Chapter XV: Rhinoplasty (2)

“Ten days after, I detached the flap from the arm and reformed the nose with the flap, which hung down like an apron. It is necessary to have a flap sufficiently long to fold in for the nostrils. I used bronze aluminum wires for all the sutures.”

The position of the hand while the flap was healing to the root of the old nose and the slight twist of the flap is shown in Fig. 353.

STEINTHAL METHOD.]

THE COMBINED FLAP METHOD

To overcome the consequent cicatricial contraction and falling in of the flap used to make the new nose by either of the three grand methods given, various surgeons have resorted to lining the flap with skin flaps, bringing their raw surfaces together so that the nose actually received in this way an integumentary lining.

While this had the tendency to thicken the new nose, it did not give the support necessary to it, especially at the lower third, and the lobule, at first quite satisfactory, resulted only in the appearance and form of a small tubercule of tissue, with a decided saddle effect above it. This combined method did overcome, however, the slow process of cicatrization, and its accompanying suppuration.

The raw surfaces of the two flaps, if properly brought together, healed upon themselves readily, as has been referred to in the lining or doubling in of the basal sections to form the nostrils and subseptum.

The method of lining the nasal flap in this manner is never sufficient to give a satisfactory result in total rhinoplastic cases, but may be of great service in restoring parts of the nose, as will be shown later.

The requirement is that of support, whether it be organic or inorganic, and these methods will be considered presently.

=Volkmann Method.=—This surgeon fashioned the frontal flap as shown in Fig. 354. This resulted in leaving a triangle of skin at the root of the nose, which he dissected up, down, to and inclusive of the periosteum, and turned downward so that its raw surface faced upward, as in Fig. 355. The flap was sutured into place to retain it.

The frontal flap was brought down, so that the two raw surfaces came together.

This method overcame the contraction of the flap over the nasal bridge or superior third of the new nose, and an excellent adhesion of that part of the flap to the denuded bone and flap resulted, but the same faults about the base were not mitigated.

VOLKMANN METHOD.]

=Keegan Method.=—The frontal flap method of Keegan has been referred to. For the lining of the upper nose he cuts two flaps from the skin above the old nasal orifice, as shown in Fig. 356, which he turns down, raw surfaces out. This gave a lining to either side of the median line; the skin remaining intact between the two flaps gave additional prominence and support to the upper third of the new nose.

=Verneuil Method.=—Contrariwise to the methods just given, Verneuil, after cutting out the frontal flap, cuts the flap from the remaining sides of the old nose somewhat involving the skin of the cheeks, as in Fig. 357. This done, the frontal flap is simply turned down, raw surface out, and the cheek flaps are slid over it, bringing the raw surfaces together. The inner borders of the flaps were sutured in the median line, as shown in Fig. 358. The base of the nose is made from the frontal flap by any of the methods already given.

VERNEUIL METHOD.]

=Thiersch Method.=—The frontal flap is cut from the skin of the forehead in the shape shown in Fig. 359. Then two quadrilateral flaps are raised from the cheeks, as also illustrated. These are made wide enough that, when they were brought together, their inner borders could be made to face each other. In this position they were sutured along the median line, so as to give a double-gun-barrel form to the nose, with a septal wall between.

From the lower border the nostrils were formed, giving to the new nose a normal appearance, the continuous septum curving downward to form the subseptum, the whole being sutured to the remains of the old nose.

The frontal flap was now brought down over it, the raw surfaces facing each other, and sutured in place, as shown in Fig. 360. Later, Thiersch replanted the sides of the nose, to give it better contour, and attained a very satisfactory result. The frontal wound was covered with skin grafts, but the cheek wounds were allowed to heal by granulation. The cicatrization of the latter was not sufficient to effect the lower eyelids nor the angles of the mouth.

THIERSCH METHOD.]

=Helferich Method.=—His is an ingenious application of the French method. Both flaps are cut from the cheeks; the lining flap was made from the left and the covering one from the right cheek. The shape of the flaps is shown in Fig. 361.

The lining flap is stitched along the freshened margin of the right side of the nose. The flap should be wide enough to give convexity to the nose, as shown in Fig. 362.

The covering or right flap, cut much larger, is now slid over this. It should be cut amply large to cover the flap just sutured in place. It is sutured on both sides of the nose to hold it in place, also at the inferior margin. The nose is lightly packed with iodoform gauze.

The pedicle of the right flap was cut after two and a half weeks and brought into place across the root of the nose, and sutured in place to give better contour to the part after freshening the skin about the left side of the nose at this point. He does not make a subseptum, but thinks the inferior base of the nose of sufficient size to hide the absence thereof.

The subseptum could, however, be readily made from the upper lip, as will be shown later.

HELFERICH METHOD.]

=Sedillot Method.=—This operation is particularly efficacious in giving a splendid subseptum and support of the point of the nose, but does not overcome the falling-in of the whole anterior line, so common with all Indian-flap methods. A flap one centimeter wide and extending downward almost to the vermilion border is cut from the thickness of the upper lip, not including the mucous membrane, however. It is turned upward, as shown in Fig. 363.

The frontal flap is fashioned as shown, care being taken to cut a subseptal rectangle of greater length than usual, since it is intended to overlie the raw surface of the flap taken from the lip. It is rotated downward and sutured into place at both sides, and also to the lip flap, to assure of accurate union.

