Chapter XIV: Subcutaneous Hydrocarbon Protheses (4)

Some authorities have injected noses of this type from the point of the nose, but it will be found that the position of the puncture at this point allows a considerable portion of the mass to work out during molding and also to permit of the readier oozing out of the mass during the pressure exerted by what reactive inflammation follows the operation. This is accounted for by the fact that the needle creates a tubelike canal in the tightly bound down tissue overlying the lower lateral cartilages, whereas in the lateral punctures the short canal is easily displaced by the swelling, thus causing its obliteration and preventing the free oozing.

On the other hand, it will be found to be more difficult to inject from the point of the nose alone and that a very long needle has to be used which must be withdrawn as the parts above the point are filled. Furthermore, it will be found necessary to thrust the point of the needle in different directions to overcome vertical attachments of the skin which are more readily lifted up than thrust aside by the mass, hence necessitating a greater amount of injury to the tissues, not to speak of the possibility of injecting transverse blood vessels higher up in the nose of which the operator would not be aware at the time; showing only in the resultant phlebitis and unexpected reactive symptoms, associated with a discoloration more or less lasting according to the extent of obliteration of the vessels.

The post-operative treatment should be as heretofore advised.

=Lateral Insufficiency= (_Unilateral and Bilateral_).—Depressions about the sides of the nose are usually due to hereditary causes, when they are likely to be bilateral, yet intranasal ulcerations may cause a falling-in, as it were, of either one or both nasal walls, involving in such instances the entire side or part of it. In the partial cases the depression may be in any of the division of thirds used by the author—that is, it may lie laterally over the region of the nasal bone and such of the nasal process of the superior maxillary bone as goes to make up that part of the nose, or in the middle third below the bone structure and above the superior limitation of the lower lateral cartilages, or within the lower third over the inferior border of the cellular tissue making up the nasal rim.

Traumatism may be found to be the cause of such depressions, especially in the middle third, after fracture or luxation of the nose. In such cases the defect is usually unilateral or at the seat of the former injury, a convexity usually being exhibited on the opposite side.

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. This is true in most cases unless the depression is of traumatic origin and beyond the size of deformity usually corrected.

The author advocates the employment of a hypodermic needle attached to the syringe in place of the regular needle and that the injection be of sterile white vaselin without additions of any kind.

Such injections may be made very readily, one or more at the first sitting, being introduced below the deepest part of the defect. It is surprising how much four or five drops of such an injection will accomplish. Furthermore, it is to be remembered that the injections about the side of the nose are readily replaced by new connective tissue, equal to, if not commonly greater in amount, than the mass injected, such growth being completed in about two months after the time of injection. This may be explained by a more or less active perichondritis when the injection is made over the cartilage, the inflammation, thus set up, being of longer duration than where the skin and bone or areolar tissue are involved. Any subsequent injection should not be undertaken until at the end of two weeks or more for the reasons above stated.

The injected mass at all times should be introduced under normal pressure, never to the extent of rendering the skin above it white in color. The mass should also be molded out with the tip of the finger or the rounded, dull handle end of a scalpel. If necessary, the small finger may be introduced into the nostril to facilitate this molding. Should the reactive inflammation be severe such remedial agents as have been referred to should be used to reduce it.

Phlebitis following injections at the side of the nose is due entirely to the injection of a blood vessel and must be avoided. When a fine needle is used there is less likelihood of free bleeding from an injured vessel, therefore a thorough knowledge of the usual position of the vessels about the sides of the nose is absolutely essential. Bleeding of greater extent than that which would follow the thrust of the needle through the skin should put the surgeon on his guard. Experience is the better teacher and conservatism in these ofttimes delicate, subcutaneous operations will save the surgeon much annoyance and eventually the need of having the patient submit to a cutting operation to reduce an overcorrected area.

Should a hyperplasia of connective tissue result from such an operation, a small linear incision, under four per cent eucain anesthesia, should be made directly over the greatest prominence, through which the offending mass can be removed by the aid of a small hooked knife or a fine pair of curved scissors.

The mass should be removed beyond the plane of the skin; in fact, it should be rather removed in conelike form, apex inward, and the peripheral attachment completely obliterated, in order to obtain the desired result, as it is not unusual to have the prominence reappear after imperfect extirpation and improper dissection.

Moist pressure dressings may be applied over the small wound thus made, for several days, or until the inflammation following the operation has subsided. Suturing such a wound is hardly necessary, but if the incision be over one fourth of an inch long, two fine silk sutures, deeply placed, may be utilized, their tension adding to the compression needed to bring the mobilized skin into position in reference to the base of the wound.

The author has used contractile collodion in place of compress dressings with very good result. This should be renewed within forty-eight hours.

After eight or ten days silk isinglass adhesive plaster is applied over the wound until it falls off.

