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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. ⁹⁶

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.

(2.) From the Forehead.—The Indian operation may be used as a last resource, in cases where, from disease, the cheeks also have suffered, and are not to be trusted to for flaps.

Operation.—1. It should be decided as to the shape and size of the portion of skin necessary, by fitting on pieces of soft leather or moulding wax. To allow for shrinking, the flap should be made at least one-third larger than is at first apparently necessary. The exact boundaries of the flap to be raised should then be marked out on the forehead by lightly pencilling it with nitrate of silver, the mark from which is not effaced by blood, as is sure to be the case with an ink line. Various shapes have been proposed for the flap varying in length of neck, in the shape of the angles, and especially in the arrangements made for the formation of a columna. Some (as Liston) prefer afterwards to provide for the columns separately, by a flap raised from the upper lip in a subsequent operation. The flap is then to be raised from the forehead, care being taken not to injure the periosteum. The incision is to be carried lower down on the side (generally the left), to which the flap is to be twisted. The flap is then to be brought round (Fig. xviii.) and carefully fitted on to the edges previously prepared for its reception. The neck must be left as lax as possible, lest by tight twisting the supply of blood be cut off, and the flaps thus deprived of nourishment. Both silk and metallic sutures are recommended. Hamilton of Dublin,⁹⁷ after a large experience of both, prefers the former.

Fig. xviii. ⁹⁸

There are various risks; sloughing of the whole flap at once, shrinking of it after weeks or even months; certain inevitable drawbacks, as the cicatrix on the forehead, the very various and ludicrous changes of colour to which the new organ is subject,—these cannot be remedied by further operation. Two points generally require a second use of the knife a few weeks after:—(1.) The neck of the flap is sure to be redundant and prominent, but can be pared. (2.) The columna almost always requires improving, and, in Liston's method, to be made. He pared the inner surface of the apex of the nose, and then raised a central flap of the lip in the middle line, about a quarter of an inch broad, and extending from the remains of the old septum to the free border, raising it from the gum, and stitched the free end of it to the prepared apex, bringing together the two divided portions of the lip by ordinary harelip sutures. Tho columna, if redundant, could be shaved down, and it was found that the mucous surface very quickly became like skin on exposure.

For other points with regard to the operation, reference may be made to the works of Liston and Skey, and Hamilton's monograph, referred to above.

Note.—The tongue and groove suture proposed by Professor Pancoast, and recommended by Professor Gross, is said to be specially suitable for such plastic operations. It is very complicated, as it requires one edge to be bevelled to a wedge shape, the other being grooved to include the wedge, thus opposing four raw surfaces, which are retained in contact by being transfixed by fine silk sutures.

(3.) There are certain cases in which neither cheeks nor forehead are available for flaps, and yet the patients press very much for some operation. If they have patience and determination, the Taliacotian or Italian operation may be attempted.

Without going into detail, the principle of it is as follows:—1. A piece of skin of suitable size was marked out over the left biceps, and defined by two longitudinal incisions, and raised from the subcutaneous cellular tissue, thus being left attached by its two ends only; a piece of linen was pulled below it. 2. After a few days the upper end was also divided, and the flap thus contracted. In a few days more the sides of the old nose were made raw, and the upper free surface of the flap also made raw and stitched to them, the arm being fastened up by a most elaborate series of bandages. 3. After a fortnight in this position, the last attachment of the flap to the arm was severed, and the new nose could then be modelled at pleasure.

The literature of the subject is exceedingly curious, especially the cases in which the new material was obtained from an accommodating friend or servant.

Operative Treatment of Lupus.—We may here notice a mode of treatment which has admirable results. The patient being put deeply under an anæsthetic, the surgeon with a sharp spoon carefully pares away all the diseased tissues, and then destroys the base either by nitric acid or a strong solution of chloride of zinc. The author has done this in a great number of cases with excellent effect.

Nasal Polypi, Removal of.—Of these there are different kinds.

1. Ordinary Mucous Polypi.—These grow from the spongy bones, generally the superior one, are non-malignant in their character, soft and vascular, often fill up the whole of both nasal cavities, and frequently hang down behind into the pharynx. The practical point to remember is that, however large and numerous they may be, they invariably have their origin from a comparatively limited spot, the edge of the spongy bone, and always hang from a narrow neck. Hence the treatment is easy and satisfactory, if the neck be attacked, and not the body of the tumour.

