wound are carefully united by superficial sutures (Figs. 967, 968).
If more than half the under lip has to be removed, the opening of the
mouth becomes very narrow ; and, owing to the great retraction of the
remainder of the under lip, the upper lip projects in the form of a snoutlike
disfiguration ; however, that disappears in a short time on account of the
great elasticity of the tissue of the lips.
Fig. 969 Fig. 970
Grafting Lo\yer Lip, restored by Plasty, with the Vermilion
Border of the Upper Lip — Suture
3. If the border of tJie lip is diseased thronghont its whole extent, and if
the proliferation extends so deep into the tissues of the lip that, after surface
520
SURGICAL TECHNIC
excision, tlie lip would become too short, the removed margin can be replaced
by utilising a portion of tJic labial border of the upper lip. For this purpose,
the whole upper lip is divided closely above the vermilion border in such a
manner and to such an extent that the detached strip of the labial margin
can be drawn around the opening of the mouth and that the under lip can
be lined with, the same {Dieffetibach, von Langenbeck, Figs. 969, 970).
Fig. 971 Fic. 972
BrUxXs's Cheiloplasty (Formation of lips)
In a similar manner, Brujis restored a large portion of the lower lip.
He encircled the buccal orifice by two curved incisions and united again the
edges of the wound thereby made movable (Figs. 971, 972).
â– /^ In like manner, Estlander uses the upper lip for forming the lozver lip.
He cuts from the upper lip a triangular flap, the vascular bridge of which
lies on the margin of the lip, and, by rotation, places the flap into the defect
of the lower lip (Figs. 973, 974).
Fiu. 973 Fiu. 974
E.stlander's Cheiloplasty
For the restoration of the whole lower lip, many methods have been
devised.
I. DieffenbacJi, after a cuneiform excision of the diseased lower lip, made
horizontal incisions from both anjrles of the mouth throusrh the whole thick-
PLASTIC OPERATIONS ON THE FACE
521
ness of the cheek ; from the ends of these, he made obhque incisions
downward and parallel to the margins of the wound. He united in the
middle the rhomboid flaps thus obtained, and on the free margin of the new
lip sutured the mucous membrane to the skin (Figs. 975, 976). After this
procedure, gaping wounds are left at both sides of the lip ; these must heal
Fig. 975 Fig. 976
Dieffenbach's Cheiloplasty
by granulation. It is better, according toJciscJie, to make the incisions of
the cheek hi a curve outzuard and then downward (Fig. 977). The margins
of the wound which have been brought into approximation can be closed
throughout by suturing after the formation of the lip (Fig. 978). Tre;/de/eu-
burg modified the form of the incision, so that, by a greater curve of the
Fig. 977
Fig. 978
Jasche's Cheiloplasty
arch, its external point came to lie in front of the facial artery (Fig. 979).
For the purpose of obtaining sufficient mucous membrane to cover the margin
of the lip, he made the incision of the cheek only down to the mucous mem-
brane, dissected the latter somewhat from the upper part of the cheek, and
divided it abont \ a centiineter above the external incision ; the flap of
522
SURGICAL TECHNIC
mucous membrane still adhering to the cheek was used for lining the surface
of the wound.
Fiu. 979 l-'iG. 980
Tkenuelenburg's Cheiloplasty
2. After a quadrangular excision of the lozver lip, Bruns forms, from the
anterior upper portion of the cheek, two square flaps, which on both sides of
the upper lip ascend to the alae of the nose.
Having first circumscribed the tumor along its margin by a transverse
incision through healthy tissue, he adds at the angles of the mouth two
lateral incisions ascending from the angles ; from these two flaps are formed
outside of the angles of the mouth.
He turns these in the direction of the wound, and having united them by
sutures, he lines the border of the lip with the freely movable mucous mem-
brane of the cheeks adhering to them (Figs. 981, 982). But if the mucous
Fig. 98 1
Fig. 982
Bkuns's Cheiloplasty
membrane covering the flaps becomes too much stretched longitudinally, it
is nicked at its base by transverse incisions.
3. Burow, with his method of lateral triangles, obtained very good results,
although two JiealtJiy portions of skin are unnecessarily sacrificed thereby.
PLASTIC OPERATIONS OX THE FACE
523
The mucous membrane of the triangles to be excised may, however, be saved
and used very advantageously for lining the surface of the wound (Figs.
983, 984).
Fig. 983
Fig. 984
BuRow's Cheiloplasty
The skill of the cJiin may also be used for restoration of the lower lip ;
this is best done according to the procedure of Blasius, Morgan, and von
Langenbeck.
