CHAPTER XVICOSMETIC RHINOPLASTY
The operations herein considered have to do with overcoming deformities, congenital or acquired, as a result of traumatism, and in which there is no loss of tissue, the sole object being to give to the nasal organ a more desirable size and contour.
There are many types of abnormalities involving both the size and shape of the nose. Some of these deformities may be readily corrected by subcutaneous or submucous operations, while others involve more or less cutting of the skin.
The object of the surgeon at all times is to accomplish the best results with as little disfigurement as possible.
Anesthesia.—All the cosmetic operations of the nose should be done under local anesthesia, unless there be serious objections to its employment.
The author advocates the use of a four-per-cent solution of β Eucain, in preference to all others. It is less toxic than cocain and harmless to the patient; no untoward symptoms are exhibited from its use post-operatio. Various patients complain of slight uneasiness about the epigastrium, and many speak of a peculiar weakness about the knees, but these symptoms pass away quickly.
More or less stinging is felt in the wounds made in this manner, immediately after the operations, especially about the lobule of the nose, as with blepharoplasties, but this usually subsides in less than an hour. It may persist,however, in some cases, for several hours. It is well, therefore, to acquaint the patient with this fact to avoid worry or fear.
Where severe, hot applications, dry or moist, may be used to overcome it.
More or less edema follows the employment of local anesthetics, which passes away in various lengths of time, from one to four, or even five days, according to the amount used and the site and circulation of the part operated upon.
In over ten thousand hypodermic injections of eucain the author has observed only two cases of collapse, which responded readily to the usual treatment employed in such event, and has never met with a single fatality.
Sutures.—Twisted silk sutures are to be preferred, as they do not invite sepsis, as softening catgut does, and retain the parts during the entire time required for healing, while the latter is liable to become separated by uneven absorption, allowing the wound to gape at that point and causing more or less of a cicatrix, so intolerant to patients of this class.
Dressings.—Bulky bandages are not required; they heat the parts, and look unsightly. The author employs antiseptic adhesive silk plaster for covering all external wounds, except where the hair prevents its use. Moist dressings are never indicated, except in the later treatment of infected wounds.
This is, perhaps, the most common of all nose deformities. The nose is overprominent about the osseous bridge, extending outward and downward, hook or hump fashion. It may be congenital or the result of external violence.
There are various methods of reducing the redundant bones and cartilage; those involving submucous excisionare difficult to perform for the inexperienced operators, and the external means of reduction are advised to be followed. The resultant scar, if the skin has been properly incised and not damaged by retracting pressure, and, lastly, properly and neatly sutured, should be barely visible.
Monk’s Method.—This author made a small incision through the skin just posterior to the inferior edge of the lobule, as inFig. 469a. Then with a dull instrument, introduced through the opening, he detached the connecting tissue that binds the skin along the anterior dorsum as far as the root of the nose, giving more or less width to this freed area about the nasal bones.
A dull-pointed scissors is introduced through the sublobular opening, and the bones and cartilage are reduced until the desired nasal line has been attained.
The method of procedure is shown inFig. 469b.
Fig. 469a.Fig. 469b.Monk’s Method.
Fig. 469a.Fig. 469b.Monk’s Method.
Fig. 469a.Fig. 469b.
Monk’s Method.
The wound is cleansed of all spiculæ of bone or bits of cartilage and the skin opening is closed by suture. Healing takes place with more or less ecchymosis in about six days.
The difficulty the author finds with this method is that it is practically impossible to do good work with the scissors in this position.
The use of an electric drill has been advocated to doaway with the scissors, but it is a dangerous instrument and requires great skill for its manipulation and reduces the bone particles to such fine fragments that much of it is left in the wound, which may induce sepsis or cause unevenness of the skin surface until later absorbed or removed. The same fault is observed with cartilage, which it grinds into pulpy pieces and for which it should never be used.
Anterior Median Incision.—This, perhaps the oldest method, has been extensively employed. The incision is made down the median line of the dorsum of the nose, beginning above the deformity, and ending slightly below the inferior bone line, as shown inFig. 470. The skin is incised obliquely.