Slightly curved, narrow-bladed forceps should be passed along by the side of the superior spongy bone, with their blades open, till the neck of the polypus is seized. Holding it firmly, the forceps should then be slowly twisted round till the neck is destroyed and the polypus detached. This should be repeated till the patient can blow freely through both nostrils. If attempts are made to seize the body of the polypus, it will break down under the forceps, bleed, and give much trouble.

2. The Fibrous Polypus.—This form is fortunately much more rare than the other. It is almost invariably single, is attached to the posterior margin of the nares by a narrow but very strong root, is extremely firm in consistence, may grow to a large size so as to obstruct both nostrils, generally gives rise to severe and frequent hæmorrhages. The hæmorrhage during any attempt to remove it is generally of the most severe character, but ceases immediately on its complete detachment.

We owe nearly all that we do know about the treatment of this form of polypus to Mr. Syme. His method is—By the ordinary polypus forceps described already, he seized the tumour through the nostril, and then with the fore and middle fingers of the left hand introduced behind the soft palate, he attacked the point of attachment, and by his nails, aided by the forceps, detached it from its narrow base.⁹⁹

3. Malignant Polypi should not be meddled with unless it is absolutely certain that the whole of the bone from which they grow can be removed also. This is very rarely the case. (See Excision of Superior Maxilla.)

Operations on the Lips.—1. Epithelial cancers of the lower lip are very frequent, and require removal.

Fig. xix. ¹⁰⁰

If the tumour or ulcer is small, and involves a considerable thickness of the lip, it is most easily removed by a V-shaped incision (Fig. xix. A B A). Its shape permits the most accurate apposition of the cut surfaces; and if the lips are full and the tumour small, very slight trace of the operation will remain.

Again, if the tumour be more extensive, involving a large portion of the prolabium, and yet not extending deeply into the substance of the lip, it may be very easily removed by a pair of curved scissors, applied in the direction shown in the diagram (Fig. xx. A B). The skin must then be stitched to the mucous membrane by numerous points of interrupted suture.

But if the tumour be at once extensive and deep, mere removal is not sufficient, but some provision must be made for supplying the blank left by the operation.

Fig. xx. ¹⁰¹

In cases where a third, or even a half, of the lower lip has thus been removed, it may be found sufficient freely to dissect what is left of the lip from the gums, and thus approximate the cut surfaces in the middle line.

This alone, however, would so much diminish the buccal orifice, and twist its corners, as to cause great deformity. The addition of an incision horizontally outwards, at one or both angles of the mouth, will do away with such risk, and allow the surfaces to come together without puckering; while by stitching the skin and mucous membrane together in the course of these horizontal incisions, we can increase the size of the buccal orifice almost ad libitum.

Lastly, when the lower lip has been entirely removed, it is still possible to supply its place in the following manner, which was devised by Mr. Syme: The tumour being fairly isolated by a V-shaped incision (Fig. xxi.) C A C including the whole thickness of the lip, each of the incisions should be prolonged downwards and outwards, as shown by the dotted lines A D, A D. The flaps thus marked out must be separated from the bone, brought upwards, and approximated in the middle line. Possibly it may be necessary still further to enlarge the buccal orifice by short lateral incisions, C C. Whether these are required or not, silk stitches are to be introduced to unite the skin and mucous membrane along the lines a c. The gap left between D B D must be left to granulate, but in most cases may be very much diminished in size by additional sutures at its outer corners, near d. The granulating surface E E very rapidly heals up, leaving a dimple on each side, which rather improves the appearance, by adding to the prominence of the chin, b.

Fig. xxi. ¹⁰²

Fig. xxii. ¹⁰³

The Operations for Harelip, though all conducted on the same general principles, vary considerably in extent required according to the position and size of the fissure or fissures to be remedied.

1. For Single Harelip.—Where the fissure extends only from the prolabium up to the attachment of the lip to the gums: this is very easily remedied, the chief risk being lest the surgeon should not remove enough of the edges of the fissure.

Operation.—Bleeding being controlled by an assistant, the surgeon fixes a pair of spring artery forceps into the mucous membrane and skin at the salient angle at each side of the fissure. Taking one of these in his left hand, he puts the edge to be pared on the stretch, and then with a sharp narrow straight bistoury he transfixes the lip at the point just beyond the upper angle of the fissure, and cuts outwards, being careful to remove the whole thinner part of the lip, and to leave the edge rather concave than convex. If left convex, or even quite straight, there is a risk that, after union has taken place, an angle remain showing the position of the cleft. The same is then to be done on the other side. The bleeding is then to be controlled by twisting the larger vessels, and if oozing still continues from the smaller ones, a pad of lint should be placed in the wound, and a few minutes' delay given, as, to facilitate immediate union, it is of the greatest importance that all hæmorrhage should have ceased before the edges are brought together.

