COSMETIC RHINOPLASTY
The operations herein considered have to do with overcoming deformities,
congenital or acquired, as a result of traumatism, and in which there is
no loss of tissue, the sole object being to give to the nasal organ a
more desirable size and contour.
There are many types of abnormalities involving both the size and shape
of the nose. Some of these deformities may be readily corrected by
subcutaneous or submucous operations, while others involve more or less
cutting of the skin.
The object of the surgeon at all times is to accomplish the best results
with as little disfigurement as possible.
=Anesthesia.=—All the cosmetic operations of the nose should be done
under local anesthesia, unless there be serious objections to its
employment.
The author advocates the use of a four-per-cent solution of β Eucain,
in preference to all others. It is less toxic than cocain and harmless
to the patient; no untoward symptoms are exhibited from its use
post-operatio. Various patients complain of slight uneasiness about the
epigastrium, and many speak of a peculiar weakness about the knees, but
these symptoms pass away quickly.
More or less stinging is felt in the wounds made in this manner,
immediately after the operations, especially about the lobule of the
nose, as with blepharoplasties, but this usually subsides in less than an
hour. It may persist, however, in some cases, for several hours. It is
well, therefore, to acquaint the patient with this fact to avoid worry or
fear.
Where severe, hot applications, dry or moist, may be used to overcome it.
More or less edema follows the employment of local anesthetics, which
passes away in various lengths of time, from one to four, or even five
days, according to the amount used and the site and circulation of the
part operated upon.
In over ten thousand hypodermic injections of eucain the author has
observed only two cases of collapse, which responded readily to the
usual treatment employed in such event, and has never met with a single
fatality.
=Sutures.=—Twisted silk sutures are to be preferred, as they do not
invite sepsis, as softening catgut does, and retain the parts during the
entire time required for healing, while the latter is liable to become
separated by uneven absorption, allowing the wound to gape at that point
and causing more or less of a cicatrix, so intolerant to patients of this
class.
=Dressings.=—Bulky bandages are not required; they heat the parts, and
look unsightly. The author employs antiseptic adhesive silk plaster for
covering all external wounds, except where the hair prevents its use.
Moist dressings are never indicated, except in the later treatment of
infected wounds.
ANGULAR NASAL DEFORMITY
This is, perhaps, the most common of all nose deformities. The nose is
overprominent about the osseous bridge, extending outward and downward,
hook or hump fashion. It may be congenital or the result of external
violence.
There are various methods of reducing the redundant bones and cartilage;
those involving submucous excision are difficult to perform for the
inexperienced operators, and the external means of reduction are advised
to be followed. The resultant scar, if the skin has been properly incised
and not damaged by retracting pressure, and, lastly, properly and neatly
sutured, should be barely visible.
=Monk’s Method.=—This author made a small incision through the skin just
posterior to the inferior edge of the lobule, as in Fig. 469_a_. Then
with a dull instrument, introduced through the opening, he detached the
connecting tissue that binds the skin along the anterior dorsum as far as
the root of the nose, giving more or less width to this freed area about
the nasal bones.
A dull-pointed scissors is introduced through the sublobular opening, and
the bones and cartilage are reduced until the desired nasal line has been
attained.
The method of procedure is shown in Fig. 469_b_.
[Illustration: FIG. 469_a._ FIG. 469_b._
MONK’S METHOD.]
The wound is cleansed of all spiculæ of bone or bits of cartilage and the
skin opening is closed by suture. Healing takes place with more or less
ecchymosis in about six days.
The difficulty the author finds with this method is that it is
practically impossible to do good work with the scissors in this position.
The use of an electric drill has been advocated to do away with the
scissors, but it is a dangerous instrument and requires great skill for
its manipulation and reduces the bone particles to such fine fragments
that much of it is left in the wound, which may induce sepsis or cause
unevenness of the skin surface until later absorbed or removed. The same
fault is observed with cartilage, which it grinds into pulpy pieces and
for which it should never be used.
=Anterior Median Incision.=—This, perhaps the oldest method, has been
extensively employed. The incision is made down the median line of the
dorsum of the nose, beginning above the deformity, and ending slightly
below the inferior bone line, as shown in Fig. 470. The skin is incised
obliquely.
