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 The author advises the injection of white sterile vaselin or sperm
oil for this form of correction. It should be carefully injected, since the
vessels lie close to the skin with the anterior auricular crossing
transversely about the center of the furrow.
Every precaution should be taken, one injection only being made
from below upward at each sitting if more than one is necessary, and
then only after the needle has been unscrewed from the syringe to
make sure vessel bleeding does not follow the puncture.
The reaction is usually severe, with considerable edema and
ecchymosis.
The resultant tissue formation likewise is active, and hyperplasia
at this site is not uncommon, especially if the mixture or hard paraffin
has been employed.
A cellulitis following such an injection is exceedingly troublesome,
the injected mass being thrown off usually at the base of the furrow,
which is followed by a low type of inflammation with a protracted
oozing of serous exudate. Should such a case come under the care
of the surgeon, thorough cleansing of the affected site under
scrupulous antisepsis should be done at once, and wet antiseptic
dressings be applied daily until the wound is entirely healed.
A plastic skin operation must be done in most of these cases to
overcome the ragged cicatrix formed upon healing of the wound.
This should never be undertaken until the wound has been healed
for several weeks at least.
After the injection of the parts cold antiseptic dressings should be
applied at once, and kept up until every sign of reactive inflammation
has subsided. At no time should the subsequent injection be
undertaken before a month has elapsed from the time of the former
operation.
Post-auricular Deficiency.—This defect is invariably unilateral,
and then the result of a mastoid operation.
The skin about the depressed site will be found to be more or less
firmly adherent, necessitating subcutaneous dissection before an
injection for correction can be undertaken.
 In this case the cold mixture of vaselin and paraffin is indicated,
since the softer products will hardly suffice to elevate the tense skin.
If the former surgical operation has been done some time previous to
the required injection the parts may at one or two sittings be restored
to a fairly normal contour, depending entirely upon the amount of
ungiving scar tissue at the site. If the parts are tender and not
reduced to normal, the injections should be made frequently, about
ten days apart, injecting a small mass across and through the
subcutaneous scar attachment at each sitting.
The reactions following such injections help to tease the scar away
from the bony tissue, but should not be sufficient to cause extensive
inflammation.
The same mode of post-operative treatment as has been given
with pro-auricular corrections should be followed.

SPECIFIC TECHNIQUE FOR THE CORRECTION

OF DEFORMITIES ABOUT THE SHOULDERS
Deficiencies about the base of the neck and the shoulders are
very commonly found in women. These defects are usually bilateral,
except in rare cases. The much-desired contour is readily restored
by the subcutaneous-injection method, and since the technic for one
part is the same as for the whole there is no need to dilate
specifically upon the treatment of each part.
The author advocates the injection of cold sterile white vaselin
only, for the restoration of the contour about the neck, anterior and
posterior shoulder, and the mammæ, except in the unilateral
correction of a flattening of the breast following amputation for the
removal of neoplasms, when the mixture of white vaselin and
paraffin should be used, owing to the tenseness of the skin following
the excision of a large part of the integument covering the diseased
gland.
In the restoration of the contour about the neck and shoulders it is
well for the surgeon to familiarize himself thoroughly with the
superficial veins of the parts, since the vessels here are larger, and
the introduction of foreign matter into them is liable to lead to serious
and even fatal results.
The injections should never be made until the operator has
assured himself of the fact that a vessel has not been entered into,
and then only should a small quantity of the mass—i. e., about two
or three drams—be injected at one point.
The easiest mode of introducing the needle is to pinch up the skin
between the fingers of one hand, introducing the needle into the fold
thus raised. As the mass is injected the skin should be raised by aid
of the needle, so as to allow all the immediate room possible for its
reception.
The mass injected is at once molded down flat with the thumb or
forefinger.
A number of such injections may be made at both sides at the one
sitting. The ethyl-chlorid spray may be employed to render the parts
less painful. At no time should the entire shoulders be filled at one
sitting, for fear that the reaction may be severe or that for any
unforeseen cause infection results which would in such instance be
indeed difficult of treatment, eventually leaving the parts scarred and
unsightly.
Nor should the mass be injected intracutaneously, a fault
sometimes observed about the base line of the neck anteriorly and
laterally where the operator has been timid in avoiding the exterior
and anterior jugular veins. Such injections invariably result in
abscess, or when not extensive enough to cause necrosis the skin
assumes a more or less permanent red or yellow discoloration over
the site so injected.
The treatment for the partial or total removal of such spots has
been referred to.
In the average case of contour restoration of the shoulders about
eight sittings are required, two sittings being given each week, and
as many injections made as is deemed necessary or advisable at
each.
 All the precautions of technic heretofore given should be
employed. The reaction following such injections is never severe,
and little or no treatment is necessary.
The needle openings are covered with aristol collodion or the
isinglass adhesive plaster.
At the end of six months or more after the injected matter has
been quite thoroughly replaced with new connective tissue it is often
found necessary to inject small quantities here and there about the
shoulders, owing to the contraction of the new tissue and its ultimate
fixed disposition about the parts more than to the absorption of the
mass injected.
Furthermore, a certain amount of edema or swelling follows the
injection of any foreign matter under the skin which is not, in cases of
this kind, so readily absorbed, giving during that period of time a
more pronounced contour or fullness, which, passing away in the
natural course of events, does not imply the absorption of the matter
injected—a statement so often made by those not in favor of using
paraffins of low melting points for subcutaneous protheses.
Such result, however extensive, as it might be in some cases for
the lack of proper injection or in the case with oil injections is at all
times correctable, while the hyperplastic knobs, so often following
the injection of paraffins of high melting points about the shoulder,
can only be removed by surgical means, which leave the parts more
unsightly than before anything had been done for the patient.
 CHAPTER XV
RHINOPLASTY
(Surgery of the Nose)

