RHINOPLASTY
(_Surgery of the Nose_)
Rhinoplastic operations serve to correct deformities of or restore the
nose. Such operations may involve only a part of or the entire organ,
hence may be termed partial or total. Furthermore, a fine distinction may
be drawn between general rhinoplasty as applied to such deformities when
caused by traumatism, the excision of neoplasms or destructive disease,
whether such correction be partial or total, and cosmetic rhinoplasty
when such corrections are made purely with the object of improving the
nasal form when the deformity is either hereditary or the result of
remote accident.
For some unaccountable reason the latter art has not met with the general
favor the profession should grant it, yet the results obtained by such
specialists as have undertaken this artistic branch of surgery have
been all that could be desired, and have consequently added much to the
comfort and happiness of the patient.
Without a comparatively thorough knowledge of the extent of cosmetic
rhinoplasty it would be difficult to draw any conclusion as to the
value of this art. If it has not met with the favor it deserves it is
solely due to the fact that the art has been limited to the few, and the
literature on the subject is so meager, indeed, that the surgeon has been
compelled in many cases to trust to his own originality in undertaking an
operation of this nature.
The limitation to rhinoplasty is due primarily to the artistic skill
required to obtain results; secondly, to the risks involved by loss of
tissue due to gangrene, imperfect healing or accidental interference,
post-operatio; and thirdly, to scarring about the face as a result of
the primary and secondary wounds; in fact, so much so that many surgeons
prefer to allow a small defect to remain, to escape the risks involved in
correcting them.
The author believes such fear misplaced, because with the methods of
surgery of the present day and the proper knowledge of the art there need
be little risk involved and the result expected should be as near perfect
as human skill can make it.
True, a surgeon cannot be expected to build an entire nose from the
skin or other tissue of the forehead or cheeks and make it a thing of
aforethought beauty and shape, but if the result be no more than a
curtain of skin to hide the hideous deformity he has done his share, and
such result is the worst he might look forward to.
For the correction of nasal deformities the author will consider first
such operations as involve the entire loss of the nasal organ or _total
rhinoplasty_; thereafter _partial loss_ of the nose, and lastly such
cases involving no loss of tissue and dependent on malformation only
under _cosmetic rhinoplasty_.
It is not here intended to lay down a law for the surgeon for the
restoration of the entire or part of the nose for the reason that each
case differs more or less; that in each case there is more or less tissue
that may be utilized, and that there are many methods advanced for such
procedure, but the author does desire to give to the operator a concise
and comprehensive treatise on rhinoplasty and to illustrate the best of
such operations as have been placed on record as a ready guide and for
immediate reference—a matter of no small moment when this literature can
be gained only by searching through innumerable medical journals and
short references and in all languages of the civilized world.
In the chapter on history some idea of the time in which rhinoplasty has
been practiced may be obtained. It is not deemed necessary to go into
further historical facts here, except, perhaps, to divide the subject
into the three most important schools or countries that have given
individuality to the art.
THE CAUSES OF NASAL DESTRUCTION
The loss of the entire nose may be due to traumatism, actual amputation,
the bites of man or beast, duels, the removal of neoplasms, gangrene
after freezing or disease, rhinosclerosis, syphilis, the application
of caustics, tubercular disease, lupus, cancer, and rarely congenital
absence of the organ. The loss may be total or partial.
The extent of loss of substance in each case differs, and it is for this
reason that surgeons have been compelled to originate many methods of
operation, each having for its object to correct the deformity as neatly
and as near to the normal as possible.
CLASSIFICATION OF DEFORMITIES
To give correctly a classification of nasal deformities would simply mean
to mention each anatomical part or division of the nose referring to the
deformity involving the same. For this reason such an arrangement would
be uselessly extensive, but for the proper recording of such cases the
author advises a systematic method of nomenclature in which the deformity
is stated, as: left, unilateral deficiency of inferior lobule; or right,
median third deficiency of nasal dorsum of the parts destroyed and
mentioned as such.
[Illustration: FIG. 306.—DEFICIENCY OF SUPERIOR AND MIDDLE THIRD OF NOSE.
(Saddle Nose.)]
[Illustration: FIG. 307.—POST-ULCERATIVE DEFORMITY OF SUPERIOR THIRD OF
NOSE.]
[Illustration: FIG. 308.—LOSS OF RIGHT ALA, LOBULE AND COLUMNA.]
[Illustration: FIG. 309.—LOSS OF LOBULE, INFERIOR SEPTUM AND COLUMNA.]
A fair idea of typical deformities may be obtained from the following
illustrations in which deformities from the milder to the most extensive
extent are shown. The types here shown are all pathological with the
exception of Fig. 306, in which a saddle nose is illustrated which may
or may not be the result of disease or traumatism.
[Illustration: FIG. 310.—ULCERATIVE LOSS OF RIGHT MEDIAN LATERAL SKIN OF
NOSE WITH INVOLVEMENT OF ALA.]
[Illustration: FIG. 311.—LOSS OF NASAL BONES AND PARTIAL ULCERATIVE
DESTRUCTION OF DORSUM, LOBULE AND SEPTUM OF NOSE.]
[Illustration: FIG. 312.—DESTRUCTION OF NASAL BONES WITH DORSAL
INTEGUMENT AND LOBULE INTACT.]
[Illustration: FIG. 313.—TOTAL LOSS OF NOSE.]
Many other deformities of the nose exist, of course, such as lateral
deviation, twists, etc., but as in most of such cases cosmetic
rhinoplastic operations and subcutaneous injection are required for their
correction, inasmuch as in these cases the skin is healthy and intact,
they will be considered under that part of the chapter that has to do
with purely cosmetic rhinoplasty or under the chapter on subcutaneous
protheses.
SURGICAL TECHNIQUE
Before going into the individual methods involved in the correction of
deformities of the nose, it is well here to go into the special details
required for the performance of operations about the nose proper.
=Anesthesia.=—It may be well here to state that many of the smaller
or cosmetic operations can and should be done under local anesthesia,
and that the anterior nares should be plugged to prevent the blood
from running into the pharynx, but in operations of greater extent the
posterior nares should be plugged by Bellocq or other method, and that
since the patient must be placed under a general anesthetic, some special
plan must be followed to give the same.
The author has found no special apparatus on the market for this purpose.
A most practical apparatus may be made as follows: A medium hard piece
of rubber is cut into such shape as will fit into the patient’s mouth
between the lips and the teeth. In its center a hole is made, into
which a metal tube is fixed to which a rubber tube of three-fourth-inch
diameter is securely fastened. This tube is connected by its distal end
to the anesthetic container, which should be so constructed as to permit
the required amount of air to be given with the anesthetic at the desired
time.
Such an apparatus practically seals the oral orifice, and prevents blood
from flowing into the mouth, gives the operator a free field to work in
without the encumbrance of large external mouthpieces, and is one that
in case of vomiting can be easily removed for the time being, and be
replaced without interference to the surgeon.
=Preparation and Cutting of Nasal Flaps.=—Under a division of skin
grafting some preliminary steps in the preparation and cutting of a nasal
flap has been referred to, but the author thinks it timely to repeat here
the necessity for a systematic method of procedure.
