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, 1 1 4 6-
CHARLES C. MILLER, M: D.
PUBLISHED BY THE AUTHOR
70 STATE ST., CHICAGO
Oak Printing Co., 9 Wendell St.
I wish to thank the editors of the Wisconsin Medi-
cal Recorder, The American Journal of Dermato-
logy, The American Journal of Clinical Medicine,
The Craciimati Lancet Clinic, The Medical Fort-
nightly and the Medical Brief for the use of cuts and
half tones used in illustrating various portions of
COPYRIGHT 1907 by CHARLES C. MILLBR.
In this volume my eflfort has been to explain as
concisely as possible the numerous operations which
I have found useful in treating featural imperfec-
tions. There is today a well established demand for
Q skillful featural surgeons and I feel that I can do
the profession no greater service than to offer them
the results. of my experience in this seemingly imper-
fect manner — ^that is without discussion or without
re-iteration of what has already been published in
text books and systems of surgery. Some of the
members of the profession who have had opportunity
to see me operate for featural imperfections may
notice that I have refrained from describing certain
operations which I practice. I have done this be-
cause the operations have not as yet been tried to my
own satisfaction in my own hands.
A large number of the profession are at the pres-
ent day apathetic regarding elective surgery for the
correction of those featural imperfections which are
not actual deformities but such apathy cannot pre-
vent the development of this specialty as the demand
for featural surgeons is too great on the part of the
public. I feel confident that this little book is mere-
ly the forerunner of works as pretentious as any we
have upon special subjects.
All the operations described in this book are per-
formed painlessly after infiltration. My technic for
infiltration is very simple. I use plain boiled water
and add to each oimce from one-half to one-fourth
grain of cocain. In the hospitals I use the sterile
normal salt solution as the solution is conveniently
at hand and is less irritating to the tissues. The co-
cain is added in the same proportion. I do not deny
the efficiency of sterile water or salt solutions without
cocain but I add this drug within the limits of safety
to insure painless injections. I inject the tissues un-
til puncture or incision is entirely painless. Should
the infiltrating solution escape during the operation
and the patient complain of pain I discontinue oper-
ating and reinfiltrate the field. In the operation for
htcmp nose the bone may be chiselled away without
pain if the pereosteum is properly infiltrated.
T9E PREVENTION OF OUTSTANDING EARS.
Before detailing the methods of operating for the
correction of the unduly prominent or outstanding
ear, it is well to call attention to the factors most
frequently causing this condition, so that efforts
may be encouraged at the proper time in life to pre-
vent the development of the condition.
There is no doubt that in early childhood a head-
dress which turns the ear outward and forward and
holds it in this position, if used continuously over a
considerable time, will produce a permanent effect
upon the position of the ear. The physician should
always note in the children of his patrons any ten-
dency of a headdress to hold the ears in an abnormal
position, and should advise against the use of such,
and in any child, where a tendency exists for the ear
to project unduly, the parents should have their at-
tention called to the condition, and be influenced, if
possible, to adopt a plan of bandaging during the
night to hold the ears snugly against the side of the
cranium. A simple bandage devised for this purpose
may be applied during the night without discomfort
to the child. By tact and persuasion a child may be
influenced to have no objection to the contrivance.
The use of such simple means in early childhood,
if persisted in, will, in very many instances correct
the condition satisfactorily. After adult life is
reached the possibilities of good results following
this plan of treatment are greatly diminished.
Attention has been called to the greater frequency
of outstanding ears in women than in men, and it
has been given as an explanation, that the habit of
wearing the hair long and dressed in certain fash-
ions, is responsible for the development of the con-
dition. Parents should be warned of this and should
not allow a plan of dressing the hair of their chil-
dren, which is likely to press the ear outward.
The normal angle of the ear to the head varies
from ten to forty degrees, and an organ which ex-
ceeds this angle to any appreciable extent is usually
conspicuous as an outstanding ear unless it be quite
Sometimes the small ear which appears very un-
satisfactory, will be greatly improved by an altered
The Anatomy of the External Ear.
The pinna or auricle is made up of a framework
of yellow elastic cartilage which is covered with in-
tegument. The organ in the human family is of
slight functional importance, hearing being almost
imperceptibly altered by its loss. Its size, outline or
development, if faulty, go far toward marring the
good appearance so that frequently the surgeon in-
terested in cosmetic surgery finds opportunity for
alteration and improvement of faulty ears.
The free margin of the pinna curves forward and
inward and is known as the helix. Situated near the
height of this curve of the helix frequently a pro-
jecting tubercle is noticed which is known as the
** Darwinian tubercle'' and which is said to be the
analogue of the pointed tip noted in the quadruped.
Internal to the helix we find a groove known as
the fossa of the helix and internal to this parallel to
the helix is the eminence known as the antihelix.
The antihelix above divides into two portions which
include between them the fossa of the antihelix. The
antihelix curves about a large concavity known as
the concha, which leads into the external auditory
The anterior wall of the external auditory canal
is continued outward as a rather prominent projec-
tion known as the tragus, and opposite the tragus is
a less marked projection known as the antitragus.
Between these two points is an interval called the
The ear below terminates as a soft pendant mass
varying in shape and degree of development, known
as the lobule. It is made up of adipose and fibro-
areolar tissue and contains no cartilage. The lobule
varies in shape and size and while making up a small
portion of the ear it plays an important part in in-
fluencing the impression as to the beauty or lack of
beauty of the organ. The lobule should be well
formed and should not be attached along its inner
margin to the side of the head.
There is only a small amount of subcutaneous
tissue intervening between the integument and the
cartilage of the ear and this tissue is practically
devoid of fat.
The blood supply of the pinna is good, the blood
reaching the organ through the superficial temporal,
the occiptal and posterior auricular arteries.
This very brief consideration of the anatomy of
the ear should be kept in mind by the surgeon
so that he may recognize variations of the external
ear from the normal, and may be able to decide as
to the extent any variation from the normal alters
the appearance of the organ.
Operations for Correcting Outstanding Ears.
The operations for the correction of outstanding
ears are performed with the aid of infiltration an-
esthesia. The anesthetic agent is injected along the
line of juncture of the ear with the cranium poster-
iorly. The tissues are infiltrated and divided along
this line, and the skin is dissected off somewhat from
the side of the head and from the posterior surface
of the concha of the ear. The simplest operation
does not include the division or removal of any of
The ear may be drawn into the position it should
occupy, and with a fine curved needle and chromi-
tized catgut the concha is sutured to the soft parts
of the side of the cranium. By such a step the ear
is drawn closer to the skull and held in a correct
position. The operator may prefer to draw the ear
as close as possible to the side of the head without
putting undue tension on the sutures. In this way,
some return of the ear to the previous position does
not again leave it unduly prominent. If the stitches
are drawn too tightly, they may cut their way
through before the ear has become fixed in its new
The superficial parts are sutured carefully so that
the least possible amount of scarring follows the
operation and then the parts are sealed with col-
The hair should be dressed away from the ears,
in women, after the operation, and wherever possi-
ble the patient should wear a bandage which holds
the ears close to the head until healing is complete.
If the patient is unwilling to stay indoors and wear
a bandage continuously during the first few days,
they should at least do so when in the privacy of
their own apartments. The bandage is dispensed
with in from three to sfix days.
Free Excision, of Skin.
A second plan of operation has been described in
which an elliptical piece of skin is removed from the
posterior portion of the ear and from the side of the
cranium. The ear is now held in its corrected posi-
tion by closely suturing the skin margins. The effect
of this operation is the same as where the chromi-
tized gut suture is applied as in the previous opera-
tion, but the strain of holding the ear in the correct-
ed position is thrown upon the skin sutures and the
bandage which in this operation must be used after
the operation. The disadvantage of throwing the
strain of holding the ear in the corrected position
upon the skin sutures lies in the tendency of sutures
to cut through the tissues when a strain or constant
tension is placed upon them, so that there is a chance
of the sutures cutting through and some separation
of the skin margins occuring so that considerable
more scarring may follow this operation than the
one previously described. The scar is hidden be-
hind the ear, but nevertheless, where such can be
avoided, it is well to do so.
Where the ear resists correction and sutures hold-
ing the ear in the corrected position are drawn upon
unduly, it is well to divide the cartilages of the ear
more or less with a tenatome or scalpel, through the
incision behind the ear so as to overcome its resist-
ance before completing the operation. The extent
of division of the cartilages and the direction of the
division varies in each individual case and the judg-
ment of the operator must be used as a guide as to
the extent and direction of the division.
Operators have also insisted that it was a valuable
and important step in these cases after exposing the
posterior surface of the ear and the side of the skull
to remove all loose cellular tissue before suturing.
The sutures are then placed through the cartilage of
the ear and the fibrous tissue covering the bones of
Some further recommend that the cartilage of the
ear be attacked and that a wedge shaped portion of
this part be removed. In extreme cases such a plan
may be advisable, the ear being then drawn into its
corrected position without difficulty, and easily held
so by sutures.
Where the ear is undermined and is thoroughly
loosened from behind, my own experience has been
that it may be held against the side of the cranium
by sutures, even if the cellular tissue is undisturbed
and no section of the cartilage made.
In removing a wedge of cartilage considerable
care is necessary as the skin is very closely adherent
to the cartilage anteriorly and it may be divided in
removing the wedge. This will be an accident of no
great moment, but it should be avoided as it subjects
the patient to the possibility of having a visible scar
When the wedge of cartilage is removed from the
ear in some instances it may be only necessary to
suture the margins of the divided cartilage together
and then to close the skin incision, while in others it
is well to suture the margins of the divided cartilage
together before suturing to the side of the cranium,
as otherwise the ear may present an irregular, un-
THE EXCESSIVELY LARGE EAR.
The surgeon frequently has opportunity to reduce
the size of the ear. The reduction of an ear is not as
easily accomplished as the bringing of the ear closer
to the side of the head. If the undue prominence is
due to outstanding of the ear rather than the excess
in size of the organ the operation for overcoming
such outstanding should be practiced rather than the
operation for actually diminishing its size. !
In some cases one ear is unduly large, the other
being normal or small, in which case the operator
must carefully judge as to the extent he will reduce
the ear. A small ear may be as unsightly as a large
organ. A large ear should be reduced in size until
the difference between it and its fellow is not con-
The operation for reducing the ear is accomplish-
ed' with local anesthesia. The injections are made
beneath the skin of the ear posteriorly and then as
close to the cartilage of the ear as possible, and final-
ly beneath the skin of the ear anteriorly. Consider-
able care should be taken in infiltrating so that com-
plete insensitiveness is secured.
The simplest operation recommended for the dim-
inution of the size of the ear consists in the excision
of a wedge of all the tissues of the external ear, and
the approximation of the parts by sutures. This
operation in a few instances gives a result which is
sufficiently satisfactory to justify its adoption. The
operation should be adopted where the tissues can
be accurately approximated after the removal of the
wedge and where the approximation will not cause
an unnatural or abrupt termination of a ridge or
other irregularity of the ear.
The removal of a wedge from the ear is started
posteriorly. A portion of skin somewhat smaller
than the size of the wedge of cartilage, which it is
proposed to remove from the ear, is carefully
marked off with a scalpel ; the skin is divided. It is
well to adopt the plan of a slanting incision so that
the skin may be overlapped after the removal of the
remainder of the tissues. The skin along the mar-
gins of the wedge is freed slightly and pushed back,
then the cartilage is carefully divided. The skin
anteriorly, is divided so that it slightly overhangs
the wedge of cartilage removed.
Any bleeding developing during the incision of
the tissues from the ear is controlled before closing
the defect in the tissues.
The skin, anteriorly, is approximated with a sub-
cutaneous suture of fine catgut. The cartilage is
approximated with chromitized gut. If it resists ap-
proximation the gut should be strong and placed so
as to safely hold the margins of the cartilage to-
gether. The gut sutures through the cartilage bear
all tension. The skin, posteriorly, is approximated
by a subcutaneous suture of fine gut and the parts
covered with a collodion dressing. Adhesive strips
may be used, if the operator prefer, for protecting
the wound and for minimizing the tension upon the
wound margins, although a collodion dressing is
The Excision of a Crescent.
The second plan of operation which is recom-
mended for the diminution of the size of the ear con-
sists in the removal of a crescent of tissues coupled
with a small strip from the outer margin or helix.
