Chapter XIV: Subcutaneous Hydrocarbon Protheses (3)

After using, the syringe should be emptied entirely, unscrewed and sterilized, and placed in the metal case furnished for it. A screw cap is furnished to take the place of the needle when not in use.

The method of filling and using the syringe will be considered later.

PREPARATION OF THE SITE OF OPERATION

The same surgical precautions should be observed when a paraffin injection is to be undertaken, as with a minor surgical operation.

It is hardly found necessary to prepare the site of operation the day before, nor need the patient be detained for such time for the purpose of making him ready.

With careful observance of ordinary surgical technique, both as to surgeon and patient, all of this class of operations can be performed in any physician’s office, providing that both instruments and the mass to be injected have been rendered sterile.

Especial care should be given to the operator’s hands, for with these he not only handles the instruments, but must also mold the mass injected, thus frequently coming in contact with the needle opening or openings made in the skin.

When injections are to be made in the cheeks of the patient, the mouth should be prepared by cleansing the teeth thoroughly and washing out the buccal cavity with warm boric acid or hydrogen peroxid solution, or any of the preparations of the Listerine composition.

This rinsing should be continued every few minutes for at least ten minutes before the operation is undertaken.

This is necessary, as the surgeon must introduce his finger into the mouth and behind the cheek to mold out the mass injected subcutaneously, and infection could easily be introduced by his fingers during this procedure.

Externally a generous field of the operation is scrubbed with a brush dipped into green soap and water.

The skin is then thoroughly washed with gauze sponges steeped in absolute alcohol, followed with spongings with a 1-5,000 solution of bichlorid of mercury. The whole surface is then wiped off with a sponge dipped in ether and covered for the time being with a pad of sterilized gauze until the operator is ready to proceed with the operation.

PREPARATION OF THE INSTRUMENTS FOR OPERATION

The manner of preparing the necessary mixture of paraffin has been described on page 244. After such preparation, the mixture, still hot, may be poured into test tubes, which are sealed and put away for further use, each tube holding just enough to fill the syringe two thirds full.

When a syringe is to be filled, one of the tubes is opened and the contents are again boiled over a spirit flame, or simply liquefied and poured into one of the types of heaters already described for the same purpose of resterilization.

From the test tubes or the heater, the boiling mixture may be drawn up into the sterilized syringe to the required amount or it may be poured into the opened piston screw cap end.

In the latter event the ready cooling of the mixture as it enters the needle will permit it to be retained in the barrel, or the needle may be immersed in sterile water as the paraffin is poured into the syringe, yet even if a few drops escape from the needle in the former method, no harm is done, as such loss amounts to nothing and helps to eventually fill the syringe evenly and free of air.

If the mixture is drawn up into the barrel to the required height, more or less air enters, which must be removed by turning the syringe, needle up, and screwing up the piston rod until either the liquid or cylindrical thread of the cooled mixture appears.

If the mixture is poured into the syringe the piston is slowly pressed into the barrel, thus allowing the air to escape along its sides if the mixture is set, or if warm the syringe is turned up and the piston screwed into place. As this is done the few drops of cooled paraffin will be forced from the needle before the air is exhausted. The screw is turned until the paraffin emerges evenly from the needle.

The syringe must now be laid aside, or placed in sterile water of the temperature of the room, to allow the liquid within to set evenly and become uniform in consistency.

The operator will follow what method he pleases in filling his syringe, but at no time should he fill it with the cooled product with a spatula, or other such means, as he is sure to fill it unevenly in this way, incorporating a number of air spaces. The air issues from time to time during an operation with sudden sputtering outbursts, that not only tend to annoy the patient, but also to frighten him—the shock being unusual and unexpected, while the air thus forced into the subcutaneous tissues puffs out the parts and interferes with a perception of the proper amount to be injected and adds to the danger of air embolisms.

Slipshod methods are inexcusable, and should not be tolerated. The best results possible should be given the patient, and only from the best results obtained with the best care can the most reliable data be attained, all helping to fix the reliability, efficacy, and exactitude of this branch of cosmetic surgery.

THE PRACTICAL TECHNIQUE

The field of operation and the instruments having been properly prepared, as described, the _modus operandi_ must next be considered.

Since the various parts of the face to be injected demand specific procedure, they will be considered somewhat individually hereafter, whereas the general technique, applicable in as far as the method of injection is concerned and applying similarly in all cases, may tersely be first taken up.

Various and noted surgeons point out that these subcutaneous injections should be made under general anesthesia, i. e., ether, while others consider the hypodermic use of cocaine or Eucain β solution in one to four per cent necessary to accomplish good results.

The author considers the method in the first case objectionable both as to patient and operator, entailing much discomfort to the one operated on and demanding an unnecessary waste of time for the etherizing and recovery. Likewise is the employment of a local anesthetic not indicated or demanded, since the operation to be undertaken necessitates only the pain associated with the prick of the needle through the skin.

The objection to etherization is obvious, while the hypodermic employment of any local anesthetic, by the very fact of its presence of volume and its physiological action upon the tissue, tends to interfere with the proper injection of the parts by reason of temporary swelling of the parts, not caused by the later injections of the prothetic mass.