A lateral view of the nose as formed in this manner is shown in Fig. 364.

The free end of the septal flap is fixed into the superior lobial wound with a harelip pin. The lobial wound is sutured as in ordinary harelip operations. This method is particularly valuable in total rhinoplasties involving the columna and alæ in conjunction with flaps obtained by the Italian method.

SEDILLOT METHOD.]

=Küster-Israel Method.=—A flap was taken from the arm by the Italian method, which was sutured to the remains of the old nose so that its raw surface looked upward, not downward, as in the ordinary case.

The flap was made sufficiently large to permit of building the wings and subseptum. After it had healed into place the pedicle was cut, and a frontal flap was cut from the forehead to cover it.

An unusually large flap was required to do this, since it had to overcome the greater curvature already given and added to by the arm flap, necessitating an extensive secondary wound.

The reverse order of procedure would be the more advisable for this reason, and is resorted to by the following:

=Berger Method.=—This surgeon makes the lining flap from the forehead. The secondary wound is at once closed. A flap is then made from the arm by the Italian method, and brought into place before the one just made. It should be of sufficient size to allow of building the base of the nose, which is done not later than three weeks after the pedicle of the arm flap is severed, which may be done at any time between the eighth and the twelfth day.

All the precautions are used as already given in the description of the Italian method. The arm is held in the position shown in Fig. 365.

Berger sutures the arm wound before bringing the flap into place upon the face to overcome the discomfort of suppuration to the patient.

The apparatus is fixed definitely after the patient has recovered from the anesthetic. Great care is exercised to prevent coryza from exposure. Dressings are made twice daily.

The pedicle is cut under local cocain anesthesia.

To make the subseptum and wings of the nose, the base of the flap is cut into three sections. The posterior surface is freshened and the parts are folded upon themselves and sutured into position.

Instead of employing rubber tubes, he resorts to a specially devised apparatus to retain two metal tubes in the nares, and at the same time make gentle pressure to the sides of the nose to mitigate the columna contraction. The latter is planted into a V-shaped incision made into the tissue of the upper lip at the proper place of attachment. The subseptum may be lined with a flap of mucosa dissected up from the floor of the inner nose.

For the wings of the nose, such tissue as may be of service to give them stability and structure is taken from the remains of the old nose.

The apparatus just mentioned and shown in Fig. 366 is used from the very first day until total cicatrization has taken place, and even for a longer period to aid in shaping the entire nose and the tendency to collapse has been overcome.

=Szymanowski Method.=—A frontal flap, divided along the median line and shaped as outlined in Fig. 367, is made from the forehead.

Two triangular flaps are then raised from either side, and including the angle of the nose as shown. The divided frontal flap is now brought down in such manner that their raw surfaces meet, thus forming a vertical septum. The margins are united by suture, and the lower ends are fixed into a wound made for the purpose at the base of the nose, as shown in Fig. 368, to form the new subseptum.

The lateral triangular flaps are dissected up so that they can be readily slid forward toward the median line. Their inner freshened margins are sutured to the raw edge of the septum just made, and to themselves. The objection here is that there is a liability of considerable contraction of these lateral flaps, with a tendency to fall in and drag with them the new septum; and again, in total restorations, the upper third of the nose is only partially covered, and necessitates later upbuilding. The author finds difficulty in making the four margins thus brought together unite evenly throughout, and that a vertical contraction is caused by the cicatrization of the median marginal wound.

FIG. 368.—Disposition of frontal flaps.

SZYMANOWSKI METHOD.]

=Goris Method.=—The operation is performed as follows, having given very good results, according to the author:

I. The frontal flap is divided lengthwise so that its raw surfaces face each other. The resulting fold, representing the bridge of the nose, is held in place by catgut suture.

II. The skin to make the wings of the nose is folded in, as in the Langenbeck method.

III. A flap, half the thickness of the upper lip is brought up to form the new subseptum.

IV. Dissection and turning down the triangular flap of skin which surmounts the orifices of the old nose, and making it serve to line the lower part of the frontal flap.

V. Suturing the frontal flap thus modeled into two grooves made into the margins of the old nose along both sides to its base.

ORGANIC SUPPORT OF NASAL FLAPS

It soon became evident to the rhinoplastic surgeon that without some support to the flap or flaps used for the construction of the new nose all of the preceding methods, as far as æsthetic results were concerned, were useless. Truly, the deformity lost its hideous appearance to a great extent, but the general results obtained hardly warranted a patient to undergo restorative operations of the nose. In fact, many surgeons advised against total rhinoplasty when practically all of the old nose was lost.

Langenbeck says “that total rhinoplasty, or even operation as to repair partial loss of the nose by the use of soft flaps, should not be undertaken. It is better to rely upon some prothesis.”

All that could be expected of utilizing the flap and making it heal into place had been accomplished up to about the year 1879. Thereafter many surgeons proceeded to evolve and use some kind of intranasal prothesis made of various inorganic materials. It may be stated, however, that Rousset in 1828 wrote: “Perhaps some day surgeons will give whatever shape they desire to the reconstructed nose. Then a frame of gold or silver, cleverly shaped and solidly fixed in the nose, will give the patient, at his own option, a Roman or Carthaginian nose, and to the ladies a choice of a roguish type, and to our Sultans a nose a la Roxelane.”

