I
OXFORD MEDICAL PUBLICATIONS
With the Compliments of the
Joint War Committee of the 'British
T^d Cross Society gf the Order of
St. John of Jerusalem in England
83 Vail Mall, London, S.ff.t.
PLASTIC SURGERY OF THE FACE
PUBLISHED BY THE JOINT COMMITTEE OF
HENRY FROWDE, HODDER AND STOUGHTON
17 WARWICK SQUARE, LONDON, E.C-4
PLASTIC SURGERY OF THE FACE
BASED ON SELECTED CASES OF
WAR INJURIES OF THE FACE
INCLUDING BURNS
WITH ORIGINAL ILLUSTRATIONS
«Y
H. D. GILLIES, C.B.E., F.R.G.S.
MAJOR R.A.M.G.
SURGICAL SPECIALIST TO THE QUEEN'S HOSPITAL, S1DCUP
SURGEON IN CHARGE OK THE DEPARTMENT FOR PLASTIC SURGERY, AND LATE SURGEON IN CHARGE
OF THE EAR, NOSE, AND THROAT DEPARTMENT, PRINCE OF WALEs's HOSPITAL, TOTTENHAM
I.ATE CHIEF CLINICAL ASSISTANT, THROAT DEPARTMENT, ST. BARTHOLOMEW'S HOSPITAL
HON. FELLOW NATIONAL DENTAL SOCIETY OF AMERICA
WITH CHAPTER ON
THE PROSTHETIC PROBLEMS OF PLASTIC SURGERY
BY
GAPT. W. KELSEY FRY, M.C., R.A.M.C.
SENIOR DENTAL SURGEON, QUEEN'S HOSPITAL, SIDCCP ; SENIOR DEMONSTRATOR AND DENTAL OFFICER IN CHARGE OF THE 1'KOSTHETIC AND METALLURGICAL DEPARTMENT, GUY'S HOSPITAL
AND
REMARKS ON ANESTHESIA
BY
CAPT. R. WADE, R.A.M.C.
LATE SENIOR ANAESTHETIST, QUEEN'S HOSPITAL ; ASSISTANT ANAESTHETIST, ST. BARTHOLOMEW'S HOSPITAL ; ANAESTHETIST, GREAT NORTHERN CENTRAL HOSPITAL
LONDON HENRY FllOWDE HODDER AND STOUGHTON
OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.C.
1920
PRINTED IX OREAT BRITAIN
nv HA7.ru., WATSON AND TINEY, LT>.,
LONDON AND AYLESIH'HY'.
DEDICATED I!Y SPECIAL PERMISSION TO
HER MAJESTY QUEEN MARY
WHOSE NEVER-FAILING INTEREST AND BENEFICENT INFLUENCE HAVE BEEN A PERPETUAL SOURCE OF HELP AND ENCOURAGEMENT TO PATIENT, DOCTOR, AND NURSE
INTRODUCTION
I HAVE had the pleasure of watching Major Gillies's plastic work since its initiation at the Cambridge Hospital at Aldershot, and later at the Queen's Hospital at Sidcup, where he and his British colleagues competed so cordially and so successfully with the surgeons from the Dominions in their efforts to restore the disfigured faces of the wounded to their normal form.
It was largely due to him that such rapid progress was effected in this special and difficult form of surgery, of which little or nothing was known before the war. Methods were employed and scrapped with great rapidity as im- provements were devised.
It would be difficult to exaggerate the excellence of the work that was done by the several surgeons. Advantage was taken of it by many Americans and others, who profited greatly from observing the methods of treatment that had been developed there.
This book, which is so handsomely illustrated, gives a very thorough account of the many novel procedures which have been devised or elaborated at the Queen's Hospital. It will afford an excellent basis for much civil work, and I trust that special departments for plastic surgery will be started at the several teaching hospitals, and that means will be taken to secure the services of those surgeons who have had such wonderful opportunities to perfect themselves in this special work. It is not sufficiently recognised how readily the skill de- veloped in this branch of war surgery is directly applicable to the relief of dis- figurements met with in civil life. Ugly scars resulting from burns and accidents, deformities of the nose and lips, hare lip and cleft palate, abnormal protrusion or ill development of the mandible, moles, port- wine stains, all abound, and are not only the constant source of the greatest distress and anguish, but materially lower the market value of the individual. There is also a vast field in the oblitera- tion of marks of operative interference, such as removal of malignant growths.
