Chapter XIV: Subcutaneous Hydrocarbon Protheses (5)

A cellulitis following such an injection is exceedingly troublesome, the injected mass being thrown off usually at the base of the furrow, which is followed by a low type of inflammation with a protracted oozing of serous exudate. Should such a case come under the care of the surgeon, thorough cleansing of the affected site under scrupulous antisepsis should be done at once, and wet antiseptic dressings be applied daily until the wound is entirely healed.

A plastic skin operation must be done in most of these cases to overcome the ragged cicatrix formed upon healing of the wound. This should never be undertaken until the wound has been healed for several weeks at least.

After the injection of the parts cold antiseptic dressings should be applied at once, and kept up until every sign of reactive inflammation has subsided. At no time should the subsequent injection be undertaken before a month has elapsed from the time of the former operation.

=Post-auricular Deficiency.=—This defect is invariably unilateral, and then the result of a mastoid operation.

The skin about the depressed site will be found to be more or less firmly adherent, necessitating subcutaneous dissection before an injection for correction can be undertaken.

In this case the cold mixture of vaselin and paraffin is indicated, since the softer products will hardly suffice to elevate the tense skin. If the former surgical operation has been done some time previous to the required injection the parts may at one or two sittings be restored to a fairly normal contour, depending entirely upon the amount of ungiving scar tissue at the site. If the parts are tender and not reduced to normal, the injections should be made frequently, about ten days apart, injecting a small mass across and through the subcutaneous scar attachment at each sitting.

The reactions following such injections help to tease the scar away from the bony tissue, but should not be sufficient to cause extensive inflammation.

The same mode of post-operative treatment as has been given with pro-auricular corrections should be followed.

SPECIFIC TECHNIQUE FOR THE CORRECTION OF DEFORMITIES ABOUT THE SHOULDERS

Deficiencies about the base of the neck and the shoulders are very commonly found in women. These defects are usually bilateral, except in rare cases. The much-desired contour is readily restored by the subcutaneous-injection method, and since the technic for one part is the same as for the whole there is no need to dilate specifically upon the treatment of each part.

The author advocates the injection of cold sterile white vaselin only, for the restoration of the contour about the neck, anterior and posterior shoulder, and the mammæ, except in the unilateral correction of a flattening of the breast following amputation for the removal of neoplasms, when the mixture of white vaselin and paraffin should be used, owing to the tenseness of the skin following the excision of a large part of the integument covering the diseased gland.

In the restoration of the contour about the neck and shoulders it is well for the surgeon to familiarize himself thoroughly with the superficial veins of the parts, since the vessels here are larger, and the introduction of foreign matter into them is liable to lead to serious and even fatal results.

The injections should never be made until the operator has assured himself of the fact that a vessel has not been entered into, and then only should a small quantity of the mass—i. e., about two or three drams—be injected at one point.

The easiest mode of introducing the needle is to pinch up the skin between the fingers of one hand, introducing the needle into the fold thus raised. As the mass is injected the skin should be raised by aid of the needle, so as to allow all the immediate room possible for its reception.

The mass injected is at once molded down flat with the thumb or forefinger.

A number of such injections may be made at both sides at the one sitting. The ethyl-chlorid spray may be employed to render the parts less painful. At no time should the entire shoulders be filled at one sitting, for fear that the reaction may be severe or that for any unforeseen cause infection results which would in such instance be indeed difficult of treatment, eventually leaving the parts scarred and unsightly.

Nor should the mass be injected intracutaneously, a fault sometimes observed about the base line of the neck anteriorly and laterally where the operator has been timid in avoiding the exterior and anterior jugular veins. Such injections invariably result in abscess, or when not extensive enough to cause necrosis the skin assumes a more or less permanent red or yellow discoloration over the site so injected.

The treatment for the partial or total removal of such spots has been referred to.

In the average case of contour restoration of the shoulders about eight sittings are required, two sittings being given each week, and as many injections made as is deemed necessary or advisable at each.

All the precautions of technic heretofore given should be employed. The reaction following such injections is never severe, and little or no treatment is necessary.

The needle openings are covered with aristol collodion or the isinglass adhesive plaster.

At the end of six months or more after the injected matter has been quite thoroughly replaced with new connective tissue it is often found necessary to inject small quantities here and there about the shoulders, owing to the contraction of the new tissue and its ultimate fixed disposition about the parts more than to the absorption of the mass injected.

Furthermore, a certain amount of edema or swelling follows the injection of any foreign matter under the skin which is not, in cases of this kind, so readily absorbed, giving during that period of time a more pronounced contour or fullness, which, passing away in the natural course of events, does not imply the absorption of the matter injected—a statement so often made by those not in favor of using paraffins of low melting points for subcutaneous protheses.

Such result, however extensive, as it might be in some cases for the lack of proper injection or in the case with oil injections is at all times correctable, while the hyperplastic knobs, so often following the injection of paraffins of high melting points about the shoulder, can only be removed by surgical means, which leave the parts more unsightly than before anything had been done for the patient.