From the middle of the lip, which has been excised in a semilunar form,
Blasius makes two sciniliinar incisions into the sides of the chin. The flaps
thus formed are transferred upward on the '^ spnr'' of the skin of the chin
remaining between them and are thus reunited (Figs. 985, 986).
Fig. 985
Fig. 986
Blasius's Cheiloplasty
Von Langenbeck forms from the middle of the chin a flap zvith a lateral
peduncle. He lifts it over the " spur " of skin which has remained on the
opposite side and sutures it in this position. The "spur" itself is also
detached and again united with the lower margin of the flap wound
(Figs. 987, 988).
The lip formed according to these methods has a tendency to swell and
to draw in, sutce it is not sufficiently covered with vuicons' membrane. It is,
524
SURGICAL TECHNIC
therefore, advisable to line the free margin with mucous membrane drawn
over from the upper lip or from the mucous membrane of the cheeks
{e.g. Figs. 969, 970).
(
Fig. 9S7 Fig. 9S8
Von Langenbeck's Cheiloplasty
Morgan (1829), in very extensive defects, restored the upper lip by utiliz-
ing the skin of the chin or the submental region. Along the lower jaw
he made a curved incision about 12 centimeters long and distant from
the margin of the defect about i centimeter above the level of the extir-
pated lower lip (removing any diseased glands). The cutaneous bridge
formed by the incision is liberated by horizontal incisions from its basement
membrane, turned up like the visor of a helmet and held in position by
a few sutures. At its lower margin, it is stitched to the lower jaw to prevent
it from descending. Strips of gauze are inserted between the wound surface
of the flap and the jaw. The gaping defect of the submental region is
/ V
Pig. 9S9 Fig. 990
Morgan's Cheiluplasty
diminished by suturing, the rest of the wound is left to heal by granula-
tion or is paved by skin grafts according to the method of Thiersch ( Wolflcr,
Regnier). The result of this operation is good beyond expectation. Although
the new lip does not become easily movable, there appears less inclination
PLASTIC OPERATIONS OX THE FACE
525
to contraction and drawing in than in lips restored without any mucous
membrane according to other methods.
The upper lip can be restored either by sHding the surrounding parts or
by forming lateral pedunculated flaps.
Fig. 991 Fig, 992
Dieffexbach's Sincous In'cision
Fig. 993
Dieffenbach makes incisions on both sides, which encircle the alae of the
nose and ascend to one-half their height. Next, he detaches the soft parts
sufficiently from the upper jaw, draws them down and over the margin of
the teeth, and unites them in the median line under the nose {sinuous incision,
Figs. 991-993)-
If, by this means, the flaps do not become sufficiently movable, a curved
incision may be added on each side in an outward direction (Fig. 991 ).
Fig. 994
Fig. 995
BrUXS'S CHElLOPLAiTY
It is better, however, to form two lateral flaps from the cheek, which,
having been detached from the bone, may be united in the median line
{Brims, Figs. 994, 995).
The method of Sedillot is also applicable in certain cases. He cuts out
from the lower region of the cheek tzvo lateral sqiiare flaps with upper bases,
and turns them up over the under lip (Figs. 996, 997).
526
SURGICAL TECHXIC
Fig. 996 Fig. 997
Sedillot's Cheiloplasty
STOMATOPLASTY
(STOMATOPOESIS OR PLASTIC SURGERY OF THE MOUTH)
This is made in cases of contraction of the oral orifice, which most fre-
quently ensues from cicatricial contraction after ulcerations, but which also
occurs congenitally.
The procedure of Dieffcnbach is as follows : From the oral orifice, tii.'o
lateral incisions are made through the ivholc thickness of tJie cheek to answer
the dimensions of the new mouth (Fig. 998). Next, tJie mucous vienibrane
is sewed to the skin; if this does not succeed easily, on account of the
Fig. 998 Fig. 999
Dieffenbach's Stomatoplasty (Plastic surgery uf the mouth)
cicatricial condition of the skin and the mucous membrane, the latter for
some distance is dissected off from the underlying tissues and thereby made
more movable. A complete lining of mucous membrane should be carefully
obtained especially at the nezu angles of the nioiith. Since a new contraction
of the rima oris can be prevented only when the mucous membrane unites
with the angles of the mouth by first intention, it is advisable to sew the
PLASTIC OPERATIONS ON THE FACE 527
mucous membrane into the angle in the form of a small triangular flap
{Roser, Fig. 999).