But it was after 1878 that such prothesis came into use, and these were at first made so that they might be removed at night and be replaced in the morning.

The intranasal supports were made of all kinds of material, such as gutta percha, gold plates, leaden devices, amber, silver, porcelain, celluloid, aluminum, platinum, etc.

With all due respect to the ingenuity of these inventions, especially that of Martin, which was made of platinum in the form of a St. Andrew’s cross, having at the four ends sharp pins which were driven and fixed into the skeleton of the nose, the use of these protheses resulted in nothing but failure.

The movable devices were a source of irritation and pressure, and could not overcome the consequent contraction of the flaps whether placed below a single flap or between two flaps, and the fixed protheses of whatever form or material caused so much pressure that gangrene resulted, and they had to be removed sooner or later.

Before the discovery of Gersuny, the author had many occasions to utilize such movable protheses in the correction of saddle noses. These were generally made of a silver shell, gutta percha, and later of decalcified bone, as advised by Senn. The former remained in place from six months to two and a half years, and then were thrown off or had to be removed because of irritation. The bone chips soon became absorbed, leaving the nose as before, or a thin median strip that became broken with the least violence, and then was absorbed.

In several cases where other surgeons had resorted to such protheses, the author was called upon at a later period to remove them.

While the immediate result is very gratifying, the ultimate result is worse than useless, since in the elimination of the foreign body the flap of the nose was married by cicatrices that added still further to the contraction and falling-in of the nose.

PERIOSTITIC SUPPORTS

Some other method had to be devised, and organic supports became known. These organic protheses were made of the tissue in the near vicinity of the flap, and at first formed a part thereof. The earlier method included only the periosteum; later bone and periosteum were added to the flap to give it shape and support, and lastly cartilage was employed for the purpose.

Of the methods employing only the periosteum, it may be said that what the surgeon expected of this membrane—namely, the springing up of bone cells—did not take place; at least, not to the extent desired. The very best to be attained was a thickening of flap in the membrane, but not sufficient to add necessary support to the nose.

OSTEOPERIOSTITIC SUPPORTS

The inclusion of the periosteum-lined flap was soon abandoned, and recourse was had to such bone additions to the flaps as could be obtained from the vicinity of the nose.

The bone was removed with its periosteum, adherent or nonadherent to the flap, as will be shown by the methods described hereafter.

Both single and combined flap methods are employed as might be expected, following the procedures of the Indian, French, or Italian schools. The greatest credit for the methods herein involved belongs to the surgeons of Germany.

The earliest operation on these lines was that of König, who published his first successes in 1886.

=König Method.=—Extending upward from the root of the old nose, a flap is outlined in vertical ending at the hair line of the scalp, as shown in Fig. 369.

This flap was made about one centimeter wide, and is made to include the skin and periosteum. With the chisel a thin strip of bone is raised from the frontal bone to nearly the full length and width of the flap, making it an osteoperiostitic cutaneous section attached by its pedicle at the root of the nose.

This flap is brought down with bony surface outward, and the distal or skin end is fixed by suture into the upper lip at the point of the intersection of the subseptum.

Any of the soft parts of the old nose remaining are now dissected up toward the median line, and are folded upward and inward and sutured by their freshened margins to this median flap.

An Indian flap in oblique direction and of the form shown is cut from the skin of the forehead and rotated down into position before the bone-lined flap, and sutured into place.

He advises not to include the periosteum in the flap making up the subseptum, as it is likely to interfere with respiration. In fact, he deems it best to make the tegumentary flap sufficiently long to build the bone of the nose, doubling the raw edges upon themselves with a celluloid tube apparatus that may be removed for cleansing, and be kept in place long enough to give contour to the nares.

=Von Hacker Method.=—The frontal flap was cut in the ordinary Indian method, and of the shape shown in Fig. 355. The skin at either side of the median line was dissected up to within four millimeters, leaving a strip eight millimeters wide from the root of the nose to the distal or scalp end. The two loose lips of the flap were brought together at the anterior median line by a few sutures to keep them in place.

This was done to give freedom to the surgeon while he detached a strip made of the periosteum and bone chiseled from the frontal bone. At the root of the nose or below the pedicle the bone was not included to the extent that it would interfere with torsion of the flap, and yet sufficient to allow the raw bone surface to fall upon what remained of the bony bridge of the old nose.

FIG. 371.—Making the osteoperiostitic support.

FIG. 372.—Bone-lined flap brought into position.

VON HACKER METHOD.]

He utilizes pins driven into the bone to outline this bony section, as shown in Fig. 370.

The latter is done in an oblique direction. See Fig. 371. The septal section is made to include the bone strip.

The bridge of bone holding the flap at its inferior end was now broken, leaving, however, the periosteum as part of the pedicle hinge.

The whole flap thus outlined was rotated downward into position and sutured, as shown in Fig. 372.

The margins at the base intended to form the subseptum were sutured behind the osseous structure, or, in other words, were doubled inward and fixed by suture. The bony strip was broken at the proper point to give prominence to the lobule.