It is well for the surgeon to have fully decided upon the certain
operative plan he is to follow several days prior to the operation. He
must, especially in total rhinoplastic cases, prepare a paper or oiled
silk model of the flap or flaps he has decided upon to take from the
forehead or cheek, and to fold and bend this model into the place of the
deformity to be overcome, to make sure of the result to be attained,
allowing for the loss, if any, of mass by reason of the torsion of the
flap at its pedicle.
If the hair of the frontal scalp lies within the flap outline, it should
be shaven away well beyond the border to permit of unhindered work.
Thoroughly cleanse and keep clean with a suitable antiseptic the parts to
be operated upon for at least twenty-four hours.
Place a rubber cap over the hair of the head, or a fixed gauze or
waterproof arrangement to keep it in place.
If there be any hair adornment of the face remove it.
The surgeon should remember to get the flaps to be utilized on forming
the lost parts of the nose, at least one third larger to overcome the
consequent retraction.
Sterilized sutures, preferably silk of suitable size, should be ready and
be cut of such length as will facilitate quick action.
Rubber tubes of proper diameter for insertion into the nares should be at
hand if required.
When all is ready the operator is to proceed quickly and accurately,
never changing his prearranged idea of the operation. His assistants
should be ready to control by torsion or pressure the bleeding occasioned
by cutting, since it covers the field of operation and hinders rapid work.
The surgeon in making flaps should use the greatest gentleness in
handling them to prevent pressure gangrene. His finger tips are far
better than fixation forceps. Sharp tenaculi may be employed with gentle
traction only. Never permit the use of serrated forceps in autoplasty.
In cutting, employ the rules laid down under the principles of plastic
surgery, and in dressing flap operations such methods as have been
heretofore described.
=Dressing.=—Do not be too hasty in dressing such wounds, as early
interference often results in partial if not total loss of the flap.
The author has found that in flap operations blood dressing under
perforated rubber tissue is best. This helps to give nutriment to the
parts and permits of free removal of the dressings. Never apply the
blood treatment on gauze, since the latter is liable to become hard and
attached to the suture lines, requiring undue force for its removal.
=Care of the Nares.=—Remove all packing from the nares before fixing the
lobular section of the flap, and have all bleeding controlled before
suturing the part of the flap intended for the columna. Blood clots tend
to pressure and infection. If nare tubes are used rather let them remain
in place for some time than to drag them forth forcibly.
The interior nose and nares can be kept clean by gentle irrigation
through them.
=Number of Operations.=—Instruct the patient as to the probable outcome
of the operation, and advise him that more than two or three operations
may be necessary to correct the deformity.
_Von Esmarch_ has said that twenty operations about the nose are none too
many if the desired result can be obtained. Dieffenbach has said that it
is more difficult to restore smaller nasal defects than those of greater
extent.
The latter applies particularly to cosmetic operations in which the
surgeon is compelled to work through small openings or incisions always
with the view of leaving little if any scar, and to place such scar where
it may be least observed.
The best cosmetic surgeon is he who can accomplish results with the least
secondary disfigurement.
PROTHESES
When for any cause there is a loss of the entire nose, and the patient is
unwilling to undergo surgical operation for its restoration, the surgeon
may resort to the use of protheses or artificial noses.
Such noses are made of papier-maché, rubber, wood, or light metal, and
painted to imitate the color of the skin of the individual. They should
be made after a model previously prepared by molding the new organ upon
the face of the patient or after such patterns as the surgeons may have
to choose from, fitting the skin juncture accurately in such cases.
If the surgeon lacks such artistic ability, a sculptor should be employed
to model the proper organ suitable for and on the face of the patient,
from which a plaster cast or mold may be made from which the maker of
protheses can work.
With the model in hand and no expert on protheses within reach, a
skillful surgeon-dentist could easily make a vulcanized rubber nose,
which may then be painted to suit.
Some method of attachment must be provided for, such as one or two soft
rubber plugs or stems to fit into the nasal orifice or permanent fixture
to the bridge of a pair of spectacles. Gums or pastes as advised with
aural protheses may be of service.
Celluloid protheses should never be used because of their inflammable
nature; furthermore, they are easily damaged or cracked. Wax noses are
of little use, although resembling the normal very closely; they crack
easily, and when soiled by dust or friction soon have to be replaced with
new ones.
The following list of authorities shows the various materials employed by
them for nasal protheses:
_Martin_—Porcelain.
_Richter_—Wood.
_Debout_—Rubber or silver covered with colored wax.
_Mathieu_—Aluminum.
_Charrière_—Silver.
NASAL REPLANTING
The plastic surgeon is often, especially in later years, called upon to
attend to traumatic injuries of the nose. Sometimes there is a total
severance of the nose; often a partial loss or injury, practically
involving a loss of a part of the organ. Since the advent of the
automobile such accidents are not unusual.
The author has found that a remarkable history lies back of the
replanting of parts or all of the nose when found detached by accident or
intent.
If the part cut from the nose or face has been not too severely bruised,
it should be cleansed gently in a normal salt solution at about 100° F.,
and be sutured in place as quickly as possible. Partly separated sections
should be treated in the same way. It is remarkable how Nature will take
care of these traumatisms. So well did the executioners in India, where
nasal amputation is a criminal sentence, know this that they destroyed
the amputated organ by fire, so that the victim could not replant it upon
himself.
Chelius successfully replanted a nose after it had been severed about an
hour.
Hoffacker has replanted a number of noses cut off in the duels of
Heidelburg students. In one case one and a half hours intervened between
the accident and the operation.
In partial separations about the nose the flap, still hanging by a
slight pedicle, should be brought in place by suture, and because of the
peculiar hypertrophy that always follows the wounds one or two intraflap
sutures should be employed to fix the part centrally to the deeper
tissues, if any, to prevent the formation of clots that are liable to
organize and encourage such enlargement.
Such sutures are only to be made when the flap is of sufficient size to
necessitate them. If the hypertrophy or hyperplasia cannot be prevented
by this means later cosmetic operations should be employed to make the
parts heal into normal contour.
Blood dressings should be employed after the parts have been fixed by
a number of fine silk sutures, the coaptation being made as neatly as
possible to get the best results.
NASAL TRANSPLANTING
The making of a nose or part thereof from a nonpedicled flap of skin
taken from the patient has met with more or less success in the remote
past, but of later years such methods have fallen into disuse because of
the many and better methods of modern times involving the use of flaps
with nutrient pedicles.
Branca is said to have made a nose for a patient out of the skin of the
arm of a slave.
Velpeau states that “In the land of the Pariahs the men in power had no
scruples in having the nose of one of their subjects cut off to replace
the lost organ of another.”
Van Helmont is said to have made a nose for a gentleman from the skin of
the buttocks of a street porter.
Bünger, of Marburg, in 1822 made a total nose from the anterior thigh.
Several surgeons later than the above date have successfully restored
parts of the nose by transplanting skin flaps from remote parts of the
body, the method involved being practically what is now accomplished by
the so-called skin-grafting methods of nonpedunculated flaps heretofore
referred to.
While for small defects such procedure has proven quite successful, the
employment of large flaps for nasal reconstruction has been exceedingly
discouraging, although the author advises trying transplanting of such
flaps when the patient hesitates giving up sufficient facial skin for
rhinoplastic purposes for fear of disfiguring scars, or when there are
untoward reasons.
In such event there is only the secondary wound to be considered apart
from the death of the flap, and the minor operation about the remains of
the nasal organ to permit of the fixation of the latter.
