OPERATIONS ON THE NOSE AND LIPS.
RHINOPLASTIC OPERATIONS.--The operations for the restoration or repair
of lost or mutilated noses are so various, and the minuteness of detail
necessary for full description of them so great, that a complete account
in a manual such as this is impossible; a brief notice of some of the
most important varieties of the operation is all that can be given.
_Principles._--1. It is necessary in every case that a suitable edge be
prepared on which to fix the flap of skin, however obtained. To be
suitable, this edge, should be (_a_) made in healthy skin, not in old or
weak cicatrices; hence no trace of the original disease should be left;
(_b_) it should be made thoroughly raw, by the removal of an appreciable
amount of its edge; it should be pared, not merely scraped.
2. It is useless to attempt to restore a nose unless the patient is in
good general health, well nourished, and perfectly free from all remains
of disease in the nose or its neighbourhood. The flaps which are to form
the new nose may be obtained either from (1.) the cheeks; (2.) the
forehead; (3.) a distant part either of the patient or of another
person.
(1.) _From the Cheeks._--When the cheeks are healthy, and specially if
they are tolerably full and lax, the flaps from the cheeks produce much
the most satisfactory result. As performed by Mr. Syme, the operation
consists in the shaping of two equal flaps (A, A) from the skin of the
cheek at each side, having the attachment above. A site for each flap is
formed by the careful paring away of the whole thickness of the edge of
the cavity of the lost organ (see Fig. XVII.)
[Illustration: FIG. XVII.[95]]
The flaps are then raised from their attachments to the upper jaw-bone,
and approximated in the middle line by several points of metallic suture
and the outer edges stitched to the raw surface on each side at a proper
distance from the nasal orifice. If any septum remains of the old nose,
it may be made very useful as a fixed point, a straight needle being
thrust through one flap close to its outer lower edge, then through the
septum, and out at a corresponding point of the other flap. The edges of
the wound left in the cheek at each side can generally be, to a certain
extent, approximated by silver stitches (B, B) and the triangular
portion (C, C), which is necessarily left to heal by granulation, proves
an advantage, as by its depression it enhances the apparent height and
prominence of the new organ. The cavity should be very gently distended
with lint, and may be supported by the blades of a small pair of
forceps, applied so as to embrace the nose.
(2.) _From the Forehead._--The Indian operation may be used as a last
resource, in cases where, from disease, the cheeks also have suffered,
and are not to be trusted to for flaps.
_Operation._--1. It should be decided as to the shape and size of the
portion of skin necessary, by fitting on pieces of soft leather or
moulding wax. To allow for shrinking, the flap should be made at least
one-third larger than is at first apparently necessary. The exact
boundaries of the flap to be raised should then be marked out on the
forehead by lightly pencilling it with nitrate of silver, the mark from
which is not effaced by blood, as is sure to be the case with an ink
line. Various shapes have been proposed for the flap varying in length
of neck, in the shape of the angles, and especially in the arrangements
made for the formation of a columna. Some (as Liston) prefer afterwards
to provide for the columns separately, by a flap raised from the upper
lip in a subsequent operation. The flap is then to be raised from the
forehead, care being taken not to injure the periosteum. The incision is
to be carried lower down on the side (generally the left), to which the
flap is to be twisted. The flap is then to be brought round (Fig.
XVIII.) and carefully fitted on to the edges previously prepared for its
reception. The neck must be left as lax as possible, lest by tight
twisting the supply of blood be cut off, and the flaps thus deprived of
nourishment. Both silk and metallic sutures are recommended. Hamilton of
Dublin,[96] after a large experience of both, prefers the former.
[Illustration: FIG. XVIII.[97]]
There are various risks; sloughing of the whole flap at once, shrinking
of it after weeks or even months; certain inevitable drawbacks, as the
cicatrix on the forehead, the very various and ludicrous changes of
colour to which the new organ is subject,--these cannot be remedied by
further operation. Two points generally require a second use of the
knife a few weeks after:--(1.) The neck of the flap is sure to be
redundant and prominent, but can be pared. (2.) The columna almost
always requires improving, and, in Liston's method, to be made. He pared
the inner surface of the apex of the nose, and then raised a central
flap of the lip in the middle line, about a quarter of an inch broad,
and extending from the remains of the old septum to the free border,
raising it from the gum, and stitched the free end of it to the prepared
apex, bringing together the two divided portions of the lip by ordinary
harelip sutures. Tho columna, if redundant, could be shaved down, and it
was found that the mucous surface very quickly became like skin on
exposure.