The margins for the nostrils were turned inward and doubled on themselves, and sutured with silk.

Rubber tubes were left in the nares, for drainage and to keep them distended.

=Rotter Method.=—The frontal flap is made in the shape shown in Fig. 373, containing a section of the frontal bone and its periosteum. The width of the flap is about three and a half centimeters wide.

This flap is turned downward so that its raw surfaces look outward.

Owing to the loose adherence of the bony section to the skin flap, he allows the raw bone surface to granulate over for four weeks, to fix it more solidly to the soft parts.

The bone plate is then sawn into three sections made by two vertical incisions, made as shown in the illustration.

The median section forms the bridge and dorsal prominence of the nose.

The adherent skin of the lateral bony plates is dissected up sufficiently to permit of the proper formation of the sides and wings of the nose.

This gives a shape to the nose, as shown in Fig. 374.

The lateral margins of the integumentary flap are now sutured to the freshened margins of the old nose, and the remaining skin, if any, is made to cover the granulating surface; if this is lacking or insufficient, skin grafts are utilized to cover it completely.

FIG. 374.—Disposition of frontal flap.

ROTTER METHOD.]

=Schimmelbusch Method.=—The principle herein is to give an osseous wall to the whole length of the restored nose, covering well the skin inside and outside, and, if possible, to fix the new nose solidly at the pyriform opening.

“I cut an osteo-cutaneous flap from the middle of the forehead, of a size proportional to the size and shape of the nose. Its pedicle between the eyebrows is two or three centimeters wide; it widens out superiorly to form seven to nine centimeters. It is triangular, and its base lies near the hair line. In cutting it out, preferably a little large, it goes at first to the bone, through skin and periosteum. With a large, sharp chisel, a thin bone plate throughout the whole extent of the cutaneous flap is detached. It is not always possible to make this a plate in one piece; it often breaks or gives off splinters. This is of no consequence, if care be taken not to lose them and to keep them adherent to the periosteum. They are attached as well as possible to the cutaneoperiostitic flap by passing threads crosswise from one edge of the flap to the other over bony surface, as in Fig. 375. The whole flap is then enveloped in iodoformed suture.

“The frontal wound I close at the same sitting by sliding large lateral flaps whose upper border follows the margin of the hair as far as the ears. These are freed completely, brought down and stitched, leaving eventually only a linear cicatrix on the forehead. The lateral loss of substance which results is healed by granulation, and the scars concealed by the hair.

“At first parts of the bone die; they ought to be expected to fall out; after four, six, or eight weeks the bone is completely covered with fleshy granulation, and adheres solidly to the flap. The prominent granulations are then scratched, or, better, trimmed away with the knife, and the whole surface is covered with Thiersch grafts.

“When the flap is thus furnished with skin within and without, it is put into place. I saw the bony plate with a fine-toothed saw from the grafted side; then I model the flap and place it on the loss of substance freshened by turning the grafted surface toward the interior of the nose by twisting its pedicle, as in Fig. 376. The osseous rim of the pyriform opening is uncovered at the moment of this freshening, and the bony edges of the flap are placed exactly on the bony edge of the aperture. The skin of the flap is then stitched at its lower margins to the skin of the cheeks. To preserve the height of the nasal profile and avoid displacing the bones of the nose, the nose is kept in place with a pin thrust through the nose, and furnished at each end with a rubber button. This aids to form the wings of the nose. If a subseptum is needed, it is made by taking from the skin that covers the circumference of the pyriform opening two small flaps, which are dissected from without toward the median line as far as the point where the septum is normally found.

“These are stitched at this point, first upon themselves, then to the end of the nose. Three weeks later the pedicle of the frontal flap is cut; it is turned, put in splints, and the stitching is finished.”

FIG. 376.—Disposition of frontal and skin-grafted flap.

SCHIMMELBUSCH METHOD.]

=Helferich Method.=—A lining flap is made, according to the French method, from the one cheek, which is dissected up and turned over to bridge most of the loss of nasal tissue, and sutured to the opposite freshened margin, as showed in Fig. 377.

A frontal flap, as outlined in the same illustration, is now cut from the forehead, leaving a pedicle as shown, and containing a section of bone at its median line. This is rotated downward and into place, and sutured along the same margin to which the genian flap is fixed, as shown in Fig. 378.

When the frontal and genian flaps have become well united, the latter’s pedicle is cut when the freshened lateral margin of the frontal flap is sutured into place.

A subseptum is now made or deemed necessary by this surgeon.

At a later period the pedicle of the frontal flap is cut, and fixed by suture and some cutting, to reduce the resultant prominence thereof.

HELFERICH METHOD.]

=Preidesberger Method.=—This author cuts away the skin surrounding the arch of the old nose, and turns this flap downward to form the lining to the flap made from the forehead made in the same manner as Helferich.

The bone section is made in the median line, and is one centimeter wide and four long.

The frontal flap should be made long enough to permit of building a subseptum and the nostrils.

=Krause Method.=—This frontal cutaneo-osteo-periostitic flap is made according to the method of König.

After turning down the flap it was covered with a nonpedunculated skin flap taken from the upper part of the arm by transplanting after its subcutaneous fatty tissue had been removed. (See Fig. 379.)