This book, written by so skilled and experienced an operator as Major Gillies, is invaluable to every general surgeon as well as to the plastic specialist.
I would also like to congratulate the publishers on the excellent manner in which they have produced this volume.
W. ARBUTHNOT LANE.
September 1919.
vii
PEEFACE
PLASTIC Surgery of the Face is not a new development. Surgeons of all civilised and some uncivilised countries have from time to time evolved methods of repair for various disfigurements.
But not until the organisation of the new home Medical Service necessitated by the late war, with the need for refinement in the matter of segregation of cases in special hospitals so ably met by Lieut.-General Sir Alfred Keogh, our late Director-General, has there been opportunity for anything but disjointed study in this department of surgery.
In the later development of the work, the continuity of research was main- tained by facilities afforded by his successor, Sir John Goodwin, for the retention of the specially trained staff, in spite of the difficulties caused by the growing shortage of medical officers.
The author wishes to place on record his thanks to Major-Generals Sir Anthony Bowlby and Sir George Makins, and Sir Frank Colyer, who, in their capacity as consultants, laid before the Director-General the importance of organising means for the intensive study of this special branch of reparative surgery.
The work on which this book is founded began in January 1916, at the Cambridge Hospital, Aldershot, where, under the stimulus and able direction of Colonel Sir W. Arbuthnot Lane, the treatment of war injuries of the face and jaw was studied under suitable conditions in wards earmarked for the purpose.
The author had the advantage there of co-operating with Captain L. A. B. King, L.D.S., attached R.A.M.C., whose help as Chief Dental Surgeon through that stern period of doubt, trial, and error was invaluable. The influence of his work is still evident in our treatment of jaw injuries to-day.
A rapid increase in the scope of the work led to the removal of the hospital to Sidcup, where, thanks to the sympathy and energy of Colonel Sir William Arbuthnot Lane, Lieut. -Colonel J. 11. Colvin, and Major Waldron, C.A.M-C.,
Plastic Surgery of the Face by H.D. Gillies, Oxford, University Press, 1920.
x PREFACE
it was placed on an Imperial basis. The collection of the cases of facial injuries from the British, Canadian, Australian, and New Zealand forces in one hospital under their own medical officers has proved a factor of prime importance in the improvement of methods of treatment.
Major Waldron and Captain Risdon (Canadian Section), Colonel Xewland, D.S.O. (Australian Section), and Major Pickeril, O.B.E. (New Zealand Section), and the officers serving with them, joined heartily in friendly rivalry and healthy competition, to the great benefit of these poor mutiles.
Further, with the arrival of American surgeons in 1918 under Colonel Vilray P. Blair, M.R.C.U.S.A., our wounded had call upon surgical, skill from the whole Anglo-Saxon race. Each surgeon had the assistance of one or more colleagues from the New World, to their mutual advantage.
NYcdless to say, the author realises his indebtedness to the numerous visiting and consulting surgeons who from time to time have encouraged him by their advice.
The knowledge of their interest and good-will has been a most powerful stimulus towards perseverance in times when difficulties appeared insurmount- able. He wishes particularly to thank Sir W. Arbuthnot Lane, Sir Francis Farmer, and Sir Frank Colyer, among consultants ; and, among his British colleagues, Major G. C. Chubb, Captains C. F. Rumsey, the late E. G. Robertson, F. E. Sprawson, J. L. Aymard, R. Montgomery, H. C. Malleson, and A. L. Fraser in the earlier part of the work, and later Captain T. P. Kilner, T. Jackson, and Majors H. Bedford Russell and J. J. M. Shaw, M.C.
In particular, the stimulus of co-operation with Major Seccombe Hett has considerably advanced the treatment of injuries to the nose ; while the pioneer work of Captain King on the jaw has been maintained and further developed by Captain W. Kelsey Fry, M.C., R.A.M.C., Chief Dental Surgeon, who has written a chapter on the use of Prostheses in this work. In this connection the work of Valadier and Kasanjian in France has been of great service in the improvement of the treatment of jaw wounds. I am indebted to the former for many photographs of the original conditions, and to both for the stimula- tion of their work and for much kindly encouragement.
Among many American colleagues Captain Ferris Smith has shown himself the most constructive critic the author has had the pleasure of knowing. He was of great assistance in the preparation of the early proofs of this work.
Not a small feature in the development of this work is the compila- tion of case records. The foundation of the graphic method of recording these cases lies to the credit of Professor H. Tonks (Slade Professor), many of whose diagrams and photographs of his remarkable pastel drawings adorn these pages.