To prevent recurrence of the contracture, the wear-
ing of an artificial mouth {^Hiieter) for some time after
the operation is advisable. The artificial mouth con-
sists of a hard rubber tube, the size of which corresponds ' ^\'^„ ,
to the new mouth; it is similar in shape, as illustrated in cordingtoHueter)
Fig. 1000.
MELOPLASTY
(plastic surgery of the cheeks)
In extirpating tumors of the cheek, the cheek may be incised from the
angle of the mouth as far as the margin of the masseter down to the adipose
tissue ; this is partly removed and partly pushed aside. The tumor, in order
that its limits may be more easily determined, is pushed outward with the
finger introduced into the mouth, and with curved scissors is excised com-
pletely by cutting through healthy tissue. The wound is sutured through-
out ; the defect of the mucous membrane is tamponed, and, after four or
five days, is cover'ed with TJnerscJi's grafts. These skin grafts in the course
of time resemble the mucous membrane, and no contraction results {Ezvald-
Albert).
Smaller defects of the cheeks may be closed by detaching tht surrounding
soft parts sufficiently from mucous membrane, so that the latter can be
united by suture in any direction. Especial care must be taken, however,
that the traction of the sutures does not cause other deformities (ectropium,
distortion of the rima oris and the alas of the nose). If sufficient mucous
membrane is still at hand, a smaller defect may be closed successfully by
two pedunculated y?c7/'jr_//-6'w the mucous menibrane of the cheek and that of
the lips {Ob erst).
In larger defects, flaps must be formed from the surrounding parts ; by
stretching and sliding \h& defect is covered; Figs, icxdi— 1004 may serve as
examples.
If the mticons membrane in these places is deficient, and the mouth can-
not be opened, as is the case in most instances, this condition would be
increased by a contraction of the flaps. To prevent this a portion of the
lower jaw may be sawed out, so that 2^ false joint is formed {Es march,
see page 492) ; or a flap of skin with the epidermis as a cover may be turned
into the defect, and over this another flap of skin ; or, finally, the attempt
528
SURGICAL TECHNIC
may be made by skin transplantation to cover with skin a pedunculated flap
already formed at its wound surface before its transplantation into the defect
( Thiersch). Bayer forms a large-sized flap from the mucous membrane of
Fu;. looi V\(;. icx)2
MELorLASTV (Plastic surgery of the cheeks) BY stretching a Pedincilated Flap
the palate. The flap of skin to be applied over this surface is taken from
the submaxillary region.
From the immediate surroimdings of the defect Kraske forms a flap
which is turned into the defect ; this flap may heal in, though its pedicle co)i-
sists only of subcutaneous tissue {Gersuny). Having been sewed into the
defect, its epidermal surface forms the inner side of the new cheek, while
its wound surface, as well as the place from which it has been taken, is
covered by Tliierscli's skin grafts (Figs. 1005, 1006). This procedure may
Fiu 1003 Fig. 1004
Meloplasty by sliding Two Pedunculated Flaps
result satisfactorily if performed in one sitting ; still, in the male, the hair of
the beard growing into the buccal cavity causes great inconvenience.
Although it has been observed several times that the inverted skin became
PLASTIC OPERATIONS ON THE FACE
529
similar in structure to the mucous membrane, and that the follicles of hair
were destroyed, still Israel and Hahn have devised procedures which, they
Fig. icx)5
Fig. 1006
Kraske's Meloplasty
claim, avoid this unpleasant condition by supplying large flaps of skin with-
out hair, taken from viore remote parts of the body (neck, breast).
Israel cuts a long flap 02ct of the skin on the side of the neck, which
remains attached at the base. He turns this flap over and sews it with its
anterior half to the margin of the mucous membrane of the defect, so that
the epidermal surface lies inward toward the buccal cavity (Fig. 1008).
Fig. 1007
Fig. 1008
Israel's Meloplasty
Fig. 1009
■After this piece has healed in — from fourteen to seventeen days — the
pedicle is severed, and the posterior portion, which has now become free, is
530 SURGICAL TECHNIC
likewise turned over, and, after all granulations have been scraped off, is
sewed to the former (wound surface being in apposition to wound surface)
so that the new-formed portion of the cheek consists of a double layer of
skin (Fig. 1009). The angle of the mouth is covered with skin by displacing
the vermilion border of the lips (see page 519), and the posterior opening at
the place where it was turned over is vivified and sutured.