This method necessitates a long-continued dressing of the forehead before the pedicle is cut, because of the needed nutrition to make the two flaps heal upon each other.

After union has been established the sides of the transplanted flaps are raised by dissection, as shown in Fig. 380, to expose the bone plate of the frontal flap. A median strip is left intact.

With a fine saw the bony plate is cut into three sections, making the narrowest the median.

The margins of the old nose are now freshened, and the combined flap is sutured along the sides, preserving what tissue the surgeon can use to add support to the nose, which is done by dissection and turning or folding, as heretofore described.

The lower or forehead flap is sutured to the soft parts of the old nose, and the transplanted lateral margins to the marginal skin of the cheeks, giving to the nose the appearance as shown in Fig. 381.

At a later period the pedicle is cut and the wound that cannot, at this time, be overcome by sliding of the adjacent skin, is covered by skin grafting.

FIG. 380.—Second step.

FIG. 381.—Third step.

KRAUSE METHOD.]

=Nélaton Method.=—A lateral flap of skin is taken from the cheeks, beginning on a line with the root of the nose and as low as a point two thirds of its normal length. These flaps are made wide enough, so that when dissected up and folded inward they will meet on the median line, as shown in Fig. 382, having their raw surface facing outward. They are sutured along the median line. The frontal flap was cut in the form of a horse-shoe having its pedicle at the root of the nose just above the eyebrows, and being about three centimeters wide and six long.

The skin at the outer margins was dissected up from the bone, leaving sufficient attachment at its center to allow for a bony plate.

With a fine saw, and in the manner shown in Fig. 383, this plate was made from the frontal bone, being about two and a half centimeters wide and four long.

FIG. 383.—Making bony support to flap.

NÉLATON METHOD.]

There is some difficulty associated with the making of the flap, which ends at the superior border of the frontal, leaving the pedicle composed only of skin.

The flap is now turned down, exposing its raw surface. The bony plate is sawed through at the median line, as shown in Fig. 384, and the skin of the flap is also divided along this line, giving two partly bone-lined flaps.

The two flaps are now rotated downward before the lost nose, so that their raw surfaces face inward, and in this position they are sutured along the median line and the sides, as shown in Fig. 385.

The method gives an angular dorsum of satisfactory consistency to the new nose, but furnishes a serious drawback, in that the cicatrization along the median line is liable to affect the shape of the organ and leaves a prominent scar line. The use of two small pedicles is another objection in that the danger of gangrene is greater as the nourishment to each flap is less.

FIG. 385.—Disposition of frontal flap.

NÉLATON METHOD.]

=Israel Method.=—From the ulnar side of the left forearm Israel cuts a skin flap, as shown in Fig. 386, with its smaller end nearest to the wrist, where it is detached, the pedicle being broad, assuring of better nourishment to the flap.

The narrow end of the flap is cut down to the bone, then the sides are dissected up until the borders of the ulna are reached on both sides, reserving an adherent strip about eight millimeters wide and six centimeters long.

The bone below this strip is now removed with the saw from the lower end upward, and ending about one centimeter beyond the base line of the flap, where the strip so made is left connected to the bone proper.

The flap is now raised gently and bent upward without breaking the bone. It is sawed half through, transversely, at a point corresponding to the lobule of the nose.

The flap is then enveloped in iodoform gauze, and the head, forearm, and arm are fixed in plaster of Paris, the forearm being bent at a right angle to the arm (see Fig. 387).

After nine days the osseous connection still remaining is severed, and the nose is modeled upon the forearm, as heretofore described in these operations, this surgeon using silver wire to retain the parts. The raw skin surfaces are allowed to heal upon each other and the flap is permitted to come in contact with the wound on the forearm temporarily, to which it might adhere, the gauze being now removed.

After twelve days the newly modeled nose is freed from such adhesions and kept from healing to the parts by using dressings between the flap and wound.

Five days after, the margins of the old nose are freshened in the form of an inverted V. If there be sufficient cicatricial tissue it is turned down, raw surface out, to line the new nose.

A prolongation of the pedicle is now cut, widening out toward the radial side of the arm, made obliquely, as shown, so that its pedicle now corresponds to a width of seven centimeters.

The whole flap except this newly formed pedicle is cut free of this forearm. The arm is put into the position shown in Fig. 387, and the freshened flap margins at the root, the whole length of the left side, and part of the upper right lateral. The plaster dressing to hold the arm in the proper position until complete union is established is used. This done, the pedicle is cut, and such minor operations are done to fix the remaining free margin and the base of the new nose.

CARTILAGINOUS SUPPORT OF FLAP

The methods just described in which an osseous plate of various size and form is included with skin flaps for the restoration of the nose give undoubtedly the best rhinoplastic results. The new nose is given not only better shape, but a permanency of such form that skin flaps of themselves could never give.

The unfortunate factors in these osteo-cutaneous operations are the many difficulties experienced.

The cutting or making of the bony plate is no simple task.

The skin is an uncertain agent to employ, because of the peculiar contour of the bony surface from which the plate is to be removed. The chisel, no matter how dexterously used, is liable to cut through the entire bone thickness, which has occurred in several recorded cases.

There is also the possibility of necrosis of a part or all of the bony plate thus obtained, and where the latter is not lined interiorly there is the added danger of infection.

