliary Furrow          { Single.
                                               { Multiple.

                  Temporal Muscular Deficiency { Unilateral.
                                               { Bilateral.


DEFORMITIES OF THE NOSE

    Anterior Nasal Deficiency { Superior Third.
                              { Middle     ”
                              { Inferior   ”
                              { Superior Half.
                              { Inferior   ”
                              { Total.

    Lateral Insufficiency     { Unilateral.
                              { Bilateral.

    Lobular Insufficiency.

    Interlobular Deficiency.

    Alar Deficiency           { Unilateral.
                              { Bilateral.

    Subseptal Deficiency      { Partial.
                              { Complete.


DEFORMITIES ABOUT THE MOUTH

                                      { Unilateral.
                          { Upper Lip { Median.
    Labial Deficiency     {           { Bilateral.
                          {
                          {           { Unilateral.
                          { Lower Lip { Median.
                                      { Bilateral.

    Nasolabial Furrow                 { Unilateral.
                                      { Bilateral.

    Oral Angular Furrow               { Unilateral.
                                      { Bilateral.


DEFORMITIES ABOUT THE CHEEKS

                                  { Unilateral.
                        { Total   { Bilateral.
    Deficiency of Cheek {
                        { Partial { Unilateral.
                                  { Bilateral.


DEFORMITIES ABOUT THE ORBIT

                                            { Unilateral.
                              { Upper Lid   { Bilateral.
    Deficiency of Lid Contour {
                              { Lower Lid   { Unilateral.
                                            { Bilateral.

    Furrow About Canthus                    { Unilateral.
                                            { Bilateral.

    Deficiency of Ocular Stump              { Unilateral.
                                            { Bilateral.


DEFORMITIES ABOUT THE CHIN

    Anterior Mental Deficiency           { Partial.
                                         { Total.

    Lateral Mental or Angular Deficiency { Unilateral.
                                         { Bilateral.


DEFORMITIES ABOUT THE EAR

    Pro-auricular Deficiency   { Unilateral.
                               { Bilateral.

    Post-auricular Deficiency  { Unilateral.
                               { Bilateral.


SPECIFIC CLASSIFICATION FOR THE EMPLOYMENT AND INDICATION OF HYDROCARBON
PROTHESES ABOUT THE SHOULDERS, ETC.

    Supraclavicular Deficiency                 { Unilateral.
                                               { Bilateral.

    Infraclavicular Deficiency                 { Unilateral.
                                               { Bilateral.

    Interclavicular (Notch) Deficiency.

    Supra-acromion Deficiency                  { Unilateral.
                                               { Bilateral.

    Infra-acromion                             { Unilateral.
                                               { Bilateral.

    Supramammary Deficiency                    { Unilateral.
                                               { Bilateral.

                                               { Unilateral.
                                     { Partial { Bilateral.
    Mammary Deficiency               {
                                     { Total   { Unilateral.
                                               { Bilateral.

    Supraspinous Deficiency                    { Unilateral.
                                               { Bilateral.

    Infraspinous Deficiency                    { Unilateral.
                                               { Bilateral.

    Interscapular Deficiency.


SPECIFIC TECHNIQUE FOR THE CORRECTION OF REGIONAL DEFORMITIES ABOUT THE
FACE


TRANSVERSE DEPRESSIONS

=Punctate Form.=—Such deficiencies are either of sharply defined
depressions in a part of the frontal bone due to congenital malformation
or of traumatic origin.

In the first instance they are usually unilateral or median and rarely
ever bilateral. In those of the second class the deformity may be median,
but is more often found to be unilateral.

=Linear depressions= of the forehead are usually found to be congenital,
although traumatism in the form of direct violence may be the cause, as,
for instance, the kick from a horse or a severe blow or fall.

The acquired linear form of lack of contour is found in people of middle
life given to undue use or corrugation of the forehead, as in frowning.

The correction of this class of deformities may be accomplished by
carefully raising the depressed area by repeated injections of small
quantities, always avoiding the frontal and supra-orbital vessels.

At no time should such a deformity be corrected in one sitting, unless
when the defect is a congenital one of small moment.

The reaction following these injections, owing to the close attachment of
the integument to the bone, is usually found to be more severe than where
the skin is more loosely attached.

In traumatic cases the scar attachments should be freely liberated, under
eucain anesthesia, by the aid of a fine probe-pointed tenotome, before
the cold paraffin mixture is introduced.

In such event only one opening should be made and just enough of the
mixture be injected to raise the skin to its normal contour, if this be
possible. Generally, later injections are required, and these may be
made without further dissection. They should not be undertaken until the
incised wound made with the tenotome has healed thoroughly, otherwise
the pressure of the injection is liable to burst through the delicately
healed wound, and thus delay if not endanger the success of the first
operation.

When the reaction following such injections be severe, associated with
considerable edema, cold pack or ice cloths should be applied or resort
may be had to hot applications of antiphlogistin. The patient should be
kept on his feet during the day and sleep with the head high at night.
The bowels should be kept open, and general tonics be given if indicated.
The patient usually returns to the normal, except for a little tenderness
about the forehead, in three or four days under the treatment outlined.


DEFICIENT OR RECEDING FOREHEAD

In this condition there is usually a transverse lack of contour across
the forehead above the superciliary ridges, giving the patient a
degenerate appearance. The defect is congenital and is to be corrected,
as described in the foregoing division, although the injections may be
at either outer or temporal end of the forehead, gradually being brought
nearer to the median line until the contour of the whole forehead has
been raised by subsequent injections.


UNILATERAL DEFICIENCY

This defect may be traumatic—the result of direct violence, but is more
commonly due to a frontal sinus operation.

In both events it will be found necessary to detach the cicatrices that
bind the skin down to the injured bone, before a prothetic injection may
be undertaken.

In some cases where the cause of the deformity has been moderate and
the scar is linear and of long standing the injection may be undertaken
without subcutaneous dissection.

Several injections are necessary, as the tissue about such parts is
usually much thickened, apart from the firmness added by the scar tissue.

A short stout needle should be employed, the puncture being preferably
made under ethyl-chlorid anesthesia, as the pressure necessary to raise
the tissue causes considerable pain.

To further facilitate the injection the operator should raise the skin
with the needle introduced subcutaneously.

Only one injection of small amount (10 to 15 drops) should be done at
a sitting. The injected mass, unless too easily introduced, and thus
forming a tumefaction, need not be molded out, since the pressure of
the skin overlying it will accomplish it more satisfactorily, while the
pressure required in molding tends only to press out more or less of the
mass, thus lessening the benefit of the operation.

A second sitting must be undertaken in not less than one week, or even
later, if a subcutaneous dissection has been done.

The secondary treatment should be followed as heretofore described.
The reaction, for even a small injection in these cases, is usually
considerable.


INTERCILIARY FURROW

This deformity is usually spoken of as a frown. It may be said to be
congenital, when it appears in early life, but is commonly acquired
through the habit of frowning.

The furrow may be a simple linear one or made up of a number of furrows.
The author has been called upon to correct one made up of six distinct
furrows.

The furrows or creases radiate upward and outward, conelike from a point
beginning at the root of the nose.

In the correction of this common deformity the operator is tempted to
overdo the fault by hyperinjection. A single furrow is readily corrected
by a few drops of the injection, which should be neatly smoothed out.
A little of the mass at this part of the face seems to accomplish
considerable; in fact, the part seems overcorrected for some time after
a judicious and carefully done operation, which is undoubtedly due to
the active reaction that follows such cosmetic procedure, owing to the
close proximity of the frontal veins and those of the venous arch at the
root of the nose, which undergo more or less phlebitis of a mild type,
the resultant edema depending upon the pressure caused by the mass on
these vessels. The intimate relation and anastomoses of the latter is
clearly shown in the carefully prepared dissection represented in the
frontispiece.

In injecting, the needle should be introduced at a point directly at the
root of the furrow or furrows—that is, at the junction of the forehead
with the nose.

A needle one inch long should be used, taking care not to puncture any
of the veins which are found to be very differently placed in various
patients. If blood flows from the needle puncture, no injection should
be made at that point, but another be chosen which does not give such
result, preferably at a later sitting.

The needle should be introduced well upward under the skin so that its
point corresponds to the point of greatest depression.

The injection should be made slowly and continued until a tumor, judged
to be sufficient to overcome the major deformity when molded out has been
formed.

This knowledge can only be gained by experience, and the operator must be
cautioned to underinject rather than cause undue prominence of that part
of the face.

If, however, his judgment has not been accurate enough, the operator can
immediately thereafter squeeze out enough of the filling to give him the
desired correction.

If more than a single furrow is to be corrected, he may inject the two
center ones, leaving the outer for later operation.

In multiple furrows the injections must be made in conelike form, to give
a normal contour to the forehead. The apex of such cone corresponding to
a point at the root of the nose, and the base to an arc with its greatest
convexity near the median hair line of the scalp, depending upon the
length of the furrows.

The injections in such cases should be made at least three days
apart, two being made at each sitting, after the central or two inner
depressions have been raised by the first operations. These later
injections should be made to relieve the furrows lying next to the
median, gradually working out to each slant side of the cone until the
contour of the middle forehead has been made normal.

Never superimpose an injection about the median line until the major
defect in general has been overcome, and only then when the first
injections have become settled and organized, as such untimely
disturbance is liable to set up considerable reaction, with enough
induration and resultant new connective-tissue formation to cause a
decided lumpy or protuberant appearance of the part.

The mixtures of low melting points should be preferred to the harder
variety in frown corrections. They lend themselves to better molding, and
seem to undergo organization with less pathological change than those of
the latter class.

When the injections must be made over the inner third or half of the
eyebrows, as is often the case, they should be made well above the hair
line and molded out in an upward direction, to avoid the dropping down
of the mass into the upper lids or to prevent the resultant displacing
connective tissue from involving them.

If the upper lids do become involved, as shown by fullness, hardness, and
partial ptosis, the connective tissue causing the same must be carefully
cut out from the lid by a transverse semicircular incision made in the
upper lid along the line of its backward fold or hinge. If need be, an
elliptical strip of the skin of the lid may be removed at the same time
to give better scope to the extirpation under consideration.

The author has recently corrected two such cases where a surgeon had
hyperinjected the entire forehead with a combination of oils at one or
two sittings. The resultant involvement and later discoloration of the
lids at the end of a year’s time might have been expected.

Such wounds, when neatly sutured with No. 1 twisted silk, leave
surprisingly little scars; in fact, the cicatrices are rarely ever
detected a few days after healing has been established.

The treatment post-injectio for all furrow protheses should be as already
laid down.

Apart from general surgical cleanliness and an antiseptic powder, the
blepharoplastic operation mentioned required no special attention. The
sutures may be removed in forty-eight hours.


TEMPORAL MUSCULAR DEFICIENCY


_Unilateral and Bilateral_

This facial defect while possibly unilateral, as in hemiatrophy, is
generally met with in the bilateral form due to either hereditary causes
or a lack of nourishment of the parts, the latter usually involving the
greater part of the face. Chronic diseases and the cachexia dependent
upon disease may be the origin, in which the deformity is rarely ever
overcome entirely by internal treatment and massage of the parts; if
anything, massage tends to elongate the skin about the temples, causing
a worse disfigurement in the form of numerous fine furrows.

The correction of the defect under consideration may be readily overcome
by repeated and careful injections of a hydrocarbon of low melting point.

The author prefers the use of sterilized vaselin injected in its cold
state. The use of paraffin of high melting points or its compounds is not
advisable, and if employed leaves the temples uneven or lumpy, due to
the unequal organization or new tissue formation caused thereby, at the
same time causing sagging of the skin of the adjacent parts, particularly
the upper eyelids, owing to the added weight of the new tissue growth
occasioned by such preparations.

Contrary to general expectation, this part of the face is readily
injected and corrected.

The skin should be pinched up with the thumb and forefinger of the left
hand and the needle introduced with the right hand in such way as to
exclude the puncturing of blood vessels.

To assure the operator against such difficulty the needle may be
withdrawn after insertion, and if blood does not trickle from the wound
it may be reintroduced without pain to the patient and the injection
begun.

It is not advisable to correct the defect at one sitting. One third or
one half of the depressed area may be overcome by one injection. The
resultant tumefaction must then be thoroughly molded out, until little
seems to have been accomplished by the injection.

The operator trusts in these particular cases more to the development of
new connective tissue than in any other part of the face, except perhaps
in the correction of an interciliary furrow. It is surprising how much is
attained by the most conservative injections in and about the temples.

The molding of the injected mass must be done in a superio-posterior
direction to avoid forcing it into the upper eyelids, resulting in the
same overdevelopment previously referred to.

Both temples should be injected as advised at one sitting. The use of the
ethyl-chlorid spray makes the operation less fearful to the patient.

Subsequent injections should not be done earlier than three weeks or
until any discoloration of the skin of the parts has disappeared. The
latter is not an unusual occurrence, and is undoubtedly due to the
pressure of the injected mass upon the numerous blood vessels found there.

The post-operative treatment should be followed as heretofore advocated.


DEFORMITIES OF THE NOSE

The use of hydrocarbon protheses for the correction of nasal deformities
has revolutionized, to a great extent, the rhinoplasty of many centuries.
Through their employment many unsatisfactory cutting operations have been
entirely displaced, and it is quite right to hold that the introduction
of other subcutaneous protheses and like apparatuses of amber, celluloid,
caoutchouc, silver, gold, aluminium, ivory, or other nature have been
supplanted by this method of operation, when these were needed to correct
a partial deformity of the nose.

When a total rhinoplasty has to be undertaken the paraffin group of
protheses of course cannot be resorted to, owing to a lack of the
necessary retentive walls of tissue, except perhaps in such cases where
the so-called double flap, or French method, is employed, and there only
after the parts have become thoroughly organized.

A somewhat complete tabulation of nasal defects has been given heretofore
which gives an excellent idea of the extensive use these hydrocarbon
injections may be put to.

Such nasal deformities as are amenable to this method of correction
may be due to either congenital causes, lack of development, direct
violence, ulcerative changes following catarrh, syphilis, and tubercular
disease. In some cases, however, the defects are purely of a cosmetic
nature, and not considered as abnormalities except by the critical eye
of the patient. This is true particularly with lobular and supra-alar
deficiencies, as well as a slight lack of contour about the anterior line.

In some instances the defect may be an acquired one, as in the lateral
deviation known as handkerchief bend.

A specific and somewhat elaborate classification has been given to the
more important and distinctive deformities of the nose, principally to
facilitate the proper citation and recording of cases.

It may be readily understood that each one of these classifications may
be further subdivided, but such subdivision can be only of the degree or
extent of the deformity, and must be left to the individual operator and
his thoroughness of observation and nicety of recording.

The author prefers making a plaster cast of the entire nose which is to
be corrected, and a second cast after the operation has been completed,
or at the time of his discharge. A record sheet, or a direct photograph,
can be made before and after operation for the same purpose, which is
not so desirable, however, because it has been found quite impossible
to procure the desired accurate pictures of a nasal deformity, the
photographer not being given to bringing out imperfections as the surgeon
wishes them, even under the most explicit instructions, unless the
surgeon accompanies the patient to the studio to supervise the posing.
This requires a waste of valuable time; not to speak of the expense of
making pictures of a pathological nature. The better way would be to have
an apparatus in the operating room. The surgeon can then pose his patient
against a screen background in the position and to the size of picture he
may desire. Plate cameras and time exposures are best for this purpose.
For recording and half-tone reproduction silver prints are found best.

For all deformities of the anterior nasal line a hydrocarbon compound
of the higher melting points should be used. This should be injected
in the cold form. The mixture given on page 39, with perhaps an added
half dram or dram of paraffin, has been found excellent, the addition of
paraffin being made to assure a suitable fineness of contour and width.
The softer mixtures are more liable to cause a lack of contour and a
consequent widening of the part injected, even after molding, because of
the contractility of the skin overlying the injected mass, which tends to
flatten it out, giving the nose a less artistic and delicate appearance.

Furthermore, a soft mixture will be found to be inefficient in overcoming
the tension of the skin in most cases, especially those about the middle
third of the nose.

In some cases of lateral deformity, and where otherwise mentioned, it
is advisable to use only a mixture of the lower melting points, as in
the case in the correction of interciliary furrows and temporal muscular
deficiency.

=Superior Third Deficiency.=—The degree of depression about the superior
third or root of the nose varies considerably. The most extensive form
may be commonly found in the negro nose, where there is almost an absence
of a rise in that part of the nasal bones. Such noses are also found in
the Chinese and Japanese. The condition ofttimes may be associated with
epicanthus.

Epicanthus, formerly corrected by an elliptical excision done anteriorly,
can be entirely overcome by the subcutaneous injection method, thus
not only avoiding the resultant linear cicatrix, but building up the
depressed nose to its normal contour.

The skin overlying most of the defects of the superior third is usually
found to be loose, hence injection is readily accomplished.

[Illustration: FIG. 292. FIG. 293.

ANTERIOR SUPERIOR THIRD NASAL DEFICIENCY AND CORRECTION THEREOF.]

The needle should be introduced laterally and anterior to the angular
vessels to prevent their occlusion and injection. The point of selection
is made at about the middle of the deformity. The needle is introduced
until its point lies in the center of the depression, or at the median
line from the anterior view.

The mass is injected slowly as the skin of the nose is pinched up between
the forefinger and thumb of an assistant.

The part is injected until a tumefaction, equal in body to the extent of
the deformity, is attained.

The needle is allowed to remain in place for a moment, to permit of a
stoppage of the threadlike mass, usually following the pressure applied
to the piston, after the operator has stopped turning the screw. This
will prevent the mass from following into the channel made by the needle,
or the backing up of the mass, as it were. Should this occur the paraffin
mixture should be squeezed from the skin opening to prevent the formation
of an intercutaneous encystment.

Immediately the needle is withdrawn the operator places a finger tip over
the opening and proceeds with the thumb and forefinger of the right hand
to mold the mass into the desired shape.

The post-operative treatment should be as previously given, and is the
same with all injections about the nose, so that it will not be referred
to again under this heading.

While a fairly large defect can be corrected at one sitting, it is
advisable to rather reinject one or two weeks later to secure the exact
shape.

It is to be impressed upon the operator that there is always a slight
broadening of this part of the nose following the development of the
connective tissue which takes the place of the injected mass, hence the
injection should not be overcrowded nor the parts overcorrected.

The mass should be molded out as narrow as possible and be pinched
between the fingers by the patient two or three times a day after
the reaction has subsided, which is usually about the third day. This
procedure will keep the mass from being flattened during the time tissue
replacement takes place.

=Middle Third Deficiency.=—This defect is commonly seen in football
players and pugilists as the result of a breaking of the inferior
extremities of the nasal bones and the displacement of the articulating
cartilages, although the defect is often seen as a result of an injury to
the nose early in life, causing a lack of development in the superior or
articulating extremities of the cartilages. Nondevelopment from catarrh,
syphilis, and intranasal disease are other causes. This type of deformity
is generally designated as the saddle nose.

In the latter cases the skin is usually bound down to the cartilaginous
structure by cicatricial bands, and needs to be liberated. This is
accomplished subcutaneously with a fine tenotome introduced laterally.

To assure the operator of a thorough dissection he may inject the site
with sterile water through the opening made with the knife, squeezing it
out before injecting the nose.

If the skin has had to be freed by surgical means the mass injected
should be sufficient to overcome the defect almost entirely, to prevent
the reformation of the bands of connective tissue which have been
severed. Their re-establishment would mean an unequal development of the
new connective tissue springing up from the injected mass, thus defeating
the object of the operation.

If no dissection has been done the defect should be corrected about two
thirds and added to by a subsequent injection.

The mass in either case should be well molded out, especially at both
sides, to keep the nose as narrow as possible. There will be more or less
widening ultimately following the organization of the mass.

[Illustration: FIG. 294. FIG. 295.

ANTERIOR MEDIAN THIRD NASAL DEFICIENCY AND CORRECTION THEREOF.]

It is not uncommon to find a dividing wall of subcutaneous tissue about
the articulation of the nasal bones and cartilages, as evidenced by a
rising up or down of the injected mass above or below this line. If
this be found, rather than break down this wall with the injection, it
is deemed advisable to inject each chamber separately and mold the two
masses after injection, as in the ordinary type of cases.

=Inferior Third Deficiency.=—This deformity of the nose is due purely to
a lack of development or a luxation of the cartilage of the septum and
the upper lateral cartilages. The point or lobule of the nose is usually
tilted upward and the subseptum curved upward at its middle third.

The cause of this deformity is usually due to direct violence at some
time in life, with improper replacement at the time of injury. Syphilis
and intranasal catarrh, lupus and ulcerative diseases, are also causes.

The skin overlying the defect may or may not be closely adherent, but is
in most cases rather thickened and inelastic. It is therefore necessary,
in most cases, to loosen the skin by subcutaneous dissection, done as
already described before the injection is made.

To rebuild such a nasal defect without dissection, except in such
instances where the skin is quite elastic, is not to be advised, since
the injected mass would be flattened, more or less, antero-posteriorly,
giving the nose a broad and ugly appearance after the connective-tissue
formation has been attained.

It is with cases of this kind that paraffin injections introduced in the
liquid form and of high melting points are usually expelled in a week or
ten days, or even later, subsequent to a breaking down of the surrounding
tissues and the resultant abscess.

The best preparation to employ is the form of paraffin mixture advocated
in the preceding operation used in its cold state and injected slowly,
after the integument has been rendered mobile enough to permit the
desirable correction.

[Illustration: FIG. 296. FIG. 297.

ANTERIOR INFERIOR THIRD NASAL DEFICIENCY AND CORRECTION THEREOF.]

The defect should not be corrected in one sitting, for the very reason
that some widening of the nose may take place, owing to the contractility
of the skin, post-operatio.

The mass injected should correct the major part of the defect and be
molded out carefully, especially from both sides of the nose, and the
patient be instructed to pinch the nose laterally several times a day
after the reactive inflammation has subsided with the object of keeping
the nose as narrow as possible.

After the mass has been thoroughly replaced with connective tissue and
the anterior line is found to be too depressed, a fine line of the mass
about the thickness of the needle may be injected over it in a vertical
direction, the point of a fairly large needle being introduced just above
the anterior aspect of the lobule and thrust upward to the superior
border of the now existing deformity, and be slowly withdrawn as the mass
is injected.

This will leave a rounded cylindrical-like mass along the anterior nasal
line, which must not be molded at all, except to soften or shade off the
superior and inferior extremities.

The author advocates making two such injections, at the same sitting,
when the deformity has persisted. These injections are made parallel to
each other with a distance of about one eighth inch between them.

The subseptal deficiency will also have to be corrected. This will be
referred to later under its separate division.

The reaction in cases of this type is usually more severe than those just
mentioned. There may be considerable swelling and discoloration, but by
following the methods of treatment laid down heretofore the symptoms
usually subside in two or three days.

=Superior Half Deficiency.=—In this type of deformity there is found
a nondevelopment of the bridge of the nose, while the greater part of
the cartilage of the septum and the lower lateral cartilages seem to be
quite normal in contour. The nose has a dished appearance, with an undue
prominence of the nasal base or lower half.

Various causes may be given to this condition, but heredity is
responsible in a great majority of the cases.

The deformity in the type under consideration rarely takes in an accurate
half of the nose, there being an involvement more or less of the lower
anterior half, yet it is sufficiently distinctive to give it specific
classification.

For the correction of the defect in such cases the injection is made
laterally, the same mass being employed as in the preceding cases.

In this type of case the mass injected should quite correct the defect
and be molded with great care to a desired contour, keeping in mind
always the condition and elasticity of the skin overlying it.

An inflexible skin should be rendered mobile by digital massage,
practiced for a few days prior to operation, or in tense conditions be
loosened by subcutaneous dissection.

The great fault in injecting so large a quantity as is necessary in these
cases is to make the nose too wide from the very beginning, which, added
to the widening following the replacement by new tissue, makes the shape
of the nose unsatisfactory.

For this reason it will be found of some benefit to apply an anterior
nasal splint of aluminium, covered interiorly with a fold of white
flannel or gauze and pressed into such shape that when applied to the
nose it will keep the latter pinched up laterally to the desired width.
This splint will hardly ever be borne by a patient and causes great
discomfort until after the post-operative reaction has subsided. It may
then be bandaged or held in place by strips of Z. O. Adhesive plaster for
an hour or two in the day and during the entire night.

After the first few days’ wearing the patient soon becomes accustomed
to the splint. It should be worn as mentioned for about three weeks,
when the patient may be permitted to pinch the nose laterally with his
fingers two or three times a week or more.

The secondary injection may be made in the ordinary way or as advocated
by the author in the manner described in correcting defects of the
inferior third of the nose.

=Inferior Half Deficiency.=—In this type of deformity the greater point
of nondevelopment or deficiency is found at the upper extremity of the
cartilage of the septum, below its articulation with the inferior border
of the nasal bones, and involving to a greater extent the area over the
upper lateral cartilages.

This deformity, due to whatever cause, rarely affects the base or
inferior part of the nose, owing undoubtedly to the greater protection
and stability offered by the lower lateral and sesamoid cartilages and
the dense cellular tissue making up the alæ. Except in such cases where
violence of an extreme nature has been exerted in early life, or where
ulcerative disease has broken down most of the cartilage of the septum,
the point of the nose is usually normal in size and shape. In the latter
cases there is an upper tilt of the lobule and a shortening of the
columna upon itself with a convexity in an upward direction.

The cause of this type of deformity is usually a direct blow upon the
point of the nose, syphilitic ulceration internally, catarrh, or other
ulcerative disease.

When due to violence the point of the nose may or may not present a
normal appearance, there may be a normal base tilted upward (retroussé or
snout nose) or a dropping forward and downward (hook or beak nose).

The shape of the nasal base depends much upon the time of life the injury
was received—that is, before or long after puberty, also upon the extent
of injury inflicted and where applied.

From injuries received early in life we may look to a lack of development
in the cartilage of the septum alone, or associated with deficiency in
one or both lateral cartilages.

The deformity is usually symmetrical, but where the nasal bones have been
injured as well, particularly where one bone is injured more than its
fellow, there is a possibility of the disfigurement being unilateral.
This is rarely the case except when due to punctured wounds; generally in
such cases the anterior nasal line assumes a twisted form.

Some operators have included noses of undue lobular prominence (à la
Cyrano de Bergerac) under this type of deformity, and while it is to
be admitted such a nose might be built up by subcutaneous prothesis
the result is anything but harmonious or normal. Such a nose should be
reduced by cutting operations instead of being added to. The seeming
depression above the lobule is only comparative to the overdeveloped form
of the lobule. The face values of every patient should be studied, and
the surgeon should never attempt to break up the harmony of facial form
by simplifying an operation and rendering the patient’s appearance even
more ridiculous than before his attempt to correct a fault.

The correction of the deficiencies of the lower half of the nose is
associated with difficulties in various directions. Either the skin over
the defect is too dense to render injection an easy matter, or the nose
is so broadened horizontally from the original injury that the injection,
no matter how artistically done, leaves the nose bulky and ugly in
appearance.

When the nasal processes of the superior maxillary bones have not been
widened unduly by an injury and the skin is dense, simple subcutaneous
dissection before injection will overcome the difficulty easily enough.

In that case the needle is inserted laterally in a line with the maximum
depth of the depression and the point shoved up to the median line
anteriorly.

Enough of the cold mixture of paraffin and vaselin, as heretofore
advised, is injected to reduce the deformity nearly to the normal.

The mass is molded to give the nose as near a normal contour as possible,
always keeping in mind the later broadening of the nose when the new
connective tissue has taken the place of the injected mass. A later
injection made, as advised heretofore, will restore the anterior line to
better form.

If the nasal processes of the superior maxillary bones have been thrown
outward considerably a surgical operation is necessary to reduce them.

No injection should be made until the wounds from such operation are
thoroughly healed and contracted.

In all cases of this type the skin will be found to be rather dense and
likely to be tied down by past inflammations to the anterior aspects of
the lower lateral cartilages at their juncture with the upper lateral
cartilages. If the adhesions are not too dense the harder form of the
cold mixture should be used. This will not only permit of raising the
skin more readily than with a softer kind of mixture, but will be more
likely to retain its form under the contractile pressure brought to bear
down upon it.

When the skin is closely adherent it should be loosened subcutaneously,
as already advised. The injection may be done at the same sitting, and be
of greater quantity than in the cases where this had not been done, for
the reasons mentioned.

Pressure splints and manual compression should be employed as in the
preceding deformity.

The reaction following the first injection is likely to be severe. Cold
applications, as previously referred to, are indicated, and should be
continued for at least two days.

Care should be taken not to inject into the lateral vessels, which
usually lie on a line with the juncture between the lateral and lower
lateral cartilages. If this should happen, the point of the nose at
once assumes a bluish hue, and there is more or less pain felt at once,
with considerable swelling a few hours after the injection. Later,
every symptom of gangrene of the lobule is liable to be noticed, yet
with faithful attention to furthering the circulation of the parts
by either cold or hot applications, the active inflammatory symptoms
usually subside in ten to fourteen days, leaving the patient with a whole
nose, more or less colored at the lobule, according to the state of the
circulation and the exposure of the parts to the various temperatures.
This may be overcome in time, yet it may persist for years, depending
entirely upon the ability of the anastomosing vessels to overcome the
artificial thrombus or occlusion offered by the mass injected.

That a reaction quite similar in character, but of milder degree, is
likely to be seen when one of these vessels has not been injected,
can be readily understood when we consider that a hard and somewhat
ungiving mass is made to overlie the vessels themselves. The symptoms
just described in such case are apt to be noted much later, even
several hours after the injection, because the swelling has then begun
to add its pressure to that of the mass in obstructing the flow of
blood to the lobule. Such condition may be termed pressure occlusion in
contradistinction to thrombotic obstruction.

These symptoms usually subside in a day or two, or with the swelling
caused by the reaction.

If the symptoms appear at once after the injection, it is best to force
out as much of the injected mass as is possible through the needle hole
through which it has been introduced.

[Illustration: FIG. 298_a_. FIG. 298_b_.

ANTERIOR, SUPERIOR AND INFERIOR THIRD NASAL DEFICIENCY AND CORRECTION
THEREOF.]

The author was called to attend a case several hours after the operator
had injected a nose. The acute symptoms pointed to a direct occlusion
of the vessels, yet the surgeon who had performed the operation assured
me he had not injected until he found that blood did not flow from the
needle after its insertion. To relieve the patient of immediate fright
and some pain, a dull pointed needle of larger caliber than the one
used in operation was pushed through the needle wound previously made,
taking the place of a cannula, and a greater part of the injected mass
was squeezed out. Ice cloth applications were followed through the night
and the nose recovered in three days without showing the discoloration
of the skin usually observed following such cases. The nose was never
injected again, on account of the dread of the patient, but peculiarly
the anterior line showed almost a normal contour after four weeks had
elapsed. This only goes to prove that very much less of the mass to be
injected is required than is commonly supposed by operators.

=Total Anterior Deficiency.=—In this condition there is a scooped-out
or general curved-in appearance of the entire anterior nasal line. The
lobule of the nose is usually normal in size.

This defect should be corrected by two injections of the paraffin
compound previously referred to. The points of injection should be
lateral and anterior to the angular vessel on the side of the nose
preferred by the operator—one about the center or major curvature and the
other about the inferior third.

Care should be taken to mold the injected mass as narrow as possible, or
as much as the skin will permit. If the latter is bound down it should be
mobilized by subcutaneous dissection or levation. A subsequent injection
should not be undertaken until the entire mass has become settled or
fairly organized, which is about the end of three weeks.

The mass should be injected well up to the root of the nose to give it
the appearance of the normal bridge. If this is found impossible owing to
a dividing skin attachment, a third needle puncture should be made at a
point on a level with the internal canthus.

[Illustration: FIG. 299. FIG. 300.

ANTERIOR TOTAL NASAL DEFICIENCY AND CORRECTION THEREOF.]

Care must be exercised to keep the mass from creeping into the loose
tissue about the internal canthi by having an assistant press the sides
of the nose at that point with the thumb and forefinger.

This undesirable condition is much more liable to occur when a hot liquid
paraffin is employed, since the operator can observe quite accurately the
extent and direction taken by the mass injected when the cold product is
used.

Some authorities have injected noses of this type from the point of
the nose, but it will be found that the position of the puncture at
this point allows a considerable portion of the mass to work out during
molding and also to permit of the readier oozing out of the mass during
the pressure exerted by what reactive inflammation follows the operation.
This is accounted for by the fact that the needle creates a tubelike
canal in the tightly bound down tissue overlying the lower lateral
cartilages, whereas in the lateral punctures the short canal is easily
displaced by the swelling, thus causing its obliteration and preventing
the free oozing.

On the other hand, it will be found to be more difficult to inject
from the point of the nose alone and that a very long needle has to be
used which must be withdrawn as the parts above the point are filled.
Furthermore, it will be found necessary to thrust the point of the needle
in different directions to overcome vertical attachments of the skin
which are more readily lifted up than thrust aside by the mass, hence
necessitating a greater amount of injury to the tissues, not to speak of
the possibility of injecting transverse blood vessels higher up in the
nose of which the operator would not be aware at the time; showing only
in the resultant phlebitis and unexpected reactive symptoms, associated
with a discoloration more or less lasting according to the extent of
obliteration of the vessels.

The post-operative treatment should be as heretofore advised.

=Lateral Insufficiency= (_Unilateral and Bilateral_).—Depressions about
the sides of the nose are usually due to hereditary causes, when they
are likely to be bilateral, yet intranasal ulcerations may cause a
falling-in, as it were, of either one or both nasal walls, involving
in such instances the entire side or part of it. In the partial cases
the depression may be in any of the division of thirds used by the
author—that is, it may lie laterally over the region of the nasal bone
and such of the nasal process of the superior maxillary bone as goes
to make up that part of the nose, or in the middle third below the
bone structure and above the superior limitation of the lower lateral
cartilages, or within the lower third over the inferior border of the
cellular tissue making up the nasal rim.

Traumatism may be found to be the cause of such depressions, especially
in the middle third, after fracture or luxation of the nose. In such
cases the defect is usually unilateral or at the seat of the former
injury, a convexity usually being exhibited on the opposite side.

Since the skin is rather firmly adherent at the sides of the nose,
except in the major part of the superior third, it will be found best to
raise the skin of such defect into normal contour by a series of very
small injections instead of following the method heretofore advised in
connection with tense or adherent areas of skin, for the reason that such
dissection would render the skin too mobile over an area usually beyond
the defect itself and inviting the surgeon to an annoying hyperinjection
which renders the part more unsightly than prior to the operation. This
is true in most cases unless the depression is of traumatic origin and
beyond the size of deformity usually corrected.

The author advocates the employment of a hypodermic needle attached to
the syringe in place of the regular needle and that the injection be of
sterile white vaselin without additions of any kind.

