CHAPTER XIVSUBCUTANEOUS HYDROCARBON PROTHESES
Although the subcutaneous employment of oil and liquefied paraffin has been known for some years, particularly by Corning, who refers to his use of solidifying oils in surgery in an article published in 1891, no actual application for prothetic purposes was made until 1900, when Gersuny first advocated the method. In his published report he says that, “if vaselin, which at the temperature of the body has the consistency of ointment, be liquefied by heat and by the means of a Pravaz syringe is injected into dilatable tissue of the human body, there is produced, at the site where the injection is made, a tumefaction whose volume corresponds to the quantity of vaselin injected. The reaction which results from the procedure is insignificant and the mass appears to rest without change where injected.”
This subcutaneous method of vaselin injection he employed in the case of a young girl to correct a saddle or depressed nose. The operation was purely a cosmetic one, and was performed on May 8, 1900, with a very satisfactory result.
From the time of the appearance of Gersuny’s paper, “Ueber eine Subcutane Prothese,” a number of operators, such as Halban, von Frisch, Kapsammer, Delangre, Rohmer, Stein, and others, began to follow the method with gratifying results.
Pfannenstiel, shortly after, claimed that the injection of vaselin was not wholly without danger, and that pulmonaryembolism had been observed by him subsequent to its use. Moszkowicz denied the possibilities of such danger, although at this date it is quite evident that there are many objections to the sole use of sterile vaselin for all subcutaneous cosmetic purposes where such protheses might be indicated.
Eckstein, on July 24, 1901, rehearses these objections and advocates the use of “Hart paraffin,” or paraffin with a melting point of 57-60° C. (140° F.). His method was taken up by Brœckært, Baratoux, Brindel, Watson Cheyne, Walker Downie, Leonard Hill, Lake, Scanes Spicer, Karewski, and other prominent surgeons abroad, and by Parker, Harmon Smith, Hamilton, Quinlan, Connell, and others in the United States.
Drs. Lynch and Heath were the first American physicians to place themselves on record in the employment of the method of Gersuny for the correction of nasal deformities.
Each of the operators employing the now so-called Gersuny method advanced their individual ideas and improvements in the art, and those of distinctive merit will be considered later by the author, who has employed both methods from the time of their incipiency.
The method of procedure in the injection of vaselin or paraffin is practically similar, except for the various ways in which the paraffin of different melting points is rendered liquid.
The indications for the protheses of either method are the same, except where the author advocates the use of either one or the other or a combination of the two from an experience with over five hundred personally conducted cases.
The advantages of the Gersuny method is that the operation is practically painless, causes no scar if properlyperformed, and corrects a deformity that could not be overcome otherwise in some cases, while in others it would entail not only difficult surgical interferences, but subsequently unsightly cicatrices that would render them more objectional than the very defects which were intended to be corrected.
This is particularly true in the cosmetic correction of depressions about the forehead resulting from direct violence or frontal sinus operations, for obliterating habit furrows, or frowns, between the eyebrows; also to restore the symmetry of the face in hollows of the cheek due to the removal of malignant growths, the maxillæ, or when caused by facial hemiatrophy or a congenital or long-acquired sinking in of the cheeks; while it may also be employed with excellent result to prevent post-operative adhesions about the face after mastoid operations and even to restore the form of the breast after operation for malignant disease and the raising of smallpox pits.
Numerous other uses may be mentioned, such as elevating an undue depression at the root of the nose, raising sunken furrows below the eyes, obliterating nasolabial folds, angular droops about the chin, rebuilding weak or pronounced oval or peaked chins, filling hollows about the neck and shoulders, and in fact anywhere about the body to restore the contour.
In correcting the deformities of the nose, whether congenital or acquired, this method has met an urgent and most useful demand, so much so that many rhinoplastic operations of extensive delicacy have been thrown aside for this simpler, rapid, and gratifying means of surgery.
Not only has it been employed to restore the nasal line in saddle noses, but also in many other deformities of that organ which do not require the removal of superabundant tissue.