An assistant separates the wounds with hook tenaculi, exposing the osseous bridge, as inFig. 471.
Fig. 470.Fig. 471.Fig. 472.Median Nasal Incision.
Fig. 470.Fig. 471.Fig. 472.Median Nasal Incision.
Fig. 470.Fig. 471.Fig. 472.
Median Nasal Incision.
The author advocates dividing the periosteum and dissecting it well back to either side of the bony elevation. By bringing it back over the denuded surface after the chiseling has been done, it aids materially in establishing a smooth surface and hastens the bone repair.
The periosteum being held aside, the straight chisel and mallet are used to reduce the bone. The operator may proceed to do this from above down orvice versa,according to the formation and position of the protuberance.
The redundant cartilage is removed with the knife from above downward, cutting from side to side.
Usually the operator does not remove enough of the cartilage and a new angulation of the nose appears after the swelling has disappeared, necessitating a second operation.
The wound is closed as shown inFig. 472.
Lateral Incision.—The incision in this case is made slightly posterior to the beginning of the lateral border, as shown inFig. 473.
The skin is held back, as shown inFig. 474, and the same mode of procedure is followed as that just given.
Fig. 473.Fig. 474.Lateral Nasal Incision(Author’s method).
Fig. 473.Fig. 474.Lateral Nasal Incision(Author’s method).
Fig. 473.Fig. 474.
Lateral Nasal Incision(Author’s method).
The operator will have some difficulty to reach the opposite anterior border of bone elevation, especially if the incision has not been made long enough. This should be done. At no time should the assistant employ too much force in retracting the anterior flap to better expose the field of operation; it is certain to cause gangrene of the skin.
To overcome a long scar line, and to facilitate the cutting away of the bone, the author had a special set of chisels made with curved cutting blades, one angular and the other straight-edged. There are two each for working from the right and left sides. The striking point lies midway between the blade and the end of the handle.
They are shown inFigs. 475 and 476.
Fig. 475.Fig. 476.Author’s Chisel Set.
Fig. 475.Fig. 476.Author’s Chisel Set.
Fig. 475.Fig. 476.
Author’s Chisel Set.
To the set the author has added a suitable metal mallet, an instrument very hard to obtain for osteoplastic operating. All the mallets obtainable are too large and heavy for delicate work (seeFig. 477).
Fig. 477.—Author’s Metal Mallet.
Fig. 477.—Author’s Metal Mallet.
Fig. 477.—Author’s Metal Mallet.
After the bone is reduced to the proper level, the cartilage is cut away as before described, and the wound is sutured.
The resultant scar is much better than when made in the median line, and is not so noticeable in this position.
This operation gives the best results of all external methods employed for this purpose.
(Retroussé Nose)
This condition is frequently a deformity. The base of the nose is tilted upward, unduly exposing the nares.
The author prefers to bring the lobule down by excision of the anterior third of the subseptum in preference to submucous dissection of the cartilaginous tissue, causing the deformity.
Fig. 478.Fig. 479.Author’s Method.
Fig. 478.Fig. 479.Author’s Method.
Fig. 478.Fig. 479.
Author’s Method.
With an angular scissors introduced through the nares, a triangular section of the septum is removed, as shown inFig. 478. The apex of the triangle should be placed well up into the septum to break the elasticity of its structure, the base of the triangle being sufficiently wide to somewhat overcorrect the deformity.
Such noses are usually narrow at the lobule, and no interference with the lower lateral cartilages is called for.
The septal mucoid and the subseptal skin wounds are brought together by suture, as shown inFig. 479, leaving only a slight transverse linear scar on the subseptum.
Roe corrects this deformity by making an incision, either vertically or horizontally, in the mucosa in one or both nares, through which he introduces the blades of a fine curved scissors, with which sufficient redundant tissue is removed to bring the lobule down into the desired contour.
The mucosa should be sutured to facilitate rapid cicatrization. The operation should be overdone to get the desired result.
Not infrequently the extreme convexity of the lower lateral cartilage must be overcome by either removal submucously or by excision of the cartilage itself, employing an elliptical incision in the mucosa for the purpose.