This operation is recomn\ended as one which is
likely to give nearly perfect results and a casual ex-
amination of the plan of operation would convey
this impression to the reader, but in using the opera-
tion for the excision of a considerable tissue from
the ear it is found to be an operation in which the
results are not all that may be desired.
The tissues are infiltrated as in the preceding
operation, and the operation begins posteriorly. The
operator marks off the skin so as to include an out-
line of the tissues which are to be removed. The skin
incision includes a smaller crescent of skin than the
crescent of cartilage to be removed ; the skin is care-
fully divided. It is separated from the cartilage so
as to give access to the cartilage. The removal of
the cartilage is accomplished. The operator removes
a crescent of tissue and then a small portion from
the helix. The skin, anteriorly, is trimmed so that
it slightly overhangs the cartilage, permitting ap-
proximation with a buried catgut suture. When the
cartilages are held closely together there is no ten-
sion upon the skin suture. The illustrations usually
given by operators showing a crescent to be removed
from the ear, show this crescent including the anti-
helix, which in the usual ear is a prominent ridge.
The removal of this ridge and its replacement by a
linear scar alters the natural state to an extent
which is noticeable, and rather than the removal of
this portion of the cartilage, the operator should re-
move a crescent of cartilage from beneath the anti-
helix, so that it includes a portion of the concha.
Following such an operation the scar on the anterior
surface of the ear over the site of the crescent re-
moved is beneath the antihelix and within the con-
<;ha. Here it is in the shadow and is much less con-
spicuous than along the site of the antihelix.
The skin anteriorly should be carefully sutured
and the cartilage approximated, taking deep stitches
with chromitized catgut so that the cartilage is firm-
ly and safely held in approximation. The skin of the
ear posteriorly is carefully approximated, and the
ear dressed with collodion or adhesive strips.
The Operation of Election.
The third operation is one which may be applica-
ble in cases where a long, narrow strip of cartilage
is removed and the desired result secured in this
way. The operation has in view the removal of the
cartilage and skin of the ear posteriorly, but the
skin of the anterior surface is not disturbed, so that
no scar is left after the operation, except upon the
posterior surface of the ear, and this is rendered in-
conspicuous by completing the operation so that the
ear lies close to the head.
The skin incision is made as before so as to over-
lie the cartilage which is removed. The cartilage is
removed in a long, narrow, crescent-shaped strip
just within the concha, and a strip is also removed
extending inward and outward.
After the skin is separated posteriorly, the carti-
lage is but partly divided with a scalpel and the
operator, with sharp, strong scissors, bites out the
cartilage bit by bit without injuring the skin over
the anterior portion of the ear.
When the cartilage is all removed and the bleed-
ing controlled with a fairly blunt dissector the skin
is slightly separated from the margins if the carti-
lage anteriorly, and then the cartilage is sutured as
in the previous operations. The cartilage having
been closely approximated the skin is brought to-
gether posteriorly and the parts dressed.
In some cases it is necessary to carry an incision
inward toward the attachment of the ear to the head
and to excise a segment of cartilage along this line,
and afeo to carry the incision outward over the
helix, excising a strip to the margin of the ear. If,
after this operation, the ear shows a tendency to
stand out unduly, this is overcome by dressing the
ear close to the head and holding it in this position
until healing occurs. In other cases, the wedge of
tissue may be removed from the concha close to the
attachment of the ear to the head and a strip of car-
tilage removed outward over the helix and the anti-*
helix. The cartilage is now sutured and if the ear
stands out unduly, the operator completes the opera-
tion by suturing the cartilages to the tissues of the
side of the head before closing the skin incision.
The last operation described for the diminution of
the size of the ear is one which will be found more
universally useful than the others as it enables the
operator to secure a result which is more nearly per-
fect than others, with the least amount of scarring,
and the scars situated most inconspciously.
Attention has been called to the importance of
placing the scar caused by the removal of a crescent
of tissue as much in the shadow as possible and not
out along the line of the antihelix where it is likely
to be most conspicuous.
In order that the ear may be adequately reduced
in size it is necessary to remove a section of tissue
from the helix and if this is removed from the mid-
dle of the free margin of the ear as has been recom-
mended in the previous operations, it may be diffi-
cult to hide the scar subsequently.
Women will most often submit to the operations
for reducing the size of the ears, and in such patients
the hair, if dressed low, covers the ears and scars are
hidden, but before the operator allows such a
thought to decide him as to selecting an operation
which necessitates such plan of dressing the hair
subsequently, he should decide whether or not such
a dressing of the hair is becoming to the particular
woman before him, and whether or not the dictates
of fashion will not at some subsequent time make her
very anxious to dress her hair away from the ears.
If the operation for diminishing the size of the
ears is performed somewhat along the same lines as
has been previously described, but instead of remov-
ing a segment of the helix about the middle of the
free margin of the ear, it is removed from the ear at
the beginning of the helix above, we will have the
scar situated at a point where either in the male or
female it can be easily hidden from view.
In many cases the long, narrow crescent can be
removed from the ear and the work done from be-
hind so that the skin is not punctured or removed
anteriorly and the ear diminished in size without
subsequently leaving a visible scar anteriorly.
RECONSTRUCTION OF THE EAR.
Where from some cause the ear has been entirely
lost, it . is a problem at the present day whether to
attempt to reconstruct an- ear from the soft parts
about the site of the lost organ, or if it is not a bet-
ter plan to recommend the wearing of an artificial
organ. In women, it may be justifiable to attempt
the reconstruction of an auricle, as the organ can be
more or less perfectly hidden, if it does not prove to
be entirely pleasing in its outlines. In men the hair
cannot be worn so as to conceal the organ in great
part and an imperfect organ hardly improves ap-
pearances. In any case the patient contemplating
submitting to an operation for the reconstruction of
the auricle should understand the uncertain nature
of the work.
Where the organ is merely imperfectly formed,
much may be accomplished in improving its appear-
ance by overcoming any tendency to curl on the part
of its cartilages. If a woman presents with an im-
perfect auricle, if it is possible to reconstruct the
lower portion of the ear so that it appears to be in a
normal condition, the remainder of the organ may
be so hidden in dressing the hair that the deformity
is of little importance. Unfortunately, many women
dislike wearing the hair low so as to cover the ears,
and certain of them, justly, as such a plan of dress-
ing is far less becoming than other styles. Where a
rudimentary lobule exists and the patient is willing
to dress the hair over the upper portion of the organ,
the lobule may be filled out to an advantage with
paraffin. The injection of the drug is made easily,
the agent being in a semi-solid state. The operator
having injected a sufficient quantity of the prepara-
tion may mould it so as to give the lobule a natural
appearance. The tissues may not permit of the in-
jection of all the paraffin desired at the first opera-
tion, where the rudimentary lobule is very small,
and, in such instances, a second injection may be
made, after the lapse of considerable time. The tis-
sues gradually relax after an injection, so that the
second injection permits of the depositing of more
of the preparation than could have been placed at
the first sitting without causing undue tension upon
the involved parts. The lobule, if moulded to a nat-
ural appearance, may be allowed to show beneath
the hair, and the individual in this way appears to
have a normal auricle.
When the ear is entirely absent in a woman who
is willing to wear the hair low so as to cover the site
of the auricle above the lobule, a lobule may be easi-
ly formed from a fold of skin. This fold is modeled
into the desired shape after having been cut free ex-
cept for attachment above, and after healing has
occured, it may be injected with paraffin so as to
give it the desired shape, and to prevent atrophic
The operator, to form a lobule, picks up a fold of
skin with the thumb and index finger ajid cuts it
free below and laterally. The fold so freed is then
sutured so as to give to it a shape similar to that of
the lobule. This is accomplished by first suturing
the triangular interval left after freeing the fold of
skin. Then the operator proceeds to suture the fold
so that the line of suture is hidden by the newly
formed lobule. The apex of the fold should be
drawn upward in this latter step of the operation,
so that the lobule formed has not an unnatural point-
Othematoma or Hematoma.
This is a condition which has been dilated upon
by numerous writers, and it will not be the subject
of any extended discussion in the present work.
The affection consists of a tumor of the external
ear filled with blood and serum. The manner of its
formation is clear in many cases, while in other in-
stances it apparently develops spontaneously, and
much discussion has been engendered as to whether
the apparently spontaneous lesions were of local or
constitutional origin. The reputed spontaneous othe-
matomae are seen in nearly all instances in the in-
sane and it is easily possible to understand how such
an individual may have the condition following an
injury which has escaped the attention of those
about the patient.
The tumor appears suddenly, as a rule, and may
or may not be accompanied by more or less inflamma-
tion of the adjacent structures of the ear. It varies
in appearance. In some there is an excess of blood,
in others of serum in the interval which is formed be-
tween the cartilage and the overlying skin.
The course of the lesion varies. In some cases
there is a considerable inflammation, particularly
where a severe injury of the ear has been suffered,
and the crushing may «o facilitate the development
of bacteria which gain entrance to the affected parts
that sloughing occurs. In other instances an ery-
sipelatous inflammation develops and extends from
the ear to adjacent structures. The development of
pyogenic organisms in the contents of the tumor is
followed by an alteration of the contents of the tumor
into pus, and if this material is not evacuated by the
surgeon, the tissues overlying the pus will ultimately
give way and spontaneous evacuation occur.
Our present perfected knowledge of aseptic and
antiseptic surgery leads me to believe that it is al-
ways well to open these lesions after carefully steri-
lizing* the surrounding parts, and then to carefully
syringe the cavity with a mildly antiseptic and as-
tringent solution. The cavity may be syringed with
a warm saturated solution of boric acid, and if a
hemorrhage occurs, after the cavity has been opened,
it is well to syringe with a solution of the active
principal of the suprarenal gland. This agent for a
time tightly closes the small vessels entering the
cavity of the lesion, and before its effects are lost,
the parts should be carefully dressed with sterile
lint, and slight compression exerted to prevent fur-
ther bleeding. The opening into one of these lesions
should be made so that the consequent scar will be
as inconspicuous as possible. In some cases follow-
ing the othematoma and in other instances following
repeated inflammations of the ear a marked shrivel-
ing occurs of the cartilage and other parts of the ex-
ternal ear. Such a condition causes a very notice-
able deformity, the correction of which is difficult if
The irregularities and bulk of the ear may be
slightly overcome by the injection of paraffin. In
this work the judgment of the operator must be
brought into play to decide as to the extent and
manner of placing the paraffin.
Where acute inflammation of the ear • exists it
should be treated with soothing applications such as
lotions of lead water and opium. . Where a chronic
inflammation exists the parts should be treated with
a view of preventing this shrinking of the ear sub-
sequently. For the chronic inflammations such ap-
plications as those of iodine, guaiacol or mercury
should be used. The iodine is used in the form of
the diluted tincture or as an ointment; the guaiacol
in a salve or in glycerine in strengths varying from
five to twenty per cent; the mercury is used as an
ointment of the metal or some of the salts as the
ammoniated or the red iodide.
Sebaceous Qysts of the External Ear.
The majority of sebaceous cysts seen upon the ex-
ternal ear are small and remain so, though in a few
instances they grow to considerable size. If the di-
lated but plugged opening of the cyst is visible as a
black speck over the tumor an attempt may be made
to dilate this duct with a probe, and the contents
squeezed out through this opening. After the cyst
is emptied, nothing further may be done or a tinc-
ture of iodine injection may be used. For this pur-
pose take a glass hypodermic syringe, and a very
short, fine needle, the extremity of which is blunted.
The syringe is partly filled with the iodine tincture,
and the needle introduced into the cavity of the cyst
through the patent duct and the iodine injected.
After it has remained in the cavity for several min-
utes it is expressed through the duct, and the parts
protected with a small piece of adhesive plaster.
Should the cyst subsequently reform, it may be
evacuated again or removed. In the consideration
of the subject of sebaceous cysts under a separate
head the technic to be followed in their removal will
be dilated upon. Here attention is called to but one
point. In some cases the cyst will be so situated
that an incision made directly over the cyst for its
complete removal leaves a scar which is clearly visi-
ble. Such a scar may be insignificant, but it is pre-
ferable to have it entirely hidden. In order that this
may be accomplished an incision made posteriorly
may be utilized to gain access to the cyst. If neces-
sary the incision is carried through the cartilage to
gain access to the cyst. After the contents have
been removed the sac itself should be extirpated.