If in nervous irritable patients an anesthetic is required to allay fear it is best to use the ethyl-chlorid spray upon the skin sufficiently to overcome the sharp sting of the needle insertion. For this purpose the ether spray is used only to the point of blanching the skin, and no longer.

This mode of procedure is especially useful when a number of injections are to be made, as in the rounding out of a cheek or of the shoulders, in which the contour cannot be restored from one point of injection, as will hereinafter be described.

The patient, being now in readiness, the skin over the area is lifted or pinched up with the fingers of the left hand of the operator as a guide to its mobility and to steady the part.

The point of the needle is now forced through the skin and into the subcutaneous tissue at a point along the periphery of the deformity and pushed a little beyond the center of the cavity to be filled.

The elevation of the skin is in the meantime partly kept up with the needle itself, while the syringe is grasped with the freed hand, the thumb and forefinger of the right hand being placed upon the handle of the screw or piston rod, which they must rotate to force the semisolid mass from the instrument.

Before beginning the injection an assistant is instructed to press with his fingers the tissue about the margin of the defect to prevent the filling from becoming misplaced or being forced into undesirable channels, especially if the skin over the defect is found to be thick and inelastic.

The screw handle is now rotated evenly and slowly, discharging the mass to be injected, which will soon be evidenced by the rise of the skin over the depression to be corrected.

Only sufficient of the mass must be injected to fairly correct, never to overcorrect, the defect.

Experience alone will assure the surgeon when this point has been attained, since he cannot immediately judge the necessary amount injected, as it will appear as a round or irregular lump under the skin, until it has been molded or worked out into shape.

Owing to the pressure exerted upon the contents of the syringe, which will continue to emerge from the needle for a time, the needle is left in place for a few seconds before withdrawal, so that the needle canal through the skin will not become filled with the semisolid mixture.

Such blocking up of the opening causes a cystic development or enlargement about the opening in the skin by this backing up or exuding, ofttimes crowding itself in between the layers of the skin and necessitating later removal with the knife. If not this fault it tends to keep the wound open unnecessarily after the operation, preventing healing and permitting the escape of a certain amount of the injected mass, if a mixture of low melting point has been utilized.

The needle, having been allowed to remain as advised, is now withdrawn. The tip of one finger is placed over the opening in the skin and held there gently, but firmly, while the mass is molded into the shape required or desired with the fingers of the right hand.

If it now appears that the injection is insufficient the needle may again be introduced through the same opening and more is injected, remembering, however, that if the correction is quite normal no more should be added for several days, or until the injected mass has become organized, which should take place in about three weeks.

If it is found that the skin over the defect is inflexible and bound down, it will be found advisable to sever or dissect subcutaneously the adhesions that bind it down with the use of a fine tenotome or a spear-headed paracentesis knife.

This may be done two or three days before the parts are injected to assure the surgeon of an absolute cleanliness of the wound.

Mayo advocates the injection of a saline solution into subcutaneous wounds thus made as a guide to the extent of dissection and to further loosen the tissues.

When the parts, thus loosened, show little tendency to bleed, the author advocates immediate injection, as the waiting for several days permits the throwing out of new connective-tissue cells that interfere to a certain extent with the proper injection of the part.

It is with such wounds that secondary elimination is most likely to take place, especially if “Hart paraffin” or paraffin of a high melting point has been employed.

This is undoubtedly due to the healing down and contraction of the margins of the wound, which seems to progress more and more, encroaching eventually upon the hard mass and ending in inflammation of the overlying skin and ultimate elimination. With injections of softer consistency this is less frequent and, in fact, may be entirely overcome by limiting the amount of the injection at the first sitting, relying upon a full correction for later operations, when the periphery of the wound has become more or less influenced by the presence of the neutral mass between the wounded surfaces.

The subcutaneous dissection referred to must, of course, be done under local anesthesia, preferably the Schleich mixture or a one-per-cent solution of Eucain β.

The injection of the paraffin, or hydrocarbon mixture, in semisolid form, having been made and properly molded into shape, is set or fixed by spraying the part with ether or by the application of sterile ice cloths. When liquid paraffin has been injected it will be noted that the paraffin in setting contracts upon itself considerably, leaving less of a correction than anticipated.

The needle opening in the skin is next washed off with a twenty-five-per-cent solution of hydrogen peroxid and closed over with a drop of collodion.

The patient may then be discharged for the time being, with the instruction to apply ice cloths to the part for at least twelve hours to reduce, as far as possible, the reactive resultant inflammation.

On the third day the collodion patch may be removed and replaced with isinglass adhesive plaster applied with an antiseptic solution. The latter is allowed to remain on the skin until it falls off.

SPECIFIC CLASSIFICATION FOR THE EMPLOYMENT AND INDICATION OF HYDROCARBON PROTHESES ABOUT THE FACE

Reference has been made heretofore to the general indications for which subcutaneous injections of paraffin or its compounds may be employed. With the object of systematizing such indications and to further bring out the practicability and judicious use of the method under consideration the author submits the following tabulated arrangement, with the hope that it may lead to a more concise and better knowledge of the possibilities within the reach of the plastic or cosmetic surgeon.