=Lobular Insufficiency.=—This defect of the nose is usually of hereditary origin, although it may be occasioned by the retraction of the inferior half of the organ in tubercular or syphilitic ulceration in which the lobule falls inward and upward by the loss of the retaining cartilages.

Owing to the close adhesion of the skin to the lower lateral cartilages and the cellular tissue about the rim of the alæ it is found difficult to restore the contour or elongate the organ at that site by subcutaneous injection.

Even after thorough mobilization of the integument the subsequent injected mass is liable to be thrown off by an overactive inflammatory reaction, due undoubtedly to the adhesions formed between the divided surfaces from the periphery inward which has a tendency to crowd the injected mass forward and downward before a new connective tissue has had time to be formed, causing a breaking down of the skin at some point overlying the mass and allowing it to escape.

The author has attempted to replace the injection by small solid paraffin plates introduced through a small lateral incision made for the subcutaneous dissection, and while the wound healed readily enough and the nose appeared normal, the plates were in every case thrown off by a later inflammatory process before the end of the third week.

The author then attempted to replace the solid plates with granular paraffin, gently packing the latter into the wound until the desired elevation had been obtained with the idea that such mass would accommodate itself much better under the pressure caused by reactive inflammation, but even this procedure proved unsuccessful.

The best results are obtained with sterilized white vaselin injections when there is considerable mobility of the skin. A single needle opening should be made, preferably about the center of the side of the lobule, or slightly anterior to this point, carrying the point of the needle forward to the anterior median line and a little above the actual point of the nose.

The injection should be made slowly, closely watching the size of the elevation caused by the mass and the state of the circulation about the entire lobule.

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 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.

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.

Here, as with lateral nasal injections, there seems to be an overproduction of new connective tissue following such an injection; a decided factor in eventually pleasing the patient.

It is needless to say that the operator must avoid injecting one of the blood vessels of the lobule, as this will cause considerable inflammation from which the lobule does not recover readily, owing to the dense tissue the surgeon has to deal with, leaving the tip of the nose discolored and bluish for some time after the operation.

If the injected mass causes an immediate venous stasis of the lobule, hot applications should be applied at once, or as soon as the operator discovers that the proper massage and pressure to remove the offending mass does not improve the circulation.

The author advocates the judicious use of antiphlogistin, faithfully applied hot every six hours and continued until the acute inflammatory symptoms subside, when the surgeon may resort to ice cloths or cold pack until the danger of pressure and resultant gangrene have subsided.

Despite the very grave symptoms associated with such inflammation, the operator may assure the patient against permanent disfigurement, although the three or four weeks’ duration of treatment, usually required in such cases, is an ordeal the cosmetic surgeon and the patient are not liable to forget.

If the injected mass causing this state of affairs has been of liquid paraffin, the better method to pursue is to make several small incisions into the site of the injections and remove the little masses of solid paraffin as far as possible with the view of relieving the pressure or encroachment, at the same time alleviating the pain and stasis by the resultant depletion. Moist, hot applications should follow this procedure. The small wounds made in the skin will heal without suture, leaving hardly any perceptible scar.

The author, however, advises against any mixture or liquid paraffin injections about the lobule, never having seen a satisfactory result when either had been employed.

The post-operative treatment in uncomplicated cases may be of aristol and adhesive isinglass plaster or collodion.

=Interlobular Deficiency.=—This condition is hereditary in the great majority of cases. The defect, while quite disfiguring, giving the appearance of a cleft nasal point, is easily corrected by the subcutaneous injection method.

Paraffins of high melting points should, however, never be employed for this purpose for diverse reasons: first, the hardening of the mass after cooling causes too much pressure upon the small blood vessels at the point of the nose and results in more or less permanent discoloration of the tip; second, by reason of the pressure of a hard mass, at the end of the nose, considerable inflammation results which usually terminates in the evacuation of the entire mass and consequent cicatrization; third, by virtue of the greater irritating qualities of paraffin a greater amount of new connective tissue than necessary is thrown out, causing a general and hyperplastic rounding of the entire tip of the nose that requires surgical interference to overcome. In the illustration shown the patient’s nose was injected along the entire anterior line and the lobule with paraffin liquefied under heat. A marked post-operative inflammation resulted, with permanent redness of the entire organ and several decisive capillaries showing about the sides and tip of the nose. This was followed in about six weeks by a progressive hyperplasia which left the nose about three times its natural size, and the lobule a hard, ball-like knob of high red color. Several cosmetic operations were required to make the nose appear anywhere near normal, while the electrolytic needling process was resorted to for a number of sittings to destroy the acute redness and the individual vessels showing.

While a great many workers with paraffin deny any beneficial results from the employment of sterile white vaselin for subcutaneous injections, the author claims that in this particular class of deformity it is almost exclusively required.