PREFACE xi
Unfortunately, his other duties forbade his taking as large a part in the work as he and we ourselves could have wished. Latterly, his work has been ably carried on by Mr. Sidney Hornswick, who, on his own initiative, has considerably improved and standardised methods of recording flap operations.
The compilation of notes in the early part of our work was carried on voluntarily by Mr. Thomas Pope. The author cannot sufficiently thank him for the sterling value of his work and the loyalty with which he persevered at his self-appointed task through two full and difficult years.
Lieutenant J. Edwards has not only been responsible for the preparation of routine plaster-cast records, but for a very important part of our work, the reconstruction of features on the casts as a preliminary to surgical reconstruction.
Herein, guided by the surgeon in the matter of surgical possibilities, he strives, sometimes for the ideal, more often for the best possible surgical com- promise ; and his work calls for constructive imagination of a very high order. Where chances of surgical repair are not evident he co-operates with Captain Fry in the provision of as perfect a mechanical restoration as possible.
In the X-ray Department Captain H. Mulrea Johnston has displayed great ingenuity and resource in evolving standard positions for radiographic records, particularly of jaw injuries. Latterly, his place has been ably taken by Captain R. A. C. Rigby.
The majority of the photographic figures in the book have been prepared by Mr. Sidney Walbridge. Their excellence speaks for itself, but gives no idea of the time and care this late N.C.O. has devoted to ensuring that they shall be an honest and true record. He has had to suborn his art to this end, sternly suppressing the temptation to manipulate the lighting or retouch the negatives.
The work of correcting later proofs has been kindly undertaken by my colleague, Mr. H. Bedford Russell. The heavy secretarial work has been chiefly performed by the author's patients (for the most part E. J. Greenaway ; partly also R. W. D. Seymour), who have stuck to their task with persistent, cheerful loyalty, in the intervals between their operations.
The author takes this opportunity of thanking his publishers for their oft- tried leniency in regard to delays in the production of " copy." In extenuation, he would plead a strong penchant for laying aside the pen in favour of the scalpel whenever a plastic problem presented itself.
Above all, the author cannot adequately express what he owes to the loyal co-operation and assistance of the medical officers — surgeons, physicians, and
xii PREFACE
ana-sthetists alike — and the Matron, and the theatre- and ward-nursing staffs of this hospital, whose shoulders have borne the brunt of the work. Assiduous and intelligent care in the after-treatment of these eases is a prime necessity, and calls for the highest standard of watchful skill.
Finally, the author wishes to thank Lieut. -Colonel J. R. Colvin, Com- mandant of the Queen's Hospital, for his unfailing help and fairness of treatment throughout two long years. His powers of organisation and ready grasp of the situation have alone rendered possible the continuity of the work in times of stress.
H. D. G.
February 1920.
CONTENTS
CHAPTER I
PAGE
PRINCIPLES : HISTORICAL ......... 3
CHAPTER II
REPAIR OF THE CHEEK . . . . . . . . .37
CHAPTER III
INJURIES OF THE UPPER LIP ........ 77
CHAPTER IV
INJURIES OF THE LOWER LIP AND CHIN ...... 123
CHAPTER V
PROSTHETIC APPLIANCES IN RELATION TO PLASTIC SURGERY . . 193
CHAPTER VI
INJURIES OF THE NOSE ....... .211
CHAPTER VII
INJURIES IN THE REGION OF THE EYES, INCLUDING BURNS OF THE FACE 300 INJURIES TO THE PINNA ......... 381
CHAPTER VIII
PLASTIC SURGERY IN CIVIL CASES 391
INDEX 401
PRINCIPLES
CHAPTER I HISTORICAL
THE origin of plastic surgery is of the greatest antiquity. From time i mmemorial rhinoplasty has been performed in India for the relief of the dis- figurement caused by punitive mutilation of the nose. Two methods appear to have been employed, though the forehead-flap is the only one the use of which has survived in India to this day.
A method embodying the use of cheek-flaps is described in the Ayurveda, the sacred medical record of the Hindoos, but it has had to yield to the forehead- flap method — a striking parallel to what has occurred in Europe in the last few centuries. The French (or German) cheek-flap method has been relegated to the lumber-room of surgery, and a development of the Indian method, which includes the important improvements evolved by Keegan and Smith, has pride of place Jx^djiy.