The face will be considered in such grand divisions as are easily and readily understood, the defects of each part being shown under its distinctive regional heading.

DEFORMITIES ABOUT THE FOREHEAD

Transverse Depressions { Punctate.
{ Linear.
Deficient or Receding Forehead:
(Exhibition of Undue Superciliary Ridges.)

Unilateral Deficiency { Surgical (Frontal Sinus).
{ Traumatic.

Interciliary Furrow { Single.
{ Multiple.

Temporal Muscular Deficiency { Unilateral.
{ Bilateral.

DEFORMITIES OF THE NOSE

Anterior Nasal Deficiency { Superior Third.
{ Middle ”
{ Inferior ”
{ Superior Half.
{ Inferior ”
{ Total.

Lateral Insufficiency { Unilateral.
{ Bilateral.

Lobular Insufficiency.

Interlobular Deficiency.

Alar Deficiency { Unilateral.
{ Bilateral.

Subseptal Deficiency { Partial.
{ Complete.

DEFORMITIES ABOUT THE MOUTH

{ Unilateral.
{ Upper Lip { Median.
Labial Deficiency { { Bilateral.
{
{ { Unilateral.
{ Lower Lip { Median.
{ Bilateral.

Nasolabial Furrow { Unilateral.
{ Bilateral.

Oral Angular Furrow { Unilateral.
{ Bilateral.

DEFORMITIES ABOUT THE CHEEKS

{ Unilateral.
{ Total { Bilateral.
Deficiency of Cheek {
{ Partial { Unilateral.
{ Bilateral.

DEFORMITIES ABOUT THE ORBIT

{ Unilateral.
{ Upper Lid { Bilateral.
Deficiency of Lid Contour {
{ Lower Lid { Unilateral.
{ Bilateral.

Furrow About Canthus { Unilateral.
{ Bilateral.

Deficiency of Ocular Stump { Unilateral.
{ Bilateral.

DEFORMITIES ABOUT THE CHIN

Anterior Mental Deficiency { Partial.
{ Total.

Lateral Mental or Angular Deficiency { Unilateral.
{ Bilateral.

DEFORMITIES ABOUT THE EAR

Pro-auricular Deficiency { Unilateral.
{ Bilateral.

Post-auricular Deficiency { Unilateral.
{ Bilateral.

SPECIFIC CLASSIFICATION FOR THE EMPLOYMENT AND INDICATION OF HYDROCARBON PROTHESES ABOUT THE SHOULDERS, ETC.

Supraclavicular Deficiency { Unilateral.
{ Bilateral.

Infraclavicular Deficiency { Unilateral.
{ Bilateral.

Interclavicular (Notch) Deficiency.

Supra-acromion Deficiency { Unilateral.
{ Bilateral.

Infra-acromion { Unilateral.
{ Bilateral.

Supramammary Deficiency { Unilateral.
{ Bilateral.

{ Unilateral.
{ Partial { Bilateral.
Mammary Deficiency {
{ Total { Unilateral.
{ Bilateral.

Supraspinous Deficiency { Unilateral.
{ Bilateral.

Infraspinous Deficiency { Unilateral.
{ Bilateral.

Interscapular Deficiency.

SPECIFIC TECHNIQUE FOR THE CORRECTION OF REGIONAL DEFORMITIES ABOUT THE FACE

TRANSVERSE DEPRESSIONS

=Punctate Form.=—Such deficiencies are either of sharply defined depressions in a part of the frontal bone due to congenital malformation or of traumatic origin.

In the first instance they are usually unilateral or median and rarely ever bilateral. In those of the second class the deformity may be median, but is more often found to be unilateral.

=Linear depressions= of the forehead are usually found to be congenital, although traumatism in the form of direct violence may be the cause, as, for instance, the kick from a horse or a severe blow or fall.

The acquired linear form of lack of contour is found in people of middle life given to undue use or corrugation of the forehead, as in frowning.

The correction of this class of deformities may be accomplished by carefully raising the depressed area by repeated injections of small quantities, always avoiding the frontal and supra-orbital vessels.

At no time should such a deformity be corrected in one sitting, unless when the defect is a congenital one of small moment.

The reaction following these injections, owing to the close attachment of the integument to the bone, is usually found to be more severe than where the skin is more loosely attached.

In traumatic cases the scar attachments should be freely liberated, under eucain anesthesia, by the aid of a fine probe-pointed tenotome, before the cold paraffin mixture is introduced.

In such event only one opening should be made and just enough of the mixture be injected to raise the skin to its normal contour, if this be possible. Generally, later injections are required, and these may be made without further dissection. They should not be undertaken until the incised wound made with the tenotome has healed thoroughly, otherwise the pressure of the injection is liable to burst through the delicately healed wound, and thus delay if not endanger the success of the first operation.