According to the appended classification of nasal deformities,given by Roe, it will be seen that many faults of that organ may be overcome by the method.
From the above arrangement, and taking each division separately, the author enumerates the applicability of the subcutaneous prothesis, adding such as are not included in the above.
1. Vertical concavity. An overmarked depression at the site of the bony structure and about the root of the nose.
2. Lateral deficiency of form about the root of the nose extending downward as far as the inferior borders of the nasal bones.
3. Median anterior vertical concavity or saddle nose involving the middle third, otherwise the inferior and superior sections.
4. Deviations of the cartilaginous structure about the middle third of the nose, either unilateral or bilateral.
5. Deviation of the lobule.
6. Deficiency of the lobule.
7. Lobular cleft.
8. Subseptal cleft.
9. Collapsed alæ, unilateral or bilateral.
10. Retraction of subseptum.
In these ten subdivisions much can be done to bring about a normal appearance of the nose.
In selecting a case for subcutaneous injection the operator must well consider the methods to be employed, his successes with such methods, the importance and gravity of the operation, the condition of the patient, the extent of the deformity, the peculiarity of the patient and, particularly, the state of mind of the patient.
While at this date of the use of this method of beautifying parts of the human face we may feel certain of the happy outcome of an operation undertaken by the operator, he must not lose sight of the hypercritical person upon whom the work is to be done; even with an outcome gratifying in the extreme from a surgical standpoint, the patient will insist, and that in eighty per cent of all cases, to still further improve them in spite of the fact that a normal appearance has been attained, often leading the operator into doing what he should not do, and eventually undoing his own excellent efforts.
The author does not mean to imply this as a weakness on the part of the surgeon, but cannot impress too deeply upon him the unreasonable demands of a person insanely bent upon having the alabaster cheek ideal of the poets, the nose of a Venus, the chin of an Apollo, the neck of swanlike form, etc.
The patient believes it lies in the power of the cosmetic surgeon to do with their malformations as a sculptor would model in clay and will insist upon gaining their ideal beyond all reason.
Let the author warn the operator against the “beauty cranks,” especially of those who are just about to engage in great theatrical ventures, circus performances, or “acts,” and very desirable marriages. These are patients who are not only difficult to deal with, but the first to harm the hard-earned, well-deserved reputation of the surgeon and to drag him into courts for reimbursementfor all kinds of damages, especially backed up by events, losses, and sufferings largely imaginable and untrue, and ofttimes entirely impossible.
In all cosmetic surgery this branch is the most dangerous from that point of view; therefore the operator should take his case well in hand, proceed with an unshakable determination and give the patient to understand his position, even to explaining what disappointments there might be and what dangers, if any, he might look forward to. The author believes it no unjust demand to have an agreement made with the one to be treated in which these matters are fully considered. Such an arrangement will save him much worry and will tend in the majority of cases to keep his patient satisfied.
On the other hand, the operator should not undertake to do an operation of a cosmetic nature unless he has a fundamental and practical experience of long standing in this branch of surgery, and is ready at all times to cope with such post-operative conditions as are likely to arise, which will be described later.
The author has on various occasions been asked to correct the most hideous malformations of parts of the face, particularly the nose, in which surgeons of high standing, both here and abroad, had injected paraffin in liquid form, usually under a general anesthetic, the most remarkable being that of a hospital orderly in the United States service, who had been subjected to not only one of such injections to correct a saddle nose under chloroform anesthesia, but to three distinctive operations, with the result of a permanent disfigurement, bettered only by a succession of excisions at different parts of the nose.
Apropos of such cases it may be timely to state that a general anesthetic for the performance of a prothetic injection operation is never justifiable and should be considered a lack of knowledge on the part of the operator,unless its use be advised by another surgeon in consultation.
The greatest mistake made with this so-called “filling method” has been a desire on the part of the patient or the operator, or both, to complete the work too quickly. Unscrupulous operators have restored a saddle nose or the contour of the cheeks in a few minutes, when it is an established fact that the work should be done slowly, giving time for the injections to accommodate themselves and to organize before others are attempted. This is not only true of fillings about the cheeks and shoulders, but also of injections about the nose and forehead.