Such injections may be made very readily, one or more at the first
sitting, being introduced below the deepest part of the defect. It
is surprising how much four or five drops of such an injection will
accomplish. Furthermore, it is to be remembered that the injections about
the side of the nose are readily replaced by new connective tissue, equal
to, if not commonly greater in amount, than the mass injected, such
growth being completed in about two months after the time of injection.
This may be explained by a more or less active perichondritis when the
injection is made over the cartilage, the inflammation, thus set up,
being of longer duration than where the skin and bone or areolar tissue
are involved. Any subsequent injection should not be undertaken until at
the end of two weeks or more for the reasons above stated.

The injected mass at all times should be introduced under normal
pressure, never to the extent of rendering the skin above it white in
color. The mass should also be molded out with the tip of the finger or
the rounded, dull handle end of a scalpel. If necessary, the small finger
may be introduced into the nostril to facilitate this molding. Should
the reactive inflammation be severe such remedial agents as have been
referred to should be used to reduce it.

Phlebitis following injections at the side of the nose is due entirely to
the injection of a blood vessel and must be avoided. When a fine needle
is used there is less likelihood of free bleeding from an injured vessel,
therefore a thorough knowledge of the usual position of the vessels about
the sides of the nose is absolutely essential. Bleeding of greater extent
than that which would follow the thrust of the needle through the skin
should put the surgeon on his guard. Experience is the better teacher and
conservatism in these ofttimes delicate, subcutaneous operations will
save the surgeon much annoyance and eventually the need of having the
patient submit to a cutting operation to reduce an overcorrected area.

Should a hyperplasia of connective tissue result from such an operation,
a small linear incision, under four per cent eucain anesthesia, should be
made directly over the greatest prominence, through which the offending
mass can be removed by the aid of a small hooked knife or a fine pair of
curved scissors.

The mass should be removed beyond the plane of the skin; in fact,
it should be rather removed in conelike form, apex inward, and the
peripheral attachment completely obliterated, in order to obtain the
desired result, as it is not unusual to have the prominence reappear
after imperfect extirpation and improper dissection.

Moist pressure dressings may be applied over the small wound thus made,
for several days, or until the inflammation following the operation has
subsided. Suturing such a wound is hardly necessary, but if the incision
be over one fourth of an inch long, two fine silk sutures, deeply placed,
may be utilized, their tension adding to the compression needed to bring
the mobilized skin into position in reference to the base of the wound.

The author has used contractile collodion in place of compress dressings
with very good result. This should be renewed within forty-eight hours.

After eight or ten days silk isinglass adhesive plaster is applied over
the wound until it falls off.

=Lobular Insufficiency.=—This defect of the nose is usually of hereditary
origin, although it may be occasioned by the retraction of the inferior
half of the organ in tubercular or syphilitic ulceration in which the
lobule falls inward and upward by the loss of the retaining cartilages.

Owing to the close adhesion of the skin to the lower lateral cartilages
and the cellular tissue about the rim of the alæ it is found difficult to
restore the contour or elongate the organ at that site by subcutaneous
injection.

Even after thorough mobilization of the integument the subsequent
injected mass is liable to be thrown off by an overactive inflammatory
reaction, due undoubtedly to the adhesions formed between the divided
surfaces from the periphery inward which has a tendency to crowd the
injected mass forward and downward before a new connective tissue has
had time to be formed, causing a breaking down of the skin at some point
overlying the mass and allowing it to escape.

The author has attempted to replace the injection by small solid
paraffin plates introduced through a small lateral incision made for the
subcutaneous dissection, and while the wound healed readily enough and
the nose appeared normal, the plates were in every case thrown off by a
later inflammatory process before the end of the third week.

The author then attempted to replace the solid plates with granular
paraffin, gently packing the latter into the wound until the desired
elevation had been obtained with the idea that such mass would
accommodate itself much better under the pressure caused by reactive
inflammation, but even this procedure proved unsuccessful.

The best results are obtained with sterilized white vaselin injections
when there is considerable mobility of the skin. A single needle opening
should be made, preferably about the center of the side of the lobule, or
slightly anterior to this point, carrying the point of the needle forward
to the anterior median line and a little above the actual point of the
nose.

The injection should be made slowly, closely watching the size of the
elevation caused by the mass and the state of the circulation about the
entire lobule.

Usually ten drops of the mass suffice to give the desired result. The
mass may be molded out if found desirable, but if the skin appears normal
after the operation and the tumefaction thus made does not make the
nose look grotesque, it may be allowed to remain as injected, depending
upon the subsequent reactive pressure to force it into shape. In this
way a greater part of the mass is retained at the wanted site and is
not crowded to the sides of the lobule by the customary post-operative
molding.

Even with this method great care must be exercised in not injecting too
much at each sitting. A failure is sure to result in hyperinjection about
the lobule. When it be remembered that only a very small quantity of the
mass will make a decided difference, the surgeon and patient should be
satisfied with the slightest gain.

If, however, the mass be retained and further elongation of the lobule is
desired, a subsequent injection can be undertaken, but not until a full
month after the primary operation.

Here, as with lateral nasal injections, there seems to be an
overproduction of new connective tissue following such an injection; a
decided factor in eventually pleasing the patient.

It is needless to say that the operator must avoid injecting one of the
blood vessels of the lobule, as this will cause considerable inflammation
from which the lobule does not recover readily, owing to the dense tissue
the surgeon has to deal with, leaving the tip of the nose discolored and
bluish for some time after the operation.

If the injected mass causes an immediate venous stasis of the lobule,
hot applications should be applied at once, or as soon as the operator
discovers that the proper massage and pressure to remove the offending
mass does not improve the circulation.

The author advocates the judicious use of antiphlogistin, faithfully
applied hot every six hours and continued until the acute inflammatory
symptoms subside, when the surgeon may resort to ice cloths or cold pack
until the danger of pressure and resultant gangrene have subsided.

Despite the very grave symptoms associated with such inflammation,
the operator may assure the patient against permanent disfigurement,
although the three or four weeks’ duration of treatment, usually required
in such cases, is an ordeal the cosmetic surgeon and the patient are not
liable to forget.

If the injected mass causing this state of affairs has been of liquid
paraffin, the better method to pursue is to make several small incisions
into the site of the injections and remove the little masses of solid
paraffin as far as possible with the view of relieving the pressure
or encroachment, at the same time alleviating the pain and stasis by
the resultant depletion. Moist, hot applications should follow this
procedure. The small wounds made in the skin will heal without suture,
leaving hardly any perceptible scar.

The author, however, advises against any mixture or liquid paraffin
injections about the lobule, never having seen a satisfactory result when
either had been employed.

The post-operative treatment in uncomplicated cases may be of aristol and
adhesive isinglass plaster or collodion.

=Interlobular Deficiency.=—This condition is hereditary in the great
majority of cases. The defect, while quite disfiguring, giving
the appearance of a cleft nasal point, is easily corrected by the
subcutaneous injection method.

Paraffins of high melting points should, however, never be employed for
this purpose for diverse reasons: first, the hardening of the mass after
cooling causes too much pressure upon the small blood vessels at the
point of the nose and results in more or less permanent discoloration of
the tip; second, by reason of the pressure of a hard mass, at the end of
the nose, considerable inflammation results which usually terminates in
the evacuation of the entire mass and consequent cicatrization; third, by
virtue of the greater irritating qualities of paraffin a greater amount
of new connective tissue than necessary is thrown out, causing a general
and hyperplastic rounding of the entire tip of the nose that requires
surgical interference to overcome. In the illustration shown the
patient’s nose was injected along the entire anterior line and the lobule
with paraffin liquefied under heat. A marked post-operative inflammation
resulted, with permanent redness of the entire organ and several decisive
capillaries showing about the sides and tip of the nose. This was
followed in about six weeks by a progressive hyperplasia which left the
nose about three times its natural size, and the lobule a hard, ball-like
knob of high red color. Several cosmetic operations were required to make
the nose appear anywhere near normal, while the electrolytic needling
process was resorted to for a number of sittings to destroy the acute
redness and the individual vessels showing.

[Illustration: FIG. 301.—UNTOWARD EFFECT OF PARAFFIN INJECTION ABOUT
LOBULE AND ANTERIOR NASAL LINE. Scar lines on nose indicate the various
attempts made to reduce the resultant hyperplasia.]

While a great many workers with paraffin deny any beneficial results from
the employment of sterile white vaselin for subcutaneous injections, the
author claims that in this particular class of deformity it is almost
exclusively required.

The vaselin in cold state should be injected directly under the skin
overlying the deepest point of the cleft and be slowly continued until
the lobule assumes its normal contour. The puncture may be made below the
point of the nose.

One such injection usually suffices to correct the fault. The reactive
symptoms are not severe if proper technic has been applied, and cold
compresses usually relieve it within twenty-four hours.

Should the skin be adherent about the anterior aspect of the lower
lateral cartilages, it can be forced away with a small, dull,
round-pointed knife resembling an eye spud, the opening for which need
not necessarily be greater than that made for the needle. The latter
is inserted through the same opening, which must be closed over in
this event with a drop of contractile collodion into which aristol is
introduced with the pulverflator, which not only embodies an antiseptic,
but at the same time hastens its hardening.

=Alar Deficiency= _(Unilateral and Bilateral)_.—The contraction about the
nasal rims may be due to hereditary causes or the result of intranasal
disease. The defect is usually bilateral, involving the entire alæ or
only their lower half or third.

The fault should be corrected by several injections made along the rim
of the nasal wing, using a fine needle, preferably of the hypodermic
size. Vaselin only should be used and two or three drops, according to
the extent of the deformity, be injected into the cellular tissue at the
point of each needle insertion.

Three of such punctures may be made along the rim, one beyond the other
in each wing. According to the defect the injection may be carried
higher or lower above the margin of the rim by shoving the needle upward
and toward the inferior border of the lower lateral cartilage.

The reaction in these cases is very little, rarely necessitating other
than an antiseptic powder-plaster dressing. Subsequent injections should
be made if the first do not give the desired contour; but never until the
surgeon is satisfied that the resultant new connective tissue thrown out
has reached its ultimate growth.

The harder paraffins, especially those injected in the liquefied state,
are not to be tolerated for the reasons given with the preceding method
of correction.

=Subseptal Deficiency= _(Partial and Complete)_.—It is not uncommon to
find a marked concavity of the subseptum in noses that have sunken in by
reason of intranasal disease or traumatism.

This concavity, when partial, is usually most marked near the lobule,
but in the complete variety the upward curve may be greatest near its
juncture with the lip.

Owing to the usual adhesions formed during the inflammatory period
causing the deformity the correction of this defect is quite difficult.
As a rule, the skin of the entire subseptum needs to be dissected away
from the underlying structure before it will permit of correction by the
injection method.

This dissection is advocated and can be readily done from one of the
nostrils at a point just beyond the union of skin and mucous membrane.

The dissection under such method can be made more thoroughly than when
done exteriorly, for the reason that the entire field is laid open to
a free use of the scalpel, leaving no visible cicatrix externally. The
dissection may be followed by the immediate injection of the mixture of
paraffin and vaselin, as already referred to, used cold, or the area is
injected with normal salt solution until the intranasal wound has healed,
which usually takes place in about five days. The mucous membrane in
such instance may be neatly but not too tightly sutured with No. 1 silk.
If the operator deems it advisable he may inject the salt solution again
on the third day to prevent the formation of such adhesions as may
interfere with the ultimate hydrocarbon injection. This is rarely found
necessary.

If the post-operative inflammation prove mild, then the adhesions will
not be as tenacious, in which case the surgeon may wait until even the
seventh or eighth day before injecting the paraffin compound, to be sure
of not forcing the intranasal wound apart under the pressure of the mass
injected.

Never should so large a quantity of the mass be injected as to cause
blanching of the narrow strip of skin. This is sure to result in gangrene
of some, if not all, of the skin of the subseptum—a result much to be
regretted, since subsequent correction of the deformity increased by the
contraction of the dermal cicatrix is rendered well-nigh impossible by
reason of this very tissue.

Hard paraffin injected in its molten state is never borne in this part
of the human economy. It is usually thrown off after a few days of very
painful and highly inflammatory symptoms, undoubtedly explained by the
fact that the circulation of the subseptum is principally dependent upon
the delicate branches of the two small septal arteries of the superior
coronary and a hard, ungiving mass would readily cause their obliteration.


DEFORMITIES ABOUT THE MOUTH

=Labial Deficiency= _(Upper and Lower Lip)_.—There are a number of causes
creating deficiencies about the labial orifice. The same causes apply
naturally to both lips, whether the defect be unilateral, bilateral,
or median. Some of these deformities are more often met with than
others, as, for instance, a median deficiency of the upper lip following
cicatricial contraction due to a harelip operation done early in life;
in elderly patients a partial paralysis is found to affect one half
the upper and sometimes a part of the lower lip, giving to the mouth a
drooped and grinning appearance.

Other causes are dental defects, abnormalities of the alveolar processes,
traumatism, and disease.

In those conditions where loss of tissue is responsible for the defect,
as in the extirpation of neoplasms, ulcerative disease, etc., it is
quite likely that cheiloplasty is required to rebuild the parts, but in
many of these cases splendid results may be obtained by the judicious
use of hydrocarbon protheses to overcome the usual post-operative
oral distortion. It is understood that such injections should not be
undertaken until the wounds are thoroughly healed and the cicatricial
union fully contracted. This is true also in harelip operations
undertaken later in life.

The correction of labial defects coming under this method is not at
all difficult, but artistic skill and judgment are as necessary as the
surgical technic.

The lips are plentifully supplied with blood vessels, and therefore
greater care in injecting a foreign mass into their structure is
necessary; furthermore, the lips cannot be placed at rest for any long
period of time, so that the mass injected can never be expected to be
kept in place if of a consistency hard enough to permit the contraction
of the orbicularis muscle to move it about.

From the very fact of this practically constant movement of a part it is
self-evident such hard mass could not be retained or held in position for
any length of time, unless the mass is small enough not to be affected
by the movement, and under such condition the correction of a defect as
desired by the patient would require perhaps months to accomplish, owing
to the very fact that only droplike masses may be deposited under the
skin in perhaps a half dozen places with the necessity of a long period
of rest until the injections have been replaced by the new tissue before
the next operation could be undertaken.

It is absolutely absurd to think of injecting a lip with hard paraffin
liquefied by heat and expect to obtain a satisfactory result. While it
is true the mass is moldable immediately after its introduction, so
that a desired shape may be obtained, it does not overcome the fact,
however, that the mass must harden, as it will, and that, while a part
of it is broken away, as it were, from the mass proper, there is a
nuclear contraction as the hardening takes place, thus overcoming partly
the molded form; furthermore, the movement of the parts here tends to
displace the mass. Unequal muscular contraction breaks up not only the
form but also the mass itself, during all of which time it is made to
act as an irritant by virtue of the movement of the uneven edges of the
paraffin upon the adjacent tissue.

Furthermore, the presence of paraffin and the resultant mass of new and
hard connective tissue, so well recognized by all experienced surgeons,
is not desirable in the lip structure; it makes the lip appear bulky and
hard and anything but natural.

It is in these very cases that the injections of cold sterile white
vaselin is indicated. After injection the mass may be evenly and
satisfactorily molded out, the mass being soft and readily pressed into
shape in the various cells of areolar tissue without leaving hard and
uneven lumps.

The movement of the lip is not then a source of danger in displacing
the mass, since the acute swelling of the lip tissue prevents its free
movement for several days, which gives the injected mass an opportunity
to establish itself and find its proper place.

Another advantage in using this preparation subcutaneously is that it is
less irritating than hard paraffin, permits freer movement, and creates a
better production of new connective tissue.

While a part of the mass may be absorbed during the replacement period
the lip retains its normal consistency, and if the desired contour has
not been attained a subsequent injection may be made in three weeks’ time
without interfering in any way with the former result.

The only precaution, aside from avoiding the injection of blood vessels,
is to keep the injection from the prolabium or vermilion border. The
latter tissue is very prone to fatty degeneration or to yellowish
discolorations when such a foreign mass has been introduced into or near
its structure.

There is no objection in injecting the lip, upper or lower, in several
places, as the cellular network about the mouth is sufficiently dense to
prevent the escape of the vaselin injected from the adjacent opening if
the distance is not less than a half inch between the punctures.

The injections may be made from above downward in the upper lip and, vice
versa, in the lower. They should be begun at the outer angle working
toward the median line.

The reaction following such an injection is usually more severe than in
any other tissue of the face, owing to the great number of fine blood
vessels, but the swelling is readily controlled in two or three days by
cold applications.

Aristol collodion dressings over each wound suffice to close the
punctures.

In the median variety of defect, where a cicatricial band separates
the lip into halves, it may be found necessary to do a subcutaneous
dissection before a suitable injection can be done, but in cases of
long standing the dividing wall is exceedingly thin and the threadlike
adhesions below are quite easily broken up by the force of the injection.
The later product of new connective tissue will tend to further improve
the contour.

=Nasolabial Furrows= _(Unilateral and Bilateral)_.—This condition in the
bilateral form is exceedingly common in adults beyond middle age. It is
also found in those individuals suffering from inanition, due to whatever
cause. The unilateral form is found principally in patients suffering
from semifacial paralysis in which the tissue lacking the proper neurotic
supply droops or sags down, causing a deep furrow to appear from the
attachment of the alæ to the angle of the mouth, associated more or less
by a flattening of the cheek contour of that side of the face.

The method of correction advocated by the author varies entirely from the
technic advanced by other surgeons.

The usual method has been to introduce the needle of the syringe at the
outer or lower extremity of the furrow and from one of such punctures to
inject the whole line of depression.

While this seems right theoretically the method does not give the desired
result. Owing to the free movement of the upper lip the mass, at first
neatly restoring the contour, is crowded upward into the inferior malar
region and very often downward toward the angle of the mouth, where it
settles in a hard lump which is not only obnoxious to the sight but
interferes with the proper use of the parts concerned in mastication
and vocalization. Invariably the operator is called upon to remove the
disfigurement.

It can be readily understood that hard paraffin itself, in such case,
would prove more objectionable than a softer mass which, upon early
discovery, could be molded or massaged into better position, while
nothing less than excision would prove efficacious with paraffin.

As with the lip, then, the author advocates the use of either the cold
mixture of paraffin, as heretofore described, or the cold white vaselin
according to the operator’s opinion in overcoming the extent of the
fault. For all ordinary cases white vaselin alone is necessary.

The technic of injection as used by the author is as follows: In the
ordinary case when the furrow is not too pronounced one sitting only
is required. Two needle punctures are made above the upper line of the
defect, the first being made about one half inch from the wing of the
nose and the other about one inch outward and downward.

The needle is pushed downward under the skin until its opening
corresponds to the median line or deepest part of the furrow. Enough cold
white vaselin is injected to bring the depressed area slightly above
the plane of the skin of the upper lip. The second puncture is made
perpendicular to the first and the injection made in the same manner.

With the tip of the indicis over the first needle opening the mass is
molded out evenly by a gentle rocking or rubbing movement. The same is
done with the second mass.

It will be found, then, that the two masses are made to meet at about the
center of the furrow, leaving a slight wall of tissue between them. This
wall has the virtue of preventing the falling down of the upper mass, at
the same time dividing the quantity of the injected mass into two, and
lessening the weight.

If the condition is bilateral both sides are operated on at the same
sitting. If subsequent injections are needed they are done three weeks
later, the punctures being made between the former first and second
punctures and the second and outer border of the furrow. In this way the
entire site is filled with a series of injections.

If the surgeon desires he may increase the number of these needle
punctures at the first sitting, making them nearer together in that event.

It will be found necessary in some cases to inject the cold mixture of
vaselin and paraffin into the furrow directly below the wing of the nose,
since the integument at that point requires a mass somewhat harder than
vaselin to force and hold it up.

The rest of the furrow must, however, be injected with vaselin alone, for
the reasons already given in parts that are movable.

The reaction is rarely very marked and subsides in about three days.

Gentle massage may be permitted above the site of injection to keep
the mass from crawling into the cheek. This is done by gently stroking
the skin from below upward toward the nose on a line an inch above the
original depression.

The dressings are the same as before mentioned, although collodion
painted over the needle openings is most serviceable after having sponged
off the sites with absorbent cotton dipped into absolute alcohol to
remove the vaselin that may have exuded from the openings during the
molding-out process.

=Oral-Angular Furrow.=—These furrows occur at the corners of the mouth,
running downward upon the anterior chin. Small as these defects appear,
they are found difficult of obliteration, for the reason that the tissues
are more or less under constant movement during the waking hours.
Repeated injections, each of small quantity, are necessary. Hard paraffin
is contra-indicated.

The injections are made from above the defect downward at right angles to
the defect.

It will be found difficult to keep the mass from being expelled on
account of the movement, there being more or less oozing from the
puncture, but if the openings can be controlled for at least twenty-four
hours this danger may be overcome to a great extent.

Ethyl chlorid may be sprayed over the part immediately the needle is
withdrawn to set the mass and followed with a drop of collodion. The
patient is advised to keep the mouth as immovable as possible for the
rest of the day.

The reaction is never severe, and is easily controlled by cold
applications. If, after one week, there is shown a tendency to sagging
of the mass, it should be gently massaged upward with the finger several
times during the day for at least two weeks; this will keep it in place,
and allow nature to replace it with new connective tissue when desired.


DEFORMITIES ABOUT THE CHEEKS

=Deficiency of Cheek= _(Total and Partial)_.—A total lack of proper
contour of the cheek, generally termed flattening, may be due to
hereditary causes, but is generally dependent upon a cachexia due to a
general disease, or fatty degeneration of the muscular structure of the
cheeks, as found in those beyond middle age.

A partial deficiency of the cheek or cheeks is usually hereditary, but
may be dependent upon digestive disorders or other causes of malnutrition.

This class of deformity is found more often in women than men. It is
usually bilateral.

Unilateral cheek deficiency, whether partial or total, may be congenital,
but is often the result of a local paralysis causing hemiatrophy.
Traumatisms early in life or during birth and amputation of the inferior
maxillary are other causes.

This class of deformity is quite readily corrected by subcutaneous
injection; in fact, it is the only known method of merit, superseding
the former resort to partial correction by massage or artificial and
temporary correction by the wearing of plumpers in the buccal cavity.

The method of procedure is the same in all cases, the number of
injections and quantity varying, of course, with the extent of the defect.

As with the rebuilding of the contour of the lips so with the cheeks,
which must of necessity be mobile and flexible, the injection of hard
paraffin is out of the question. The author has observed a number of such
cases, and is free to say that in each case the result was not only
abnormal in appearance, but a source of great annoyance to the patient.

What is worse is that the paraffin once injected can never be removed
except in places where an actual encystment has taken place, in which
case the hard mass may be removed through a small incision made directly
over the mass and introducing a grooved director into the opening then
by the rotation, or to-and-fro movement of which, combined with digital
pressure, the cyst is evacuated. Once the mass is replaced by a network
of connective tissue it could not be removed except by an extensive
dissection and extirpation, which leaves behind it cicatrices far worse
than the appearance of the parts before operation.

The author injects cold sterile white vaselin below the skin here and
there about the cheek at the sites of deepest deficiency.

These injections may be made under ethyl-chlorid anesthesia.

Each injection is carried to the extent of causing a lump below the skin,
the quantity being judged from a thorough experience with similar cases.

After the injections have all been done, the thumb of the right hand is
passed into the mouth against the buccal mucous membrane of the left
cheek and the index finger over it externally or on the skin surface. For
the right cheek the index finger instead of the thumb is placed in the
mouth. The mass or lumps are now gently pressed into the desired shape
and thickness by the aid of these two fingers. A few drops of the mass
may be forced out of the needle holes under this procedure, but this is
of no consequence when it is considered that from one to two ounces may
have been injected into each cheek.

This gliding form of massage should be continued until the entire cheek
presents an even and rounded-out appearance.

It will be found, in the majority of cases, that the integument of the
cheeks about the region of the inferior border of the zygomatic process
is rather firmly adherent, and that a subsequent injection will be
necessary to elevate the cheek at that point.

Injections over the malar bone are prone to cause severe reaction,
leaving a puffed appearance just below the eyelids. This may be more or
less permanent and is very undesirable. It should be avoided by injecting
very small quantities at that site. It is always safer to add a little
subsequently.

The reaction, generally, is not severe, and is readily controlled by
cold applications, yet the author has experienced considerable swelling
and tenderness in two cases of total cheek deficiency corrections which
lasted for several weeks after the operation, giving excellent result
eventually, however. Such symptoms are dependent upon circulatory
interference, but resolution should take place without untoward results
with judicious treatment, unless the operator has been negligent by
injecting one or more blood vessels, in which case the resultant
thrombosis may cause breaking down of the subcutaneous tissue, abscess,
evacuation of the mass, and possibly death in part of the integument. The
precautions referred to in avoiding any such possibility have been fully
given heretofore.

Never should the operator hyperinject the cheeks, even if the patient
insists upon looking like a puffed ball. He should be satisfied with a
normal contour, and truthfully assure the patient such hyperinjected
contour could not be retained owing to the weight and dropping down of
the mass before nature could properly replace it by organized tissue.

Subsequent injections may be made about three weeks after the first
sitting.

With nervous and hypercritical patients the surgeon may elect to give
the patient a number of sittings, injecting only small quantities at
two or three places each time. This in the majority of cases will give
better results than when an entire cheek is injected, for the reason that
the larger mass is likely to be displaced by the unconscious act of the
patient in sleeping on one or both of the rebuilt cheeks or the willful
massage to improve the handiwork of the surgeon in their own belief.

Massage of the cheeks after the replacement period is not to be
tolerated. It tends to create hyperplasia by circulatory stimulation.

It is not unusual to have the patient tell you that for weeks after the
replacement period the cheeks are swollen considerably in the morning
upon arising, going down gradually during the day.

This is due to the spongy or loose character of the new tissue caused to
be formed by the foreign mass, which gradually takes on a harder and more
compact form.

The post-operative dressing will be either adhesive isinglass plaster
or collodion. With the former, moist applications during the stage of
reaction are not permissible.


DEFORMITIES ABOUT THE ORBIT

=Deficiency of Lid Contour= _(Upper and Lower Lids—Unilateral and
Bilateral)_.—The lack of contour in the eyelids is not as frequently met
with as redundancy of their integumentary structure; there are cases,
however, where the eyes seem to lie deep in their sockets, owing to a
sinking in or a collapse of the surrounding lids.

This condition is often found to be hereditary, in other cases it is the
result of malnutrition, a peculiar lack of adipose tissue about the orbit
for no known reason, or fatty degeneration in past middle life.

The fault is usually bilateral. In rare instances trauma about the
orbital borders may result in lack of nutrition. Such cases are usually
unilateral, and the upper lid is affected in the majority of cases.

The correction of these defects is found to be rather difficult, owing to
the thickness of the tissue under consideration.

The use of hard paraffin plays havoc with eyelid tissue, rendering it
hard, immobile, and causing a hyperplasia of the new connective tissue
formed thereby, as well as the peculiar yellowish pigmentary spots
of irregular form resembling on casual inspection xanthalasma. This
discoloration has been fully described earlier in the work.

The author has had occasion to remove these hard irregular masses
investing the lower lid in several cases where paraffin had been
injected, also two cases in which the pigmentary discoloration involved
both upper and lower lids associated with the same hard fibrous masses.
Excision under local anesthesia and silk suture was the method of
correction employed.

From an experience of twenty-two cases the author believes these
conditions most amenable for correction by the injection of sterile oils
in preference to any other substance. Even white vaselin does not here
seem to answer the purpose, owing to its stimulating property of causing
the resultant growth of connective tissue.

While vaselin injected in the lids causes less of this new tissue to
be formed, such tissue is never of the consistency required. This is
especially true of the upper lids.

The oil injected, sterilized sperm oil being employed by the writer, is
prone to absorption of more or less degree, but the result is gratifying,
and lasts from six months to one year, leaving no untoward effect.

If the absorption has been sufficient to leave the parts as before the
operation, a subsequent injection of the same character may be undertaken
six months from the time of the first or even later, as the patient may
choose.

The tissue of the eyelid is prone to swell immediately the oil is
injected, and this swelling is entirely out of proportion to the
quantity introduced. This edema, due to a retardation by pressure of
the blood supply, is very misleading, the operator believing the parts
overinjected. A screw-drop syringe is therefore absolutely required.

A fine hypodermic needle is used, and after a few drops of the foreign
matter have been injected, the lid should be massaged gently with the tip
of the indicis, employing the circular movement.

The injection should be made at the outer end of the lid about one fourth
inch above or below the canthus for upper or lower lid respectively.

The needle, slightly dulled, should be long enough to reach the full
length of the part to be injected. Its course can be readily seen under
the thin, overlying skin.

As the injection progresses slowly and evenly the needle is withdrawn.

A second puncture or injection should not be made at one sitting; if the
parts are underinjected the operation is repeated as soon as the swelling
of the lid has subsided, which is about the end of the fourth or fifth
day.

The reaction, apart from the edema, is very little, although there may be
more or less discoloration of the parts, as the result of the obstruction
offered the blood vessels.

This is always an alarming symptom to the patient, but passes away
completely in the usual manner in several days.

The post-operative dressings may be collodion or silk protective.

Cold or hot applications, as may be best borne by the patient, can be
used; they tend to reduce the puffing and lessen the ecchymosis. The
patient should be instructed to lie with the head higher than usual for
the first two nights to retard the edema.

=Furrow about Canthus= _(Unilateral and Bilateral)_.—This condition is
commonly called “Crow’s Feet,” and is, in the majority of cases, due to
advancing age, but is acquired by habitually contracting the eyelids,
as in laughing or grimacing. It is particularly noticeable in persons
employed in the drama.

The defect is usually bilateral, but may exist at one side only in rare
cases.

The correction is easily accomplished by this method of subcutaneous
injection, although a reduction of the furrow alone does not suffice,
leaving a lump or elevation at the site. The author shades off the
injection, as it were, making the site somewhat conelike, the apex being
at the canthus and the base outward toward the hair line of the temporal
region.

Sterile oil should be injected near the canthus, where the overlying
integument is delicate. One such injection, covering an area of the
diameter of half to three fourths of an inch, should be made, and thus
backed up or built outward with two or three injections of the white
vaselin, as described under temporal muscular deficiency.

The hypodermic needle should be used near the canthus, and the regular
one over or about the temple.

The reaction near the canthus is similar to that with lid injections. The
same post-operative treatment as with the lids should be employed.

=Deficiency of the Ocular Stump.=—It frequently happens that by reason
of extensive inflammatory disease and adjacent adhesions of the eye, a
greater part of the globe must be excised than in the usual case, whether
the operation be an ordinary excision, the Mules’s evisceration or the
Frost modification of the latter.

In such event the granular button or the stump made of Tenon’s capsule
is too small to permit of the placing and retention of the artificial
eye. In other instances the stump is so contracted that while the
artificial eye is retained it must of necessity be allowed to rest deep
in the socket, destroying the entire contour of the orbit. Again in the
enucleation operation so little of Tenon’s capsule engages the artificial
eye that movement is entirely destroyed, particularly when the Mules’s
glass globe has not been introduced.

Excellent results may be obtained in some of these cases, others are not
amenable to the injection method because of a lack of sufficient stump
to inject, and the danger of injecting through the posterior wall of the
capsule, the mass in part escaping into the orbital apex, where it is
liable to impinge sufficiently upon the remains of the optic nerve to
cause sympathetic inflammation of the normal eye. A condition at once not
easily corrected, proving dangerous to the sight of the healthy eye, and
possibly producing a fatal termination.

It is with the use of paraffin, liquefied by heat and injected in this
state, that such fatal cases as have been placed on record have been
operated. The liquid mass under pressure forced into a soft pultaceous
mass cannot be easily controlled, if at all, and accidents here are of
more serious import than in any other part of the human anatomy, apart
from the direct injection of a facial artery of sufficient size to
produce an alarming embolism and death.

The author cannot speak too forcibly against such irrational procedure.
Other surgeons are beginning to realize the danger of the use of hard
paraffin injections near the eye.

The proper and safe method of improving the stump is to introduce into
it, under local eucain or cocain anesthesia, small masses of the mixture
of vaselin and paraffin in cold state. These injections into the stump
and mucous membrane should be done several weeks apart, always keeping a
respectful distance from the remains of the optic nerve.

The injections should be begun as near to the surface as possible without
breaking down the tissue by necrosis, keeping in mind that one or two of
such successfully introduced masses will do much toward supporting the
artificial eye.

If necessary the mucous membrane back of the palpebral rim can be
injected in like manner to give firmer hold to the eye and at the same
time give support to the usually depressed and atrophied lids.

Wet dressings are applied to allay the reactive inflammation, which
should be proportionate in severity to the amount of the mass injected.

In three cases operated upon by the author excellent results were
attained, and no untoward results had been experienced two years after
injection.


DEFORMITIES ABOUT THE CHIN

=Anterior and Lateral Deficiencies.=—An anterior lack of contour of the
chin is generally regarded as of the receding type. With this is usually
found a bilateral lack of form, especially in men. With a generally
well-formed face such a chin gives it a weak and ofttimes a degenerate
appearance. In women a deficient chin is not as noticeable, because of
the smallness of the face in general and the predomination of the oval
type.

The lack of prominence about the chin may be anterior only, the broadness
being sufficient, due to a lack of development of the mental process, or
it may be deficient laterally with a pronounced mental prominence, giving
it a sharp, protruding, or pointed appearance, or the lack of form is
combined, as is commonly the case.

Such chins may be made to appear normal, and even ideal, by the
subcutaneous injection method. The type of chin most favored by American
men is the square angular, now so plentifully seen in pen-and-ink
illustrations.

The tissue of the chin lends itself readily to the building-up process.
Almost any form may be attained by the judicious employment of the method
under consideration.

[Illustration: FIG. 302. FIG. 303.

PROFILE VIEW, SHOWING CORRECTION OF ANTERO-LATERAL DEFICIENCY ABOUT
CHIN.]

While it is true excellent results may be obtained with hard paraffin,
used in liquefied form, it can often be shown, however, that the paraffin
injected under pressure will run down in narrow, pencil-like streams
underneath the chin and skin of the anterior aspect of the neck, where
they may be felt afterward as hard oval cysts or of elongated form. This
is not possible when the cold mixture of vaselin and paraffin is used,
since the position of the mass can be easily followed with the eye or
felt with the fingers.

The injections should be made from either angle at the first sitting.
Enough of the mass should be introduced to leave a ridgelike formation
across the anterior chin, varying in thickness according to the shape of
the chin previous to operation and the form desired.

It is not well in chins of very deficient type to attempt to make the
anterior contour as it should be in the first sitting. Too much pressure
would be required, and unless the skin was freely movable considerable
reactive inflammation would result, with possible necrosis of the skin in
part and consequent expulsion of the injected mass.

The anterior line of such chins should be rebuilt in several sittings,
always waiting for the parts to become normal in appearance and
sensitiveness.

This method helps to stretch the skin, allowing of further injections and
the introductions of a greater quantity than could be introduced at one
time only.