When the reaction following such injections be severe, associated with considerable edema, cold pack or ice cloths should be applied or resort may be had to hot applications of antiphlogistin. The patient should be kept on his feet during the day and sleep with the head high at night. The bowels should be kept open, and general tonics be given if indicated. The patient usually returns to the normal, except for a little tenderness about the forehead, in three or four days under the treatment outlined.

DEFICIENT OR RECEDING FOREHEAD

In this condition there is usually a transverse lack of contour across the forehead above the superciliary ridges, giving the patient a degenerate appearance. The defect is congenital and is to be corrected, as described in the foregoing division, although the injections may be at either outer or temporal end of the forehead, gradually being brought nearer to the median line until the contour of the whole forehead has been raised by subsequent injections.

UNILATERAL DEFICIENCY

This defect may be traumatic—the result of direct violence, but is more commonly due to a frontal sinus operation.

In both events it will be found necessary to detach the cicatrices that bind the skin down to the injured bone, before a prothetic injection may be undertaken.

In some cases where the cause of the deformity has been moderate and the scar is linear and of long standing the injection may be undertaken without subcutaneous dissection.

Several injections are necessary, as the tissue about such parts is usually much thickened, apart from the firmness added by the scar tissue.

A short stout needle should be employed, the puncture being preferably made under ethyl-chlorid anesthesia, as the pressure necessary to raise the tissue causes considerable pain.

To further facilitate the injection the operator should raise the skin with the needle introduced subcutaneously.

Only one injection of small amount (10 to 15 drops) should be done at a sitting. The injected mass, unless too easily introduced, and thus forming a tumefaction, need not be molded out, since the pressure of the skin overlying it will accomplish it more satisfactorily, while the pressure required in molding tends only to press out more or less of the mass, thus lessening the benefit of the operation.

A second sitting must be undertaken in not less than one week, or even later, if a subcutaneous dissection has been done.

The secondary treatment should be followed as heretofore described. The reaction, for even a small injection in these cases, is usually considerable.

INTERCILIARY FURROW

This deformity is usually spoken of as a frown. It may be said to be congenital, when it appears in early life, but is commonly acquired through the habit of frowning.

The furrow may be a simple linear one or made up of a number of furrows. The author has been called upon to correct one made up of six distinct furrows.

The furrows or creases radiate upward and outward, conelike from a point beginning at the root of the nose.

In the correction of this common deformity the operator is tempted to overdo the fault by hyperinjection. A single furrow is readily corrected by a few drops of the injection, which should be neatly smoothed out. A little of the mass at this part of the face seems to accomplish considerable; in fact, the part seems overcorrected for some time after a judicious and carefully done operation, which is undoubtedly due to the active reaction that follows such cosmetic procedure, owing to the close proximity of the frontal veins and those of the venous arch at the root of the nose, which undergo more or less phlebitis of a mild type, the resultant edema depending upon the pressure caused by the mass on these vessels. The intimate relation and anastomoses of the latter is clearly shown in the carefully prepared dissection represented in the frontispiece.

In injecting, the needle should be introduced at a point directly at the root of the furrow or furrows—that is, at the junction of the forehead with the nose.

A needle one inch long should be used, taking care not to puncture any of the veins which are found to be very differently placed in various patients. If blood flows from the needle puncture, no injection should be made at that point, but another be chosen which does not give such result, preferably at a later sitting.

The needle should be introduced well upward under the skin so that its point corresponds to the point of greatest depression.

The injection should be made slowly and continued until a tumor, judged to be sufficient to overcome the major deformity when molded out has been formed.

This knowledge can only be gained by experience, and the operator must be cautioned to underinject rather than cause undue prominence of that part of the face.

If, however, his judgment has not been accurate enough, the operator can immediately thereafter squeeze out enough of the filling to give him the desired correction.

If more than a single furrow is to be corrected, he may inject the two center ones, leaving the outer for later operation.

In multiple furrows the injections must be made in conelike form, to give a normal contour to the forehead. The apex of such cone corresponding to a point at the root of the nose, and the base to an arc with its greatest convexity near the median hair line of the scalp, depending upon the length of the furrows.

The injections in such cases should be made at least three days apart, two being made at each sitting, after the central or two inner depressions have been raised by the first operations. These later injections should be made to relieve the furrows lying next to the median, gradually working out to each slant side of the cone until the contour of the middle forehead has been made normal.

Never superimpose an injection about the median line until the major defect in general has been overcome, and only then when the first injections have become settled and organized, as such untimely disturbance is liable to set up considerable reaction, with enough induration and resultant new connective-tissue formation to cause a decided lumpy or protuberant appearance of the part.

The mixtures of low melting points should be preferred to the harder variety in frown corrections. They lend themselves to better molding, and seem to undergo organization with less pathological change than those of the latter class.

When the injections must be made over the inner third or half of the eyebrows, as is often the case, they should be made well above the hair line and molded out in an upward direction, to avoid the dropping down of the mass into the upper lids or to prevent the resultant displacing connective tissue from involving them.

