Plastic and cosmetic surgery

“Summary.—Histological Diagnosis.—Diffuse fibromatories with fatty infiltration and giant-cell formation in a vacuolated area produced by paraffin injection.”

Once the hyperplasia is established the surgeon must simply wait until he believes the activity of the abnormal growth has subsided and then remove the superabundant tissue with the knife.

With another case, in which the patient was operated on by another surgeon, the author was called upon to remove the growth. A part of the coarse, yellowish pale and cartilagelike tissue was excised, sufficient to restore the parts to a normal contour. After an uneventful recovery the patient went away, greatly pleased, only to return in six months, presenting a similar condition as before the extirpation.

A second operation was done, this time more extensively, the entire yellowish connective tissue being removed by the aid of a long median incision on the anterior aspect of the nose.

The wound healed readily and showed very little scar, and the patient was discharged. One year after the last operation the nose was still normal in appearance and the growth had not reappeared.

From this it is deemed absolutely necessary to remove practically all of the newly formed tissue to warrant a nonrecurrence of the fibromatosis.

21. A Yellow Appearance and Thickening of the Skin after Organization of the Injected Mass Has Taken Place.—This condition of the skin is evidenced some time after the injected mass has become organized, beginning about the sixth month after the time of injection. It has been especially noticed with the hard paraffin fillings of the nose, but also with other injections, even of the lowest melting points, about the sternoclavicular regions of the neck.

The skin becomes at first streaked with a superficial and irregularly defined patch of red, the forerunning indication of the size of the ultimate pathological change. The red color subsides slowly, leaving the area pale, which thereafter gradually thickens, taking on the appearance of a light yellow stain in the skin.

Practically opposite to the condition in xanthalasma, where the yellow area is slightly elevated and occurs in the loose tissue of the eyelids.

The cause seems to be a degenerative change in the skin dependent on pressure upon its underlying tissues. Evidently the pressure of an overproduction of the connective tissue which has sprung up to replace the injected mass.

Seemingly the cause is due to an injection being made too close to the derma where the latter is bound down to the subcutaneous tissue, or a desire on the part of the surgeon to prevent an injection into the deeper areolar tissue, especially when the injection is made in the vicinity of the larger blood vessels, for fear of causing embolisms or phlebitis.

Excluding the use of hard paraffin for such injection, the operator should be sufficiently experienced to use these injections properly and without fear, and at all times avoid injecting into the skin instead of subcutaneously.

Making the puncture first and observing if blood flows freely or trickles from the detached needle will assure the operator into what tissues he has thrust his needle.

Should active bleeding follow the puncture, he should withdraw the needle and wait to inject the site at a later sitting, using the same precaution; at no time should he be in doubt as to the absolute placing of the injected mass.

When the injections are done about the lower neck or shoulders great care must be exercised to avoid the blood vessels, and small quantities be only injected to prevent reactions that may cause phlebitis of these vessels; furthermore, the injected mass must be carefully molded to prevent the formation of uneven elevations or lumps. Without doubt an injection into one of the blood vessels of the neck would mean certain death.

Kofman lost a patient by pulmonary embolism twenty-four hours after an injection of 10 c.c. of paraffin. How many punctures he made to inject this amount is not stated, but certain it must be that he introduced part of the mass directly into some blood vessel.

The author advises, when injecting about the neck, to use a stout, dull-pointed needle introduced under local ethyl chloride anesthesia and to elevate the tissue with the needle as the injection is made. In this way the operator can observe the behavior or placing of the injected mass, at the same time stretching the skin to permit of the injection without encroaching upon the blood vessels. The mass is immediately molded after each injection. The further question of the practical method of making these injections will be fully considered later.

If, however, the pigmentation under consideration has taken place, electrolysis with a fine needle may be resorted to, with the object of whitening the discoloration by producing scar tissue, in the form of punctations, in the discolored area.

While the numerous white spots so caused are objectionable, they are better borne by patients than the pigmented appearance. A thorough needling of the spot in this way eventually brings about an improvement, and if, for æsthetic reasons, the patient objects to the unsightliness of the result thus obtained, the white area may be carefully tattooed with an appropriate color to match the rest of the skin of the face or neck.