In perusing the literature of this subject, one is struck chiefly with the lack of appreciation of the need for a lining membrane for all mucous-lined cavities. Not until Keegan's time was it given any prominence, and perhaps even he did not appraise it at its true value. And so it is that the various classical methods take their name from the covering flap employed. In actual fact, except that forehead skin most closely resembles nose skin, the origin of the covering is the least important part.
The Italian method, which originated apparently in Sicily about 1415 and was developed by Tagliacozzi in Italy forty years later, consists in the transference of skin for a nose-covering from the patient's own arm, in two stages, the patient being immured in a fixation apparatus while the flap takes. This method was feasible in those stern times, but the more than irksome fixation is not tolerated by the modern patient, and it has been discarded. The principle on which it is based, however, is of wide application, and a modification of it, the author's tube-pedicle method, is in routine use for some of our operations.
As in rhinoplasty, so in the rest of present-day plastic work, the principles laid down by the fathers of surgery are found still to be of general application. There is hardly an operation — hardly a single flap— in use to-day that has not been suggested a hundred years ago. But our work is original in that all
4 PLASTIC SURGERY
of it has had to be built up again de novo. It does not fall to the lot of every surgeon to see even one chciloplasty in his training.
The earlier months, then, were spent in a very thorough trial of the then known methods. It has been illuminating to discover the impracticability of many of these, which would appear to have been put forward on the study of one case only, or even on purely theoretical grounds. Among the sponsors of really practicable methods the names of Tagliacozzi, Nelaton, Keegan, and Smith stand out prominently.
PRINCIPLES
It is the author's aim here to discuss principles in the order of their ap- plication in a given case. They will thus be dealt with, in the following order :
HISTORY, ETC. ANESTHESIA.
EXAMINATION. OPERATION. EARLY TREATMENT. General Technique.
PLANNING THE REPAIR. Stages.
1. Lining Membrane. Suture.
2. Contour and Supports. Dressings.
3. Covering Tissues. After Treatment.
HISTORY, ETC.
The history of the injury is obtained, together with any existing record of the early condition, and if possible of the condition prior to injury. It is of importance also to obtain information as to the presence of luctic or tuber- cular taint, and as to the patient's healing powers as shown in former operations.
EXAMINATION
The majority of failures in plastic surgery are due to errors the commission of which would lead to failure in any form of surgery. Thus, mistakes in diagnosis due to inadequate examination are perhaps the commonest cause of indifferent treatment. This element of difficulty in diagnosis may not at first sight be obvious. The word diagnosis in this work is used in its literal sense, namely, to mean a thorough knowledge of the condition present — i.e. the exact loss in terms of anatomical structure.
The routine examination of our cases, with preparation of records of the condition on admission, occupies nearly a week ; but the time so lost is regained a hundredfold. The examination merely of the surface of. the lesion, simple as
PRINCIPLES 5
it would sound, is fraught with dangerous pitfalls. One has seen a case in which a point a quarter of an inch above the angle of the mouth really belonged to the infra-orbital margin. The tissues had been stretched to this extent without dragging down the lower lid to any marked degree, and one might have been forgiven for regarding the stretched skin as part of the cheek.
Here, as elsewhere, the aim is to estimate first the amount of loss ; and, secondly, the possibility of correcting displacement.
It is often impossible to do so till one has undone some previous effort at repair.
A moment's consideration will show that no estimation of the loss or dis- tortion of soft tissues can be of use unless coupled with a knowledge of the condition of the bony tissue. When there is greater loss of the underlying mandible than of the skin, one is apt to conclude that there is no great loss of skin. In such a case, one must visualise a completely restored mandible, and then judge whether the remaining soft tissues are sufficient to cover it. In this connection, if a photograph is obtainable of the condition before injury it will often be of great assistance. In the case of any organ forming the wall of a mucous cavity, such as the lip, it is necessary to make an accurate estimate of the loss of mucous membrane. In fact, estimation of loss should be made separately in regard to (1) the mucous lining, (2)- the bony or cartilaginous support, and (3) the skin covering. The estimation of bony loss necessitates intranasal and intra-oral and radiographic examination in addition to surface palpation, and even then is often difficult to make in cases where the injury is symmetrical. One has seen an intrinsically well-made nose constructed upon a bed at least one inch posterior to the normal plane : the loss of the nasal spine and premaxilla had not been taken into consideration, and the face, to the surgeon's disappointment, presented an undershot appearance.