The author advocates making two or three sittings of the anterior
restoration of contour and two for each angle.

The angles of the chin are injected at a point about midway between
the mental process and beginning of external oblique line. The mass is
injected as near the inferior ridge as possible, and somewhat above the
attachment of the platysma myoides muscle.

[Illustration: FIG. 304. FIG. 305.

FRONTAL VIEW, SHOWING CORRECTION OF ANTERO-LATERAL DEFICIENCY ABOUT CHIN;
ALSO CORRECTION OF DEFICIENCY OF CHEEKS.]

Only one needle insertion is made at each angle, and the mass is injected
until a round elevated tumor is attained, which is pinched or squeezed
with the fingers into the desired angular form, one finger being placed
over the needle opening to avoid squeezing the mass out.

It can be readily seen that with this puttylike mass much better results
than with the comparatively soft vaselin could be obtained while with
the liquefied paraffin the operator would be at a loss to know just what
had been accomplished until the mass had become fairly solidified, and
then often finding the semisolid mass, which required rapid molding to
give the desired shape before it would become hard and unmanageable, in a
different position and much more distributed than he had expected.

For the latter reason repeated small injections have been advised, but
the author believes oft-repeated injections of paraffin in a small area
are prone to set up considerable disturbance, and that the resultant
tissue replacement is interfered with. Furthermore, the injected mass
would eventually be in grape-bunch like form, and in that condition not
as manageable or inducive to the establishment of contour angulation,
such as is required in the chin. The final appearance of chins thus
rebuilt is heavy and rounded, lacking the concavity above the inferior
prominence along the anterior line as well as the angulation laterally.

With the cold mixture advised a considerable mass may be injected at one
sitting, which is easily molded into form and which retains that form
unless the reactive inflammation is severe. This should not follow unless
actual hyperinjection has been done or an unclean product has set up an
infective cellulitis.

When the chin is uncommonly peaked, or small, it may be found necessary
to inject both sides of the chin beyond the angle and in an upward
direction slightly below and following the external oblique line.

Such deficiency may be found decidedly unilateral as a result of lack
of development of one half of the lower maxillary bone, a resection of
either maxilla for whatever cause, imperfect union following fracture or
disease of the bone early in life.

In such cases the lateral deficiency must be first restored, using the
same method, before the chin proper can be built up. Ofttimes the lower
cheek of the affected side must also be injected. This should be done
after the site overlying the former body of the maxilla of the affected
side has been rebuilt. The cheek should then be built out above this
hard linear mass by the injection of cold white vaselin, as heretofore
referred to.

The following illustrations show a chin deficient anteriorly and
laterally before and the result after correction.

The post-operative treatment should be collodion dressing, followed
by cold antiseptic applications for at least two days. The latter
ameliorates the inflammation and helps to retain the molded shape of the
mass. Subsequent sittings may be made one a week or ten days apart.


DEFORMITIES ABOUT THE EAR

=Pro-auricular Deficiency= _(Unilateral and Bilateral)_.—A deep furrow
in front of the ear may be found unilateral in hemiatrophy of the face,
but the condition is usually a bilateral one, due to malnutrition or the
fatty degeneration of past middle age. In the latter case the depression
is accompanied by a redundancy and wrinkling of the skin.

Owing to the close proximity of the large temporal vessels a hard mass
should never be injected subcutaneously for the relief of this condition.
Even the mixture of vaselin and paraffin has caused considerable reaction
when injected to overlie these vessels.

The author advises the injection of white sterile vaselin or sperm oil
for this form of correction. It should be carefully injected, since the
vessels lie close to the skin with the anterior auricular crossing
transversely about the center of the furrow.

Every precaution should be taken, one injection only being made from
below upward at each sitting if more than one is necessary, and then only
after the needle has been unscrewed from the syringe to make sure vessel
bleeding does not follow the puncture.

The reaction is usually severe, with considerable edema and ecchymosis.

The resultant tissue formation likewise is active, and hyperplasia at
this site is not uncommon, especially if the mixture or hard paraffin has
been employed.

A cellulitis following such an injection is exceedingly troublesome, the
injected mass being thrown off usually at the base of the furrow, which
is followed by a low type of inflammation with a protracted oozing of
serous exudate. Should such a case come under the care of the surgeon,
thorough cleansing of the affected site under scrupulous antisepsis
should be done at once, and wet antiseptic dressings be applied daily
until the wound is entirely healed.

A plastic skin operation must be done in most of these cases to overcome
the ragged cicatrix formed upon healing of the wound. This should never
be undertaken until the wound has been healed for several weeks at least.

After the injection of the parts cold antiseptic dressings should be
applied at once, and kept up until every sign of reactive inflammation
has subsided. At no time should the subsequent injection be undertaken
before a month has elapsed from the time of the former operation.

=Post-auricular Deficiency.=—This defect is invariably unilateral, and
then the result of a mastoid operation.

The skin about the depressed site will be found to be more or less firmly
adherent, necessitating subcutaneous dissection before an injection for
correction can be undertaken.

In this case the cold mixture of vaselin and paraffin is indicated,
since the softer products will hardly suffice to elevate the tense skin.
If the former surgical operation has been done some time previous to
the required injection the parts may at one or two sittings be restored
to a fairly normal contour, depending entirely upon the amount of
ungiving scar tissue at the site. If the parts are tender and not reduced
to normal, the injections should be made frequently, about ten days
apart, injecting a small mass across and through the subcutaneous scar
attachment at each sitting.

The reactions following such injections help to tease the scar away
from the bony tissue, but should not be sufficient to cause extensive
inflammation.

The same mode of post-operative treatment as has been given with
pro-auricular corrections should be followed.


SPECIFIC TECHNIQUE FOR THE CORRECTION OF DEFORMITIES ABOUT THE SHOULDERS

Deficiencies about the base of the neck and the shoulders are very
commonly found in women. These defects are usually bilateral, except
in rare cases. The much-desired contour is readily restored by the
subcutaneous-injection method, and since the technic for one part is the
same as for the whole there is no need to dilate specifically upon the
treatment of each part.

The author advocates the injection of cold sterile white vaselin
only, for the restoration of the contour about the neck, anterior and
posterior shoulder, and the mammæ, except in the unilateral correction
of a flattening of the breast following amputation for the removal of
neoplasms, when the mixture of white vaselin and paraffin should be used,
owing to the tenseness of the skin following the excision of a large part
of the integument covering the diseased gland.

In the restoration of the contour about the neck and shoulders it
is well for the surgeon to familiarize himself thoroughly with the
superficial veins of the parts, since the vessels here are larger, and
the introduction of foreign matter into them is liable to lead to serious
and even fatal results.

The injections should never be made until the operator has assured
himself of the fact that a vessel has not been entered into, and then
only should a small quantity of the mass—i. e., about two or three
drams—be injected at one point.

The easiest mode of introducing the needle is to pinch up the skin
between the fingers of one hand, introducing the needle into the fold
thus raised. As the mass is injected the skin should be raised by aid
of the needle, so as to allow all the immediate room possible for its
reception.

The mass injected is at once molded down flat with the thumb or
forefinger.

A number of such injections may be made at both sides at the one sitting.
The ethyl-chlorid spray may be employed to render the parts less painful.
At no time should the entire shoulders be filled at one sitting, for
fear that the reaction may be severe or that for any unforeseen cause
infection results which would in such instance be indeed difficult of
treatment, eventually leaving the parts scarred and unsightly.

Nor should the mass be injected intracutaneously, a fault sometimes
observed about the base line of the neck anteriorly and laterally where
the operator has been timid in avoiding the exterior and anterior
jugular veins. Such injections invariably result in abscess, or when
not extensive enough to cause necrosis the skin assumes a more or less
permanent red or yellow discoloration over the site so injected.

The treatment for the partial or total removal of such spots has been
referred to.

In the average case of contour restoration of the shoulders about eight
sittings are required, two sittings being given each week, and as many
injections made as is deemed necessary or advisable at each.

All the precautions of technic heretofore given should be employed. The
reaction following such injections is never severe, and little or no
treatment is necessary.

The needle openings are covered with aristol collodion or the isinglass
adhesive plaster.

At the end of six months or more after the injected matter has been
quite thoroughly replaced with new connective tissue it is often found
necessary to inject small quantities here and there about the shoulders,
owing to the contraction of the new tissue and its ultimate fixed
disposition about the parts more than to the absorption of the mass
injected.

Furthermore, a certain amount of edema or swelling follows the injection
of any foreign matter under the skin which is not, in cases of this kind,
so readily absorbed, giving during that period of time a more pronounced
contour or fullness, which, passing away in the natural course of events,
does not imply the absorption of the matter injected—a statement so often
made by those not in favor of using paraffins of low melting points for
subcutaneous protheses.

Such result, however extensive, as it might be in some cases for the
lack of proper injection or in the case with oil injections is at all
times correctable, while the hyperplastic knobs, so often following the
injection of paraffins of high melting points about the shoulder, can
only be removed by surgical means, which leave the parts more unsightly
than before anything had been done for the patient.




CHAPTER XV

RHINOPLASTY

(_Surgery of the Nose_)


Rhinoplastic operations serve to correct deformities of or restore the
nose. Such operations may involve only a part of or the entire organ,
hence may be termed partial or total. Furthermore, a fine distinction may
be drawn between general rhinoplasty as applied to such deformities when
caused by traumatism, the excision of neoplasms or destructive disease,
whether such correction be partial or total, and cosmetic rhinoplasty
when such corrections are made purely with the object of improving the
nasal form when the deformity is either hereditary or the result of
remote accident.

For some unaccountable reason the latter art has not met with the general
favor the profession should grant it, yet the results obtained by such
specialists as have undertaken this artistic branch of surgery have
been all that could be desired, and have consequently added much to the
comfort and happiness of the patient.

Without a comparatively thorough knowledge of the extent of cosmetic
rhinoplasty it would be difficult to draw any conclusion as to the
value of this art. If it has not met with the favor it deserves it is
solely due to the fact that the art has been limited to the few, and the
literature on the subject is so meager, indeed, that the surgeon has been
compelled in many cases to trust to his own originality in undertaking an
operation of this nature.

The limitation to rhinoplasty is due primarily to the artistic skill
required to obtain results; secondly, to the risks involved by loss of
tissue due to gangrene, imperfect healing or accidental interference,
post-operatio; and thirdly, to scarring about the face as a result of
the primary and secondary wounds; in fact, so much so that many surgeons
prefer to allow a small defect to remain, to escape the risks involved in
correcting them.

The author believes such fear misplaced, because with the methods of
surgery of the present day and the proper knowledge of the art there need
be little risk involved and the result expected should be as near perfect
as human skill can make it.

True, a surgeon cannot be expected to build an entire nose from the
skin or other tissue of the forehead or cheeks and make it a thing of
aforethought beauty and shape, but if the result be no more than a
curtain of skin to hide the hideous deformity he has done his share, and
such result is the worst he might look forward to.

For the correction of nasal deformities the author will consider first
such operations as involve the entire loss of the nasal organ or _total
rhinoplasty_; thereafter _partial loss_ of the nose, and lastly such
cases involving no loss of tissue and dependent on malformation only
under _cosmetic rhinoplasty_.

It is not here intended to lay down a law for the surgeon for the
restoration of the entire or part of the nose for the reason that each
case differs more or less; that in each case there is more or less tissue
that may be utilized, and that there are many methods advanced for such
procedure, but the author does desire to give to the operator a concise
and comprehensive treatise on rhinoplasty and to illustrate the best of
such operations as have been placed on record as a ready guide and for
immediate reference—a matter of no small moment when this literature can
be gained only by searching through innumerable medical journals and
short references and in all languages of the civilized world.

In the chapter on history some idea of the time in which rhinoplasty has
been practiced may be obtained. It is not deemed necessary to go into
further historical facts here, except, perhaps, to divide the subject
into the three most important schools or countries that have given
individuality to the art.


THE CAUSES OF NASAL DESTRUCTION

The loss of the entire nose may be due to traumatism, actual amputation,
the bites of man or beast, duels, the removal of neoplasms, gangrene
after freezing or disease, rhinosclerosis, syphilis, the application
of caustics, tubercular disease, lupus, cancer, and rarely congenital
absence of the organ. The loss may be total or partial.

The extent of loss of substance in each case differs, and it is for this
reason that surgeons have been compelled to originate many methods of
operation, each having for its object to correct the deformity as neatly
and as near to the normal as possible.


CLASSIFICATION OF DEFORMITIES

To give correctly a classification of nasal deformities would simply mean
to mention each anatomical part or division of the nose referring to the
deformity involving the same. For this reason such an arrangement would
be uselessly extensive, but for the proper recording of such cases the
author advises a systematic method of nomenclature in which the deformity
is stated, as: left, unilateral deficiency of inferior lobule; or right,
median third deficiency of nasal dorsum of the parts destroyed and
mentioned as such.

[Illustration: FIG. 306.—DEFICIENCY OF SUPERIOR AND MIDDLE THIRD OF NOSE.
(Saddle Nose.)]

[Illustration: FIG. 307.—POST-ULCERATIVE DEFORMITY OF SUPERIOR THIRD OF
NOSE.]

[Illustration: FIG. 308.—LOSS OF RIGHT ALA, LOBULE AND COLUMNA.]

[Illustration: FIG. 309.—LOSS OF LOBULE, INFERIOR SEPTUM AND COLUMNA.]

A fair idea of typical deformities may be obtained from the following
illustrations in which deformities from the milder to the most extensive
extent are shown. The types here shown are all pathological with the
exception of Fig. 306, in which a saddle nose is illustrated which may
or may not be the result of disease or traumatism.

[Illustration: FIG. 310.—ULCERATIVE LOSS OF RIGHT MEDIAN LATERAL SKIN OF
NOSE WITH INVOLVEMENT OF ALA.]

[Illustration: FIG. 311.—LOSS OF NASAL BONES AND PARTIAL ULCERATIVE
DESTRUCTION OF DORSUM, LOBULE AND SEPTUM OF NOSE.]

[Illustration: FIG. 312.—DESTRUCTION OF NASAL BONES WITH DORSAL
INTEGUMENT AND LOBULE INTACT.]

[Illustration: FIG. 313.—TOTAL LOSS OF NOSE.]

Many other deformities of the nose exist, of course, such as lateral
deviation, twists, etc., but as in most of such cases cosmetic
rhinoplastic operations and subcutaneous injection are required for their
correction, inasmuch as in these cases the skin is healthy and intact,
they will be considered under that part of the chapter that has to do
with purely cosmetic rhinoplasty or under the chapter on subcutaneous
protheses.


SURGICAL TECHNIQUE

Before going into the individual methods involved in the correction of
deformities of the nose, it is well here to go into the special details
required for the performance of operations about the nose proper.

=Anesthesia.=—It may be well here to state that many of the smaller
or cosmetic operations can and should be done under local anesthesia,
and that the anterior nares should be plugged to prevent the blood
from running into the pharynx, but in operations of greater extent the
posterior nares should be plugged by Bellocq or other method, and that
since the patient must be placed under a general anesthetic, some special
plan must be followed to give the same.

The author has found no special apparatus on the market for this purpose.
A most practical apparatus may be made as follows: A medium hard piece
of rubber is cut into such shape as will fit into the patient’s mouth
between the lips and the teeth. In its center a hole is made, into
which a metal tube is fixed to which a rubber tube of three-fourth-inch
diameter is securely fastened. This tube is connected by its distal end
to the anesthetic container, which should be so constructed as to permit
the required amount of air to be given with the anesthetic at the desired
time.

Such an apparatus practically seals the oral orifice, and prevents blood
from flowing into the mouth, gives the operator a free field to work in
without the encumbrance of large external mouthpieces, and is one that
in case of vomiting can be easily removed for the time being, and be
replaced without interference to the surgeon.

=Preparation and Cutting of Nasal Flaps.=—Under a division of skin
grafting some preliminary steps in the preparation and cutting of a nasal
flap has been referred to, but the author thinks it timely to repeat here
the necessity for a systematic method of procedure.

It is well for the surgeon to have fully decided upon the certain
operative plan he is to follow several days prior to the operation. He
must, especially in total rhinoplastic cases, prepare a paper or oiled
silk model of the flap or flaps he has decided upon to take from the
forehead or cheek, and to fold and bend this model into the place of the
deformity to be overcome, to make sure of the result to be attained,
allowing for the loss, if any, of mass by reason of the torsion of the
flap at its pedicle.

If the hair of the frontal scalp lies within the flap outline, it should
be shaven away well beyond the border to permit of unhindered work.

Thoroughly cleanse and keep clean with a suitable antiseptic the parts to
be operated upon for at least twenty-four hours.

Place a rubber cap over the hair of the head, or a fixed gauze or
waterproof arrangement to keep it in place.

If there be any hair adornment of the face remove it.

The surgeon should remember to get the flaps to be utilized on forming
the lost parts of the nose, at least one third larger to overcome the
consequent retraction.

Sterilized sutures, preferably silk of suitable size, should be ready and
be cut of such length as will facilitate quick action.

Rubber tubes of proper diameter for insertion into the nares should be at
hand if required.

When all is ready the operator is to proceed quickly and accurately,
never changing his prearranged idea of the operation. His assistants
should be ready to control by torsion or pressure the bleeding occasioned
by cutting, since it covers the field of operation and hinders rapid work.

The surgeon in making flaps should use the greatest gentleness in
handling them to prevent pressure gangrene. His finger tips are far
better than fixation forceps. Sharp tenaculi may be employed with gentle
traction only. Never permit the use of serrated forceps in autoplasty.

In cutting, employ the rules laid down under the principles of plastic
surgery, and in dressing flap operations such methods as have been
heretofore described.

=Dressing.=—Do not be too hasty in dressing such wounds, as early
interference often results in partial if not total loss of the flap.

The author has found that in flap operations blood dressing under
perforated rubber tissue is best. This helps to give nutriment to the
parts and permits of free removal of the dressings. Never apply the
blood treatment on gauze, since the latter is liable to become hard and
attached to the suture lines, requiring undue force for its removal.

=Care of the Nares.=—Remove all packing from the nares before fixing the
lobular section of the flap, and have all bleeding controlled before
suturing the part of the flap intended for the columna. Blood clots tend
to pressure and infection. If nare tubes are used rather let them remain
in place for some time than to drag them forth forcibly.

The interior nose and nares can be kept clean by gentle irrigation
through them.

=Number of Operations.=—Instruct the patient as to the probable outcome
of the operation, and advise him that more than two or three operations
may be necessary to correct the deformity.

_Von Esmarch_ has said that twenty operations about the nose are none too
many if the desired result can be obtained. Dieffenbach has said that it
is more difficult to restore smaller nasal defects than those of greater
extent.

The latter applies particularly to cosmetic operations in which the
surgeon is compelled to work through small openings or incisions always
with the view of leaving little if any scar, and to place such scar where
it may be least observed.

The best cosmetic surgeon is he who can accomplish results with the least
secondary disfigurement.


PROTHESES

When for any cause there is a loss of the entire nose, and the patient is
unwilling to undergo surgical operation for its restoration, the surgeon
may resort to the use of protheses or artificial noses.

Such noses are made of papier-maché, rubber, wood, or light metal, and
painted to imitate the color of the skin of the individual. They should
be made after a model previously prepared by molding the new organ upon
the face of the patient or after such patterns as the surgeons may have
to choose from, fitting the skin juncture accurately in such cases.

If the surgeon lacks such artistic ability, a sculptor should be employed
to model the proper organ suitable for and on the face of the patient,
from which a plaster cast or mold may be made from which the maker of
protheses can work.

With the model in hand and no expert on protheses within reach, a
skillful surgeon-dentist could easily make a vulcanized rubber nose,
which may then be painted to suit.

Some method of attachment must be provided for, such as one or two soft
rubber plugs or stems to fit into the nasal orifice or permanent fixture
to the bridge of a pair of spectacles. Gums or pastes as advised with
aural protheses may be of service.

Celluloid protheses should never be used because of their inflammable
nature; furthermore, they are easily damaged or cracked. Wax noses are
of little use, although resembling the normal very closely; they crack
easily, and when soiled by dust or friction soon have to be replaced with
new ones.

The following list of authorities shows the various materials employed by
them for nasal protheses:

_Martin_—Porcelain.

_Richter_—Wood.

_Debout_—Rubber or silver covered with colored wax.

_Mathieu_—Aluminum.

_Charrière_—Silver.


NASAL REPLANTING

The plastic surgeon is often, especially in later years, called upon to
attend to traumatic injuries of the nose. Sometimes there is a total
severance of the nose; often a partial loss or injury, practically
involving a loss of a part of the organ. Since the advent of the
automobile such accidents are not unusual.

The author has found that a remarkable history lies back of the
replanting of parts or all of the nose when found detached by accident or
intent.

If the part cut from the nose or face has been not too severely bruised,
it should be cleansed gently in a normal salt solution at about 100° F.,
and be sutured in place as quickly as possible. Partly separated sections
should be treated in the same way. It is remarkable how Nature will take
care of these traumatisms. So well did the executioners in India, where
nasal amputation is a criminal sentence, know this that they destroyed
the amputated organ by fire, so that the victim could not replant it upon
himself.

Chelius successfully replanted a nose after it had been severed about an
hour.

Hoffacker has replanted a number of noses cut off in the duels of
Heidelburg students. In one case one and a half hours intervened between
the accident and the operation.

In partial separations about the nose the flap, still hanging by a
slight pedicle, should be brought in place by suture, and because of the
peculiar hypertrophy that always follows the wounds one or two intraflap
sutures should be employed to fix the part centrally to the deeper
tissues, if any, to prevent the formation of clots that are liable to
organize and encourage such enlargement.

Such sutures are only to be made when the flap is of sufficient size to
necessitate them. If the hypertrophy or hyperplasia cannot be prevented
by this means later cosmetic operations should be employed to make the
parts heal into normal contour.

Blood dressings should be employed after the parts have been fixed by
a number of fine silk sutures, the coaptation being made as neatly as
possible to get the best results.


NASAL TRANSPLANTING

The making of a nose or part thereof from a nonpedicled flap of skin
taken from the patient has met with more or less success in the remote
past, but of later years such methods have fallen into disuse because of
the many and better methods of modern times involving the use of flaps
with nutrient pedicles.

Branca is said to have made a nose for a patient out of the skin of the
arm of a slave.

Velpeau states that “In the land of the Pariahs the men in power had no
scruples in having the nose of one of their subjects cut off to replace
the lost organ of another.”

Van Helmont is said to have made a nose for a gentleman from the skin of
the buttocks of a street porter.

Bünger, of Marburg, in 1822 made a total nose from the anterior thigh.

Several surgeons later than the above date have successfully restored
parts of the nose by transplanting skin flaps from remote parts of the
body, the method involved being practically what is now accomplished by
the so-called skin-grafting methods of nonpedunculated flaps heretofore
referred to.

While for small defects such procedure has proven quite successful, the
employment of large flaps for nasal reconstruction has been exceedingly
discouraging, although the author advises trying transplanting of such
flaps when the patient hesitates giving up sufficient facial skin for
rhinoplastic purposes for fear of disfiguring scars, or when there are
untoward reasons.

In such event there is only the secondary wound to be considered apart
from the death of the flap, and the minor operation about the remains of
the nasal organ to permit of the fixation of the latter.

A thorough and practical knowledge of skin grafting is of the greatest
necessity to the surgeon, because he must be ready to cope with any
emergency in such cases, and thus be able to save a flap graft from death
or partial gangrene, when he would otherwise fail.


TOTAL RHINOPLASTY


PEDUNCULATED FLAP METHOD

The most practical and safe methods of rebuilding the nasal organ have
been those in which flaps having nutrient pedicles have been employed,
whether these flaps be taken from the skin of the forehead, cheek, or
both. These procedures are autoplasties, and may be grouped according to
their peculiar differentiation into three classes, as follows:

_The Indian or Hindu Method_, in which the flap is made from the forehead.

_The French Method_, in which the flap is made from the tissue about the
borders of the deformity.

_The Italian Method_, in which the flap is taken from some distant member
or part of the body.

Furthermore, there are the combined methods of one or the other in
which inverted skin flaps are used, or those lined with an osseous and
cartilaginous support, and in some rare and rather unsuccessful cases by
metallic supports.


_The Indian or Hindu Method_

The method of rebuilding the nose by taking one or two flaps from the
forehead dates back to the Koomas, from whom the art of rhinoplasty has
come down to the present time, all of the methods of to-day involving
the utilization of the pedunculated flap being a result of their early
surgical ingenuity.

Originally, their operation consisted of cutting an oval flap, having its
pedicle as the root of the nose, and extending over the forehead, and
upward vertically into the hair line. The flap thus made was dissected
away from the bone and brought down by twisting it to the extent of
a hundred and eighty degrees on its pedicle in front of the nasal
deformity, the edges of which had been prepared to receive it. To hold
the flap in position they resorted to some kind of clay, sutures being
unknown to them.

The pedicle was cut after the flap had thoroughly united to the freshened
borders of the deformed nose.

The steps of the operation as performed by them are shown in Figs. 314,
315, and 316.

Naturally, many improvements in the above method have been evolved,
principally to overcome the extreme and injurious torsion of the pedicle,
and from the desire on the part of the surgeon to bring about a better
cosmetic result. Therefore, not only the position of the pedicle and
its shape were altered, but also the size of the flap itself, as will
be shown in the specific methods of the various authorities mentioned
hereafter.

The author does not consider it necessary to go into chronological
details of the evolvement of the art, and begs the surgeon to be content
to learn of those operations and methods that have given the best result.

[Illustration: FIG. 314. FIG. 315. FIG. 316.

KOOMAS METHOD.]

Where one surgeon has changed his incisions in the slightest direction
and another has advised increasing the number of sutures is of little
import to the operator of to-day; the gist of it all is the successful
method for the successful outcome.

The first to be considered will be those methods wherein the vertical
direction and the position of the pedicle have been similar to that of
the Koomas. It will therein be noted that the principal change has been
in the formation of the distal end of the flap with the object solely of
forming a better base to the nose.

=Graefe Method.=—The flap was made in the shape of a heart with a
rectangular addition at its upper or scalp border. The pedicle is made to
lie between the inner limitations of the eyebrows (see Fig. 317).

The flap is twisted into position and sutured into the freshened remains
of the nose, the pedicle being cut at a second operation after the flap
has healed into place, which was about the tenth day.

[Illustration: FIG. 317.—GRAEFE METHOD.]

=Delpech Method.=—The shape of the frontal flap was cut in the form of a
trident, as shown in Fig. 318.

The object of the arrangement was to give a rimlike lining to the two
nostrils, the raw surfaces of the outer points being brought into contact
with each other.

He also hollowed out a groove at the root of the nose, to better
accommodate the pedicle when twisted. The steps are shown in Figs. 319 to
321. The pedicle was later severed when the conditions warranted it.

[Illustration: FIG. 318. FIG. 319. FIG. 320. FIG. 321.

DELPECH METHOD.]

=Method of Lisfranc.=—Lisfranc conceived the idea that if he carried down
the one incision for the flap at the root of the nose somewhat lower than
the other he would overcome some of the torsion at this point. This he
consequently did, making the left incision half an inch lower than the
right. The lateral incisions ascend at an angle of forty-five degrees
(see Fig. 322), uniting in rectangular form at the scalp line, as shown,
the rectangle of skin being utilized to make the subseptum.

Instead of sutures he dissected up the old nasal borders and slid the
flap borders into this groovelike arrangement, holding it in place with
the aid of sticking plasters.

With the above method the pedicle was allowed to remain intact. Fig.
323 shows the position of the flap, and the treatment of the subseptal
section.

[Illustration: FIG. 322. FIG. 323.

LISFRANC METHOD.]

=Labat Method.=—Labat uses a frontal flap shaped as in Fig. 324. The
left bordering incision is carried down one half inch below the point of
beginning on the right and carried downward in such manner that its lower
point lies in a line with that of the right above it.

The object of this was to overcome torsion, and, where obtainable, the
small triangle of healthy tissue at the root of the nose, as shown in
the illustration, was dissected off from above downward, and turned
downward with the cutaneous side facing the nasal chasm and its dissected
side facing that of the flap. He avoids injury to the angular artery,
as should be done in all cases. The pedicle was replaced at a second
operation.

[Illustration: FIG. 324.—LABAT METHOD.]

=Keegan Method.=—Utilized a flap, shaped as in Fig. 325. The pedicle
occupies the internal angle of the eye, care being taken to preserve the
angular artery. The flap is mapped out obliquely, not perpendicularly. To
get the best results he advises pasting a paper model upon the forehead
to guide the operator in making the flap, which includes all the tissue
down to the periosteum. Horsehair sutures are employed to approximate
the parts accurately. The pedicle is divided in about twenty days, and a
wedge-shaped piece of skin is excised at the root of the nose to prevent
the tuberosity at this point of the new nose, so commonly observed with
Indian-flap methods.

[Illustration: FIG. 325.—KEEGAN METHOD.]

=Duberwitsky Method.=—The flap at its root resembles that of Labat, but
at its superior border it formed an oval with an elongated point running
into the hair line, which he divided, as shown in Fig. 326, to form the
subseptum and nasal wings.

At the root the pedicle was about half an inch wide made in the oblique.

The middle section of the superior pointlike projection and intended for
the subseptum was folded upon itself or doubled, as it were, to give
support to the nasal point. The same was done with the alar or lateral
sections, so as to line the nares with epitheliar surface to prevent
contraction. The lower part of the nose was fixed into position by a
harelip pin inserted transversely after all parts of the flap had been
sutured into place.

[Illustration: FIG. 326.—DUBERWITSKY METHOD.]

=Dieffenbach Method.=—The flap is cut very much like that advised by
Lisfranc, being wider only at its upper extremity, as shown in Fig. 327.

He advocates removing the remains of the old nose, almost circumscribing
the nose, as shown in the illustration, except for the deep linear
incision at the base of the nose on a level with the oval fissure,
leaving a bridge of skin at either angle into which the square or septal
part of the superior frontal flap is affixed.

The flap is made so that the right oblique line lies an inch above that
of the left, the latter incision running into the angle formed at the
root of the old nose caused by the ablation.

[Illustration: FIG. 327.—DIEFFENBACH METHOD.]

=Von Ammon Method.=—The flap is cut at its superior border, similar to
that of Keegan, but made in the perpendicular; the point of beginning,
at the end of the right eyebrow, lies about an inch above the end of the
incision of the opposite side, but in line with it (Fig. 328). The same
method of removing the remains of the old nose advocated by Dieffenbach
is followed as well as the lobial incision to receive the septal section.

The shape of this flap permits of bringing the secondary wound on the
forehead more readily than where square exsections are resorted to.

[Illustration: FIG. 328.—VON AMMON METHOD.]

=Auvert Method.=—Like the method of Keegan, the frontal flap is made at
an angle of forty-five degrees instead of the perpendicular, the flap
being cut to the left of the median line. Its outline is shown in Fig.
329, and differs little at its superior extremity from that of Labat,
except that it is made longer and narrower. The left lateral incision
runs into the superior border of the old nose at the median line.

[Illustration: FIG. 329.—AUVERT METHOD.]

=Von Langenbeck Method.=—The flap is fashioned like that of Duberwitsky,
but the left lateral incision enters the remains of the old nose, as
Dieffenbach advised. The superior border was shaped, as shown in Fig.
330, to form the alæ and columna.

[Illustration: FIG. 330.—VON LANGENBECK METHOD.]

=Petrali Method.=—The shape of the flap is cut in ovate form with its
rounded base near the hair line of the forehead. Petrali likens it to the
form of the mulberry leaf. The left lateral incision dips down into the
median line of the old deformity at its upper border.

The flap, after having been cut free, is folded upon itself along the
median line, bringing the raw surfaces together along the dorsum of the
new nose, thus giving body to the whole anterior nasal line. Presumably
he introduces several sutures through the side of the flap to facilitate
union along this line.

The method is illustrated in Figs. 331 and 332.

[Illustration: FIG. 331. FIG. 332.

PETRALI METHOD.]

=Forque Method.=—Herein the right lateral incision of the frontal flap is
begun at a point above and corresponding to the middle of the eyebrow.
The base is fashioned as shown in Fig. 333, and the left lateral incision
is carried down to the median line of the old nasal defect, coming within
the inner border of the eyebrow.

[Illustration: FIG. 333.—FORQUE METHOD.]

=D’Alguie Method.=—This author conceived the idea of further relieving
the torsion of the pedicle by making the frontal flap transverse along
the forehead, instead of perpendicular.

The incision at the root of the nose is on a level and in line with the
inner ends of the eyebrows. The left lateral incision is made to lie just
above the eyebrow and the right sweeps upward and outward, as shown in
Fig. 334.

The base is made with a rectangular projection to form the columna.

[Illustration: FIG. 334.—D’ALGUIE METHOD.]

=Landreau Method.=—The direction of the frontal flap is transverse, but
the root of pedicle, instead of having a downward direction, is so cut as
to have its attachment upward, as shown in Fig. 335. This position of the
pedicle thus overcomes to a great extent the torsion at this point. The
flap must be cut somewhat longer in its transverse axis to allow for the
higher position of the pedicle on the forehead.

The distal end of the flap is trident-shaped, as shown.

[Illustration: FIG. 335.—LANDREAU METHOD.]

=Langenbeck Method.=—The flap is cut on an oblique line along its left
border, running the incision down and across the root of the nose to the
right while the right incision begins just under the eyebrow and extends
less obliquely upward, as shown in Fig. 336. The base of the pedicle is
fashioned as shown. The bordering remains of the old nose are removed.

[Illustration: FIG. 336.—VON LANGENBECK METHOD.]

In another operation by the same operator the right incision was begun at
a point above the eyebrow and carried transversely along to the rising
point of the lateral. The left lateral incision was so made that it left
an area of skin over the root of the nose, as shown in Fig. 337, which he
dissected away, giving that part of the flap to cover it an opportunity
to adhere, at the same time furnishing a nourishing area for its future
life.

[Illustration: FIG. 337.—VON LANGENBECK METHOD.]

=Szymanowski Method.=—The flap is formed as shown in Fig. 338, the
pedicle having its upper incision just below the end of the right eyebrow
and the lower below the inner canthus on a line with the first, giving it
an oblique position.

Just below the curvature of the basal incision two short incisions are
made on either side into the forehead tissue with a view of rendering
more flexible the skin to be utilized in correcting the secondary wound.
The margin of the old nose is freshened.

[Illustration: FIG. 338.—SZYMANOWSKI METHOD.]

=Labat, Blasius, Linhart Method.=—These operators performed their
operations in two sittings. In the first the incisions were so made at
the base as to permit of that part of the flap intended for the rim of
the nares to be tucked in, as it were, where these two triangular little
folds were held in place by silk suture. When the parts had become
thoroughly united, or at the second sitting, the entire flap was cut away
and brought into place for the new nose. The object of this procedure
was to give body to the wings of the nose and to overcome the consequent
curling and contraction of the skin so commonly found with the single
sitting operation.

