CHAPTER VI.
OPERATIONS ON THE NOSE AND LIPS.
Rhinoplastic Operations.—The operations for the restoration or repair of lost or mutilated noses are so various, and the minuteness of detail necessary for full description of them so great, that a complete account in a manual such as this is impossible; a brief notice of some of the most important varieties of the operation is all that can be given.
Principles.—1. It is necessary in every case that a suitable edge be prepared on which to fix the flap of skin, however obtained. To be suitable, this edge, should be (a) made in healthy skin, not in old or weak cicatrices; hence no trace of the original disease should be left; (b) it should be made thoroughly raw, by the removal of an appreciable amount of its edge; it should be pared, not merely scraped.
2. It is useless to attempt to restore a nose unless the patient is in good general health, well nourished, and perfectly free from all remains of disease in the nose or its neighbourhood. The flaps which are to form the new nose may be obtained either from (1.) the cheeks; (2.) the forehead; (3.) a distant part either of the patient or of another person.
(1.) From the Cheeks.—When the cheeks are healthy, and specially if they are tolerably full and lax, the flaps from the cheeks produce much the most satisfactory result. As performed by Mr. Syme, the operation consists in the shaping of two equal flaps (a, a) from the skin of the cheek at each side, having the attachment above. A site for each flap is formed by the careful paring away of the whole thickness of the edge of the cavity of the lost organ (see Fig. xvii.)
Fig. xvii. [95]
The flaps are then raised from their attachments to the upper jaw-bone, and approximated in the middle line by several points of metallic suture and the outer edges stitched to the raw surface on each side at a proper distance from the nasal orifice. If any septum remains of the old nose, it may be made very useful as a fixed point, a straight needle being thrust through one flap close to its outer lower edge, then through the septum, and out at a corresponding point of the other flap. The edges of the wound left in the cheek at each side can generally be, to a certain extent, approximated by silver stitches (b, b) and the triangular portion (c, c), which is necessarily left to heal by granulation, proves an advantage, as by its depression it enhances the apparent height and prominence of the new organ. The cavity should be very gently distended with lint, and may be supported by the blades of a small pair of forceps, applied so as to embrace the nose.