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.