The vaselin in cold state should be injected directly under the skin overlying the deepest point of the cleft and be slowly continued until the lobule assumes its normal contour. The puncture may be made below the point of the nose.

One such injection usually suffices to correct the fault. The reactive symptoms are not severe if proper technic has been applied, and cold compresses usually relieve it within twenty-four hours.

Should the skin be adherent about the anterior aspect of the lower lateral cartilages, it can be forced away with a small, dull, round-pointed knife resembling an eye spud, the opening for which need not necessarily be greater than that made for the needle. The latter is inserted through the same opening, which must be closed over in this event with a drop of contractile collodion into which aristol is introduced with the pulverflator, which not only embodies an antiseptic, but at the same time hastens its hardening.

=Alar Deficiency= _(Unilateral and Bilateral)_.—The contraction about the nasal rims may be due to hereditary causes or the result of intranasal disease. The defect is usually bilateral, involving the entire alæ or only their lower half or third.

The fault should be corrected by several injections made along the rim of the nasal wing, using a fine needle, preferably of the hypodermic size. Vaselin only should be used and two or three drops, according to the extent of the deformity, be injected into the cellular tissue at the point of each needle insertion.

Three of such punctures may be made along the rim, one beyond the other in each wing. According to the defect the injection may be carried higher or lower above the margin of the rim by shoving the needle upward and toward the inferior border of the lower lateral cartilage.

The reaction in these cases is very little, rarely necessitating other than an antiseptic powder-plaster dressing. Subsequent injections should be made if the first do not give the desired contour; but never until the surgeon is satisfied that the resultant new connective tissue thrown out has reached its ultimate growth.

The harder paraffins, especially those injected in the liquefied state, are not to be tolerated for the reasons given with the preceding method of correction.

=Subseptal Deficiency= _(Partial and Complete)_.—It is not uncommon to find a marked concavity of the subseptum in noses that have sunken in by reason of intranasal disease or traumatism.

This concavity, when partial, is usually most marked near the lobule, but in the complete variety the upward curve may be greatest near its juncture with the lip.

Owing to the usual adhesions formed during the inflammatory period causing the deformity the correction of this defect is quite difficult. As a rule, the skin of the entire subseptum needs to be dissected away from the underlying structure before it will permit of correction by the injection method.

This dissection is advocated and can be readily done from one of the nostrils at a point just beyond the union of skin and mucous membrane.

The dissection under such method can be made more thoroughly than when done exteriorly, for the reason that the entire field is laid open to a free use of the scalpel, leaving no visible cicatrix externally. The dissection may be followed by the immediate injection of the mixture of paraffin and vaselin, as already referred to, used cold, or the area is injected with normal salt solution until the intranasal wound has healed, which usually takes place in about five days. The mucous membrane in such instance may be neatly but not too tightly sutured with No. 1 silk. If the operator deems it advisable he may inject the salt solution again on the third day to prevent the formation of such adhesions as may interfere with the ultimate hydrocarbon injection. This is rarely found necessary.

If the post-operative inflammation prove mild, then the adhesions will not be as tenacious, in which case the surgeon may wait until even the seventh or eighth day before injecting the paraffin compound, to be sure of not forcing the intranasal wound apart under the pressure of the mass injected.

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. It is usually thrown off after a few days of very painful and highly inflammatory symptoms, undoubtedly explained by the fact that the circulation of the subseptum is principally dependent upon the delicate branches of the two small septal arteries of the superior coronary and a hard, ungiving mass would readily cause their obliteration.

DEFORMITIES ABOUT THE MOUTH

=Labial Deficiency= _(Upper and Lower Lip)_.—There are a number of causes creating deficiencies about the labial orifice. The same causes apply naturally to both lips, whether the defect be unilateral, bilateral, or median. Some of these deformities are more often met with than others, as, for instance, a median deficiency of the upper lip following cicatricial contraction due to a harelip operation done early in life; in elderly patients a partial paralysis is found to affect one half the upper and sometimes a part of the lower lip, giving to the mouth a drooped and grinning appearance.

Other causes are dental defects, abnormalities of the alveolar processes, traumatism, and disease.

In those conditions where loss of tissue is responsible for the defect, as in the extirpation of neoplasms, ulcerative disease, etc., it is quite likely that cheiloplasty is required to rebuild the parts, but in many of these cases splendid results may be obtained by the judicious use of hydrocarbon protheses to overcome the usual post-operative oral distortion. It is understood that such injections should not be undertaken until the wounds are thoroughly healed and the cicatricial union fully contracted. This is true also in harelip operations undertaken later in life.

The correction of labial defects coming under this method is not at all difficult, but artistic skill and judgment are as necessary as the surgical technic.

