Plastic and cosmetic surgery

by Frederick Strange Kolle

Fig. 342.—Szymanowski Method.

Serre Method.—The flaps are made to either side of the remains of the old nose, each leaving its pedicle about one fourth inch below the inner canthus of the eye. The flaps were cut rather obliquely, their bases extending somewhat below the nasal orifices. The remaining skin of the latter was dissected downward and folded down upon the median third of the lip. If cut in two sections their inner borders were sutured so that their raw surfaces faced each other. The object of the latter step was to form the subseptum, according to Lisfranc. The sections of skin lying with their bases on a level with the nasal orifices were dissected downward and united in the median line to assist in forming the end of the nose. All along the borders of the old nose were also dissected up where possible and folded inward, so that their raw surfaces would adhere to the new dorsum of the nose, and thus give it stability and form. These pieces of skin were united at the median line when possible.

The cheek flaps with indented bases were now brought forward and united, as shown in [Fig. 343]. The skin of the cheeks was dissected up to the extent of the dotted line in the former illustration, and when necessary two lower curved incisions were made to permit of free sliding. The skin of the cheeks was retained by three sutures at either side, as shown in [Fig. 344]. The subseptum may be made at the same sitting, or at a later operation.

Fig. 343. Fig. 344.

Serre Method.

Syme Method.—The procedure is very like that of Heuter, except that the somewhat curved line making the inner borders of the flaps extended over the root of the old nose. The lower ends or bases of the two cheek flaps were stitched around and to the orifice to form the end of the nose, rubber tubes being used to form the nostrils, where they were retained until healing was complete.

Blasius Method.—He forms the cheek flaps in triangular form, including all of the tissue making up the buccal cavity. The outer or cheek incision is made through all of the tissue and extends to a point corresponding to a point a given distance beyond the angle of the mouth. The inner incision is made from a point just below the angle of the ala downward and through the thickness of the lip. A third incision unites the angle of the mouth with the outer incision. Both cheek flaps are made alike, each remaining attached along all of the remains of the old nose. They are now raised upward and inward, with their mucosa facing outward, and united along the median line. The raw cheek borders are now brought forward and held in place by suturing them at either side to the remaining rectangular flap of the upper lip. The formation of the subseptum is left for a second sitting. This method is not only too extensive, but too disfiguring to make its employment practicable. The mucous membrane would, of course, in time take on the function and appearance of skin, but the shape of the mouth never assumes a normal form, especially since there is quite a loss of the vermilion border at either side which is raised upward with the cheek flaps to assist in forming the base of the nose.

Maisonneuve Method.—Where there is more or less occlusion of the nares and yet an integumentary covering corresponding to the nose, as it might rarely be in congenital cases, Maisonneuve utilizes the sliding flap method to overcome the abnormality. In the case presented, the nasal orifices were hardly three sixty-fourths of an inch in diameter and about one inch apart. The correction was accomplished as follows, and shown in [Fig. 345]: An incision was made transversely outward from each nostril, then two converging incisions were made from both nares downward, meeting at the vermilion border of the lip in the form of a V, which were made to include the whole thickness of the lip. This flap was brought upward to form the subseptum. The skin to form the nasal lobule was now slid forward from either end of the incision and the subseptum sutured in place. Rubber tubes were employed to keep the nares distended and permit of the wings of the nose to form.

The defect in the upper lip was brought together as in a median harelip operation, the parts appearing after operation as illustrated in [Fig. 346].