A thorough and practical knowledge of skin grafting is of the greatest
necessity to the surgeon, because he must be ready to cope with any
emergency in such cases, and thus be able to save a flap graft from death
or partial gangrene, when he would otherwise fail.
TOTAL RHINOPLASTY
PEDUNCULATED FLAP METHOD
The most practical and safe methods of rebuilding the nasal organ have
been those in which flaps having nutrient pedicles have been employed,
whether these flaps be taken from the skin of the forehead, cheek, or
both. These procedures are autoplasties, and may be grouped according to
their peculiar differentiation into three classes, as follows:
_The Indian or Hindu Method_, in which the flap is made from the forehead.
_The French Method_, in which the flap is made from the tissue about the
borders of the deformity.
_The Italian Method_, in which the flap is taken from some distant member
or part of the body.
Furthermore, there are the combined methods of one or the other in
which inverted skin flaps are used, or those lined with an osseous and
cartilaginous support, and in some rare and rather unsuccessful cases by
metallic supports.
_The Indian or Hindu Method_
The method of rebuilding the nose by taking one or two flaps from the
forehead dates back to the Koomas, from whom the art of rhinoplasty has
come down to the present time, all of the methods of to-day involving
the utilization of the pedunculated flap being a result of their early
surgical ingenuity.
Originally, their operation consisted of cutting an oval flap, having its
pedicle as the root of the nose, and extending over the forehead, and
upward vertically into the hair line. The flap thus made was dissected
away from the bone and brought down by twisting it to the extent of
a hundred and eighty degrees on its pedicle in front of the nasal
deformity, the edges of which had been prepared to receive it. To hold
the flap in position they resorted to some kind of clay, sutures being
unknown to them.
The pedicle was cut after the flap had thoroughly united to the freshened
borders of the deformed nose.
The steps of the operation as performed by them are shown in Figs. 314,
315, and 316.
Naturally, many improvements in the above method have been evolved,
principally to overcome the extreme and injurious torsion of the pedicle,
and from the desire on the part of the surgeon to bring about a better
cosmetic result. Therefore, not only the position of the pedicle and
its shape were altered, but also the size of the flap itself, as will
be shown in the specific methods of the various authorities mentioned
hereafter.
The author does not consider it necessary to go into chronological
details of the evolvement of the art, and begs the surgeon to be content
to learn of those operations and methods that have given the best result.
[Illustration: FIG. 314. FIG. 315. FIG. 316.
KOOMAS METHOD.]
Where one surgeon has changed his incisions in the slightest direction
and another has advised increasing the number of sutures is of little
import to the operator of to-day; the gist of it all is the successful
method for the successful outcome.
The first to be considered will be those methods wherein the vertical
direction and the position of the pedicle have been similar to that of
the Koomas. It will therein be noted that the principal change has been
in the formation of the distal end of the flap with the object solely of
forming a better base to the nose.
=Graefe Method.=—The flap was made in the shape of a heart with a
rectangular addition at its upper or scalp border. The pedicle is made to
lie between the inner limitations of the eyebrows (see Fig. 317).
The flap is twisted into position and sutured into the freshened remains
of the nose, the pedicle being cut at a second operation after the flap
has healed into place, which was about the tenth day.
[Illustration: FIG. 317.—GRAEFE METHOD.]
=Delpech Method.=—The shape of the frontal flap was cut in the form of a
trident, as shown in Fig. 318.
The object of the arrangement was to give a rimlike lining to the two
nostrils, the raw surfaces of the outer points being brought into contact
with each other.
He also hollowed out a groove at the root of the nose, to better
accommodate the pedicle when twisted. The steps are shown in Figs. 319 to
321. The pedicle was later severed when the conditions warranted it.
[Illustration: FIG. 318. FIG. 319. FIG. 320. FIG. 321.
DELPECH METHOD.]
=Method of Lisfranc.=—Lisfranc conceived the idea that if he carried down
the one incision for the flap at the root of the nose somewhat lower than
the other he would overcome some of the torsion at this point. This he
consequently did, making the left incision half an inch lower than the
right. The lateral incisions ascend at an angle of forty-five degrees
(see Fig. 322), uniting in rectangular form at the scalp line, as shown,
the rectangle of skin being utilized to make the subseptum.
Instead of sutures he dissected up the old nasal borders and slid the
flap borders into this groovelike arrangement, holding it in place with
the aid of sticking plasters.
With the above method the pedicle was allowed to remain intact. Fig.
323 shows the position of the flap, and the treatment of the subseptal
section.
[Illustration: FIG. 322. FIG. 323.
LISFRANC METHOD.]
=Labat Method.=—Labat uses a frontal flap shaped as in Fig. 324. The
left bordering incision is carried down one half inch below the point of
beginning on the right and carried downward in such manner that its lower
point lies in a line with that of the right above it.
The object of this was to overcome torsion, and, where obtainable, the
small triangle of healthy tissue at the root of the nose, as shown in
the illustration, was dissected off from above downward, and turned
downward with the cutaneous side facing the nasal chasm and its dissected
side facing that of the flap. He avoids injury to the angular artery,
as should be done in all cases. The pedicle was replaced at a second
operation.
[Illustration: FIG. 324.—LABAT METHOD.]
=Keegan Method.=—Utilized a flap, shaped as in Fig. 325. The pedicle
occupies the internal angle of the eye, care being taken to preserve the
angular artery. The flap is mapped out obliquely, not perpendicularly. To
get the best results he advises pasting a paper model upon the forehead
to guide the operator in making the flap, which includes all the tissue
down to the periosteum. Horsehair sutures are employed to approximate
the parts accurately. The pedicle is divided in about twenty days, and a
wedge-shaped piece of skin is excised at the root of the nose to prevent
the tuberosity at this point of the new nose, so commonly observed with
Indian-flap methods.
[Illustration: FIG. 325.—KEEGAN METHOD.]
=Duberwitsky Method.=—The flap at its root resembles that of Labat, but
at its superior border it formed an oval with an elongated point running
into the hair line, which he divided, as shown in Fig. 326, to form the
subseptum and nasal wings.
At the root the pedicle was about half an inch wide made in the oblique.
The middle section of the superior pointlike projection and intended for
the subseptum was folded upon itself or doubled, as it were, to give
support to the nasal point. The same was done with the alar or lateral
sections, so as to line the nares with epitheliar surface to prevent
contraction. The lower part of the nose was fixed into position by a
harelip pin inserted transversely after all parts of the flap had been
sutured into place.
[Illustration: FIG. 326.—DUBERWITSKY METHOD.]
=Dieffenbach Method.=—The flap is cut very much like that advised by
Lisfranc, being wider only at its upper extremity, as shown in Fig. 327.
He advocates removing the remains of the old nose, almost circumscribing
the nose, as shown in the illustration, except for the deep linear
incision at the base of the nose on a level with the oval fissure,
leaving a bridge of skin at either angle into which the square or septal
part of the superior frontal flap is affixed.
The flap is made so that the right oblique line lies an inch above that
of the left, the latter incision running into the angle formed at the
root of the old nose caused by the ablation.
[Illustration: FIG. 327.—DIEFFENBACH METHOD.]
