Plastic and cosmetic surgery

by Frederick Strange Kolle

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 foreign matter, 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 which instance 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.