Eschweiler particularly emphasizes the advocacy of oft-repeated injections, and the author recommends such rule without reserve or deviation.
As has been said, the advantage of the Gersuny method over other procedures is that it can be undertaken practically without pain, that it is quick, bloodless, leaves no scar, and is harmless except under such conditions as will be referred to under a separate heading.
While the method entails only the pain of a pin prick a local anesthesia may be employed to overcome this, but never a general anesthetic. The ethyl-chloride spray, except at very small points of the skin, is not to be recommended because it freezes and consequently hardens the very tissue which should be flexible, the operation being undertaken the moment the needle is inserted and lasting only a few seconds. The hypodermic use of a two-per-cent solution of cocain, or better Eucain β, can be employed, but the author sees no advantage in it, as the hyperemic engorgement following its use obliterates, to a certain degree, the actual extent of the deformity.
It is desirable to obtain the best result to have the skin above the part as free as possible. When closely adherent it should be freed by the careful use of a delicate tenotome, inserted at the point where the injection is to be made, the same opening being used for the introduction of the needle of the syringe. If this opening has been made too large a fine suture of silk should be employed to bring the lips of the wound together before the injection is made; the needle point, being knife-edged, will not disturb the apposition and will tend to retain the filling if no undue pressure is used, as in the case of hyperinjection.
Connell has tabulated the difficulties and dangers met with in this work as follows:
1. Toxic absorption.
2. Marked inflammatory reaction.
3. Loss of tissue, due to infection and abscess formation.
4. Pressure necrosis, caused by hyperinjection.
5. Sloughing of tissue as a result of the heat of paraffin.
6. Injection into very dense or inelastic structures, or where scar tissue is firmly attached to the underlying and adjacent parts.
7. Subinjection of too small an amount of paraffin with an insufficient correction of the deformity.
8. Hyperinjection with overcorrection of deformity.
9. Air embolism.
10. Paraffin embolism.
11. Primary diffusion or extension of paraffin (when first introduced) into adjacent normal structures.
12. Interference with muscular action of the nose.
13. Escape of paraffin after the withdrawal of the needle or primary elimination.
14. Solidification of the paraffin in the needle, which renders the injection difficult and causes injudicious expedition on the part of the operator.
15. Absorption or disintegration of the paraffin.
16. The difficulty of procuring paraffin at the proper melting point.
17. Hypersensitiveness of the skin over the injected area.
18. Redness of the skin over the injected area.
To those the author would add:
19. Secondary diffusion of the injected mass.
20. Hyperplasia of the connective tissue following the organization of the injected matter.
21. A yellow appearance and thickening of the skin after organization of the injected mass.
22. The breaking down of tissue and the resulting abscess due to the pressure of the injected mass upon the adjacent tissue after the injection has become organized.
Each of the above subdivisions may be advantageously considered individually, to wit:
1. Intoxication.—The danger of intoxication may truly be said to be more so due to the unclean or unsterilized matter injected than to the absorption following its employment, although Meyer has claimed untoward symptoms found in his experiments from absorption of injections of vaselin in the animal. Taddie and Delain, Stubenrath, Straume, Sobieranski, and Dunbar have corroborated this claim. They injected paraffin of various melting points in the lower animals and observed results therefrom, among which were loss of hair, a reduction of eighteen per cent in the body weight in two months and death.
Stein and Harmon Smith refute these conditions and remarked neither systemic nor local untoward results from such injections when paraffin of higher melting points were used.
Jukuff claims that no toxic symptoms resulting from the absorption of paraffin injected into tissues are shown, unless the amount be equal to ten per cent of the weight of the animal. To have this apply to the human as much as ten to fifteen pounds would have to be injected—an amount never required in operations of this nature.
While it cannot be denied that the injected mass becomes more or less absorbed in from two to three months and is replaced by connective tissue, it may be definitely stated that no toxic symptoms are caused directly thereby, except by the employment of an impure product.