Furthermore, the secondary wound is more extensive; the bone exposed requires about a month’s time to granulate over before skin grafts can be successfully applied over it.

With the employment of a cheek-flap lining there is the added objection of cicatrization. The use of a flap from the arm is complicated and requires considerable time for the completion of the operation, and there is always the added danger of infection and consequent death of the osseous plate.

To overcome these many difficulties von Mangold advocates the use of a section of cartilage to support the anterior prominence of the nose.

It has been found, since the first attempt of and the successful result obtained in 1897 by this surgeon, that cartilage to be used for this purpose should be taken from the costal cartilage, where a strip of the required length and width can be obtained.

The results thus far recorded are excellent, and much is hoped for from this method, especially in the reconstruction of loss about the wing of the nose in partial rhinoplasties, where the convexed contour may be reproduced to a nicety.

The first attempt to support the flap for a total rhinoplasty by this method was made in 1902 by Charles Nélaton.

The use of cartilaginous supports may be combined with any of the methods given heretofore. The flap containing the cartilage may be lined or unlined. All tissue found about the old nose should, of course, be utilized to give added support and to reduce as far as possible extensive secondary cicatrization.

The combined Hindu and Italian methods give splendid results, the frontal flap and its support being brought down from the forehead, raw surface outward, and the arm or forearm flap being placed immediately in front of it.

The frontal flap with the support requires a preliminary operation to permit of the attachment of the cartilage. Fortunately, this step requires but little time and shows a very slight disfigurement during this period.

The secondary wound at the site of the cartilage excision requires little attention and heals readily, and the cicatrix involved is very small.

Steinthal proposes taking the flap and cartilage from the thoracic region, grafting it during the preparatory period to the forearm, from which it is transplanted to the face at a second sitting.

There is the objection to this method that it requires the arm to be retained in position for a very long time.

The author advocated the use of an arm flap made by the Italian method to line the one to be brought down from the forehead in cases of total rhinoplasty where little or no tissue can be obtained from the remains of the old nose. Such procedure reduces the time required by the Steinthal method to one half, and therefore greatly lessens the discomfort to the patient.

The fundamental principles as laid down by Nélaton are excellent, and may be applied to any modification of method the surgeon may decide upon where a section of costal cartilage is employed to support the flap, whether this be taken from the forehead, other parts of the face, or remote places.

The procedure of Nélaton is as follows:

=Nélaton Method.=—The method involved a preparatory and a final operation.

The preparatory operation has to do with obtaining and placing in position the section of cartilage under the skin flap wherever located.

The final operation may or may not consist of two sittings, the first being necessitated by the bringing upon the remains of the nose a flap of skin to line the one brought down in front of it and containing the support.

_Preparatory Operation._—To begin properly, the frontal flap to be utilized is marked out on the forehead with nitrate of silver the day before the operation, so that its outline will be plainly discernible, and act as a guide for the placing of the cartilage. The shape of the flap is fashioned as shown in Fig. 388.

In the illustration is also shown the incisions later made to utilize the borders of the remaining nose to line the frontal flap. This is done by making an inverted V incision at a distance from the inner borders, corresponding to the lateral line of union of the frontal flap with the face. The resultant flap is turned down, raw surface outward, curtainlike, and is sutured to the frontal flap, where it falls into position.

The flap outline shows that its pedicle lies between the outer end of the inner third and above the right eyebrow and a little to the left of the median line at the root of the old nose. This will avoid considerable tension at this point, the rotation as made being ninety degrees.

Nearly horizontally, as shown in the figure, a line is drawn through the center of the flap, showing the position the strip of cartilage is to occupy.

This done, a pattern of the outline is cut from stiff paper or oiled silk to preserve as a guide for the making of the flap, it being understood that the outlining has been made to the measurement of the required nose, allowance being given for cicatricial contraction.

This done, the surgeon having prepared the skin about the costal prominences of the left thorax, he proceeds as follows:

A vertical line is drawn the width of two fingers to the right of the nipple, as shown in Fig. 389, the length of the line being obvious.

Where the vertical crosses the eighth costal cartilage an incision is made downward over and not under the border of the cartilage.

The incision extends downward for a distance of eight centimeters, where it is turned upward at an angle, as shown, to a distance of three centimeters.

By separating the muscular aponeurosis made visible by this incision the lower edge of the eighth costal cartilage is exposed. The knife is moved along the lower edge of the cartilage, dividing the fibers of the insertion of the transverse muscle from without inward. The cartilage can now be grasped between the thumb and forefinger and be forced out of its normal position after a slight anterior dissection.

The union between cartilage and bone is exposed. The chisel is used to divide the cartilage about one centimeter from the rib, after the costal or inner extremity has been made.

The position of the hands and the exposed cartilage is shown in Fig. 390.

This accomplished, the wound is temporarily dressed. The cartilage is then fashioned to suit the required size and shape.

It is thinned down on its lower surface to about three millimeters in diameter. This thickness is maintained to a length of two and a half centimeters, the part being intended for the subseptum.

A notch is made on the upper surface at this distance from the end, which marks the point at which it must be eventually bent to form the point of the nose. This notch is cut to two thirds of the entire thickness.