The alæ are kept in position after such ablation by compress dressings or by a suture made transversely through both wings of the nose and the septum, and tied over a quill or cork support placed externally upon the skin at either side of the nose. This is removed about the sixth day.
Sheet lead or a splint of aluminum of proper thickness and covered with gauze may also be used to retain the parts during cicatrization.
When the lobule is unduly broad at its base and is more or less concave above the rim of the alæ, it can be reduced by removing a diamond-shaped piece of tissue at either side of the subseptum.
The bases of the two triangles making up the diamond at its widest area meet at the anterior rim of the nostrils,extending with their apices upward and backward, as shown inFig. 480.
If there be a prominence of the cartilaginous structure of the lobule, this may be removed subcutaneously after the two ablations have been made.
Fig. 480.Fig. 481.Author’s Method.
Fig. 480.Fig. 481.Author’s Method.
Fig. 480.Fig. 481.
Author’s Method.
Before suturing the wounds, it is advisable to free the skin of the inferior lobule to overcome tension.
The sutures are applied as inFig. 481. None are used to unite the mucosa unless the interior wounds are large enough to permit of their use.
The operations herein described apply particularly to the correction or reduction of an overprominent nasal tip due to an excessive growth of congenital malformation of that part of the nose, giving the organ undue prominence and a hooklike appearance, usually associated with a narrow, sharply upward inclined upper lip.
Pozzi Method.—The same operation, on a larger scale, can be readily employed for the correction of hyperplasia nasi and rhinophyma.
In the operation of Pozzi (Bulletin et mémoire de Société de chirurgie, 1897, p. 729) an elliptical section of skin and cartilage are removed from the lobule with its widest part corresponding to the point of the nose; the cicatrices occasioned thereby are practically as bad, if not worse, than the unscarred overprominent nose, whilethe submucous procedure of Roe (Medical Record, July 18, 1891) is not only insufficient in these cases, but, according to my experience, practically useless.
Roe Method.—Roe’s method requires a submucous extirpation of the redundant cartilage at the tip through a necessarily small opening within the nasal orifice, also the division in several places of the anterior fold of the lower lateral cartilage with the object of reducing the undue convexity of the alæ. The latter is, we might say, impossible, since the cartilages will be reduced by such a method, even under pressure dressings, which are likely to cause gangrene of the skin of the wings; or if this be avoided, the cicatrix resulting from such division usually restores the very fault that it is expected to overcome, while the mucous lining of the alæ becomes thickened and more firmly tied down than previous to the operation.
One is tempted to exsect the major curvature of the lower lateral cartilage, but this leads to a flattening of the wings of the nose, partial atresia of the nasal orifice, and a decided lack in its symmetry.
Secondly, in Roe’s operation there is always a lack of knowing how much or how little to remove of the cartilage of the tip, a second cosmetic operation being made necessary after the parts have contracted and healed, a common fault with most cosmetic plastic operations performed under local anesthesia, owing to the immediate edematous enlargement following its hypodermic use.
Operation as Commonly Practiced.—The operation heretofore most commonly practiced is one in which an elliptical piece of skin is cut from the tip of the nose, followed by the extirpation of the anterior prominences of the lateral cartilages, and amputation of the septal cartilages. Unfortunately, the result, at first quite satisfactory to the eye, culminates in the pulling apart of the cicatrix formed by bringing the sides of the wound togetheralong the median line with a later depression of the tip in this median line, occasioned by the outward traction of the lower lateral cartilages. Even a second or third operation does not overcome this result entirely, and at best leaves an ugly irregular gash in the median line of the tip and the columna.
In one of the cases here cited this same operation had been unsuccessfully tried twice by another surgeon, with very unsatisfactory and unsightly result. (Case II.)
The ideal operation for all of this type of cases from the view of the surgeon is to leave as little disfigurement as possible, and the method to be here considered, when properly followed, leaves no scar whatever, except for a slight white line across the columna of the nose, where it is out of view, and when contracted offers no objection on the part of the hypercritical patient.