Chalky concretions are sometimes found in the
ear. These deposits are the result of a gouty diathe-
sis and may be removed by incising and dissecting
FIBROUS TUMORS AND KELOID OF THE EX-
These conditions are seen affecting the lobule, as
a rule, and when large cause a noticeable deformity
so situated as to be diflScult to conceal.
Fibrous tumors are seen developing within the
lobule, and keloid growths are seen following
wounding of the lobule. The wound made in pierc-
ing the ear, for the wearing of an ear ring, is par-
ticularly likely to undergo keloid development. This
is due to the subsequent irritation in keeping the
Where the tumor is of a fibrous nature and has
developed beneath the skin of an uninjured lobule,
the growth should be removed. If a portion of the
growth be allowed to remain it will re-develop.
To remove the tumor from an uninjured lobule
the parts should be cleansed and the ear all about
the tumor infiltrated. The tumor should be ap-
proached from behind and close to the attachment of
the lobule to the head, or along its inner margin.
The incision so situated leaves a scar hidden from
When the tumor is reached the dissection should
be carried about it until it is free, and in doing so
care exercised to avoid puncturing the skin.
When the bleeding is controlled the wound made
in excising the growth is approximated with sutures.
In some instances, the former site of the tumor be-
comes distended with a blood clot, but this need
cause no concern as it will gradually disappear.
After the operation should it be found that the
lobule is too thin and is diminished in size as the re-
sult of the removal of too much tissue, the parts are
cleansed and a few drops of paraffine deposited in
the lobule to increase it to the normal size.
Keloid growths are removed by complete excision
and the parts carefully sutured. These growths are
likely to return and at the present day the best plan
for a patient to pursue is to allow of repeated exci-
sion until a time in life is reached when no further
tendency for it to return exists. After middle life
is passed, keloid growths diminish in size and disap-
pear, as a rule. These growths are not often met in
the white race.
The Repair of Clefts and Fissures of the External
The most common form of cleft seen in the ear is
the one acquired by the tearing out of an ear ring.
Such an accident, properly treated, should not be
followed by the development of the cleft we are
sometimes called upon to repair.
Where the surgeon is consulted immediately fol-
lowing. tearing out of an ear ring, he should cleanse
the wounded part and with fine scissors trim away
any lacerated shreds of tissue. The parts are su-
tured with catgut or silk and an antiseptic dressing
After cleansing the lobule and its contiguous area
where such has an acquired cleft in it, the surgeon
infiltrates both sides of the cleft and with scissors
or scalpel denudes the margins of the cleft. This
accomplished, the parts are approximated with gut,
silk or horse-hair. This is the operation which is to
be performed where practically no tissue has been
lost from the lobule. In some cases we see a lobule
which has suffered this accident, «nd from which a
wedge of tissue has been torn. Such a lobule should
not be denuded in the manner previously described
as already a deficiency of tissues exists from which
to reconstruct the lobule, and this first method of
denudation calls for further sacrifice of tissue. The
denudation may be accomplished in such a manner
that no tissue is removed from the lobule. This is
accomplished by separating the cleft of the lobule
and making an incision along the margins of the
cleft midway between the anterior and posterior
surfaces of the lobule. This incision, when widened,
presents two raw surfaces, one on each side of the
cleft, and these are brought together with sutures
as in the former operation. In widening the incision
made along the margins of the cleft, a pair of fine
scissors are used to an advantage. In some cases a
very neat operation is performed by making the in-
cision along one side of the cleft near the posterior
surface of the lobe and near the anterior surface
along the other side of the cleft. The tissues are
freed in one direction only so that two small skin
flaps are formed. These flaps are sutured so that the
interval of the cleft is obliterated. Where one side
of the cleft heals, leaving an irregular scar and the
other is comparatively smooth, this technic is used
to an advantage, the smooth flap being so formed
that it is used anteriorly and the rough or cicatrized
one posteriorly. Where the deficiency in the lobule
is decided, the tissues are re-united as I have out-
lined and the operator improves the appearance of
the lobule after healing occurs by depositing in it a
few drops of paraffin. In this work the needle
should not merely be forced into the lobule and a
mass of paraffin deposited at one point, but the
needle should be carried about so that the lobule will
be infiltrated with the paraffin. The paraffin is mol-
ded into a smooth, even plate as fast as it is deposit-
ed. If it is simply deposited in a lump subsequent
atrophic changes may render it noticeable and un-
The Reduction of the Size of the Lobule.
We sometimes see patients with a lobule unduly
large and thick, and in such instances surgical means
may be taken to diminish the size of the lobule.
The lobule is operated upon after the parts are
infiltrated and any quantity of the lobule removed
with or without a portion of the skin.
The operation should be performed through an
incision situated posteriorly and close to the side of
the head. The incision may be transverse or perpen-
dicular. If the lobule is merely too thick, a very
short incision suffices for the introduction of the
points of a pair of curved iris scissors and a portion
of the soft parts from the middle of the lobule is
excised. The excised portion is lifted out and the
operator notes whether or not the desired effect is
obtained. If not the procedure is repeated until a
satisfactory result is secured. The cavity of the lo-
bule is then syringed with a mild antiseptic solution
and the small incision in the skin closed.
If the lobule is too long or too broad a portion of
the skin is excised in one or the other direction and
the parts carefully sutured as before. In some cases
the lobule appears too long and too narrow. To
overcome this the preliminary incision should be
made in a direction parallel to the long axis of the
lobule. When the excess of tissue has been removed
the line of incision is sutured in the direction oppo-
site to that which it originally pursued, the result
being a shortening and a broadening of the lobule.
The operation above described is reversed where the
lobule appears too short and too broad and in this
way a narrowing and lengthening of the part is se-
cured. It is important in this work that the incision
which is altered in direction, be fairly deep so that
the greater portion of the structures of the lobule
are altered in position.
ADHERENT AND UNDEVELOPED LOBULE.
It is a very common condition to find the inner
margin of the lobule of the ear attached to the side
of the head. This is a condition which often mars
the appearance of the ear, because it so often in-
creases the resemblance of the human ear to that of
the lower animals. In some cases the attachment is
of such a nature and the lobule is so developed that
there is a continuous slant from the side of the head
to the margin of the helix, and if this is coupled
with a slight pointed condition of the ear above we
have an ear strikingly like that of some animals.
The attachment of the lobule of the ear to the side
of the head and its pointed development above are
classified among the stigmata of degeneration. The
opportunity for overcoming this condition in its
varying degrees frequently presents itself to the
surgeon interested in cosmetic work and the condi-
tion is easily corrected by a simple operation which
varies somewhat according to the particular type of
ear the patient possesses. Where the lobule is fairly
well formed and merely attached to the side of the
head bv a fold of skin this fold is divided and the
skin of the posterior margin of the lobe sutured to
the margin of the anterior surface and the skin
edges on the side of the head approximated by
Where the lobule is not well formed but its out-
line is that of a triangle, the operator finds that if it
is cut free internally and a small flap formed along
the outer margin of the lobule, the lobule can be
trimmed to the desired shape and the small flap
brought up and attached to the side of the face so
that it encircles more or less the side of the newly
formed lobule. The wound left along the side of the
head to the inner side of the lobule should be closed
with sutures and when healing occurs a well formed
lobule is secured.
In these cases if the ear has more or less of a
pointed appearance above, it may be well to excise
a wedge-shaped portion of the helix posteriorly to
overcome this appearance, after the lobule has been
In certain cases the lobule is attached to the side
of the head, and is so imperfectly developed that if
the operation above outlined is completed a satisfoc-
tory appearance is not secured, the lobule being en-
tirely too small. In such cases the size of the lobule
is increased by the injection of paraffin. Where
paraffin is injected into a small lobule, it should not
be allowed to accumulate in a mass, but spread so
that it forms a thin, even sheet.
In rare instances fibromata are seen in other por-
tions of the ear. Where such develop they are felt as
smooth or nodular tumors — quite firm in consist-
ence. They should be removed entirely, as the leav-
ing of a portion may permit of their return. The re-
turn of these growths is not a matter to be looked
upon without concern, as they may ultimately under-
go malignant changes.
Some surgeons insist upon describing cystoma of
the auricle as a circumscribed collection of fluid
which has not resulted from traumatism. The same
treatment of this condition is usually demanded as
that used in the treatment of othematoma. Aspira-
tion of the contents of the cyst followed by pressure
may be tried rather than incising the cyst. In some
cases after repeated aspirations it is necessary to
incise the lesion, and in such a case the incision
should be made posteriorly whenever possible.
Where it is made anteriorly it should be made in the
shadow of some of the more prominent portions of
the ear and should correspond with the lines and
curves of the ear so that scarring will be least no-
This is a condition seen in one or both ears. The
organ or organs are unduly small and imperfectly
developed. In such cases the external auditory
canal is not infrequently closed and there may be an
auricular appendage or a second imperfect ear in
Where the ear is small and imperfectly developed
an improvement may be secured in its appearance
by the judicious use of paraffin injections, and
should the organ be curled and twisted upon itself
the cartilage may be divided subcutaneously in vari-
ous directions and the parts held in a corrected posi-
tion until healing occurs.
"Where the ear is very much smaller than the nor-
mal and the use of the paraffin is unsuccessful in
correcting its unnatural appearance, the organ may
be removed and an artificial ear worn to a better ad-
It is hardly within the scope of this volume to
discuss the formation of a new meatus and auditory
canal, where this canal is impervious at birth. When
such a condition exists the surgeon may feel if an
opening is made down to the middle ear, and kept
open for a time, that healing will occur, and an
epithelial covering develop for the passage, but such
is not the rule. Tubes have been inserted and worn
for an indefinite time in these cases and yet when re-
moved the passages close. Granulations form and
fill the canal and the lumen of the tube. If the oper-
ator desires to maintain the patency of the canal
which he forms he must do his operation so that
epithelial flaps can be turned into the canal, and held
there until they unite to the raw surfaces. Even this
technic does not insure success and grafts still at-
tached at their base may slough.
Amputation of Auricle.
The amputation of the ear is easily performed. It
is indicated where the ear is badly deformed and
markedly undersize, and in some cases of malignant
disease and extensive involvement with lupus. This
latter disease in this situation may extend into the
external auditory canal and middle ear, if not
checked in its ravages.
In the removal of auricular appendages it is al-
ways well to preserve from a convenient surface of
the appendage sufficient skin to cover the raw sur-
face left after the excision. The technic, otherwise,
is exceedingly simple and the operation is performed
with perfect satisfaction with the aid of infiiltration
Sometimes small congenital fistula communicating
with small cyst-like cavities are seen in these cases.
These should be opened and curetted. If they per-
sist and fail to close after such treatment a probe
wrapped with a fine strand of cotton saturated with
a twenty per cent solution of chromic acid may be
passed into them at intervals of several days. This
agent destroys the epithelial lining of the tract and
causes their obliteration.
Wounds of the Auricle.
Wounds of the auricle are common, and where
carelessly treated a perichondritis may develop, the
subsidence of which may leave the ear marred in
Where an open wound exists and there is any
considerable trauma to the organ, the auricle and
the parts about it should be cleansed and an anti-
septic dressing applied. An ice bag is placed outside
the dressing, particularly, should a perichondritis
develop. , ,
Wounds penetrating entirely through the auricle
should be carefully sutured so as to approximate
the parts anteriorly as neatly as possible. Through
and through sutures should not be used. A row
of sutures may be applied posteriorly which extend
through the cartilage, but which . do not extend
through the skin anteriorly. The skin may be
brought together very nicely by such sutures but
should it gape anteriorly a fine silk or horsehair
suture should be used. Through and through
sutures are objectionable as they cut more or less
and are likely to leave visible stitch marks.
Where a punctured wound is made and the parts
are bruised and their integrity doubtful, it is well
to close the parts anteriorly and to leave the wound
open posteriorly. ,
In the removal of auricular appendages it is always
well to preserve from a convenient surface of the
appendage sufficient skin to cover the raw surface
left after the excision. The technic, otherwise, is ex-
ceedingly simple and the operation is performed
with perfect satisfaction with the aid of infiltration
Sometimes small congenital fistula communicating
with small cyst-like cavities are seen in these cases.
These should be opened and curetted. If they per-
sist and fail to close after such treatment a probe
wrapped with a fine strand of cotton saturated with
a twenty per cent solution of chromic acid may be
passed into them at intervals of several days. This
agent destroys the epithelial lining of the tract and
causes their obliteration.
