Plastic and cosmetic surgery

by Frederick Strange Kolle

Lobular Insufficiency.—This defect of the nose is usually of hereditary origin, although it may be occasioned by the retraction of the inferior half of the organ in tubercular or syphilitic ulceration in which the lobule falls inward and upward by the loss of the retaining cartilages.

Owing to the close adhesion of the skin to the lower lateral cartilages and the cellular tissue about the rim of the alæ it is found difficult to restore the contour or elongate the organ at that site by subcutaneous injection.

Even after thorough mobilization of the integument the subsequent injected mass is liable to be thrown off by an overactive inflammatory reaction, due undoubtedly to the adhesions formed between the divided surfaces from the periphery inward which has a tendency to crowd the injected mass forward and downward before a new connective tissue has had time to be formed, causing a breaking down of the skin at some point overlying the mass and allowing it to escape.

The author has attempted to replace the injection by small solid paraffin plates introduced through a small lateral incision made for the subcutaneous dissection, and while the wound healed readily enough and the nose appeared normal, the plates were in every case thrown off by a later inflammatory process before the end of the third week.

The author then attempted to replace the solid plates with granular paraffin, gently packing the latter into the wound until the desired elevation had been obtained with the idea that such mass would accommodate itself much better under the pressure caused by reactive inflammation, but even this procedure proved unsuccessful.

The best results are obtained with sterilized white vaselin injections when there is considerable mobility of the skin. A single needle opening should be made, preferably about the center of the side of the lobule, or slightly anterior to this point, carrying the point of the needle forward to the anterior median line and a little above the actual point of the nose.

The injection should be made slowly, closely watching the size of the elevation caused by the mass and the state of the circulation about the entire lobule.

Usually ten drops of the mass suffice to give the desired result. The mass may be molded out if found desirable, but if the skin appears normal after the operation and the tumefaction thus made does not make the nose look grotesque, it may be allowed to remain as injected, depending upon the subsequent reactive pressure to force it into shape. In this way a greater part of the mass is retained at the wanted site and is not crowded to the sides of the lobule by the customary post-operative molding.

Even with this method great care must be exercised in not injecting too much at each sitting. A failure is sure to result in hyperinjection about the lobule. When it be remembered that only a very small quantity of the mass will make a decided difference, the surgeon and patient should be satisfied with the slightest gain.

If, however, the mass be retained and further elongation of the lobule is desired, a subsequent injection can be undertaken, but not until a full month after the primary operation.