An assistant separates the wounds with hook tenaculi, exposing the
osseous bridge, as in Fig. 471.
[Illustration: FIG. 470. FIG. 471. FIG. 472.
MEDIAN NASAL INCISION.]
The author advocates dividing the periosteum and dissecting it well
back to either side of the bony elevation. By bringing it back over the
denuded surface after the chiseling has been done, it aids materially in
establishing a smooth surface and hastens the bone repair.
The periosteum being held aside, the straight chisel and mallet are
used to reduce the bone. The operator may proceed to do this from above
down or _vice versa_, according to the formation and position of the
protuberance.
The redundant cartilage is removed with the knife from above downward,
cutting from side to side.
Usually the operator does not remove enough of the cartilage and a new
angulation of the nose appears after the swelling has disappeared,
necessitating a second operation.
The wound is closed as shown in Fig. 472.
=Lateral Incision.=—The incision in this case is made slightly posterior
to the beginning of the lateral border, as shown in Fig. 473.
The skin is held back, as shown in Fig. 474, and the same mode of
procedure is followed as that just given.
[Illustration: FIG. 473. FIG. 474.
LATERAL NASAL INCISION (Author’s method).]
The operator will have some difficulty to reach the opposite anterior
border of bone elevation, especially if the incision has not been made
long enough. This should be done. At no time should the assistant employ
too much force in retracting the anterior flap to better expose the field
of operation; it is certain to cause gangrene of the skin.
To overcome a long scar line, and to facilitate the cutting away of the
bone, the author had a special set of chisels made with curved cutting
blades, one angular and the other straight-edged. There are two each for
working from the right and left sides. The striking point lies midway
between the blade and the end of the handle.
They are shown in Figs. 475 and 476.
[Illustration: FIG. 475. FIG. 476.
AUTHOR’S CHISEL SET.]
To the set the author has added a suitable metal mallet, an instrument
very hard to obtain for osteoplastic operating. All the mallets
obtainable are too large and heavy for delicate work (see Fig. 477).
[Illustration: FIG. 477.—AUTHOR’S METAL MALLET.]
After the bone is reduced to the proper level, the cartilage is cut away
as before described, and the wound is sutured.
The resultant scar is much better than when made in the median line, and
is not so noticeable in this position.
This operation gives the best results of all external methods employed
for this purpose.
CORRECTION OF ELEVATED LOBULE
(Retroussé Nose)
This condition is frequently a deformity. The base of the nose is tilted
upward, unduly exposing the nares.
The author prefers to bring the lobule down by excision of the anterior
third of the subseptum in preference to submucous dissection of the
cartilaginous tissue, causing the deformity.
[Illustration: FIG. 478. FIG. 479.
AUTHOR’S METHOD.]
With an angular scissors introduced through the nares, a triangular
section of the septum is removed, as shown in Fig. 478. The apex of the
triangle should be placed well up into the septum to break the elasticity
of its structure, the base of the triangle being sufficiently wide to
somewhat overcorrect the deformity.
Such noses are usually narrow at the lobule, and no interference with the
lower lateral cartilages is called for.
The septal mucoid and the subseptal skin wounds are brought together by
suture, as shown in Fig. 479, leaving only a slight transverse linear
scar on the subseptum.
CORRECTION OF BULBOUS LOBULE
Roe corrects this deformity by making an incision, either vertically
or horizontally, in the mucosa in one or both nares, through which he
introduces the blades of a fine curved scissors, with which sufficient
redundant tissue is removed to bring the lobule down into the desired
contour.
The mucosa should be sutured to facilitate rapid cicatrization. The
operation should be overdone to get the desired result.
Not infrequently the extreme convexity of the lower lateral cartilage
must be overcome by either removal submucously or by excision of the
cartilage itself, employing an elliptical incision in the mucosa for the
purpose.
The alæ are kept in position after such ablation by compress dressings
or by a suture made transversely through both wings of the nose and the
septum, and tied over a quill or cork support placed externally upon the
skin at either side of the nose. This is removed about the sixth day.