2. Reaction.—The reaction following a properly made injection is of a mild inflammatory character. Considerable inflammation points to some fault in the technique or impurity of the injection. More or less edema of the site and its adjacent area may be noted, associated with slight or marked discoloration and pain of variable degree. The normal reaction following the injection is temporary and does not necessitate treatment or confinement of the patient, who can resume the duties of life fifteen hours after the operation.
3. Infection.—The cause of infection cannot be said to be due to anything but surgical uncleanliness, as it is with any surgical undertaking, and can be overcome by the same means.
The material injected should be thoroughly sterilized by boiling before using. Brœckært suggests combining an antiseptic with the paraffin and has used guiaform, a combination of formic aldehyde and guiacol in a proportion of five to ten per cent; yet this is of little value when we consider how readilythese hydrocarbons can be rendered sterile at high temperatures.
4. Necrosis.—Death of tissue may follow an injection of paraffin when too much pressure has been applied, or when too much has been injected into the tissue, cutting off the blood supply, or when the injection has been made into the skin instead of beneath it. Again, constitutional disease, such as diabetes or Bright’s disease, may superinduce the breaking down of the tissue.
Hyperinjection should and can be avoided by the use of the proper instrument with which the required amount is graduated to a nicety. At no time should an injection be crowded into a dense tissue or where the skin is closely adherent, nor carried so far as to create a blanching of the skin. By carefully injecting the mass this danger should be overcome.
Dense or bound-down areas of skin should be loosened and freed, as has already been mentioned.
If care be exercised and small amounts be injected, in preference to overcoming the defect in one sitting, pressure effects are entirely overcome.
The circulation in the skin over the site of injection should be normal immediately after the operation has been performed, determined by observing the reaction in the color of the skin after delicate digital pressure.
5. Sloughing.—That sloughing of the skin should be occasioned by the high temperature of the paraffin injected is a condition entirely inexcusable. Paraffin of high melting points 58° to 65° C., or the so-called “Hart paraffin” employed by Wolff, liquefying at from 57° to 60° C., are to be used with caution. The author doubts whether the temperature of the paraffin at the time of injection, even in the latter method, is ever beyond 54° C. even if the thermometer registers 60° C. in the liquefying, hot-water bath.
By the time it has been drawn into the syringe, which has been heated by dipping into hot water, and themoment it is injected it has lost several degrees in heat.
It would not be permissible to inject a molten mass of a temperature so high as to scar or burn the tissues, and the best results of most operators have been obtained with such of the paraffin group that become liquefied at a temperature of not over 45° C. (112° F.).
The claim of Eckstein, that paraffins of low melting points are more likely to be absorbed, has not been substantiated in actual practice, since we now know that any and all of these injections, irrespective of their melting points, are absorbed in time, giving place to connective tissue, and that rarely, if ever, is there a true and complete encapsulation or encystment of the mass thus introduced. Even the hard paraffins are split up in time into minute pearllike particles which are displaced by the growth of tissue arising from the presence of the foreign substance. This is true even in those cases in which the author has introduced by surgical means solid paraffin plates in the cold state.
6. Sloughing Due to Pressure.—When an injection is forced into a dense or firmly bound-down tissue, as into the body of a thickened cicatrix, or about the point of the nose or the subseptum of the nose without first dissecting off the skin above the subcutaneous layers, an acute anemia is at once marked, followed by inflammation and gangrene.
By injecting sterile water into the area thus loosened with the knife a good idea of the thoroughness of the dissection and the possibility of building up the part to be corrected is obtained, yet in these cases the author has always found more or less difficulty in keeping the injected mass in place for the reason that the divided surfaces tend to unite at their peripheral borders, crowding the mass upward or to one side or diffusing it in such a way that the result has been anything but satisfactory.
To overcome this it is advisable to inject a smaller quantity than necessary to entirely correct the defect, to mold it out flat and to allow it to organize before more is introduced.
