Plastic and cosmetic surgery

by Frederick Strange Kolle

Care must be exercised to keep the mass from creeping into the loose tissue about the internal canthi by having an assistant press the sides of the nose at that point with the thumb and forefinger.

This undesirable condition is much more liable to occur when a hot liquid paraffin is employed, since the operator can observe quite accurately the extent and direction taken by the mass injected when the cold product is used.

Some authorities have injected noses of this type from the point of the nose, but it will be found that the position of the puncture at this point allows a considerable portion of the mass to work out during molding and also to permit of the readier oozing out of the mass during the pressure exerted by what reactive inflammation follows the operation. This is accounted for by the fact that the needle creates a tubelike canal in the tightly bound down tissue overlying the lower lateral cartilages, whereas in the lateral punctures the short canal is easily displaced by the swelling, thus causing its obliteration and preventing the free oozing.

On the other hand, it will be found to be more difficult to inject from the point of the nose alone and that a very long needle has to be used which must be withdrawn as the parts above the point are filled. Furthermore, it will be found necessary to thrust the point of the needle in different directions to overcome vertical attachments of the skin which are more readily lifted up than thrust aside by the mass, hence necessitating a greater amount of injury to the tissues, not to speak of the possibility of injecting transverse blood vessels higher up in the nose of which the operator would not be aware at the time; showing only in the resultant phlebitis and unexpected reactive symptoms, associated with a discoloration more or less lasting according to the extent of obliteration of the vessels.

The post-operative treatment should be as heretofore advised.

Lateral Insufficiency (Unilateral and Bilateral).—Depressions about the sides of the nose are usually due to hereditary causes, when they are likely to be bilateral, yet intranasal ulcerations may cause a falling-in, as it were, of either one or both nasal walls, involving in such instances the entire side or part of it. In the partial cases the depression may be in any of the division of thirds used by the author—that is, it may lie laterally over the region of the nasal bone and such of the nasal process of the superior maxillary bone as goes to make up that part of the nose, or in the middle third below the bone structure and above the superior limitation of the lower lateral cartilages, or within the lower third over the inferior border of the cellular tissue making up the nasal rim.

Traumatism may be found to be the cause of such depressions, especially in the middle third, after fracture or luxation of the nose. In such cases the defect is usually unilateral or at the seat of the former injury, a convexity usually being exhibited on the opposite side.

Since the skin is rather firmly adherent at the sides of the nose, except in the major part of the superior third, it will be found best to raise the skin of such defect into normal contour by a series of very small injections instead of following the method heretofore advised in connection with tense or adherent areas of skin, for the reason that such dissection would render the skin too mobile over an area usually beyond the defect itself and inviting the surgeon to an annoying hyperinjection which renders the part more unsightly than prior to the operation. This is true in most cases unless the depression is of traumatic origin and beyond the size of deformity usually corrected.