Sheet lead or a splint of aluminum of proper thickness and covered with
gauze may also be used to retain the parts during cicatrization.
ANGULAR EXCISION TO CORRECT LOBULE
When the lobule is unduly broad at its base and is more or less concave
above the rim of the alæ, it can be reduced by removing a diamond-shaped
piece of tissue at either side of the subseptum.
The bases of the two triangles making up the diamond at its widest area
meet at the anterior rim of the nostrils, extending with their apices
upward and backward, as shown in Fig. 480.
If there be a prominence of the cartilaginous structure of the lobule,
this may be removed subcutaneously after the two ablations have been made.
[Illustration: FIG. 480. FIG. 481.
AUTHOR’S METHOD.]
Before suturing the wounds, it is advisable to free the skin of the
inferior lobule to overcome tension.
The sutures are applied as in Fig. 481. None are used to unite the mucosa
unless the interior wounds are large enough to permit of their use.
CORRECTION OF MALFORMATIONS ABOUT THE NASAL LOBULE
The operations herein described apply particularly to the correction or
reduction of an overprominent nasal tip due to an excessive growth of
congenital malformation of that part of the nose, giving the organ undue
prominence and a hooklike appearance, usually associated with a narrow,
sharply upward inclined upper lip.
=Pozzi Method.=—The same operation, on a larger scale, can be readily
employed for the correction of hyperplasia nasi and rhinophyma.
In the operation of Pozzi (_Bulletin et mémoire de Société de chirurgie_,
1897, p. 729) an elliptical section of skin and cartilage are removed
from the lobule with its widest part corresponding to the point of
the nose; the cicatrices occasioned thereby are practically as bad,
if not worse, than the unscarred overprominent nose, while the
submucous procedure of Roe (_Medical Record_, July 18, 1891) is not only
insufficient in these cases, but, according to my experience, practically
useless.
=Roe Method.=—Roe’s method requires a submucous extirpation of the
redundant cartilage at the tip through a necessarily small opening within
the nasal orifice, also the division in several places of the anterior
fold of the lower lateral cartilage with the object of reducing the undue
convexity of the alæ. The latter is, we might say, impossible, since
the cartilages will be reduced by such a method, even under pressure
dressings, which are likely to cause gangrene of the skin of the wings;
or if this be avoided, the cicatrix resulting from such division usually
restores the very fault that it is expected to overcome, while the mucous
lining of the alæ becomes thickened and more firmly tied down than
previous to the operation.
One is tempted to exsect the major curvature of the lower lateral
cartilage, but this leads to a flattening of the wings of the nose,
partial atresia of the nasal orifice, and a decided lack in its symmetry.
Secondly, in Roe’s operation there is always a lack of knowing how much
or how little to remove of the cartilage of the tip, a second cosmetic
operation being made necessary after the parts have contracted and
healed, a common fault with most cosmetic plastic operations performed
under local anesthesia, owing to the immediate edematous enlargement
following its hypodermic use.
=Operation as Commonly Practiced.=—The operation heretofore most
commonly practiced is one in which an elliptical piece of skin is cut
from the tip of the nose, followed by the extirpation of the anterior
prominences of the lateral cartilages, and amputation of the septal
cartilages. Unfortunately, the result, at first quite satisfactory to
the eye, culminates in the pulling apart of the cicatrix formed by
bringing the sides of the wound together along the median line with
a later depression of the tip in this median line, occasioned by the
outward traction of the lower lateral cartilages. Even a second or third
operation does not overcome this result entirely, and at best leaves an
ugly irregular gash in the median line of the tip and the columna.
In one of the cases here cited this same operation had been
unsuccessfully tried twice by another surgeon, with very unsatisfactory
and unsightly result. (Case II.)
The ideal operation for all of this type of cases from the view of the
surgeon is to leave as little disfigurement as possible, and the method
to be here considered, when properly followed, leaves no scar whatever,
except for a slight white line across the columna of the nose, where it
is out of view, and when contracted offers no objection on the part of
the hypercritical patient.