7. Subinjection.—Insufficient injection leading to an undercorrection of the defect is a far more desirable condition than hyperinjection, and is easily corrected by a repetition of the treatment, even to a third sitting, until the desired result is obtained. Following this rule will give far better results, as has been said, than to be compelled to remove a part of the filling and some of the connective tissue which has resulted therefrom.
8. Hyperinjection.—The injection of too much vaselin or paraffin is one of the most common faults found with operators. In the first instance a tumefaction of the site results which with the production of the tissue which takes the place of part of the filling makes the result very unsatisfactory and requires one or more cutting operations to reduce it. A peculiar fact with these hyperplastic growths is that even though they may be reduced with the knife to a normal size they seem to redevelop again and again, giving both surgeon and patient great concern.
This, in the opinion of the author, is due to the binding down of the marginal borders, which, in the event of partial extirpation, are not injured sufficiently to displace them and that they unite again in their former position. To overcome this it is found best to excise the entire filling much beyond the margins and to apply pressure over the area until perfect union has taken place.
This is best accomplished with a disk of aluminium, bent to conform to the shape of the part operated, lined with sterilized lint and fixed over the site by strips of Z. O. plaster.
While the hyperinjection of vaselin is not as objectionable as that of paraffin, because of the more readyaccommodation and absorption of the mass, it nevertheless leads to diffusion of the material, owing to its softer consistency and consequent greater facility in seeking fine avenues of escape, paraffin having the advantage of cooling upon itselfen masse, leaving little to escape into undesirable channels after it has once been molded and set.
Vasserman cites a case in which gangrene of the bridge of the nose resulted after an injection of 2.05 c.c. of vaselin.
However, when these faults occur they are errors of technique, and should be avoided, as has been mentioned heretofore.
The removal of such hyperinjected masses by the aid of paraffin solvents, such as benzine, ether, chloroform, or xycol, applied to the skin above the filling, has proved a failure, nor will heat used externally in the same manner remedy evil.
What is left to the operator is to open the skin and, with a small, sharp spoon curette, remove the mass early, before it has become organized, or to excise the new connective tissue and the broken-down filling, as mentioned.
When, however, the tumefaction resulting from such hyperinjection is not extensive, as is often found about the chin and at the root of the nose, the secondary deformity can be materially, if not entirely, remedied by electrolysis. A needle or brooch of certain hardness is to be employed, connected with the negative pole of a continuous current apparatus. From twelve to twenty milliampères are required. The process is similar to that used with the destruction of hair, nævi, or moles on the face. The needle should puncture the entire tumor or penetrate its maximum diameter and be charged with the current for two or three minutes. Several of such punctures should be made at each sitting, the latter being repeated as often as is deemed necessary by the operator.The reaction which follows this procedure is of little moment, and these sittings can be undertaken every three or four days.
While this method is liable to leave little punctuate scars at the sites where the needle is introduced, it is nevertheless more satisfactory than the linear scar made with the knife, to the use of which the patient may, on the other hand, object, not to speak of the difficulty and unsatisfactory results usually obtained therewith.
9. Air Embolism.—The fault of introducing air under the skin with the syringe at the time of injection can only be the result of flagrant negligence. Every physician should know enough to hold the syringe in an erect or vertical position, and to expel the air above the solution in his syringe, as is done with any hypodermic injection.
Air embolisms are also occasioned by a careless filling of the syringe with the hydrocarbon in a cold state, as the material is now generally used, and while the dangers of such emboli are very much exaggerated they should not be permitted, when by the pouring in of the liquefied material the syringe can be filled evenly.
Practically there is no harm done by the injection of air under the skin, yet it elevates the skin at the site of the defect and hinders the surgeon in accomplishing the best results.
These emboli cause a bulging up of the skin for the time being and may occasion more or less pain to the patient, which passes away in ten or twelve hours, leaving the parts as injected except for such reactionary symptoms or edema, already referred to.
10. Paraffin Embolism.—The creation of an embolism is invariably due to an injection of the foreign substance directly into a blood vessel. This condition is one of the most objectionable, if not the most dangerous, factor associated with the subcutaneous injection of any foreignmatter, be it a liquid substance, as, for instance, an oil; many cases have been placed on record where they have been observed after the introduction of even paraffin of high melting points, when introduced under the skin in hot liquid state. Consequently the use of vaselin liquefied by the aid of heat is especially liable to give rise to such condition.