The attachment of the ear to the head is very
firm ; it is said that the entire weight of the body can
be borne by the ears. Partial detachment of the or-
gan is common as the result of various accidents,
and in these cases reunion promptly occurs when the
organ is sutured in place. Where the ear is entirely
detached from the head, it should be sutured in
place after cleaning the separated organ and the
stump. When the operator least expects it, reunion
may occur. The parts should be dressed in such a
way as to render the ear which has been separated
from the body perfectly immobile. No attempt
should be made for at least four or five days to re-
dress the parts. The dressings may be repeatedly
moistened with a normal saline solution and kept
warm with a hot water bag applied externally.
Where a mass of tissue is grafted the skin of the
grafted part becomes black and to all appearances
the part is dead, but the operator should under no
circumstances pull such a part away. Even if he
is certain the part is dead he should leave it until it
comes away of its own accord. The apparently d'ead
organ may unite and after the superficial layers
separate the ear may be saved.
Lupus Vulgaris of the Auricle.
The auricle is not often attacked by lupus, but it
is well to remember the condition, as its extension
may inflict serious damage to the individual, if not
recognized and checked.
The disease begins as dry indolent nodules, which,
for some time, may give the patient no concern.
They become itchy and by scratching or picking the
surface is removed. A superficial ill-defined erosion
forms, which gradually deepens until a well-defined
ulceration exists. This extends by tissue necrosis
and by the formation of new nodules. This disease
is one which should be treated vigorously as soon as
recognized. The lesions should be freely cauterized
by active caustics, or the involved tissues excised. If
the operator hesitates to take such radical steps, the
lesions should be thoroughly curetted and strong
lactic acid rubbed into them.
As caustics, in these cases, chromic acid, sulphuric
acid paste, arsenic paste or hydrate of potassium are
used. These agents, destroying considerable tissue,
are quite as efficient as a free excision. The X-ray
has been used a great deal in the treatment of lupus
in the last few years. It represents a rather expen-
sive means of applying a caustic treatment. Its
proper application cannot be condemned as we must
admit that it is effectual. Many serious burns are
made by the eareleas use of the X-ray and users
learn by bitter experience to apply it with caution.
All parts, except the affected area, should be pro-
tected from the ray where a considerable exposure
FOLDS, BAGS AND WRINKLES OF THE SKIN
ABOUT THE ETES.
Folds and wrinkles frequently develop prema-
turely about the eyes of individuals, adding years
to the apparent age Bagging' of the skin beneath
the eyes not only adds somewhat to the appearance
of age, but revolts sensitive people so that unfortu-
nates so afflicted earnestly desire relief, if such is
Wrinkles, folds and bags beneath the eyes are
eradicated by the removal of a crescent of skin be-
neath the eye. The convexity of the crescent should
be downward, and the concavity of the crescent
should lie close to the lashes along the lower lid. The
width of the crescent varies according to the depth
of the wrinkles or the size of the folds or bags. The
first incision should be made with a sharp scalpel
along the lid. The skin should be divided entirely,
and loosened somewhat. It should then be drawn
upward, the operator observing carefully just how
much must be removed to entirely overcome the con-
dition demanding the operation, then, with the scis-
sors, the skin is cut aw^ so that the crescent is made
Just sufficient skin is left along the margin of the
lid to permit the stitches being passed in closing.
The line of union is brought in this way under the
shadow of the lashes, and is entirely invisible.
Hemostasis should be complete before the skin
interval is closed. Bleeding is never troublesome
in these cases. A few .moments pressure with a
small pad of sterile cotton will control it. Should
the operator desire, the bleeding points may be
twisted. Styptics are not needed. The approxima-
tion of the skin should be accurate. Continuous or
interrupted stitching may be used according to the
election of the operator. I use fine silk and fine cam-
bric needle. Sutures should not be tied tightly, as
this favors cutting of the stitches so that stitch
marks may be left.
Excision of fold above the Eye.
The fold above the eye after infiltration is picked
up and trimmed away. The line of closure here is at
the upper extremity of the lid, so that the slight line
of union is hidden in the fold between the lid and
the brow, when the eye is open, and only shows
slightly when the eye is closed. The proposition is
a very simple one when operating above. The excess
of tissue is cut away, and the skin margins of the
interval accurately closed with sutures.
Dressing of these cases is somewhat important.
Collodion dressings may be applied so as to remove
all tension from the sutures: the sutures in such a
case merely serving to insure accurate approxima-
tion of the skin margins.
A strip of cotton should be tucked under the
lashes, and plastered securely to the skin with sever-
al coats of collodion. The collodion dressing is ap-
plicable above the eye as well as below.
REDUCTION OF HUMP NOSE.
The aqueline nose entirely alters the appearance
of the individual, and the removal of the excess of
tissue will strikingly improve the appearance if the
operation can be performed so that no visible
traces of the surgical attack, remain subsequent to
A hump high on the nasal bridge is easily acessi-
ble through one of both nostrils and the surgeon
who has had experience with such cases will seldom
hesitate to choose operation through the nostril
rather than through a skin incision along the median
line of the nose. The removal of bony or cartilagin-
ious tissue is no contra-indication to the use of infil-
tration for the purpose of overcoming the pain, for
cartilage or bone may be chiselled away without
pain if the soft parts and pereosteum are thoroughly
When the surgeon contemplates attack through
the nostrils, the nasal vestibule should be thoroughly
cleansed with strips of gauze and an antiseptic or
soapy solution. Care should be taken to prevent
strong antiseptics trickling over the delicate mucosa
lining the upper portion of the air passages. With
the nasal vestibule clean and the operator exercising
ordinary aseptic precautions healing is as satisfac-
tory following these intra-nasal operations as f oUoav-
ing operations through a healthy skin incision.
The line of incision to gain access to the hump
should lie along the free margin of the nasal bone.
The incision need not be long, as a very narrow
chisel serves best for loosening the hump.
In my earliest operations I loosened the soft parts
overlying the entire nasal bridge before attacking
the hump, but I have found the operation to be quite
as easy where the tissues are not loosened at all, but
attack is made at once upon the prominence to the
In using the chisel, care should be taken not to
chisel beneath the nasal bones and to lift them as a
whole, for this may occur if the chisel is driven
deeply into the mass of projecting tissue and it
proves to be bone rather than cartilage. The por-
tion of the hump beneath which the chisel is driven
should be felt to give and when it is entirely free
except from the overlying pereosteum the chisel
should be removed from the wound and a pair of
small forceps passed upward, and the loosened frag-
ment grasped tightly and peeled from the pereosteum
so that the pereosteum is drawn downward as the
fragment is extracted.
Both nostrils may be used as means of access to
the hump if the operator elects, but I find it quite a
simple matter to remove the entire hump through
The incision I make along the free margin of the
nasal bone is seldom more than a quarter of an inch
in length. I make no effort to see, or to pass my
finger upward, but depend entirely upon an eleva-
tion of the nasal tip to give me an almost direct ac-
cess to the hump so that I work without hindrance
upon the highest hump.
In some instances a hump is brittle and shatters in
spite of efforts to prevent it, and when this occurs
care must be used to smooth the remaining tissues
as small projections will show distinctly after the
reaction subsequent to the operation has subsided.
After fragmentation of a hump the operator should
palpate very carefully through the overlying skin
and every irregularity palpable should be smoothed
with the chisel or with a cutting rasp.
Bleeding sometimes is quite free during the opera-
tion and should it be such as to annoy the operator
or interfere with accurate work the operative steps
may be discontinued temporarily and compression
exercised for a few moments. This compression will
soon check the hemorrhage and the operator may
Should the infiltration solution escape from the
tissues to such an extent that the patient feels pain
re-infiltration should be practiced. Patients should
be instructed to inform the surgeon if any pain is
felt and should they complain further distension of
the tissues will overcome the pain In the beginning
of their experience operators are likely to fail in
their infiltration in two areas. They are likely to
distend the ^issues external to the point of entrance
of the knife along the margin of the nasal bone, so
that the first incision may be painful, and then they
are likely to fail to perfectly distend the pereosteum.
The needle point should be forced along against the
bone to infiltrate the pereosteum, and the surgeon
should assure himself that the site of the first in-
cision is perfectly insensitive.
THE TIP TILTED NOSE.
The tip tilted nose sometimes mars the appearance
greatly. This is particularly true where the tip and
alae are thick and blunt. The operator must decide
before beginning his operation whether the bringing
down of the tip is all that is needed, or whether it
will be necessary to reduce its bulk as well.
This operation is performed without difficulty af-
ter the parts have been infiltrated. Infiltration is
effective in entirely overcoming pain if the proper
precautions are taken to«infiltrate the tissues system-
atically so that none incised are uninfiltrated. The
solution used is not of material importance, it should
contain a trace of cocain or similar agent, so that
the injection itself is painless.
Our object in this operation is to bring the tip of
the nose down and to retain it in its lowered posi-
tion. To accomplish this we must free it from the
septum within the nose, then in some cases incise the
alae within the nose, with the tip thus freed above
and at the sides we can bring it down with little re-
sistance, and it may be held in its lowered position
by properly applied sutures until reunion occurs. If
the tip is too bulky the tissue beneath the skin must
be Cut away. If the wings of the nose are also too
bulky they must be incised and tissue removed
to reduce them to the required extent.
The first incision is made with a narrow bladed
scalpel. It should be carried through the septum,
and the tip of the nose freely separated from the
septum. If the tip does not come down readily the
incision is lengthened along the inner surface of the
alae nasi parallel to the free margin of the nasal
bone and about one-third or one-fourth of an inch
below the margin of this bone. Care should be ex-
ercised not to allow the scalpel to pierce the skin at
any point, the incision through its entirety being
within the nose and beneath the skin.
The loosened tip must be held in its lowered posi-
tion by sutures until imion occurs. Sometimes one
suture will hold the tip in the required position, al-
though two or three sutures insure greater stability
of the parts, and should invariably be placed if the
tip is to be held in its lowered position under tension.
With the tip turned up by the thumb and index
finger and the cut surface exposed through one or
the other nasal orifice the first portion of the stitch
may be passed without difficulty. The needle may
be made to enter through one nasal orifice and
emerge through the other, or the tip may be dis-
placed to one or the other side and the curved needle
made to complete the stitch above through a single
orifice. The suture or sutures below should pass en-
tirely through the cartilaginous septum. In the ear-
liest operations surgeons will sometimes experience
diflEiculty in passing the sutures so that when tied
they hold the tip in the desired position. Should
difficulty be experienced in this respect stitches
should be cut and reapplied. The tip should be held
down by stitches placed within the nose and the
operator should not trust to plasters externally for
accomplishing this purpose if the stitches fail to do
so. If the tip is held down under tension, the oper-
ator may place a plaster strip across the nasal bridge
and secure it so as to splint and hold down the soft
parts, but this should not be relied upon; primarily
the stitches within the nose should accomplish this.
Adhesive strips externally applied are objection-
able, as they necessitate confinement of the patient.
Without external dressing the patient need lose no
time from ordinary duties.
NOSE WITH THE BULBOUS TIP.
The nose with the bulbous tip is seen frequently.
Very often the bridge is comparatively low. When
the fad of injecting paraffin into the tissues over
any and all nasal bridges was most popular, such
noses were filled out, to the (iisadvantage of the in-
dividual. Advertisers are still guilty of this prac-
tice. The nose with a bulbous tip is more sightly
than a nose which is large and coarse in all its pro-
portions. We must not forget that it is almost im-
possible to find a really large nose which is sightly,
therefore the possessor of a nose with a thick and
bulbous tip must not be treated by any method
which fills out the nose above the tip. A tip which
is bulbous must be reduced in all cases to moderate
We cannnot forget that the small nose is in near-
ly all instances sightly. A nose without a bridge, or
with a very low and very brbad bridge, may not be
sightly, but too often the low bridge of a nose does
not mar appearances as much as one would suspect
from a profile view. Heightening a bridge does not
improve the appearance of the individual, as the pro-
file would lead us to infer, if the heightened bridge
is broad and coarse.
A bulbous tip may be reduced to normal propor-
tions through incisions within the nose. This plan
of operation leaves no external scars.