This step marked the first advancement toward attaining much more
successful results in total rhinoplasty by using skin-lined flaps, which
not only added to the better nutriment to the part, but also gave support
and firmness to the new organ.


_The French Method_

This method, _per se_, is not in itself sufficient to bring about a
satisfactory result. The fundamental principle is that of the sliding
flap of Celsus, and in which the two flaps intended to form the new nose
are taken from the tissue of the cheek at either side of the remains of
the old nose.

The total outcome is simply to bring before the opening a curtain of skin
with a median scar running from the root to the lobule, which in itself
is sufficient upon contraction to mar the result; furthermore, there are
the two lateral wounds which have to be covered by skin grafts which,
upon healing, have their tension of contraction, added to that of the
median scar, with the result that the anterior nose becomes flattened and
ugly, practically amounting only to an unevenly contracted curtain of
marred skin.

The author would not advise resorting to such method, but, owing to
the fact that a step in the advancement of the art was conceived under
this particular method, space is given to the subject. This step, first
introduced by Nélaton, consisted of allowing all of the cicatricial
tissue of the old nose to remain with which the new nose could be
built. As the possibility of this is rare in total rhinoplastic cases,
the method is more useful in partial rhinoplastics, where it forms an
important factor, as will be shown later under that subdivision.

=Nélaton Method.=—Two lateral flaps of triangular form, having their
pedicles below the internal canthi, are cut from the cheeks, each flap
containing all of the remains of the old nose. The entire inner borders
of these flaps were freshened throughout their whole thickness.

In making the flaps, dissection is made down and through the periosteum,
thus giving firmness and thickness to the new nose. The flaps are slid
forward and sutured along the median line, leaving a triangular wound of
the cheek on either side, as shown in Fig. 339.

To keep the raw surfaces in contact with the newly dissected area and to
retain the nose in place as far as possible, a silver pin is inserted
through the base of the new nose, going through the skin and remains of
the old nose. It should be of sufficient length to permit holding a disk
of cork at either end, beyond the skin and for the retention of the metal
ring ends of a hook bent in inverted U-shape. The diameter of the latter
bent wire is equal to that of the pin.

He claims for his method a perfect and fixed cicatrization of the newly
placed parts.

[Illustration: FIG. 339.—NÉLATON METHOD.]

=Heuter Method.=—The cheek flaps are cut from the cheeks, as shown in
Fig. 340, leaving intact a triangular piece of skin with the object of
giving support to the new nose. The inner and upper borders of the two
flaps were stitched to the rim of this triangle, and then along the
median line. The flaps are not made to include the periosteum, as in
Nélaton’s method. The results thus obtained are not equal to the latter’s
procedure.

[Illustration: FIG. 340.—HEUTER METHOD.]

=Bürow Method.=—The cheek flaps are made as in Fig. 341. The projection
intended for the subseptum is an elongated strip at the inferior border
and inner angle of the left flap.

The shaded triangles at either extremity of the outer incisions show
the removal of the skin at these points, to facilitate sliding of the
flaps, adding, however, to the extent of cicatricial contraction upon
final healing, with the resultant flattening of the new nose. The lobular
prominence takes an upward position eventually, and altogether the
extensive secondary wounds and the effect of their behavior does not
warrant the use of this method.

[Illustration: FIG. 341.—BÜROW METHOD.]

=Szymanowski Method.=—His method is an improvement on that of Bürow.
The flaps, inclusive of considerable cellular tissue, are fashioned in
Fig. 342, except under the two narrow extension flaps, which are to be
utilized in building up the subseptum. Their raw surfaces are sutured
together with silk. The flaps are united along the median line.

If the tissue from the cheeks do not permit of free sliding forward of
the flaps, further incisions shown by the dotted lines over each malar
prominence are made. The skin of the shaded irregular areas on either
side is removed, as in the Bürow method.

[Illustration: FIG. 342.—SZYMANOWSKI METHOD.]

=Serre Method.=—The flaps are made to either side of the remains of the
old nose, each leaving its pedicle about one fourth inch below the inner
canthus of the eye. The flaps were cut rather obliquely, their bases
extending somewhat below the nasal orifices. The remaining skin of the
latter was dissected downward and folded down upon the median third of
the lip. If cut in two sections their inner borders were sutured so
that their raw surfaces faced each other. The object of the latter step
was to form the subseptum, according to Lisfranc. The sections of skin
lying with their bases on a level with the nasal orifices were dissected
downward and united in the median line to assist in forming the end of
the nose. All along the borders of the old nose were also dissected up
where possible and folded inward, so that their raw surfaces would adhere
to the new dorsum of the nose, and thus give it stability and form. These
pieces of skin were united at the median line when possible.

The cheek flaps with indented bases were now brought forward and united,
as shown in Fig. 343. The skin of the cheeks was dissected up to the
extent of the dotted line in the former illustration, and when necessary
two lower curved incisions were made to permit of free sliding. The skin
of the cheeks was retained by three sutures at either side, as shown in
Fig. 344. The subseptum may be made at the same sitting, or at a later
operation.

[Illustration: FIG. 343. FIG. 344.

SERRE METHOD.]

=Syme Method.=—The procedure is very like that of Heuter, except that the
somewhat curved line making the inner borders of the flaps extended over
the root of the old nose. The lower ends or bases of the two cheek flaps
were stitched around and to the orifice to form the end of the nose,
rubber tubes being used to form the nostrils, where they were retained
until healing was complete.

=Blasius Method.=—He forms the cheek flaps in triangular form, including
all of the tissue making up the buccal cavity. The outer or cheek
incision is made through all of the tissue and extends to a point
corresponding to a point a given distance beyond the angle of the mouth.
The inner incision is made from a point just below the angle of the ala
downward and through the thickness of the lip. A third incision unites
the angle of the mouth with the outer incision. Both cheek flaps are
made alike, each remaining attached along all of the remains of the old
nose. They are now raised upward and inward, with their mucosa facing
outward, and united along the median line. The raw cheek borders are
now brought forward and held in place by suturing them at either side
to the remaining rectangular flap of the upper lip. The formation of
the subseptum is left for a second sitting. This method is not only
too extensive, but too disfiguring to make its employment practicable.
The mucous membrane would, of course, in time take on the function and
appearance of skin, but the shape of the mouth never assumes a normal
form, especially since there is quite a loss of the vermilion border at
either side which is raised upward with the cheek flaps to assist in
forming the base of the nose.

=Maisonneuve Method.=—Where there is more or less occlusion of the nares
and yet an integumentary covering corresponding to the nose, as it might
rarely be in congenital cases, Maisonneuve utilizes the sliding flap
method to overcome the abnormality. In the case presented, the nasal
orifices were hardly three sixty-fourths of an inch in diameter and about
one inch apart. The correction was accomplished as follows, and shown in
Fig. 345: An incision was made transversely outward from each nostril,
then two converging incisions were made from both nares downward, meeting
at the vermilion border of the lip in the form of a V, which were made
to include the whole thickness of the lip. This flap was brought upward
to form the subseptum. The skin to form the nasal lobule was now slid
forward from either end of the incision and the subseptum sutured in
place. Rubber tubes were employed to keep the nares distended and permit
of the wings of the nose to form.

The defect in the upper lip was brought together as in a median harelip
operation, the parts appearing after operation as illustrated in Fig. 346.

[Illustration: FIG. 345. FIG. 346.

MAISONNEUVE METHOD.]


_The Italian Method_

In this classification of total rhinoplasty the skin flap is taken from
another part of the body and not from the face. The integument of the
arm is usually employed, the pedicle remaining intact until the flap has
healed into place.

The method has been accredited to the Italian author-surgeon Tagliacozzi,
but it was practiced long before his time; yet he was the first to fully
describe the steps of the successful operation. It has been referred to
quite fully under skin grafting.

The flap having an attached pedicle is cut from the entire thickness
of the skin of the arm. The free end of the flap is sutured to the
freshened borders of the old nose, and the arm is held in place until
union has been established, when the pedicle is cut. There are no
special advantages in this method, since the outcome is no better than
that obtained with the Indian method; at best the result is merely the
curtain of skin covering the defect, with the one thing in its favor—the
avoidance of the frontal scar. Against this is the great discomfort the
patient must suffer in having his arm retained in the necessary position
to prevent movement and strain on the flap, to which may be added the
danger of embolism occasioned by freeing the arm at the time the pedicle
is cut. There is also difficulty of properly dressing the wounds,
owing to the constrained position which consequently invite sepsis and
imperfect healing. Hence, for total rhinoplasty, this method may be
termed unsatisfactory; yet for certain partial rhinoplastic results it
supersedes all other methods, as will be hereinafter shown.

To make the flap a pattern is laid upon the skin, from which it is to be
made; it should be one third larger than the actual size of flap needed,
to allow for contraction. The incisions should go through the entire
thickness of the skin, leaving an attachment or pedicle, what in this
case would be the part of the flap intended for the base of the nose, and
directly opposite to those described heretofore.

The flap may be sutured in place immediately after the cutting, or it
may be allowed to remain upon the arm until contraction has taken place
in the flap, or the flap may first be modeled into nose shape and then
sutured upon the freshened margins of the old nose.

The arm must in any of these methods be held in place during the days
required to have the flap heal or unite with the facial tissue. The
various operators have devised means to accomplish this. There is the
linen network of bandages of Tagliacozzi, the harness of Berger, the
starched linen and book-board affair of Sedillot, the one-piece suit of
Lalenzowski, the leather sleeve and helmet of Graefe and Delpech and many
others.

Having determined upon the method to be followed in securing the flap,
the surgeon is advised to consider such apparatus as he may be able to
procure to retain the parts, or to use his own ingenuity to construct one
of plaster-of-Paris bandages to meet the requirements of the case at not
only less expense, but with greater comfort to the patient. At best, any
apparatus employed will do little to overcome the agony of the retained
member, which must be held in position.

Various operators give this period between six and twenty days. The
apparatus should be so constructed that dressings can be easily made
without discomfort to the patient, and without doing damage to the parts,
and also to expose the face of the patient as much as possible. The
various operations employed to perform total rhinoplasty by the Italian
method may now be considered.

=Tagliacozzi Method.=—This surgeon resorted to four steps to accomplish
his operations, which were:

I. Massage of or stretching the skin of the part from which the flap is
to be made.

II. Cutting the flap, and allowing the same to cicatrize.

III. Freshening the flap and suturing in place, and use of apparatus.

IV. Cutting the pedicle and making the subseptum.

The various details of these steps should be considered here, since the
methods are practically the same for all other operations of this kind,
except in certain particulars as to time and mode of procedure.

I. Massaging the tissue of the arm to render it supple. This is of some
consequence, in some cases, where the skin is tense, but requires no
especial description.

II. He then compressed a fold of the skin with a large forceps at the
lower half of the biceps. Upon opening these forceps he forced a bistoury
under the skin fold and cut down toward the elbow-joint a distance
sufficient to form a flap. This gave him a piece of raised skin, attached
at either end, double the size of that required to make the nose. Under
this he introduced linen mesh dressings in the form of a seton, with the
object of irritating the skin to encourage the circulation, and render it
thicker by consequent suppurations and granulations. This was continued
for fifteen days, when the skin was detached at its upper end, leaving
it attached by the lower or wider pedicle intended for the base of the
nose. The flap was now turned down and both flap and wound were allowed
to cicatrize.

III. When the flap had become dry he fitted the linen bandage apparatus
to retain the arm. Then the borders of the old nose were freshened.
Thereafter he cut a paper pattern as a model for the new nose, upon which
the margins and shape of the flap were cut. The flap was finally sutured
in place, and the apparatus was tightened to prevent movement of the
parts.

IV. After twenty days he cut the pedicle. The latter was then cut into,
to divide it in three parts, which he formed into the subseptum and nasal
wings, which were sutured in place, metal tubes being employed to keep
the nares open.

=Dieffenbach Method.=—This surgeon followed seven steps to complete the
operation, as follows:

I. The pattern of the new nose, cut one third larger, is fixed upon the
skin of the arm, with the basic pedicle just above the fold of the elbow.
Skin is now raised sufficiently to permit of its being incised, the
incisions being made laterally, as shown in the dark lines in Fig. 347.

This gives a triangular flap, the apex lying upon the biceps and having
two adherent pedicles at apex and base.

The base is now incised at one angle, transversely and again vertically,
as shown. This incision liberates the part of the flap intended for one
of the ala of the nose.

II. Diachylon plasters are placed under the flap to contract the arm
wound immediately the bleeding has been arrested. The free angle of the
base of the flap is now turned inward and under the attached part of
the flap, as in Fig. 348, so that its margin protrudes from the other
lateral incision, and its skin surface lying above the plaster. The edges
of the flap are now stitched together, and the flap is allowed to lie
cushionlike upon itself while the arm wound heals. This requires about
six weeks.

[Illustration: FIG. 347. FIG. 348. FIG. 349.

DIEFFENBACH ARM-FLAP METHOD.]

III. The holding of the flap cushion in place by the use of splints of
leather held in place by three needles. The latter are moved about, as
the shape of the cushion becomes modeled, about every three weeks. The
process ends when cicatrization of the flap or the newly formed nose has
been accomplished, shown by firmness and contour.

IV. The margins of the old nose are freshened; the lateral incisions
extend to the root of the nose, where they are united with an upward
convex incision. The skin is well raised, gutterlike, from the deeper
tissue, to assure of the best vascularity.

V. The upper or apex pedicle of the flap on the arm is cut (see Fig.
349), and the thickened roll of skin, or what may now be termed the new
nose, is turned down toward the elbow. It is divided along the line where
the two margins of skin had been sutured; in other words, it is laid open
longitudinally.

VI. The nose thus prepared is brought into place before the freshened
margins of the old nose and is sutured into place beginning at the root
before the sides are coapted.

VII. At the end of fifteen days the pedicle attaching the nose to the
arm is severed, the angle for the wing being cut slightly larger than
that of the other side, which by this time has, of course, undergone full
contraction. The subseptum is made out of the square projection folded
upon itself, raw surfaces facing, and is brought into place by suturing
it into an incision made in the lip at the required point.

=Graefe Method.=—This surgeon devotes six steps to his operation, as
follows:

I. The borders of the old nose are freshened.

II. Sutures are passed through the raised skin of the borders of the old
nose.

III. The flap is cut from the arm after a pattern made one fourth larger
than the new nose required, leaving it attached by the small pedicle
intended for the subseptum.

IV. The sutures where required are now passed through the flap, having
already been placed through the old nasal borders and left untied. The
forearm is drawn against the forehead and the arm is fixed in place with
the retention apparatus. The sutures are now tied. They are allowed to
remain in about four or five days, not long enough to irritate.

V. About the tenth day the head apparatus is removed and the pedicle of
the arm flap is divided. The arm may now be carefully lowered to its
normal position.

VI. The subseptum is not formed from the free end of the attached flap
for several weeks. It is then divided by two parallel incisions directed
outward. The septal section is folded upon itself, and inserted and
sutured in place into an incision made into the upper lip.

=Szymanowski Method.=—This author advises making the base of the flap
sufficiently wide, and of the form shown in Fig. 350, to permit of
the three sections of skin of this part of the flap to be folded upon
themselves before being sutured in place at the base of the nose, so as
to form lined nares and a thickened and supportative subseptum.

[Illustration: FIG. 350.—SZYMANOWSKI METHOD.]

=Fabrizi Method.=—This author utilized the immediate method of flap
fixation, but makes his flap of triangular form from the inner and upper
skin of the forearm.

The transverse base is made to lie one half inch below the radio-ulnar
space. The flap should be about three inches long and of about the same
width. It is cut while the forearm is relaxed; bleeding is controlled by
gentle pressure. In the meantime the cicatricial tissue of the old nose
margins has been removed and the skin freshened to receive the flap.

To approximate the parts, the hand is laid palm down upon the shoulder;
the resultant position of the arm and forearm are retained by bandages.
The parts are now sutured. On the thirteenth day the line of division is
traced out upon the arm with nitrate of silver, at the same time giving
the flap somewhat the form required to give the nose its contour.

The next day the pedicle is cut and the arm is brought back into its
normal position. With the division of the pedicle he advises including
a portion of the aponeurosis and a few fibers of the supinator longus
muscle.

The flap is allowed to remain free at its base until contraction and
cicatrization have been established, when the subseptum and wings are
made.

The position of the arm and the attached flap at the root of the nose is
shown in Fig. 351.

He advises, when possible, to dissect up a flap of the cartilage of the
old septum, letting it adhere at its lower border and turning it from
below upward with the skin which covers it to form the subseptum. This
will help to hold up the point of the nose firmly (an important matter
because it is at this point that all noses constructed of skin flaps
alone sink down for the want of suitable prop of tissue).

This cartilaginous flap he held in place with two pins thrust through the
latter and the skin flap proper, and held them in place with a figure
twist of silk. He removed the needles about the sixth day.

[Illustration: FIG. 351.—FABRIZI METHOD.]

=Steinthal Method.=—This authority made the flap for the nose from the
skin over the sternum, proceeding as follows:

“From the sternum I cut a flap of skin and periosteum in the form of a
tongue whose lower base was five centimeters wide, and the summit forming
the pedicle three centimeters wide; its length was twelve centimeters.

“I could have taken away with this flap some of the costal cartilage to
utilize in making the wings of the new nose.

“I dissected up this flap and closed the wound over the sternum with
sutures. The flap was then stitched to the forearm by its base into an
incision of appropriate length made near the radius. (See Fig. 352.) The
arm was properly fastened in a plaster apparatus and the flap enveloped
in a dressing of borated vaselin. The forearm was held in front of the
breast, an attitude easily retained. Twelve days later I cut the pedicle.

“I let a few days pass by, and then stitched the pedicle end of the flap
to the root of the nose. A new plaster apparatus was put in a suitable
position. The hand was placed on the forehead.

“Ten days after, I detached the flap from the arm and reformed the nose
with the flap, which hung down like an apron. It is necessary to have
a flap sufficiently long to fold in for the nostrils. I used bronze
aluminum wires for all the sutures.”

The position of the hand while the flap was healing to the root of the
old nose and the slight twist of the flap is shown in Fig. 353.

[Illustration: FIG. 352. FIG. 353.

STEINTHAL METHOD.]


THE COMBINED FLAP METHOD

To overcome the consequent cicatricial contraction and falling in of
the flap used to make the new nose by either of the three grand methods
given, various surgeons have resorted to lining the flap with skin flaps,
bringing their raw surfaces together so that the nose actually received
in this way an integumentary lining.

While this had the tendency to thicken the new nose, it did not give the
support necessary to it, especially at the lower third, and the lobule,
at first quite satisfactory, resulted only in the appearance and form of
a small tubercule of tissue, with a decided saddle effect above it. This
combined method did overcome, however, the slow process of cicatrization,
and its accompanying suppuration.

The raw surfaces of the two flaps, if properly brought together, healed
upon themselves readily, as has been referred to in the lining or
doubling in of the basal sections to form the nostrils and subseptum.

The method of lining the nasal flap in this manner is never sufficient
to give a satisfactory result in total rhinoplastic cases, but may be of
great service in restoring parts of the nose, as will be shown later.

The requirement is that of support, whether it be organic or inorganic,
and these methods will be considered presently.

=Volkmann Method.=—This surgeon fashioned the frontal flap as shown in
Fig. 354. This resulted in leaving a triangle of skin at the root of the
nose, which he dissected up, down, to and inclusive of the periosteum,
and turned downward so that its raw surface faced upward, as in Fig. 355.
The flap was sutured into place to retain it.

The frontal flap was brought down, so that the two raw surfaces came
together.

This method overcame the contraction of the flap over the nasal bridge or
superior third of the new nose, and an excellent adhesion of that part of
the flap to the denuded bone and flap resulted, but the same faults about
the base were not mitigated.

[Illustration: FIG. 354. FIG. 355.

VOLKMANN METHOD.]

=Keegan Method.=—The frontal flap method of Keegan has been referred to.
For the lining of the upper nose he cuts two flaps from the skin above
the old nasal orifice, as shown in Fig. 356, which he turns down, raw
surfaces out. This gave a lining to either side of the median line; the
skin remaining intact between the two flaps gave additional prominence
and support to the upper third of the new nose.

[Illustration: FIG. 356.—KEEGAN METHOD.]

=Verneuil Method.=—Contrariwise to the methods just given, Verneuil,
after cutting out the frontal flap, cuts the flap from the remaining
sides of the old nose somewhat involving the skin of the cheeks, as in
Fig. 357. This done, the frontal flap is simply turned down, raw surface
out, and the cheek flaps are slid over it, bringing the raw surfaces
together. The inner borders of the flaps were sutured in the median line,
as shown in Fig. 358. The base of the nose is made from the frontal flap
by any of the methods already given.

[Illustration: FIG. 357. FIG. 358.

VERNEUIL METHOD.]

=Thiersch Method.=—The frontal flap is cut from the skin of the forehead
in the shape shown in Fig. 359. Then two quadrilateral flaps are raised
from the cheeks, as also illustrated. These are made wide enough that,
when they were brought together, their inner borders could be made to
face each other. In this position they were sutured along the median
line, so as to give a double-gun-barrel form to the nose, with a septal
wall between.

From the lower border the nostrils were formed, giving to the new nose
a normal appearance, the continuous septum curving downward to form the
subseptum, the whole being sutured to the remains of the old nose.

The frontal flap was now brought down over it, the raw surfaces facing
each other, and sutured in place, as shown in Fig. 360. Later, Thiersch
replanted the sides of the nose, to give it better contour, and attained
a very satisfactory result. The frontal wound was covered with skin
grafts, but the cheek wounds were allowed to heal by granulation. The
cicatrization of the latter was not sufficient to effect the lower
eyelids nor the angles of the mouth.

[Illustration: FIG. 359. FIG. 360.

THIERSCH METHOD.]

=Helferich Method.=—His is an ingenious application of the French method.
Both flaps are cut from the cheeks; the lining flap was made from the
left and the covering one from the right cheek. The shape of the flaps is
shown in Fig. 361.

The lining flap is stitched along the freshened margin of the right side
of the nose. The flap should be wide enough to give convexity to the
nose, as shown in Fig. 362.

The covering or right flap, cut much larger, is now slid over this. It
should be cut amply large to cover the flap just sutured in place. It
is sutured on both sides of the nose to hold it in place, also at the
inferior margin. The nose is lightly packed with iodoform gauze.

The pedicle of the right flap was cut after two and a half weeks and
brought into place across the root of the nose, and sutured in place to
give better contour to the part after freshening the skin about the left
side of the nose at this point. He does not make a subseptum, but thinks
the inferior base of the nose of sufficient size to hide the absence
thereof.

The subseptum could, however, be readily made from the upper lip, as will
be shown later.

[Illustration: FIG. 361. FIG. 362.

HELFERICH METHOD.]

=Sedillot Method.=—This operation is particularly efficacious in giving
a splendid subseptum and support of the point of the nose, but does not
overcome the falling-in of the whole anterior line, so common with all
Indian-flap methods. A flap one centimeter wide and extending downward
almost to the vermilion border is cut from the thickness of the upper
lip, not including the mucous membrane, however. It is turned upward, as
shown in Fig. 363.

The frontal flap is fashioned as shown, care being taken to cut a
subseptal rectangle of greater length than usual, since it is intended
to overlie the raw surface of the flap taken from the lip. It is rotated
downward and sutured into place at both sides, and also to the lip flap,
to assure of accurate union.

A lateral view of the nose as formed in this manner is shown in Fig. 364.

The free end of the septal flap is fixed into the superior lobial wound
with a harelip pin. The lobial wound is sutured as in ordinary harelip
operations. This method is particularly valuable in total rhinoplasties
involving the columna and alæ in conjunction with flaps obtained by the
Italian method.

[Illustration: FIG. 363.—Anterior view. FIG. 364.—Side view.

SEDILLOT METHOD.]

=Küster-Israel Method.=—A flap was taken from the arm by the Italian
method, which was sutured to the remains of the old nose so that its raw
surface looked upward, not downward, as in the ordinary case.

The flap was made sufficiently large to permit of building the wings and
subseptum. After it had healed into place the pedicle was cut, and a
frontal flap was cut from the forehead to cover it.

An unusually large flap was required to do this, since it had to overcome
the greater curvature already given and added to by the arm flap,
necessitating an extensive secondary wound.

The reverse order of procedure would be the more advisable for this
reason, and is resorted to by the following:

=Berger Method.=—This surgeon makes the lining flap from the forehead.
The secondary wound is at once closed. A flap is then made from the arm
by the Italian method, and brought into place before the one just made.
It should be of sufficient size to allow of building the base of the
nose, which is done not later than three weeks after the pedicle of the
arm flap is severed, which may be done at any time between the eighth and
the twelfth day.

All the precautions are used as already given in the description of the
Italian method. The arm is held in the position shown in Fig. 365.

Berger sutures the arm wound before bringing the flap into place upon the
face to overcome the discomfort of suppuration to the patient.

The apparatus is fixed definitely after the patient has recovered from
the anesthetic. Great care is exercised to prevent coryza from exposure.
Dressings are made twice daily.

The pedicle is cut under local cocain anesthesia.

To make the subseptum and wings of the nose, the base of the flap is cut
into three sections. The posterior surface is freshened and the parts are
folded upon themselves and sutured into position.

Instead of employing rubber tubes, he resorts to a specially devised
apparatus to retain two metal tubes in the nares, and at the same time
make gentle pressure to the sides of the nose to mitigate the columna
contraction. The latter is planted into a V-shaped incision made into the
tissue of the upper lip at the proper place of attachment. The subseptum
may be lined with a flap of mucosa dissected up from the floor of the
inner nose.

For the wings of the nose, such tissue as may be of service to give them
stability and structure is taken from the remains of the old nose.

[Illustration: FIG. 365.—BERGER METHOD.]

The apparatus just mentioned and shown in Fig. 366 is used from the
very first day until total cicatrization has taken place, and even for
a longer period to aid in shaping the entire nose and the tendency to
collapse has been overcome.

[Illustration: FIG. 366.—BERGER RETENTION APPARATUS.]

=Szymanowski Method.=—A frontal flap, divided along the median line and
shaped as outlined in Fig. 367, is made from the forehead.

Two triangular flaps are then raised from either side, and including the
angle of the nose as shown. The divided frontal flap is now brought down
in such manner that their raw surfaces meet, thus forming a vertical
septum. The margins are united by suture, and the lower ends are fixed
into a wound made for the purpose at the base of the nose, as shown in
Fig. 368, to form the new subseptum.

The lateral triangular flaps are dissected up so that they can be readily
slid forward toward the median line. Their inner freshened margins are
sutured to the raw edge of the septum just made, and to themselves. The
objection here is that there is a liability of considerable contraction
of these lateral flaps, with a tendency to fall in and drag with them
the new septum; and again, in total restorations, the upper third of the
nose is only partially covered, and necessitates later upbuilding. The
author finds difficulty in making the four margins thus brought together
unite evenly throughout, and that a vertical contraction is caused by the
cicatrization of the median marginal wound.

[Illustration: FIG. 367.—First Step.

FIG. 368.—Disposition of frontal flaps.

SZYMANOWSKI METHOD.]

=Goris Method.=—The operation is performed as follows, having given very
good results, according to the author:

I. The frontal flap is divided lengthwise so that its raw surfaces face
each other. The resulting fold, representing the bridge of the nose, is
held in place by catgut suture.

II. The skin to make the wings of the nose is folded in, as in the
Langenbeck method.

III. A flap, half the thickness of the upper lip is brought up to form
the new subseptum.

IV. Dissection and turning down the triangular flap of skin which
surmounts the orifices of the old nose, and making it serve to line the
lower part of the frontal flap.

V. Suturing the frontal flap thus modeled into two grooves made into the
margins of the old nose along both sides to its base.


ORGANIC SUPPORT OF NASAL FLAPS

It soon became evident to the rhinoplastic surgeon that without some
support to the flap or flaps used for the construction of the new nose
all of the preceding methods, as far as æsthetic results were concerned,
were useless. Truly, the deformity lost its hideous appearance to a great
extent, but the general results obtained hardly warranted a patient
to undergo restorative operations of the nose. In fact, many surgeons
advised against total rhinoplasty when practically all of the old nose
was lost.

Langenbeck says “that total rhinoplasty, or even operation as to repair
partial loss of the nose by the use of soft flaps, should not be
undertaken. It is better to rely upon some prothesis.”

All that could be expected of utilizing the flap and making it heal into
place had been accomplished up to about the year 1879. Thereafter many
surgeons proceeded to evolve and use some kind of intranasal prothesis
made of various inorganic materials. It may be stated, however, that
Rousset in 1828 wrote: “Perhaps some day surgeons will give whatever
shape they desire to the reconstructed nose. Then a frame of gold or
silver, cleverly shaped and solidly fixed in the nose, will give the
patient, at his own option, a Roman or Carthaginian nose, and to the
ladies a choice of a roguish type, and to our Sultans a nose a la
Roxelane.”

But it was after 1878 that such prothesis came into use, and these were
at first made so that they might be removed at night and be replaced in
the morning.

The intranasal supports were made of all kinds of material, such as gutta
percha, gold plates, leaden devices, amber, silver, porcelain, celluloid,
aluminum, platinum, etc.

With all due respect to the ingenuity of these inventions, especially
that of Martin, which was made of platinum in the form of a St. Andrew’s
cross, having at the four ends sharp pins which were driven and fixed
into the skeleton of the nose, the use of these protheses resulted in
nothing but failure.

The movable devices were a source of irritation and pressure, and could
not overcome the consequent contraction of the flaps whether placed below
a single flap or between two flaps, and the fixed protheses of whatever
form or material caused so much pressure that gangrene resulted, and they
had to be removed sooner or later.

Before the discovery of Gersuny, the author had many occasions to utilize
such movable protheses in the correction of saddle noses. These were
generally made of a silver shell, gutta percha, and later of decalcified
bone, as advised by Senn. The former remained in place from six months
to two and a half years, and then were thrown off or had to be removed
because of irritation. The bone chips soon became absorbed, leaving the
nose as before, or a thin median strip that became broken with the least
violence, and then was absorbed.

In several cases where other surgeons had resorted to such protheses, the
author was called upon at a later period to remove them.

While the immediate result is very gratifying, the ultimate result is
worse than useless, since in the elimination of the foreign body the flap
of the nose was married by cicatrices that added still further to the
contraction and falling-in of the nose.


PERIOSTITIC SUPPORTS

Some other method had to be devised, and organic supports became known.
These organic protheses were made of the tissue in the near vicinity of
the flap, and at first formed a part thereof. The earlier method included
only the periosteum; later bone and periosteum were added to the flap
to give it shape and support, and lastly cartilage was employed for the
purpose.

Of the methods employing only the periosteum, it may be said that what
the surgeon expected of this membrane—namely, the springing up of bone
cells—did not take place; at least, not to the extent desired. The very
best to be attained was a thickening of flap in the membrane, but not
sufficient to add necessary support to the nose.


OSTEOPERIOSTITIC SUPPORTS

The inclusion of the periosteum-lined flap was soon abandoned, and
recourse was had to such bone additions to the flaps as could be obtained
from the vicinity of the nose.

The bone was removed with its periosteum, adherent or nonadherent to the
flap, as will be shown by the methods described hereafter.

Both single and combined flap methods are employed as might be expected,
following the procedures of the Indian, French, or Italian schools. The
greatest credit for the methods herein involved belongs to the surgeons
of Germany.

The earliest operation on these lines was that of König, who published
his first successes in 1886.

=König Method.=—Extending upward from the root of the old nose, a flap is
outlined in vertical ending at the hair line of the scalp, as shown in
Fig. 369.

This flap was made about one centimeter wide, and is made to include the
skin and periosteum. With the chisel a thin strip of bone is raised from
the frontal bone to nearly the full length and width of the flap, making
it an osteoperiostitic cutaneous section attached by its pedicle at the
root of the nose.

This flap is brought down with bony surface outward, and the distal
or skin end is fixed by suture into the upper lip at the point of the
intersection of the subseptum.

Any of the soft parts of the old nose remaining are now dissected up
toward the median line, and are folded upward and inward and sutured by
their freshened margins to this median flap.

An Indian flap in oblique direction and of the form shown is cut from the
skin of the forehead and rotated down into position before the bone-lined
flap, and sutured into place.

He advises not to include the periosteum in the flap making up the
subseptum, as it is likely to interfere with respiration. In fact, he
deems it best to make the tegumentary flap sufficiently long to build the
bone of the nose, doubling the raw edges upon themselves with a celluloid
tube apparatus that may be removed for cleansing, and be kept in place
long enough to give contour to the nares.

[Illustration: FIG. 369.—KÖNIG METHOD.]

=Von Hacker Method.=—The frontal flap was cut in the ordinary Indian
method, and of the shape shown in Fig. 355. The skin at either side of
the median line was dissected up to within four millimeters, leaving a
strip eight millimeters wide from the root of the nose to the distal or
scalp end. The two loose lips of the flap were brought together at the
anterior median line by a few sutures to keep them in place.

This was done to give freedom to the surgeon while he detached a strip
made of the periosteum and bone chiseled from the frontal bone. At the
root of the nose or below the pedicle the bone was not included to
the extent that it would interfere with torsion of the flap, and yet
sufficient to allow the raw bone surface to fall upon what remained of
the bony bridge of the old nose.

[Illustration: FIG. 370.—Arrangement of frontal flap to allow of
chiseling.

FIG. 371.—Making the osteoperiostitic support.

FIG. 372.—Bone-lined flap brought into position.

VON HACKER METHOD.]

He utilizes pins driven into the bone to outline this bony section, as
shown in Fig. 370.

The latter is done in an oblique direction. See Fig. 371. The septal
section is made to include the bone strip.

The bridge of bone holding the flap at its inferior end was now broken,
leaving, however, the periosteum as part of the pedicle hinge.

The whole flap thus outlined was rotated downward into position and
sutured, as shown in Fig. 372.

The margins at the base intended to form the subseptum were sutured
behind the osseous structure, or, in other words, were doubled inward and
fixed by suture. The bony strip was broken at the proper point to give
prominence to the lobule.

The margins for the nostrils were turned inward and doubled on
themselves, and sutured with silk.

Rubber tubes were left in the nares, for drainage and to keep them
distended.

=Rotter Method.=—The frontal flap is made in the shape shown in Fig. 373,
containing a section of the frontal bone and its periosteum. The width of
the flap is about three and a half centimeters wide.

This flap is turned downward so that its raw surfaces look outward.

Owing to the loose adherence of the bony section to the skin flap, he
allows the raw bone surface to granulate over for four weeks, to fix it
more solidly to the soft parts.

The bone plate is then sawn into three sections made by two vertical
incisions, made as shown in the illustration.

The median section forms the bridge and dorsal prominence of the nose.

The adherent skin of the lateral bony plates is dissected up
sufficiently to permit of the proper formation of the sides and wings of
the nose.

This gives a shape to the nose, as shown in Fig. 374.