The lips are plentifully supplied with blood vessels, and therefore greater care in injecting a foreign mass into their structure is necessary; furthermore, the lips cannot be placed at rest for any long period of time, so that the mass injected can never be expected to be kept in place if of a consistency hard enough to permit the contraction of the orbicularis muscle to move it about.

From the very fact of this practically constant movement of a part it is self-evident such hard mass could not be retained or held in position for any length of time, unless the mass is small enough not to be affected by the movement, and under such condition the correction of a defect as desired by the patient would require perhaps months to accomplish, owing to the very fact that only droplike masses may be deposited under the skin in perhaps a half dozen places with the necessity of a long period of rest until the injections have been replaced by the new tissue before the next operation could be undertaken.

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; furthermore, the movement of the parts here tends to displace the mass. 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.

Furthermore, the presence of paraffin and the resultant mass of new and hard connective tissue, so well recognized by all experienced surgeons, is not desirable in the lip structure; it makes the lip appear bulky and hard and anything but natural.

It is in these very cases that the injections of cold sterile white vaselin is indicated. After injection the mass may be evenly and satisfactorily molded out, the mass being soft and readily pressed into shape in the various cells of areolar tissue without leaving hard and uneven lumps.

The movement of the lip is not then a source of danger in displacing the mass, since the acute swelling of the lip tissue prevents its free movement for several days, which gives the injected mass an opportunity to establish itself and find its proper place.

Another advantage in using this preparation subcutaneously is that it is less irritating than hard paraffin, permits freer movement, and creates a better production of new connective tissue.

While a part of the mass may be absorbed during the replacement period the lip retains its normal consistency, and if the desired contour has not been attained a subsequent injection may be made in three weeks’ time without interfering in any way with the former result.

The only precaution, aside from avoiding the injection of blood vessels, is to keep the injection from the prolabium or vermilion border. The latter tissue is very prone to fatty degeneration or to yellowish discolorations when such a foreign mass has been introduced into or near its structure.

There is no objection in injecting the lip, upper or lower, in several places, as the cellular network about the mouth is sufficiently dense to prevent the escape of the vaselin injected from the adjacent opening if the distance is not less than a half inch between the punctures.

The injections may be made from above downward in the upper lip and, vice versa, in the lower. They should be begun at the outer angle working toward the median line.

The reaction following such an injection is usually more severe than in any other tissue of the face, owing to the great number of fine blood vessels, but the swelling is readily controlled in two or three days by cold applications.

Aristol collodion dressings over each wound suffice to close the punctures.

In the median variety of defect, where a cicatricial band separates the lip into halves, it may be found necessary to do a subcutaneous dissection before a suitable injection can be done, but in cases of long standing the dividing wall is exceedingly thin and the threadlike adhesions below are quite easily broken up by the force of the injection. The later product of new connective tissue will tend to further improve the contour.

=Nasolabial Furrows= _(Unilateral and Bilateral)_.—This condition in the bilateral form is exceedingly common in adults beyond middle age. It is also found in those individuals suffering from inanition, due to whatever cause. The unilateral form is found principally in patients suffering from semifacial paralysis in which the tissue lacking the proper neurotic supply droops or sags down, causing a deep furrow to appear from the attachment of the alæ to the angle of the mouth, associated more or less by a flattening of the cheek contour of that side of the face.

The method of correction advocated by the author varies entirely from the technic advanced by other surgeons.

The usual method has been to introduce the needle of the syringe at the outer or lower extremity of the furrow and from one of such punctures to inject the whole line of depression.

While this seems right theoretically the method does not give the desired result. Owing to the free movement of the upper lip the mass, at first neatly restoring the contour, is crowded upward into the inferior malar region and very often downward toward the angle of the mouth, where it settles in a hard lump which is not only obnoxious to the sight but interferes with the proper use of the parts concerned in mastication and vocalization. Invariably the operator is called upon to remove the disfigurement.

It can be readily understood that hard paraffin itself, in such case, would prove more objectionable than a softer mass which, upon early discovery, could be molded or massaged into better position, while nothing less than excision would prove efficacious with paraffin.

As with the lip, then, the author advocates the use of either the cold mixture of paraffin, as heretofore described, or the cold white vaselin according to the operator’s opinion in overcoming the extent of the fault. For all ordinary cases white vaselin alone is necessary.

The technic of injection as used by the author is as follows: In the ordinary case when the furrow is not too pronounced one sitting only is required. Two needle punctures are made above the upper line of the defect, the first being made about one half inch from the wing of the nose and the other about one inch outward and downward.

The needle is pushed downward under the skin until its opening corresponds to the median line or deepest part of the furrow. Enough cold white vaselin is injected to bring the depressed area slightly above the plane of the skin of the upper lip. The second puncture is made perpendicular to the first and the injection made in the same manner.