When the bleeding has ceased, the edges should be approximated by two or more points of interrupted metallic suture inserted very deeply through the tissues, and taking a good hold of the edges of the wound. If the edges do not fit accurately, one or two horse-hair sutures will help. Some surgeons still prefer the old harelip needles secured by a figure-of-eight suture. A silk suture inserted through the prolabium is of great advantage, as it keeps the inner surface of the wound closed, which without it is very apt to be kept open by the pressure of the teeth or gums, and in infants by the movements of the tip of the tongue.

Various methods have been devised to utilise, if possible, the portion of the edge of the lip which is separated during the operation of refreshing the edges, for the purpose of filling up the sort of cleft or gap which is apt to be noticed at the edge of the prolabium. The most ingenious and simplest of these is that proposed by M. Nelaton, for use in cases where the fissure does not extend so far up as the nose. It consists in leaving the two portions which are pared off (Fig. xxiii.) the sides of the cleft attached to each other as well as to the free edge of the lip, then pulling them down, so as to bring their bleeding surfaces into apposition, and make a diamond-shaped wound instead of a triangular cleft (Fig. xxiv.) When brought together by sutures a projection is left at the edge of the lip; this, in most cases, disappears; if it does not, it can easily be pared down.

Fig. xxiii. ¹⁰⁴

Fig. xxiv. ¹⁰⁵

2. When the fissure, though single, extends upwards into the nose, the operation is more difficult, and the result frequently less satisfactory. The first thing to be done is to separate the lips from the gums, so as to make them more freely mobile. The whole edges of the cleft require refreshing.

3. Double Harelip, without bony deformity, and where the intervening portion of the skin is vertical, does not project, and can be made useful for the new lip. Such cases are not very common, but when they do occur the question arises, How are they to be managed—in two separate operations or at once? I believe, in every case, at once. The central wedge-shaped portion is not large enough to extend downwards as far as the prolabium, but still should not be removed altogether, as it may be of great use, especially in bearing the columna nasi, and allowing its full development. The edges should be pared in the same way, and to the same extent as in single harelip, with the addition that the intervening portion should have its edges completely removed, and be left in the form of a wedge, with its apex downwards. The highest suture should be passed through first one side, then the base of the wedge, and then the other side; the second one through both, and the apex of the wedge; and a third should unite the prolabium, not including the wedge.

Fig. xxv. ¹⁰⁶

4. Double Harelip combined with fissures of the hard palate, and projection of a central bone. This is the analogue of the inter-maxillary bone in the lower animals, and bears the two middle incisor teeth, and projects very variously in different cases. In some it projects horizontally forwards in the most hideous manner, in others it lies at an angle more or less oblique; in very few does it maintain its proper position; when projecting forwards, and as the teeth also share in its projection, it entirely prevents approximation of the edges of the fissures by operation, so it must first be dealt with in one of two ways, either—

Fig. xxvi. ¹⁰⁷

(1.) It may be at once removed with bone-pliers, the piece of skin over it being saved. This is the best that can be done in cases of old standing after the first year or two, though attempts have been made to break the neck of the projecting portion, and thus permit of its being shoved back.

(2.) By gradual pressure by a spring truss, strapping, or a bandage, it may be forced back. This is possible only in cases where the deformity has been comparatively slight, and the patient has been seen early. The edges must then be pared and approximated as directed above.

One or two points about the operation for harelip require a special notice:—

1. When to operate.—Great differences in opinion exist. Some say not before two or three years, others within two or three days, or even hours, after birth.

Probably the safest time is not much earlier than the second month in very strong children, the fifth in weakly ones, up to the commencement of the first dentition; and when once dentition has commenced it is not so safe to operate till it is over.

Prior to dentition the operation is attended with rather more risk, but again, if delayed, there is great risk that the teeth do not come in properly.

2. With regard to the most delicate part of the operation, the management of the prolabium.—Some are satisfied, and I believe rightly, with careful apposition by a silk suture after a sufficient amount of the edges has been removed; others have proposed various plans to obviate any risk of an angle remaining.

Malgaigne proposes to retain a small portion of the parings of the edge to make small flap at each side; Lloyd a single one from the long half of the lip, and brings it up under the opposite one, securing it with a stitch.