Author’s Method.—The method of the author is as follows: Given a nose, typified by the illustration inFig. 482, the skin above the site of the operation is thoroughly cleansed with soap and hot water, then rinsed with alcohol, ninety-five per cent, and vigorously scrubbed withgauze sponges, dipped into hot bichlorid solution, 1 to 2,000, followed with a thorough lavage with sterilized water. Both nostrils are now cleansed with warm boric-acid solution by the aid of small tufts of absorbent cotton wound over a dressing forceps. The patient is then instructed to breathe through the mouth during the operation. A number of small round gauze sponges dipped into sterilized water and squeezed dry are placed within reach of the assistant. About one drachm of two-per-cent Beta Eucain solution is now injected about the tip of the nose, the columna, and the alæ, as far back as their posterior fold.
Fig. 482.Fig. 483.Author’s Method.
Fig. 482.Fig. 483.Author’s Method.
Fig. 482.Fig. 483.
Author’s Method.
A thin bistoury is then thrust into the nose from right to left, entering at the pointE(Fig. 483), and brought down parallel to the anterior line of the nose, and emerging below the tip in a line with the anterior border of the nasal orifices. This procedure leaves a strip (A) about one quarter inch wide, laterally, rounded at its inferior extremity, and attached superiorly to the nose. Next the round inferior tip (B) is cut away obliquely, sloping inward toward the nose by the aid of a small angular scissors. Each blade of the angular scissors is now placed into each nostril, the tips of the blades inclined forward, and the columna or subseptum is divided atC, also the septum along the lineDup to a point a little above the first incision made externally atE. The two arterioles of the columna are controlled by the use of mosquito-bill forceps. The two projecting folds of the lower lateral cartilage in the columna are next severed as deeply as possible to give mobility to the stump, a step necessary to overcome the changed position, otherwise resulting in a droop, which would have to be corrected at a later sitting.
The next step is to give the needed shape to both wings. This is accomplished with a specially designed scissors, so curved on the flat that its convexity facing upward corresponds to the normal curvature of the orificialrim. A clean cut with these scissors, beginning atGand ending at the pointE, is made, leaving the base of the nose, as shown inFig. 484. The anterior flapAis now bent backward to meet the stump of the columna atC. If it does not fall readily into place a little more of the septal cartilage is removed along the lineDuntil this is accomplished.
It may be necessary to shorten the flapAin cases where a very prominent hook is to be corrected.
Fig. 484.Fig. 485.Base of Nose After Excisions.
Fig. 484.Fig. 485.Base of Nose After Excisions.
Fig. 484.Fig. 485.
Base of Nose After Excisions.
The free end of the flapAis now sutured with No. 4 sterilized twisted silk to the stump of the columna atB. Two stitches usually suffice (seeFig. 485). One or two sutures may also be taken across the angles of union of the alæ and the flapA. The inferior raw surface of each wing may be found to be too wide, owing to the presence of the thickened cartilage at this point of the wing. The skin and the mucous membrane are then carefully peeled away from the cartilage, and the latter cut away as high as possible, or a gutterlike incision is made along its edges as shown inC(Fig. 485), excising the elongated elliptical piece of tissue which includes the cartilage. The raw mucocutaneous edges of the wings are now brought together with a No. 1 twisted silk continuous suture, completing the operation.
An antiseptic powder is dusted over the parts operated on, and small gauze dressings are applied with the aid of strips of silk isinglass plaster. A small tampon of cotton, well dusted over with an antiseptic powder, is placed into each nostril.
The dressings are changed the second day, when the resultant swelling will have practically subsided. The sutures in the columna are removed the fourth day preferably, and those of the wings about the sixth day. Complete cicatrization follows in about ten days, when the patient can be discharged.
The following cases are given to show the types of cases thus far operated upon and to illustrate the results obtained:
Fig. 486.Fig. 487.Author’s Case.
Fig. 486.Fig. 487.Author’s Case.
Fig. 486.Fig. 487.
Author’s Case.
Case I.—Mr. R., aged thirty-two; foreman mechanic. Had been operated upon for angular nose, also at point of nose by Dr. S. Presented himself for operation October 19, 1904, when cast was made (seeFig. 486). Bromides given during recovery. Patient had been subject to fits of depression on account of his nose for over ayear. Wounds healed in ten days, when second cast was made (Fig. 487). Complete recovery.
