Plastic and cosmetic surgery

by Frederick Strange Kolle

Secondly, in Roe’s operation there is always a lack of knowing how much or how little to remove of the cartilage of the tip, a second cosmetic operation being made necessary after the parts have contracted and healed, a common fault with most cosmetic plastic operations performed under local anesthesia, owing to the immediate edematous enlargement following its hypodermic use.

Operation as Commonly Practiced.—The operation heretofore most commonly practiced is one in which an elliptical piece of skin is cut from the tip of the nose, followed by the extirpation of the anterior prominences of the lateral cartilages, and amputation of the septal cartilages. Unfortunately, the result, at first quite satisfactory to the eye, culminates in the pulling apart of the cicatrix formed by bringing the sides of the wound together along the median line with a later depression of the tip in this median line, occasioned by the outward traction of the lower lateral cartilages. Even a second or third operation does not overcome this result entirely, and at best leaves an ugly irregular gash in the median line of the tip and the columna.

In one of the cases here cited this same operation had been unsuccessfully tried twice by another surgeon, with very unsatisfactory and unsightly result. (Case II.)

The ideal operation for all of this type of cases from the view of the surgeon is to leave as little disfigurement as possible, and the method to be here considered, when properly followed, leaves no scar whatever, except for a slight white line across the columna of the nose, where it is out of view, and when contracted offers no objection on the part of the hypercritical patient.

Author’s Method.—The method of the author is as follows: Given a nose, typified by the illustration in [Fig. 482], the skin above the site of the operation is thoroughly cleansed with soap and hot water, then rinsed with alcohol, ninety-five per cent, and vigorously scrubbed with gauze sponges, dipped into hot bichlorid solution, 1 to 2,000, followed with a thorough lavage with sterilized water. Both nostrils are now cleansed with warm boric-acid solution by the aid of small tufts of absorbent cotton wound over a dressing forceps. The patient is then instructed to breathe through the mouth during the operation. A number of small round gauze sponges dipped into sterilized water and squeezed dry are placed within reach of the assistant. About one drachm of two-per-cent Beta Eucain solution is now injected about the tip of the nose, the columna, and the alæ, as far back as their posterior fold.

Fig. 482. Fig. 483.

Author’s Method.

A thin bistoury is then thrust into the nose from right to left, entering at the point E ([Fig. 483]), and brought down parallel to the anterior line of the nose, and emerging below the tip in a line with the anterior border of the nasal orifices. This procedure leaves a strip (A) about one quarter inch wide, laterally, rounded at its inferior extremity, and attached superiorly to the nose. Next the round inferior tip (B) is cut away obliquely, sloping inward toward the nose by the aid of a small angular scissors. Each blade of the angular scissors is now placed into each nostril, the tips of the blades inclined forward, and the columna or subseptum is divided at C, also the septum along the line D up to a point a little above the first incision made externally at E. The two arterioles of the columna are controlled by the use of mosquito-bill forceps. The two projecting folds of the lower lateral cartilage in the columna are next severed as deeply as possible to give mobility to the stump, a step necessary to overcome the changed position, otherwise resulting in a droop, which would have to be corrected at a later sitting.

The next step is to give the needed shape to both wings. This is accomplished with a specially designed scissors, so curved on the flat that its convexity facing upward corresponds to the normal curvature of the orificial rim. A clean cut with these scissors, beginning at G and ending at the point E, is made, leaving the base of the nose, as shown in [Fig. 484]. The anterior flap A is now bent backward to meet the stump of the columna at C. If it does not fall readily into place a little more of the septal cartilage is removed along the line D until this is accomplished.