If necessary the mucous membrane back of the palpebral rim can be injected in like manner to give firmer hold to the eye and at the same time give support to the usually depressed and atrophied lids.
Wet dressings are applied to allay the reactive inflammation, which should be proportionate in severity to the amount of the mass injected.
In three cases operated upon by the author excellent results were attained, and no untoward results had been experienced two years after injection.
Deformities about the Chin
Anterior and Lateral Deficiencies.—An anterior lack of contour of the chin is generally regarded as of the receding type. With this is usually found a bilateral lack of form, especially in men. With a generally well-formed face such a chin gives it a weak and ofttimes a degenerate appearance. In women a deficient chin is not as noticeable, because of the smallness of the face in general and the predomination of the oval type.
The lack of prominence about the chin may be anterior only, the broadness being sufficient, due to a lack of development of the mental process, or it may be deficient laterally with a pronounced mental prominence, giving it a sharp, protruding, or pointed appearance, or the lack of form is combined, as is commonly the case.
Such chins may be made to appear normal, and even ideal, by the subcutaneous injection method. The type of chin most favored by American men is the square angular, now so plentifully seen in pen-and-ink illustrations.
The tissue of the chin lends itself readily to the building-up process. Almost any form may be attained by the judicious employment of the method under consideration.
Fig. 302. Fig. 303.
Profile View, showing Correction of Antero-lateral Deficiency about Chin.
While it is true excellent results may be obtained with hard paraffin, used in liquefied form, it can often be shown, however, that the paraffin injected under pressure will run down in narrow, pencil-like streams underneath the chin and skin of the anterior aspect of the neck, where they may be felt afterward as hard oval cysts or of elongated form. This is not possible when the cold mixture of vaselin and paraffin is used, since the position of the mass can be easily followed with the eye or felt with the fingers.
The injections should be made from either angle at the first sitting. Enough of the mass should be introduced to leave a ridgelike formation across the anterior chin, varying in thickness according to the shape of the chin previous to operation and the form desired.
It is not well in chins of very deficient type to attempt to make the anterior contour as it should be in the first sitting. Too much pressure would be required, and unless the skin was freely movable considerable reactive inflammation would result, with possible necrosis of the skin in part and consequent expulsion of the injected mass.
The anterior line of such chins should be rebuilt in several sittings, always waiting for the parts to become normal in appearance and sensitiveness.
This method helps to stretch the skin, allowing of further injections and the introductions of a greater quantity than could be introduced at one time only.
The author advocates making two or three sittings of the anterior restoration of contour and two for each angle.
The angles of the chin are injected at a point about midway between the mental process and beginning of external oblique line. The mass is injected as near the inferior ridge as possible, and somewhat above the attachment of the platysma myoides muscle.
Fig. 304. Fig. 305.
Frontal View, showing Correction of Antero-lateral Deficiency about Chin; also Correction of Deficiency of Cheeks.
Only one needle insertion is made at each angle, and the mass is injected until a round elevated tumor is attained, which is pinched or squeezed with the fingers into the desired angular form, one finger being placed over the needle opening to avoid squeezing the mass out.
It can be readily seen that with this puttylike mass much better results than with the comparatively soft vaselin could be obtained while with the liquefied paraffin the operator would be at a loss to know just what had been accomplished until the mass had become fairly solidified, and then often finding the semisolid mass, which required rapid molding to give the desired shape before it would become hard and unmanageable, in a different position and much more distributed than he had expected.
For the latter reason repeated small injections have been advised, but the author believes oft-repeated injections of paraffin in a small area are prone to set up considerable disturbance, and that the resultant tissue replacement is interfered with. Furthermore, the injected mass would eventually be in grape-bunch like form, and in that condition not as manageable or inducive to the establishment of contour angulation, such as is required in the chin. The final appearance of chins thus rebuilt is heavy and rounded, lacking the concavity above the inferior prominence along the anterior line as well as the angulation laterally.
With the cold mixture advised a considerable mass may be injected at one sitting, which is easily molded into form and which retains that form unless the reactive inflammation is severe. This should not follow unless actual hyperinjection has been done or an unclean product has set up an infective cellulitis.
When the chin is uncommonly peaked, or small, it may be found necessary to inject both sides of the chin beyond the angle and in an upward direction slightly below and following the external oblique line.
Such deficiency may be found decidedly unilateral as a result of lack of development of one half of the lower maxillary bone, a resection of either maxilla for whatever cause, imperfect union following fracture or disease of the bone early in life.
In such cases the lateral deficiency must be first restored, using the same method, before the chin proper can be built up. Ofttimes the lower cheek of the affected side must also be injected. This should be done after the site overlying the former body of the maxilla of the affected side has been rebuilt. The cheek should then be built out above this hard linear mass by the injection of cold white vaselin, as heretofore referred to.
The following illustrations show a chin deficient anteriorly and laterally before and the result after correction.
The post-operative treatment should be collodion dressing, followed by cold antiseptic applications for at least two days. The latter ameliorates the inflammation and helps to retain the molded shape of the mass. Subsequent sittings may be made one a week or ten days apart.
Deformities about the Ear
Pro-auricular Deficiency (Unilateral and Bilateral).—A deep furrow in front of the ear may be found unilateral in hemiatrophy of the face, but the condition is usually a bilateral one, due to malnutrition or the fatty degeneration of past middle age. In the latter case the depression is accompanied by a redundancy and wrinkling of the skin.
Owing to the close proximity of the large temporal vessels a hard mass should never be injected subcutaneously for the relief of this condition. Even the mixture of vaselin and paraffin has caused considerable reaction when injected to overlie these vessels.