Case II.—Miss B. P., aged twenty-two; actress. Patient presented herself for operation March 22, 1905. A long, irregular depressed cicatrix showing at point of nose, the result of an attempt to reduce tip of nose by an elliptical extirpation of the lobule (Dr. N.). No cast was made of the case at the time, so that a second cast showing the result would be of no use. Recovery complete in twelve days. Patient returned to her profession three weeks later much pleased with the result.
Fig. 488.Fig. 489.Author’s Case.
Fig. 488.Fig. 489.Author’s Case.
Fig. 488.Fig. 489.
Author’s Case.
Case III.—Mr. L. L., aged twenty-eight; broker. Presented himself, at the advice of Dr. T., for operation May 2, 1905. Cast of cast made and shown inFig. 488. Uneventful recovery in twelve days, when caseFig. 489was made.
Case IV.—Mr. M. B., aged twenty-eight; operatic baritone. Presented himself for operation June 4, 1906.Photograph shown inFig. 490. Uneventful recovery in fifteen days, when photograph inFig. 491was made; angular nose operated upon (at this time discharged; recovery complete).
Fig. 490.Fig. 491.Author’s Case.
Fig. 490.Fig. 491.Author’s Case.
Fig. 490.Fig. 491.
Author’s Case.
Case V.—Miss L. W., aged twenty-seven. Presented herself for operation and cast (Fig. 492) made August 4, 1906. Uneventful recovery in ten days. Cast of result made August 18, 1906 (seeFig. 493).
In each of these cases the patient was discharged highly satisfied and well pleased with the result of the operation, although in Case V the patient was requested to return in about one month for an operation to reduce the width of the wings of the nose, which was not attempted at the first sitting, but could have been with little difficulty by beginning the primary incision atE,Fig. 483, higher up, and cutting out a triangular section on either side of the flapA, the apex of each triangle being at pointE, and the base along the lineD. The wounds are sutured along the dorsum of the nose with No. 1 twistedsilk, after exsecting much of the lower lateral cartilages of the wings, as can easily be reached in the triangular point formed by the raw dorsal border and the inferior edge (F). The latter method, however, would be likely to leave a slight cicatricial line on either side of the nose. This could be much overcome by making the incision from pointEtoBobliquely to the plane of the skin, likewise the posterior sides of the triangles mentioned, just as the incisions atB, and across the columna atC, are made. Recovery should be complete in five days.
Fig. 492.Fig. 493.Author’s Case.
Fig. 492.Fig. 493.Author’s Case.
Fig. 492.Fig. 493.
Author’s Case.
Where there is a lack of lobular prominence it may be enlarged and brought forward by a subcutaneous prothesis if the skin is flexible enough to permit of injection, as has heretofore been described. If this cannot be done, the following operation may be employed to advance the point of the nose, and reduce the width at its base so commonly observed with these cases.
Gensoul Method.—A deep incision is made from the floor of each nostril downward and backward, meeting at a point just below the union of the subseptum with the upper lip, as inFig. 494.
The deeper tissues are loosened from their attachments to the bone until the subseptum at its base, including the triangular appendage thus made, is freely movable.
The lobule is now drawn forward to its required prominence and the parts are sutured Y fashion, as inFig. 495.
If the subseptum be too wide, an elliptical section is removed, including the cartilage, sufficient to give it the desired thickness when brought together, as illustrated. The lips of the wound are brought together as shown.
Fig. 494.Fig. 495.Gensoul Method.
Fig. 494.Fig. 495.Gensoul Method.
Fig. 494.Fig. 495.
Gensoul Method.
When the base of the nose at its juncture with the lip is too broad, the reversed procedure mentioned under correction of a broad lobule is to be employed.
The diamond-shaped section is removed from the posterior rim of the nares as shown inFig. 496.
The tissues at either side are freed from their subcutaneous attachments so as to render them mobile.
The mucosa and skin wounds are sutured as inFig. 497.
A retention splint or suture is to be employed to retain the parts as with the anterior lobule operation just described until healing has taken place.
Fig. 496.Fig. 497.Author’s Method.