Rhinoplastic operations serve to correct deformities of or restore

the nose. Such operations may involve only a part of or the entire
organ, hence may be termed partial or total. Furthermore, a fine
distinction may be drawn between general rhinoplasty as applied to
such deformities when caused by traumatism, the excision of
neoplasms or destructive disease, whether such correction be partial
or total, and cosmetic rhinoplasty when such corrections are made
purely with the object of improving the nasal form when the deformity
is either hereditary or the result of remote accident.
For some unaccountable reason the latter art has not met with the
general favor the profession should grant it, yet the results obtained
by such specialists as have undertaken this artistic branch of surgery
have been all that could be desired, and have consequently added
much to the comfort and happiness of the patient.
Without a comparatively thorough knowledge of the extent of
cosmetic rhinoplasty it would be difficult to draw any conclusion as to
the value of this art. If it has not met with the favor it deserves it is
solely due to the fact that the art has been limited to the few, and the
literature on the subject is so meager, indeed, that the surgeon has
been compelled in many cases to trust to his own originality in
undertaking an operation of this nature.
The limitation to rhinoplasty is due primarily to the artistic skill
required to obtain results; secondly, to the risks involved by loss of
tissue due to gangrene, imperfect healing or accidental interference,
post-operatio; and thirdly, to scarring about the face as a result of the
primary and secondary wounds; in fact, so much so that many
surgeons prefer to allow a small defect to remain, to escape the risks
involved in correcting them.
The author believes such fear misplaced, because with the
methods of surgery of the present day and the proper knowledge of
the art there need be little risk involved and the result expected
should be as near perfect as human skill can make it.
True, a surgeon cannot be expected to build an entire nose from
the skin or other tissue of the forehead or cheeks and make it a thing
of aforethought beauty and shape, but if the result be no more than a
curtain of skin to hide the hideous deformity he has done his share,
and such result is the worst he might look forward to.
For the correction of nasal deformities the author will consider first
such operations as involve the entire loss of the nasal organ or total
rhinoplasty; thereafter partial loss of the nose, and lastly such cases
involving no loss of tissue and dependent on malformation only
under cosmetic rhinoplasty.
It is not here intended to lay down a law for the surgeon for the
restoration of the entire or part of the nose for the reason that each
case differs more or less; that in each case there is more or less
tissue that may be utilized, and that there are many methods
advanced for such procedure, but the author does desire to give to
the operator a concise and comprehensive treatise on rhinoplasty
and to illustrate the best of such operations as have been placed on
record as a ready guide and for immediate reference—a matter of no
small moment when this literature can be gained only by searching
through innumerable medical journals and short references and in all
languages of the civilized world.
In the chapter on history some idea of the time in which
rhinoplasty has been practiced may be obtained. It is not deemed
necessary to go into further historical facts here, except, perhaps, to
divide the subject into the three most important schools or countries
that have given individuality to the art.

THE CAUSES OF NASAL DESTRUCTION

 The loss of the entire nose may be due to traumatism, actual
amputation, the bites of man or beast, duels, the removal of
neoplasms, gangrene after freezing or disease, rhinosclerosis,
syphilis, the application of caustics, tubercular disease, lupus,
cancer, and rarely congenital absence of the organ. The loss may be
total or partial.
The extent of loss of substance in each case differs, and it is for
this reason that surgeons have been compelled to originate many
methods of operation, each having for its object to correct the
deformity as neatly and as near to the normal as possible.

CLASSIFICATION OF DEFORMITIES
To give correctly a classification of nasal deformities would simply
mean to mention each anatomical part or division of the nose
referring to the deformity involving the same. For this reason such an
arrangement would be uselessly extensive, but for the proper
recording of such cases the author advises a systematic method of
nomenclature in which the deformity is stated, as: left, unilateral
deficiency of inferior lobule; or right, median third deficiency of nasal
dorsum of the parts destroyed and mentioned as such.
Fig. 306.—Deficiency of Superior and
Middle Third of Nose. (Saddle Nose.)
Fig. 307.—Post-ulcerative Deformity
of Superior Third of Nose.
Fig. 308.—Loss of Right Ala, Lobule
and Columna.
 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.
Fig. 310.—Ulcerative Loss of Right
Median Lateral Skin of Nose with
Involvement of Ala.
 Fig. 311.—Loss of Nasal Bones and
Partial Ulcerative Destruction of
Dorsum, Lobule and Septum of Nose.
 Fig. 312.—Destruction of Nasal
Bones with Dorsal Integument and
Lobule Intact.
 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