The author advises the injection of white sterile vaselin or sperm oil for this form of correction. It should be carefully injected, since the vessels lie close to the skin with the anterior auricular crossing transversely about the center of the furrow.
Every precaution should be taken, one injection only being made from below upward at each sitting if more than one is necessary, and then only after the needle has been unscrewed from the syringe to make sure vessel bleeding does not follow the puncture.
The reaction is usually severe, with considerable edema and ecchymosis.
The resultant tissue formation likewise is active, and hyperplasia at this site is not uncommon, especially if the mixture or hard paraffin has been employed.
A cellulitis following such an injection is exceedingly troublesome, the injected mass being thrown off usually at the base of the furrow, which is followed by a low type of inflammation with a protracted oozing of serous exudate. Should such a case come under the care of the surgeon, thorough cleansing of the affected site under scrupulous antisepsis should be done at once, and wet antiseptic dressings be applied daily until the wound is entirely healed.
A plastic skin operation must be done in most of these cases to overcome the ragged cicatrix formed upon healing of the wound. This should never be undertaken until the wound has been healed for several weeks at least.
After the injection of the parts cold antiseptic dressings should be applied at once, and kept up until every sign of reactive inflammation has subsided. At no time should the subsequent injection be undertaken before a month has elapsed from the time of the former operation.
Post-auricular Deficiency.—This defect is invariably unilateral, and then the result of a mastoid operation.
The skin about the depressed site will be found to be more or less firmly adherent, necessitating subcutaneous dissection before an injection for correction can be undertaken.
In this case the cold mixture of vaselin and paraffin is indicated, since the softer products will hardly suffice to elevate the tense skin. If the former surgical operation has been done some time previous to the required injection the parts may at one or two sittings be restored to a fairly normal contour, depending entirely upon the amount of ungiving scar tissue at the site. If the parts are tender and not reduced to normal, the injections should be made frequently, about ten days apart, injecting a small mass across and through the subcutaneous scar attachment at each sitting.
The reactions following such injections help to tease the scar away from the bony tissue, but should not be sufficient to cause extensive inflammation.
The same mode of post-operative treatment as has been given with pro-auricular corrections should be followed.
SPECIFIC TECHNIQUE FOR THE CORRECTION OF DEFORMITIES ABOUT THE SHOULDERS
Deficiencies about the base of the neck and the shoulders are very commonly found in women. These defects are usually bilateral, except in rare cases. The much-desired contour is readily restored by the subcutaneous-injection method, and since the technic for one part is the same as for the whole there is no need to dilate specifically upon the treatment of each part.
The author advocates the injection of cold sterile white vaselin only, for the restoration of the contour about the neck, anterior and posterior shoulder, and the mammæ, except in the unilateral correction of a flattening of the breast following amputation for the removal of neoplasms, when the mixture of white vaselin and paraffin should be used, owing to the tenseness of the skin following the excision of a large part of the integument covering the diseased gland.
In the restoration of the contour about the neck and shoulders it is well for the surgeon to familiarize himself thoroughly with the superficial veins of the parts, since the vessels here are larger, and the introduction of foreign matter into them is liable to lead to serious and even fatal results.
The injections should never be made until the operator has assured himself of the fact that a vessel has not been entered into, and then only should a small quantity of the mass—i. e., about two or three drams—be injected at one point.
The easiest mode of introducing the needle is to pinch up the skin between the fingers of one hand, introducing the needle into the fold thus raised. As the mass is injected the skin should be raised by aid of the needle, so as to allow all the immediate room possible for its reception.
The mass injected is at once molded down flat with the thumb or forefinger.
A number of such injections may be made at both sides at the one sitting. The ethyl-chlorid spray may be employed to render the parts less painful. At no time should the entire shoulders be filled at one sitting, for fear that the reaction may be severe or that for any unforeseen cause infection results which would in such instance be indeed difficult of treatment, eventually leaving the parts scarred and unsightly.
Nor should the mass be injected intracutaneously, a fault sometimes observed about the base line of the neck anteriorly and laterally where the operator has been timid in avoiding the exterior and anterior jugular veins. Such injections invariably result in abscess, or when not extensive enough to cause necrosis the skin assumes a more or less permanent red or yellow discoloration over the site so injected.
The treatment for the partial or total removal of such spots has been referred to.
In the average case of contour restoration of the shoulders about eight sittings are required, two sittings being given each week, and as many injections made as is deemed necessary or advisable at each.
All the precautions of technic heretofore given should be employed. The reaction following such injections is never severe, and little or no treatment is necessary.
The needle openings are covered with aristol collodion or the isinglass adhesive plaster.
At the end of six months or more after the injected matter has been quite thoroughly replaced with new connective tissue it is often found necessary to inject small quantities here and there about the shoulders, owing to the contraction of the new tissue and its ultimate fixed disposition about the parts more than to the absorption of the mass injected.
Furthermore, a certain amount of edema or swelling follows the injection of any foreign matter under the skin which is not, in cases of this kind, so readily absorbed, giving during that period of time a more pronounced contour or fullness, which, passing away in the natural course of events, does not imply the absorption of the matter injected—a statement so often made by those not in favor of using paraffins of low melting points for subcutaneous protheses.
Such result, however extensive, as it might be in some cases for the lack of proper injection or in the case with oil injections is at all times correctable, while the hyperplastic knobs, so often following the injection of paraffins of high melting points about the shoulder, can only be removed by surgical means, which leave the parts more unsightly than before anything had been done for the patient.