If the pigmented area is not too large, it can be excised with the knife and the healthy skin be brought together with a fine silk suture, thus leaving a thin linear scar which can be dealt with as the punctate scar area, if desired; the electrolysis being a painful procedure at all times, since sufficient milliampères must be used to cause scar-tissue formation, which is between 20 to 30 milliampères in such cases.

22. The Breaking Down of Tissue and Resultant Abscess Due to the Pressure of the Injected Mass upon the Adjacent Tissue after the Injection Has Become Organized.—The above result is particularly noticeable when the injections have been made into the cheek or the breast. It is understood that the suppurative changes under consideration herein are not attributable to imperfect sterilization of the injected matter, although it is possible, and perhaps is the cause in fifty per cent of the suppurative elimination of the infected mass from the cheek, that a nucleus of infection is carried into the tissues and is held in suspense for a time, because of its imbedment in a neutral media that does not readily permit of bacteriological propagation, but eventually this nucleus must come in contact with tissue which it can affect, and only then may its infection be taken up.

The author believes that such secondary affections are accountable to pressure effects upon the blood vessels or glandular structure, as in the case of breast injections, the new connective tissue causing a lack of nourishment in the part or gland, and a resultant breaking down of the tissue, directly influenced in some instances by external violence.

Tuffier reports the elimination of paraffin injected into the breast several weeks after the injection. If this elimination had been caused by primary infection an acute reaction would have taken place at least within forty-eight hours, ending in abscess shortly after.

A case which came to the author’s attention was that of a lady who had been operated upon for the correction of a saddle nose three months before. The result had been satisfactory. The day previous to consulting the author she had injured her nose in an automobile accident. The nose was much swollen, very painful, and red over the entire upper and middle third. The use of external cold did not relieve the condition much, and on the fourth day the skin broke open at one point, allowing pieces of the paraffin to escape. Immediate relief followed, the wound healed with a marked sinking of the middle third of the nose. After three weeks the nose was again injected with no further untoward symptoms, the result being satisfactory for two years past.

In this case undoubtedly the exciting cause was directly due to violence, which may be the forerunner in many of such cases, but there is a number of such eliminations directly due to a breaking down of the tissue from internal pressure alone.

There is no way to overcome this difficulty, except to await the definite formation of the abscess and then to puncture the skin directly over the soft fluctuating area and to drain the cavity.

Once relieved, the condition quickly subsides, leaving a certain amount of loss of contour, which can, however, be corrected several weeks after by a secondary injection.

When the abscess occurs in the cheek it is not advisable to open interiorly, but to make the puncture through the skin, on account of the danger of infection from the buccal cavity and of the imperfect evacuation thus attained.

A trocar and cannula of proper size will be found to be the most suitable, the parts being gently manipulated to evacuate the contents of the abscess.

Aspiration can also be resorted to, but for the breast a small linear incision, made under local anesthesia at the most dependent point, best answers the purpose.

A small gauze strip drain may be employed for a few days to insure of perfect drainage in the latter case, the wound being brought together eventually by a delicate cosmetic operation if desirable.

THE PROPER INSTRUMENTS FOR THE SUBCUTANEOUS INJECTION OF HYDROCARBON PROTHESES

Although Gersuny advocated the use of a Pravaz syringe for injecting the liquefied vaselin mixture for prothetic purposes, it was soon found that such an instrument was practically useless, especially when the parts to be injected offered more or less resistance to the introduction of the foreign matter.

Other operators, following the advice of Eckstein, who advised the employment of “Hart paraffin” of high melting point liquefied by heat, raised the objection that the metal needle became so easily obstructed by the rapid setting of the paraffin in its distal end that the great force necessary to eject the contents of the syringe usually resulted in a breakage of the glass barrel in the hands of the operator, or, as in some types of the syringe, a separation of needle and syringe at the point where the former was slipped upon the ground point of the latter, with the annoyance of the paraffin squirting over the faces of both patient and operator.

Eckstein tells us how to overcome the first difficulty with this same style of syringe as used by him. He covers the syringe with a rubber insulating sleeve and draws several drops of hot, sterilized water into the needle to overcome the plugging up of the latter; an illustration of his syringe has been shown on page 232. Mention has also been made of the various methods used to overcome this difficulty by other operators.