In a similar case, I have taken a long flap from the skin of the neck, the
pedicle of which lay directly by the side of the margin of the defect. By
turning over the lower half, I doubled it and sewed it into the defect, so
that the place where it was turned formed the new angle of the mouth. It
is rather difficult, however, to apply the suture, since first the inverted end
of the flap must be sewed to the remainder of the mucous membrane, and
next the external part to the margins of the wound of the skin. The place
from which the flap has been taken may be closed by suture throughout its
whole extent.
RHINOPLASTY
(plastic surgery of the nose)
Restoration of the nose may be attempted if it has been destroyed by
trauma, tubereiilosis, syphilis, and neoplasms.
According to the procedure by which either the whole nose or only por-
tions of it are to be restored, we distinguish total and partial rhinoplasty.
TOTAL rhinoplasty
I. By forming a flap front the skin of the forehead {so-called Hindoo
method).
{a) In case of loss of the soft parts of the whole nose : —
For determining the size of the flap, a model of leather or of adhesive
plaster is made and fitted to the defect to be restored. In making the
model, the following proportions are to be observed : —
The lower dimension of the nose, measured over the tip, must be equal
to the distance from the lower angle of the eye to the angle of the mouth —
about 7 centimeters ; the length of the bridge of the nose must be equal to
the distance from the limit of the hairy scalp to the glabella ; the longer the
septum is made, the higher the nose becomes. In order to obtain a curved
(Roman) nose, the lateral margins of the flap are somewhat curved; straight
lateral margins produce a form more like the Grecian.
PLASTIC OPERATIONS ON THE FACE
531
The flap of skin has been made in very different ways by various sur-
geons ; compare Fig. lOio.
After the form and the size of the flap have been determined upon and
cut out in adhesive plaster, the model is fastened on the forehead over the
Fig. loro. Models for Rhinoplasty (Plastic surgery of the nose), i, original Hindoo model;
2, 5, Dieffenbach's models; 4, von Ammon-Zeis's model; 3, 6, 7, 8, von Langenbeck's models
nose, tJie pedicle of t lie flap being directed obliquely toward the margin of
one of the orbits, so that the angular artery is included in the vascular
bridge (Fig. loi i). The operation is then performed as follows : —
The patient is placed in a half-sitting position under mixed chloroform
narcosis (previous injection of maximum dose of morphine). By this means,
during the entire operation, even when the application of the chloroform
mask is no longer possible, a condition of painlessness is produced, whilst
the patient still responds to requests.
1. First, the remainder of the diseased nose is vivified in equiangular
form by making deep incisions along the margin of the defect as far as the
site where the alae of the nose are to be implanted. Above the philtrum, a
small triangular slit is made with the knife on the place where the new sep-
tum is to be implanted. The margins of the lateral incisions as well as the
upper lip are detached from the bone outwardly to the extent of about \
centimeter.
2. With a sharp knife, the model fastened to the forehead is circum-
scribed accurately everywhere down to the bone. The internal or lower
margin of the pedicle in the neighborhood of the angle of the eye is made
to terminate in the upper angle of the wound of the vivified remainder of
the nose ; the external or upper margin is deflected outwardly above the
532
SURGICAL TECHNIC
eyebrow in the shape of a hook. By this means, traction and tearing in
turning the pedicle are avoided as much as possible. The flap of skin thus
circumscribed by the knife is detached from the bone together with tJie peri-
osteum, and the adhesive plaster is removed ; the flap is then turned dozvn-
ward so that it hangs in front of the nasal cavity.
3. Before the flap is sutured, it is advisable to reduce the large wound of
the forehead by suturing the angles of the wound, as far as this is pos-
sible without too much tension. The defect remaining in the middle can be
covered immediately or at the end of the operation by Thiersch's or Wolfe s
skin grafts (Fig. 1012).
In the meantime, hemorrhage from the flap hanging down in front has
ceased and it has turned pale ; it is then sutured in proper position.
Fig. ioii Fig. 1012
Total Rhinoplasty (Hindoo method) by a Flap from the Skin of the Forehead
4. First, the piece of flap designed for the septum is vivified superficially
with a sharp knife at its lower angles and is lightly folded lefigthwise ; it is
then sewed with interrupted sutures into the triangular incision above the
philtrum ; next, the alee of the nose are formed by tiwjiing over in an ijiward
direction the two lateral angles. They are fixed in this folded condition by
a loose quilt suture applied throughont the whole thickness of the new ala of
the nose, and the posterior sides are stitched to the freshened lower angle
of the wound of the defect by button sutures. Then, the lateral margins
are carefully sewed into the fold of the wound with numerous button sutures.