To overcome such difficulties, Surgery calls Art to its aid. A^ pi aster cast of the face is made, and thereon the sculptor, aided by early photographs if available, models the missing contours. With radiographs to confirm that the apparent loss is not merely displacement, the surgeon now has data for adequate diagnosis.
EARLY TREATMENT
The diagnosis established and recorded, the surgeon plans his repair. The first principle is one which the author believes to govern the whole treatment of facial injuries, and this is that all jiormal jjssue_shmild be replaced as early asjjossible, and maintained in its normal position. In treating an early wound there is a natural disposition to try to close unsightly gaps. More harm than
6 PLASTIC SURGERY
good is done thereby, as the reactionary swelling and the frequent suppuration cause more scar tissue than would otherwise have to be dealt with, and the stitches only too often give way. In addition to this undue stretching of the damaged tissues, the early cutting of flaps is, in the author's opinion, to be condemned ; for, even when this procedure is successful, no obvious gain in time or appearance is obtained, while considerable risk of suppuration is run. It follows, therefore, that split lips, lacerated noses, and gashed cheeks, where the loss of tissue is negligible, should be carefully sewn up with drainage as soon as possible. Every effort should be made to replace tissues in their normal position by stitches, strapping, head-gear apparatus, nasal supports and splints, but never into abnormal positions. There is one exception to this which de- serves mention, namely, that tags of mucous membrane should, faute de mieux, be delicately attached to any neighbouring raw surface to preserve their form and vitality.
In the very common facial injury, where one of the mucous cavities is involved in the wound and the loss is so great that the repair cannot be done without undue stretching, the modern practice of excising the wound should be brought into play, and then the skin sewn to mucous membrane round the margin of the defect. This should be done wherever possible, so that as little raw area as possible is left to granulate. In dealing with lacerated mucous membrane, the greatest delicacy of touch must be used, and in effecting the suture as little manipulation of the tissues as possible should be indulged in. A corollary of this belief of the author's is that in clearly defined gaps of the mandible, the end of the bone should be smoothed off and the buccal mucous membrane sewn across the raw bone, a procedure advocated by Trotter. Were it possible of achievement as a routine, it would almost certainly prevent ci- catricial approximation of the fragments ; but one realises that, with many other suggestions for early treatment, it is a counsel of perfection, and, in very severe injuries, may well be impracticable under conditions of active warfare.
In the early treatment of all wounds involving the oral cavity the dental surgeon must be encouraged to take a large share of responsibility. His treat- ment will begin naturally with a general nettoyage of the alveolar area. Loose and septic teeth and stumps must be extracted, and, as soon as can be accurately determined, the teeth obviously in the line of fracture (the persistence of which is not of vital importance for the fixation of the fragments) should be removed. Frequently the decision as to whether a tooth is or is not in the line of fracture has to be modified, and it may become necessary to remove more teeth than was first expected. The most careful watch for persistent pockets of pus must be maintained.
In many cases it will be found of great advantage to provide infra-mandibular
PRINCIPLES 7
drainage on to the neck surface beneath the various lines of fracture. This sounds reasonable and simple, but in practice it is found quite difficult adequately to drain some classes of comminuted fractures, and the mandibular remains are apt to carry on their existence in a sump of pus (visually, one must admit, with considerable success !).
For this as well as for general reasons, the passive drainage is greatly assisted by frequent forcible irrigation, the Carrel continuous irrigation being not always practicable in this region.
By adequate drainage alone are the dangers of secondary haemorrhage avoided, and it is one's experience that those cases in which there is a small perforating wound of the body of the mandible are most prone to this disaster. One has never seen a serious haemorrhage in a case of facial wound in which the loss of bone and soft tissues is great, and it would almost seem advisable that these small wounds should be considerably enlarged, and skin sewn to mucous membrane to make these openings persist till secondary suture can be safely undertaken. The author does not propose to dilate upon the treatment of secondary haemorrhage.
Apart from this dental toilet, the chief role of the dentist lies in controlling the bony fragments. The author is disappointed with the results of the so-called suspensory wiring of fragments, which involves the wrong principle of putting foreign bodies in contact with inflammatory bone lesions. The facial surgeon has the advantage of the orthopaedist, in that his instrument-maker is a pro- fessional colleague who has for his goal the provision of the best masticatory result. The dental surgeon must be fully alive to the possibilities of his surgeon and of surgery in general. Thus, in the early days of bone-grafting, many wide gaps of the mandible were brought together by the dental surgeon in the early stages in order to get bony union in a shortened mandibular arch. With the rapid success of mandibular grafting this procedure has become extinct, and it is the author's opinion that it is rarely justifiable to shorten the mandibular arch. The class of case where it is permissible is that in which the patient is edentulous, and the loss of bone minimal.