It was presently found that such an instrument was not only impractical, but also a detriment to procuring desirable results, the paraffin solution shooting out suddenly, in some instances causing hyperinjection, and at other times emerging so slowly that it required unusual force on the part of the operator—a painful procedure for delicate hands, inasmuch as the fingers only can be applied to operate the instrument.

With the object of overcoming this uncertainty of the amount of the injection and the unnecessary exertion to inject any given quantity, as well as to establish enough vice à tergo to keep the needle free from plugging up with cooling paraffin, various operators devised instruments, all having practically similar points of mechanical merit and usefulness. The required necessities being to invent a syringe which would have a known capacity, a piston under control of the operator at all times, and metallic needles of proper lumen, to prevent the solidification of the liquid paraffin, screwed to the syringe to prevent loosening.

With the object of overcoming these difficulties the author devised a syringe which was made for him by Tiemann & Co., early in 1902. He begs to introduce the same here, as a type similar to which most operators have built their special instrument.

The syringe at that time consisted of a glass barrel, of a size to hold 6 c.c. of liquefied paraffin. At either end of the barrel tube were placed metal ends, the distal one containing a cap with a screw thread to receive the needle, the upper cap being threaded to receive a check nut through its center and on its outer surface, on opposite sides to each other, two metallic rings to accommodate the thumb and forefinger. The center of the check nut was double threaded to receive the piston rod, the piston or plunger being held in place by two, upper and lower, washer nuts, the lower being threaded to receive a small rod passing through the bored-out center of the piston rod, and which ended in a check nut, in the handle, threaded upon the outer or manual end of the piston rod, in such a way that the fiber or asbestos piston washer could be tightened and loosened at will.

The syringe permitted of being used as an ordinary syringe by unscrewing the cap check nut or be made into a screw drop syringe by screwing the same nut into place. By turning the handle end of the piston rod the contents of the syringe were forced out smoothly and evenly in any quantity desired.

With the later employment of the cold, semisolid preparation of vaselin and paraffin, as heretofore considered, it was found necessary to reënforce this syringe, so that the greater pressure necessary to eliminate the wormlike thread of hydrocarbon would not force off the lower cap or break the barrel of the syringe at its needle end.

This was done for the author by the Kny-Scheerer Company, December 6, 1902, when metallic strips were added to opposite sides of the glass barrel connecting the lower with the upper cap.

The instrument as then made is shown in Fig. 289.

At the same time the same firm made the author a syringe entirely of metal, similar in construction, except that the barrel was made larger in diameter and shorter in proportion to bring the instrument near to the seat of operation. The regulating washer rod was not needed, since in this instrument no washers were required, the piston head being made of solid metal throughout and the rod being soldered to the plunger, thus overcoming any objectionable fault in sterilization.

This type of syringe was found to be most suitable for the cold, semisolid injections, and is of the type now universally used except for the slight modifications of the various operators. It is illustrated in Fig. 290.

Since there were no objections to making the barrel large enough to permit of injections, such as are required for restoring the contour of the cheek and the neck and shoulder, it was made to contain 10 c.c. working capacity, overcoming the necessity of constant refilling, when comparatively large injections had to be made—a fact worth remembering from a practical standpoint, although two or three of these syringes, specially prepared for each patient, might be found desirable by some operators. Yet the simplicity and ready facility with which this instrument can be used and refilled renders it useful and sufficient for performing operations of this nature to any judicious extent.

Syringes holding small quantities of the paraffin mixture are found to be a nuisance.

The following operators employ syringes of the capacity given:

The instrument employed by Brœckært, holding less than one dram, would be of little use except to correct very slight deformities about the brow or nose, or dressing up or completing the contour of parts previously filled by larger injections.

Another syringe similar in type to the author’s, but of a capacity of 5.6 c.c., was introduced by Harmon Smith.

The principles of the syringe are alike, but the style of handles, two flat metal bars at opposite sides, offers no objection when comparatively hard mixtures of paraffin and vaselin are used.