If the upper lids do become involved, as shown by fullness, hardness, and partial ptosis, the connective tissue causing the same must be carefully cut out from the lid by a transverse semicircular incision made in the upper lid along the line of its backward fold or hinge. If need be, an elliptical strip of the skin of the lid may be removed at the same time to give better scope to the extirpation under consideration.

The author has recently corrected two such cases where a surgeon had hyperinjected the entire forehead with a combination of oils at one or two sittings. The resultant involvement and later discoloration of the lids at the end of a year’s time might have been expected.

Such wounds, when neatly sutured with No. 1 twisted silk, leave surprisingly little scars; in fact, the cicatrices are rarely ever detected a few days after healing has been established.

The treatment post-injectio for all furrow protheses should be as already laid down.

Apart from general surgical cleanliness and an antiseptic powder, the blepharoplastic operation mentioned required no special attention. The sutures may be removed in forty-eight hours.

TEMPORAL MUSCULAR DEFICIENCY

_Unilateral and Bilateral_

This facial defect while possibly unilateral, as in hemiatrophy, is generally met with in the bilateral form due to either hereditary causes or a lack of nourishment of the parts, the latter usually involving the greater part of the face. Chronic diseases and the cachexia dependent upon disease may be the origin, in which the deformity is rarely ever overcome entirely by internal treatment and massage of the parts; if anything, massage tends to elongate the skin about the temples, causing a worse disfigurement in the form of numerous fine furrows.

The correction of the defect under consideration may be readily overcome by repeated and careful injections of a hydrocarbon of low melting point.

The author prefers the use of sterilized vaselin injected in its cold state. The use of paraffin of high melting points or its compounds is not advisable, and if employed leaves the temples uneven or lumpy, due to the unequal organization or new tissue formation caused thereby, at the same time causing sagging of the skin of the adjacent parts, particularly the upper eyelids, owing to the added weight of the new tissue growth occasioned by such preparations.

Contrary to general expectation, this part of the face is readily injected and corrected.

The skin should be pinched up with the thumb and forefinger of the left hand and the needle introduced with the right hand in such way as to exclude the puncturing of blood vessels.

To assure the operator against such difficulty the needle may be withdrawn after insertion, and if blood does not trickle from the wound it may be reintroduced without pain to the patient and the injection begun.

It is not advisable to correct the defect at one sitting. One third or one half of the depressed area may be overcome by one injection. The resultant tumefaction must then be thoroughly molded out, until little seems to have been accomplished by the injection.

The operator trusts in these particular cases more to the development of new connective tissue than in any other part of the face, except perhaps in the correction of an interciliary furrow. It is surprising how much is attained by the most conservative injections in and about the temples.

The molding of the injected mass must be done in a superio-posterior direction to avoid forcing it into the upper eyelids, resulting in the same overdevelopment previously referred to.

Both temples should be injected as advised at one sitting. The use of the ethyl-chlorid spray makes the operation less fearful to the patient.

Subsequent injections should not be done earlier than three weeks or until any discoloration of the skin of the parts has disappeared. The latter is not an unusual occurrence, and is undoubtedly due to the pressure of the injected mass upon the numerous blood vessels found there.

The post-operative treatment should be followed as heretofore advocated.

DEFORMITIES OF THE NOSE

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.

When a total rhinoplasty has to be undertaken the paraffin group of protheses of course cannot be resorted to, owing to a lack of the necessary retentive walls of tissue, except perhaps in such cases where the so-called double flap, or French method, is employed, and there only after the parts have become thoroughly organized.

A somewhat complete tabulation of nasal defects has been given heretofore which gives an excellent idea of the extensive use these hydrocarbon injections may be put to.

Such nasal deformities as are amenable to this method of correction may be due to either congenital causes, lack of development, direct violence, ulcerative changes following catarrh, syphilis, and tubercular disease. In some cases, however, the defects are purely of a cosmetic nature, and not considered as abnormalities except by the critical eye of the patient. This is true particularly with lobular and supra-alar deficiencies, as well as a slight lack of contour about the anterior line.

In some instances the defect may be an acquired one, as in the lateral deviation known as handkerchief bend.

A specific and somewhat elaborate classification has been given to the more important and distinctive deformities of the nose, principally to facilitate the proper citation and recording of cases.

It may be readily understood that each one of these classifications may be further subdivided, but such subdivision can be only of the degree or extent of the deformity, and must be left to the individual operator and his thoroughness of observation and nicety of recording.

The author prefers making a plaster cast of the entire nose which is to be corrected, and a second cast after the operation has been completed, or at the time of his discharge. 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. This requires a waste of valuable time; not to speak of the expense of making pictures of a pathological nature. The better way would be to have an apparatus in the operating room. The surgeon can then pose his patient against a screen background in the position and to the size of picture he may desire. Plate cameras and time exposures are best for this purpose. For recording and half-tone reproduction silver prints are found best.

For all deformities of the anterior nasal line a hydrocarbon compound of the higher melting points should be used. This should be injected in the cold form. The mixture given on page 39, with perhaps an added half dram or dram of paraffin, has been found excellent, the addition of paraffin being made to assure a suitable fineness of contour and width. The softer mixtures are more liable to cause a lack of contour and a consequent widening of the part injected, even after molding, because of the contractility of the skin overlying the injected mass, which tends to flatten it out, giving the nose a less artistic and delicate appearance.

