When the condition is due to mal-union of a fracture, the contour of the nose may be restored by operation. A narrow knife is passed in at the nostril and the skin freely separated from the bone; the bone is then broken into several pieces with necrosis forceps, and the fragments moulded into shape. A rubber drainage tube introduced into each nostril maintains the contour of the nose till union has taken place.
When it results from disease, it is much less amenable to treatment. The present-day tendency is to discard the use of subcutaneous paraffin injection and to employ grafts of cartilage or bone. An artificial bridge has been made by turning down from the forehead a flap, including the periosteum and a shaving of the outer table of the skull, or by implanting portions of bone or plates of gold, aluminium, or celluloid.
Portions of the alæ nasi may be lost from injury, or from lupus, syphilis, or rodent cancer. After the destructive process has been arrested, the gap may be filled in by a flap taken from the cheek or adjacent part of the nose. When the tip of the nose is lost, it may be replaced by Syme's operation, which consists in raising flaps from the cheeks and bringing them together in the middle line.
The whole of the nose, including the cartilages and bones, may be destroyed by syphilitic ulceration or by lupus. In parts of India the nose is sometimes cut off maliciously or as a punishment for certain crimes.
In reconstructing the nose it is necessary to provide skin, a supporting structure in the form of cartilage or bone, and an epithelial lining. In the “Indian operation” a racket-shaped flap, including skin and periosteum, is turned down from the forehead and fixed in position, the edges of the flap being inturned to provide a lining for the passage. An implant of free cartilage may be necessary to support the skin flaps and to prevent subsequent contraction. Flaps of skin may be formed by Gillies' tube-pedicle method from the cheek, the forehead, or the neck, and utilised to form the covering of the nose. When the deformity cannot be corrected by operation, the appearance may be greatly improved by wearing an artificial nose held in position by spectacles.
The term Rhinophyma has been applied by Hebra to a condition in which the skin of the tip and alæ of the nose becomes thick and coarse, and presents large, irregular, tuberous masses on which the orifices of the sebaceous follicles are unduly evident—potato or hammer nose ([Fig. 266]). The capillaries of the skin are dilated and tortuous, and the nose assumes a bluish-red colour, and its surface is soft and greasy. The condition is met with in elderly men, and the masses appear to be chiefly composed of sebaceous adenomas. The term lipoma nasi, formerly employed, is therefore misleading.
Fig. 266.—Rhinophyma or Lipoma Nasi in man æt. 65.
The treatment consists in paring away the protuberant masses until the normal size and contour of the nose are restored, care being taken not to encroach on the cartilages or on the orifices of the nostrils. There is comparatively little bleeding, and the raw surface rapidly becomes covered with epidermis.