With the tip of the indicis over the first needle opening the mass is molded out evenly by a gentle rocking or rubbing movement. The same is done with the second mass.

It will be found, then, that the two masses are made to meet at about the center of the furrow, leaving a slight wall of tissue between them. This wall has the virtue of preventing the falling down of the upper mass, at the same time dividing the quantity of the injected mass into two, and lessening the weight.

If the condition is bilateral both sides are operated on at the same sitting. If subsequent injections are needed they are done three weeks later, the punctures being made between the former first and second punctures and the second and outer border of the furrow. In this way the entire site is filled with a series of injections.

If the surgeon desires he may increase the number of these needle punctures at the first sitting, making them nearer together in that event.

It will be found necessary in some cases to inject the cold mixture of vaselin and paraffin into the furrow directly below the wing of the nose, since the integument at that point requires a mass somewhat harder than vaselin to force and hold it up.

The rest of the furrow must, however, be injected with vaselin alone, for the reasons already given in parts that are movable.

The reaction is rarely very marked and subsides in about three days.

Gentle massage may be permitted above the site of injection to keep the mass from crawling into the cheek. This is done by gently stroking the skin from below upward toward the nose on a line an inch above the original depression.

The dressings are the same as before mentioned, although collodion painted over the needle openings is most serviceable after having sponged off the sites with absorbent cotton dipped into absolute alcohol to remove the vaselin that may have exuded from the openings during the molding-out process.

=Oral-Angular Furrow.=—These furrows occur at the corners of the mouth, running downward upon the anterior chin. Small as these defects appear, they are found difficult of obliteration, for the reason that the tissues are more or less under constant movement during the waking hours. Repeated injections, each of small quantity, are necessary. Hard paraffin is contra-indicated.

The injections are made from above the defect downward at right angles to the defect.

It will be found difficult to keep the mass from being expelled on account of the movement, there being more or less oozing from the puncture, but if the openings can be controlled for at least twenty-four hours this danger may be overcome to a great extent.

Ethyl chlorid may be sprayed over the part immediately the needle is withdrawn to set the mass and followed with a drop of collodion. The patient is advised to keep the mouth as immovable as possible for the rest of the day.

The reaction is never severe, and is easily controlled by cold applications. If, after one week, there is shown a tendency to sagging of the mass, it should be gently massaged upward with the finger several times during the day for at least two weeks; this will keep it in place, and allow nature to replace it with new connective tissue when desired.

DEFORMITIES ABOUT THE CHEEKS

=Deficiency of Cheek= _(Total and Partial)_.—A total lack of proper contour of the cheek, generally termed flattening, may be due to hereditary causes, but is generally dependent upon a cachexia due to a general disease, or fatty degeneration of the muscular structure of the cheeks, as found in those beyond middle age.

A partial deficiency of the cheek or cheeks is usually hereditary, but may be dependent upon digestive disorders or other causes of malnutrition.

This class of deformity is found more often in women than men. It is usually bilateral.

Unilateral cheek deficiency, whether partial or total, may be congenital, but is often the result of a local paralysis causing hemiatrophy. Traumatisms early in life or during birth and amputation of the inferior maxillary are other causes.

This class of deformity is quite readily corrected by subcutaneous injection; in fact, it is the only known method of merit, superseding the former resort to partial correction by massage or artificial and temporary correction by the wearing of plumpers in the buccal cavity.

The method of procedure is the same in all cases, the number of injections and quantity varying, of course, with the extent of the defect.

As with the rebuilding of the contour of the lips so with the cheeks, which must of necessity be mobile and flexible, the injection of hard paraffin is out of the question. The author has observed a number of such cases, and is free to say that in each case the result was not only abnormal in appearance, but a source of great annoyance to the patient.

What is worse is that the paraffin once injected can never be removed except in places where an actual encystment has taken place, in which case the hard mass may be removed through a small incision made directly over the mass and introducing a grooved director into the opening then by the rotation, or to-and-fro movement of which, combined with digital pressure, the cyst is evacuated. Once the mass is replaced by a network of connective tissue it could not be removed except by an extensive dissection and extirpation, which leaves behind it cicatrices far worse than the appearance of the parts before operation.

The author injects cold sterile white vaselin below the skin here and there about the cheek at the sites of deepest deficiency.

These injections may be made under ethyl-chlorid anesthesia.

Each injection is carried to the extent of causing a lump below the skin, the quantity being judged from a thorough experience with similar cases.

After the injections have all been done, the thumb of the right hand is passed into the mouth against the buccal mucous membrane of the left cheek and the index finger over it externally or on the skin surface. For the right cheek the index finger instead of the thumb is placed in the mouth. The mass or lumps are now gently pressed into the desired shape and thickness by the aid of these two fingers. A few drops of the mass may be forced out of the needle holes under this procedure, but this is of no consequence when it is considered that from one to two ounces may have been injected into each cheek.