Incisions should be made just far enough within
the nose to insure that they will not show. No form
of nasal speculum is needed. A small, stout, sharp
scalpel is needed for making this incision along with-
in the nose. After the first incision scissors may be
necessary for trimming out the tissues. The bulbous
tip must be reduced without regard to the tissues
which are dissected away. Sometimes it is necessary
to sacrifice more or less of the lining of the nose,
though this is to be avoided if possible, as the epith-
elial layers cut away may leave a raw surface which
heals over slowly. The excision must be upon both
sides, and frequently the tip itself must be complete-
ly undermined from either side and a large part of
the tissue forming it must be excised.
Bleeding in these cases may be free for a few
moments. Should it persist, the operator can con-
trol it by grasping the parts between his thumb and
index-finger. The bleeding will cease if it is con-
trolled by compression for a few moments. No at-
tention should be given to bleeding until the excision
of tissue is complete.
Too much tissue should not be removed, the sur-
geon should remember that an operation may be re-
peated if too little tissue is removed in a first opera-
When sufficient reduction of the tip is accom-
plished, the operation may be considered complete.
As the surgeon acquires skill, he may turn up a flap
within the nose, and this flap may be sutured in
place by one or two fine sutures. Such a technic
hastens the healing process, but iS of secondary im-
portance to the removal of the right amount of tis-
PARTIAL STENOSIS OF THE NOSE.
Dr. Roe of Eochester, New York, some years ago
described a condition which we sometimes meet in
which a contracture of the nasal orifice exists. I have
not the reference at hand, but in this article Dr. Roe
illustrated a flap operation which enabled him to
overcome the stenosis and to secure a prompt heal-
ing subsequent to the operation.
The formation of a flap as described by Dr. Roe
has not appealed to me particularly and I prefer to
make an incision directly in the median line. This
incision is carried backward where the stenosis is
posteriorly and forward when the stenosis is toward
the nasal tip, and after the parts have been com-
pletely divided, with the index finger and the thumb,
the tissues are everted through the nares and trimm-
ed away with scissors so that the skin alone is left.
When this excision of tissue has been completed on
both sides of the incision along the median line of
the obstruction, two skin flaps are left and these
may be turned upward into the nose and sutured
with fine silk. Small curved needles serve best for
suturing and these delicate flaps should be drawn
upward into the nose.
By practicing the technic I have described no
visible scar is to be seen after the operation unless
sloughing of a flap occurs and this method of flap
formation insures to the flap the best possible blood
COMPLETE NASAL STENOSIS.
Complete stenosis of the nostril should be treated
in a similar manner unless a distortion exists of the
parts which renders such restoration impossible.
Should the parts be deficient and the simple oper-
ation for occlusion be unlikely to secure a condition
entirely normal owing to contraction of the tissues,
the alae may be sectioned at several points and a
plug inserted in the nostril to minimize contraction
while healing is taking place.
Sectioning may be subcutaneous, and should be
performed before the skin flap is sutured in place
within the nose.
Distortion of the septum may throw the nasal tip
to one or the other side of the median line, and
should such a condition exist, the septum should be
freely sectioned and sutures passed to hold the tip
in a corrected position.
Should the tip of the nose be upturned unduly it
may be separated from the septum and freely under-
mined so that it may be drawn down and sutured in
a normal position and should the reverse be true and
the nose appear too long the excess of tissues should
be excised from the septum and tip and it should be
fixed by sutures so that symmetrical healing will be
REMOVAL OF HUMP l^ROUGH SKIN
If an incision is made along the bridge of the nose
the hump becomes easily accessible but this opera-
tion always has the disadvantage of leaving a visible
trace along the median line of the nose The skin
may be divided obliquely and careful suturing may
result in a very slight subsequent scarring. Con-
sidering the ease with which a hump may be re-
moved through the nostrils the operation through
a skin incision cannot commend itself to me.
EXCISION OF SCARS.
Irregular scars of considerable breadth may be
excised and the skin margins re-approximated.
Where the skin is carefully divided in a slanting
direction so that one margin may overlap the other
healing may be so satisfactory as to leave a barely
When it is difficult to secure immediate approxi-
mation of the divided edges of the skin, such approx-
imation may be favored by undermining.
Removal of Small Growths.
Caustics are recommended for the destruction of
small growths but a thorough destruction with the
electric needle is more satisfactory as a rule.
Moles or pigmented Spote may be destroyed by
the electric needle. Where only a small amount of
pigment exists it may be picked out with the electric
needle after the surface of the overlying skin has
been softened and scraped away.
These discolored spots are destroyed by the action
of the electric needle.
Where tattooing has been practiced the surface
of the skin may be softened by the action of the
electric needle and the pigment destroyed or scraped
away. This is the most reliable means of removing
these marks without danger of scarring.
The mother's mark may be destroyed by the ac-
tion of the electric needle. A more rapid method
consists of infiltration of the parts and scarification
bleeding being controlled by compression.
The application of paraffin injections in featural
surgery is objectionable, as certain unpleasant after
effects may develop.
The judicious use of paraffin is permissable. The
injection may be followed by redness which persists
for months. The small bloodvessels of the skin may
dilate and remain so until they have been destroyed
by the electric needle. Sweating over a paraffin in-
jection sometimes annoys a patient for some time
after the injection. The injection of paraffin is not
free from danger of embolus if certain precautions
are not taken. Failure to improve the appearance
is not unusual in unskilled hands. Paraffins particu-
larly prepared for subcutaneous injections are now
• on sale. The lower the melting point the more read-
ily the agent is injected. Unless the melting point
be above the temperature of the body absorbtion
is likely to occur.
The injection should not be attempted except
with a special syringe which enables the operator to
deposit the agent in a solid state. The needle should
be of fairly large caliber and- as short as possible.
The skin may be cocainized to enable the insertion
of the needle without pain. I use a blunted needle
with a rounded extremity. A technic is recom-
mended which includes the infiltration of the area
to be injected and the aspiration of the injected co-
cain solution. I have been unable to carry out this
proceedure with even moderate success. It is a safe
plan to attempt to form a cavity and then to aspirate
it to see if bleeding into it is occuring. The success-
ful application of such a technic insures against em-
The paraffiin should flow from the needle in a
solid worm-like string before the needle is inserted
for the injection. In raising the nasal bridge the
needle should be inserted quickly and the paraffin
forced into the subcutaneous tissue steadily. If the
needle becomes firmly sealed with paraffin it may
be shot violently from the needle and forced into
the forehead or into loose tissue on either side of the
root of the nose. Moulding in saddle nose should be
to secure a nose with a narrow bridge for the broad,
bulky nose is never sightly. If the skin is put tight-
ly on, the stretch as the result of a large injection,
sloughing is possible as an after complication and a
persistant redness at least is to be expected. If the
nasal tip is not too large and other features are
symmetrical a comparatively low bridge is not par-
When the paraffin consolidates it is impossible to
mould it with any degree of certainty and the sur-
geon has a very limited time to smooth and shape
the parts. If he is at all dextrous and distinctly
understands the proceedure the time at his disposal
is ample for moulding. Paraffin may be used to fill
the interval between the brows when this location
is unusually low and marked by a perpendicular line
or lines. I have placed paraffin successfully in the
cheeks to fill out unnatural hollows. When the dim-
ple has degenerated into an unsightly line the line
may be obliterated by paraffin. Eradication of the
naso-labial line with paraffin has not been success-
ful in a majority of my cases. Paraffin thrown into
bulky soft parts shows a decided tendency to lump.
Paraffin injections should be made only after care-
ful aseptic and antiseptic precautions have been
The Removal of Paraffin from the Tissues.
Paraffin which has been placed in the tissues and
which mars the appearance may be removed through
punctures after the parts have been infiltrated. The
removal of the paraffin is difficult, calling for dis-
section of the tissues and the extraction a particle at
a time with a strong cutting pick. Through an in-
cision no more than one-sixteenth of an inch in
length a fine pick may be carried for an inch or
more in any direction and quantities of paraffin
Extensive discoloration from subcutaneous bleed-
ing has been the only complication following this
I operation and in several instances I have fairly
shredded the subcutaneous tissues in all directions.
Paraifin above the naBal bridge is accessible through
the nostrils as in the case of the cartilaginous or
bony hump and attack by this route insures against
visible scars subsequently.
INVEKSION OF THE EVERTED LIP.
What is usually considered as a lip of excessive
thickness in most instances, proves to be on close
examination, an everted lip. The lip which appears too
thick may be inverted by simple plastic operations
and in most Instances actual excision of tissue is not
required to correct the conditon.
Sometimes one lip appears too thick or too long.
This may be either the upper or lower lip. Where
the entire length of the lip is everted it may appear
as the so-called "double lip.'' In a few instances
there is an actual hypertrophy of the lip so that in-
version will not render it entirely sightly.
Where eversion is in -the median line above or be-
low a single incision may be made at right angles to
the free margin of the lip, and in the median line,
and when this is converted into an incision lying
parallel to the free margin of the lip, sufficient in-
version may be secured to render the part entirely
sightly. This incision may be made from the point
of attachment of the lip and the gum to the inner
margin of the exposed portion of the lip, but in dos-
ing the incision in an opposite direction care should
be used not to unduly shorten the lip. If the lip
appears too long considerable shortening may be se-
cured by passing the first sutures in the median line
so that it is fixed in the connective tissue overlying
the gum, and then the degree of shortening of the
lip will depend entirely upon the degree of tightness
with which this suture is tied.
Where the entire lip is everted incisions may be
made at right angles to the free margin of the lip
and these may be closed by sutures so that the re-
sulting line of union will lie parallel to the free mar-
gin of the lip. Mve or six short incisions may be
made and each closed by a single suture.
A segment of mucosa may be excised in these
cases, and in a few instances this will be demanded
by an actual thickness of the lip. The excision
should be well within the mouth so that when the
individual laughs or smiles subsequently there will
be no danger of the scar showing, as labial scars
when visible contrast strikingly with the natural
unscarred labial tissues.
A crescent of tissue may be removed from the
mucosa at the point of juncture of the lip and the
gum although this is not advisable if an actual short-
ening of the lip is to be avoided. The operation is
more certain when the excision is along the line of
attachment of the gum and the lip, or rather it is
more difficult to judge as to the exact effect which
will be secured, so that this latter operation should
be avoided by the beginner.
The portion of the lip which shows as a ''double
lip'' should never be excised for it is almost impos-
sible even for the expert to close the wound so that
no portion of it will show at any time.
THE INVEBTED LIP.
The apparently too thin lip is rarely more than
an inverted lip the result of long misuse of the mus-
cles of the face. While it is more or less natural that
the face should characterize to some extent the emo-
tions which are felt by an individual, these emotions
depicted by expressions merely represent a lack of
self control on the part of the individual, and it is
important to all individuals that they learn to sup-
press many of the emotional characteristics ex-
pressed by the muscles of the face, if they hope to
avoid the acquisition of facial characteristics, which
One of the common faults acquired most often in
attempting to suppress emotion is the compressed or
thin inverted lip.
In the preliminary examination of these cases, it
is usually possible to decide whether the lip is simply
inverted or if it is unduly thin in which latter case
operations for everting the lips are of value in im-
proving the appearance of the individual, but are in-
sufficient to secure a perfect result. In these latter
cases, where the lip is actually thinned it is neces-
sary to combine the operations for everting the lips
with paraffin injections to give the lips the neces-
The plan of operation in these cases is along the
same lines as those enumerated for the correction of
the everted lip. Lines of incision are made parallel
to the direction of the lips well within the mouth,
and are converted into incisions running at right
angles to the free margin of the lips, and held thus
by sutures until healing occurs.
The first incision is made crossing the median line.
It will be found advisable to make this incision
about one-half an inch long, as a rule. The incision
is then sutured in the opposite direction and the
operator makes, if necessary, incisions upon each
side, and these are sutured in the same manner, as
the first, so that the lip is everted.
Figure 38. Illustrates the direction of incisions for slight-
ly everting the lower lip. These incisions are clo ed in a
direction at right angles to their original course.
Figure 39. lUus rates the incisions for everting the lower
lip after sutures have been applied.
Figure 40. Illustrates the direction made by the operator
in both the upper and lower lips. These incisions are closed
as in shown in Figure 39.
Figure 41. In some instances we observe an undue com-
pression and inversion of the lips about the angles of the
mouth, and in such instances the incisions within the mouth
are made so that the mucosa may be slightly everted at this
Figure 42. Illustrates the direction of the incisions after
closure for everting the mucosa at the angles.