=Author’s Method.=—The method of the author is as follows: Given a nose,
typified by the illustration in Fig. 482, the skin above the site of the
operation is thoroughly cleansed with soap and hot water, then rinsed
with alcohol, ninety-five per cent, and vigorously scrubbed with gauze
sponges, dipped into hot bichlorid solution, 1 to 2,000, followed with
a thorough lavage with sterilized water. Both nostrils are now cleansed
with warm boric-acid solution by the aid of small tufts of absorbent
cotton wound over a dressing forceps. The patient is then instructed to
breathe through the mouth during the operation. A number of small round
gauze sponges dipped into sterilized water and squeezed dry are placed
within reach of the assistant. About one drachm of two-per-cent Beta
Eucain solution is now injected about the tip of the nose, the columna,
and the alæ, as far back as their posterior fold.
[Illustration: FIG. 482. FIG. 483.
AUTHOR’S METHOD.]
A thin bistoury is then thrust into the nose from right to left, entering
at the point _E_ (Fig. 483), and brought down parallel to the anterior
line of the nose, and emerging below the tip in a line with the anterior
border of the nasal orifices. This procedure leaves a strip (_A_) about
one quarter inch wide, laterally, rounded at its inferior extremity, and
attached superiorly to the nose. Next the round inferior tip (_B_) is
cut away obliquely, sloping inward toward the nose by the aid of a small
angular scissors. Each blade of the angular scissors is now placed into
each nostril, the tips of the blades inclined forward, and the columna
or subseptum is divided at _C_, also the septum along the line _D_ up to
a point a little above the first incision made externally at _E_. The
two arterioles of the columna are controlled by the use of mosquito-bill
forceps. The two projecting folds of the lower lateral cartilage in the
columna are next severed as deeply as possible to give mobility to the
stump, a step necessary to overcome the changed position, otherwise
resulting in a droop, which would have to be corrected at a later sitting.
The next step is to give the needed shape to both wings. This is
accomplished with a specially designed scissors, so curved on the flat
that its convexity facing upward corresponds to the normal curvature of
the orificial rim. A clean cut with these scissors, beginning at _G_ and
ending at the point _E_, is made, leaving the base of the nose, as shown
in Fig. 484. The anterior flap _A_ is now bent backward to meet the stump
of the columna at _C_. If it does not fall readily into place a little
more of the septal cartilage is removed along the line _D_ until this is
accomplished.
It may be necessary to shorten the flap _A_ in cases where a very
prominent hook is to be corrected.
[Illustration: FIG. 484. FIG. 485.
BASE OF NOSE AFTER EXCISIONS.]
The free end of the flap _A_ is now sutured with No. 4 sterilized twisted
silk to the stump of the columna at _B_. Two stitches usually suffice
(see Fig. 485). One or two sutures may also be taken across the angles
of union of the alæ and the flap _A_. The inferior raw surface of each
wing may be found to be too wide, owing to the presence of the thickened
cartilage at this point of the wing. The skin and the mucous membrane
are then carefully peeled away from the cartilage, and the latter cut
away as high as possible, or a gutterlike incision is made along its
edges as shown in _C_ (Fig. 485), excising the elongated elliptical piece
of tissue which includes the cartilage. The raw mucocutaneous edges of
the wings are now brought together with a No. 1 twisted silk continuous
suture, completing the operation.
An antiseptic powder is dusted over the parts operated on, and small
gauze dressings are applied with the aid of strips of silk isinglass
plaster. A small tampon of cotton, well dusted over with an antiseptic
powder, is placed into each nostril.
The dressings are changed the second day, when the resultant swelling
will have practically subsided. The sutures in the columna are removed
the fourth day preferably, and those of the wings about the sixth day.
Complete cicatrization follows in about ten days, when the patient can be
discharged.
The following cases are given to show the types of cases thus far
operated upon and to illustrate the results obtained:
[Illustration: FIG. 486. FIG. 487.
AUTHOR’S CASE.]
_Case I._—Mr. R., aged thirty-two; foreman mechanic. Had been operated
upon for angular nose, also at point of nose by Dr. S. Presented himself
for operation October 19, 1904, when cast was made (see Fig. 486).
Bromides given during recovery. Patient had been subject to fits of
depression on account of his nose for over a year. Wounds healed in ten
days, when second cast was made (Fig. 487). Complete recovery.