PLANNING THE LATE REPAIR IN A TYPICAL CASE
A man with loss of the upper lip, say, arrives from France with the remains sutured across beneath his nose and possibly healed there. Frequently the first step is to reconstitute the wound by the release of the overstretched tissues. The mucosa of the lip stumps is then secured by suturing it to skin over the raw edges. This very important measure should be employed by the first surgeon who sees the case after injury. Only now, as a rule, is it possible really
8 PLASTIC SURGERY
to diagnose the loss and plan the restoration. (Sometimes this replacement of the first stage of any plastic operation can be imitated by moving putty flaps upon the plaster cast as one would the flesh.) In planning the restoration, junction is the first consideration, and it is indeed fortunate that the best cos- metic results are, as a rule, only to be obtained where function has been restored. Perhaps the first question that arises in any case is the relative expediency of attempting surgical repair or mechanical camouflage, and a satisfactory decision can be arrived at only as a result of long experience. Sometimes in the end the repair undertaken is a compromise between surgery and mechanics, the decision being based on the severity and multiplicity of the operations needed to effect a surgical cure, and on the patient's lack of stamina ; or on factors outside the present discussion. One looks forward with confidence to a plastic millennium when, given a healthy patient and no time restrictions, it will be possible to cope surgically with any reasonable facial loss.
The restoration is designed from within outwards. The lining membrane must be considered first, then the supporting structures, and finally the skin covering.
Lining Membrane. — Omission to provide a lining membrane for mucous cavities has in the past been the supreme cause of plastic failure. Kcegan quotes a President of the Royal College of Surgeons in 1863, as mournfully describing how a well-shaped plastic nose is prone to wither away on the patient's face. The author has seen examples of a similar occurrence in recent times, for want of a lining ; and many cases of post-operative nasal stenosis, microstoma, and contracted eye-socket are traceable to the same cause. Even to this date the author has frequently to perform a second rhinoplasty upon patients who, during a portion of their plastic career, proudly flaunted new and shapely noses, which gradually diminished in size as a result of ulcerative processes within.
Mucous membrane is not often available except in the smaller mouth defects, and the results of free mucosal grafts have been poor. Recourse, therefore, is had to skin, either in the form of flaps or grafts. In its new and moist condition of existence the surface epithelium appears macroscopically to approach the mucosal type. In the nose, the formation of the mucosal lining by swinging turbinatcs and septum into the desired position has been successfully used on a number of occasions. When not available, an epithelial lining is usually provided by means of cheek and bridge flaps turned skin in- wards. If these flaps are not available, their place is taken by a Thiersch graft. Similar type flaps from the margin of the defect or Thiersch grafts are used in the rebuilding of the ocular aspect of new eyelids. In the smaller lesions of the oral cavity, the new cheek or lip is lined by the advancement of mucous flaps from the intact portions. Mucous membrane flaps are also used to replace
PRINCIPLES 9
losses of the vermilion border of the lips. When sewn over the raw edge of the lip and thus exposed to the air, the buccal mucosa seems gradually to give up the power of secreting without losing its colour, and a very natural appear- ance is produced. In larger losses, the method of inturned skin flaps from the neighbourhood is resorted to. It often happens that these flaps are hair- bearing, a property which they retain in their new situation. The disability, however, is not greatly complained of, and when excessive can be over- come by dissecting off the hair-bearing layer later on, and Thiersch grafting. The author has utilised non-hairy portions of forehead or of chest flaps turned in as a lining for a buccal restoration. Several surgeons favour the grafting of a separate flap of hairless epithelium on to the under-surface of the flap designed to form the outside covering, before the latter is moved into position. This is tedious, and a similar result can be more easily arrived at by the tube-pedicle principle. Epilation by X-rays is unsatisfactory in the author's experience. There is long delay. Permanent epilation is rarely obtained, and when obtained the skin is avascular and atonic, and burns are liable to occur in the process.
The fitting of an efficient denture upon a mandible robbed of its alveolar ridge usually depends on the provision of a much-deepened labiogingival sulcus to hold a flange of the appliance. Before the importance of lining the deepened sulcus had been recognised, it was found impossible to prevent its gradual obliteration by fibrous tissue. Now, thanks to development of the Esser inlay, the sulcus can be permanently deepened in one small operation.