Figure 43. Where the lips have been uniformly com-
pressed and inverted, a condition is found which requires
multiple incisions. Such are made in a direction parallel to
Figure 44. Illustrates appearance after closure of in-
cisions as made in Figure 43.
Figure 45. It is sometimes advisable to secure the ever-
sion of the lips desired by using oblique incisions rather
than those parallel to the free margins of the lips as is seen
in Figure 43.
Figure 46. Showing condition after closure of the oblique
Figure 47. Illustrating the situation of the incisions
made parallel to the direction of the lips as the first step in
the operation for everting the lips.
Figure 48. The incisions as made in Figure 47 after su-
tures are applied. Attention is called in the text to the al-
tering of the direction of the original incisions where it is
desired to modify the degree of eversion and the point of
Figure 49, Illustrating the incisions at the angle of the
mouth for everting the mucosa at this point. These incisions
may be used alone or in conjunction with others for everting
the mucosa nearer the median line.
In some cases, it is advisable to make incisions on
each side of the median incision farther within the
mouth, so that the portions of the lip near the angle
of the mouth are not unduly everted.
In many cases, the incisions everting the lips,
must be combined with the operation for raising the
angle of the mouth to overcome a downward ten-
dency of the angle.
The operation for raising the angle of the mouth
has its chief effect upon the mucosa and tends to in-
vert the lip rather than evert it. In these instances
the lips should be fully everted by properly placed
incisions, and those above near the angle of the
mouth should rather unduly evert the lip. Then the
incision made above and to the outer side of the
angle of the mouth and either perpendicular or cor-
responding to the naso-labial line will correct this
conditiin, and exercise a tendency to raise the angle.
Sometimes a foriH of advancement operation can
be performed to an advantage in this class of cases.
The operator makes an incision along the line of
juncture of the lip and gum leaving a very narrow
portion of the mucosa attached to the gum so as to
permit suturing Without carrying the needles into
the tissues of the gum. The operator has in the be-
ginning everted the lip, and it is now drawn outward
and everted, and commencing laterally the mucosa
of the lip and the margin of mucosa attached to the
gums is sutured together until the median line is
reached. The operator then begins at the other
angle and sutures as before drawing out the lip as
he does so. When he has thus sutured the tissues
with the lip drawn out there will be a strip of raw
surface which has been formed by the traction on
the lip while the sutures were applied. This is to be
approximated along the median line by a continuous
suture. The result after this operation will be a T
shaped line of sutures, one portion of the T extend-
ing along the gingivi-labial juncture and the remain-
der along the median line.
In some cases a more extensive advancement of
the lip is accomplished by making this incision as
described in the previous operation along the line of
juncture of the gum and lip and then drawing the
lip forward and outward and suturing so that an ad-
vancement of the lip occurs and a raw surface is left
to heal by granulation on the inner surface of the lip.
This latter plan is to be avoided whenever possible,
as the raw surface may require, "some time to heal
In the previous paragraphs the conditions under
consideration are those in which the lip is unduly
large as the result of a simple over-development. A
condition knoAvn as macrocheilia is sometimes seen in
which there is an increase in the number and size of
the mucous glands, the lymphatic vessels, and more
or less of a connective tissue hyperplasia. One or all
of these conditions together may result in the decided
thickening and eversion of either the upper or lower
lip or both.
These conditions are treated by the excision of
tissues present in excess, followed by an immediate
suture of the deficiency formed in the mucosa.
Where the glandular elements are much hyper-
trophied and increased in number they may be ex-
cised without difficulty, the masses of glandular tis-
sue resembling fatty tissue.
In these cases the enlargement of the lips is chief-
ly due to hypertrophy and increase in the number of
the lymphatic vessels. By excision of the excess of
tissue and suturing of the deficiency a satisfactory
condition is secured. Where the blood vessels are
much increased in size and number we have, in some
instances, a condition which is relieved only with dif-
Operations upon the Unduly Large Mouth.
In many instances, where the mouth appears un-
duly large, if a close examination of the patient is
made, the true condition noted will be an eversion of
the lips or an undue thickness of these parts. Often
the former condition is the cause of the apparent un-
Where a mouth is at all large, during the expres-
sion of various emotions the lips are everted or in-
verted or drawn into some unnatural and unbecom-
ing position much more readily than where the
mouth is small. In such a case the apparent size of
the mouth can be diminished by correcting any ever-
sion, inversion or undue thickness of the lips, and it
is not necessary to submit the patient to. a more dif-
ficult and more uncertain operation for actually di-
minishing the distance between the angles of the
An undue projection of the teeth, particularly
where the teeth are rather long or large, will give to
the mouth an appearance of undue size. This con-
dition is not only unbecoming because of the appar-
ently large size of the mouth, but whenever the pa-
tient smiles or laughs, the prominent teeth and gums
become visible, to mar the individuals' appearance.
This condition is corrected by any competent dentist,
and if the teeth are unduly prominent, the patient
should be referred to the dentist for such treatment.
The correction of any deviation in the teeth from
the normal will take considerable time, and before
the patient is referred to the dental surgeon the
operator should correct any imperfections about the
remainder of the face. Unless the appearance of the
lips be very bad, it may be well to leave the correc-
tion of eversion or inversion until after the teeth
have been drawn into their normal line, when such
correction is accomplished with more certainty .of
a perfect result.
The first operation described upon the angle of
the mouth is one which is rather difficult, and it may
require considerable practice upon the part of the
operator before he can secure with it decided results
in bringing closer together the angles of the mouth.
The operation is performed entirely within the
mouth so that no scars are left, which are visible ex-
ternally after the operation. The object of the opera-
tion is to loosen the tissues about the angle of the
mouth and then, by proper suturing, to hold them in
a position advanced toward the median line.
The operation will have a tendency to cause an
eversion of the mucosa about the angle of the mouth,
and an eversion and outward pouting of the entire
lip in some instances. These conditions are of course
to be avoided, if possible, but their development will
occur in some instances in spite of any care on the
part of the operator, in which case they are cor-
rected by appropriate operations, such as have been
or will be described.
If the operator have an assistant, the assistant
grasps the upper and lower lip on each side of the
angle of the mouth and everts the angle. The opera-
tor thus gains free access to the mucosa. A V-shaped
incision is made within the angle of the mouth. It
should lie from one-fourth to one-half an inch within
the mouth. It may vary in length according to the
degree of advancement of the angle desired. The
operator then carries the incision well through the
mucosa with scalpel or scissors. It is well to stop
and control any points which are bleeding freely.
Hemostats, ligatures or torsion may be used, as is
A not too blunt dissector is carried through the
muscular fibers surrounding the angle of the mouth
until the cellular tissue beneath the skin is reached.
It is then carried about separating the skin from the
tissues beneath. The operator while freeing the skin,
tentatively draws the angle of the mouth toward the
median line. It may be desirable to sweep the dis-
sector around so that the separation of tissues about
the angle of the mouth includes somewhat more than
a semi-circle. When the angle is loosened as much
as appears necessary for its advancement, the sur-
geon withdraws his dissector.
The angle of the mouth is held in its advanced
position, care being exercised to see that the skin is
rlrawn forward and not merely the mucosa from
within the mouth.
The angle of the mouth is held away from the
gums or is carefully everted and with a curved
needle a stitch is applied. This stitch begins on one
side of the apex of the V-shaped incision and the
needle is carried deeply so that it picks up the deep-
er layer of the skin. As it is turned again toward
the mucosa, care is taken to note that it has not been
carried sufficiently near the surface of the skin to
cause a dimple to form. The point of the needle is
caused to emerge through the mucosa on the oppo-
site side of the base of the V-shaped incision in the
This first suture is carefully tied or held to one
side and another applied in the same manner nearer
the angle of the mouth. The sutures are carried
from the mucosa to the deep layers of the skin, and
care is used to see that they include a portion of the
deeper layer of the skin, but at the same time not
too deeply so that the dimple or depression previous-
ly mentioned be not formed. The sutures must be
tied with care so that they will not cause a dimple or
cut their way through the slight amount of the deep-
er layer of the skin in their grasp, as such would al-
low the skin to slip back, leaving only the mucosa
advanced and everted as the result of the operation.
When the advancement is complete a portion of
the incision above and below the angle of the mouth
may gape. If such is the case these short intervals
are to be closed with sutures which pass through the
mucosa. The incision made through the mucosa was
of a V-shape and at the conclusion of the operation
will be of a Y-shape, though where it was very short
it may be converted into a straight line.
When the advancement of the angle of the mouth
is complete, in many of the cases we will find the
mucosa of the lips unduly everted at the angle and
this condition should be corrected, if the appearance
of the patient is to be greatly improved by the opera-
The eversion of the lips is corrected along the.
same lines outlined in the preceding chapters. In-
cisions are made within the mouth, and these altered
in direction by sutures so that the unduly conspicu-
ous mucosa is inverted. In making incisions about
the angle of the mouth care is taken that the inci-
sions below are not too long, and that the angle of
the mouth is not drawn downward, as this gives the
patient, a melancholy expression.
In some cases it is preferable to excise a small por-
tion of the mucosa within the mouth as the lips are
quite full and prominent. The excision is made ac-
cording to the judgment of the operator both as to
extent and location.
If, during the operation, a small depression de-
velops external to the angle of the mouth after this
operation, when healing is complete the undue thin-
ness about this point may be corrected by placing a
thin plate of paraffin beneath the skin.
The placing of paraffin beneath the skin in the
cheek calls for no particular skill as the drug can be
placed between the thumb and index finger grasping
the cheek, and as it is deposited by pressure it is
spread into a thin, even plate.
In placing the paraffin external to the angle of
the mouth, care is used not to carry the injection too
far externally if the individual be the possessor of a
dimple, or such may be obliterated. The patient is
caused to smile and then any dimple or tendency to
dimple formation can be noted. If the operator finds
that rather than a dimple the patient possess a line
like a crease, when smiling, this should be filled out
above or below with a view of altering it from a
crease into a more sightly dimple.
Should our undermined area beneath the skin de-
velop an infection, drainage should be instituted
through a small opening into the mouth at the lower
margin of the undermined area.
Healing almost always is uninterrupted, and prac-
tically no after treatment is required other than care
to prevent the undue use of the parts about the
mouth so that cutting of the stitches is prevented.
In some cases the operator finds the form of opera-
tion just described, inadequate, and it is preferable
to correct an abnormally large mouth by incisions
along the line of juncture of the mucosa of the lips
and skin. Such incisions are made after the parts
have been cocainized, and will vary in length accord-
ing to the degree of correction demanded. The in-
cision must be carried rather deep and with fine
chpomitized catgut sutures the angle of the mouth is
sutured, transferring the angle inward.
In order that the scar formed by the operation be
least conspicuous, the operation should be supple-
mented by the inversion of the lips. This is accom-
plished by making short incisions within the mouth
radiating from the angle and altering their direction
by sutures. The incision above should be somewhat
longer and deeper than that below, so that the angle
will be tilted slightly upward.
In some cases the result of this last operation is
further improved by depositing a drop of paraffin
above and to the outer side of the angle of the
mouth. This will cause a slight over-hanging or
rather a fullness of the parts at this point, an ap-
pearance which is entirely natural, and not the least
unsightly in a properly selected case.
After the last operation described, the incision at
the angle of the mouth may be sealed with a small
amount of collodion. After all of these operations
the patients are cautioned not to open the mouth too
widely until healing has occurred.
The surgeon must never lose sight of the import-
ant part that e version of the lips plays in increasing
the apparent size of the mouth, and he should assure
himself that correction of this condition will not be
sufiicient to overcome the apparent over-size before
any attempt is made to actually diminish the inter-
val between the angles.
Denudation at the Angle and Suturing for Undue
Size of the Mouth.
In the event of the failure of the method pre-
viously described, the operator may be forced to use
the following plan of operation, although it should
always be reserved for those cases which cannot be
corrected by other means.
Cocainize only the mucosa and skin close about
the angle of the mouth. With a very sharp scalpel
an incision is made along the line of juncture of the
skin and mucosa at the angle of the mouth. This
incision should be made as smoothly as possible and
the mucosa dissected backward.