CHAPTER VII.
OPERATIONS ON THE JAWS

1. Excision of the Upper Jaw.—With regard to the morbid conditions for which this operation is undertaken, it may be sufficient here to observe, that in no case can the operation be called justifiable in which the disease extends beyond the upper jaw-bone and the corresponding palate-bone, for unless the morbid growth be entirely removed, recurrence is inevitable, and no advantage is gained by the operation. It is undertaken for the removal of tumours of the antrum and of the alveolar margins, in all which cases the section for its removal must be made through healthy bone, and wide of the disease, so as to insure that the whole is removed. There are other cases in which the whole or part of the upper jaw has been removed for the purpose of giving access to disease behind, for example, to naso-pharyngeal polypi with extensive attachments.

In describing the operation for the excision of the entire upper jaw, we have to consider—(1.) what incisions through the soft parts will expose the tumour best, and with least deformity; (2.) what bony processes require to be divided, and where. Very various incisions have been recommended by various authors; some describing three, in various directions, forming flaps of different sizes, while others, again, are satisfied with a very small division of the upper lip into the nose, or even attempt removal of the bone without any incision through the skin at all. These discrepancies depend in great measure on different views of what constitutes excision of the upper jaw, the more complicated ones contemplating removal of the whole bone anatomically so called, including the floor of the orbit, while the less complicated ones are suitable for cases in which a much less extensive removal is required.

To remove the whole bone, an incision (Fig. xxvii. A) of the skin must extend from the angle of the mouth upwards and outwards in a slightly curved direction with its convexity downwards, as far on the malar bone as half an inch outside of the outer angle of the eye. The flaps must then be raised in both directions, the inner one specially dissected off the bones, so as to expose thoroughly the nasal cavity. It is of great importance thoroughly to display the floor of the orbit, so that the attachment of the orbital fascia may be accurately cut through, the inferior oblique muscle divided at its origin, and the eye and the fat of the orbit cautiously raised from its floor.

Fig. xxvii. ¹⁰⁸

Three processes of bone then require attention and division.

(1.) The articulation with the opposite bone in the hard palate. To divide this, one incisor tooth at least must be drawn, the soft palate divided by a knife to prevent laceration, and the thick alveolar portion sawn through in a longitudinal direction from before backwards.

(2.) The articulation with the malar bone at the upper angle of the incision through the skin. This must be notched with a small saw in a direction corresponding to the articulation, and then wrenched asunder by a pair of strong bone-pliers.

(3.) The nasal process of the upper jaw must now be divided by the pliers, one limb of which is cautiously inserted into the orbit, the other into the nose. If the disease extends high up in this process, it may be necessary partially to separate the corresponding nasal bone, and thus reach the suture between the nasal process and the frontal bone. The pliers must now be inserted into the groove already made by the saw on the hard palate, and the separation continued to the full extent backwards. A comparatively slight force exerted on the tumour either by the hand, or (when the tumour is small) by a pair of strong claw forceps, will suffice to break down the posterior attachments of the bone and remove it entire. The necessary laceration of the soft parts behind is so far an advantage, as it lessens the risk of hæmorrhage from the posterior palatine vessels.

The hæmorrhage from this operation was at one time much dreaded, but is rarely excessive; very few vessels require ligature, except those divided in the early stages in making the skin flaps; the hollow left should be stuffed with lint, which may be soaked in the perchloride of iron should there be any oozing.

The incisions recommended for this operation have been very various, and a knowledge of some of them may occasionally be useful, on account of specialities in the shape and size of the tumour. Liston "entered the bistoury over the external angular process of the frontal bone, and carried it down through the cheek to the corner of the mouth. Then the knife is to be pushed through the integument to the nasal process of the maxilla, the cartilage of the ala is detached from the bone, and lip cut through in the mesial line; the flap thus formed is to be dissected up and the bones divided."¹⁰⁹ Dieffenbach made an incision through the upper lip and along the back or prominent part of the nose, up towards the inner canthus, from whence he carried the knife along the lower eyelid, at a right angle to the first incision as far as the malar bone.

In cases where the tumour is of moderate size, Sir W. Fergusson found¹¹⁰ it sufficient to divide the upper lip by a single incision exactly in the middle line, this incision to be continued into one or both nostrils, if required. The ala of the nose is so easily raised, and the tip so moveable as to give great facilities to the operator for clearing the bone even to the floor of the orbit.