The lateral margins of the integumentary flap are now sutured to
the freshened margins of the old nose, and the remaining skin, if
any, is made to cover the granulating surface; if this is lacking or
insufficient, skin grafts are utilized to cover it completely.

[Illustration: FIG. 373.—First step.

FIG. 374.—Disposition of frontal flap.

ROTTER METHOD.]

=Schimmelbusch Method.=—The principle herein is to give an osseous
wall to the whole length of the restored nose, covering well the skin
inside and outside, and, if possible, to fix the new nose solidly at the
pyriform opening.

“I cut an osteo-cutaneous flap from the middle of the forehead, of a
size proportional to the size and shape of the nose. Its pedicle between
the eyebrows is two or three centimeters wide; it widens out superiorly
to form seven to nine centimeters. It is triangular, and its base lies
near the hair line. In cutting it out, preferably a little large, it
goes at first to the bone, through skin and periosteum. With a large,
sharp chisel, a thin bone plate throughout the whole extent of the
cutaneous flap is detached. It is not always possible to make this a
plate in one piece; it often breaks or gives off splinters. This is
of no consequence, if care be taken not to lose them and to keep them
adherent to the periosteum. They are attached as well as possible to the
cutaneoperiostitic flap by passing threads crosswise from one edge of the
flap to the other over bony surface, as in Fig. 375. The whole flap is
then enveloped in iodoformed suture.

“The frontal wound I close at the same sitting by sliding large lateral
flaps whose upper border follows the margin of the hair as far as the
ears. These are freed completely, brought down and stitched, leaving
eventually only a linear cicatrix on the forehead. The lateral loss of
substance which results is healed by granulation, and the scars concealed
by the hair.

“At first parts of the bone die; they ought to be expected to fall out;
after four, six, or eight weeks the bone is completely covered with
fleshy granulation, and adheres solidly to the flap. The prominent
granulations are then scratched, or, better, trimmed away with the knife,
and the whole surface is covered with Thiersch grafts.

“When the flap is thus furnished with skin within and without, it is
put into place. I saw the bony plate with a fine-toothed saw from the
grafted side; then I model the flap and place it on the loss of substance
freshened by turning the grafted surface toward the interior of the nose
by twisting its pedicle, as in Fig. 376. The osseous rim of the pyriform
opening is uncovered at the moment of this freshening, and the bony
edges of the flap are placed exactly on the bony edge of the aperture.
The skin of the flap is then stitched at its lower margins to the skin
of the cheeks. To preserve the height of the nasal profile and avoid
displacing the bones of the nose, the nose is kept in place with a pin
thrust through the nose, and furnished at each end with a rubber button.
This aids to form the wings of the nose. If a subseptum is needed, it
is made by taking from the skin that covers the circumference of the
pyriform opening two small flaps, which are dissected from without toward
the median line as far as the point where the septum is normally found.

“These are stitched at this point, first upon themselves, then to the end
of the nose. Three weeks later the pedicle of the frontal flap is cut; it
is turned, put in splints, and the stitching is finished.”

[Illustration: FIG. 375.—First step.

FIG. 376.—Disposition of frontal and skin-grafted flap.

SCHIMMELBUSCH METHOD.]

=Helferich Method.=—A lining flap is made, according to the French
method, from the one cheek, which is dissected up and turned over to
bridge most of the loss of nasal tissue, and sutured to the opposite
freshened margin, as showed in Fig. 377.

A frontal flap, as outlined in the same illustration, is now cut from the
forehead, leaving a pedicle as shown, and containing a section of bone
at its median line. This is rotated downward and into place, and sutured
along the same margin to which the genian flap is fixed, as shown in Fig.
378.

When the frontal and genian flaps have become well united, the latter’s
pedicle is cut when the freshened lateral margin of the frontal flap is
sutured into place.

A subseptum is now made or deemed necessary by this surgeon.

At a later period the pedicle of the frontal flap is cut, and fixed by
suture and some cutting, to reduce the resultant prominence thereof.

[Illustration: FIG. 377. FIG. 378.

HELFERICH METHOD.]

=Preidesberger Method.=—This author cuts away the skin surrounding the
arch of the old nose, and turns this flap downward to form the lining to
the flap made from the forehead made in the same manner as Helferich.

The bone section is made in the median line, and is one centimeter wide
and four long.

The frontal flap should be made long enough to permit of building a
subseptum and the nostrils.

=Krause Method.=—This frontal cutaneo-osteo-periostitic flap is made
according to the method of König.

After turning down the flap it was covered with a nonpedunculated skin
flap taken from the upper part of the arm by transplanting after its
subcutaneous fatty tissue had been removed. (See Fig. 379.)

This method necessitates a long-continued dressing of the forehead before
the pedicle is cut, because of the needed nutrition to make the two flaps
heal upon each other.

After union has been established the sides of the transplanted flaps are
raised by dissection, as shown in Fig. 380, to expose the bone plate of
the frontal flap. A median strip is left intact.

With a fine saw the bony plate is cut into three sections, making the
narrowest the median.

The margins of the old nose are now freshened, and the combined flap
is sutured along the sides, preserving what tissue the surgeon can use
to add support to the nose, which is done by dissection and turning or
folding, as heretofore described.

The lower or forehead flap is sutured to the soft parts of the old nose,
and the transplanted lateral margins to the marginal skin of the cheeks,
giving to the nose the appearance as shown in Fig. 381.

At a later period the pedicle is cut and the wound that cannot, at this
time, be overcome by sliding of the adjacent skin, is covered by skin
grafting.

[Illustration: FIG. 379.—First step.

FIG. 380.—Second step.

FIG. 381.—Third step.

KRAUSE METHOD.]

=Nélaton Method.=—A lateral flap of skin is taken from the cheeks,
beginning on a line with the root of the nose and as low as a point two
thirds of its normal length. These flaps are made wide enough, so that
when dissected up and folded inward they will meet on the median line,
as shown in Fig. 382, having their raw surface facing outward. They are
sutured along the median line. The frontal flap was cut in the form of
a horse-shoe having its pedicle at the root of the nose just above the
eyebrows, and being about three centimeters wide and six long.

The skin at the outer margins was dissected up from the bone, leaving
sufficient attachment at its center to allow for a bony plate.

With a fine saw, and in the manner shown in Fig. 383, this plate was made
from the frontal bone, being about two and a half centimeters wide and
four long.

[Illustration: FIG. 382.—First step.

FIG. 383.—Making bony support to flap.

NÉLATON METHOD.]

There is some difficulty associated with the making of the flap, which
ends at the superior border of the frontal, leaving the pedicle composed
only of skin.

The flap is now turned down, exposing its raw surface. The bony plate is
sawed through at the median line, as shown in Fig. 384, and the skin of
the flap is also divided along this line, giving two partly bone-lined
flaps.

The two flaps are now rotated downward before the lost nose, so that
their raw surfaces face inward, and in this position they are sutured
along the median line and the sides, as shown in Fig. 385.

The method gives an angular dorsum of satisfactory consistency to the new
nose, but furnishes a serious drawback, in that the cicatrization along
the median line is liable to affect the shape of the organ and leaves a
prominent scar line. The use of two small pedicles is another objection
in that the danger of gangrene is greater as the nourishment to each flap
is less.

[Illustration: FIG. 384.—Cutting through bony plate.

FIG. 385.—Disposition of frontal flap.

NÉLATON METHOD.]

=Israel Method.=—From the ulnar side of the left forearm Israel cuts a
skin flap, as shown in Fig. 386, with its smaller end nearest to the
wrist, where it is detached, the pedicle being broad, assuring of better
nourishment to the flap.

The narrow end of the flap is cut down to the bone, then the sides
are dissected up until the borders of the ulna are reached on both
sides, reserving an adherent strip about eight millimeters wide and six
centimeters long.

[Illustration: FIG. 386.—ISRAEL METHOD.]

The bone below this strip is now removed with the saw from the lower end
upward, and ending about one centimeter beyond the base line of the flap,
where the strip so made is left connected to the bone proper.

The flap is now raised gently and bent upward without breaking the bone.
It is sawed half through, transversely, at a point corresponding to the
lobule of the nose.

The flap is then enveloped in iodoform gauze, and the head, forearm, and
arm are fixed in plaster of Paris, the forearm being bent at a right
angle to the arm (see Fig. 387).

[Illustration: FIG. 387.—ISRAEL METHOD. Position of forearm for placing
of flap.]

After nine days the osseous connection still remaining is severed, and
the nose is modeled upon the forearm, as heretofore described in these
operations, this surgeon using silver wire to retain the parts. The
raw skin surfaces are allowed to heal upon each other and the flap is
permitted to come in contact with the wound on the forearm temporarily,
to which it might adhere, the gauze being now removed.

After twelve days the newly modeled nose is freed from such adhesions and
kept from healing to the parts by using dressings between the flap and
wound.

Five days after, the margins of the old nose are freshened in the form
of an inverted V. If there be sufficient cicatricial tissue it is turned
down, raw surface out, to line the new nose.

A prolongation of the pedicle is now cut, widening out toward the radial
side of the arm, made obliquely, as shown, so that its pedicle now
corresponds to a width of seven centimeters.

The whole flap except this newly formed pedicle is cut free of this
forearm. The arm is put into the position shown in Fig. 387, and the
freshened flap margins at the root, the whole length of the left side,
and part of the upper right lateral. The plaster dressing to hold the arm
in the proper position until complete union is established is used. This
done, the pedicle is cut, and such minor operations are done to fix the
remaining free margin and the base of the new nose.


CARTILAGINOUS SUPPORT OF FLAP

The methods just described in which an osseous plate of various size and
form is included with skin flaps for the restoration of the nose give
undoubtedly the best rhinoplastic results. The new nose is given not only
better shape, but a permanency of such form that skin flaps of themselves
could never give.

The unfortunate factors in these osteo-cutaneous operations are the many
difficulties experienced.

The cutting or making of the bony plate is no simple task.

The skin is an uncertain agent to employ, because of the peculiar contour
of the bony surface from which the plate is to be removed. The chisel,
no matter how dexterously used, is liable to cut through the entire bone
thickness, which has occurred in several recorded cases.

There is also the possibility of necrosis of a part or all of the bony
plate thus obtained, and where the latter is not lined interiorly there
is the added danger of infection.

Furthermore, the secondary wound is more extensive; the bone exposed
requires about a month’s time to granulate over before skin grafts can be
successfully applied over it.

With the employment of a cheek-flap lining there is the added objection
of cicatrization. The use of a flap from the arm is complicated and
requires considerable time for the completion of the operation, and there
is always the added danger of infection and consequent death of the
osseous plate.

To overcome these many difficulties von Mangold advocates the use of a
section of cartilage to support the anterior prominence of the nose.

It has been found, since the first attempt of and the successful result
obtained in 1897 by this surgeon, that cartilage to be used for this
purpose should be taken from the costal cartilage, where a strip of the
required length and width can be obtained.

The results thus far recorded are excellent, and much is hoped for from
this method, especially in the reconstruction of loss about the wing of
the nose in partial rhinoplasties, where the convexed contour may be
reproduced to a nicety.

The first attempt to support the flap for a total rhinoplasty by this
method was made in 1902 by Charles Nélaton.

The use of cartilaginous supports may be combined with any of the
methods given heretofore. The flap containing the cartilage may be lined
or unlined. All tissue found about the old nose should, of course, be
utilized to give added support and to reduce as far as possible extensive
secondary cicatrization.

The combined Hindu and Italian methods give splendid results, the frontal
flap and its support being brought down from the forehead, raw surface
outward, and the arm or forearm flap being placed immediately in front of
it.

The frontal flap with the support requires a preliminary operation
to permit of the attachment of the cartilage. Fortunately, this step
requires but little time and shows a very slight disfigurement during
this period.

The secondary wound at the site of the cartilage excision requires
little attention and heals readily, and the cicatrix involved is very
small.

Steinthal proposes taking the flap and cartilage from the thoracic
region, grafting it during the preparatory period to the forearm, from
which it is transplanted to the face at a second sitting.

There is the objection to this method that it requires the arm to be
retained in position for a very long time.

The author advocated the use of an arm flap made by the Italian method
to line the one to be brought down from the forehead in cases of total
rhinoplasty where little or no tissue can be obtained from the remains of
the old nose. Such procedure reduces the time required by the Steinthal
method to one half, and therefore greatly lessens the discomfort to the
patient.

The fundamental principles as laid down by Nélaton are excellent, and
may be applied to any modification of method the surgeon may decide upon
where a section of costal cartilage is employed to support the flap,
whether this be taken from the forehead, other parts of the face, or
remote places.

The procedure of Nélaton is as follows:

=Nélaton Method.=—The method involved a preparatory and a final operation.

The preparatory operation has to do with obtaining and placing in
position the section of cartilage under the skin flap wherever located.

The final operation may or may not consist of two sittings, the first
being necessitated by the bringing upon the remains of the nose a flap
of skin to line the one brought down in front of it and containing the
support.

_Preparatory Operation._—To begin properly, the frontal flap to be
utilized is marked out on the forehead with nitrate of silver the day
before the operation, so that its outline will be plainly discernible,
and act as a guide for the placing of the cartilage. The shape of the
flap is fashioned as shown in Fig. 388.

[Illustration: FIG. 388.—NÉLATON METHOD. Outlining of frontal flap.]

In the illustration is also shown the incisions later made to utilize
the borders of the remaining nose to line the frontal flap. This is
done by making an inverted V incision at a distance from the inner
borders, corresponding to the lateral line of union of the frontal flap
with the face. The resultant flap is turned down, raw surface outward,
curtainlike, and is sutured to the frontal flap, where it falls into
position.

The flap outline shows that its pedicle lies between the outer end of the
inner third and above the right eyebrow and a little to the left of the
median line at the root of the old nose. This will avoid considerable
tension at this point, the rotation as made being ninety degrees.

Nearly horizontally, as shown in the figure, a line is drawn through the
center of the flap, showing the position the strip of cartilage is to
occupy.

This done, a pattern of the outline is cut from stiff paper or oiled silk
to preserve as a guide for the making of the flap, it being understood
that the outlining has been made to the measurement of the required nose,
allowance being given for cicatricial contraction.

This done, the surgeon having prepared the skin about the costal
prominences of the left thorax, he proceeds as follows:

A vertical line is drawn the width of two fingers to the right of the
nipple, as shown in Fig. 389, the length of the line being obvious.

[Illustration: FIG. 389.—METHOD OF LOCATING STRIP OF CARTILAGE.]

Where the vertical crosses the eighth costal cartilage an incision is
made downward over and not under the border of the cartilage.

The incision extends downward for a distance of eight centimeters,
where it is turned upward at an angle, as shown, to a distance of three
centimeters.

By separating the muscular aponeurosis made visible by this incision
the lower edge of the eighth costal cartilage is exposed. The knife is
moved along the lower edge of the cartilage, dividing the fibers of the
insertion of the transverse muscle from without inward. The cartilage can
now be grasped between the thumb and forefinger and be forced out of its
normal position after a slight anterior dissection.

The union between cartilage and bone is exposed. The chisel is used to
divide the cartilage about one centimeter from the rib, after the costal
or inner extremity has been made.

The position of the hands and the exposed cartilage is shown in Fig. 390.

[Illustration: FIG. 390.—EXCISING STRIP OF COSTAL CARTILAGE.]

This accomplished, the wound is temporarily dressed. The cartilage is
then fashioned to suit the required size and shape.

It is thinned down on its lower surface to about three millimeters in
diameter. This thickness is maintained to a length of two and a half
centimeters, the part being intended for the subseptum.

A notch is made on the upper surface at this distance from the end, which
marks the point at which it must be eventually bent to form the point of
the nose. This notch is cut to two thirds of the entire thickness.

The required length, that of the nasal line and its added septal length,
is preserved.

The cartilage being prepared is now ready for the insertion under the
frontal periosteum at the site already marked.

For this purpose a vertical incision one and a half centimeters,
extending down to the bone, is made, as shown in Fig. 391.

[Illustration: FIG. 391.—CARTILAGE PLACED UNDER FRONTAL FLAP.]

The periosteum is peeled away from the bone with the dull or rounded
handle of a knife.

The cartilage is now thrust into the tunnel thus made, the thinned-down,
notched-off section facing forward and lying toward the vertical incision.

The skin wound is sutured and a gentle compress is used to keep the
cartilage in contact with the periosteum, which requires at least two
months. A longer interval of time is advocated to give greater vitality
to the cartilage.

The wound of the thorax is simply sutured and dressed as any surgical
wound.

_Final Operation._—The part cut is prepared as in the Hindu method.
A lining for the frontal is made of such tissue as remains, and its
freshened borders are sutured where possible, as shown in the last figure.

When this cannot be done, a flap may be taken from the arm, as already
suggested, or a Krause nonpedunculated skin flap may be used, according
to the methods given heretofore.

The epidermis is made to face inward. If either of these methods is used,
the frontal lap is not brought down until healthy granulation has been
established.

The frontal flap is made to include the periosteum, from which it is
separated with a blunt instrument. The cartilaginous strip will be found
to be attached to the periosteum.

The freed flap is now brought before the nasal defect and fitted into
place. The cartilaginous strip should occupy the anterior median line.

The subseptal cartilage is bent inward and downward and the skin of the
flap is sutured to it with catgut to form the subseptum, as shown in Fig.
392.

[Illustration: FIG. 392.—BRINGING DOWN FRONTAL FLAP.]

The free margins of skin remaining at the septal bone of the flap are
folded inward to line the new nostrils. Catgut sutures are used to keep
these folds in position.

The nose is now ready to be sutured into place. The subseptum is inserted
first and fixed into the upper lip, then the nose being held so that its
median line occupies the proper position, both wings are sutured to the
freshened margins, and lastly the sides (see Fig. 393).

[Illustration: FIG. 393.—PLACING OF FRONTAL FLAP.]

The frontal wound may be drawn together as near as possible by suture.

Rubber drainage-tubes are kept in the nares for a few days, and are
thereafter replaced by rolls of gauze.

Dry dressings are preferred for the nasal wounds, which heal in about
five days.

A month after, Thiersch grafts are employed to cover the frontal wound
remaining. They require about eight days to heal into place.


PARTIAL RHINOPLASTY


RESTORATION OF BASE OF NOSE

In this defect there may be a loss of the lobule and both alæ, including
the subseptum, or there may be a lateral loss, involving more or less of
the base.

There are many types of this deformity, so that to include all would
involve considerable space, and at best most of the operations involved
would be those utilizing the methods heretofore mentioned.

The earlier operations for the correction of lesions of large extent
are founded upon the use of skin flaps, which have been shown to be
unsatisfactory because of their consequent cicatrization. Reference is
made, however, to several of these to exhibit the disposition of the
remaining parts of the old nose.

Later will be considered the methods involving osteo-cartilaginous
supports.

=Steinhausen Method.=—The inferior remains of the old nose are detached
from the margins and brought downward; a Hindu flap is fashioned as shown
in Fig. 394, and brought down to form the new nose; the size of the flap
is given as being four inches wide and eight inches long.

The distal end of the flap is sutured to the freed flaps obtained from
the borders, as shown in Fig. 395.

The method is purely of the Hindu type, and the results are not,
therefore, very satisfactory.

[Illustration: FIG. 394. FIG. 395.

STEINHAUSEN METHOD.]

=Neumann Method.=—This author cuts down the remains of both lower margins
of the old nose, as in the Steinhausen operation. A wedge-shaped section
is cut from the entire thickness of the upper lid and turned upward to
form the subseptum, and is sutured to the lateral parts brought down by
the former incisions, to which it is sutured at the median line, as shown
in Fig. 396.

Two lateral flaps are now made from the sides of the remaining nose
retaining their cartilages, as shown in the illustration, _A_, _B_, _C_,
_D_, showing one of them. The two flaps remain attached, anteriorly along
the median line over the bridge of the nose. These two lateral flaps
_A_, _B_, _C_, are turned down from the point _A_, which represents the
pedicle, and are sutured at the median line by their lower borders, _A_,
_B_, the borders _B_, _C_, being thus brought down, fall before the
fresh borders taken from the margins of the old nose, to which they are
sutured, as shown in Fig. 397.

This procedure will leave two exposed areas at either side of the nose,
which are permitted to heal by granulation.

[Illustration: FIG. 396. FIG. 397.

NEUMANN METHOD.]

=Later Neumann Method.=—An incision is made to circumscribe the remains
of the old nose at either side, extending upward in rectangular form
above the root of the nose, between the inner canthi and upward, and
somewhat above the eyebrows, as shown in Fig. 398.

This flap thus outlined is freely dissected down to the bones of the
nose, leaving it attached only at the roots of the wings, so that it can
be turned downward, hanging over the mouth, like a curtain.

A deep transverse incision is then made through the remaining
cartilaginous structure of the nose, just below the inferior borders of
the nasal bones. This gives a cartilaginous, archlike support to this
part of the flap, which is utilized to give firmness and shape to the
base of the new nose.

The incision just mentioned is depicted in Fig. 399, in which is also
shown the turned-down flap.

After the hemorrhage has been controlled the flap is turned upward and
into such position as to form the new nose, utilizing the cartilaginous
arch, above referred to, to the best advantage to give the proper
contour. This will lower the apex of the flap considerably. The lateral
borders are sutured to the freshened margins where possible, but as a
rule an opening is left at either side, communicating with the inner
nose, which must be healed by granulation.

The wound on the forehead may be brought together completely by suture.
The appearance of the nose assumes at this time the form shown in Fig.
400.

The objection to this method lies in the fact that the cartilaginous
arch brought down with the flap is usually insufficient to give proper
support to the base of the nose, permitting the lobule to contract and
sink. In most cases there is an absence of sufficient cartilage to employ
the method at all. An osseous arch would, therefore, preferably be
incorporated with the flap, taken from the remaining nasal bones.

[Illustration: FIG. 398. FIG. 399. FIG. 400.

LATER NEUMANN METHOD.]

=Bardenheuer Method.=—This author makes a transverse incision across the
root of the nose, and two lateral incisions from either end of the first,
carrying them downward and outward, as shown in Fig. 401. These incisions
are made down to the bone. With a chisel the nasal bones are separated
from their frontal and superior maxillary attachments, giving an arch of
bone to the flap, which is brought downward and outward, the bone being
dissected from the underlying mucosa. To facilitate the bringing down of
this flap the anterior border of the cartilaginous septum must be divided
if present.

The flap thus made is attached only at the two points of skin at the
inferior borders, the epidermal surface looking inward. The archlike
mass of bone is gently bent backward at either side to practically
reverse its convexity. The position of the flap is shown in Fig. 402.

The raw surface of the flap above mentioned is now covered with a flap
taken from the forehead in the form shown in the figures.

The resultant nose is entirely lined with skin, and contains sufficient
bone to support it. The objection is that there must necessarily be
a large secondary wound in the forehead, which must be covered with
Thiersch grafts.

[Illustration: FIG. 401.—Shape of flap.

FIG. 402.—Disposition of nasal flap.

BARDENHEUER METHOD.]

=Ollier Method.=—This author uses an inverted V incision, beginning on
the forehead at a point about three centimeters above the superior margin
of the eyebrows. The diverging incisions are carried down to a point just
above the base of what remains of the old nose, where it remains attached.

The shape of the flap thus made is shown in Fig. 403.

[Illustration: FIG. 403.—OLLIER METHOD. First Step.]

The flap is dissected up and made to contain the periosteum as far as the
juncture of the frontal nasal bones.

The skin over the right nasal bone is now dissected up, without, however,
including the periosteum. The left nasal bone, still adherent to the
skin, is removed with the chisel, beginning at the median line, then at
its frontal attachment, and lastly along its union with the superior
maxillary bone.

On the right side what remained of the cartilaginous structure was
divided so as to include it in the flap.

This gave a large triangular flap, periosteo-cutaneous above,
osteo-cutaneous below that, and ending in a chondro-cutaneous border,
attached to the face by a double pedicle, as shown in Fig. 404.

To give further support to this flap at the median line, Ollier divided
the septum with the scissors in such a way as to form an antero-posterior
cartilaginous flap attached by its lower base.

The flap was brought downward in the same manner as in the method of
Neumann and sutured into position, the parts involved assuming the
position shown in Fig. 405, in which the lateral nasal surface is left
uncovered to show the space occasioned by the removal of the nasal bone,
and in dotted line the position that bone now occupies.

In five weeks the two nasal bones united, end to end, and three months
after the operation the space made by the removal of the bone had become
filled with hard tissue, that eventually ossified in about seven months.

[Illustration: FIG. 404.—Second step.

FIG. 405.—Position nasal bone occupies.

OLLIER METHOD.]

=Langenbeck Method.=—A median incision is made through the remaining skin
of the old nose, dividing it into halves. The incisions about the base
and the shape of flap to be brought down from the forehead are shown in
Fig. 406.

The skin over the nose is dissected up, moving toward the cheek, exposing
the bony frame of the nose.

From the lower border of the pyriform aperture two elongated triangular
plates of bone are made, being attached posteriorly to superior
maxillary bones. They should be made about one sixth inch wide.

By their subsequent displacement they are made to lie antero-posteriorly.
With a saw the nasal bones are separated from their maxillary connection
from below upward, making a median bone plate, which is raised with
a levator to the height desired for the new nasal bridge, remaining
attached to the frontal bone, as shown in Fig. 407.

A frontal flap is taken from the forehead and sutured to the freshened
raw margins of the lateral flaps.

The bone plates are fastened to each side of the frontal flap by suture.

The nasal base is preferably made of the tissue remaining of the
old nose, as depicted, to prevent closure of the nostrils, the only
difficulty being to keep the poorly nourished tissue from dying. When
used the raw surface is brought in contact with that of the frontal flap.

The objection in this case is that the median third anterior line usually
falls in rapidly, leaving the nose dished or saddled, and unless there be
sufficient tissue to construct the base, the objections so often referred
to heretofore will occur.

[Illustration: FIG. 406.—First step.

FIG. 407.—Showing separation and elevation of nose flaps.

LANGENBECK METHOD.]

=Ch. Nélaton Method.=—This author uses an osteo-cutaneous flap taken from
the forehead. The shape of the latter is shown in Fig. 408.

The lateral incisions are to be made the width of a finger from the
margins of the old nose, extending upward in curved fashion through
the inner edge of the eyebrows and meeting at a point on the forehead,
becoming slightly oblique near the border of the hair.

The flap is dissected up from the borders inward, including the
periosteum, leaving a strip of bony attachment at the median line.

The dissected sides of the flap are held up by an assistant while the
operator proceeds to chisel a thin bony plate from the frontal. The bony
plate ends just above the root of the nose.

The dissection is now carried on downward until the bones proper of the
nose appear, and latterly, so that the saw does not injure the soft
parts, and to act as a guide for the course of the latter.

The position of the flap and the saw in position is shown in Fig. 409.

[Illustration: FIG. 408.—First step.

FIG. 409.—Making lower nasal flap section.

NÉLATON METHOD.]

The saw is made to sever the nasal bones from the apophyses of the
superior maxillary. The blade follows a line starting one centimeter
anterior to the anterior and superior nasal spine, and is directed
downward toward the second molar, not going entirely through the
apophyses.

The latter are broken with the chisel in such way that some of the bony
border lies in contact with the nasal process of the superior maxillary.

This fracturing is made as the flap is still further brought down, as in
Fig. 410.

The flap is now so adjusted that its median bone-lined section will form
the median third of the nose, the base being made by folding the flap
upon itself, as shown in Fig. 411.

[Illustration: FIG. 410.—Forming base of nose.

FIG. 411.—Ultimate disposition of entire flap.

NÉLATON METHOD.]

The raw surfaces are sutured at their point of coaptation, laterally, and
to the margins of the genian flaps.

The frontal wound is brought together by suture as closely as possible,
and Thiersch grafts are employed to close any wound still remaining.

The objections to this operation is that of all bone-plate flaps. A
flap containing a cartilaginous support taken from the eighth costal
cartilage, as previously described, would undoubtedly give the best
results.


RESTORATION OF LOBULE AND ALÆ

The defect being at a distance from the forehead, the employment of
frontal flaps for the restoration of the lobule and alæ are to be
eliminated; furthermore, such methods would involve the incision
and dissection of the healthy skin of the nose to no advantage but
disfigurement, and possible further loss of the organ.

The results with autoplasties about this part of the nose are usually
excellent, and particularly gratifying are those obtained with the
Italian method, in which the flap is made from the skin of the forearm.

French methods involving large nasogenian flaps are not to be used
because of their consequent retraction and cicatrization of the cheeks.
Small lining nasogenian flaps may be utilized where necessary, since they
cause little scarring.

If the loss of tissue is very small, the flaps to reform the parts may
be taken from the nasal skin and the septum be made of a flap from the
upper lip. Both such secondary wounds could be drawn together by suture,
leaving slight linear scars. Operations of this nature will be described
separately later. Some of the methods referred to might be combined for
small defects of this nature.

Defects of larger extent may be corrected as follows:

=Küster Method.=—A flap of considerable size is outlined on the skin of
the arm and cut laterally, leaving it attached at both ends in bridge
fashion.

Gauze dressings are inserted under the flap. Several days later the
superior pedicle is severed and the flap is sutured to the freshened
margin of the nose. An application of borated vaselin on gauze is used
as the dressing. The arm is held in position by a proper apparatus, a
plaster-of-Paris fixture being used by the author.

Six days later the brachial plexus is divided to half its width, and
totally divided three days thereafter.

Fifteen days later the free border of the flap is divided into three
sections, the median one being made narrowest. The outer small flaps thus
made are sutured to the remaining wings of the nose.

Five days later the septum is formed of the remaining unattached flap,
which is sutured to the stump of the old septum. It is not folded upon
itself, but allowed to heal by cicatrization.

Eight days later minor operations are performed to reduce the exuberant
portions of the side flaps.

=Berger Method.=—This author makes a flap of the skin above the border
of the nose, which he turns down, raw surface outward, upon which he
immediately brings a flap from the arm. The object of the lining is to
give stability to the base of the new nose as well as to prevent curling
and contraction of the rims of the nostrils.

=Bayer-Payr Method.=—Two flaps two and a half centimeters wide are cut
from the nasolabial furrow, extending down to the lower border of the
inferior maxillary bone, as shown in Fig. 412.

The flaps are dissected up and brought forward and upward, their raw
surfaces meeting in the median line, where they are sutured upon one
another to the extent of three centimeters, as shown in Fig. 413.

The nasolabial wounds are brought together by suture except for a
small triangular space near each pedicle, which are allowed to heal by
granulation.

The superior borders of the flaps were then united by suture to the
freshened margins of the nose, which have been prepared as shown in the
illustration.

The septal ends of the two flaps are likewise sutured to the stump of the
old septum.

The raw or outer surfaces of the flaps are to be covered with Thiersch
grafts when ready for them, though this may not be necessary with small
flaps.

The pedicles of the flaps are not cut until the end of the fourth week,
when the fresh ends may be sutured to freshened surfaces of the wings
made to receive them.

The disposition of the parts at this period is shown in Fig. 414.

[Illustration: FIG. 412.—First step.

FIG. 413.—Disposition of flaps.

FIG. 414.—Ultimate placing of pedicles after division.

BAYER-PAYR METHOD.]

=Ch. Nélaton Method.=—This author in cases of extensive destruction of
the point of the nose advocates the lining of an Italian flap with skin
flaps made in similar manner, as in the foregoing operation.

The lining flaps are taken from the nasogenian furrow, placed and sutured
as just described, without twisting of their pedicles, and are sutured at
the median line and at their free ends to the freshened septal stumps.

The Italian flap is placed over those two flaps immediately, or the
Italian flap is first made to unite to the raw margin of the defect, and
the two nasogenian flaps are made and employed at a later sitting by
subplanting.

The Italian flap may be taken from the arm or forearm, this surgeon
preferring the forearm. The attached flap and position of the hand on the
forehead where it is retained with an apparatus for the required time is
shown in Fig. 415.

The adherent Italian flap and its subseptal addition and the outlines for
the lining flaps are shown in Fig. 416.

The secondary nasogenian wounds reduced by suture and the flaps so
obtained are shown in Fig. 417. The subseptal section of the Italian
flap is raised to show the disposition of the flap ends to form the new
septum. The raised flap is brought down and sutured to the raw edges of
the two septal flaps covering the median cicatrix, its own cicatrices
falling within the rim of the nostrils.

[Illustration: FIG. 415.—Attachment of flap from forearm.

FIG. 416.—Forearm flap in position and outline of lateral flaps.

FIG. 417.—Disposition of lateral flaps.

CH. NÉLATON METHOD.]

This surgeon advises in less severe losses of tissue to do without lining
the Italian flap, but to make the latter large enough to be able to fold
in enough of its base sections to line the nostrils to the extent of the
inferior line of the mucosa. The flap should be cut one fourth longer
than the nasal deformity.

This procedure also overcomes to a great extent the shrinking of the
nasal orifices.

The pedicle of the flap is cut close to the arm at the end of two weeks.
The subseptum may be made at once if the flap shows good nutrition, as
evidenced by marked bleeding at the time of cutting away the bridge
tissue.


RESTORATION OF THE ALÆ

The method of restoration of the wing or wings of the nose depends
largely upon the extent of the tissue loss.

The use of the Hindu method is not advisable, since the flap must be
made with a long pedicle, which involves the making of a large wound and
predisposes to consequent large cicatrices, although many surgeons have
resorted to the method. The author does not see any advantage with this
method, even if the loss of tissue about the lobule is great.

The best results, both as to the primary and secondary wounds, are
those obtained with the Italian method, and in extensive cases the
use of a combined flap, wherein the lining flap is taken from the
nasolabial furrow or just above it. This leaves a linear scar that
does not disfigure the face, and assures of better contour than when a
single integumentary flap is employed which, as has been so frequently
mentioned, is liable to curl inward and contract in an upward direction,
adding little to the area of lost tissue.

The ideal operations are those which include cartilaginous supports,
which may be obtained from about the border of the deformity or from some
remote place, as of the ear. The surgeon is hardly justified to use the
remaining healthy tissue of the nose, unless the case is such that the
secondary wound can be corrected, so as not to add scars to the face.

Small defects can be easily corrected by sliding flaps taken from the
vicinity of the defect, whether they include cartilage or not, and by
granulation or dissection and approximation of the skin, the secondary
wound may be entirely closed. It is remarkable how little linear scars
show about the nose when the lips of the wounds have been neatly brought
together.

The author advocates the use of the continuous silk suture for this
purpose, since it fulfills both the object of suture and splint and
overcomes the corrugating effect, so often found with interrupted
sutures; furthermore, a continuous suture is more easily withdrawn, and
there is no danger of wounding the skin on removal, and the discomfort to
the patient is greatly reduced.

From the foregoing descriptions of procedure, the surgeon has been
sufficiently familiarized with such steps in rhinoplasty as are usually
employed, and it would be a matter of constant repetition to rehearse
these same steps for the following operations; therefore the author
trusts the illustrations given will be sufficiently lucid to work from.
All special features to be observed are given.