The condition produced is more easily illustrated
than described. The upper and lower lip are de-
nuded above and below at the angle of the mouth
without removing any tissue. The extent of the de-
nudation varies according to the extent the operator
desires to diminish the size of the mouth.
In some cases it is a good plan to carry the in-
cision and dissection well within the angle of the
mouth, so that the tissues when drawn together by
the sutures prevent an appearance of undue thinness
about the angle.
When the denudation has been carried to the ex-
tent desired the operator carefully draws the de-
nuded area of the upper and lower lips together and
holds them with fine forceps while sutures are care-
fully passed approximating the denuded areas.
In some cases excellent approximaton can be se-
cured by a fine buried chromitized gut suture which
does not penetrate through the skin, while in other
cases fine silk or horse hair sutures serve to a better
purpose. In all cases the sutures must be applied so
as to secure perfect approximation of the skin mar-
gins, and at the same time the sutures must not be
drawn or tied at all tight and cause cutting of the
Approximation of the parts having been per-
fected, it is a good plan to seal the small skin wound
with collodion and place over this a strip of adhesive
plaster, which further splints these parts until heal-
ing occurs. The patient should remain indoors for
several days after this operation and to prevent in-
advertently opening the mouth too widely should
wear a bandage, which does not permit separating
the jaws. The bandage is removed for eating or
drinking and during the first day ortwo it is well
for the patient to be limited to a soft or liquid diet,
so that the chances of bringing the muscles of the
face into play unnecessarily are reduced to a mini-
When healing occurs from this first operation, as
a rule, the condition present can be improved upon
by operations directed toward rendering the scar as
inconspicuous as possible.
If the operator will place within the mouth in-
cisions radiating from the angle of the mouth, and
alter the direction of these incisions by sutures, there
will be a tendency to invert the angle of the mouth,
and any scar along the line of suture will be ren-
dered less noticeable.
In some cases the condition of the angle of the
mouth can be improved by depositing a small
amount of paraffin above the slight line-like scar,
which is left and above the angle of the mouth, so
that the upper lip and the tissues above the angle at
the site of the operation are slightly more prominent
than those below. This condition is not unnatural,
if not present to too great an extent, and when pro-
duced after the operation upon the angle of the
mouth previously described, tends to throw the
slight scar left by the operation into shadow and
render it much less noticeable.
MARGINAL TATTOOING AS A MEANS OF ADD-
ING TO THE APPARENT WIDTH
OF THE LIPS.
Tattooing is to have a definite place among the
recognized operations of the f eatural surgeons of the
future. Tattooing is something with which we are
all acquainted. We have seen the effects of the prac-
tice for the purpose of adornment, and while we
have questioned the taste of those who have pre-
viously submitted to this procedure, when performed
so that it is indistinguishable from the natural I
think it will satisfy the most esthetic, and as its ef-
fects are permanent and unchangeable, these effects
are likely to remain satisfactory.
Tattooing about the margin of the lips to overcome
the appearance of undue thinness of the lips requires
a good deal of delicacy on the part of the surgeon to
secure a tinting which will be a shade between the
normal redness of the lips and the natural color of
the skin. The surgeon should not attempt to match
the natural carmine red of the lips when he tattoos,
but should secure an effect somewhat lighter than
that of the lip so that should the patient become
anemic at some future time the red line will not show
The matter of shading is merely a matter of care,
and in the first few cases the surgeon should re-
member that it is easier to repeat the operation and
increase the amount of pigment rather than decrease
it. The placing of pigment is a matter of no diffi-
The skin is punctured or picked open with a
needle. The puncturing does not extend through the
skin, but merely into the true skin. After the punc-
tures have been made the coloring is rubbed in with
the point of the needle or with a slightly flattened
spud. Some reaction may be expected to follow the
operation, but healing is complete in a few days.
Where the lips are much inverted and show a con-
siderable degree of inversion as the result of the hab-
itual compression of the labial muscles it is well to
evert the labial mucosa by plastic operations within
the mouth and division of the orbiculars oris at the
angle of the mouth is usually advisable as well.
THE ERADICATION OF THE NASOLABIAL
The nasolabial line is seen quite frequently in
comparatively young women. It is an expression
line which changes the appearances of the entire
lower face and may well engage the attention of the
A few years ago attempts were made to eradicate
this line by filling along the fold with paraffin, but
this is not an entirely satisfactory operation — in
fact, it is almost invariably a failure. Simple filling
of the tissues along the bottom of the crease seldom
produces even a temporary eradication, but the suc-
cessful depositing of a thin plate under the tissues
of the skin for a considerable distance on either side
of the line may so stiffen them as to overcome it, but
this is accomplished with difficulty, as paraffin tends
to lump in these soft tissues and does not spread ac-
curately, and we have not the means here to influ-
ence it as we have in other parts where it is more
accessible Paraffin protected by bulky soft parts
cannot be molded accurately.
Nasolabial lines are due in large part to the exces-
sive action of the muscles external to and above the
nasolabial line, and a subcutaneous section made ex-
ternal to this line and parallel to it will divide more
or less perfectly these fibers. Sucessful division of
these fibers diminishing their action will remove to
a degree the cause of these lines; then eradication
may be aided somewhat by a plastic operation within
the mouth, and a condition of the parts may be at-
tained which will predispose toward the complete
disappearance of the lines if they have not become
too deeply marked.
To accomplish the subcutaneous section of the
fibers the sectioning knife may be entered at several
points. This knife should have a very narrow blade,
and in the absence of a better instrument the Graefe
cataract knife may be used.
Entered externally the knife makes so small a
wound that the scar should not be noticeable subse-
quently, but should the operator care to take the
very slight chances of an infection and subsequent
inflammatory action the fibers may be divided
through an incision made within the mouth. The
division when made from within is not accomplished
with the same degree of accuracy as when the knife
is entered through the skin, as it is possible from this
latter entering point to carry the blade along be-
neath the muscular fibers and then to divide these
fibers in a line directly parallel to the nasolabial line.
When the knife is carried through the tissues from
within the division must be made with its point, and
this interferes with accuracy and thoroughness.
When the section is made through a puncture in the
skin the knife should be entered at what I may term
the dimple point — that is, the point where a dimple
develops or should develop when the patient smiles.
The knife is carried along parallel to the nasolabial
line and should pass in deeply, so that it approaches
very close to the mucosa. Section is accomplished
by a sawing motion, and the edge of the knife, not
the point, should accomplish the division. When the
edge approaches close to the skin it is withdrawn
and pressure applied externally to control subcu-
taneous bleeding. The puncture in the skin is sealed
with a drop of collodion.
The sectioning is repeated on both sides, and then
the lip is turned upward by an assistant, and after
infiltration the mucosa is incised in a semilunar di-
rection. The convexity may be in either direction,
the section beginning beneath the alae nasi and ex-
tending downward for about three-quarters of an
inch so that it terminates about one-eighth of an
inch above the angle of the mouth. This interval in
the mucosa is deepened by as blunt a dissection as
possible, so that as few of the blood-vessels as pos-
sible are divided. The angles of the semilunar in-
cision are brought together so that the tissues are
bunched under the nasolabial line.
It is a simple matter to make the incision with
the convexity downward, but the operator must re-
member when the incision is so made that the com-
pletion of the operation may alter the appearance of
the lips to a disadvantage. If this is likely to occur
he should elect the opposite course, although it will be
somewhat more difficult to close the incision when
made high up unless the surgeon has at hand an as-
sistant capable of retracting the lip for him satis-
The operator may find it more convenient to do
the plastic operation within the mouth first and sec-
tion the fibers external to the nasolabial line subse-
quently. This is a matter of election.
Where the lips are inverted multiple incisions
may be made as in figure 59 — and these closed in a
direction opposite their original course as in fig-
The overhanging of the lower lip which closely
resembles an e version may be overcome by making
incisions at right angles to the lip as is illustrated
in figure 61. These incisions when closed as illus-
trated in figures 62 and 63, cause a shortening and
inversion of the lip. A crescent may be removed
from the mucosa as illustrated in figure 64, and
closed as illustrated in figure 65.
HARDNESS OF MOUTH EXPRESSION.
One of the most common alterations of the ap-
pearance of the mouth with advancing years is the
development of a certain hardness of expression.
This is due to a slight general contraction of the
facial muscles about the mouth. The lips are more
or less compressed and the person, by indifference
to this compression and mimicry of those about, des-
troys the youthful bow-lines which might otherwise
remain for many years.
Many people not only slightly compress all the
muscles about the mouth but also contract certain
groups more than others. We have a group of mus-
cles which advance the lip in the median line below.
These muscles are brought into action particular-
ly where there is a feeling of more or less despon-
dency. The advancement of the lower lip in the
median line is accompanied by a slight contraction
of the orbicularis oris muscle surrounding the mouth
and the muscles of the angle, so that the corners of
the mouth turn downward. This downward turning
of the angles gives, of course, in extreme cases the
appearance of sadness, but we see it in people of
middle life and do not associate it thus, for the cor-
ners have been drawn down gradually and have re-
mained so long in this position that, whether they
be glad or sad, the angles are deflected.
Women dread the development of this condition
of the oral angles and frequently consult for relief
after the habit of muscular contraction has become
fixed and the muscles have been so long contracted
that simple training cannot overcome the condition.
In young women I am in the habit of insisting that
they watch themselves and prevent this habitual
overuse of the muscles about the mouth, and I also
have them practice before a mirror exercising the
elevators of the angle of the mouth. It is remark-
able what control some acquire over these muscles
by such exercises.
Subcutaneous section of the muscles of the lips
which are used to excess, I have practiced and be-
lieve it has been of distinct value in the treatment
of these cases.
Sectioning of the muscles of the face with a view
of diminishing their action is a logical means of
treatment, for we know quite well that the paralyzed
side of the face loses its expression line. By section
of the muscles of the face we cannot hope to over-
come their action entirely, for these muscles are too
intimately connected with the skin to obliterate their
action by section unless we should cut off their nerve
supply. Of course we do not desire to paralyze both
facial nerves, for that would be carrying featural
surgery to an extreme which we could in no way
The section of the muscles of the lower lip, or
those muscles which elevate the lower lip in the me-
dian line, produces but a slight effect upon them.
Their action is not destroyed, merely diminished,
and as the operation is easily performed, I recom-
mend it for improving the appearance of the mouth
which has been marred by compression and down-
turning of the angles. With the section of these
muscles of the lower lip a section of the orbicularis
at each oral angle is advisable.
These operations are performed siibcutaneously
through punctures made within the mouth. The
narrow blade of a cataract knife may be entered
within the angle of the mouth. It should be carried
directly outward until it is beyond the bundle of
muscular fibers which may be felt with the index
finger and the thumb of the operator and then these
fibers are carefully severed. The procedure is re-
peated upon the opposite side.
If the subject contracts the muscles it will assist
the surgeon slightly, otherwise he should pick them
up between the index finger and the thumb. The
knife is made to traverse a fan-shaped area through
the tissues of the chin, and if the operator has judged
correctly, division of the muscles should be accom-
plished. Of course an absolutely complete section of
these muscles may not be secured by this operation,
but in my own experience it has apparently been of
decided value in overcoming the faulty overaction
of these muscles and is of undoubted cosmetic value.
TATTOOING ANL THE ELECTRIC NEEDLE FOR
IMPROVING THE APPEARANCE
OF THE BROW.
The eyebrows may add greatly to the personal
appearance when pleasing in outline, shading and
extent. The eyebrows are seldom so perfect in their
natural state that the featural surgeon who is skill-
full, cannot improve them by his art. No matter
how carefully the brows may be trained and cared
for, a few stray hairs may be removed to advantage
in many cases, while in other instances the shading
of the brow may be augmented or modified by judi-
Many individuals have a distinct connection of
the brows in the median line. The connecting hairs
may be removed to advantage. In other cases we
have stray hairs projecting directly upward at the
inner angle of the brow, and no amount of combing
or brushing will cause these hairs to lay smoothly,
so that they can be sacrificed to advantage. Above
the brows stray hairs may be seen in other individ-
uals and their removal will add to the appearance.
The use of the electric needle for the removal of
hair is simple enough and the physician who has a
galvanic battery of any sort can do this work. The
galvanic current has an electrolytic effect upon the
tissues and in the removal of superflous hair the
negative pole of the battery is attached to the needle.