The required length, that of the nasal line and its added septal length, is preserved.

The cartilage being prepared is now ready for the insertion under the frontal periosteum at the site already marked.

For this purpose a vertical incision one and a half centimeters, extending down to the bone, is made, as shown in Fig. 391.

The periosteum is peeled away from the bone with the dull or rounded handle of a knife.

The cartilage is now thrust into the tunnel thus made, the thinned-down, notched-off section facing forward and lying toward the vertical incision.

The skin wound is sutured and a gentle compress is used to keep the cartilage in contact with the periosteum, which requires at least two months. A longer interval of time is advocated to give greater vitality to the cartilage.

The wound of the thorax is simply sutured and dressed as any surgical wound.

_Final Operation._—The part cut is prepared as in the Hindu method. A lining for the frontal is made of such tissue as remains, and its freshened borders are sutured where possible, as shown in the last figure.

When this cannot be done, a flap may be taken from the arm, as already suggested, or a Krause nonpedunculated skin flap may be used, according to the methods given heretofore.

The epidermis is made to face inward. If either of these methods is used, the frontal lap is not brought down until healthy granulation has been established.

The frontal flap is made to include the periosteum, from which it is separated with a blunt instrument. The cartilaginous strip will be found to be attached to the periosteum.

The freed flap is now brought before the nasal defect and fitted into place. The cartilaginous strip should occupy the anterior median line.

The subseptal cartilage is bent inward and downward and the skin of the flap is sutured to it with catgut to form the subseptum, as shown in Fig. 392.

The free margins of skin remaining at the septal bone of the flap are folded inward to line the new nostrils. Catgut sutures are used to keep these folds in position.

The nose is now ready to be sutured into place. The subseptum is inserted first and fixed into the upper lip, then the nose being held so that its median line occupies the proper position, both wings are sutured to the freshened margins, and lastly the sides (see Fig. 393).

The frontal wound may be drawn together as near as possible by suture.

Rubber drainage-tubes are kept in the nares for a few days, and are thereafter replaced by rolls of gauze.

Dry dressings are preferred for the nasal wounds, which heal in about five days.

A month after, Thiersch grafts are employed to cover the frontal wound remaining. They require about eight days to heal into place.

PARTIAL RHINOPLASTY

RESTORATION OF BASE OF NOSE

In this defect there may be a loss of the lobule and both alæ, including the subseptum, or there may be a lateral loss, involving more or less of the base.

There are many types of this deformity, so that to include all would involve considerable space, and at best most of the operations involved would be those utilizing the methods heretofore mentioned.

The earlier operations for the correction of lesions of large extent are founded upon the use of skin flaps, which have been shown to be unsatisfactory because of their consequent cicatrization. Reference is made, however, to several of these to exhibit the disposition of the remaining parts of the old nose.

Later will be considered the methods involving osteo-cartilaginous supports.

=Steinhausen Method.=—The inferior remains of the old nose are detached from the margins and brought downward; a Hindu flap is fashioned as shown in Fig. 394, and brought down to form the new nose; the size of the flap is given as being four inches wide and eight inches long.

The distal end of the flap is sutured to the freed flaps obtained from the borders, as shown in Fig. 395.

The method is purely of the Hindu type, and the results are not, therefore, very satisfactory.

STEINHAUSEN METHOD.]

=Neumann Method.=—This author cuts down the remains of both lower margins of the old nose, as in the Steinhausen operation. A wedge-shaped section is cut from the entire thickness of the upper lid and turned upward to form the subseptum, and is sutured to the lateral parts brought down by the former incisions, to which it is sutured at the median line, as shown in Fig. 396.

Two lateral flaps are now made from the sides of the remaining nose retaining their cartilages, as shown in the illustration, _A_, _B_, _C_, _D_, showing one of them. The two flaps remain attached, anteriorly along the median line over the bridge of the nose. These two lateral flaps _A_, _B_, _C_, are turned down from the point _A_, which represents the pedicle, and are sutured at the median line by their lower borders, _A_, _B_, the borders _B_, _C_, being thus brought down, fall before the fresh borders taken from the margins of the old nose, to which they are sutured, as shown in Fig. 397.

This procedure will leave two exposed areas at either side of the nose, which are permitted to heal by granulation.

NEUMANN METHOD.]

=Later Neumann Method.=—An incision is made to circumscribe the remains of the old nose at either side, extending upward in rectangular form above the root of the nose, between the inner canthi and upward, and somewhat above the eyebrows, as shown in Fig. 398.

This flap thus outlined is freely dissected down to the bones of the nose, leaving it attached only at the roots of the wings, so that it can be turned downward, hanging over the mouth, like a curtain.

A deep transverse incision is then made through the remaining cartilaginous structure of the nose, just below the inferior borders of the nasal bones. This gives a cartilaginous, archlike support to this part of the flap, which is utilized to give firmness and shape to the base of the new nose.

The incision just mentioned is depicted in Fig. 399, in which is also shown the turned-down flap.

After the hemorrhage has been controlled the flap is turned upward and into such position as to form the new nose, utilizing the cartilaginous arch, above referred to, to the best advantage to give the proper contour. This will lower the apex of the flap considerably. The lateral borders are sutured to the freshened margins where possible, but as a rule an opening is left at either side, communicating with the inner nose, which must be healed by granulation.