Pfannenstiel cites a case wherein he injected paraffin in which the patient was at once attacked with violent coughing, and for three days exhibited symptoms of grave nature, such as pain in side, intense dyspnea, acceleration of the pulse, hyperthermia, cyanosis of the face, hemoptysis, violent cephalalgia, and vomiting—all indications of pulmonary and cerebral embolism. The injection in this case was one of 30 c.c. of paraffin, with a melting point of 45° C. The symptoms as mentioned continued for about one week, gradually subsiding, and followed by recovery.
Kapsammer has also noticed such symptoms. Leiser, after injecting vaselin to correct a saddle nose, noted an immediate collapse of the patient, which was obviated only by the hypodermic use of ether and the resort to artificial respiration. When the patient returned to consciousness, he was found to be entirely blind in the right eye, the eye before the operation having been known to show only a pronounced astigmatism.
Kofman cites the loss of a patient from the injection of 10 c.c. of paraffin for vaginal prolapsis. Moskowicz observed two cases of pulmonary embolism treated in the same manner, stating that an alarming dyspnea continued for several hours.
Especially have cases in which the injections of paraffin were made submucously for the correction of atrophic coryza shown embolic tendencies. This is especially true when paraffins of high melting points have been employed, as in the case of Pfannenstiel, in whichinstance the condition of the mass permitted of freer absorption or the high temperature caused a coagulation of the blood in the veins, leading to thrombosis and embolism, and when the amount of such an injection is so large as to prevent cooling and hardening in the normal space of time added to the quantity and associated at the same time with consequent pressure, predisposing to absorption or dissemination, especially if the injection be made into the parenchymatous instead of the subcutaneous tissue.
Comstock, in his experience on animals, states that “in all cases in which paraffin was used at 102° F. the animals died within two weeks’ time, hence the specimens at that temperature are limited (death being by thrombosis). In all other cases with the higher melting point, 110° F., no unpleasant results were experienced.”
Hurd and Holden have observed a patient who had previously undergone two injections of paraffin for the correction of a depression in the upper part of the nose. A third injection was advised and made under the same conditions as the first, except that no cocain anesthesia was employed, the paraffin being at same temperature as before.
The moment the injection was made complete blindness in the right eye resulted, while a small ecchymotic spot appeared at the site of the needle insertion in the skin. Half an hour later an examination of the eye showed the right pupil dilated and inactive light stimulus, the patient being unable to distinguish light from darkness. Ophthalmoscopically the lower branch of the central retinal artery and its subdivisions were found to be empty and in a state of collapse, evidenced by their pale appearance. The upper branch of the same vessel was found to be poorly filled.
The authors endeavored to remove the embolism to a collateral branch of the artery by the use of amylnitrate, digitalis, and pressure on the globe of the eye, with no effect. Some hours later edema of the retina appeared, followed by permanent loss of sight. The same authors have observed several cases of pulmonary embolism result from the injection of paraffin.
It is also a fact that injections of the nature being considered, while not causing immediate embolism, may do so as a result of phlebitis, caused by a direct injection into the vein or over or upon it in such a way as to cause irritation.
Mintz reports a third case of amaurosis following a paraffin injection. The latter was made to correct a saddle deformity caused by syphilis. Three minutes after the injection the patient complained of pain in the left eye, which was followed by total blindness, vomiting, and a pulse of 48. Several days later there appeared symptoms of venous congestion in the orbit, paralysis of the ocular muscles, corneal cloudiness, and exophthalmos, a small gangrenous spot appeared at the site of the injection.
Brœckært observed a case of facial phlebitis, followed by pulmonary infarction. Brindel cites a case in which he observed a hard line of considerable extent and painful to the touch, extending from the inner angle of the eye to the angle of the eye, where it deviated toward the root of the nose and terminated at the origin of the eyebrow.