This gliding form of massage should be continued until the entire cheek presents an even and rounded-out appearance.

It will be found, in the majority of cases, that the integument of the cheeks about the region of the inferior border of the zygomatic process is rather firmly adherent, and that a subsequent injection will be necessary to elevate the cheek at that point.

Injections over the malar bone are prone to cause severe reaction, leaving a puffed appearance just below the eyelids. This may be more or less permanent and is very undesirable. It should be avoided by injecting very small quantities at that site. It is always safer to add a little subsequently.

The reaction, generally, is not severe, and is readily controlled by cold applications, yet the author has experienced considerable swelling and tenderness in two cases of total cheek deficiency corrections which lasted for several weeks after the operation, giving excellent result eventually, however. Such symptoms are dependent upon circulatory interference, but resolution should take place without untoward results with judicious treatment, unless the operator has been negligent by injecting one or more blood vessels, in which case the resultant thrombosis may cause breaking down of the subcutaneous tissue, abscess, evacuation of the mass, and possibly death in part of the integument. The precautions referred to in avoiding any such possibility have been fully given heretofore.

Never should the operator hyperinject the cheeks, even if the patient insists upon looking like a puffed ball. He should be satisfied with a normal contour, and truthfully assure the patient such hyperinjected contour could not be retained owing to the weight and dropping down of the mass before nature could properly replace it by organized tissue.

Subsequent injections may be made about three weeks after the first sitting.

With nervous and hypercritical patients the surgeon may elect to give the patient a number of sittings, injecting only small quantities at two or three places each time. 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.

Massage of the cheeks after the replacement period is not to be tolerated. It tends to create hyperplasia by circulatory stimulation.

It is not unusual to have the patient tell you that for weeks after the replacement period the cheeks are swollen considerably in the morning upon arising, going down gradually during the day.

This is due to the spongy or loose character of the new tissue caused to be formed by the foreign mass, which gradually takes on a harder and more compact form.

The post-operative dressing will be either adhesive isinglass plaster or collodion. With the former, moist applications during the stage of reaction are not permissible.

DEFORMITIES ABOUT THE ORBIT

=Deficiency of Lid Contour= _(Upper and Lower Lids—Unilateral and Bilateral)_.—The lack of contour in the eyelids is not as frequently met with as redundancy of their integumentary structure; there are cases, however, where the eyes seem to lie deep in their sockets, owing to a sinking in or a collapse of the surrounding lids.

This condition is often found to be hereditary, in other cases it is the result of malnutrition, a peculiar lack of adipose tissue about the orbit for no known reason, or fatty degeneration in past middle life.

The fault is usually bilateral. In rare instances trauma about the orbital borders may result in lack of nutrition. Such cases are usually unilateral, and the upper lid is affected in the majority of cases.

The correction of these defects is found to be rather difficult, owing to the thickness of the tissue under consideration.

The use of hard paraffin plays havoc with eyelid tissue, rendering it hard, immobile, and causing a hyperplasia of the new connective tissue formed thereby, as well as the peculiar yellowish pigmentary spots of irregular form resembling on casual inspection xanthalasma. This discoloration has been fully described earlier in the work.

The author has had occasion to remove these hard irregular masses investing the lower lid in several cases where paraffin had been injected, also two cases in which the pigmentary discoloration involved both upper and lower lids associated with the same hard fibrous masses. Excision under local anesthesia and silk suture was the method of correction employed.

From an experience of twenty-two cases the author believes these conditions most amenable for correction by the injection of sterile oils in preference to any other substance. Even white vaselin does not here seem to answer the purpose, owing to its stimulating property of causing the resultant growth of connective tissue.

While vaselin injected in the lids causes less of this new tissue to be formed, such tissue is never of the consistency required. This is especially true of the upper lids.

The oil injected, sterilized sperm oil being employed by the writer, is prone to absorption of more or less degree, but the result is gratifying, and lasts from six months to one year, leaving no untoward effect.

If the absorption has been sufficient to leave the parts as before the operation, a subsequent injection of the same character may be undertaken six months from the time of the first or even later, as the patient may choose.

The tissue of the eyelid is prone to swell immediately the oil is injected, and this swelling is entirely out of proportion to the quantity introduced. This edema, due to a retardation by pressure of the blood supply, is very misleading, the operator believing the parts overinjected. A screw-drop syringe is therefore absolutely required.

A fine hypodermic needle is used, and after a few drops of the foreign matter have been injected, the lid should be massaged gently with the tip of the indicis, employing the circular movement.

The injection should be made at the outer end of the lid about one fourth inch above or below the canthus for upper or lower lid respectively.

The needle, slightly dulled, should be long enough to reach the full length of the part to be injected. Its course can be readily seen under the thin, overlying skin.