Fig. 496.Fig. 497.Author’s Method.
Fig. 496.Fig. 497.
Author’s Method.
When the alæ are thickened they add to the width of the nasal bone and cause more or less atresia of the nostrils. The cause may be due to superabundant connective tissue or a congenital enlargement of the lower lateral cartilage.
To overcome this deformity the following operations may be followed:
Linhardt Method.—This author excises an elliptical section of tissue from the inferior base of both nasal wings, as shown inFig. 498.
A similar procedure has heretofore been described inFig. 485in connection with correction of the lobule.
The section removed includes as much of the cartilage as is necessary to thin out the wing of the nose and to overcome the atresia.
The parts are sutured as shown inFig. 499.
Fig. 498.Fig. 499.Linhardt Method.
Fig. 498.Fig. 499.Linhardt Method.
Fig. 498.Fig. 499.
Linhardt Method.
Dieffenbach Method.—In this method cone-shaped section of skin and cartilage are removed from the wings of the nose, as shown inFig. 500.
If the septum is too wide, two or three of the same shaped sections are removed from it.
The skin wounds are drawn together by suture, as shown inFig. 501.
Fig. 500.Fig. 501.Dieffenbach Method.
Fig. 500.Fig. 501.Dieffenbach Method.
Fig. 500.Fig. 501.
Dieffenbach Method.
In this deformity the nose is bent or twisted to one side. The cause is usually traumatism, but may be congenital.
The interior cartilaginous septum is usually found malformed on one or both sides.
To correct the deviation, the redundant cartilaginous septum is cut or sawed away to clear both nares and the anterior nasal vestibule. After this has been done the nasal attachments are freed subcutaneously, until the nasal organ is freely movable from its attachment to the superior maxillary bones.
The nose is now placed in the position desired, somewhat overdoing the correction, and is held in place by gauze packs in the nares or by Roberts’ spear-pointed pins thrust through the lateral skin of the nose at either side and through the septum, as shown inFig. 339, p. 365.
The use of the pins placed as shown allows of free drainage to the nares and gives little inconvenience to the patient.
Plugs of gauze contract and harden, thus overcoming the object of their use and cause a disturbance of the wounds and pain when reapplied.
The pins should not be withdrawn until the nose hashealed into its new position, or begin to cause irritation of the parts punctured.
Where the deviation is unilateral it should be corrected by subcutaneous injection, as previously described.
The protuberance of bone lies external to the middle meatus, involving an abnormal convexity of the nasal process of the superior maxillary. Its external removal or reduction involves considerable tissue and would leave a conspicuous linear scar, therefore the surgeon must attempt its reduction from the inner nose.
The author prefers to make a horizontal incision below the inferior border of the process, beginning anteriorly just before the articulation with the nasal bone and extending backward as far as the view from the nare will allow.
Through this opening, the skin overlying the bone is raised by dull dissection. A fine nasal saw is next introduced through the submucous wound and several vertical incisions are made into or even through the bone about three sixteenths of an inch apart, dividing the convexed osseous tissue into several sections adherent at their superior extremity which lies inferior to the insertion of the levator labii superioris alæque nasi muscle.
A forceps, such as Adams’s, is now introduced and each section of bone thus made is fractured from below upwards inwardly to produce a concavity of the osseous tissue.
The operation requires considerable dexterity. The amplitude of the sawing movement is very much restricted, because of the palpebral muscular attachment just above.
A frail bone cutting forceps may be employed andthe lower half of the process be removed to avoid encroachment upon the middle meatus, but this is rarely necessary, as that chamber is found unusually wide in this case. If the bone is removed, the remaining bone may be cut into sections, as described, or by the cutting forceps, and fractured backwards as described.
Retention dressings must be resorted to, to keep the fragments of the bone in their new position until cicatrization has been sufficiently established to keep them in place.
When possible Roe advises sawing off the convexity submucously and, after loosening the skin over the dorsum of the nose, to move the bony plate thus made over to the opposite side of the nose and into the concavity usually found there in these cases. If there be no deviation at the latter site the bone plate can be entirely removed through the inferior wound in the mucosa.