De Cazeneuve made an injection, and on the following day noted that the right cheek had increased considerably in size with an elevation of temperature in the part. Two days after, under the right eye and to the right of the nose, the whole cheek was red, hot, and much distended, giving the skin a glazed appearance. Palpation was extremely painful. A hard line could be made out, extending from the inner angle of the eye outward and downward under the lower eyelid and terminating in the center of the edematous cheek. Thephlebitis in this case resulted without the development of an embolism.
After a careful study of the causes of such embolisms we come to the conclusion:
1. That the injected mass should not be heated above a certain melting point.
2. That hyperinjection should at all times be avoided, particularly with paraffins of high melting points.
3. That the injection should be made subcutaneously not into parenchymatous tissues, and
4. That a puncture of a vein or the introduction of the injected mass into a vein should be avoided.
In the consideration of the first two causes the author advocates using injections of low melting points only at all times; in fact, from his experience with over two thousand subcutaneous injections, he relies entirely upon such paraffins or hydrocarbon mixtures as are semisolid at 70° F., appearing as a white cylindrical thread from the needle of the syringe as pressure is applied.
With such a preparation and a careful introduction of the needle, as described later, and with the injection of an amount much less than that needed to correct the deformity and proper digital compression on the blood vessels and about the site of the injection embolism is practically impossible.
The avoidance in the third instance is self-evident, and it is to the fourth fault and cause that we must pay particular attention.
Stein says that all that is necessary to avoid puncturing a vein is to first introduce the needle alone under the skin and to attach the syringe only when it is found no flow of blood results from the puncture thus made.
Freeman and the author add to this by advocating the use of a somewhat blunt-pointed needle instead of the extremely sharply pointed knife-edged needles usually furnished with syringes intended for this purpose.
11. Primary Diffusion or Extension of Paraffin.—The spreading of paraffin into normal tissues about the site to be corrected by prothetic injection is a fault due principally to a careless use of the syringe. The employments of an improper syringe in which the amount to be injected cannot be graduated or controlled will be considered later—the result with such being hyperinjection. In this event, when the anterior line of the nose is to be restored, the mass is liable to find its way into the loose areolar tissue of the infra-orbital region; in correcting a nasolabial furrow the mass is pushed upward or is forced into the tissue of the cheek above it, aggravating the trouble; in obliterating a frown it travels upward toward the margin of the scalp, giving a median prominence to the forehead that is found to be very difficult to correct; in injections about the mouth the mass moves down upon the chin or accumulates at the angle of the jaw; in correcting the creases beneath the chin it seeks the sides of the neck, even traveling to the superior border of the clavicle at its sternal third. Many other forms of such diffusions can be mentioned directly due to primary diffusion the result of hyperinjection.
Enough has been said of the danger of hyperinjection, yet even with a proper amount of the injected mass this distention may be observed. To avoid this the operator, or his assistant, should compress the margins of the site of the injection with his fingers firmly applied, as, for instance, in the injection of the root of the nose pressure should be made at both inner canthi and over the tissue just above the root of the nose and beneath the finger tips.
Downie advocates the use of celloidin in the correction of a saddle nose as follows: He paints a band of celloidin or collodion down each side of the nose, limited by the line of junction with the cheeks, and another band across the root of the nose. These painted on bands heallows to dry and contract for fifteen minutes before undertaking the injection.
The contraction of these bands prevents to a certain extent the spreading or extension of the liquid paraffin into the cellular tissue about the eyes, yet experienced digital pressure is at all times to be preferred.
If a liquid paraffin or hydrocarbon mixture or vaselin is used, the immediate use of ice cloths applied to the part as digital pressure is removed, is advisable to aid in the rapid hardening or setting of the injected mass before the tension of the tissues over and about it might influence it. With semisolid injection this is not necessary, except in the subsequent treatment, as will be considered later, because the mass, unless of too soft a consistency, as, for instance, vaselin, will practically remain as injected and molded.
Vaselin when injected into tissue where there is tension would naturally be forced out of position and shape, and should not be used except in combination with a paraffin of a melting power high enough to give the proper consistency to the former.