As the injection progresses slowly and evenly the needle is withdrawn.

A second puncture or injection should not be made at one sitting; if the parts are underinjected the operation is repeated as soon as the swelling of the lid has subsided, which is about the end of the fourth or fifth day.

The reaction, apart from the edema, is very little, although there may be more or less discoloration of the parts, as the result of the obstruction offered the blood vessels.

This is always an alarming symptom to the patient, but passes away completely in the usual manner in several days.

The post-operative dressings may be collodion or silk protective.

Cold or hot applications, as may be best borne by the patient, can be used; they tend to reduce the puffing and lessen the ecchymosis. The patient should be instructed to lie with the head higher than usual for the first two nights to retard the edema.

=Furrow about Canthus= _(Unilateral and Bilateral)_.—This condition is commonly called “Crow’s Feet,” and is, in the majority of cases, due to advancing age, but is acquired by habitually contracting the eyelids, as in laughing or grimacing. It is particularly noticeable in persons employed in the drama.

The defect is usually bilateral, but may exist at one side only in rare cases.

The correction is easily accomplished by this method of subcutaneous injection, although a reduction of the furrow alone does not suffice, leaving a lump or elevation at the site. The author shades off the injection, as it were, making the site somewhat conelike, the apex being at the canthus and the base outward toward the hair line of the temporal region.

Sterile oil should be injected near the canthus, where the overlying integument is delicate. One such injection, covering an area of the diameter of half to three fourths of an inch, should be made, and thus backed up or built outward with two or three injections of the white vaselin, as described under temporal muscular deficiency.

The hypodermic needle should be used near the canthus, and the regular one over or about the temple.

The reaction near the canthus is similar to that with lid injections. The same post-operative treatment as with the lids should be employed.

=Deficiency of the Ocular Stump.=—It frequently happens that by reason of extensive inflammatory disease and adjacent adhesions of the eye, a greater part of the globe must be excised than in the usual case, whether the operation be an ordinary excision, the Mules’s evisceration or the Frost modification of the latter.

In such event the granular button or the stump made of Tenon’s capsule is too small to permit of the placing and retention of the artificial eye. In other instances the stump is so contracted that while the artificial eye is retained it must of necessity be allowed to rest deep in the socket, destroying the entire contour of the orbit. Again in the enucleation operation so little of Tenon’s capsule engages the artificial eye that movement is entirely destroyed, particularly when the Mules’s glass globe has not been introduced.

Excellent results may be obtained in some of these cases, others are not amenable to the injection method because of a lack of sufficient stump to inject, and the danger of injecting through the posterior wall of the capsule, the mass in part escaping into the orbital apex, where it is liable to impinge sufficiently upon the remains of the optic nerve to cause sympathetic inflammation of the normal eye. A condition at once not easily corrected, proving dangerous to the sight of the healthy eye, and possibly producing a fatal termination.

It is with the use of paraffin, liquefied by heat and injected in this state, that such fatal cases as have been placed on record have been operated. The liquid mass under pressure forced into a soft pultaceous mass cannot be easily controlled, if at all, and accidents here are of more serious import than in any other part of the human anatomy, apart from the direct injection of a facial artery of sufficient size to produce an alarming embolism and death.

The author cannot speak too forcibly against such irrational procedure. Other surgeons are beginning to realize the danger of the use of hard paraffin injections near the eye.

The proper and safe method of improving the stump is to introduce into it, under local eucain or cocain anesthesia, small masses of the mixture of vaselin and paraffin in cold state. These injections into the stump and mucous membrane should be done several weeks apart, always keeping a respectful distance from the remains of the optic nerve.

The injections should be begun as near to the surface as possible without breaking down the tissue by necrosis, keeping in mind that one or two of such successfully introduced masses will do much toward supporting the artificial eye.

If necessary the mucous membrane back of the palpebral rim can be injected in like manner to give firmer hold to the eye and at the same time give support to the usually depressed and atrophied lids.

Wet dressings are applied to allay the reactive inflammation, which should be proportionate in severity to the amount of the mass injected.

In three cases operated upon by the author excellent results were attained, and no untoward results had been experienced two years after injection.

DEFORMITIES ABOUT THE CHIN

=Anterior and Lateral Deficiencies.=—An anterior lack of contour of the chin is generally regarded as of the receding type. With this is usually found a bilateral lack of form, especially in men. With a generally well-formed face such a chin gives it a weak and ofttimes a degenerate appearance. In women a deficient chin is not as noticeable, because of the smallness of the face in general and the predomination of the oval type.

The lack of prominence about the chin may be anterior only, the broadness being sufficient, due to a lack of development of the mental process, or it may be deficient laterally with a pronounced mental prominence, giving it a sharp, protruding, or pointed appearance, or the lack of form is combined, as is commonly the case.