The circuit is completed by a sponge electrode
held in the hand of the patient. The action of the
current is to produce an alkali caustic at the point
of entrance of the needle into the tissues and about
the needle as it lies in the tissues or in the hair fol-
licle. This alkaline caustic has a destructive effect
upon tissue and where the needle has been properly
inserted into the hair follicle the caustic destroys
the hair bulb and prevents the return of the hair.
The action of the caustic produced depends upon the
amount of current and upon the length of time that
the needle is allowed to remain in contact with the
tissues. The amount of current must be limited by
the degree of discomfort which it produces, the cur-
rent being used as strong as the patient cares to
stand. The current should be continued through the
needle until the hair is softened to that degree that
it may be pulled out without causing a distinct
twinge. The length of time required in the removal
of the first few hairs should be noted and this should
not be exceeded in the removal of the remainder of
the hairs. With the ordinary dry cells from two to
five niay be used and the length of time required
will vary from ten to thirty seconds as a rule. Care
should be used in too freely applying the needle as
the caustic action of the current may be such that
a distinct pitting of the tissues remains after opera-
The needle used for electrolysis should be ex-
tremely fine and it is well for it to have a bulbous
tip. The needle should be passed along the side of
the hair until the slight resistance at the bottom of
the follicle is felt. During the passage of the needle
the circuit may be broken by the removal of the
sponge electrode from contact with the body of the
Tattooing the brows is accomplished with ease and
as the results desired are usually intended to be dis-
tinct no great degree of care is needed in this work.
The tattooing for darkening the brows is performed
after the brows have been thoroughly scrubbed and
the skin mopped with alcohol. The hairs are parted
and the skin pricked with a sharp needle. The prick-
ing should not extend into the skin far enough to
cause bleeding. The tattooing may be at a single por-
tion of the brow or the entire base of the brow may
be scarified with the needle before the pigment is
A special instrument may be secured for tattooing.
This instrument works very rapidly and the pigment
is driven into the skin as the punctures are made.
The Scarred Brow.
A scar involving the brow may show very plainly
as the result of contrast and tattooing cleverly per-
formed may secure a tinting of the scar identical to.
that of the brow. Proper tinting of a scar coupled
with the removal of all distorted hair may render a
THE DOUBLE CHIN.
The double chin is a source of much distress to its
possessor Certain advertisers are performing an
operation which I must condemn. They make an
incision just anterior to the ear and extending down-
ward on to the neck. Through this incision a quan-
tity of tissue is removed and then an attempt is made
to secure healing with but slight scarring. Owing to
the position of the incision and tension, considerable
scarring is common and renders the operation ob-
jectionable. I have been operating within the mouth
excising the tissues as well as possible and suturing
so as to draw the tissues upward as much as possible,
but so far my experience has been such that I hesi-
tate to recommend it for general adoption. In time
I hope to be able to overcome certain technical diffi-
culties so that I may be able to recommend the opera-
Skin grafting may improve a condition which is
undesirable, but the chances of such improvement
are slight except in very irregular scars. One can-
not expect to graft and have an entirely smooth and
natural appearing skin at the site of the deposited
OUTSTANDING ALAE NASI.
In some instances the alae nasi are wide apart and
the individual's appearance is marred by this single
defect. To correct such outstanding the cartilaginious
tissues may be sectioned at a number of points as is
illustrated in fi^re 67, and in other instances a
wedge of 'tissue may be removed from each nasal
The first step in the removal of the wedge is illus-
trated in figure 68, and the concluding steps in figure
69. Figure 70 illustrates the condition at the con-
clusion of the operation when the wedge shaped in-
terval has been closed by sutures.
THE FORMATION OF THE DIMPLE.
It is my practice in these cases to thoroughly
scrub the cheek, and then after having the patient
smile, select the point where a dimple should form
under ordinary circumstances. This point may be
found if the patient is caused to elevate and draw
outward the angle of the mouth I mark this point,
and insert my hypodermic needle. With the hypo-
dermic, the tissues should be infiltrated for a radius
of about one-half inch. For this purpose about one-
half drachm of a one-fourth of one per cent solution
of cocain is used.
A very narrow-bladed scalpel is passed through
the tissues, the line of the puncture being parallel to
the long axis of the face. This puncture is only
about one-tenth of an inch in length, and should not
exceed under any circumstances one-eighth ot aii
The point of the knife is carried into the cellular
and fatty tissue of the cheek, and then these tissues
are drawn up with a very small hook and snipped
off. The amount of tissue excised is hard to describe,
as, to a certain extent, this is a matter of judgment.
The snipping away of the tissues beneath the skin
should be followed by the out-turning of the skin
and the cutting away of a certain amount of the
deeper layers of the true skin, so that the tissues will
dimple after healing occurs.
No suture is passed in the simplest operation. The
opening is covered with a very small piece of cotton,
and sealed with collodion. A slight dimple will be
left when healing is complete, and if this is properly
situated when the patient laughs or smiles, it will
deepen naturally, and the patient has, to all appear-
ances, a normal dimple.
. Where no tendency whatever exists for the tis-
sues to dimple, the operation described may be in-
sufficient, and it may be necessary to turn the skin
in somewhat by a suture. This suture should invert
the margin of the skin, so that a dimple may be
formed which exists whether the individual be smil-
ing or not. The disadvantage of forming a dimple
which may be present at all times lies in the fact that
dimples of the cheek ordinarily show only when the
individual laughs or smiles.
This is an operation described in detail in the
various works upon diseases of the eye. It is an
operation which will add to the appearance of many
women by causing a widening of the palpebral in-
terval. Where the disposition for ** Crow's feet" to
form is pronounced this operation may be coupled
with subcutaneous section of the orbicularis palpe-
Subcutaneous Section of the Orbicularis
This operation may be performed with a very
narrow bladed knife, the sectioning being in a direc-
tion downward and outward or upward and outward
from the external canthus.
When the eye protudes unduly the margins of
the lids at the external canthus. may be denuded and
the parts sutured so as to narrow the palpebral in-
terval. Sutures should be carried into the fibrous
plates of the lid and should be reinforced for a day
or two by a strip of adhesive plaster.
In the surgical treatment of the scowl when lines
have developed between the brows these may be
eradicated by the deposit of paraffin beneath the
skin if the interval at this point is low. Should the
interval between the brows be prominent the corru-
gator muscles lying beneath the inner one-third of
the brow may be sectioned subcutaneously.
Figure 1. Outstanding (
FIGURE 2 FIGURE 3
Figures 2 and 3. Cartilages of the ear and tbcir nnrnial
relation to the e
Figure 4. Illustrating the operation of exposing and t
moving a segment of cartilage.
Figure 5. Manner of applying strip to hold e
against aide of liead during healing process.
FiaURE 6 PIGUEE 7
Figure 6. IllustiBitiiig lines of escisioo to be followed iu
Bome instances. The excision should be made so that the
Bubaeqneut scars He along the natural deproasions of the ear.
Figure 7. A long narrow crescent excision ma; be used
in many instances to a greater advantage than the broad
crescent outlined in Figure 6.
FIGURE 8 PIGUBE 9
Figure S. Excision of triangular section in reducing the
ezeessivel; large ear.
Figure 9. Operation completed.
Figures 10, 11, 12. Excision from behind. In this opera-
tion the skin anteriorly is in no wise disturbed. The tissues
excised including only the skin posteriorly and the cartilage
of the ear. This operation is preferable to others as no
visible scar is left.
Fignre 13. IlluHtratiDg lines of inciaic
eonBtnicting an ear from tbe soft parts.
Figure 14 illustrates (he tondpncy of the imperfect aiiriele
to curl. This organ can be made to appear quite sightly by
section of the cartilages and denudation and partial attach-
ment of the organ posteriorly, so that it docs not project
more than thirty degrees from the side of the c
Figure 15. The result of iincurling the cartilage, and
spreading it along the side of the head can be seen by the
appearance of the auricle as held by the finger, the illustra-
tion being of the same case aa shown in Figure 4. Section
of the cartilage above permits of upward uncurling.
Figures 16, 17, 18 illustrate the various charaeteristlca
tea in othematoma.
FIGURE 19 FIGURE 20
Figure 19. The lobule of exceaaive aize or length. This
condition ahould be corrected by inciaiona made poatoriorly.
Figure 20. Direction of inciaion for ahortening lobule.
If any exceaa of tisaue la removed through the incision, then
it ia cloaed io a direction at a right angle to ita course.
FIGURE SI riGUBE 22
Kgure 21. Operntion completed for shortening the lobule.
Figure 22. Direction of incision for lengthening lobule.
Operation completed for lengthening lobule.
Figures 24, 25 and 26. Laceration of lobule 8
tearing ont of ear ring.
FIGURE 27 nOUBE 28
Figure 27. Lobule restored.
Figure 38. Where lobule ia closely attached along its in-
ner margin to the aide of the bead the first step in the opera-
tion includes the separation of the lobule at its attachment.
The skin is sectioned so that a narrow strip maj be carried
upward along the inner margin of the severed lobule.
Figure 29. Illustration the formation of a skin flap in
the operation for separation of the attached lobule.
Figures 30 Hnd 31. Concluding step in the operation for
separating the attaeliod lobule.
Figure 32. Illustrates the line of incision in the opera-
tion below the eye. The crescent of akin is entirely re-
moved. The aize of the crescent varies according to the
amount of bagging, folding or wrinkling of the skin. Above
the eye the area of skin removed varies in shape, the opera-
tor simply picking up and cutting away the excess.
Figure 33. lllustratea operation for lowering the tip-
tilted noae. E, marks profile of nose, D, the line of the
cartilaginous septum, a, b, marks the inciaion beneatb the
tip for freeing same. Points marked c. c, mark an entrance
for sutures to hold tip in lowered position.
II I » M
Figure 50. Illustrates the two plans of closing the parts
after the operation for advancing the angle of the mouth.
Figure 52. In some cases there is a pouting of the mu-
cosa above and below the angle of the mouth after the ad-
vancement, and in these cases it may be desirable to make
incisions above and below the angle and close them as is
luustrated in Figure 2.
Figure 52. Illustrates the position and shape of the
paraffin plate injected at this point to overcome the un-
natural drawn appearance caused by some of the operations
for inverting the mucosa of the lips at this point.
Figure Sit. lllustiatca the manner of everting the angle
while performing tbe subcutaneous operation for advancing
tho angle. If tbe operation is performed without assistance
this manner of everting the lips is not used.
Figure 54. Illustrates the lines o
mouth, the dotted line marking the ar
Figure 55. Illustrate the unduly full lips due
rather than to a thickueBs of these parts. It will also be
noted that the mouth is somewhat large, a condition fre-
quently noted in conjunction with the everted lipa. Inver-
sion here is sufficient c
id. These iu-
at completion of ad-
Figure 58. Shows subsidary
ciaions above and below are to
which condition is noted in a few
Figure 57. Illustrating line of subcutaneous section of
facial muscles external to the nasolabial line. The knife is
more conveniently entered from below.
Figure 58. Illustrating the mucous membr&ne iocisioA
beneath the uasolabial line. AA are to be brought as eloBelj
together as poBBible, bunching the tissues under the naso-
labial line and elevating tbe depressed angle of the mouth.
SUBCUTANEOUS SECTION OF MUSCLES
—At Angles of Mouth B— Of the Chin Musclca
Figure 71. Illastrating location of incision for formation
of dimple, dotted circle representing area of infiltration.
Figue 72. Illustrating the dissection beneath the skin ia
the operation for formation of the dimple and the manner
of passing suture to invert the skin.
. FIGURE 73
Figure 73. Illustrating operation for formation of dimple
after the suture has been tied.
Prevention of outstanding ears 5
Anatomy of the external ear 6
Operations for correcting outstanding ears 8
Free excision of skin • 9
Excessively large ears 12
Excision of a Crescent 14
Operation of Election 15
Reconstruction of the ear 19
Othematoma or Hematoma 21
Sebaceous Cysts of the external ear 24
Fibrous Tumors and Keloid mi the external ear 26
Repair of Clefts and Fissures of the external ear 27
Reduction of the size of I/obule 29
Adherent and undeveloped Lobule 31
Amputation of Auricle 35
Wounds of the Auricle 35
I/Upus Vulgaris of the Auricle 38
Folds, bags and wrinkles of the skin about the eyes 40
Excision of fold above the eye 41
Reduction of Hump nose 43
Tip tilted nose 47
Nose with the bulbous tip 50