=Von Ammon Method.=—The flap is cut at its superior border, similar to
that of Keegan, but made in the perpendicular; the point of beginning,
at the end of the right eyebrow, lies about an inch above the end of the
incision of the opposite side, but in line with it (Fig. 328). The same
method of removing the remains of the old nose advocated by Dieffenbach
is followed as well as the lobial incision to receive the septal section.
The shape of this flap permits of bringing the secondary wound on the
forehead more readily than where square exsections are resorted to.
[Illustration: FIG. 328.—VON AMMON METHOD.]
=Auvert Method.=—Like the method of Keegan, the frontal flap is made at
an angle of forty-five degrees instead of the perpendicular, the flap
being cut to the left of the median line. Its outline is shown in Fig.
329, and differs little at its superior extremity from that of Labat,
except that it is made longer and narrower. The left lateral incision
runs into the superior border of the old nose at the median line.
[Illustration: FIG. 329.—AUVERT METHOD.]
=Von Langenbeck Method.=—The flap is fashioned like that of Duberwitsky,
but the left lateral incision enters the remains of the old nose, as
Dieffenbach advised. The superior border was shaped, as shown in Fig.
330, to form the alæ and columna.
[Illustration: FIG. 330.—VON LANGENBECK METHOD.]
=Petrali Method.=—The shape of the flap is cut in ovate form with its
rounded base near the hair line of the forehead. Petrali likens it to the
form of the mulberry leaf. The left lateral incision dips down into the
median line of the old deformity at its upper border.
The flap, after having been cut free, is folded upon itself along the
median line, bringing the raw surfaces together along the dorsum of the
new nose, thus giving body to the whole anterior nasal line. Presumably
he introduces several sutures through the side of the flap to facilitate
union along this line.
The method is illustrated in Figs. 331 and 332.
[Illustration: FIG. 331. FIG. 332.
PETRALI METHOD.]
=Forque Method.=—Herein the right lateral incision of the frontal flap is
begun at a point above and corresponding to the middle of the eyebrow.
The base is fashioned as shown in Fig. 333, and the left lateral incision
is carried down to the median line of the old nasal defect, coming within
the inner border of the eyebrow.
[Illustration: FIG. 333.—FORQUE METHOD.]
=D’Alguie Method.=—This author conceived the idea of further relieving
the torsion of the pedicle by making the frontal flap transverse along
the forehead, instead of perpendicular.
The incision at the root of the nose is on a level and in line with the
inner ends of the eyebrows. The left lateral incision is made to lie just
above the eyebrow and the right sweeps upward and outward, as shown in
Fig. 334.
The base is made with a rectangular projection to form the columna.
[Illustration: FIG. 334.—D’ALGUIE METHOD.]
=Landreau Method.=—The direction of the frontal flap is transverse, but
the root of pedicle, instead of having a downward direction, is so cut as
to have its attachment upward, as shown in Fig. 335. This position of the
pedicle thus overcomes to a great extent the torsion at this point. The
flap must be cut somewhat longer in its transverse axis to allow for the
higher position of the pedicle on the forehead.
The distal end of the flap is trident-shaped, as shown.
[Illustration: FIG. 335.—LANDREAU METHOD.]
=Langenbeck Method.=—The flap is cut on an oblique line along its left
border, running the incision down and across the root of the nose to the
right while the right incision begins just under the eyebrow and extends
less obliquely upward, as shown in Fig. 336. The base of the pedicle is
fashioned as shown. The bordering remains of the old nose are removed.
[Illustration: FIG. 336.—VON LANGENBECK METHOD.]
In another operation by the same operator the right incision was begun at
a point above the eyebrow and carried transversely along to the rising
point of the lateral. The left lateral incision was so made that it left
an area of skin over the root of the nose, as shown in Fig. 337, which he
dissected away, giving that part of the flap to cover it an opportunity
to adhere, at the same time furnishing a nourishing area for its future
life.
[Illustration: FIG. 337.—VON LANGENBECK METHOD.]
=Szymanowski Method.=—The flap is formed as shown in Fig. 338, the
pedicle having its upper incision just below the end of the right eyebrow
and the lower below the inner canthus on a line with the first, giving it
an oblique position.
Just below the curvature of the basal incision two short incisions are
made on either side into the forehead tissue with a view of rendering
more flexible the skin to be utilized in correcting the secondary wound.
The margin of the old nose is freshened.
[Illustration: FIG. 338.—SZYMANOWSKI METHOD.]
=Labat, Blasius, Linhart Method.=—These operators performed their
operations in two sittings. In the first the incisions were so made at
the base as to permit of that part of the flap intended for the rim of
the nares to be tucked in, as it were, where these two triangular little
folds were held in place by silk suture. When the parts had become
thoroughly united, or at the second sitting, the entire flap was cut away
and brought into place for the new nose. The object of this procedure
was to give body to the wings of the nose and to overcome the consequent
curling and contraction of the skin so commonly found with the single
sitting operation.
This step marked the first advancement toward attaining much more
successful results in total rhinoplasty by using skin-lined flaps, which
not only added to the better nutriment to the part, but also gave support
and firmness to the new organ.
_The French Method_
This method, _per se_, is not in itself sufficient to bring about a
satisfactory result. The fundamental principle is that of the sliding
flap of Celsus, and in which the two flaps intended to form the new nose
are taken from the tissue of the cheek at either side of the remains of
the old nose.
The total outcome is simply to bring before the opening a curtain of skin
with a median scar running from the root to the lobule, which in itself
is sufficient upon contraction to mar the result; furthermore, there are
the two lateral wounds which have to be covered by skin grafts which,
upon healing, have their tension of contraction, added to that of the
median scar, with the result that the anterior nose becomes flattened and
ugly, practically amounting only to an unevenly contracted curtain of
marred skin.
The author would not advise resorting to such method, but, owing to
the fact that a step in the advancement of the art was conceived under
this particular method, space is given to the subject. This step, first
introduced by Nélaton, consisted of allowing all of the cicatricial
tissue of the old nose to remain with which the new nose could be
built. As the possibility of this is rare in total rhinoplastic cases,
the method is more useful in partial rhinoplastics, where it forms an
important factor, as will be shown later under that subdivision.
=Nélaton Method.=—Two lateral flaps of triangular form, having their
pedicles below the internal canthi, are cut from the cheeks, each flap
containing all of the remains of the old nose. The entire inner borders
of these flaps were freshened throughout their whole thickness.
In making the flaps, dissection is made down and through the periosteum,
thus giving firmness and thickness to the new nose. The flaps are slid
forward and sutured along the median line, leaving a triangular wound of
the cheek on either side, as shown in Fig. 339.
To keep the raw surfaces in contact with the newly dissected area and to
retain the nose in place as far as possible, a silver pin is inserted
through the base of the new nose, going through the skin and remains of
the old nose. It should be of sufficient length to permit holding a disk
of cork at either end, beyond the skin and for the retention of the metal
ring ends of a hook bent in inverted U-shape. The diameter of the latter
bent wire is equal to that of the pin.
He claims for his method a perfect and fixed cicatrization of the newly
placed parts.
[Illustration: FIG. 339.—NÉLATON METHOD.]
=Heuter Method.=—The cheek flaps are cut from the cheeks, as shown in
Fig. 340, leaving intact a triangular piece of skin with the object of
giving support to the new nose. The inner and upper borders of the two
flaps were stitched to the rim of this triangle, and then along the
median line. The flaps are not made to include the periosteum, as in
Nélaton’s method. The results thus obtained are not equal to the latter’s
procedure.