For other points with regard to the operation, reference may be made to
the works of Liston and Skey, and Hamilton's monograph, referred to
above.
_Note._--The tongue and groove suture proposed by Professor Pancoast,
and recommended by Professor Gross, is said to be specially suitable for
such plastic operations. It is very complicated, as it requires one edge
to be bevelled to a wedge shape, the other being grooved to include the
wedge, thus opposing four raw surfaces, which are retained in contact by
being transfixed by fine silk sutures.
(3.) There are certain cases in which neither cheeks nor forehead are
available for flaps, and yet the patients press very much for some
operation. If they have patience and determination, the Taliacotian or
Italian operation may be attempted.
Without going into detail, the principle of it is as follows:--1. A
piece of skin of suitable size was marked out over the left biceps, and
defined by two longitudinal incisions, and raised from the subcutaneous
cellular tissue, thus being left attached by its two ends only; a piece
of linen was pulled below it. 2. After a few days the upper end was also
divided, and the flap thus contracted. In a few days more the sides of
the old nose were made raw, and the upper free surface of the flap also
made raw and stitched to them, the arm being fastened up by a most
elaborate series of bandages. 3. After a fortnight in this position, the
last attachment of the flap to the arm was severed, and the new nose
could then be modelled at pleasure.
The literature of the subject is exceedingly curious, especially the
cases in which the new material was obtained from an accommodating
friend or servant.
OPERATIVE TREATMENT OF LUPUS.--We may here notice a mode of treatment
which has admirable results. The patient being put deeply under an
anæsthetic, the surgeon with a sharp spoon carefully pares away all the
diseased tissues, and then destroys the base either by nitric acid or a
strong solution of chloride of zinc. The author has done this in a great
number of cases with excellent effect.
NASAL POLYPI, _Removal of._--Of these there are different kinds.
1. ORDINARY MUCOUS POLYPI.--These grow from the spongy bones, generally
the superior one, are non-malignant in their character, soft and
vascular, often fill up the whole of both nasal cavities, and frequently
hang down behind into the pharynx. The practical point to remember is
that, however large and numerous they may be, they _invariably_ have
their origin from a comparatively limited spot, the edge of the spongy
bone, and _always_ hang from a narrow neck. Hence the treatment is easy
and satisfactory, if the neck be attacked, and not the body of the
tumour.
Slightly curved, narrow-bladed forceps should be passed along by the
side of the superior spongy bone, with their blades open, till the neck
of the polypus is seized. Holding it firmly, the forceps should then be
slowly twisted round till the neck is destroyed and the polypus
detached. This should be repeated till the patient can blow freely
through both nostrils. If attempts are made to seize the body of the
polypus, it will break down under the forceps, bleed, and give much
trouble.
2. THE FIBROUS POLYPUS.--This form is fortunately much more rare than
the other. It is almost invariably single, is attached to the posterior
margin of the nares by a narrow but very strong root, is extremely firm
in consistence, may grow to a large size so as to obstruct both
nostrils, generally gives rise to severe and frequent hæmorrhages. The
hæmorrhage _during_ any attempt to remove it is generally of the most
severe character, but ceases _immediately_ on its complete detachment.
We owe nearly all that we do know about the treatment of this form of
polypus to Mr. Syme. His method is--By the ordinary polypus forceps
described already, he seized the tumour through the nostril, and then
with the fore and middle fingers of the left hand introduced behind the
soft palate, he attacked the point of attachment, and by his nails,
aided by the forceps, detached it from its narrow base.[98]
3. MALIGNANT POLYPI should not be meddled with unless it is absolutely
certain that the whole of the bone from which they grow can be removed
also. This is very rarely the case. (See _Excision of Superior
Maxilla_.)
OPERATIONS ON THE LIPS.--1. Epithelial cancers of the lower lip are very
frequent, and require removal.
If the tumour or ulcer is small, and involves a considerable thickness
of the lip, it is most easily removed by a V-shaped incision (Fig. XIX.
A B A). Its shape permits the most accurate apposition of the cut
surfaces; and if the lips are full and the tumour small, very slight
trace of the operation will remain.
[Illustration: FIG. XIX.[99]]
Again, if the tumour be more extensive, involving a large portion of the
prolabium, and yet not extending deeply into the substance of the lip,
it may be very easily removed by a pair of curved scissors, applied in
the direction shown in the diagram (Fig. XX. A B). The skin must then be
stitched to the mucous membrane by numerous points of interrupted
suture.