While operating the syringe the narrow blades are brought in contact with the soft flexor sides of the thumb and forefinger, indenting the flesh deeply, and with the least unexpected move on the part of the patient permitting it to slip out of the grasp of the surgeon. Its incapacity for large injections also offers some objection, but for correcting smaller defects it is both practical and compact. It is illustrated in Fig. 291.

It is obvious that with the screw drop type of syringe the cold semisolid paraffin mixture contained in its barrel is always under the full command of the operator, nor can there be a plugging of the needle, since the great force that can be exerted with a turn of the piston handle would free it, even if the mixture were of a comparatively high melting point, although the force to be applied would naturally increase in proportion to the hardness of the mass within the syringe.

The turning of the screw piston forces out the contents of the syringe in the form of a white thread of a diameter equal to the diameter of the lumen of the needle.

To facilitate this ejection, the needles should be of ample diameter, not over one inch long and having knife-edged points. Longer needles are not necessary, and only add to the force required to turn the screw handle.

Curved needles, used by some operators, are never needed, and the author does not see how they could be applied at any time in preference to the straight.

As much of the paraffin mixture can be forced out of the syringe as may be desired by screwing the piston down into the barrel.

The piston rod may be graduated in five- or ten-drop divisions, but the operator rarely ever refers to the scale. He judges the amount required by the elevation of the tissues brought about by the presence of the paraffin thus forced under the tissue. Experience soon teaches him the amounts necessary or judicious in each case, always remembering that it is better to do a second and later injection than to hyperinject.

The entire instrument being of metal permits it to be sterilized as readily and in the same manner as any other metallic instrument.

It is understood that the syringe must be taken apart for sterilization at all times.

Lubrication, to facilitate operation, is never required, since the nature of the mixture used in the syringe answers this purpose in every way.

Owing to the greater amount of metal in the solid piston itself, the latter is very likely to expand under dry heat sterilization or boiling, so much so that for a moment it cannot be introduced within the barrel. This can be quickly overcome by dipping it into cold sterile water or absolute alcohol, which brings about its contraction.

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

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

PREPARATION OF THE SITE OF OPERATION

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

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

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

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

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

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

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

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

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

PREPARATION OF THE INSTRUMENTS FOR OPERATION

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

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

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

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

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

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

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

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

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

THE PRACTICAL TECHNIQUE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Deformities About the Forehead

Deformities of the Nose

Deformities About the Mouth

Deformities About the Cheeks

Deformities About the Orbit

Deformities About the Chin

Deformities About the Ear

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

SPECIFIC TECHNIQUE FOR THE CORRECTION OF REGIONAL DEFORMITIES ABOUT THE FACE

Transverse Depressions

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

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

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

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

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

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

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

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

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

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

Deficient or Receding Forehead

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

Unilateral Deficiency

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

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

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

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

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

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

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

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

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

Interciliary Furrow

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Temporal Muscular Deficiency

Unilateral and Bilateral

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

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

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

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

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

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

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

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

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

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

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

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

Deformities of the Nose

The use of hydrocarbon protheses for the correction of nasal deformities has revolutionized, to a great extent, the rhinoplasty of many centuries. Through their employment many unsatisfactory cutting operations have been entirely displaced, and it is quite right to hold that the introduction of other subcutaneous protheses and like apparatuses of amber, celluloid, caoutchouc, silver, gold, aluminium, ivory, or other nature have been supplanted by this method of operation, when these were needed to correct a partial deformity of the nose.

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

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

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

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

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

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

The author prefers making a plaster cast of the entire nose which is to be corrected, and a second cast after the operation has been completed, or at the time of his discharge. A record sheet, or a direct photograph, can be made before and after operation for the same purpose, which is not so desirable, however, because it has been found quite impossible to procure the desired accurate pictures of a nasal deformity, the photographer not being given to bringing out imperfections as the surgeon wishes them, even under the most explicit instructions, unless the surgeon accompanies the patient to the studio to supervise the posing. This requires a waste of valuable time; not to speak of the expense of making pictures of a pathological nature. The better way would be to have an apparatus in the operating room. The surgeon can then pose his patient against a screen background in the position and to the size of picture he may desire. Plate cameras and time exposures are best for this purpose. For recording and half-tone reproduction silver prints are found best.

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

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

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

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

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

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