Furthermore, a soft mixture will be found to be inefficient in overcoming the tension of the skin in most cases, especially those about the middle third of the nose.

In some cases of lateral deformity, and where otherwise mentioned, it is advisable to use only a mixture of the lower melting points, as in the case in the correction of interciliary furrows and temporal muscular deficiency.

=Superior Third Deficiency.=—The degree of depression about the superior third or root of the nose varies considerably. The most extensive form may be commonly found in the negro nose, where there is almost an absence of a rise in that part of the nasal bones. Such noses are also found in the Chinese and Japanese. The condition ofttimes may be associated with epicanthus.

Epicanthus, formerly corrected by an elliptical excision done anteriorly, can be entirely overcome by the subcutaneous injection method, thus not only avoiding the resultant linear cicatrix, but building up the depressed nose to its normal contour.

The skin overlying most of the defects of the superior third is usually found to be loose, hence injection is readily accomplished.

ANTERIOR SUPERIOR THIRD NASAL DEFICIENCY AND CORRECTION THEREOF.]

The needle should be introduced laterally and anterior to the angular vessels to prevent their occlusion and injection. The point of selection is made at about the middle of the deformity. The needle is introduced until its point lies in the center of the depression, or at the median line from the anterior view.

The mass is injected slowly as the skin of the nose is pinched up between the forefinger and thumb of an assistant.

The part is injected until a tumefaction, equal in body to the extent of the deformity, is attained.

The needle is allowed to remain in place for a moment, to permit of a stoppage of the threadlike mass, usually following the pressure applied to the piston, after the operator has stopped turning the screw. This will prevent the mass from following into the channel made by the needle, or the backing up of the mass, as it were. Should this occur the paraffin mixture should be squeezed from the skin opening to prevent the formation of an intercutaneous encystment.

Immediately the needle is withdrawn the operator places a finger tip over the opening and proceeds with the thumb and forefinger of the right hand to mold the mass into the desired shape.

The post-operative treatment should be as previously given, and is the same with all injections about the nose, so that it will not be referred to again under this heading.

While a fairly large defect can be corrected at one sitting, it is advisable to rather reinject one or two weeks later to secure the exact shape.

It is to be impressed upon the operator that there is always a slight broadening of this part of the nose following the development of the connective tissue which takes the place of the injected mass, hence the injection should not be overcrowded nor the parts overcorrected.

The mass should be molded out as narrow as possible and be pinched between the fingers by the patient two or three times a day after the reaction has subsided, which is usually about the third day. This procedure will keep the mass from being flattened during the time tissue replacement takes place.

=Middle Third Deficiency.=—This defect is commonly seen in football players and pugilists as the result of a breaking of the inferior extremities of the nasal bones and the displacement of the articulating cartilages, although the defect is often seen as a result of an injury to the nose early in life, causing a lack of development in the superior or articulating extremities of the cartilages. Nondevelopment from catarrh, syphilis, and intranasal disease are other causes. This type of deformity is generally designated as the saddle nose.

In the latter cases the skin is usually bound down to the cartilaginous structure by cicatricial bands, and needs to be liberated. This is accomplished subcutaneously with a fine tenotome introduced laterally.

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. Their re-establishment would mean an unequal development of the new connective tissue springing up from the injected mass, thus defeating the object of the operation.

If no dissection has been done the defect should be corrected about two thirds and added to by a subsequent injection.

The mass in either case should be well molded out, especially at both sides, to keep the nose as narrow as possible. There will be more or less widening ultimately following the organization of the mass.

ANTERIOR MEDIAN THIRD NASAL DEFICIENCY AND CORRECTION THEREOF.]

It is not uncommon to find a dividing wall of subcutaneous tissue about the articulation of the nasal bones and cartilages, as evidenced by a rising up or down of the injected mass above or below this line. If this be found, rather than break down this wall with the injection, it is deemed advisable to inject each chamber separately and mold the two masses after injection, as in the ordinary type of cases.

=Inferior Third Deficiency.=—This deformity of the nose is due purely to a lack of development or a luxation of the cartilage of the septum and the upper lateral cartilages. The point or lobule of the nose is usually tilted upward and the subseptum curved upward at its middle third.

The cause of this deformity is usually due to direct violence at some time in life, with improper replacement at the time of injury. Syphilis and intranasal catarrh, lupus and ulcerative diseases, are also causes.

The skin overlying the defect may or may not be closely adherent, but is in most cases rather thickened and inelastic. It is therefore necessary, in most cases, to loosen the skin by subcutaneous dissection, done as already described before the injection is made.

To rebuild such a nasal defect without dissection, except in such instances where the skin is quite elastic, is not to be advised, since the injected mass would be flattened, more or less, antero-posteriorly, giving the nose a broad and ugly appearance after the connective-tissue formation has been attained.

It is with cases of this kind that paraffin injections introduced in the liquid form and of high melting points are usually expelled in a week or ten days, or even later, subsequent to a breaking down of the surrounding tissues and the resultant abscess.