The Esser Epithelial Inlay. — The provision of a lining for a deepened sulcus was first carried out by Esser (vide Annals of Surgery, March 1917). He inserted a moulded piece of dental composition wrapped round with a Thiersch graft (deep surface outwards) into a pocket dissected out subjacent to the mucosal lining of the existing sulcus, the whole operation being performed through a skin incision. After a suitable interval the bottom of the sulcus was incised, and the mould removed per oram, leaving the skin-lined cavity as an extension of the sulcus.
The author having practised the typical Esser inlay with considerable success and also extended its principles to the cure of ectropic conditions, it occurred to his Dominion colleagues to simplify the method for providing a lining membrane. Having discussed with the author the possibility of intro- ducing the skin-graft per oram, Lieut. -Colonel C. W. Waldron, C.A.M.C., was the first to perform this modification in this hospital. He was closely and independently followed by Lieut.-Colonel H. P. Pickerill, O.B.E., N.Z.M.C.
Its obvious success led to great activity in the sectional dental departments for its further improvement and simplification.
10
PLASTIC SURGERY
The details of the method are as follows :
A dental splint destined to control the Stent l is fitted to any existing teeth or to the alveolar ridge (see figs. 1 and 2), and the sulcus is deepened per oram to the satisfaction of the dental surgeon.
In this operation all scar tissue must be excised, and the knife must be kept close to the bone, so that no loose soft tissues remain on the alveolar wall of the sulcus.
An impression of the new sulcus is taken with warm Stent, which is made to distend the cavity. When set, it is adjusted to the dental splint. It is
Fio. 1. — Epithelial Inlay. (The arrows mark the limit of the skin graft.)
then taken out and completely covered with a large, thin, evenly cut Thicrsch skin-graft, deep surface outward, and is pressed firmly into the rawed sulcus and there maintained ten days by the splint. Meanwhile the dentist prepares his appliance, and must be ready to fit it the moment the Stent is removed, as the cavity is liable to shrink if left unoccupied for any length of time. As an intermediary stage between the Stent and the final appliance, a mould of black gutta-percha is sometimes used.
This operation may well be performed under regional anesthesia. The
1 The dental composition used for this purpose is that put forward by Stent, and a mould composed of it is known us a " !Stent."
PRINCIPLES
11
I. The obliterated Sulcus.
2. Incision close to the bone.
3. Sulcus deepened.
4. Skin graft on Stent.
5. Graft on Stent in position.
7. Operation completed.
6. Cap splint with horizontal 8. Ten days later. Stent removed : Sulcus adjustable flange. permanently deepened and lined.
Fio. 2. — Stages in the Epithelial Inlay.
author is of opinion that the original method of Esser, difficult as it is, is still the method of choice in a few rare cases.
A similar procedure has been successfully used in the nasal cavity, and for lining the ocular aspect of a new eyelid.
12 PLASTIC SURGERY
The principle of the Esser Inlay marks an epoch in surgery, and the oppor- tunities for its application are far from exhausted. A further modification of it is discussed in this chapter in the pages devoted to " Coverings."
Supporting Structure. — The importance of the general contour of the face in the matter of expression is only realised gradually. Disappointment is in store for him who would confine his repair to the surface tissues, heedless of Nature's lessons in architecture. Theoretically, the application of one's ana- tomical knowledge should suffice to point out the value of contour, but in practice the realisation comes only by close co-operation with the sculptor. In this matter of the general form of the part all sorts of artificial implantations have been tried. Metallic plates and filigrees, celluloid plates, and injections of liquid celluloid, solid pieces of wax, and injections of molten wax, have all been used to build up the missing contour. Speaking generally, the use of any foreign body is to be condemned whenever it is possible to substitute a graft from the patient himself. Any form of a foreign body is a tissue irritant, and tends to give trouble early qr late, in the attempt on the part of the tissues to remove it ; whereas grafts, if successful in the early stages, continue satis- factory. One celluloid plate which was used to replace a zygomatic prominence developed over it a cold abscess five months after its implantation. The healing had been primary, and when the abscess burst, the skin again healed over the plate. But by far the greater number of celluloid plates had to be removed within two months of their insertion.
Satisfactory early results are obtained by very cautious and repeated injections of paraffin wax in small quantities, but the late results are rarely good and are often appalling. It is not. suitable for the larger restorations, and the imbedding of solid blocks of paraffin has not, in the author's experience, been tolerated. The little experience the author has had with buried metallic or vulcanite plates discourages further experiment with them. Professor Mat-Bride, of the Imperial Research Laboratory, is at present carrying out a research for the author on the implantation of celloidin into the ears of mice.