12. Interference with Muscular Action of the Wings of the Nose.—That nasal respiration may be encroached upon as a result of injecting paraffin about the nose has been observed by Alter. He points out that during nasal inspiration there is a tendency for the alæ to contract upon themselves or to move inward, decreasing the lumen of the orifice, and that in the normal state this movement is counteracted by the action of dilator muscles of the alæ—that is, the dilator naris anterioris, the pyramidalis nasi, and the levator labii superioris alæque nasi—and that this muscular action is interfered with owing to the pressure of the paraffin upon these delicate structures, and resulting in more or less permanent collapse or indrawing of the alæ during inspiration. He observed considerable interference with inspiration in a case cited in which an injection of paraffin had been made.
To avoid undue pressure upon the structures referred to, it is advised to have an assistant place a thumb into each nostril and the index fingers without and above the alæ in such way that the tips of the fingers may be enabled to exert the necessary pressure over the injected mass into these structures, and to maintain this pressure until the mass has been properly molded and set. Connell advises inserting the little fingers into the nostril to prevent an encroachment on the lumen of the nasal canal.
The above applies particularly to those cases where injections are made into the anterior lower or lateral third of the nose, as, for instance, in overcoming slight depressions in the anterior line, immediately above the lobule or in a low unilateral deviation of the nose.
13. Escape of Paraffin after Withdrawal of Needle.—When the injected mass employed is of a semisolid consistency, as heretofore advised, it is hardly possible for the mass to be forced out through the opening of the skin made by the introduction and withdrawal of the needle, unless there be an unwarrantable immobility of the skin above the site to be injected. The latter should be corrected before injection.
The mass after having been molded in the shape desired may be further hardened and set by the application of ice cloths or spraying with ether before the needle is withdrawn from the skin, yet this is hardly necessary, and the author advises against the practice for the reason that pressure of the needle prevents proper and free molding of the mass and renders the tissue liable to further injury by scraping its point to and fro subcutaneously, adding to the extent of the wound and the dangers of infection and repair.
The skin immediately around the needle hole, after withdrawal of the needle, may be gently smoothed out with the dull rounded metal handle end of the bistoury to free the interdermal canal of any foreign matter.
The skin about the needle hole is then gently washed with a fifty-per-cent solution of hydrogen peroxid, dried with a sterile cotton sponge and the opening sealed with a drop of collodion. Subsequent treatment of the parts will be considered later.
14. Solidification of Paraffin in Needle.—This occurs only when paraffins of high melting points are employed in liquid form in the syringe, and is due to the rapid cooling of the paraffin in the small metallic cannulæ, or needle, wherein it sets more readily, since the volume contained therein is very small, often not more than two or three drops.
This cooling establishes a pluglike formation in the distal end of the needle, which prevents a proper use of the syringe, often breakage, and when suddenly liberated by an extra pressure on the piston rod causes a rapid discharge of the contents of the syringe to an extent not desired with the result of hyperinjection.
This fault was one of the most annoying in the early days of such injections when syringes of ordinary pattern, such as the Pravaz, or those built like the ordinary hypodermic, were used. It was not unusual to have the paraffin cool in the needle so quickly between the latter in the flame of an alcohol lamp that the syringe became unmanageable and broke in the hands of the operator. Since that time new and more useful syringes have been introduced by various operators which overcome this difficulty, yet with them, too, come the employment of semisolid paraffins or mixtures thereof. Yet, as some authors insist upon using paraffins of high melting points, it may be well to rehearse their methods of overcoming this annoying intraneedle solidification.
Eckstein surrounds the syringe and needle shaft, except the tip of the needle, with a rubber tubing, as shown inFig. 284, to act as an insulator, and thus, for a time at least, keep the preparation liquid. Before filling the syringe he heats it by several immersions in and internalwashings of hot sterile water. To prevent the paraffin from setting in the exposed tip of the needle he draws into the filled syringe a few drops of hot water, which are injected into the tissues, causing no objection to the method.