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.
THE ADVANTAGE OF THE METHOD
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.