The best preparation to employ is the form of paraffin mixture advocated in the preceding operation used in its cold state and injected slowly, after the integument has been rendered mobile enough to permit the desirable correction.

ANTERIOR INFERIOR THIRD NASAL DEFICIENCY AND CORRECTION THEREOF.]

The defect should not be corrected in one sitting, for the very reason that some widening of the nose may take place, owing to the contractility of the skin, post-operatio.

The mass injected should correct the major part of the defect and be molded out carefully, especially from both sides of the nose, and the patient be instructed to pinch the nose laterally several times a day after the reactive inflammation has subsided with the object of keeping the nose as narrow as possible.

After the mass has been thoroughly replaced with connective tissue and the anterior line is found to be too depressed, a fine line of the mass about the thickness of the needle may be injected over it in a vertical direction, the point of a fairly large needle being introduced just above the anterior aspect of the lobule and thrust upward to the superior border of the now existing deformity, and be slowly withdrawn as the mass is injected.

This will leave a rounded cylindrical-like mass along the anterior nasal line, which must not be molded at all, except to soften or shade off the superior and inferior extremities.

The author advocates making two such injections, at the same sitting, when the deformity has persisted. These injections are made parallel to each other with a distance of about one eighth inch between them.

The subseptal deficiency will also have to be corrected. This will be referred to later under its separate division.

The reaction in cases of this type is usually more severe than those just mentioned. There may be considerable swelling and discoloration, but by following the methods of treatment laid down heretofore the symptoms usually subside in two or three days.

=Superior Half Deficiency.=—In this type of deformity there is found a nondevelopment of the bridge of the nose, while the greater part of the cartilage of the septum and the lower lateral cartilages seem to be quite normal in contour. The nose has a dished appearance, with an undue prominence of the nasal base or lower half.

Various causes may be given to this condition, but heredity is responsible in a great majority of the cases.

The deformity in the type under consideration rarely takes in an accurate half of the nose, there being an involvement more or less of the lower anterior half, yet it is sufficiently distinctive to give it specific classification.

For the correction of the defect in such cases the injection is made laterally, the same mass being employed as in the preceding cases.

In this type of case the mass injected should quite correct the defect and be molded with great care to a desired contour, keeping in mind always the condition and elasticity of the skin overlying it.

An inflexible skin should be rendered mobile by digital massage, practiced for a few days prior to operation, or in tense conditions be loosened by subcutaneous dissection.

The great fault in injecting so large a quantity as is necessary in these cases is to make the nose too wide from the very beginning, which, added to the widening following the replacement by new tissue, makes the shape of the nose unsatisfactory.

For this reason it will be found of some benefit to apply an anterior nasal splint of aluminium, covered interiorly with a fold of white flannel or gauze and pressed into such shape that when applied to the nose it will keep the latter pinched up laterally to the desired width. This splint will hardly ever be borne by a patient and causes great discomfort until after the post-operative reaction has subsided. It may then be bandaged or held in place by strips of Z. O. Adhesive plaster for an hour or two in the day and during the entire night.

After the first few days’ wearing the patient soon becomes accustomed to the splint. It should be worn as mentioned for about three weeks, when the patient may be permitted to pinch the nose laterally with his fingers two or three times a week or more.

The secondary injection may be made in the ordinary way or as advocated by the author in the manner described in correcting defects of the inferior third of the nose.

=Inferior Half Deficiency.=—In this type of deformity the greater point of nondevelopment or deficiency is found at the upper extremity of the cartilage of the septum, below its articulation with the inferior border of the nasal bones, and involving to a greater extent the area over the upper lateral cartilages.

This deformity, due to whatever cause, rarely affects the base or inferior part of the nose, owing undoubtedly to the greater protection and stability offered by the lower lateral and sesamoid cartilages and the dense cellular tissue making up the alæ. Except in such cases where violence of an extreme nature has been exerted in early life, or where ulcerative disease has broken down most of the cartilage of the septum, the point of the nose is usually normal in size and shape. In the latter cases there is an upper tilt of the lobule and a shortening of the columna upon itself with a convexity in an upward direction.

The cause of this type of deformity is usually a direct blow upon the point of the nose, syphilitic ulceration internally, catarrh, or other ulcerative disease.

When due to violence the point of the nose may or may not present a normal appearance, there may be a normal base tilted upward (retroussé or snout nose) or a dropping forward and downward (hook or beak nose).

The shape of the nasal base depends much upon the time of life the injury was received—that is, before or long after puberty, also upon the extent of injury inflicted and where applied.

From injuries received early in life we may look to a lack of development in the cartilage of the septum alone, or associated with deficiency in one or both lateral cartilages.

The deformity is usually symmetrical, but where the nasal bones have been injured as well, particularly where one bone is injured more than its fellow, there is a possibility of the disfigurement being unilateral. This is rarely the case except when due to punctured wounds; generally in such cases the anterior nasal line assumes a twisted form.