[Illustration: FIG. XX.[100]]
But if the tumour be at once extensive and deep, mere removal is not
sufficient, but some provision must be made for supplying the blank left
by the operation.
In cases where a third, or even a half, of the lower lip has thus been
removed, it may be found sufficient freely to dissect what is left of
the lip from the gums, and thus approximate the cut surfaces in the
middle line.
This alone, however, would so much diminish the buccal orifice, and
twist its corners, as to cause great deformity. The addition of an
incision horizontally outwards, at one or both angles of the mouth,
will do away with such risk, and allow the surfaces to come together
without puckering; while by stitching the skin and mucous membrane
together in the course of these horizontal incisions, we can increase
the size of the buccal orifice almost _ad libitum_.
Lastly, when the lower lip has been entirely removed, it is still
possible to supply its place in the following manner, which was devised
by Mr. Syme: The tumour being fairly isolated by a V-shaped incision
(Fig. XXI.) C A C including the whole thickness of the lip, each of the
incisions should be prolonged downwards and outwards, as shown by the
dotted lines A D, A D. The flaps thus marked out must be separated from
the bone, brought upwards, and approximated in the middle line. Possibly
it may be necessary still further to enlarge the buccal orifice by short
lateral incisions, C C. Whether these are required or not, silk
stitches are to be introduced to unite the skin and mucous membrane
along the lines A C. The gap left between D B D must be left to
granulate, but in most cases may be very much diminished in size by
additional sutures at its outer corners, near D. The granulating surface
E E very rapidly heals up, leaving a dimple on each side, which rather
improves the appearance, by adding to the prominence of the chin, B.
[Illustration: FIG. XXI.[101]]
[Illustration: FIG. XXII.[102]]
THE OPERATIONS FOR HARELIP, though all conducted on the same general
principles, vary considerably in extent required according to the
position and size of the fissure or fissures to be remedied.
1. _For Single Harelip._--Where the fissure extends only from the
prolabium up to the attachment of the lip to the gums: this is very
easily remedied, the chief risk being lest the surgeon should not remove
enough of the edges of the fissure.
_Operation._--Bleeding being controlled by an assistant, the surgeon
fixes a pair of spring artery forceps into the mucous membrane and skin
at the salient angle at each side of the fissure. Taking one of these in
his left hand, he puts the edge to be pared on the stretch, and then
with a sharp narrow straight bistoury he transfixes the lip at the point
just beyond the upper angle of the fissure, and cuts outwards, being
careful to remove the whole thinner part of the lip, and to leave the
edge rather concave than convex. If left convex, or even quite straight,
there is a risk that, after union has taken place, an angle remain
showing the position of the cleft. The same is then to be done on the
other side. The bleeding is then to be controlled by twisting the larger
vessels, and if oozing still continues from the smaller ones, a pad of
lint should be placed in the wound, and a few minutes' delay given, as,
to facilitate immediate union, it is of the greatest importance that all
hæmorrhage should have ceased before the edges are brought together.
When the bleeding has ceased, the edges should be approximated by two or
more points of interrupted metallic suture inserted very deeply through
the tissues, and taking a good hold of the edges of the wound. If the
edges do not fit accurately, one or two horse-hair sutures will help.
Some surgeons still prefer the old harelip needles secured by a
figure-of-eight suture. A silk suture inserted through the prolabium is
of great advantage, as it keeps the inner surface of the wound closed,
which without it is very apt to be kept open by the pressure of the
teeth or gums, and in infants by the movements of the tip of the tongue.
Various methods have been devised to utilise, if possible, the
portion of the edge of the lip which is separated during the
operation of refreshing the edges, for the purpose of filling up
the sort of cleft or gap which is apt to be noticed at the edge of
the prolabium. The most ingenious and simplest of these is that
proposed by M. Nelaton, for use in cases where the fissure does not
extend so far up as the nose. It consists in leaving the two
portions which are pared off (Fig. XXIII.) the sides of the cleft
attached to each other as well as to the free edge of the lip, then
pulling them down, so as to bring their bleeding surfaces into
apposition, and make a diamond-shaped wound instead of a triangular
cleft (Fig. XXIV.) When brought together by sutures a projection is
left at the edge of the lip; this, in most cases, disappears; if it
does not, it can easily be pared down.
[Illustration: FIG. XXIII.[103]]
[Illustration: FIG. XXIV.[104]]
2. When the fissure, though single, extends upwards into the nose, the
operation is more difficult, and the result frequently less
satisfactory. The first thing to be done is to separate the lips from
the gums, so as to make them more freely mobile. The whole edges of the
cleft require refreshing.