=Denonvillier Method.=—The secondary wounds made by the two methods here
given may be allowed to heal by granulation or be covered with skin
grafts, as heretofore described.

[Illustration: FIG. 418.—Making of flap. Pedicle anterior.

FIG. 419.—Disposition of flap.

FIG. 420.—Pedicle posterior.

FIG. 421.—Disposition of flap.

DENONVILLIER METHOD.]

=Mutter Method.=—A skin flap is taken from the cheek and slid forward
into the defect as shown.

[Illustration: FIG. 422. FIG. 423.

MUTTER METHOD.]

=Von Langenbeck Method.=—The skin flap is taken from the healthy side of
the nose and brought into the defect by sliding.

The secondary wound is allowed to heal by granulation.

[Illustration: FIG. 424. FIG. 425.

VON LANGENBECK METHOD.]

=Busch Method.=—The same method as above is employed except that for the
incision _A_, _C_, which, upon dissection of the skin in triangle _A_,
_B_, _C_, allows the closure of a larger defect than could be corrected
with the lateral nasal flap alone (see Fig. 426).

[Illustration: FIG. 426.—BUSCH METHOD.]

The following illustrations are similar to those given and involve only
the skin in the flaps made, as shown. They are only of interest in
portraying the position of the flaps and their pedicles.

[Illustration: FIG. 427.—DIEFFENBACH METHOD.]

[Illustration: FIG. 428.—DUPUYTREN METHOD.]

[Illustration: FIG. 429.—FRITZ-REICH METHOD.]

[Illustration: FIG. 430. FIG. 431. FIG. 432. FIG. 433.

SEDILLOT METHOD.]

[Illustration: FIG. 434. FIG. 435.

NÉLATON METHOD.]

In the Bonnet method the flap is taken from the entire thickness of the
upper lip and by twisting is brought into the defect. The pedicle must be
cut at a later sitting.

[Illustration: FIG. 436. FIG. 437.

BONNET METHOD.]

=Weber Method.=—The flap is made from half the thickness of the upper
lip, as shown in Fig. 438, and brought into the defect, as in Fig. 439.
The pedicle is cut later.

[Illustration: FIG. 438. FIG. 439.

WEBER METHOD.]

=Thompson Method.=—This author uses a lateral flap taken from the cheek,
as shown in Fig. 441, and lines it with a flap of mucosa dissected from
the septum antero-posteriorly, as shown in Fig. 440, disposing of the
latter flap as shown. The raw surface meets the raw surface of the skin
flap, as in Fig. 442.

At a later sitting the two pedicles must be severed and adjusted by small
minor operations.

[Illustration: FIG. 440.—Mucosa flap.

FIG. 441. FIG. 442.

THOMPSON METHOD.]

=Blandin Method.=—The flap is made of the whole thickness of the lip. The
pedicle is cut at a second sitting.

[Illustration: FIG. 443. FIG. 444.

BLANDIN METHOD.]

=Von Hacker Method.=—This author adds a flap from the nasolabial region
to line that taken from the healthy side of the nose, as shown in the
Langenbeck method. There is little cicatrization here, and the result is
excellent for defects of large area.

The procedure and shape of flaps as used are shown in Figs. 445 and 446.

[Illustration: FIG. 445. FIG. 446.

VON HACKER METHOD.]

=Kolle Method.=—The author dissects away the flap _E_, _A_, _D_ when
part of the mucosa and cartilaginous tissue remains, and where there is
a loss, total or partial, of the alar rima, the transverse incision _E_
being made as long as required to overcome the defect by sliding, as in
Fig. 447.

The latter flap is freshened at its inferior border along the line _D_,
and a second or bordering flap of sufficient width to line and face the
nostril is taken up from the upper lip, skin only, as shown in area _C_.

The lateral or upper flap is now slid down to slightly overcome the loss
of tissue and the flap _C_ is brought upward by twisting slightly on its
pedicle and sutured in place, as shown in Fig. 448.

The secondary wound lying between the lines _E_ and _E’_, occasioned by
the sliding downward and leaving the triangular defect _F_, is allowed to
heal by granulation. The lateral flap is fixed along the line _A_.

Usually the pedicle of flap _C_ need not be cut, as it adjusts itself
under primary union.

The secondary lip wound is closed at once by suture. The author has also
used the inverted V incision of Dieffenbach, including the cartilage
or part thereof that remains above the defect, and has moved this flap
downward, suturing in Y fashion with good results.

[Illustration: FIG. 447. FIG. 448.

AUTHOR’S METHOD.]

=Denonvillier Method.=—The operation is similar to that of Dieffenbach
and the author’s modification just mentioned. Its advantage, as in the
latter, is that the inferior border or nasal rim remains intact, and
contains what cartilage remains above the defect. The shape of the
incision is as shown in Fig. 449.

The flap _A_, _B_, _C_ includes the skin and such cartilage as can be
used, while the rim below the line _B_, _D_ retains its lower cicatricial
border.

The flap is slid down until the defect has been overcome, and the
resultant superior triangular wound is allowed to heal by granulation.
The dissection of the flap is made down to the line including the skin or
cartilage referred to. At the dotted line _B_, _D_ the whole thickness of
the tissue except the overlying skin is involved.

[Illustration: FIG. 449.—DENONVILLIER METHOD.]

=Von Hacker Method.=—The flap _A_, _F_, _C_, as shown in Fig. 450, is
cut from the entire thickness of the side of the nose attached by its
posterior pedicle _C_.

This flap is moved downward, and its anterior border is sutured along the
freshened line _A_, _B_, as in Fig. 451, leaving a triangular defect,
_A_, _F_, _C_.

Two little triangular flaps of skin are dissected up, skin only, at _D_,
_E_, _C_ and _H_, _G_, _C_.

Next a rectangular flap, _I_, _K_, _L_, _M_, is dissected up from the
cheek, as in Fig. 452, including some areolar tissue.

The flap should be made sufficiently long, so that when folded over it
will fit into the defect without tension, at the same time allowing for
contraction.

This flap is sutured into the defect made by the making of the first
flap, as shown.

The secondary wound of the cheek is brought together by suture, except
for a small triangle near the pedicle to avoid its constriction.

Its raw surface is allowed to heal by granulation. The pedicle is severed
in about fifteen days, and may be cut in triangular fashion to make it
fit smoothly into the slight defect in the skin just posterior to it.

[Illustration: FIG. 450. FIG. 451. FIG. 452.

VON HACKER METHOD.]

=König Method.=—In this novel method a flap somewhat of the form of the
defect is taken from about the entire thickness of the rim of the ear,
as shown in Fig. 453.

This flap should be made slightly larger than the defect, since it
contracts somewhat immediately after excision.

It is sutured rim down to the freshened wound in the wing.

The secondary deformity of the ear is brought together by suture. The
author has found that this cannot be readily done without puckering the
rim when the line of excision is made convexly, and advises making it
triangular instead. The defect of the nose should be freshened to the
same form. The flap from the ear now becomes ideal, fits better, is more
readily sutured in place. No sutures should, however, be made through the
apex of this triangular flap to avoid gangrene at this frail point. Silk
isinglass at this point acts as a splint. Dry aristol dressings are used.

[Illustration: FIG. 453.—KÖNIG METHOD.]

=Kolle Method.=—When the defect of the ala is elongated and involves only
part of the rim, the author has taken a cutaneo-cartilaginous flap from
the back of the ear.

The flap is cut vertically, and is made to include a strip of cartilage
of about the size and form of the defect.

The flap is immediately sutured to the freshened defect and folded upon
itself with the cartilage facing the inferior margin of the defect.

The flap thus employed exhibits an epidermal face, both inside and
outside as well as at the rim of the wing.

A case in which this method was used is shown in the illustrations 454
and 455, in which the defect is shown in the former figure, and the
result after the sutures were withdrawn on the sixth day in the latter.

The secondary wound is easily brought together by suture, as the skin is
quite flexible at this point.

[Illustration: FIG. 454. FIG. 455.

AUTHOR’S CASE.]


RESTORATION OF NASAL LOBULE

This defect of the nose has been restored by the use of skin flaps taken
from the forehead, the nose itself, or from half or the whole thickness
of the upper lip. The author does not advocate the use of such flaps
except those taken from the skin of the inner side of the forearm, just
below the wrist, made according to the Italian plan, as heretofore
described.

The pedicle of such a flap is cut about the twelfth day, and at a later
period, when the inferior or free margin has cicatrized, the subseptum is
formed and sutured to the remaining stump or into a wound in the upper
lip made to receive it.

The skin of the forearm is nearer to the thickness of the skin of the
nose; hence a flap from it is preferable to that taken from the arm.

The method of obtaining the flap has been fully described heretofore.

The results obtained are excellent in most cases. The resulting cicatrix
is barely visible, and may be later improved by scar-reducing methods,
later described under that heading.

The appearance of the flap after the pedicle has been severed and the
subseptal section has been put into place may be observed in Fig. 456,
and the final appearance after total contraction, in Fig. 457.

[Illustration: FIG. 456.—Flap detached.

FIG. 457.—Final appearance.

AUTHOR’S CASE.]

For very small losses of tissue about the lobule nonpedunculated skin
grafts are to be employed. The author advises including some of the
areolar tissue with them to avoid contraction.

These are to be dressed with the blood method referred to under skin
grafting. Perforated rubber tissue is to be used next to the epidermal
surface to prevent the dressings from tearing away the graft when changed.

Fine twisted silk is most suitable for suturing purposes. The loops must
not be drawn too tightly and the knot be made so that it rests upon the
healthy skin of the nose.


RESTORATION OF SUBSEPTUM

For the correction of this defect various methods are given, and all of
these must be modified more or less, to meet the requirements or extent
of lost tissue. In some cases the entire subseptum is absent, while in
others there is more or less of a stump remaining. Again in some, the
subseptum required is unusually wide and in others quite narrow.

While a number of surgeons prefer making the flap to restore it from
part or the whole thickness of the upper lip, as will be shown, the
author believes the best results are to be obtained with the Italian
flap method, if there be great loss of tissue, or to attempt to restore
smaller defects with cartilage-supported nonpedunculated flaps taken from
back of the ear, as heretofore described, or the cartilage to be used as
a support may be taken from the nasal septum itself, having its pedicle
posteriorly.

This strip of cartilage is brought downward, freed at either side from
its mucosal attachment, and the skin flap to be used is then made wide
enough to be sutured to the inferior mucosa margins as well as to the
skin of the lobule.

The method of taking a sliding flap from the healthy skin of the nose is
not advisable, because of the resultant disfigurement.

The tissue of the lip, on the other hand, can be used, since the
secondary wound can be readily drawn together, leaving only a linear
scar. In men, this may be hidden by the mustache.

When the Italian method is used, the method referred to in restoration of
the lobule is to be followed.

=Blandin Method.=—The flap is taken vertically from the entire thickness
of the upper lip, as shown in Fig. 458, having its pedicle at the base of
the nose.

This strip of tissue is turned upward, mucosa outward, and its freshened
free end is sutured to the raw surface of the lobule.

The secondary wound of the lip is sutured as in ordinary harelip, as
shown in Fig. 459.

The mucosa soon takes on the appearance of skin, but in most cases
remains pink in color.

The flap taken in this way should not be made too wide.

[Illustration: FIG. 458. FIG. 459.

BLANDIN METHOD.]

=Dupuytren Method.=—The flap is taken vertically from the skin of the
upper lip, reaching down at its free end to the vermilion border, as
shown in Fig. 460.

The flap is twisted upon its pedicle and sutured to the skin of the
lobule; to facilitate this the left incision is made higher than that on
the right.

The pedicle may be cut as with all such flaps, and it may be allowed to
remain, if not too disfiguring.

The secondary wound of the upper lip is drawn together by suture, as
shown in Fig. 461.

The mucosa of the nose is to be sutured to the raw edge of the flap when
that is possible.

[Illustration: FIG. 460. FIG. 461.

DUPUYTREN METHOD.]

=Serre Method.=—This author advises dissecting up a flap from the
upper lip, including the skin only, leaving it attached just above the
vermilion border, as in Fig. 462.

The free and upper end is sutured to the lobule. When union has taken
place, the pedicle is divided and is brought upward and sutured into
place. The secondary wound repaired by suturing finally. There is some
difficulty in dressing the wound during the time required to have it
unite to the skin of the lobule, because of the danger of pressure and
consequent gangrene.

[Illustration: FIG. 462.—SERRE METHOD.]

=Dieffenbach Method.=—This author took up the skin flap transversely or
obliquely, as shown in Fig. 463, and twisted it into position, as shown
in Fig. 464.

The objection to the direction of making the flap in this manner is that
the consequent cicatrization has a tendency to draw the mouth out of its
normal position on the wounded side.

[Illustration: FIG. 463. FIG. 464.

DIEFFENBACH METHOD.]

The following methods show the taking of the flap from the skin of
the nose itself. Unless the defect be very small such methods are
objectionable.

[Illustration: FIG. 465.—HEUTER METHOD.]

[Illustration: FIG. 466.—SZYMANOWSKI METHOD.]

=Szymanowski Method.=—In the latter method of Szymanowski the flap must
be stretched considerably, to close over a lengthy deformity, encouraging
gangrene. The deformity is not so great, however, as with the two
preceding methods.

[Illustration: FIG. 467. FIG. 468.

SZYMANOWSKI METHOD.]

The author believes a nonpedunculated flap with or without a
cartilaginous support should be tried before other methods are resorted
to, in all cases, with the hope of healing the graft in place. The fact
that the mucosa can in some cases be sutured to the margins of the
flap adds much to the possibility of its subsequent life by adding its
nutriment to the graft.




CHAPTER XVI

COSMETIC RHINOPLASTY


The operations herein considered have to do with overcoming deformities,
congenital or acquired, as a result of traumatism, and in which there is
no loss of tissue, the sole object being to give to the nasal organ a
more desirable size and contour.

There are many types of abnormalities involving both the size and shape
of the nose. Some of these deformities may be readily corrected by
subcutaneous or submucous operations, while others involve more or less
cutting of the skin.

The object of the surgeon at all times is to accomplish the best results
with as little disfigurement as possible.

=Anesthesia.=—All the cosmetic operations of the nose should be done
under local anesthesia, unless there be serious objections to its
employment.

The author advocates the use of a four-per-cent solution of β Eucain,
in preference to all others. It is less toxic than cocain and harmless
to the patient; no untoward symptoms are exhibited from its use
post-operatio. Various patients complain of slight uneasiness about the
epigastrium, and many speak of a peculiar weakness about the knees, but
these symptoms pass away quickly.

More or less stinging is felt in the wounds made in this manner,
immediately after the operations, especially about the lobule of the
nose, as with blepharoplasties, but this usually subsides in less than an
hour. It may persist, however, in some cases, for several hours. It is
well, therefore, to acquaint the patient with this fact to avoid worry or
fear.

Where severe, hot applications, dry or moist, may be used to overcome it.

More or less edema follows the employment of local anesthetics, which
passes away in various lengths of time, from one to four, or even five
days, according to the amount used and the site and circulation of the
part operated upon.

In over ten thousand hypodermic injections of eucain the author has
observed only two cases of collapse, which responded readily to the
usual treatment employed in such event, and has never met with a single
fatality.

=Sutures.=—Twisted silk sutures are to be preferred, as they do not
invite sepsis, as softening catgut does, and retain the parts during the
entire time required for healing, while the latter is liable to become
separated by uneven absorption, allowing the wound to gape at that point
and causing more or less of a cicatrix, so intolerant to patients of this
class.

=Dressings.=—Bulky bandages are not required; they heat the parts, and
look unsightly. The author employs antiseptic adhesive silk plaster for
covering all external wounds, except where the hair prevents its use.
Moist dressings are never indicated, except in the later treatment of
infected wounds.


ANGULAR NASAL DEFORMITY

This is, perhaps, the most common of all nose deformities. The nose is
overprominent about the osseous bridge, extending outward and downward,
hook or hump fashion. It may be congenital or the result of external
violence.

There are various methods of reducing the redundant bones and cartilage;
those involving submucous excision are difficult to perform for the
inexperienced operators, and the external means of reduction are advised
to be followed. The resultant scar, if the skin has been properly incised
and not damaged by retracting pressure, and, lastly, properly and neatly
sutured, should be barely visible.

=Monk’s Method.=—This author made a small incision through the skin just
posterior to the inferior edge of the lobule, as in Fig. 469_a_. Then
with a dull instrument, introduced through the opening, he detached the
connecting tissue that binds the skin along the anterior dorsum as far as
the root of the nose, giving more or less width to this freed area about
the nasal bones.

A dull-pointed scissors is introduced through the sublobular opening, and
the bones and cartilage are reduced until the desired nasal line has been
attained.

The method of procedure is shown in Fig. 469_b_.

[Illustration: FIG. 469_a._ FIG. 469_b._

MONK’S METHOD.]

The wound is cleansed of all spiculæ of bone or bits of cartilage and the
skin opening is closed by suture. Healing takes place with more or less
ecchymosis in about six days.

The difficulty the author finds with this method is that it is
practically impossible to do good work with the scissors in this position.

The use of an electric drill has been advocated to do away with the
scissors, but it is a dangerous instrument and requires great skill for
its manipulation and reduces the bone particles to such fine fragments
that much of it is left in the wound, which may induce sepsis or cause
unevenness of the skin surface until later absorbed or removed. The same
fault is observed with cartilage, which it grinds into pulpy pieces and
for which it should never be used.

=Anterior Median Incision.=—This, perhaps the oldest method, has been
extensively employed. The incision is made down the median line of the
dorsum of the nose, beginning above the deformity, and ending slightly
below the inferior bone line, as shown in Fig. 470. The skin is incised
obliquely.

An assistant separates the wounds with hook tenaculi, exposing the
osseous bridge, as in Fig. 471.

[Illustration: FIG. 470. FIG. 471. FIG. 472.

MEDIAN NASAL INCISION.]

The author advocates dividing the periosteum and dissecting it well
back to either side of the bony elevation. By bringing it back over the
denuded surface after the chiseling has been done, it aids materially in
establishing a smooth surface and hastens the bone repair.

The periosteum being held aside, the straight chisel and mallet are
used to reduce the bone. The operator may proceed to do this from above
down or _vice versa_, according to the formation and position of the
protuberance.

The redundant cartilage is removed with the knife from above downward,
cutting from side to side.

Usually the operator does not remove enough of the cartilage and a new
angulation of the nose appears after the swelling has disappeared,
necessitating a second operation.

The wound is closed as shown in Fig. 472.

=Lateral Incision.=—The incision in this case is made slightly posterior
to the beginning of the lateral border, as shown in Fig. 473.

The skin is held back, as shown in Fig. 474, and the same mode of
procedure is followed as that just given.

[Illustration: FIG. 473. FIG. 474.

LATERAL NASAL INCISION (Author’s method).]

The operator will have some difficulty to reach the opposite anterior
border of bone elevation, especially if the incision has not been made
long enough. This should be done. At no time should the assistant employ
too much force in retracting the anterior flap to better expose the field
of operation; it is certain to cause gangrene of the skin.

To overcome a long scar line, and to facilitate the cutting away of the
bone, the author had a special set of chisels made with curved cutting
blades, one angular and the other straight-edged. There are two each for
working from the right and left sides. The striking point lies midway
between the blade and the end of the handle.

They are shown in Figs. 475 and 476.

[Illustration: FIG. 475. FIG. 476.

AUTHOR’S CHISEL SET.]

To the set the author has added a suitable metal mallet, an instrument
very hard to obtain for osteoplastic operating. All the mallets
obtainable are too large and heavy for delicate work (see Fig. 477).

[Illustration: FIG. 477.—AUTHOR’S METAL MALLET.]

After the bone is reduced to the proper level, the cartilage is cut away
as before described, and the wound is sutured.

The resultant scar is much better than when made in the median line, and
is not so noticeable in this position.

This operation gives the best results of all external methods employed
for this purpose.


CORRECTION OF ELEVATED LOBULE

(Retroussé Nose)

This condition is frequently a deformity. The base of the nose is tilted
upward, unduly exposing the nares.

The author prefers to bring the lobule down by excision of the anterior
third of the subseptum in preference to submucous dissection of the
cartilaginous tissue, causing the deformity.

[Illustration: FIG. 478. FIG. 479.

AUTHOR’S METHOD.]

With an angular scissors introduced through the nares, a triangular
section of the septum is removed, as shown in Fig. 478. The apex of the
triangle should be placed well up into the septum to break the elasticity
of its structure, the base of the triangle being sufficiently wide to
somewhat overcorrect the deformity.

Such noses are usually narrow at the lobule, and no interference with the
lower lateral cartilages is called for.

The septal mucoid and the subseptal skin wounds are brought together by
suture, as shown in Fig. 479, leaving only a slight transverse linear
scar on the subseptum.


CORRECTION OF BULBOUS LOBULE

Roe corrects this deformity by making an incision, either vertically
or horizontally, in the mucosa in one or both nares, through which he
introduces the blades of a fine curved scissors, with which sufficient
redundant tissue is removed to bring the lobule down into the desired
contour.

The mucosa should be sutured to facilitate rapid cicatrization. The
operation should be overdone to get the desired result.

Not infrequently the extreme convexity of the lower lateral cartilage
must be overcome by either removal submucously or by excision of the
cartilage itself, employing an elliptical incision in the mucosa for the
purpose.

The alæ are kept in position after such ablation by compress dressings
or by a suture made transversely through both wings of the nose and the
septum, and tied over a quill or cork support placed externally upon the
skin at either side of the nose. This is removed about the sixth day.

Sheet lead or a splint of aluminum of proper thickness and covered with
gauze may also be used to retain the parts during cicatrization.


ANGULAR EXCISION TO CORRECT LOBULE

When the lobule is unduly broad at its base and is more or less concave
above the rim of the alæ, it can be reduced by removing a diamond-shaped
piece of tissue at either side of the subseptum.

The bases of the two triangles making up the diamond at its widest area
meet at the anterior rim of the nostrils, extending with their apices
upward and backward, as shown in Fig. 480.

If there be a prominence of the cartilaginous structure of the lobule,
this may be removed subcutaneously after the two ablations have been made.

[Illustration: FIG. 480. FIG. 481.

AUTHOR’S METHOD.]

Before suturing the wounds, it is advisable to free the skin of the
inferior lobule to overcome tension.

The sutures are applied as in Fig. 481. None are used to unite the mucosa
unless the interior wounds are large enough to permit of their use.


CORRECTION OF MALFORMATIONS ABOUT THE NASAL LOBULE

The operations herein described apply particularly to the correction or
reduction of an overprominent nasal tip due to an excessive growth of
congenital malformation of that part of the nose, giving the organ undue
prominence and a hooklike appearance, usually associated with a narrow,
sharply upward inclined upper lip.

=Pozzi Method.=—The same operation, on a larger scale, can be readily
employed for the correction of hyperplasia nasi and rhinophyma.

In the operation of Pozzi (_Bulletin et mémoire de Société de chirurgie_,
1897, p. 729) an elliptical section of skin and cartilage are removed
from the lobule with its widest part corresponding to the point of
the nose; the cicatrices occasioned thereby are practically as bad,
if not worse, than the unscarred overprominent nose, while the
submucous procedure of Roe (_Medical Record_, July 18, 1891) is not only
insufficient in these cases, but, according to my experience, practically
useless.

=Roe Method.=—Roe’s method requires a submucous extirpation of the
redundant cartilage at the tip through a necessarily small opening within
the nasal orifice, also the division in several places of the anterior
fold of the lower lateral cartilage with the object of reducing the undue
convexity of the alæ. The latter is, we might say, impossible, since
the cartilages will be reduced by such a method, even under pressure
dressings, which are likely to cause gangrene of the skin of the wings;
or if this be avoided, the cicatrix resulting from such division usually
restores the very fault that it is expected to overcome, while the mucous
lining of the alæ becomes thickened and more firmly tied down than
previous to the operation.

One is tempted to exsect the major curvature of the lower lateral
cartilage, but this leads to a flattening of the wings of the nose,
partial atresia of the nasal orifice, and a decided lack in its symmetry.

Secondly, in Roe’s operation there is always a lack of knowing how much
or how little to remove of the cartilage of the tip, a second cosmetic
operation being made necessary after the parts have contracted and
healed, a common fault with most cosmetic plastic operations performed
under local anesthesia, owing to the immediate edematous enlargement
following its hypodermic use.

=Operation as Commonly Practiced.=—The operation heretofore most
commonly practiced is one in which an elliptical piece of skin is cut
from the tip of the nose, followed by the extirpation of the anterior
prominences of the lateral cartilages, and amputation of the septal
cartilages. Unfortunately, the result, at first quite satisfactory to
the eye, culminates in the pulling apart of the cicatrix formed by
bringing the sides of the wound together along the median line with
a later depression of the tip in this median line, occasioned by the
outward traction of the lower lateral cartilages. Even a second or third
operation does not overcome this result entirely, and at best leaves an
ugly irregular gash in the median line of the tip and the columna.

In one of the cases here cited this same operation had been
unsuccessfully tried twice by another surgeon, with very unsatisfactory
and unsightly result. (Case II.)

The ideal operation for all of this type of cases from the view of the
surgeon is to leave as little disfigurement as possible, and the method
to be here considered, when properly followed, leaves no scar whatever,
except for a slight white line across the columna of the nose, where it
is out of view, and when contracted offers no objection on the part of
the hypercritical patient.

=Author’s Method.=—The method of the author is as follows: Given a nose,
typified by the illustration in Fig. 482, the skin above the site of the
operation is thoroughly cleansed with soap and hot water, then rinsed
with alcohol, ninety-five per cent, and vigorously scrubbed with gauze
sponges, dipped into hot bichlorid solution, 1 to 2,000, followed with
a thorough lavage with sterilized water. Both nostrils are now cleansed
with warm boric-acid solution by the aid of small tufts of absorbent
cotton wound over a dressing forceps. The patient is then instructed to
breathe through the mouth during the operation. A number of small round
gauze sponges dipped into sterilized water and squeezed dry are placed
within reach of the assistant. About one drachm of two-per-cent Beta
Eucain solution is now injected about the tip of the nose, the columna,
and the alæ, as far back as their posterior fold.

[Illustration: FIG. 482. FIG. 483.

AUTHOR’S METHOD.]

A thin bistoury is then thrust into the nose from right to left, entering
at the point _E_ (Fig. 483), and brought down parallel to the anterior
line of the nose, and emerging below the tip in a line with the anterior
border of the nasal orifices. This procedure leaves a strip (_A_) about
one quarter inch wide, laterally, rounded at its inferior extremity, and
attached superiorly to the nose. Next the round inferior tip (_B_) is
cut away obliquely, sloping inward toward the nose by the aid of a small
angular scissors. Each blade of the angular scissors is now placed into
each nostril, the tips of the blades inclined forward, and the columna
or subseptum is divided at _C_, also the septum along the line _D_ up to
a point a little above the first incision made externally at _E_. The
two arterioles of the columna are controlled by the use of mosquito-bill
forceps. The two projecting folds of the lower lateral cartilage in the
columna are next severed as deeply as possible to give mobility to the
stump, a step necessary to overcome the changed position, otherwise
resulting in a droop, which would have to be corrected at a later sitting.

The next step is to give the needed shape to both wings. This is
accomplished with a specially designed scissors, so curved on the flat
that its convexity facing upward corresponds to the normal curvature of
the orificial rim. A clean cut with these scissors, beginning at _G_ and
ending at the point _E_, is made, leaving the base of the nose, as shown
in Fig. 484. The anterior flap _A_ is now bent backward to meet the stump
of the columna at _C_. If it does not fall readily into place a little
more of the septal cartilage is removed along the line _D_ until this is
accomplished.

It may be necessary to shorten the flap _A_ in cases where a very
prominent hook is to be corrected.

[Illustration: FIG. 484. FIG. 485.

BASE OF NOSE AFTER EXCISIONS.]

The free end of the flap _A_ is now sutured with No. 4 sterilized twisted
silk to the stump of the columna at _B_. Two stitches usually suffice
(see Fig. 485). One or two sutures may also be taken across the angles
of union of the alæ and the flap _A_. The inferior raw surface of each
wing may be found to be too wide, owing to the presence of the thickened
cartilage at this point of the wing. The skin and the mucous membrane
are then carefully peeled away from the cartilage, and the latter cut
away as high as possible, or a gutterlike incision is made along its
edges as shown in _C_ (Fig. 485), excising the elongated elliptical piece
of tissue which includes the cartilage. The raw mucocutaneous edges of
the wings are now brought together with a No. 1 twisted silk continuous
suture, completing the operation.

An antiseptic powder is dusted over the parts operated on, and small
gauze dressings are applied with the aid of strips of silk isinglass
plaster. A small tampon of cotton, well dusted over with an antiseptic
powder, is placed into each nostril.

The dressings are changed the second day, when the resultant swelling
will have practically subsided. The sutures in the columna are removed
the fourth day preferably, and those of the wings about the sixth day.
Complete cicatrization follows in about ten days, when the patient can be
discharged.

The following cases are given to show the types of cases thus far
operated upon and to illustrate the results obtained:

[Illustration: FIG. 486. FIG. 487.

AUTHOR’S CASE.]

_Case I._—Mr. R., aged thirty-two; foreman mechanic. Had been operated
upon for angular nose, also at point of nose by Dr. S. Presented himself
for operation October 19, 1904, when cast was made (see Fig. 486).
Bromides given during recovery. Patient had been subject to fits of
depression on account of his nose for over a year. Wounds healed in ten
days, when second cast was made (Fig. 487). Complete recovery.

_Case II._—Miss B. P., aged twenty-two; actress. Patient presented
herself for operation March 22, 1905. A long, irregular depressed
cicatrix showing at point of nose, the result of an attempt to reduce tip
of nose by an elliptical extirpation of the lobule (Dr. N.). No cast was
made of the case at the time, so that a second cast showing the result
would be of no use. Recovery complete in twelve days. Patient returned to
her profession three weeks later much pleased with the result.

[Illustration: FIG. 488. FIG. 489.

AUTHOR’S CASE.]

_Case III._—Mr. L. L., aged twenty-eight; broker. Presented himself, at
the advice of Dr. T., for operation May 2, 1905. Cast of cast made and
shown in Fig. 488. Uneventful recovery in twelve days, when case Fig. 489
was made.

_Case IV._—Mr. M. B., aged twenty-eight; operatic baritone. Presented
himself for operation June 4, 1906. Photograph shown in Fig. 490.
Uneventful recovery in fifteen days, when photograph in Fig. 491 was
made; angular nose operated upon (at this time discharged; recovery
complete).

[Illustration: FIG. 490. FIG. 491.

AUTHOR’S CASE.]

_Case V._—Miss L. W., aged twenty-seven. Presented herself for operation
and cast (Fig. 492) made August 4, 1906. Uneventful recovery in ten days.
Cast of result made August 18, 1906 (see Fig. 493).

In each of these cases the patient was discharged highly satisfied and
well pleased with the result of the operation, although in Case V the
patient was requested to return in about one month for an operation
to reduce the width of the wings of the nose, which was not attempted
at the first sitting, but could have been with little difficulty by
beginning the primary incision at _E_, Fig. 483, higher up, and cutting
out a triangular section on either side of the flap _A_, the apex of
each triangle being at point _E_, and the base along the line _D_. The
wounds are sutured along the dorsum of the nose with No. 1 twisted silk,
after exsecting much of the lower lateral cartilages of the wings, as can
easily be reached in the triangular point formed by the raw dorsal border
and the inferior edge (_F_). The latter method, however, would be likely
to leave a slight cicatricial line on either side of the nose. This could
be much overcome by making the incision from point _E_ to _B_ obliquely
to the plane of the skin, likewise the posterior sides of the triangles
mentioned, just as the incisions at _B_, and across the columna at _C_,
are made. Recovery should be complete in five days.

[Illustration: FIG. 492. FIG. 493.

AUTHOR’S CASE.]


DEFICIENCY OF NASAL LOBULE

Where there is a lack of lobular prominence it may be enlarged and
brought forward by a subcutaneous prothesis if the skin is flexible
enough to permit of injection, as has heretofore been described. If this
cannot be done, the following operation may be employed to advance the
point of the nose, and reduce the width at its base so commonly observed
with these cases.

=Gensoul Method.=—A deep incision is made from the floor of each nostril
downward and backward, meeting at a point just below the union of the
subseptum with the upper lip, as in Fig. 494.

The deeper tissues are loosened from their attachments to the bone until
the subseptum at its base, including the triangular appendage thus made,
is freely movable.

The lobule is now drawn forward to its required prominence and the parts
are sutured Y fashion, as in Fig. 495.

If the subseptum be too wide, an elliptical section is removed, including
the cartilage, sufficient to give it the desired thickness when brought
together, as illustrated. The lips of the wound are brought together as
shown.

[Illustration: FIG. 494. FIG. 495.

GENSOUL METHOD.]


CORRECTION OF WIDENED BASE OF NOSE

When the base of the nose at its juncture with the lip is too broad, the
reversed procedure mentioned under correction of a broad lobule is to be
employed.

The diamond-shaped section is removed from the posterior rim of the nares
as shown in Fig. 496.

The tissues at either side are freed from their subcutaneous attachments
so as to render them mobile.

The mucosa and skin wounds are sutured as in Fig. 497.

A retention splint or suture is to be employed to retain the parts as
with the anterior lobule operation just described until healing has taken
place.

[Illustration: FIG. 496. FIG. 497.

AUTHOR’S METHOD.]


REDUCTION OF THICKNESS OF ALÆ

When the alæ are thickened they add to the width of the nasal bone and
cause more or less atresia of the nostrils. The cause may be due to
superabundant connective tissue or a congenital enlargement of the lower
lateral cartilage.

To overcome this deformity the following operations may be followed:

=Linhardt Method.=—This author excises an elliptical section of tissue
from the inferior base of both nasal wings, as shown in Fig. 498.

A similar procedure has heretofore been described in Fig. 485 in
connection with correction of the lobule.

The section removed includes as much of the cartilage as is necessary to
thin out the wing of the nose and to overcome the atresia.

The parts are sutured as shown in Fig. 499.

[Illustration: FIG. 498. FIG. 499.

LINHARDT METHOD.]

=Dieffenbach Method.=—In this method cone-shaped section of skin and
cartilage are removed from the wings of the nose, as shown in Fig. 500.

If the septum is too wide, two or three of the same shaped sections are
removed from it.

The skin wounds are drawn together by suture, as shown in Fig. 501.

[Illustration: FIG. 500. FIG. 501.

DIEFFENBACH METHOD.]


CORRECTION OF NASAL DEVIATION

In this deformity the nose is bent or twisted to one side. The cause is
usually traumatism, but may be congenital.

The interior cartilaginous septum is usually found malformed on one or
both sides.

To correct the deviation, the redundant cartilaginous septum is cut or
sawed away to clear both nares and the anterior nasal vestibule. After
this has been done the nasal attachments are freed subcutaneously, until
the nasal organ is freely movable from its attachment to the superior
maxillary bones.