[Illustration: FIG. 340.—HEUTER METHOD.]
=Bürow Method.=—The cheek flaps are made as in Fig. 341. The projection
intended for the subseptum is an elongated strip at the inferior border
and inner angle of the left flap.
The shaded triangles at either extremity of the outer incisions show
the removal of the skin at these points, to facilitate sliding of the
flaps, adding, however, to the extent of cicatricial contraction upon
final healing, with the resultant flattening of the new nose. The lobular
prominence takes an upward position eventually, and altogether the
extensive secondary wounds and the effect of their behavior does not
warrant the use of this method.
[Illustration: FIG. 341.—BÜROW METHOD.]
=Szymanowski Method.=—His method is an improvement on that of Bürow.
The flaps, inclusive of considerable cellular tissue, are fashioned in
Fig. 342, except under the two narrow extension flaps, which are to be
utilized in building up the subseptum. Their raw surfaces are sutured
together with silk. The flaps are united along the median line.
If the tissue from the cheeks do not permit of free sliding forward of
the flaps, further incisions shown by the dotted lines over each malar
prominence are made. The skin of the shaded irregular areas on either
side is removed, as in the Bürow method.
[Illustration: FIG. 342.—SZYMANOWSKI METHOD.]
=Serre Method.=—The flaps are made to either side of the remains of the
old nose, each leaving its pedicle about one fourth inch below the inner
canthus of the eye. The flaps were cut rather obliquely, their bases
extending somewhat below the nasal orifices. The remaining skin of the
latter was dissected downward and folded down upon the median third of
the lip. If cut in two sections their inner borders were sutured so
that their raw surfaces faced each other. The object of the latter step
was to form the subseptum, according to Lisfranc. The sections of skin
lying with their bases on a level with the nasal orifices were dissected
downward and united in the median line to assist in forming the end of
the nose. All along the borders of the old nose were also dissected up
where possible and folded inward, so that their raw surfaces would adhere
to the new dorsum of the nose, and thus give it stability and form. These
pieces of skin were united at the median line when possible.
The cheek flaps with indented bases were now brought forward and united,
as shown in Fig. 343. The skin of the cheeks was dissected up to the
extent of the dotted line in the former illustration, and when necessary
two lower curved incisions were made to permit of free sliding. The skin
of the cheeks was retained by three sutures at either side, as shown in
Fig. 344. The subseptum may be made at the same sitting, or at a later
operation.
[Illustration: FIG. 343. FIG. 344.
SERRE METHOD.]
=Syme Method.=—The procedure is very like that of Heuter, except that the
somewhat curved line making the inner borders of the flaps extended over
the root of the old nose. The lower ends or bases of the two cheek flaps
were stitched around and to the orifice to form the end of the nose,
rubber tubes being used to form the nostrils, where they were retained
until healing was complete.
=Blasius Method.=—He forms the cheek flaps in triangular form, including
all of the tissue making up the buccal cavity. The outer or cheek
incision is made through all of the tissue and extends to a point
corresponding to a point a given distance beyond the angle of the mouth.
The inner incision is made from a point just below the angle of the ala
downward and through the thickness of the lip. A third incision unites
the angle of the mouth with the outer incision. Both cheek flaps are
made alike, each remaining attached along all of the remains of the old
nose. They are now raised upward and inward, with their mucosa facing
outward, and united along the median line. The raw cheek borders are
now brought forward and held in place by suturing them at either side
to the remaining rectangular flap of the upper lip. The formation of
the subseptum is left for a second sitting. This method is not only
too extensive, but too disfiguring to make its employment practicable.
The mucous membrane would, of course, in time take on the function and
appearance of skin, but the shape of the mouth never assumes a normal
form, especially since there is quite a loss of the vermilion border at
either side which is raised upward with the cheek flaps to assist in
forming the base of the nose.
=Maisonneuve Method.=—Where there is more or less occlusion of the nares
and yet an integumentary covering corresponding to the nose, as it might
rarely be in congenital cases, Maisonneuve utilizes the sliding flap
method to overcome the abnormality. In the case presented, the nasal
orifices were hardly three sixty-fourths of an inch in diameter and about
one inch apart. The correction was accomplished as follows, and shown in
Fig. 345: An incision was made transversely outward from each nostril,
then two converging incisions were made from both nares downward, meeting
at the vermilion border of the lip in the form of a V, which were made
to include the whole thickness of the lip. This flap was brought upward
to form the subseptum. The skin to form the nasal lobule was now slid
forward from either end of the incision and the subseptum sutured in
place. Rubber tubes were employed to keep the nares distended and permit
of the wings of the nose to form.
The defect in the upper lip was brought together as in a median harelip
operation, the parts appearing after operation as illustrated in Fig. 346.
[Illustration: FIG. 345. FIG. 346.
MAISONNEUVE METHOD.]
_The Italian Method_
In this classification of total rhinoplasty the skin flap is taken from
another part of the body and not from the face. The integument of the
arm is usually employed, the pedicle remaining intact until the flap has
healed into place.
The method has been accredited to the Italian author-surgeon Tagliacozzi,
but it was practiced long before his time; yet he was the first to fully
describe the steps of the successful operation. It has been referred to
quite fully under skin grafting.
The flap having an attached pedicle is cut from the entire thickness
of the skin of the arm. The free end of the flap is sutured to the
freshened borders of the old nose, and the arm is held in place until
union has been established, when the pedicle is cut. There are no
special advantages in this method, since the outcome is no better than
that obtained with the Indian method; at best the result is merely the
curtain of skin covering the defect, with the one thing in its favor—the
avoidance of the frontal scar. Against this is the great discomfort the
patient must suffer in having his arm retained in the necessary position
to prevent movement and strain on the flap, to which may be added the
danger of embolism occasioned by freeing the arm at the time the pedicle
is cut. There is also difficulty of properly dressing the wounds,
owing to the constrained position which consequently invite sepsis and
imperfect healing. Hence, for total rhinoplasty, this method may be
termed unsatisfactory; yet for certain partial rhinoplastic results it
supersedes all other methods, as will be hereinafter shown.
To make the flap a pattern is laid upon the skin, from which it is to be
made; it should be one third larger than the actual size of flap needed,
to allow for contraction. The incisions should go through the entire
thickness of the skin, leaving an attachment or pedicle, what in this
case would be the part of the flap intended for the base of the nose, and
directly opposite to those described heretofore.
The flap may be sutured in place immediately after the cutting, or it
may be allowed to remain upon the arm until contraction has taken place
in the flap, or the flap may first be modeled into nose shape and then
sutured upon the freshened margins of the old nose.
The arm must in any of these methods be held in place during the days
required to have the flap heal or unite with the facial tissue. The
various operators have devised means to accomplish this. There is the
linen network of bandages of Tagliacozzi, the harness of Berger, the
starched linen and book-board affair of Sedillot, the one-piece suit of
Lalenzowski, the leather sleeve and helmet of Graefe and Delpech and many
others.
Having determined upon the method to be followed in securing the flap,
the surgeon is advised to consider such apparatus as he may be able to
procure to retain the parts, or to use his own ingenuity to construct one
of plaster-of-Paris bandages to meet the requirements of the case at not
only less expense, but with greater comfort to the patient. At best, any
apparatus employed will do little to overcome the agony of the retained
member, which must be held in position.