PLASTIC OPERATIONS ON THE FACE 533
Near the twisted pedicle, the sutures must not be applied too closely ; it is
best to insert them alternately.
Two rubber tubes, wrapped with iodoform gauze, are inserted into the
newly formed nostrils to counteract the great tendency to form adhesions
and also to press gently together the upturned margins of the skin (Fig.
1012). Even after the wounds have healed, the tubes must be worn for a
long time.
In order to remedy this troublesome inconvenience, iwn Volkmann advised
not to sictiire tJie septum but to leave it hanging down ; in the course of heal-
ing, it rolls up inwardly into the nose and leaves sufficient passage for the
entrance of air. At the same time, by means of this round swelling, there
is formed a passably good tip for the nose, the good appearance of which
in all methods leaves more or less to be desired. If, afterward, an improve-
ment of the deformity is desirable, the septum may be formed by a subse-
quent operation (see page 541).
The best dressings after rhinoplasty are small strips of iodoform gauze
or small compresses of linen covered with boric salve, applied over the sutures
so that the surgeon can always observe the condition and the color of the
new nose. The sutured and grafted large wound in the forehead may be
protected by a light antiseptic dressing.
K pale c^/^r exhibited by the nose on the following day is rather a favorable
sign ; during the next few days it turns pale-pink, and finally assumes the
normal color. If, however, it is discolored, bluish red or dark brown, then, in
most cases, a partial failure of the operation, on account of partial gangrene,
is to be feared ; sometimes the application of leeches renders good service.
The deformity from tzvisting of the pedicle, at first very disfiguring, is
removed afterward by a simple excision of the prominence ; likewise, several
smaller operations may become necessary to improve the cosmetic result.
All these operations, however, must not be made too early ; at any rate, not
before the fourth to the sixth week, since the new nose changes more and
more by subsequent contraction (in most cases disadvantageously), especially
if the hoped-for ossification of the pericranium is limited or does not set in
at all.
ib) In cases of the loss of the whole nose together with its bony structure,
the new nose, formed in the manner described above, contracts from want
of support, and becomes more and more flattened.
To prevent this condition, surgeons have endeavored, by suitable lining
with bone-producing tissue, to give greater support to the soft parts of the
nose.
534
SURGICAL TECHNIC
Vo7i Langoibeck thought that greater soHdity or strength might be given
to the nose by including the periosteum in the soft tissues taken from the
forehead. He conceived also the plan of forming a flap with a bony
framework ( " knochenspange " ) corresponding to the new bridge of the
nose ; this has been successfully done by von Hacker in recent times.
Huetcr formed from the skin of the remaining portions of the nose a
flap, which he turned downward so that its wound surface appeared exter-
nally. Upon this the flap of skin taken from the forehead is applied.
Owing to the tendency of the twisted flap to assume its former position, the
bridge of the nose may remain somewhat raised {^elastic support flap —
" federnder stiitzlappen " ) (see also Fig. 1014).
Fig. 1013. Thiersch's Rhinoplasty
Fiu. 1014. Verneuil's Rhinoplasty
TJiierscJi used two lateral qnadrajigular flaps from the skin of the cheeks
for lining the nostrils ; these flaps he sewed together in the median line
with the wound surface outwardly, and over them applied the flap from
the forehead ; the large defects thus caused are covered by skin grafts
(Fig. 1013).
Verncitil and Bonisson proceeded in a similar but reversed manner ; they
used the flap of the foreJicad for lining and covered it by two lateral flaps
from the cheeks (Fig. 1014).
Von Langenbeck attempted to restore the bony frameivork of the nose by
an osteoplastic p7'ocednre ; he raised the bony support of the nose, which in
most cases was sunken in, but which still existed in fragments, together with
the callous masses produced by the chronic course of former ulcerations.
After the pyriform aperture has been laid free by a median incision running
from the nasal process of the frontal bone downward, and the skin has been
somewhat dissected backward toward both sides, the operator, with the
PLASTIC OPERATIONS ON THE FACE
535
metacarpal saw, saws off from the margin of the pyriform aperture on both
sides a small strip of bone which, at its lower end, remains in connection
with the superior maxillary bone (Fig. 1015). The trabeculas thus formed
are raised perpendicularly with the elevator, and the flaps of skin previously
detached are fastened to them ; next, the depressed nasal bones are sawed off
on both sides from the nasal process of
the superior maxillary bone and slowly