3. _Double Harelip_, without bony deformity, and where the intervening
portion of the skin is vertical, does not project, and can be made
useful for the new lip. Such cases are not very common, but when they do
occur the question arises, How are they to be managed--in two separate
operations or at once? I believe, in every case, at once. The central
wedge-shaped portion is not large enough to extend downwards as far as
the prolabium, but still should not be removed altogether, as it may be
of great use, especially in bearing the columna nasi, and allowing its
full development. The edges should be pared in the same way, and to the
same extent as in single harelip, with the addition that the intervening
portion should have its edges completely removed, and be left in the
form of a wedge, with its apex downwards. The highest suture should be
passed through first one side, then the base of the wedge, and then the
other side; the second one through both, and the apex of the wedge; and
a third should unite the prolabium, not including the wedge.
[Illustration: FIG. XXV.[105]]
4. _Double Harelip_ combined with fissures of the hard palate, and
projection of a central bone. This is the analogue of the
inter-maxillary bone in the lower animals, and bears the two middle
incisor teeth, and projects very variously in different cases. In some
it projects horizontally forwards in the most hideous manner, in others
it lies at an angle more or less oblique; in very few does it maintain
its proper position; when projecting forwards, and as the teeth also
share in its projection, it entirely prevents approximation of the edges
of the fissures by operation, so it must first be dealt with in one of
two ways, either--
[Illustration: FIG. XXVI.[106]]
(1.) It may be at once removed with bone-pliers, the piece of skin over
it being saved. This is the best that can be done in cases of old
standing after the first year or two, though attempts have been made to
break the neck of the projecting portion, and thus permit of its being
shoved back.
(2.) By gradual pressure by a spring truss, strapping, or a bandage, it
may be forced back. This is possible only in cases where the deformity
has been comparatively slight, and the patient has been seen early. The
edges must then be pared and approximated as directed above.
One or two points about the operation for harelip require a special
notice:--
1. _When to operate._--Great differences in opinion exist. Some say not
before two or three years, others within two or three days, or even
_hours_, after birth.
Probably the safest time is not much earlier than the second month in
very strong children, the fifth in weakly ones, up to the commencement
of the first dentition; and when once dentition has commenced it is not
so safe to operate till it is over.
Prior to dentition the operation is attended with rather more risk, but
again, if delayed, there is great risk that the teeth do not come in
properly.
2. With regard to the most delicate part of the operation, _the
management of the prolabium_.--Some are satisfied, and I believe
rightly, with careful apposition by a silk suture after a _sufficient_
amount of the edges has been removed; others have proposed various plans
to obviate any risk of an angle remaining.
Malgaigne proposes to retain a small portion of the parings of the edge
to make small flap at each side; Lloyd a single one from the long half
of the lip, and brings it up under the opposite one, securing it with a
stitch.
FOOTNOTES:
[95] Operation for formation of a new nose from the cheeks; A A, flaps
approximated in middle line; B B, outer part of bed of flaps stitched
up; C C, triangle at each side left to granulate.
[96] _The Restoration of a Lost Nose by Operation_, p. 57; an excellent
monograph on the subject.
[97] Operation for formation of a new nose from the forehead:--_a_,
prominence of flap which is to be used as septum; _b_, left-hand corner
of flap, which is twisted and fastened at _c_; _d_, one of the tubes or
quills over which the nose is moulded.--(_Modified from Bernard and
Huette._)
[98] Syme's _Observations in Clinical Surgery_, p. 132.
[99] Diagram of V-shaped incision; A B A, dots showing points for
sutures.
[100] Diagram of incision for scooping out a shallow tumour by scissors.
[101] Diagram of incisions:--C A C, outline of incision for removal; C A
D, outline of flap on each side; B, prominence of chin; C C, dotted
lines, showing incisions to enlarge mouth, if required.
[102] Diagram of flaps in position:--A A, corners of flaps brought up
and approximated by _silver_ sutures; C C, new lip got by lateral
incisions, skin and mucous membrane being united by _silk_ threads; E E,
gap left to granulate.
[103] Fig. XXIII. shows the incision bounding the cleft.
[104] Fig. XXIV. shows the diamond-shaped wound before the sutures are
applied.
[105] Diagram of operation for double harelip:--_a_, stitch through both
sides and wedge-shaped portion, which also aids the septum; _b_, other
stitches approximating edges.
[106] Diagram of double harelip, with projecting bone:--_a_, central
piece of lip, dotted lines showing incision; _b_, projecting bone
bearing teeth, which are generally small and stunted.