Various operators give this period between six and twenty days. The
apparatus should be so constructed that dressings can be easily made
without discomfort to the patient, and without doing damage to the parts,
and also to expose the face of the patient as much as possible. The
various operations employed to perform total rhinoplasty by the Italian
method may now be considered.
=Tagliacozzi Method.=—This surgeon resorted to four steps to accomplish
his operations, which were:
I. Massage of or stretching the skin of the part from which the flap is
to be made.
II. Cutting the flap, and allowing the same to cicatrize.
III. Freshening the flap and suturing in place, and use of apparatus.
IV. Cutting the pedicle and making the subseptum.
The various details of these steps should be considered here, since the
methods are practically the same for all other operations of this kind,
except in certain particulars as to time and mode of procedure.
I. Massaging the tissue of the arm to render it supple. This is of some
consequence, in some cases, where the skin is tense, but requires no
especial description.
II. He then compressed a fold of the skin with a large forceps at the
lower half of the biceps. Upon opening these forceps he forced a bistoury
under the skin fold and cut down toward the elbow-joint a distance
sufficient to form a flap. This gave him a piece of raised skin, attached
at either end, double the size of that required to make the nose. Under
this he introduced linen mesh dressings in the form of a seton, with the
object of irritating the skin to encourage the circulation, and render it
thicker by consequent suppurations and granulations. This was continued
for fifteen days, when the skin was detached at its upper end, leaving
it attached by the lower or wider pedicle intended for the base of the
nose. The flap was now turned down and both flap and wound were allowed
to cicatrize.
III. When the flap had become dry he fitted the linen bandage apparatus
to retain the arm. Then the borders of the old nose were freshened.
Thereafter he cut a paper pattern as a model for the new nose, upon which
the margins and shape of the flap were cut. The flap was finally sutured
in place, and the apparatus was tightened to prevent movement of the
parts.
IV. After twenty days he cut the pedicle. The latter was then cut into,
to divide it in three parts, which he formed into the subseptum and nasal
wings, which were sutured in place, metal tubes being employed to keep
the nares open.
=Dieffenbach Method.=—This surgeon followed seven steps to complete the
operation, as follows:
I. The pattern of the new nose, cut one third larger, is fixed upon the
skin of the arm, with the basic pedicle just above the fold of the elbow.
Skin is now raised sufficiently to permit of its being incised, the
incisions being made laterally, as shown in the dark lines in Fig. 347.
This gives a triangular flap, the apex lying upon the biceps and having
two adherent pedicles at apex and base.
The base is now incised at one angle, transversely and again vertically,
as shown. This incision liberates the part of the flap intended for one
of the ala of the nose.
II. Diachylon plasters are placed under the flap to contract the arm
wound immediately the bleeding has been arrested. The free angle of the
base of the flap is now turned inward and under the attached part of
the flap, as in Fig. 348, so that its margin protrudes from the other
lateral incision, and its skin surface lying above the plaster. The edges
of the flap are now stitched together, and the flap is allowed to lie
cushionlike upon itself while the arm wound heals. This requires about
six weeks.
[Illustration: FIG. 347. FIG. 348. FIG. 349.
DIEFFENBACH ARM-FLAP METHOD.]
III. The holding of the flap cushion in place by the use of splints of
leather held in place by three needles. The latter are moved about, as
the shape of the cushion becomes modeled, about every three weeks. The
process ends when cicatrization of the flap or the newly formed nose has
been accomplished, shown by firmness and contour.
IV. The margins of the old nose are freshened; the lateral incisions
extend to the root of the nose, where they are united with an upward
convex incision. The skin is well raised, gutterlike, from the deeper
tissue, to assure of the best vascularity.
V. The upper or apex pedicle of the flap on the arm is cut (see Fig.
349), and the thickened roll of skin, or what may now be termed the new
nose, is turned down toward the elbow. It is divided along the line where
the two margins of skin had been sutured; in other words, it is laid open
longitudinally.
VI. The nose thus prepared is brought into place before the freshened
margins of the old nose and is sutured into place beginning at the root
before the sides are coapted.
VII. At the end of fifteen days the pedicle attaching the nose to the
arm is severed, the angle for the wing being cut slightly larger than
that of the other side, which by this time has, of course, undergone full
contraction. The subseptum is made out of the square projection folded
upon itself, raw surfaces facing, and is brought into place by suturing
it into an incision made in the lip at the required point.
=Graefe Method.=—This surgeon devotes six steps to his operation, as
follows:
I. The borders of the old nose are freshened.
II. Sutures are passed through the raised skin of the borders of the old
nose.
III. The flap is cut from the arm after a pattern made one fourth larger
than the new nose required, leaving it attached by the small pedicle
intended for the subseptum.
IV. The sutures where required are now passed through the flap, having
already been placed through the old nasal borders and left untied. The
forearm is drawn against the forehead and the arm is fixed in place with
the retention apparatus. The sutures are now tied. They are allowed to
remain in about four or five days, not long enough to irritate.
V. About the tenth day the head apparatus is removed and the pedicle of
the arm flap is divided. The arm may now be carefully lowered to its
normal position.
VI. The subseptum is not formed from the free end of the attached flap
for several weeks. It is then divided by two parallel incisions directed
outward. The septal section is folded upon itself, and inserted and
sutured in place into an incision made into the upper lip.
=Szymanowski Method.=—This author advises making the base of the flap
sufficiently wide, and of the form shown in Fig. 350, to permit of
the three sections of skin of this part of the flap to be folded upon
themselves before being sutured in place at the base of the nose, so as
to form lined nares and a thickened and supportative subseptum.
[Illustration: FIG. 350.—SZYMANOWSKI METHOD.]
=Fabrizi Method.=—This author utilized the immediate method of flap
fixation, but makes his flap of triangular form from the inner and upper
skin of the forearm.
The transverse base is made to lie one half inch below the radio-ulnar
space. The flap should be about three inches long and of about the same
width. It is cut while the forearm is relaxed; bleeding is controlled by
gentle pressure. In the meantime the cicatricial tissue of the old nose
margins has been removed and the skin freshened to receive the flap.
To approximate the parts, the hand is laid palm down upon the shoulder;
the resultant position of the arm and forearm are retained by bandages.
The parts are now sutured. On the thirteenth day the line of division is
traced out upon the arm with nitrate of silver, at the same time giving
the flap somewhat the form required to give the nose its contour.
The next day the pedicle is cut and the arm is brought back into its
normal position. With the division of the pedicle he advises including
a portion of the aponeurosis and a few fibers of the supinator longus
muscle.
The flap is allowed to remain free at its base until contraction and
cicatrization have been established, when the subseptum and wings are
made.
The position of the arm and the attached flap at the root of the nose is
shown in Fig. 351.
He advises, when possible, to dissect up a flap of the cartilage of the
old septum, letting it adhere at its lower border and turning it from
below upward with the skin which covers it to form the subseptum. This
will help to hold up the point of the nose firmly (an important matter
because it is at this point that all noses constructed of skin flaps
alone sink down for the want of suitable prop of tissue).
This cartilaginous flap he held in place with two pins thrust through the
latter and the skin flap proper, and held them in place with a figure
twist of silk. He removed the needles about the sixth day.
[Illustration: FIG. 351.—FABRIZI METHOD.]