_Case II._—Miss B. P., aged twenty-two; actress. Patient presented
herself for operation March 22, 1905. A long, irregular depressed
cicatrix showing at point of nose, the result of an attempt to reduce tip
of nose by an elliptical extirpation of the lobule (Dr. N.). No cast was
made of the case at the time, so that a second cast showing the result
would be of no use. Recovery complete in twelve days. Patient returned to
her profession three weeks later much pleased with the result.
[Illustration: FIG. 488. FIG. 489.
AUTHOR’S CASE.]
_Case III._—Mr. L. L., aged twenty-eight; broker. Presented himself, at
the advice of Dr. T., for operation May 2, 1905. Cast of cast made and
shown in Fig. 488. Uneventful recovery in twelve days, when case Fig. 489
was made.
_Case IV._—Mr. M. B., aged twenty-eight; operatic baritone. Presented
himself for operation June 4, 1906. Photograph shown in Fig. 490.
Uneventful recovery in fifteen days, when photograph in Fig. 491 was
made; angular nose operated upon (at this time discharged; recovery
complete).
[Illustration: FIG. 490. FIG. 491.
AUTHOR’S CASE.]
_Case V._—Miss L. W., aged twenty-seven. Presented herself for operation
and cast (Fig. 492) made August 4, 1906. Uneventful recovery in ten days.
Cast of result made August 18, 1906 (see Fig. 493).
In each of these cases the patient was discharged highly satisfied and
well pleased with the result of the operation, although in Case V the
patient was requested to return in about one month for an operation
to reduce the width of the wings of the nose, which was not attempted
at the first sitting, but could have been with little difficulty by
beginning the primary incision at _E_, Fig. 483, higher up, and cutting
out a triangular section on either side of the flap _A_, the apex of
each triangle being at point _E_, and the base along the line _D_. The
wounds are sutured along the dorsum of the nose with No. 1 twisted silk,
after exsecting much of the lower lateral cartilages of the wings, as can
easily be reached in the triangular point formed by the raw dorsal border
and the inferior edge (_F_). The latter method, however, would be likely
to leave a slight cicatricial line on either side of the nose. This could
be much overcome by making the incision from point _E_ to _B_ obliquely
to the plane of the skin, likewise the posterior sides of the triangles
mentioned, just as the incisions at _B_, and across the columna at _C_,
are made. Recovery should be complete in five days.
[Illustration: FIG. 492. FIG. 493.
AUTHOR’S CASE.]
DEFICIENCY OF NASAL LOBULE
Where there is a lack of lobular prominence it may be enlarged and
brought forward by a subcutaneous prothesis if the skin is flexible
enough to permit of injection, as has heretofore been described. If this
cannot be done, the following operation may be employed to advance the
point of the nose, and reduce the width at its base so commonly observed
with these cases.
=Gensoul Method.=—A deep incision is made from the floor of each nostril
downward and backward, meeting at a point just below the union of the
subseptum with the upper lip, as in Fig. 494.
The deeper tissues are loosened from their attachments to the bone until
the subseptum at its base, including the triangular appendage thus made,
is freely movable.
The lobule is now drawn forward to its required prominence and the parts
are sutured Y fashion, as in Fig. 495.
If the subseptum be too wide, an elliptical section is removed, including
the cartilage, sufficient to give it the desired thickness when brought
together, as illustrated. The lips of the wound are brought together as
shown.
[Illustration: FIG. 494. FIG. 495.
GENSOUL METHOD.]
CORRECTION OF WIDENED BASE OF NOSE
When the base of the nose at its juncture with the lip is too broad, the
reversed procedure mentioned under correction of a broad lobule is to be
employed.
The diamond-shaped section is removed from the posterior rim of the nares
as shown in Fig. 496.
The tissues at either side are freed from their subcutaneous attachments
so as to render them mobile.
The mucosa and skin wounds are sutured as in Fig. 497.
A retention splint or suture is to be employed to retain the parts as
with the anterior lobule operation just described until healing has taken
place.
[Illustration: FIG. 496. FIG. 497.
AUTHOR’S METHOD.]