In cases where the tumour is larger, or the bones more extensively affected, Sir W. Fergusson preferred an extension of the foregoing incision (Fig. xxvii. B) upwards along the edge of the nose almost to the angle of the eye, and thence at a right angle along the lower eyelid, as far as may be necessary, even to the zygoma. The advantages claimed for such procedures are that the deformity is less and the vessels are divided at their terminal extremities.

2. Excision of the Lower Jaw.—Removal of portions, greater or smaller, of the lower jaw, for tumours, simple or malignant, are now operations of very frequent occurrence, while in some few cases the whole bone has been removed at both its articulations.

The operative procedures vary much, according to the amount of bone requiring removal, and also the position of the portion to be excised.

(1.) Of a portion only of one side of the body of the bone.—This is perhaps the simplest form of operation, and is frequently required for tumours, specially for epulis.

Incision.—If the parts are tolerably lax and the tumour small, a single incision just at the lower edge of the bone, of a length rather greater than the piece of bone to be removed, will suffice; this will divide the facial artery, which must be tied or compressed,¹¹¹ while the surgeon, dissecting on the tumour, separates the flaps in front, cutting upwards into the mouth, and then detaches the mylohyoid below, and clears the bone freely from mucous membrane. He then, with a narrow saw, notches the bone beyond the tumour at each side, and, introducing strong bone-pliers into the notches, is enabled to separate the required portion. The wound is then stitched up, and a very rapid cure generally results with very little deformity, as the cicatrix is in shadow. If from the size of the tumour more room is needed, it can easily be got by an additional incision from the angle of the mouth joining the former.

To prevent deformity, which is apt to result from the centre of the chin crossing the middle line, it is often a wise precaution to have a silver plate prepared fitting the molar teeth of both jaws on the sound side, and thus acting as a splint. Such a precaution may be required in any operation in which the lower jaw is sawn through.

N.B.—There are certain cases in which the epulis is small and confined to the alveolar margin, in which an attempt may be made to retain the base of the jaw entire, and remove the tumour without any incision of the skin. The mucous membrane on both sides being carefully dissected from the affected part, the bone may be sawn as before, but only through the alveolar portion, the groves of the saw converging as they penetrate, then by a pair of strong curved bone-pliers, the affected alveolar portion is to be scooped out without injuring the base. This proceeding, which has been practised by Syme, Fergusson, Pollock, the author in many cases, and others, leaves no deformity, but, it must be owned, is much more liable to the risk of recurrence of the disease, and for this reason is strongly condemned by Gross.

Note.—In this, as in all other operations on the jaws, the very first thing to be done is to draw the teeth at the spots at which the saw is to be applied.

(2.) Excision of a portion involving the Symphysis.—Free access is of importance. The best incision is probably one which (Fig. xxvii. C) commences at the angle of the mouth opposite the healthy portion of jaw, extends down to the place at which the saw is to be applied and then along the base of the jaw past the middle line to the other point of section. The flap is to be thrown up and the bone cleared. The next point to be noticed is, that when, in clearing the bone behind, the muscles attached to the symphysis are divided, the tongue loses its support, and unless watched may tend to fall backwards, embarrassing respiration and even perhaps choking the patient. The tongue, being confided to a special assistant, must be drawn well forwards. Various plans have been devised for keeping it in position, as stitching it to the point of the patient's nose; putting a ligature into its apex, and fastening it to the cheek by a piece of strapping, and transfixing its roots with a harelip needle, used to stitch up a central incision in the chin. The tendency to retraction very soon ceases, new attachments are formed by the muscles, and after the first five or six days there is very little risk of the tongue giving rise to any untoward consequences by its displacement.

(3.) Disarticulation of one, or both Joints.—When the portion of bone implicated involves disarticulation for its complete removal, the difficulty of the operation is much increased. The remarkably strong attachments of the joint, especially the relation of the temporal muscle to the coronoid process, and the close proximity of large arteries and nerves, especially the internal maxillary artery and the lingual nerve, render this disarticulation very difficult.

The chief points to be attended to seem to be (1.) that the incision through the skin should extend quite up to the level of the articulation; (2.) that the bone should be sawn through at the other side of the tumour, and freely cleared from all its attachments, before any attempt be made at disarticulation, for by means of the tumour great leverage can be attained, so as to put the muscles on the stretch, and allow them to be safely divided; (3.) that the articulation should always be entered from the front, not from behind, and the inner side of the condyle should be very carefully cleaned, the surgeon cutting on the bone so as to avoid, if possible, the internal maxillary artery; (4.) free and early division of the attachment of the temporal muscle to the coronoid process.