Frederick Strange Kolle

“ 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 ideal operations are those which include cartilaginous supports, which may be obtained from about the border of the deformity or from some remote place, as of the ear. The surgeon is hardly justified to use the remaining healthy tissue of the nose, unless the case is such that the secondary wound can be corrected, so as not to add scars to the face.
Small defects can be easily corrected by sliding flaps taken from the vicinity of the defect, whether they include cartilage or not, and by granulation or dissection and approximation of the skin, the secondary wound may be entirely closed. ”

“ Unequal muscular contraction breaks up not only the form but also the mass itself, during all of which time it is made to act as an irritant by virtue of the movement of the uneven edges of the paraffin upon the adjacent tissue. ”

“ The author has used the cold-injection method in over three hundred nose cases without a single case of sloughing, embolism, or death, and in no case was there secondary diffusion or hyperinjection. The only fault has been the desire on the part of the patient to be finished too quickly, which usually leads to a result not as satisfactory as when the injections are made sufficiently far enough apart to allow the formation of organized tissue at the site of injection. ”

“ Never should so large a quantity of the mass be injected as to cause blanching of the narrow strip of skin. This is sure to result in gangrene of some, if not all, of the skin of the subseptum—a result much to be regretted, since subsequent correction of the deformity increased by the contraction of the dermal cicatrix is rendered well-nigh impossible by reason of this very tissue.
Hard paraffin injected in its molten state is never borne in this part of the human economy. ”

“ The first result obtained with many cosmetic operations is not at all gratifying to the patient, and unless this is explained to him beforehand he may become discouraged awaiting the next operation and disappear, thus losing the opportunity of being pleased finally, while the surgeon is misunderstood and underestimated by narrow-minded judges and the ever-willing friendly advisers and critics—a consummation much to be avoided. ”

“ The correction of the deficiencies of the lower half of the nose is associated with difficulties in various directions. Either the skin over the defect is too dense to render injection an easy matter, or the nose is so broadened horizontally from the original injury that the injection, no matter how artistically done, leaves the nose bulky and ugly in appearance.
When the nasal processes of the superior maxillary bones have not been widened unduly by an injury and the skin is dense, simple subcutaneous dissection before injection will overcome the difficulty easily enough. ”

“ Plastic surgery is resorted to in covering defects of the skin due to congenital or traumatic malformation, injuries, burns, the removal of neoplasms, or the ulcerative processes of disease. Furthermore, it can be employed cosmetically for the rebuilding of organs, whole or in part, or for their reduction when abnormally developed. This applies particularly to the nose, ears, and lips, wherein it may involve either the skin alone or the mucous membranes, or all the tissue making up the parts operated on. ”

“ The hands of the surgeon and his assistants must always be thoroughly prepared before operation or dressing a wound. The mere immersion of the hands into an antiseptic solution is not sufficient to remove [17] germ life. The oily secretions of the skin and its folds, as well as the cleft about the nails and the nails themselves, are common carriers of infection and are cleansed only by the vigorous method of scrubbing with soap and water and then rendered aseptic by the use of proper media. ”

“ It is absolutely absurd to think of injecting a lip with hard paraffin liquefied by heat and expect to obtain a satisfactory result. While it is true the mass is moldable immediately after its introduction, so that a desired shape may be obtained, it does not overcome the fact, however, that the mass must harden, as it will, and that, while a part of it is broken away, as it were, from the mass proper, there is a nuclear contraction as the hardening takes place, thus overcoming partly the molded form ”

“ MALPOSITION OF THE AURICLE
The most common deformity met with in ears is undue prominence. The ears stand out from the head at an obtuse angle, often lopping forward and downward, giving the patient a stupid appearance. This condition is usually inherited, but may be acquired during childhood by the careless wearing of caps that crowd the pinnæ forward and away from the head. The habit of ear-pulling is also said to be a cause, also the faulty position of the head during sleep. The deformity is usually bilateral, but in the majority of cases one ear usually projects more than the other. ”

“ Over the eyelids a thin coating of plaster should be used, whereas over other parts of the face a thickness of half an inch can be allowed without discomfort to the patient.
It is well at first to make the plaster thick, as the mold is liable to be broken upon removal or in drying. After a little experience splendid results are obtained with very thin walls of plaster.
The plaster is allowed to dry and harden, while the patient is instructed to remain still and silent. If a cast of the nose is made, the patient should refrain from talking and breathe gently through the mouth. ”

“ A record sheet, or a direct photograph, can be made before and after operation for the same purpose, which is not so desirable, however, because it has been found quite impossible to procure the desired accurate pictures of a nasal deformity, the photographer not being given to bringing out imperfections as the surgeon wishes them, even under the most explicit instructions, unless the surgeon accompanies the patient to the studio to supervise the posing. ”