Some operators have included noses of undue lobular prominence (à la Cyrano de Bergerac) under this type of deformity, and while it is to be admitted such a nose might be built up by subcutaneous prothesis the result is anything but harmonious or normal. 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.

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.

In that case the needle is inserted laterally in a line with the maximum depth of the depression and the point shoved up to the median line anteriorly.

Enough of the cold mixture of paraffin and vaselin, as heretofore advised, is injected to reduce the deformity nearly to the normal.

The mass is molded to give the nose as near a normal contour as possible, always keeping in mind the later broadening of the nose when the new connective tissue has taken the place of the injected mass. A later injection made, as advised heretofore, will restore the anterior line to better form.

If the nasal processes of the superior maxillary bones have been thrown outward considerably a surgical operation is necessary to reduce them.

No injection should be made until the wounds from such operation are thoroughly healed and contracted.

In all cases of this type the skin will be found to be rather dense and likely to be tied down by past inflammations to the anterior aspects of the lower lateral cartilages at their juncture with the upper lateral cartilages. If the adhesions are not too dense the harder form of the cold mixture should be used. This will not only permit of raising the skin more readily than with a softer kind of mixture, but will be more likely to retain its form under the contractile pressure brought to bear down upon it.

When the skin is closely adherent it should be loosened subcutaneously, as already advised. The injection may be done at the same sitting, and be of greater quantity than in the cases where this had not been done, for the reasons mentioned.

Pressure splints and manual compression should be employed as in the preceding deformity.

The reaction following the first injection is likely to be severe. Cold applications, as previously referred to, are indicated, and should be continued for at least two days.

Care should be taken not to inject into the lateral vessels, which usually lie on a line with the juncture between the lateral and lower lateral cartilages. If this should happen, the point of the nose at once assumes a bluish hue, and there is more or less pain felt at once, with considerable swelling a few hours after the injection. Later, every symptom of gangrene of the lobule is liable to be noticed, yet with faithful attention to furthering the circulation of the parts by either cold or hot applications, the active inflammatory symptoms usually subside in ten to fourteen days, leaving the patient with a whole nose, more or less colored at the lobule, according to the state of the circulation and the exposure of the parts to the various temperatures. This may be overcome in time, yet it may persist for years, depending entirely upon the ability of the anastomosing vessels to overcome the artificial thrombus or occlusion offered by the mass injected.

That a reaction quite similar in character, but of milder degree, is likely to be seen when one of these vessels has not been injected, can be readily understood when we consider that a hard and somewhat ungiving mass is made to overlie the vessels themselves. The symptoms just described in such case are apt to be noted much later, even several hours after the injection, because the swelling has then begun to add its pressure to that of the mass in obstructing the flow of blood to the lobule. Such condition may be termed pressure occlusion in contradistinction to thrombotic obstruction.

These symptoms usually subside in a day or two, or with the swelling caused by the reaction.

If the symptoms appear at once after the injection, it is best to force out as much of the injected mass as is possible through the needle hole through which it has been introduced.

ANTERIOR, SUPERIOR AND INFERIOR THIRD NASAL DEFICIENCY AND CORRECTION THEREOF.]

The author was called to attend a case several hours after the operator had injected a nose. The acute symptoms pointed to a direct occlusion of the vessels, yet the surgeon who had performed the operation assured me he had not injected until he found that blood did not flow from the needle after its insertion. To relieve the patient of immediate fright and some pain, a dull pointed needle of larger caliber than the one used in operation was pushed through the needle wound previously made, taking the place of a cannula, and a greater part of the injected mass was squeezed out. Ice cloth applications were followed through the night and the nose recovered in three days without showing the discoloration of the skin usually observed following such cases. The nose was never injected again, on account of the dread of the patient, but peculiarly the anterior line showed almost a normal contour after four weeks had elapsed. This only goes to prove that very much less of the mass to be injected is required than is commonly supposed by operators.

=Total Anterior Deficiency.=—In this condition there is a scooped-out or general curved-in appearance of the entire anterior nasal line. The lobule of the nose is usually normal in size.

This defect should be corrected by two injections of the paraffin compound previously referred to. The points of injection should be lateral and anterior to the angular vessel on the side of the nose preferred by the operator—one about the center or major curvature and the other about the inferior third.

Care should be taken to mold the injected mass as narrow as possible, or as much as the skin will permit. If the latter is bound down it should be mobilized by subcutaneous dissection or levation. A subsequent injection should not be undertaken until the entire mass has become settled or fairly organized, which is about the end of three weeks.

The mass should be injected well up to the root of the nose to give it the appearance of the normal bridge. If this is found impossible owing to a dividing skin attachment, a third needle puncture should be made at a point on a level with the internal canthus.

ANTERIOR TOTAL NASAL DEFICIENCY AND CORRECTION THEREOF.]

Care must be exercised to keep the mass from creeping into the loose tissue about the internal canthi by having an assistant press the sides of the nose at that point with the thumb and forefinger.

This undesirable condition is much more liable to occur when a hot liquid paraffin is employed, since the operator can observe quite accurately the extent and direction taken by the mass injected when the cold product is used.