REDUCTION OF THICKNESS OF ALÆ
When the alæ are thickened they add to the width of the nasal bone and
cause more or less atresia of the nostrils. The cause may be due to
superabundant connective tissue or a congenital enlargement of the lower
lateral cartilage.
To overcome this deformity the following operations may be followed:
=Linhardt Method.=—This author excises an elliptical section of tissue
from the inferior base of both nasal wings, as shown in Fig. 498.
A similar procedure has heretofore been described in Fig. 485 in
connection with correction of the lobule.
The section removed includes as much of the cartilage as is necessary to
thin out the wing of the nose and to overcome the atresia.
The parts are sutured as shown in Fig. 499.
[Illustration: FIG. 498. FIG. 499.
LINHARDT METHOD.]
=Dieffenbach Method.=—In this method cone-shaped section of skin and
cartilage are removed from the wings of the nose, as shown in Fig. 500.
If the septum is too wide, two or three of the same shaped sections are
removed from it.
The skin wounds are drawn together by suture, as shown in Fig. 501.
[Illustration: FIG. 500. FIG. 501.
DIEFFENBACH METHOD.]
CORRECTION OF NASAL DEVIATION
In this deformity the nose is bent or twisted to one side. The cause is
usually traumatism, but may be congenital.
The interior cartilaginous septum is usually found malformed on one or
both sides.
To correct the deviation, the redundant cartilaginous septum is cut or
sawed away to clear both nares and the anterior nasal vestibule. After
this has been done the nasal attachments are freed subcutaneously, until
the nasal organ is freely movable from its attachment to the superior
maxillary bones.
The nose is now placed in the position desired, somewhat overdoing the
correction, and is held in place by gauze packs in the nares or by
Roberts’ spear-pointed pins thrust through the lateral skin of the nose
at either side and through the septum, as shown in Fig. 339, p. 365.
The use of the pins placed as shown allows of free drainage to the nares
and gives little inconvenience to the patient.
Plugs of gauze contract and harden, thus overcoming the object of their
use and cause a disturbance of the wounds and pain when reapplied.
The pins should not be withdrawn until the nose has healed into its new
position, or begin to cause irritation of the parts punctured.
Where the deviation is unilateral it should be corrected by subcutaneous
injection, as previously described.
UNDUE PROMINENCE OF NASAL PROCESS OF THE SUPERIOR MAXILLARY
The protuberance of bone lies external to the middle meatus, involving
an abnormal convexity of the nasal process of the superior maxillary.
Its external removal or reduction involves considerable tissue and would
leave a conspicuous linear scar, therefore the surgeon must attempt its
reduction from the inner nose.
The author prefers to make a horizontal incision below the inferior
border of the process, beginning anteriorly just before the articulation
with the nasal bone and extending backward as far as the view from the
nare will allow.
Through this opening, the skin overlying the bone is raised by dull
dissection. A fine nasal saw is next introduced through the submucous
wound and several vertical incisions are made into or even through the
bone about three sixteenths of an inch apart, dividing the convexed
osseous tissue into several sections adherent at their superior extremity
which lies inferior to the insertion of the levator labii superioris
alæque nasi muscle.
A forceps, such as Adams’s, is now introduced and each section of bone
thus made is fractured from below upwards inwardly to produce a concavity
of the osseous tissue.
The operation requires considerable dexterity. The amplitude of the
sawing movement is very much restricted, because of the palpebral
muscular attachment just above.
A frail bone cutting forceps may be employed and the lower half of
the process be removed to avoid encroachment upon the middle meatus,
but this is rarely necessary, as that chamber is found unusually wide
in this case. If the bone is removed, the remaining bone may be cut
into sections, as described, or by the cutting forceps, and fractured
backwards as described.
Retention dressings must be resorted to, to keep the fragments of the
bone in their new position until cicatrization has been sufficiently
established to keep them in place.
When possible Roe advises sawing off the convexity submucously and, after
loosening the skin over the dorsum of the nose, to move the bony plate
thus made over to the opposite side of the nose and into the concavity
usually found there in these cases. If there be no deviation at the
latter site the bone plate can be entirely removed through the inferior
wound in the mucosa.