The nose is now placed in the position desired, somewhat overdoing the
correction, and is held in place by gauze packs in the nares or by
Roberts’ spear-pointed pins thrust through the lateral skin of the nose
at either side and through the septum, as shown in Fig. 339, p. 365.

The use of the pins placed as shown allows of free drainage to the nares
and gives little inconvenience to the patient.

Plugs of gauze contract and harden, thus overcoming the object of their
use and cause a disturbance of the wounds and pain when reapplied.

The pins should not be withdrawn until the nose has healed into its new
position, or begin to cause irritation of the parts punctured.

Where the deviation is unilateral it should be corrected by subcutaneous
injection, as previously described.


UNDUE PROMINENCE OF NASAL PROCESS OF THE SUPERIOR MAXILLARY

The protuberance of bone lies external to the middle meatus, involving
an abnormal convexity of the nasal process of the superior maxillary.
Its external removal or reduction involves considerable tissue and would
leave a conspicuous linear scar, therefore the surgeon must attempt its
reduction from the inner nose.

The author prefers to make a horizontal incision below the inferior
border of the process, beginning anteriorly just before the articulation
with the nasal bone and extending backward as far as the view from the
nare will allow.

Through this opening, the skin overlying the bone is raised by dull
dissection. A fine nasal saw is next introduced through the submucous
wound and several vertical incisions are made into or even through the
bone about three sixteenths of an inch apart, dividing the convexed
osseous tissue into several sections adherent at their superior extremity
which lies inferior to the insertion of the levator labii superioris
alæque nasi muscle.

A forceps, such as Adams’s, is now introduced and each section of bone
thus made is fractured from below upwards inwardly to produce a concavity
of the osseous tissue.

The operation requires considerable dexterity. The amplitude of the
sawing movement is very much restricted, because of the palpebral
muscular attachment just above.

A frail bone cutting forceps may be employed and the lower half of
the process be removed to avoid encroachment upon the middle meatus,
but this is rarely necessary, as that chamber is found unusually wide
in this case. If the bone is removed, the remaining bone may be cut
into sections, as described, or by the cutting forceps, and fractured
backwards as described.

Retention dressings must be resorted to, to keep the fragments of the
bone in their new position until cicatrization has been sufficiently
established to keep them in place.

When possible Roe advises sawing off the convexity submucously and, after
loosening the skin over the dorsum of the nose, to move the bony plate
thus made over to the opposite side of the nose and into the concavity
usually found there in these cases. If there be no deviation at the
latter site the bone plate can be entirely removed through the inferior
wound in the mucosa.




CHAPTER XVII

ELECTROLYSIS IN DERMATOLOGY


Several references have been made in the preceding chapter to the
specific use of electricity without a description, however, of its source
or application. The author does not deem it necessary in this volume to
go into the principles of electricity, and takes it for granted that the
practitioner is sufficiently familiar with a knowledge of the rudiments
of the subject and that he understands the meaning of an electric cell
commonly known as a battery.

=The Electric Battery.=—An electric cell or battery is made up of two
poles which are named positive, designated by the + (plus) sign, and
negative by the - (minus) sign. In the usual form of cell used the
parts are made up of a carbon and zinc cylinder placed into a glass jar
containing the electrolyte or actuating fluid. The latter is either an
aqueous solution of potassium bichromate or salammoniac contained in a
glass jar.

For continuous use or open circuit work the Le Clanche type of cell is
most practicable.

[Illustration: FIG. 502.—ELECTRIC WET CELL.]

In Fig. 502 a cell of this type is shown in which the positive pole or
element is composed of a solid piece of carbon forming a cover to the
glass jar as well, and the negative element is of zinc. The covering over
of the jar prevents evaporation of the solution and adds much to its life.

=The Voltage or Electromotive Force.=—The voltage or electromotive force
from such a cell averages about 1.5 volts. Voltage represents the force
or propelling power of current known scientifically as the electromotive
force and designated EMF. Owing to the great resistance of the body
to the electric current, a proportionate force is required to attain
therapeutic results.

The unit measure of the quantity of current is known as the ampère.
As this is too great for therapeutic use, the thousandth part, or
_milliampère_, is employed, and for the purpose of measuring the amount
of current given the patient the milliampèremeter is included in the
circuit or flow of current.

The unit of resistance is termed the Ohm, and to simplify the method of
electrotherapeutic administration the practitioner may refer to Ohm’s law
as a guide. He must remember the average resistance to the current of the
parts to be operated on by this process. The law is as follows:

                                EMF or Voltage
    C or Current in Ampères = ------------------
                               R or Resistance,

                           or commonly written

                                C = R/EMF

=The Rheostat.=—When we consider that the resistance between electrodes
placed on the palm of the left hand and the back of the neck is about
4,000 Ohms, it may be readily understood that considerable voltage is
required to overcome this resistance before the proper amount of current
can be employed. Since each cell, for quick reference, may be said to
represent one volt, at least twelve and not more than sixteen cells
would be required for electrolysis. Not all of the current given off
by a battery of such number of cells should be used on a patient for
electrolytic purpose. Some method must be employed to reduce this voltage
and to control it at will. This is necessary since the life of a cell
varies and its current capacity is limited according to the use the cell
is put to. An instrument of this nature is called a _rheostat_ and is
usually made of graphite or metal wire. Water resistances are also used,
but they do not permit of a constant current because of the consequent
heating and decomposition of the water into its elements at the two metal
poles exposed to the water. The proper instrument will be referred to
later.

The electric cell represents a certain voltage; to add to this more cells
are needed and connected with each other so that each adds its voltage
to other or the circuit. The method of connecting cells in this manner
is called series connection, in which the carbon element of one cell
is connected with the zinc of the next, and so forth, until the last
cell, leaving two free poles, one carbon and a zinc to which the wires
to hold the electrodes for the patient are connected. As has been said,
the carbon is the positive pole and the zinc the negative. The method of
connection is shown in Fig. 503.

[Illustration: FIG. 503.—SERIES CONNECTION.]

These two poles when brought in contact with human tissue exhibit
different action and effect. Without going into electro-chemistry it may
be said the current of the positive pole is sedative and that of the
negative irritant or destructive. That oxygen and acids are freed at the
positive pole and hydrogen and alkalies at the negative pole.

It is due to these properties of the current that it is employed
therapeutically, but to properly employ it the current must be controlled
so that the exact amount given or used can be estimated. This is
accomplished first of all by the interposition of resistance within the
circuit. This resistance should be such that the current can be increased
or decreased at will. It has been referred to and is called a rheostat.
Its position in the circuit is shown in Fig. 504.

[Illustration: FIG. 504.—SHUNT RHEOSTAT CONNECTION.]

=Cell Selector.=—The physician may do without such a rheostat and use a
cell selector with the object of adding one or more cells to the circuit
at will. Such instrument is composed of a marble or wooden base with a
number of disks upon it, each disk representing a cell of the battery. A
metal arm is made to slide over these disks, and as it advances over each
disk the current from that cell is added to the circuit. It may have a
second arm which is used to cut out the current from the cell or cells at
the beginning of the circuit—in fact, will permit of the selection of any
cell in the circuit by proper manipulation. Such a selector is shown in
Fig. 505.

[Illustration: FIG. 505.—CELL SELECTOR.]

The connection of the cells of the battery when a selector is used
varies from that just mentioned. The proper wiring with the disks of the
Selector is shown in Fig. 506.

[Illustration: FIG. 506.—CELL SELECTOR AND BATTERY ARRANGEMENT.]

=Milliampèremeter.=—The fact that a proper resistance has been forced in
circuit is not alone sufficient to permit of the proper use of current
for electrolysis. A measuring device should be included, as has been
referred to and called the Milliampèremeter or Milliammeter. It is shown
in Fig. 507.

[Illustration: FIG. 507.—MILLIAMPÈREMETER.]

The method of connecting this instrument in series with the current from
the rheostat has been shown in Fig. 509.

=The Electric Current.=—Where the operating room of the physician is
provided with street current it will be found more economical and
cleaner to use that current for this purpose.

Usually the direct current is furnished of a voltage varying from 100
to 125 volts. To utilize such a current a wall plate is employed and
connected to the circuit, as shown in Fig. 508. The resistance of an
electric lamp is added to guard against injuring the patient if by any
accident or negligence the circuit has been improperly closed.

[Illustration: FIG. 508.—DIRECT CURRENT SWITCH BOARD OR WALL PLATE.]

Whether the street or battery current is used with such a plate makes no
difference except that with a battery circuit the lamp is not used. The
connections are given in Fig. 509.

[Illustration: FIG. 509.—WALL-PLATE CONNECTIONS.]

It will be observed that a current changing switch has been added to the
wall plate. This is included in the circuit to permit of changing the
poles to the patient without interfering or disconnecting the electrodes
if desired at any time during treatment.

=Portable Batteries.=—The above instruments and circuits refer to those
to be used in the operating room and are stationary. The physician may be
called upon to treat a patient at a distance and for this purpose must
have a portable battery.

There are many such instruments on the market of both dry and moist
cell type. The moist cells usually require a bichromate of soda or
potash solution and are so constructed that the carbon and zinc poles
are taken out of the electrolyte or solution and placed into water-tight
compartments provided for them. Such an apparatus is shown in Fig. 510_a_.

[Illustration: FIG. 510_a_.—PORTABLE WET CELL DIRECT CURRENT APPARATUS.]

The best cell for this purpose is the silver chloride battery. It is
compact, light in weight, and gives a steady current. The only objection
is the high cost.

Portable batteries should be furnished with a milliampèremeter. A type of
a compact dry cell direct current apparatus is shown in Fig. 510_b_. In
the end the best apparatus proves the most economical.

[Illustration: FIG. 510_b_.—DIRECT CURRENT DRY CELL APPARATUS WITH
RHEOSTAT AND INTERRUPTED CURRENT ATTACHMENT.]

=Electrodes.=—Having the circuit or current under control, it now becomes
necessary to attach electrodes to the free poles to be able to properly
apply it to the patient. These electrodes vary considerably according to
their use. The author will refer to only those that are of service in
electrolysis.

_Sponge Electrode._—The one electrode held by the patient is usually made
of a metal disk covered with felt or sponge attached to a wooden handle
and is shown in Fig. 511.

[Illustration: FIG. 511.—SPONGE ELECTRODE.]

This electrode represents the positive; the negative pole is held by the
operator. When used, the felt or sponge is moistened with warm water to
which a little salt has been added and is placed into the palm of the
hand, sponge inward.

The author prefers to use a plain metal disk with the sponge and places
a piece of absorbent cotton or gauze over it when in use for hygienic
reason.

When the operator prefers he may resort to arm or wrist electrodes which
can be clamped upon the limb and be held in position and shown in Fig.
512.

[Illustration: FIG. 512.—ARM ELECTRODE.]

The hand electrode is of greater service since the patient can regulate
or make and break the current at will, a matter of no small consequence
when fairly large currents are being used to destroy a growth upon the
skin of the face.

_Needles and Needle Holders._—For the negative electrode the operator
uses a needle holder with a needle of proper form and material.

Two needle holders are shown in Figs. 513 and 514.

[Illustration: FIG. 513. FIG. 514.

ELECTROLYTIC NEEDLE HOLDERS.]

When the operator desires he may employ an interrupting needle holder
with which he can make and break the current at will during the
operation. It is shown in Fig. 515.

[Illustration: FIG. 515.—INTERRUPTING CURRENT NEEDLE HOLDER.]

Such a device is not advocated, since the patient is liable to jump as
the current is made suddenly, because of the sharp stinging pain felt
at the point when the needle has entered the tissue or hair follicle,
often resulting in the breaking of the needle and possible injury to the
patient.

Other operators employ a small magnifying glass which may be attached to
the holder, as in Fig. 516, and by a sliding arrangement be moved up or
down the handle to adjust the lens to the proper focus. This arrangement
is indeed novel and may be of service in removing fine superfluous hairs,
but the author has never resorted to the method.

[Illustration: FIG. 516.—NEEDLE HOLDER WITH MAGNIFYING GLASS.]

The proper kind of needle to be used for electrolysis varies with the
device of the operator. The ordinary cambric needle usually advocated
is too stiff and thick. Jeweler’s broaches are better, but are very
brittle and easily broken. The ideal needle should be very thin and
made of platinum or irido-platinum. The author prefers the sharp to the
bulbous-pointed. For the removal of other blemishes than hair from the
face the sharp needle only can be used.


REMOVAL OF SUPERFLUOUS HAIR

The moistened sponge electrode connected to the (+) positive pole of the
circuit is placed into the hand of the patient, who lies in a chair with
her head on a level with the physician’s chin when operating. The light
should be southern, or such that the shafts of the hairs show plainly.

The operator turns on the current, holding the needle holder in the right
hand which is connected by a flexible cord to the (-) negative pole.
The rheostat handle is brought back so that just the least current is
flowing. The needle is now thrust down into the follicle containing the
hair. This must be done very gently so as to feel when the papilla has
been reached by the needle. The depth to which the needle goes varies
very much according to the size and place of the hair. It may be less
than one eighth and more than one fourth inch.

The patient holding the sponge will at once feel a stinging sensation
when the needle enters the skin, which is later not as objectionable. The
current is now increased by advancing the handle of the rheostat until
about eight milliampères are shown by the index on the dial.

Within a few seconds a white froth will issue from the follicle,
showing that decomposition of tissue is taking place. The operator must
familiarize himself with the time and amount of current required to
destroy superfluous hairs. Coarse hairs may require as much as fourteen
milliampères, but it is advisable to use a moderate amount of current and
to leave the needle a little longer in the follicle to avoid scarring of
the skin.

The papilla having presumably been destroyed, the patient loosens her
grip on the sponge and the needle is withdrawn.

The operator now takes up an epilating forceps, such as shown in Fig.
517, and removes the hair. If the hair does not come out of the follicle
readily it shows that it has not been destroyed, and the same treatment,
just described, must be repeated, but for a shorter duration.

[Illustration: FIG. 517.—EPILATING FORCEPS.]

When the hair is removed it will show more or less bulb according to its
size and nourishment.

The physician now proceeds to remove the coarse hairs first. Hairs should
not be removed too closely placed, as the current will destroy the tissue
between the follicle and cause scarring. It is better to remove the hairs
some distance apart, leaving the remaining hairs for later sittings.

About forty or fifty hairs may be removed at one sitting. This will
require from half to an hour and a half of time, but the operator will
soon accomplish considerable work in a minimum of time.

Some of the hairs removed will return, showing as black or dark specks
in the skin, in from five to ten days. The number returning depends on
the operator’s skill. At first he should not be surprised to see fifty
per cent come back, but this ratio is reduced so that only three or four
hairs out of fifty may return, and perhaps these stunted in growth.

The electrolytic removal of hair does not stimulate the growth of the
finer hairs of the skin; that general belief has been erroneous.

Where there is considerable hair to be removed, as with a beard on a
woman’s face, several sittings may be given a week and at different parts
of the face, but with the average patient only one sitting should be
given each week.

More or less edema follows the removal of hair, which may remain for a
day or more. Warm applications will help to remove it.

The operator should at no time state a definite fee to remove the hair on
the face, unless he is certain of the number present. Such judgment is,
indeed, very misleading.


REMOVAL OF MOLES OR OTHER FACIAL GROWTHS

Moles, warts, fibromata, fungoids, and other excrescences are
best removed with this method, especially where they are of the
nonpedunculated type. It is hardly necessary to state that very light
currents should be used for the light flat growths, such as a dark
freckle or a small yellow mole. The amount of current required varies
from 6 to 24 milliampères, according to the size of the body to be
removed.

The same procedure as with the removal of hairs is followed. Positive
electrode in the hand of the patient, negative pole to the needle holder.
The needle is thrust through the growth on a plane with the skin and
slightly above it. The current will at once produce a pale color in
the mass and white froth will issue about the shaft of the needle. A
comparatively greater amount of current is needed for this purpose than
with the destruction of hairs. The operator must judge the amount and
time required from experience.

The mass is punctured in stellate fashion to assure an even necrosis, as
shown in Fig. 518.

[Illustration: FIG. 518.—ELECTROLYSIS METHOD FOR DESTROYING GROWTHS.]

The mass will appear much softer after this treatment, is in some cases,
as with flat moles, quite friable, but this disappears in a few hours and
the mass begins to shrivel and dry up, forming a scab, which is between
brown and almost black in color. This scab falls off in several days,
according to its size, leaving a pink eschar, which gradually turns white
and shows very little, if the growth has not been too large and the
electrolysis carefully done. If little tumefactions, or tips of tissue,
still appear, they are removed as soon after the scab falls off as deemed
advisable by the same method. Warts show more or less recurrence.


TELANGIECTASIS

In this condition there appear in the skin one or many dilated
capillaries. It is quite common about the sides and lobule of the nose
and just inferior to the malar prominence of the cheeks. To destroy these
the fine platinum needle is thrust through the skin and directly through
the canal of the vessel. The same disposition of the electrode is used as
heretofore described.

Immediately the current is made, a series of bubbles of hydrogen will run
through the vessel which presently becomes pale and empty, as a result of
the electro-chemical action.

The needle should be allowed to remain in the vessel from five to ten
seconds, according to the size of the latter.

The object is to set up sufficient irritation in and of the walls of
the vessel so as to occlude it when cicatrization has been established.
Some edema follows such a treatment, subsiding in a day or more. Several
vessels may be treated in the same sitting, and at either side of the
face. The operator should guard against too strong a current, to avoid
scarring of the skin. The final result in this treatment shows fine
punctate scars, as after the removal of coarse hairs, and sometimes pale
linear scars, but these are observable only on close inspection.


REMOVAL OF NÆVI

Birthmarks, port-wine marks, and other pigmentary conditions may be
entirely or partly removed from the skin of the face, according to the
size of the area treated and the nature of the case. For this purpose the
single needle attached to the negative pole is hardly sufficient, unless
the spot is exceedingly small, therefore a bunch needle electrode is
used. This electrode has a number of fine steel needles set into it, as
shown in Fig. 519.

[Illustration: FIG. 519.—MULTIPLE NEEDLE ELECTRODE.]

In this treatment the needles are made to puncture the skin at right
angles to them to a depth corresponding to the papillary layer. These
pigments lie above that, so that it is not necessary to include the
derma. At each point of puncture a white spot will appear which soon
turns red. In a day’s time a number of fine scabs, or a single scab,
will form over the parts treated, which fall away in about five days
eventually, leaving the parts paler than before, owing to a number of
minute punctate scars.

The amount of treatment given in each case varies with the extent of the
lesion. If the result from the first sitting has not accomplished as much
as desired, it can be repeated over and over until the parts assume a
normal tint. There may be more or less bleeding following the treatment;
this is easily checked by pressure. If the part worked on is quite large,
dry aristol dressing should be used to avoid infection. The scab should
not be picked off by the patient, but allowed to fall off.


REMOVAL OF TATTOO MARKS

The best method of removing such pigmentations of the skin is to remove
them with the knife when possible, and to cover the wound by sliding
flaps made by subcutaneous dissection at either side of the wound, as
in the Celsus method. Some authorities advocate their re-tattooing with
papoid solution, while others prefer caustic agents, with the object of
destroying the pigmented area. These methods are not to be preferred,
since they leave unsightly burn scars.

Electrolytic needling may be tried and is quite successful when the marks
are very small, but, as with gun-powder stains, they are best removed by
punching, or cutting out, a little cone of skin containing the pigment.
The secondary wounds thus made leave only very small punctate scars that
are hardly noticeable. Of course a number of such removals would not be
advisable.

Where the pigmentation is very pale, recourse may be had to the peeling
method, as will be later described.


THE TREATMENT OF SCARS

Not infrequently the cosmetic surgeon is called upon to remove or improve
unsightly scars about the face, the result of injuries or burns and
after the careless coaptation of such wounds. The scars vary in extent
and degree, from a mere pit due to varicella or variola to the broad
areas following the cicatrization of lupus and burns. Surgical scars vary
also from a mere line to areas of greater or less extent, dependent upon
the ablation of neoplasms or the granulation of wounds due to any cause.

The treatment of scars depends upon their size and location. A mere
linear scar may be reduced by electrolysis, the needle, negative pole,
being introduced equidistantly, from one sixteenth to a quarter inch
apart, with the hope of causing a breaking down electro-chemically of
the scar itself and waiting for secondary cicatrization. In other words,
making a scar within a scar.

This mode of treatment may be repeated in two or three weeks and has the
tendency of breaking up the shiny line of light that makes the scar stand
out prominently from the skin.

Such scars, where nonadherent, or flat with the plane of the skin, may
also be tattooed to reduce their white color.

For this purpose, the red or carmine pigment used for tattooing is
diluted and pricked into the scar tissue with a fine cambric needle by
hand or electric process.

When the scar is small the line is punctured here and there and the
aqueous solution of the pigment is painted over the area, which is again
worked over to make it take.

For larger scar surfaces multiple needles are used. These are composed of
from four to ten needles soldered together at their eye ends, leaving the
points at an even level.

The electric method is the most serviceable for tattooing large scars.

These instruments are electro-magnetic devices made to accommodate
single or multiple needle points and can be obtained from instrument
makers.

The author has had a special electric synchronous reciprocal apparatus
made, as here shown in Fig. 520, which is much more compact than the
ordinary electric apparatus found on the market. It works on the
principle of the sewing machine needle.

[Illustration: FIG. 520.—AUTHOR’S ELECTRIC APPARATUS FOR TATTOOING SCARS.]

In using the electric apparatus the needle ends are dipped into the
pigment paste, to which a little glycerin is added to bind it, and this
is tattooed or pricked into the scar.

If, after the parts are healed, the color is too light, the scar may
again be gone over until the tint matches somewhat the tint of the skin.
Other pigments may be used, according to the complexion of the patient.

Some scars, the resultant of negligent coaptation, are to be excised
according to the Celsus method and are brought together with a number of
fine silk sutures.

If the skin is found to be attached too closely to the subcutaneous
structure, it must be dissected up to render it mobile.

When the scar cannot be removed by excision the hypodermic use of
thiosinamin may be tried.

Thiosinamin or rhodallin is only slightly soluble in water, but the
addition of antipyrin according to _Michel_ renders it useful for
hypodermic use. The formula preferred by the author is made as follows:

    ℞ Thiosinamin     grs. ij
      Antipyrin       grs. j
      Aqua dest.      gtts. xx.

The above solution makes up a single injection, which is to be made
directly under the scar or into the muscular tissue below it. Two
injections are given each week.

The treatment is to be continued until the texture of the cicatrix is
equal to that of the skin.

These injections are more or less painful and may be supplanted to
advantage with the hypodermic use of fibrolysin (_Mendel_), in which each
2.3 c.c. correspond to three grains of thiosinamin.

For very small scars, as those occasioned by blepharoplastic operation,
the author employs the twenty-per-cent thiosinamin plaster mull made
by Unna. These are to be applied every day or night, according to the
convenience of the patient, and allowed to remain on for several hours
each day.

At first these plaster mulls are inclined to cause erythema and
exfoliation of the epithelium, therefore they might be used on alternate
days to keep the parts more sightly.

For scars of large extent the above method will answer best. If there is
considerable contraction, the parts should be massaged daily to soften
and stretch them. Eventually the depression of contour may be corrected
by hydrocarbon protheses introduced subcutaneously following subcutaneous
dissection, if deemed necessary.

Small pits, where discrete, are best removed with a fine knife and
brought together by a fine suture which is to be removed on the fifth day.

Confluent pittings, as after variola, must be removed by decortication or
peeling methods.

The pits, if spread about the face promiscuously, may be treated
separately by the peeling method, but when they lie less than one inch
apart, it is best to treat the skin of the whole face.

This is done by applying pure liquid carbolic acid to the skin with a
cotton swab. The skin at once assumes a white color. If the pittings are
not very deep, one application of the acid is sufficient. If deep, one or
two more applications are made as the preceding one dries. In very deep
pits, the surgeon should apply the acid to the pit proper several times,
blending off the application at the periphery.

When the surface thus treated has become dry, adhesive plaster, cut in
half-inch strips of desirable length, are put on the face, one above the
other, slightly overlapping, until the whole treated surface is well
covered, mask-like.

The author uses Unna’s zinc oxide plaster mull for this purpose, as it is
backed with gutta-percha, which readily adapts itself to the curvatures
of contour.

The adhesive plaster mask is not removed until about the fourth or
fifth day, when it will be practically forced away from the skin by the
excretions thrown out from the derma. In some cases there is considerable
pus.

After removal of the mask the skin, now very red and tender, is cleansed
with a solution of bichloride, 1 in 10,000.

After the cleansing a mild soothing ointment, such as zinc oxide in
vaselin, is used for several days until the skin takes on its normal
epitheliar layer and appears normal in color.

No water or soaps are to be allowed during the latter period. In the
later days of the treatment the skin may be cleansed with a little
borated vaselin or even olive oil used with absorbent cotton.

If there is a pigmentation of the new skin this should cause no alarm, as
it will fade out in from six to eight weeks.

Tincture of iodine has been used for the same purpose, as well as its
mixture with carbolic acid.

Resublimed resorcin is also advocated, but the resultant peeling will not
prove thick enough to give a satisfactory result.

If, for any reason, the effect obtained is not as desired, the patient
should wait for several weeks and have the treatment repeated.

It is hardly necessary to say that the application used should not get
into the eyes. The upper eyelids should not be treated, since no benefit
arises from it. If there is a redundancy of tissue, it should be removed
surgically, as heretofore described.




CHAPTER XVIII

CASE RECORDING METHODS


Every case, whether of little consequence or of important nature, should
be properly and fully recorded in a thorough and systematic manner. Apart
from the value of such a record, to the operating surgeon it often proves
of the greatest importance in cases where operations of a purely cosmetic
nature are undertaken.

Patients who beg us to make them more beautiful, or less unsightly in the
eyes of the ever-critical observer, are the most difficult to please,
and often complain, after a few days of constant mirror study, of the
parts changed by methods that are the result of years of hard-earned
experience, that the nose or the eyes or the ears have not been changed
as much as they desired—in fact, so little that their closest friends
have failed to evoke ecstatic remarks about the improvement.

This is not unusual with the most intelligent patients and is due to
the fact that cosmetic operations performed on an ugly though otherwise
normal organ have not yet become very frequent, and while friends are
inclined to remark a change in lesser defects, they fail to credit this
to the cause, owing to a lack of the knowledge of cosmetic surgery, or
their ignorance of the art entirely.

=Photographs.=—Where a pathological defect, wound, or scar or traumatic
deformity is to be corrected, the patient is usually kind enough to
permit of photographs being made of the parts to be operated on, but
where the defect is hereditary, or the result of age, objections are
invariably raised by all concerned, for fear their pictures will be used
in some outlandish way.

The objection to photographs is obvious, since it usually requires
visits to a studio, and the necessary loss of time to the surgeon, whose
presence is nearly always necessary to secure the proper negative.

This is especially true of the nose. Very few photographers will make a
satisfactory sharp profile picture. It is less artistic, but most desired
by the surgeon, and when the patient is presented for a second negative
after the operation has been performed, the picture varies more or less
in pose from the first taken.

It would be well for physicians to have a camera for use in the operating
room, and those who can manipulate one will find that taking a 5 × 7
negative the most suitable.

=Stencil Record.=—For those who cannot provide themselves or bother with
a photographic apparatus, the stencil record is recommended.

For this purpose a picture of a normal eye and its lids, a nose, lip or
ear, is drawn upon a piece of oiled or stencil paper, or upon any thick,
stiff book board.

The paper is laid down upon a plate of glass and the outlines of the
picture are cut out, wide enough to allow the sharpened point of a pencil
to pass. Where the lines are long it is advisable to allow connecting
links to remain at various intervals as desired to keep the stencil stiff
and to prevent cut margins from slipping or rolling up. (See Fig. 521.)

[Illustration: FIG. 521.—NOSE STENCIL.]

The stencil thus made is laid upon the record card and a tracing is made
upon the latter by passing the lead-pencil point along the cut outline.

The stencil is now lifted and the defect sketched into the picture of the
normal organ.

If this should be the anterior nasal line, a perfect sketch can be made
of the defect by placing a card alongside of that organ and drawing the
outline upon it as the pencil is made to glide over the nose, the point
facing the card in such a way that a true profile outline is obtained.
The card is then cut along the pencil line.

The nasal section of the card is now placed upon the stenciled nose and
its outer border traced into or over it, as the case may be, by drawing
the pencil point along the outer margin.

The same method may be followed post-operatio. This method can be
employed for the other parts of the face as well, as, for instance, the
mouth, ears, base of nose, etc.

Distances in measurements should be put into the record drawing to make
it more exact.

=The Rubber Stamp.=—Another method is to make outline sketches of normal
parts of the face with India ink upon drawing board and have those
reproduced in rubber stamps, using the stamp in place of the stencil and
marking in the defect in the manner before mentioned.

=The Plaster Cast.=—The best method by far, however, and the one found
most accurate, is the plaster cast. It is not a difficult thing to
make a cast of a nose, eyelid, lip, or ear, and the latter is much more
preferable to any other method of record.

For this purpose some modeling clay is required, which is molded into a
strip and laid around the part to be reproduced.

This forms a sort of raised ring or border and prevents the overflow of
the semiliquid plaster, and avoids the annoyance of trickling the liquid
upon other parts of the face about the site of the part worked on; at the
same time it permits of neatness and uniformity in the size and shape of
the casts to be filed away as records. (See Fig. 522.)

[Illustration: FIG. 522.—METHOD OF MAKING NASAL PLASTER CAST.]

The skin surface, and hair, if any, within this ring area, before using
this plaster of Paris, is now thoroughly coated with clean oil, or
petrolatum, applied with a soft sable brush. The inner and upper part of
the wax ring is also coated.

If there are openings in the parts of the face, such as the nostrils or
the auricular orifice, they should be plugged lightly with dry absorbent
cotton, care being taken, however, to avoid distending the alæ.

The plaster is now prepared in a small porcelain or soft rubber bowl by
adding warm water to it until the powder, upon stirring, forms an even
semiliquid paste.

This is poured first upon the area to be reproduced to fill all the finer
crevices and to avoid air holes, and is then put on with a spatula,
or wooden slab, until the space within the clay boundary is properly
filled, covering the organ all over with a layer ¼ to ½ inch in thickness
on all sides. Over the eyelids a thin coating of plaster should be used,
whereas over other parts of the face a thickness of half an inch can be
allowed without discomfort to the patient.

It is well at first to make the plaster thick, as the mold is liable to
be broken upon removal or in drying. After a little experience splendid
results are obtained with very thin walls of plaster.

The plaster is allowed to dry and harden, while the patient is instructed
to remain still and silent. If a cast of the nose is made, the patient
should refrain from talking and breathe gently through the mouth.

Tapping on the plaster now and then with a lead pencil will show when it
has hardened sufficiently to be removed.

A firm, quick pull relieves the mold.

In molds of the ear an anterior and posterior impression should be made,
if a cast of the entire organ is desired. This can be done by first
applying a layer of plaster to the posterior surface up to the outer rim,
allowing this to harden and painting the anterior ear and the exposed
plaster border with petrolatum before putting the plaster over it. Upon
traction, when set, the plaster will separate readily at the point of the
separation.

The removed piece of set plaster is called the mold.

It is allowed to dry thoroughly and then preferably coated inside with a
thin coat of liquid petrolatum, which is found to be much better than oil.

A thinly prepared paste of plaster is poured into it at the outer brim
and allowed to harden. The best results are obtained by setting the mold
into a small pasteboard box in which it is held in proper position and
prevents the thin plaster from running over the depressed edges.

By gently tapping the mold when the cast has set, it is made to separate
from the latter sufficient to permit of separating or cutting away of the
mold inside of it.

The cast, when removed and dry, is coated with white shellac varnish.
Upon its reverse side a note is scratched into it, giving the case
number, or such information as the surgeon may desire.

The author advises the addition of a small quantity of Armenian bole to
the plaster used for the cast, as it gives a less ghastly tint and aids
much by its color in the cutting away of the white mold from the cast.
Several of these casts, taken before and after operation by the author,
have been shown in the preceding chapters.

After operation and healing of the parts a second cast is made.

Hooks can be inserted into the casts, when still soft, to hang them up
by, or loops of string or wire are stuck into them, while setting for the
same purpose.

Such a collection is not only of great value to the operator, but is a
means of constant and absolute record, even to the extent of reproduction
by photography.

The necessary data in respect to the method employed in operating,
dressing, etc., is to be added to the record as generally done with
medical or other surgical causes.

=Preparation of Photographs.=—There are some cases of which no other
permanent record can be made, except by photograph. If these can be
obtained, the negatives are to be printed without retouching, the prints
being made on silver printing paper of the glossy type to permit of
reproduction in half-tone when desired at some future time.

In printing such pictures, the eyes, or other part of the face not
operated on, may be obliterated by laying strips of paper next to the
negative, the part thus covered coming out white in the positive.

The photographs made of parts to be operated on should be made as near
as the normal size, for obvious reasons of accuracy and measurement.

This can be done by comparing the size of the part to the picture found
on the ground glass.

Cameras that do not permit of ground-glass focusing are useless as well
as uncertain. Time exposures are necessary for the best results.

Dark backgrounds should be used to get the sharp outlines by contrast.
Too much light on the parts, such as direct sunshine, is undesirable, as
it makes the parts appear flat and lifeless; therefore a muslin screen is
of great value to graduate the intensity of the light, and if this is not
at hand, a sheet of paper will answer the same purpose.

In printing make note of the depth of color of the parts most desired to
be shown, varying with the different parts of the face. Look to contrast,
and in pathological cases have the diseased area printed so that it will
stand out forcibly as compared to the fellow organ in health or the
normal tissue beyond its border.

To protect photographic records, they should be properly bound in book
fashion to avoid scratching, rubbing, or breaking. This not only implies
neatness and thoroughness on the part of the surgeon, but also permits of
ready reference at all times.

An index to the contents of such a book is a desirable adjunct.




INDEX TO AUTHORS


  ADAMKIERWICZ, osteoplasty, 101.

  D’ALGUIE, rhinoplasty, 360.

  ALLIOT, history of reparative surgery, 5.

  ALLIS, inhaler, 65.

  VON ALTMANN, bioblasts, 100.

  ALTER, partial stenosis of nares after paraffin injection, 229.

  AMMON, blepharoplasty, 108.

  VON AMMON, rhinoplasty, 358.

  ANGERER, antiseptics, 38.

  VON ARTHA, blepharoplasty, 112.

  AUVERT, rhinoplasty, 359.


  BARATOUX, paraffin injections, 210.
    skin grafting method, 99.

  BARDELEBEN, antiseptics, 40.
    sutureless blepharoplasty, 119.

  BARDENHEUER, meloplasty, 203.
    rhinoplasty, 416.

  BARTLEY, antiseptics, 37.

  BAUMAN, antiseptics, 37.

  BAYER, meloplasty, 201.

