Plastic surgery

“ 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 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. ”

“ 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. ”

“ This is not unusual with the most intelligent patients and is due to the fact that cosmetic operations performed on an ugly though otherwise normal organ have not yet become very frequent, and while friends are inclined to remark a change in lesser defects, they fail to credit this to the cause, owing to a lack of the knowledge of cosmetic surgery, or their ignorance of the art entirely. ”

“ As they are removed from the solution they are squeezed as dry as possible and pressed upon, rather than wiped across, the operative field. It must be remembered that the surgeon’s work must not be hampered by slow or inefficient sponging, and that this procedure must be quick and timely. It is well for the assistant to become accustomed to the habit of the operator.
The best assistant is one who has acquired a methodical and regular manipulation, a result dependent upon constant individual association; such a one is practically invaluable for the skillful performance of plastic surgery. ”

“ 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. ”

“ The Carrel solution is applied. By plastic surgery and other means the disfigured mass is shaped. In a few short weeks the man again begins to resemble a human being and eventually is well, with little more than a few indistinct scars. Not infrequently he returns to the trenches. Some of the things that shock the mind are metal jaws, screened behind false beards, artificial noses, ears, cheeks, eyes and limbs. Sometimes when a man is facially disfigured beyond repair, that is, when nature can never replace the countenance, a copper mask is fitted. ”

“ 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. ”

“ The ideal operating room for the plastic surgeon need not necessarily be large, since it requires less work to render it aseptic. Furniture and possibly amphitheater accommodation are always a means of infection unless scrupulously cleansed, a task of time, difficult at best. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ This in the majority of cases will give better results than when an entire cheek is injected, for the reason that the larger mass is likely to be displaced by the unconscious act of the patient in sleeping on one or both of the rebuilt cheeks or the willful massage to improve the handiwork of the surgeon in their own belief. ”

“ It must always be the object of the surgeon to save as much of the presenting tissues as is possible, to avoid traction on the tissues and to overcome the consequent thinning out of the entire upper lip or the flattening so often seen in the lips of these patients. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ Apart from internal and proper external electrical and other treatment the simplest surgical method to be employed is to remove an elliptical piece of skin from the eyelid and to suture the margins of the wound together. Care should be taken not to take out too much tissue, as this would involve inability to close the lid. ”

“ Hyperinjection.—The injection of too much vaselin or paraffin is one of the most common faults found with operators. In the first instance a tumefaction of the site results which with the production of the tissue which takes the place of part of the filling makes the result very unsatisfactory and requires one or more cutting operations to reduce it. A peculiar fact with these hyperplastic growths is that even though they may be reduced with the knife to a normal size they seem to redevelop again and again, giving both surgeon and patient great concern. ”

“ To assure the operator of a thorough dissection he may inject the site with sterile water through the opening made with the knife, squeezing it out before injecting the nose.
If the skin has had to be freed by surgical means the mass injected should be sufficient to overcome the defect almost entirely, to prevent the reformation of the bands of connective tissue which have been severed. ”

“ Eventually the depression of contour may be corrected by hydrocarbon protheses introduced subcutaneously following subcutaneous dissection, if deemed necessary.
Small pits, where discrete, are best removed with a fine knife and brought together by a fine suture which is to be removed on the fifth day.
Confluent pittings, as after variola, must be removed by decortication or peeling methods.
The pits, if spread about the face promiscuously, may be treated separately by the peeling method, but when [489] they lie less than one inch apart, it is best to treat the skin of the whole face. ”

“ Such a nose should be reduced by cutting operations instead of being added to. The seeming depression above the lobule is only comparative to the overdeveloped form of the lobule. The face values of every patient should be studied, and the surgeon should never attempt to break up the harmony of facial form by simplifying an operation and rendering the patient’s appearance even more ridiculous than before his attempt to correct a fault. ”

“ 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. ”

“ 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. ”

“ In cases of severer form the cicatrix is removed by an elliptical incision, the lip returned to its natural position, and a pedunculated flap of skin is taken up from the chin or the cheek which is rotated into the wound, or a skin graft is implanted into the area by the Wölfler method and sutured to the free margins of the skin, or the Thiersch method may be employed. ”

“ This absorption, following such an injection, is productive of no harm to the human economy, and the new tissue caused to be formed by such injection truly enhances the cosmetic and surgical value of the method inasmuch as an encapsulated mass of paraffin is liable to displacement, spreading, and irregularities, should it be subjected at any time to external violence. ”

“ 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. ”

“ Usually ten drops of the mass suffice to give the desired result. The mass may be molded out if found desirable, but if the skin appears normal after the operation and the tumefaction thus made does not make the nose look grotesque, it may be allowed to remain as injected, depending upon the subsequent reactive pressure [309] to force it into shape. In this way a greater part of the mass is retained at the wanted site and is not crowded to the sides of the lobule by the customary post-operative molding. ”

“ Patients are easily frightened when cutting operations around the eye are undertaken, and should be apprised of what is to be done, and what to expect, especially when the operation has been done as a purely cosmetic one. ”

“ When becoming embodied in the coagula of serum and antiseptic powder it prevents, by pressure, perfect union, causing a wider scar at such point, as well as endangering the asepsis of the wound by being pulled off accidentally, thus tearing it open and bringing on hemorrhage.
The appearance of the resulting scar in facial surgery is often of as much importance to the patient as the operation itself, therefore, all care should be exercised in bringing about the very best result. ”