Such chins may be made to appear normal, and even ideal, by the subcutaneous injection method. The type of chin most favored by American men is the square angular, now so plentifully seen in pen-and-ink illustrations.

The tissue of the chin lends itself readily to the building-up process. Almost any form may be attained by the judicious employment of the method under consideration.

PROFILE VIEW, SHOWING CORRECTION OF ANTERO-LATERAL DEFICIENCY ABOUT CHIN.]

While it is true excellent results may be obtained with hard paraffin, used in liquefied form, it can often be shown, however, that the paraffin injected under pressure will run down in narrow, pencil-like streams underneath the chin and skin of the anterior aspect of the neck, where they may be felt afterward as hard oval cysts or of elongated form. This is not possible when the cold mixture of vaselin and paraffin is used, since the position of the mass can be easily followed with the eye or felt with the fingers.

The injections should be made from either angle at the first sitting. Enough of the mass should be introduced to leave a ridgelike formation across the anterior chin, varying in thickness according to the shape of the chin previous to operation and the form desired.

It is not well in chins of very deficient type to attempt to make the anterior contour as it should be in the first sitting. Too much pressure would be required, and unless the skin was freely movable considerable reactive inflammation would result, with possible necrosis of the skin in part and consequent expulsion of the injected mass.

The anterior line of such chins should be rebuilt in several sittings, always waiting for the parts to become normal in appearance and sensitiveness.

This method helps to stretch the skin, allowing of further injections and the introductions of a greater quantity than could be introduced at one time only.

The author advocates making two or three sittings of the anterior restoration of contour and two for each angle.

The angles of the chin are injected at a point about midway between the mental process and beginning of external oblique line. The mass is injected as near the inferior ridge as possible, and somewhat above the attachment of the platysma myoides muscle.

FRONTAL VIEW, SHOWING CORRECTION OF ANTERO-LATERAL DEFICIENCY ABOUT CHIN; ALSO CORRECTION OF DEFICIENCY OF CHEEKS.]

Only one needle insertion is made at each angle, and the mass is injected until a round elevated tumor is attained, which is pinched or squeezed with the fingers into the desired angular form, one finger being placed over the needle opening to avoid squeezing the mass out.

It can be readily seen that with this puttylike mass much better results than with the comparatively soft vaselin could be obtained while with the liquefied paraffin the operator would be at a loss to know just what had been accomplished until the mass had become fairly solidified, and then often finding the semisolid mass, which required rapid molding to give the desired shape before it would become hard and unmanageable, in a different position and much more distributed than he had expected.

For the latter reason repeated small injections have been advised, but the author believes oft-repeated injections of paraffin in a small area are prone to set up considerable disturbance, and that the resultant tissue replacement is interfered with. Furthermore, the injected mass would eventually be in grape-bunch like form, and in that condition not as manageable or inducive to the establishment of contour angulation, such as is required in the chin. The final appearance of chins thus rebuilt is heavy and rounded, lacking the concavity above the inferior prominence along the anterior line as well as the angulation laterally.

With the cold mixture advised a considerable mass may be injected at one sitting, which is easily molded into form and which retains that form unless the reactive inflammation is severe. This should not follow unless actual hyperinjection has been done or an unclean product has set up an infective cellulitis.

When the chin is uncommonly peaked, or small, it may be found necessary to inject both sides of the chin beyond the angle and in an upward direction slightly below and following the external oblique line.

Such deficiency may be found decidedly unilateral as a result of lack of development of one half of the lower maxillary bone, a resection of either maxilla for whatever cause, imperfect union following fracture or disease of the bone early in life.

In such cases the lateral deficiency must be first restored, using the same method, before the chin proper can be built up. Ofttimes the lower cheek of the affected side must also be injected. This should be done after the site overlying the former body of the maxilla of the affected side has been rebuilt. The cheek should then be built out above this hard linear mass by the injection of cold white vaselin, as heretofore referred to.

The following illustrations show a chin deficient anteriorly and laterally before and the result after correction.

The post-operative treatment should be collodion dressing, followed by cold antiseptic applications for at least two days. The latter ameliorates the inflammation and helps to retain the molded shape of the mass. Subsequent sittings may be made one a week or ten days apart.

DEFORMITIES ABOUT THE EAR

=Pro-auricular Deficiency= _(Unilateral and Bilateral)_.—A deep furrow in front of the ear may be found unilateral in hemiatrophy of the face, but the condition is usually a bilateral one, due to malnutrition or the fatty degeneration of past middle age. In the latter case the depression is accompanied by a redundancy and wrinkling of the skin.

Owing to the close proximity of the large temporal vessels a hard mass should never be injected subcutaneously for the relief of this condition. Even the mixture of vaselin and paraffin has caused considerable reaction when injected to overlie these vessels.

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.