  BAYER-PAYR, rhinoplasty, 424.

  BECK, peroxoles, 41.

  BEINL, harelip clamp, 145.

  BENNETT, cocain, 70.

  BERGER, cheiloplasty, 183.
    classification of lip deformities, 162.
    nasal retention apparatus, 385.
    rhinoplasty, 384, 424.

  VON BERGMAN, antiseptics, 38.
    history of plastic surgery, 7.
    operating gown, 19.

  BILLROTH, antiseptics, 38, 40.
    carcinoma of lips, 168.
    combined anesthesia, 67.

  BLANDIN, history of reparative surgery, 5.
    rhinoplasty, 435, 444.

  BLASIUS, cheiloplasty, 177.
    rhinoplasty, 363, 367.

  BOECKMAN, preparation of catgut, 32.

  BOJANIS, history of rhinoplasty, 3.

  BONNET, rhinoplasty, 434.

  BOUILLON, antiseptics, 40.

  BRANCA, history of rhinoplasty, 3, 349.

  BRANCA, Antonius, history of rhinoplasty, 3.

  BRETZ, sutureless coaptation, 48.

  BRINDEL, facial phlebitis after paraffin injection, 226.
    paraffin injection, 210.

  BRŒCKÆRT, antiseptic with paraffin, 218.
    facial phlebitis after paraffin injection, 226.
    paraffin injection, 210.

  BRUNS, cheiloplasty, 163, 171, 175.

  BRYANT, antiseptics, 39.

  BUCHANAN, cheiloplasty, 176.

  BUCHHOLZ, antiseptics, 38.

  BUCK, cheiloplasty, 165, 172.

  BULL, epicanthus, 113.

  BÜNGER, history of rhinoplasty, 5, 350.

  BURCHARDT, compressing forceps, 145.

  BURNETT’S fluid, 41.

  BURNS, charpie cotton, 67.
    flap method, 86.

  BÜROW, antiseptics, 35.
    cheiloplasty, 178.
    rhinoplasty, 65.
    sliding flap method, 85.

  BUSCH, rhinoplasty, 430, 433.


  CARPUE, history of rhinoplasty, 4.

  DE CAZENEUVE, facial phlebitis after paraffin injection, 226.
    hot-water jacket for syringe, 233.

  CELSUS, Aulus Cornelius, cheiloplasty, 169.
    “Father of Plastic Surgery,” _frontispiece_.
    history of plastic surgery, 1.
    skin incisions, 80, 485, 487.

  CHARRIÈRE, nasal prothesis, 348.

  CHELIUS, replantation of nose, 349.

  CHEYNE, injection of paraffin, 210.

  CLARK, J. G., Kumol apparatus, 32.

  COMSTOCK, disposition of injected paraffin, 235, 236.
    effect of paraffin on animals, 225.
    melting point of paraffin, 241.

  CONDY, fluid of, 40.

  CONNELL, injection of paraffin, 210, 230.

  COPELAND, history of plastic surgery, 7.

  CORNING, injection of oils, 209.

  COSTA, temperature of cocain solution, 72.

  CZERNY, history of plastic surgery, 6.
    sterilization of silk, 30.


  DAWBARN, preservation of needles, 16.

  DAVIDSOHN, care of instruments, 15.

  DAVY, Sir H., nitrous oxid, 67.

  DEBOUT, nasal prothesis, 348.

  DELAIN, vaselin injections in animals, 217.

  DELANGRE, nasal prothesis, 209.
    thermoform sleeve for syringe, 233.

  DELPECH, cheiloplasty, 181.
    history of rhinoplasty, 5.
    rhinoplasty, 353.

  DENONVILLIER, rhinoplasty, 428, 430, 438.

  DIEFFENBACH, blepharoplasty, 104, 105, 109.
    cheiloplasty, 157, 164, 173, 187.
    history of reparative surgery, 5.
    microstoma, 195.
    rhinoplasty, 357, 372, 431, 446, 466.

  DIEFFENBACH-VON LANGENBECK, stomatoplasty, 193.

  DOBOUSQUET, skin grafting method, 99.

  DOWNIE, celloidin in protheses, use of, 228.
    electrothermic syringe heater, 233.
    paraffin injection on carcinoma, effect of, 235.

  DREESMANN, history of plastic surgery, 7.

  DUBERWITSKY, rhinoplasty, 356.

  DUNBAR, vaselin injection in animals, 217.

  DUPUYTREN, rhinoplasty, 431, 445.


  ECKSTEIN, absorption of paraffin, 220.
    encapsulation of injected paraffin, 234.
    Hart-paraffin, 210.
    rubber insulator for syringe, 231, 263.

  EICHHOFF, aristol, 41.

  ENGLE, median cleft harelip, 148.

  ERICHSEN, JOHN ERIC, history of plastic surgery, 6.

  ESCHWEILER, new tissue formation after paraffin injection, 237.
    oft-repeated injection, 215.

  VON ESMARCH, antiseptics, 40.
    cheiloplasty, 158.
    dropping bottle, 60.
    inhaler, 60.
    number of rhinoplastic operations required, 347.

  ESTLANDER, cheiloplasty, 171.

  ESTLANDER-ABBÉ, cheiloplasty, 166.

  EWALD, thermoform sleeve for syringe, 233.

  EDWARD-ALBERT, meloplasty, 199.


  FABRICIUS, history of rhinoplasty, 3.

  FABRIZI, rhinoplasty, 375.

  FAHRENBACH, bilateral cleft, 158.

  FEHLEISEN, erysipelo-coccus, 56.

  FEINBERG, amyl nitrate inhalation, 71.

  FÉRÉOL, iodoform, 42.

  FILLEBROWN, cheiloplasty, 152.

  FISHER, osteoplasty, 102.

  FORQUE, rhinoplasty, 359.

  FOURNEAU, stovain, 75.

  FOWLER, inhaler, 66.

  FREEMAN, blunt needle for paraffin injection, 227.
    early encystment of paraffin, 235.

  FRICKE, blepharoplasty, 108.

  VON FRISCH, subcutaneous prothesis, 209.

  FRITZ-REICH, rhinoplasty, 431.


  GÄDEKE, cocain, 70.

  GARRE, skin grafting method, 93.

  GÄRTNER, care of instruments, 15.

  GAUTHIER, cocain solution, 72.

  GELEY, antithermics, 57.

  GENSOUL, rhinoplasty, 465.

  GERSUNY, correction of labial defect, 185.
    duration of paraffin protheses, 238.
    encapsulation of vaselin, 234.
    history of rhinoplasty, 8.
    meloplasty, 201.
    mucosa grafting, 101.

  GEUZMER, cheiloplasty, 157.

  GLÜCK, antisepsis, secondary, 57.
    history of plastic surgery, 6, 7.
    ivory bone plates, 101.

  GORIS, rhinoplasty, 387.

  GRAEFE, history of plastic surgery, 5.
    rhinoplasty, 352, 374.

  GRÄFE, cheiloplasty, 154.

  GREENE, correction of coloboma, 125.

  GUERSANT, bilateral facial cleft, 149.

  GUINARD, antithermics, 57.
    cheiloplasty, 183.

  GUTCH, care of instruments, 15.

  GUTHRIE, chloroform anesthesia, 60.
    history of plastic surgery, 7.


  HAAGEDORN, catgut sterilization, 31.
    cheiloplasty, 156, 159.
    needle holder, 78.
    needles, 77.

  VON HACKER, rhinoplasty, 391, 436, 438.

  HAHN, history of plastic surgery, 7.

  HAINSLEY, cheek compressor, 161.

  HALBAN, subcutaneous prothesis, 209.

  HAMILTON, injection of paraffin, 210.

  HÄNEL, quantity of cocain injection, 72.

  HARE, respiratory forgetfulness, 64.

  HARTMAN, skin grafting method, 97.

  HASSELMANN, unilateral facial cleft, 149.

  HAWLEY, ethyl chlorid, 68.

  HEATH, adhesive plaster dressing, 161.
    injection paraffin, 210.

  HELFERICH, history of plastic surgery, 6.
    rhinoplasty, 382, 397.

  VON HELMONT, total rhinoplasty, 350.

  HERTEL, chronic irritation of tissue after paraffin injection, 236.

  HEUTER, artificial mouth, 196.
    rhinoplasty, 365.
    stomatoplasty, 196.

  HEYDENREICH, history of plastic surgery, 7.

  HILL, injection of paraffin, 210.
    secondary diffusion of paraffin, 253.

  VON HIPPEL, history of plastic surgery, 7.

  HIRSCHBERG, skin-grafting method, 107.

  HOFFACKER, replanting of nose, 349.

  HOLDEN, blindness following paraffin injection, 225.

  HÜBSCHER, skin-grafting method, 94.

  HURD, blindness following paraffin injection, 225.


  ISRAEL, meloplasty, 202.
    rhinoplasty, 402.


  JACKSON, ether anesthesia, 63.

  JAKIMOWITSCH, history of plastic surgery, 7.

  JÄSCHE, cheiloplasty, 174.

  JENNESCO, stovain anesthesia, 75.

  JOBERI, history of reparative surgery, 5.

  JUILLARD, mask, 66.

  JUKUFF, disposition of injected paraffin, 235.
    safety of vaselin injection, 218.


  KALLE, iodol, 41.

  KARG, cause of skin pigmentation, 100.

  KAPSAMMER, paraffin injection, pulmonary embolism after, 224.
    subcutaneous prothesis, 209.

  KAREWSKI, hot-water jacket for syringe, 233.
    subcutaneous prothesis, 210.

  KEEGAN, rhinoplasty, 356, 380.

  KERSTEN-MATHIEU, needle forceps, 77.

  KOCH, antiseptics, 35, 38.

  KOCHER, catgut sterilization, 31.

  KOFMAN, death following paraffin injection, 224, 260.

  KOLLE, blepharoplasty, 113.
    care of hands, 18.
    cheiloplasty, 185, 187, 188.
    classification of facial deformities, 276.
    classification of nasal deformities, 212.
    danger of injecting liquid paraffin, 241.
    drop syringe, 265, 266.
    electric tattooing needle, 487.
    electrothermic paraffin heater, 244.
    hyperplasia and fibromatosis after paraffin injection, 256.
    malposition of ears, correction of, 139.
    nasal chisel and mallet, 453.
    otoplasty, 124, 135, 137.
    paraffin mixture for injection, 243.
    rhinoplasty, 437, 440, 452, 454, 456, 458, 465.
    stomatoplasty, 195.

  KOLLE-PRAVAZ, syringe, 72.

  KOLLER, cocain, 70.

  KÖNIG, cheiloplasty, 156.
    rhinoplasty, 390, 439.

  KOOMAS, history of rhinoplasty, 4, 352.

  KOSSMAN, preparation of catgut, 32.

  KRASKE, antisepsis, 35.
    meloplasty, 201.

  KRAUSE, history of skin grafting, 6.

  KRAUSE, F., rhinoplasty, 398.
    skin-grafting method, 91.

  KRONIG, preparation of catgut, 32.

  KRYMOFF, cocain solution, sterilized, 70.

  KUHNT, otoplasty, 123.

  KÜMMEL, care of instruments, 15.

  KÜSTER, iodoform collodium, 45.
    rhinoplasty, 423.

  KÜSTER-ISRAEL, rhinoplasty, 384.


  LABAT, rhinoplasty, 255, 363.

  LABORDERIE, skin grafting, 99.

  VON LAIR, history of plastic surgery, 7.

  LAKE, paraffin injection, 210.

  LANDREAU, rhinoplasty, 360.

  VON LANGENBECK, blepharoplasty, 108.
    cheiloplasty, 179.
    history of plastic surgery, 5.
    rhinoplasty, 359, 362, 388, 419, 430, 433.

  VON LANGENBECK-WOLFF-SEDILLOT, cheiloplasty, 153.

  LANGENBUCH, antiseptics, 39.

  LANGER, polyotia, 138.

  LARGER, cheiloplasty, 182.

  LARREY, history of rhinoplasty, 5.

  LEISER, collapse after paraffin injection, 224.

  LENTENNER, flap method, 86.

  LILIENTHAL, Z. O., aseptic plaster, 47.

  LINHART, rhinoplasty, 363, 466.

  LISFRANC, history of rhinoplasty, 5.
    rhinoplasty, 253.

  LITTLEWOOD, fixation of elbows in cheiloplasty, 153.

  LISTER, J., antiseptics, 34, 35.
    catgut preparation, 31.
    history of antisepsis, 5.
    protective silk plaster, 47.

  LOVE, antiseptics, 39.

  LUSK, Z., skin-grafting method, 96.

  LYNCH, subcutaneous prothesis, 210.

  LYNN, history of rhinoplasty, 4.


  MAAS, antiseptics, 35, 40.
    cheiloplasty, 156, 159.

  MACEWEN, history of reparative surgery, 7.
    osteoplasty, 101.

  MAISONNEUVE, rhinoplasty, 368.

  MALGAIGNE, cheiloplasty, 154.
    history of plastic surgery, 2.

  MALPIGHIAN, skin layer of, 89.

  VON MANGOLD, cartilaginous support in rhinoplasty, 405.

  MARTIN, nasal prothesis, 348, 388.

  MATHIEU, nasal prothesis, 248.

  MAYO, saline injection in protheses, 275.

  MENDEL, injection of fibrolysin, 197, 488.

  MERLING, beta eucain, 74.

  MEYER, WILLY, sterilizer, 24.
    vaselin injection in animals, 217.

  MICHEL, time required to replace injected mass, 238.

  MIKULICZ, use of iodoform, 42.

  MINTZ, blindness following paraffin injection, 226.

  MIRAULT-BRUNS, cheiloplasty, 155.

  MONGITORE, history of rhinoplasty, 3.

  LE MONIER, history of reparative surgery, 5.

  MONK, correction of malposed ears, 139.
    rhinoplasty, 450.

  MORGAN, antiseptics, 40.
    cheiloplasty, 180.

  MORRIS, prothesis for cheek, 207.

  MORTON, ether anesthesia, 63.
    time required to replace injected paraffin, 238.

  MOSETIG-MOORHOF, history of plastic surgery, 8.

  MOSZKOWICZ, injection of vaselin harmless, 210.
    pulmonary embolism after paraffin injection, 224.
    thermoform sleeve for syringe, 233.

  MULE, history of plastic surgery, 8.

  MUTTER, history of plastic surgery, 5.
    rhinoplasty, 429, 433.


  NÉLATON, cheiloplasty, 152.
    rhinoplasty, 364, 400, 406, 433.

  NÉLATON, CH., rhinoplasty, 420, 425.

  NEUMANN, rhinoplasty, 413.

  NICOLADONI, history of plastic surgery, 7.

  NIEMAN, cocain, 70.

  NOYES, clamp in otoplasty, 127.

  VON NUSSBAUM, hair transplanting, 102.
    history of plastic surgery, 7.


  OBERST, meloplasty, 198.

  OLLIER, ether, safety of, 64.
    history of plastic surgery, 7.
    osteoplasty, 101.
    rhinoplasty, 417.


  PAGET, heating paraffin syringe needle, 232.
    melting point of paraffin, 241.

  PANCOAST, history of reparative surgery, 5.

  PAQUEL, antiseptics, 40.

  PARE, Ambroise, history of reparative surgery, 4.

  PARKER, paraffin injection, 210.

  PARKHILL, otoplasty in macrotia, 135.

  PAVONI, B., history of rhinoplasty, 3.

  PETRALI, rhinoplasty, 359.

  PFANNENSTIEL, embolism from paraffin injection, 209.
    pulmonary embolism from paraffin injection, 224.

  PFLUGH, hot-water jacket for syringe, 233.

  VON PFOHLSPUNDT, history of rhinoplasty, 3.

  PHILLIPPEAUX, history of plastic surgery, 6.

  PLESSING, blepharoplasty, 106.

  PONCET, history of plastic surgery, 7.
    osteoplasty, 101.

  PORTER, Poplar sawdust dressing, 48.

  POZZI, rhinoplasty, 456.

  POZZI-HAAGEDORN, needle holder, 78.

  PRAVAZ, syringe, 72.

  PREIDESBERGER, rhinoplasty, 398.


  QUINLAN, injection of paraffin, 210.
    paraffin heater, 232.


  RANCKE, antiseptics, 40.

  REDARD, care of instruments, 15.

  REGNIER, skin grafting in cheiloplasty, 180.

  REVERDIN, catgut, preparation of, 32.
    history of skin grafting, 6.
    skin-grafting method, 89, 107.

  RICARD, history of reparative surgery, 5.

  RICHERAND, cheiloplasty, 168.

  RICHTER, nasal prothesis, 348.

  RIEDINGER, history of plastic surgery, 7.

  ROE, classification of nasal deformities, 212.
    rhinoplasty, 457, 469.

  ROSE, cheiloplasty, 151.
    classification of harelips, 147.
    stomatoplasty, 196.

  ROSER, otoplasty, 120.

  ROTTER, rhinoplasty, 393.

  ROUX, history of reparative surgery, 5.


  SCHAFFER, catgut sterilization, 31.

  SCHEDE, antiseptics, 38.

  SCHIMMELBUSCH, dropping bottle, 60.
    folding mask, 61.
    rhinoplasty, 394.

  SCHLEICH, cocain solution, 71, 275.

  SCHULTZ, W., antisepsis, 37.

  SCHWARTZE, fracture of ear cartilage, 120.
    otoplasty for microtia, 134.

  SCHWEININGER, hair transplanting, 102.

  SEBILEAU, diffuse fibromatosis after paraffin injection, 256.

  SEDILLOT, cheiloplasty, 164.
    rhinoplasty, 383, 432.

  SENN, history of rhinoplasty, 7.
    osteoplasty, 101.

  SERRE, history of reparative surgery, 5.
    meloplasty, 199.
    rhinoplasty, 366, 445.

  SIMON, cheiloplasty, 160.

  SMITH, skin-grafting scissors, 89.

  SMITH, HARMON, drop syringe, 267.
    heating needle of syringe, 232.
    nontoxic effect of paraffin, 235.
    paraffin heater, 246.
    paraffin injection, 210.
    redness of skin after paraffin injection, 248.
    safety of vaselin injection, 218.
    tissue replacement of paraffin, 235.

  SOBIERANSKI, vaselin injections in animals, 217.

  SOCIN, tinfoil dressing in skin grafting, 90.

  SPICER, diffusion of paraffin, 254.
    injection of paraffin, 210.

  SPRAGUE, sterilizer, 26.

  STAFFEL, meloplasty, 206.

  STEIN, safety of vaselin injections, 218.
    subcutaneous protheses, 209.
    tissue replacement by paraffin, 235.
    vein puncture, avoidance of, in paraffin injection, 227.

  STEINHAUSEN, rhinoplasty, 412.

  STEINTHAL, rhinoplasty, 377, 406.

  STRAUME, vaselin injection in animals, 217.

  STUBENRATH, vaselin injections in animals, 217.

  SUSRATA, history of rhinoplasty, 2.

  SYLVESTER, resuscitation method, 63.

  SYME, cheiloplasty, 177.
    rhinoplasty, 367.

  SZYMANOWSKI, history of reparative surgery, 5.
    restoration of auricle, 129.
    rhinoplasty, 363, 366, 375, 386, 447.


  TADDIE, vaselin injection in animals, 217.

  TAGLIACOZZI, KASPAR, history of rhinoplasty, 3.
    harness, 87.
    rhinoplasty, 371.

  TEALE, cheiloplasty, 185.

  TERRIER, ethyl bromid, 67.

  THIERSCH, history of skin grafting, 6.
    gauze compress dressings, 90.
    skin-grafting razor, 93.
    skin grafting in cheiloplasty, 180.
    rhinoplasty, 381.

  THOMPSON, rhinoplasty, 435.

  THORNDIKE, mandibular cleft, inferior, 157.

  TRENDELENBURG, cheiloplasty, 174.
    median cleft with rhinophyma, 147.

  TRIFFE, rubber apron, 19.

  TRIPIER, blepharoplasty, 111.
    stomatoplasty, 194.

  TUFFIER, secondary elimination paraffin, 262.


  UNNA, zinc oxid plaster mull, 489.


  VASSERMAN, gangrene following vaselin injection in nose, 222.

  VELPEAU, nasal amputation, 349.

  VERNEUIL, rhinoplasty, 380.

  VIANEO, VINCENT, history of plastic surgery, 3.

  VINCI, Beta eucain, 74.

  VIOLLET, electrothermically heated syringe, 233.

  VOLKMAN, rhinoplasty, 379.

  VULPIAN, history of plastic surgery, 6.


  WALCHER, dressing forceps, 55.

  WALLACE, sterilizer, 25.

  WARREN, history of reparative surgery, 5.

  WEBER, O., flap-twisting method, 85.
    history of reparative surgery, 2.
    needle holder, 78.
    rhinoplasty, 434.

  VON WECKER, skin-grafting method, 107.

  WEIRICK, skin-grafting method, 97.

  WENDEL, encystment of paraffin, 236.

  WENZEL, encapsulation of paraffin, 236.

  WHITE, A. C., liquid air anesthesia, 74.

  WILDE, polyotia, 138.

  WITZEL, malformation of lip, 148.

  WOLFE, blepharoplasty, 106.
    history of skin grafting, 6.
    skin-grafting method, 91, 107.

  WOLFE, J., history of plastic surgery, 7.

  WOLFENDEN, iodol, 42.

  WOLFF, use of Hart paraffin, 219.

  WÖLFLER, mandibular cleft, lower lip and tongue, 150.
    mucosa-grafting, 101, 110, 165.


  ZAHN, osteoplasty, 102.

  ZEIS, cheiloplasty, 181.
    history of reparative surgery, 5.




INDEX TO SUBJECTS


  Abscess, due to paraffin pressure, 261.

  Alæ, reduction of thickened, 466.
    restoration of, 427.

  Alar deficiency, 312.

  Alcohol, use of, 35.

  Alcohol-chloroform anesthesia, 67.

  Aluminium acetate, use of, 35.

  Anesthesia, combined, 66.
      alcohol-chloroform in, 67.
      chloroform-ether in, 67.
      chloroform-ether-alcohol in, 67.
    ethyl bromid, 67.
    ethyl chlorid, 68, 69.
    general, 58.
      chloroform in, 60.
      dropping bottles in, 60.
      ether in, 63.
      masks in, 61.
      preparation for, 59.
    local, 69.
      cocain in, 70.
      ethyl chlorid in, 69.
      eucain, beta, in, 74.
      liquid air in, 74.
      stovain in, 75.
    nitrous oxid, 67.

  Angular nose, correction of, 449.

  Ankyloblepharon, operation for, 116.

  Antiseptic powders, 41.

  Antiseptic solutions, 34.

  Antithermics, indication for, 57.

  Aristol, use of, 41.

  Artificial mouth, 196.

  Auricle, deficiency about, 334.
    malformation of, 128.
    malposition of, 138.
    restoration of, 121.

  Auricle, traumatism of, 120.

  Auricular appendages, 137.

  Auricular lobule, malformation of, 127.

  Auricular protheses, 125.

  Autodermic skin-grafting, 88.


  Bandages, removal of, 49.

  Battery, dry cells, 477.
    portable, 476.
    wet cell, 470.

  Benzoic acid, 35.

  Blepharoplasty, classification of, 103.

  Bone, grafting of, 101.
    Senn’s chips of, 101.

  Boric acid, use of, 35.

  Boric acid oil, use of, 55.

  Broadened base of nose, correction of, 465.

  Broadened lobule, correction of, 455.

  Bulbous lobule, correction of, 455.

  Buccal fissure, 150.


  Canthoplasty, 114.

  Carbolic acid, danger of, 36.
    use of, 35.
      in face peeling, 489.

  Cartilaginous support of flaps, use of, 404.

  Catgut, preparation of, 31.

  Cell, electric, 470.

  Cell selector, 473.
    arrangement of, 474.

  Cells, series connection of, 472.

  Cheek, prothesis for, 206.

  Cheek compressor, Hainsley, 161.

  Cheeks, deficiency of, 321.
    surgery of, 198.

  Cheiloplasty, 145.

  Chin, receding, 329.

  Chloroform anesthesia, 60.

  Chloroform-ether anesthesia, 67.

  Chloroform-ether-alcohol anesthesia, 67.

  Chromic anhydrid, 37.

  Classification for indication for protheses, 276.

  Classification of blepharoplasty, 103.
    of deformities of lower lip, 167.
      of upper lip, 162.
    of harelip, 147.
    of nasal deformities, 212, 341.
    of skin-grafting, 88.

  Coaptation, sutureless, 45.

  Cocain, in local anesthesia, 70.
    Schleich’s solution of, 71.

  Collodium dressing, 44.

  Coloboma, correction of, 125.

  Compression forceps, 145.

  Corneal graft, 7.

  Cosmetic rhinoplasty, 448.

  Creolin, use of, 37.


  Decortication method, 488.

  Deficiency, about alæ, 312.
    about cheeks, 321.
    about chin, 329.
    about ears, 334.
    about lips, 314.
    about nose, 286.
    about subseptum, 313.
    labial, 184.
    of nasal lobule, 464.
    of vermilion border, 190.

  Deformities, about the mouth, 314.
    of the nose, 286.
      classification of, 212.

  Dermatol, use of, 41.

  Deviation, nasal, correction of, 467.

  Diffusion of injected paraffin, 228, 252.

  Disinfection of operating room, 10.

  Dissection, subcutaneous, 2.

  Dressing forceps, 55.

  Dressing of wounds, 43.

  Dressings, changing of, 48.
    sterilization of, 24.

  Dropping bottles, for anesthesia, 60.


  Ear, surgery of, 120.

  Ectropion, blepharal, 103.
      correction of, 104.
    labial, 186.

  Electric battery, 470.

  Electric tattooing needle, 487.

  Electric wall plate, 475.

  Electrodes, 477.
    arm, 478.
    multiple needle, 484.
    sponge, 477.

  Electrolysis in dermatology, 470.

  Electrolytic needle holder, 479.

  Electrothermic paraffin heater, 244.

  Elevated lobule, correction of, 454.

  Embolism, after paraffin injection, 223.

  Entropion, labial, 189.

  Epicanthus, operation for, 113.

  Epilating forceps, 481.

  Ether anesthesia, 63.

  Ether inhalers, 65.

  Ethyl-bromid anesthesia, 67.

  Ethyl-chlorid, use of, in protheses, 273.

  Ethyl-chlorid anesthesia, 68.

  Eucain, beta, use of, 74, 272.

  Eucalyptol, use of, 37.

  Exfoliation of facial skin, 488.


  Face peeling, 489.

  Facial cleft, bilateral, 149.
    unilateral, 149.

  Facial pits, removal of, 488.

  Fibrolysin, use of, 488.

  Fibromatosis, after paraffin injection, 256.
    microphotographs of, 257.

  Flap method, combined, in rhinoplasty, 378.

  Flaps, implantation of, 87.
    nasal, cutting of, 345.

  Flaps, nasal, organic support of, 387, 389, 390.
    pedunculated, care of, 50.
    transplantation of, 88.

  Forceps, Burchardt’s compression, 145.
    dressing, 55.
    epilating, 481.

  Forehead, receding, 280.

  Foreign bodies, 51.

  Formaldehyd disinfection, 10.

  French method in rhinoplasty, 363.

  Furrow, about canthi, 326.
    interciliary, 279.
    nasolabial, 317.
    oral-angular, 320.


  Gangrene, symptoms of, 54.
    treatment of, 55.

  Glycerin, use of, 37.

  Granulation of wounds, 47.


  Hair, transplantation of, 102.

  Hairs, electrolytic removal of, 480.

  Hands, preparation of, 16.

  Harelip, cause of, 146.
    classification of, 147.
    correction of, 150.
    post-operative treatment of, 161.

  Harelip clamp, 145.

  Harness, Tagliacozza, 87.

  Hemorrhage, control of, 49.

  Heterodermic skin-grafting, 88-96.

  Hindoo method, in rhinoplasty, 351.

  Hydrogen peroxid, 39.

  Hyperinjection of paraffin, 221.


  Infection, erysipelatous, cause of, 56.
    treatment of, 57.

  Iodin, use of, 39.

  Iodoform gauze, use of, 57.

  Iodol, use of, 41.

  Instruments, care of, 14.

  Interlobular deficiency, 310.

  Irrigation, method of, 15.

  Italian method, in rhinoplasty, 369.

  Ivory bone protheses, 101.


  Keloid, 120.

  Koomas rhinoplasty, 352.


  Labial deficiency, 184, 314.

  Labial ectropion, 186.

  Labial entropion, 189.

  Lids, surgery of, 103.

  Ligatures, 30.

  Lips, surgery of, 145.

  Liquid air anesthesia, 74.

  Lobule, bulbous, correction of, 455.
    correction of, 455.
    deficiency of, 464.
    elevated, correction of, 454.
    nasal, restoration of, 423, 441.

  Lysol, use of, 39.


  Macrostoma, 150.
    correction of, 192.

  Macrotia, 132.

  Malformation, of auricle, 128.
    of auricular lobule, 127.

  Malposition of auricles, 137.

  Maxillary process, prominent, correction of, 468.

  Masks, anesthetic, 61, 65, 66.

  Meloplasty, 198.

  Melting points of paraffin, 239.

  Mercurial toxæmia, 38.

  Mercury bichlorid, use of, 38.

  Microstoma, correction of, 195.

  Microtia, 129.

  Milliampèremeter, 475.

  Moles, removal of, 482.

  Mouth, artificial, 196.
    deformities of, 314.
    surgery of, 192.

  Mucosa, grafting of, 101.

  Mucosa wounds, care of, 50.

  Multiple needle electrode, 484.


  Nævi, removal of, 484.

  Nasal chisels, 453.

  Nasal deficiencies, 286.

  Nasal deformities, 286.
    classification of, 341.

  Nasal destruction, cause of, 341.

  Nasal deviation, correction of, 467.

  Nasal flaps, cutting of, 345.

  Nasal mallet, 453.

  Nasal protheses, external, 347.

  Nasal replanting, 348.

  Nasal retention apparatus, 385.

  Nasal transplanting, 349.

  Nasal width, correction of, 468.

  Nasolabial furrow, 317.

  Nausea, after local anesthesia, 73.

  Needle holders, 77.
    electrolytic, 479.

  Needles, Haagedorn, 77.
    tattoo, 487.

  Nitrous oxid anesthesia, 67.

  Nose, broad base of, correction of, 465.
    surgery of, 339.


  Ocular stump, deficiency of, 327.

  Ohm’s law, 471.

  Operating room, requisites for, 9.

  Operations, number of, about nose, 346.

  Operative field, preparation of, 20.

  Oral-angular furrow, 320.

  Orbit, deficiency about, 324.

  Organic support of nasal flaps, 387, 389, 390, 404.

  Orthoform, use of, 42.

  Osteoperiostitic support of flap, 390.

  Otoplasty, 120.

  Oxid, nitrous, anesthesia by, 67.


  Paraffin, diffusion of, 228.
      secondary, 252.
    hyperinjection of, 221.
    melting point of, 239.
    subinjection of, 221.

  Paraffin compound for injection, 244.

  Paraffin embolism, 223.

  Paraffin heater, 232, 244, 246.

  Paraffin injection for epicanthus, 113.

  Paraffin syringe, Eckstein, 232.

  Pedunculated flaps, care of, 50.
    implantation of, 87.

  Periostitic support of flap, 389.

  Peroxoles, use of, 41.

  Photographic printing, 497.

  Photographs, in recording cases, 491-496.

  Plaster, protective, 44.
    removal of, 44.
    Z. O., 47.

  Plaster casts, making of, 493.

  Plastic operations, methods in, 79.
    principles of, 76.

  Polyotia, 137.

  Post-auricular deficiency, 335.

  Potassium permanganate, use of, 39.

  Powders, antiseptic, 41.

  Pressure abscess, 261.

  Principles of plastic surgery, 76.

  Pro-auricular deficiency, 334.

  Protheses, auricular, 125, 130.
    classification for indication of, 276.
    external, 8.
      nasal, 347.
    of cheek, 206.
    practical technique of, 272.
    subcutaneous, indication for, 8, 209, 210.
      precautions in, 213.
      untoward results in, 216.

  Ptosis, operation for, 115.

  Pus, laudable, 51.


  Razors, skin-grafting, 93.

  Receding forehead, 280.

  Redness of skin after paraffin injection, 248.

  Replanting nose, 348.

  Retention apparatus for nose, 385.

  Rheostat, 471.

  Rhinophyma, 147.

  Rhinoplasty, 339.
    French method of, 363.
    Hindoo method of, 351.
    Italian method of, 369.
    Koomas method of, 352.
    partial, 412.
    technique of, 344.

  Round cell infiltration after paraffin injection, 258.

  Rubber stamp recording method, 493.


  Salicylic acid, use of, 40.

  Scars, removal of, 485.
    treatment of, 486.

  Scissors, probe pointed, 114.
    curved eye, 117.

  Septicemia, 52.
    treatment of, 53.

  Series connection of cells, 472.

  Shoulders, deficiency of, contour in, 336.

  Shunt rheostat connection, 473.

  Skin-grafting, 88.
    classification of, 88.
    dermal, 6.
    epidermal, 6.
    general remarks on, 100.
    in blepharoplasty, 107.
    method of, 89.

  Skin-grafting razors, 93.

  Skin-grafting scissors, 89.

  Sodium chlorid, use of, 40.

  Solutions, antiseptic, 34.

  Spartein, use of, 57.

  Sponge electrode, 477.

  Sponges and sponging, 22.

  Stencil recording methods, 492.

  Stitch scars, 45.

  Stomatoplasty, 192.

  Stovain anesthesia, 75.

  Subcutaneous dissection, 2.

  Subseptal deficiency, 313.

  Subseptum, restoration of, 443.

  Superfluous hairs, removal of, 480.

  Sutureless coaptation, 45.

  Sutures, and their care, 30.
    placing of, 76.

  Syringe, Eckstein, 232.
    Kolle, 72, 265-266.
    Pravaz, 72.
    Kolle “Simplex,” 72.
    “Sub Q,” 72.
    Smith, 267.


  Tattoo-marks, removal of, 485.

  Telangiectasis, treatment of, 483.

  Thiosinamin solution, use of, 488.

  Thymol, use of, 40.

  Transplanting of nose, 349.

  Traumatism of auricle, 120.


  Unna plaster mull, use of, 489.

  Untoward results in paraffin injection, 216.


  Vacuoles, result of paraffin injection, 258.

  Voltage of cells, 471.


  Wall plate, electric, 475.

  Wall plate connections, 475.

  Wound dressings, 43.

  Wounds, granulation of, 47.
    of mucosa, 50.

  Wrinkled eyelids, operation for, 116.


  Xanthelasma palpebrarum, operation for, 118.


  Yellow appearance of skin after paraffin injection, 259.


  Zinc chlorid, use of, 40.

  Z. O. plaster strips, 47.

  Zoöcorneal graft, 7.

  Zoödermic skin-grafting, 88, 97.


THE END