=Steinthal Method.=—This authority made the flap for the nose from the
skin over the sternum, proceeding as follows:
“From the sternum I cut a flap of skin and periosteum in the form of a
tongue whose lower base was five centimeters wide, and the summit forming
the pedicle three centimeters wide; its length was twelve centimeters.
“I could have taken away with this flap some of the costal cartilage to
utilize in making the wings of the new nose.
“I dissected up this flap and closed the wound over the sternum with
sutures. The flap was then stitched to the forearm by its base into an
incision of appropriate length made near the radius. (See Fig. 352.) The
arm was properly fastened in a plaster apparatus and the flap enveloped
in a dressing of borated vaselin. The forearm was held in front of the
breast, an attitude easily retained. Twelve days later I cut the pedicle.
“I let a few days pass by, and then stitched the pedicle end of the flap
to the root of the nose. A new plaster apparatus was put in a suitable
position. The hand was placed on the forehead.
“Ten days after, I detached the flap from the arm and reformed the nose
with the flap, which hung down like an apron. It is necessary to have
a flap sufficiently long to fold in for the nostrils. I used bronze
aluminum wires for all the sutures.”
The position of the hand while the flap was healing to the root of the
old nose and the slight twist of the flap is shown in Fig. 353.
[Illustration: FIG. 352. FIG. 353.
STEINTHAL METHOD.]
THE COMBINED FLAP METHOD
To overcome the consequent cicatricial contraction and falling in of
the flap used to make the new nose by either of the three grand methods
given, various surgeons have resorted to lining the flap with skin flaps,
bringing their raw surfaces together so that the nose actually received
in this way an integumentary lining.
While this had the tendency to thicken the new nose, it did not give the
support necessary to it, especially at the lower third, and the lobule,
at first quite satisfactory, resulted only in the appearance and form of
a small tubercule of tissue, with a decided saddle effect above it. This
combined method did overcome, however, the slow process of cicatrization,
and its accompanying suppuration.
The raw surfaces of the two flaps, if properly brought together, healed
upon themselves readily, as has been referred to in the lining or
doubling in of the basal sections to form the nostrils and subseptum.
The method of lining the nasal flap in this manner is never sufficient
to give a satisfactory result in total rhinoplastic cases, but may be of
great service in restoring parts of the nose, as will be shown later.
The requirement is that of support, whether it be organic or inorganic,
and these methods will be considered presently.
=Volkmann Method.=—This surgeon fashioned the frontal flap as shown in
Fig. 354. This resulted in leaving a triangle of skin at the root of the
nose, which he dissected up, down, to and inclusive of the periosteum,
and turned downward so that its raw surface faced upward, as in Fig. 355.
The flap was sutured into place to retain it.
The frontal flap was brought down, so that the two raw surfaces came
together.
This method overcame the contraction of the flap over the nasal bridge or
superior third of the new nose, and an excellent adhesion of that part of
the flap to the denuded bone and flap resulted, but the same faults about
the base were not mitigated.
[Illustration: FIG. 354. FIG. 355.
VOLKMANN METHOD.]
=Keegan Method.=—The frontal flap method of Keegan has been referred to.
For the lining of the upper nose he cuts two flaps from the skin above
the old nasal orifice, as shown in Fig. 356, which he turns down, raw
surfaces out. This gave a lining to either side of the median line; the
skin remaining intact between the two flaps gave additional prominence
and support to the upper third of the new nose.
[Illustration: FIG. 356.—KEEGAN METHOD.]
=Verneuil Method.=—Contrariwise to the methods just given, Verneuil,
after cutting out the frontal flap, cuts the flap from the remaining
sides of the old nose somewhat involving the skin of the cheeks, as in
Fig. 357. This done, the frontal flap is simply turned down, raw surface
out, and the cheek flaps are slid over it, bringing the raw surfaces
together. The inner borders of the flaps were sutured in the median line,
as shown in Fig. 358. The base of the nose is made from the frontal flap
by any of the methods already given.
[Illustration: FIG. 357. FIG. 358.
VERNEUIL METHOD.]
=Thiersch Method.=—The frontal flap is cut from the skin of the forehead
in the shape shown in Fig. 359. Then two quadrilateral flaps are raised
from the cheeks, as also illustrated. These are made wide enough that,
when they were brought together, their inner borders could be made to
face each other. In this position they were sutured along the median
line, so as to give a double-gun-barrel form to the nose, with a septal
wall between.
From the lower border the nostrils were formed, giving to the new nose
a normal appearance, the continuous septum curving downward to form the
subseptum, the whole being sutured to the remains of the old nose.
The frontal flap was now brought down over it, the raw surfaces facing
each other, and sutured in place, as shown in Fig. 360. Later, Thiersch
replanted the sides of the nose, to give it better contour, and attained
a very satisfactory result. The frontal wound was covered with skin
grafts, but the cheek wounds were allowed to heal by granulation. The
cicatrization of the latter was not sufficient to effect the lower
eyelids nor the angles of the mouth.
[Illustration: FIG. 359. FIG. 360.
THIERSCH METHOD.]
=Helferich Method.=—His is an ingenious application of the French method.
Both flaps are cut from the cheeks; the lining flap was made from the
left and the covering one from the right cheek. The shape of the flaps is
shown in Fig. 361.
The lining flap is stitched along the freshened margin of the right side
of the nose. The flap should be wide enough to give convexity to the
nose, as shown in Fig. 362.
The covering or right flap, cut much larger, is now slid over this. It
should be cut amply large to cover the flap just sutured in place. It
is sutured on both sides of the nose to hold it in place, also at the
inferior margin. The nose is lightly packed with iodoform gauze.
The pedicle of the right flap was cut after two and a half weeks and
brought into place across the root of the nose, and sutured in place to
give better contour to the part after freshening the skin about the left
side of the nose at this point. He does not make a subseptum, but thinks
the inferior base of the nose of sufficient size to hide the absence
thereof.
The subseptum could, however, be readily made from the upper lip, as will
be shown later.
[Illustration: FIG. 361. FIG. 362.
HELFERICH METHOD.]
=Sedillot Method.=—This operation is particularly efficacious in giving
a splendid subseptum and support of the point of the nose, but does not
overcome the falling-in of the whole anterior line, so common with all
Indian-flap methods. A flap one centimeter wide and extending downward
almost to the vermilion border is cut from the thickness of the upper
lip, not including the mucous membrane, however. It is turned upward, as
shown in Fig. 363.
The frontal flap is fashioned as shown, care being taken to cut a
subseptal rectangle of greater length than usual, since it is intended
to overlie the raw surface of the flap taken from the lip. It is rotated
downward and sutured into place at both sides, and also to the lip flap,
to assure of accurate union.
A lateral view of the nose as formed in this manner is shown in Fig. 364.
The free end of the septal flap is fixed into the superior lobial wound
with a harelip pin. The lobial wound is sutured as in ordinary harelip
operations. This method is particularly valuable in total rhinoplasties
involving the columna and alæ in conjunction with flaps obtained by the
Italian method.
[Illustration: FIG. 363.—Anterior view. FIG. 364.—Side view.
SEDILLOT METHOD.]
=Küster-Israel Method.=—A flap was taken from the arm by the Italian
method, which was sutured to the remains of the old nose so that its raw
surface looked upward, not downward, as in the ordinary case.