“ 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. ”

“ If it is more desirable to cover the granulating area by means of skin grafts it may be accomplished readily, as later described. This is usually resorted to when there has been loss of tissue from the result of sloughing, although a sliding-flap operation may overcome the defect to a nicety; this is especially true of wounds about the anterior nasal border.
If the resulting cicatrice is no larger than the gaping wound it may be excised, the skin at either side is undermined and the edges are brought together, as was originally intended. ”

“ Autodermic Skin-grafting.—Larger pieces of skin may be excised from selected parts of the body, preferably the outer side of the arm, and utilized to cover the entire defect. The piece of skin is cut about one third larger than the size and shape of the area to be covered. This method was first introduced by R. Wolfe in 1876, and gives splendid results. He advises removing all subcutaneous adipose tissue from the graft by gently cutting it away with fine scissors or the razor, and then loosely suturing the flap to the skin surrounding the denuded defect. ”

“ The use of hydrocarbon protheses for the correction of nasal deformities has revolutionized, to a great extent, the rhinoplasty of many centuries. Through their employment many unsatisfactory cutting operations have been entirely displaced, and it is quite right to hold that the introduction of other subcutaneous protheses and like apparatuses of amber, celluloid, caoutchouc, silver, gold, aluminium, ivory, or other nature have been supplanted by this method of operation, when these were needed to correct a partial deformity of the nose. ”

“ In his published report he says that, “if vaselin, which at the temperature of the body has the consistency of ointment, be liquefied by heat and by the means of a Pravaz syringe is injected into dilatable tissue of the human body, there is produced, at the site where the injection is made, a tumefaction whose volume corresponds to the quantity of vaselin injected. The reaction which results from the procedure is insignificant and the mass appears to rest without change where injected.” ”

“ The claim of Eckstein, that paraffins of low melting points are more likely to be absorbed, has not been substantiated in actual practice, since we now know that any and all of these injections, irrespective of their melting points, are absorbed in time, giving place to connective tissue, and that rarely, if ever, is there a true and complete encapsulation or encystment of the mass thus introduced. Even the hard paraffins are split up in time into minute pearllike particles which are displaced by the growth of tissue arising from the presence of the foreign substance. ”

“ Since the skin is rather firmly adherent at the sides of the nose, except in the major part of the superior third, it will be found best to raise the skin of such defect into normal contour by a series of very small injections instead of following the method heretofore advised in connection with tense or adherent areas of skin, for the reason that such dissection would render the skin too mobile over an area usually beyond the defect itself and inviting the surgeon to an annoying hyperinjection which renders the part more unsightly than prior to the operation. ”

“ Lastly comes Gersuny’s most valuable method of injecting paraffin compounds subcutaneously for the restoration of the contour of facial surfaces and limbs, which is rapidly taking the place of extensive plastic transplantory and the much-objected-to metal and bone-plate operations for building up depressed noses and other abnormal cavities.
And the end of possibilities is not yet reached. The successful plastic surgeon has become an imitator of nature’s beauty to-day. ”

“ That the growth is not limited by the size of the mass injected is the author’s belief; in other words, the replacement of the new tissue is not proportionate to the injection, but that other forces, such as adjacent tissue pressure and presence and outer influences, as, for instance, the daily massage of the parts with the hands, have much to do with the final amount of tissue caused to be developed by the initial stimulus of the injection. ”

“ At no time should cotton be placed next to the wound, as it forms a hard mass with the secretions, the removal of which requires enough force to injure or hazard the union of a new wound. Nor should a plaster dressing be pulled off without thoroughly moistening it first, withdrawing the various layers one by one. The gauze, when moistened, readily leaves the wound without injurious traction. An excellent dressing for small, dry wounds, and one that causes little tension, is collodium, or, better, iodoform-collodium painted over the surface. ”

“ Even with this method great care must be exercised in not injecting too much at each sitting. A failure is sure to result in hyperinjection about the lobule. When it be remembered that only a very small quantity of the mass will make a decided difference, the surgeon and patient should be satisfied with the slightest gain.
If, however, the mass be retained and further elongation of the lobule is desired, a subsequent injection can be undertaken, but not until a full month after the primary operation. ”

“ Necrosis.—Death of tissue may follow an injection of paraffin when too much pressure has been applied, or when too much has been injected into the tissue, cutting off the blood supply, or when the injection has been made into the skin instead of beneath it. Again, constitutional disease, such as diabetes or Bright’s disease, may superinduce the breaking down of the tissue. ”