The wound on the forehead may be brought together completely by suture. The appearance of the nose assumes at this time the form shown in Fig. 400.

The objection to this method lies in the fact that the cartilaginous arch brought down with the flap is usually insufficient to give proper support to the base of the nose, permitting the lobule to contract and sink. In most cases there is an absence of sufficient cartilage to employ the method at all. An osseous arch would, therefore, preferably be incorporated with the flap, taken from the remaining nasal bones.

LATER NEUMANN METHOD.]

=Bardenheuer Method.=—This author makes a transverse incision across the root of the nose, and two lateral incisions from either end of the first, carrying them downward and outward, as shown in Fig. 401. These incisions are made down to the bone. With a chisel the nasal bones are separated from their frontal and superior maxillary attachments, giving an arch of bone to the flap, which is brought downward and outward, the bone being dissected from the underlying mucosa. To facilitate the bringing down of this flap the anterior border of the cartilaginous septum must be divided if present.

The flap thus made is attached only at the two points of skin at the inferior borders, the epidermal surface looking inward. The archlike mass of bone is gently bent backward at either side to practically reverse its convexity. The position of the flap is shown in Fig. 402.

The raw surface of the flap above mentioned is now covered with a flap taken from the forehead in the form shown in the figures.

The resultant nose is entirely lined with skin, and contains sufficient bone to support it. The objection is that there must necessarily be a large secondary wound in the forehead, which must be covered with Thiersch grafts.

FIG. 402.—Disposition of nasal flap.

BARDENHEUER METHOD.]

=Ollier Method.=—This author uses an inverted V incision, beginning on the forehead at a point about three centimeters above the superior margin of the eyebrows. The diverging incisions are carried down to a point just above the base of what remains of the old nose, where it remains attached.

The shape of the flap thus made is shown in Fig. 403.

The flap is dissected up and made to contain the periosteum as far as the juncture of the frontal nasal bones.

The skin over the right nasal bone is now dissected up, without, however, including the periosteum. The left nasal bone, still adherent to the skin, is removed with the chisel, beginning at the median line, then at its frontal attachment, and lastly along its union with the superior maxillary bone.

On the right side what remained of the cartilaginous structure was divided so as to include it in the flap.

This gave a large triangular flap, periosteo-cutaneous above, osteo-cutaneous below that, and ending in a chondro-cutaneous border, attached to the face by a double pedicle, as shown in Fig. 404.

To give further support to this flap at the median line, Ollier divided the septum with the scissors in such a way as to form an antero-posterior cartilaginous flap attached by its lower base.

The flap was brought downward in the same manner as in the method of Neumann and sutured into position, the parts involved assuming the position shown in Fig. 405, in which the lateral nasal surface is left uncovered to show the space occasioned by the removal of the nasal bone, and in dotted line the position that bone now occupies.

In five weeks the two nasal bones united, end to end, and three months after the operation the space made by the removal of the bone had become filled with hard tissue, that eventually ossified in about seven months.

FIG. 405.—Position nasal bone occupies.

OLLIER METHOD.]

=Langenbeck Method.=—A median incision is made through the remaining skin of the old nose, dividing it into halves. The incisions about the base and the shape of flap to be brought down from the forehead are shown in Fig. 406.

The skin over the nose is dissected up, moving toward the cheek, exposing the bony frame of the nose.

From the lower border of the pyriform aperture two elongated triangular plates of bone are made, being attached posteriorly to superior maxillary bones. They should be made about one sixth inch wide.

By their subsequent displacement they are made to lie antero-posteriorly. With a saw the nasal bones are separated from their maxillary connection from below upward, making a median bone plate, which is raised with a levator to the height desired for the new nasal bridge, remaining attached to the frontal bone, as shown in Fig. 407.

A frontal flap is taken from the forehead and sutured to the freshened raw margins of the lateral flaps.

The bone plates are fastened to each side of the frontal flap by suture.

The nasal base is preferably made of the tissue remaining of the old nose, as depicted, to prevent closure of the nostrils, the only difficulty being to keep the poorly nourished tissue from dying. When used the raw surface is brought in contact with that of the frontal flap.

The objection in this case is that the median third anterior line usually falls in rapidly, leaving the nose dished or saddled, and unless there be sufficient tissue to construct the base, the objections so often referred to heretofore will occur.

FIG. 407.—Showing separation and elevation of nose flaps.

LANGENBECK METHOD.]

=Ch. Nélaton Method.=—This author uses an osteo-cutaneous flap taken from the forehead. The shape of the latter is shown in Fig. 408.

The lateral incisions are to be made the width of a finger from the margins of the old nose, extending upward in curved fashion through the inner edge of the eyebrows and meeting at a point on the forehead, becoming slightly oblique near the border of the hair.

The flap is dissected up from the borders inward, including the periosteum, leaving a strip of bony attachment at the median line.

The dissected sides of the flap are held up by an assistant while the operator proceeds to chisel a thin bony plate from the frontal. The bony plate ends just above the root of the nose.

The dissection is now carried on downward until the bones proper of the nose appear, and latterly, so that the saw does not injure the soft parts, and to act as a guide for the course of the latter.