The flap was made sufficiently large to permit of building the wings and
subseptum. After it had healed into place the pedicle was cut, and a
frontal flap was cut from the forehead to cover it.
An unusually large flap was required to do this, since it had to overcome
the greater curvature already given and added to by the arm flap,
necessitating an extensive secondary wound.
The reverse order of procedure would be the more advisable for this
reason, and is resorted to by the following:
=Berger Method.=—This surgeon makes the lining flap from the forehead.
The secondary wound is at once closed. A flap is then made from the arm
by the Italian method, and brought into place before the one just made.
It should be of sufficient size to allow of building the base of the
nose, which is done not later than three weeks after the pedicle of the
arm flap is severed, which may be done at any time between the eighth and
the twelfth day.
All the precautions are used as already given in the description of the
Italian method. The arm is held in the position shown in Fig. 365.
Berger sutures the arm wound before bringing the flap into place upon the
face to overcome the discomfort of suppuration to the patient.
The apparatus is fixed definitely after the patient has recovered from
the anesthetic. Great care is exercised to prevent coryza from exposure.
Dressings are made twice daily.
The pedicle is cut under local cocain anesthesia.
To make the subseptum and wings of the nose, the base of the flap is cut
into three sections. The posterior surface is freshened and the parts are
folded upon themselves and sutured into position.
Instead of employing rubber tubes, he resorts to a specially devised
apparatus to retain two metal tubes in the nares, and at the same time
make gentle pressure to the sides of the nose to mitigate the columna
contraction. The latter is planted into a V-shaped incision made into the
tissue of the upper lip at the proper place of attachment. The subseptum
may be lined with a flap of mucosa dissected up from the floor of the
inner nose.
For the wings of the nose, such tissue as may be of service to give them
stability and structure is taken from the remains of the old nose.
[Illustration: FIG. 365.—BERGER METHOD.]
The apparatus just mentioned and shown in Fig. 366 is used from the
very first day until total cicatrization has taken place, and even for
a longer period to aid in shaping the entire nose and the tendency to
collapse has been overcome.
[Illustration: FIG. 366.—BERGER RETENTION APPARATUS.]
=Szymanowski Method.=—A frontal flap, divided along the median line and
shaped as outlined in Fig. 367, is made from the forehead.
Two triangular flaps are then raised from either side, and including the
angle of the nose as shown. The divided frontal flap is now brought down
in such manner that their raw surfaces meet, thus forming a vertical
septum. The margins are united by suture, and the lower ends are fixed
into a wound made for the purpose at the base of the nose, as shown in
Fig. 368, to form the new subseptum.
The lateral triangular flaps are dissected up so that they can be readily
slid forward toward the median line. Their inner freshened margins are
sutured to the raw edge of the septum just made, and to themselves. The
objection here is that there is a liability of considerable contraction
of these lateral flaps, with a tendency to fall in and drag with them
the new septum; and again, in total restorations, the upper third of the
nose is only partially covered, and necessitates later upbuilding. The
author finds difficulty in making the four margins thus brought together
unite evenly throughout, and that a vertical contraction is caused by the
cicatrization of the median marginal wound.
[Illustration: FIG. 367.—First Step.
FIG. 368.—Disposition of frontal flaps.
SZYMANOWSKI METHOD.]
=Goris Method.=—The operation is performed as follows, having given very
good results, according to the author:
I. The frontal flap is divided lengthwise so that its raw surfaces face
each other. The resulting fold, representing the bridge of the nose, is
held in place by catgut suture.
II. The skin to make the wings of the nose is folded in, as in the
Langenbeck method.
III. A flap, half the thickness of the upper lip is brought up to form
the new subseptum.
IV. Dissection and turning down the triangular flap of skin which
surmounts the orifices of the old nose, and making it serve to line the
lower part of the frontal flap.
V. Suturing the frontal flap thus modeled into two grooves made into the
margins of the old nose along both sides to its base.
ORGANIC SUPPORT OF NASAL FLAPS
It soon became evident to the rhinoplastic surgeon that without some
support to the flap or flaps used for the construction of the new nose
all of the preceding methods, as far as æsthetic results were concerned,
were useless. Truly, the deformity lost its hideous appearance to a great
extent, but the general results obtained hardly warranted a patient
to undergo restorative operations of the nose. In fact, many surgeons
advised against total rhinoplasty when practically all of the old nose
was lost.
Langenbeck says “that total rhinoplasty, or even operation as to repair
partial loss of the nose by the use of soft flaps, should not be
undertaken. It is better to rely upon some prothesis.”
All that could be expected of utilizing the flap and making it heal into
place had been accomplished up to about the year 1879. Thereafter many
surgeons proceeded to evolve and use some kind of intranasal prothesis
made of various inorganic materials. It may be stated, however, that
Rousset in 1828 wrote: “Perhaps some day surgeons will give whatever
shape they desire to the reconstructed nose. Then a frame of gold or
silver, cleverly shaped and solidly fixed in the nose, will give the
patient, at his own option, a Roman or Carthaginian nose, and to the
ladies a choice of a roguish type, and to our Sultans a nose a la
Roxelane.”
But it was after 1878 that such prothesis came into use, and these were
at first made so that they might be removed at night and be replaced in
the morning.
The intranasal supports were made of all kinds of material, such as gutta
percha, gold plates, leaden devices, amber, silver, porcelain, celluloid,
aluminum, platinum, etc.
With all due respect to the ingenuity of these inventions, especially
that of Martin, which was made of platinum in the form of a St. Andrew’s
cross, having at the four ends sharp pins which were driven and fixed
into the skeleton of the nose, the use of these protheses resulted in
nothing but failure.
The movable devices were a source of irritation and pressure, and could
not overcome the consequent contraction of the flaps whether placed below
a single flap or between two flaps, and the fixed protheses of whatever
form or material caused so much pressure that gangrene resulted, and they
had to be removed sooner or later.
Before the discovery of Gersuny, the author had many occasions to utilize
such movable protheses in the correction of saddle noses. These were
generally made of a silver shell, gutta percha, and later of decalcified
bone, as advised by Senn. The former remained in place from six months
to two and a half years, and then were thrown off or had to be removed
because of irritation. The bone chips soon became absorbed, leaving the
nose as before, or a thin median strip that became broken with the least
violence, and then was absorbed.
In several cases where other surgeons had resorted to such protheses, the
author was called upon at a later period to remove them.
While the immediate result is very gratifying, the ultimate result is
worse than useless, since in the elimination of the foreign body the flap
of the nose was married by cicatrices that added still further to the
contraction and falling-in of the nose.
PERIOSTITIC SUPPORTS
Some other method had to be devised, and organic supports became known.
These organic protheses were made of the tissue in the near vicinity of
the flap, and at first formed a part thereof. The earlier method included
only the periosteum; later bone and periosteum were added to the flap
to give it shape and support, and lastly cartilage was employed for the
purpose.
Of the methods employing only the periosteum, it may be said that what
the surgeon expected of this membrane—namely, the springing up of bone
cells—did not take place; at least, not to the extent desired. The very
best to be attained was a thickening of flap in the membrane, but not
sufficient to add necessary support to the nose.
OSTEOPERIOSTITIC SUPPORTS
The inclusion of the periosteum-lined flap was soon abandoned, and
recourse was had to such bone additions to the flaps as could be obtained
from the vicinity of the nose.