There is no royal road to the fashioning of the facial scaffold by artificial means : the surgeon must tread the hard and narrow way of pure surgery. Of the various autologous grafts available one has had enough experience to form some conclusions. It may be laid down as a guiding maxim that the replacement should be as nearly as possible in terms of the tissues lost, i.e. bone for bone, cartilage for cartilage, fat for fat, etc. The use of bone-grafts has been narrowed down to the replacement of mandibular and malar losses.
Cartilage for large cosmetic purposes stands unrivalled. It is available in sufficient quantity, is easily fashioned to the desired shape, and, what is most important, remains permanently in the shape and size in which it is imbedded,
PRINCIPLES 13
with the exception that if one perichondrial surface only is left, the graft tends to bend, the perichondrium occupying the concavity ; and this property of cartilage is utilised by the surgeon to obtain a curve in such positions as the eyelids or the mandible. In cases of suppuration, there may be necrosis of part of the cartilage and a corresponding secondary deformity may arise. This is also the case when a part of the cartilage is left exposed in a mucous cavity. The clinical evidence of the permanence of cartilage is borne out by the ex- perimental work of Staige Davis (Annals of Surgery, 1917, vol. Ixvi, p. 88), and by the histological work of Keith and Murray. (See figs. 3, 4, and 5, 6.)
The method of obtaining cartilage is a modification of that suggested by Nelaton. A six-inch vertical incision is made over the costal cartilages having its middle opposite the seventh, and is deepened through the rectus muscle, which is widely retracted. The seventh, or the seventh and eighth cartilages, are dissected free and removed with perichondrium intact, and are at once transferred, wrapped in sterile gauze, to a table with three edges raised to prevent disaster during the shaping of the graft. The wound is sutured by an assistant, and the thorax strapped as for a fractured rib in order to avoid pain, which is otherwise likely to be severe. Meanwhile, the surgeon shapes his graft with a scalpel, leaving the perichondrium on one surface in cases where a curve or a spring effect is desired. The graft is put into place and the wound sutured without drainage, except in those cases where a lijematoma appears likely, and any excess of cartilage is inserted under the skin of the upper abdomen as a store for use in future operations, the pain of a further rib excision being thus avoided. This hoard of cartilage may prove of use to others if not wholly required by the patient himself. The question of homologous grafts opened up by this procedure is of extreme interest, and a definite decision as to their expediency has not yet been arrived at. It goes without saying that the donor must be proved free from syphilis.
In this connection one had the opportunity of furnishing material from various autologous and homologous cartilage grafts to Professor Keith. Dr. J. Alexander Murray undertook this research for Professor Keith. Illustra- tions (figs. 3 and 5) of two of his sections are given. Captain V- - and Lieut. S— were operated upon the same day. Some cartilage from Captain V- - was put into the subcutaneous abdominal tissues of both Captain V- - (autologous) and Lieut. S— - (homologous). After eighteen months the opportunity arose of removing these grafts. There is no doubt that in both cases the cartilage is alive and active, but Dr. Murray finds that the cells in the homologous (Lieut. S— -) are more vacuolated and show more cal- careous changes (i.e. degenerative) than do those of Captain V- — . (See figs. 4 and 6.)
14 PLASTIC SURGERY
It should be noted that neither of these two grafts was submitted to stress or strain in the region where it was buried. The author hopes that when a cartilage graft is put under fairly normal conditions of functional existence, such as is obtained when it is employed in nasal reconstruction, it will persist in the form and position given it. Certainly, in the author's experience, no changes other than curvature toward the perichondrial surface have occurred in any of his successful autologous grafts, and in only a few of the homologous grafts has the cartilage become replaced by fibrous tissue as a late sequel. Three years is the longest that the author has had a graft under observation. Even if partial calcification should occur this does not depose cartilage from its place as facile princeps among facial supports.
The insertion of a cartilage graft may constitute a whole operation, as, for instance, when it is introduced subcutaneously to elevate a depressed nasal bridge ; or it may form a stage in a series of operations. In rhinoplasty (author's method) the cartilage support for the nasal bridge is usually inserted subcu- taneously under the skin over the glabella — the skin destined for the lining of the new nose — and is swung down attached to the deep surface of this when it is turned down at a later stage.
In the method suggested by Nelaton the support is swung down on the deep surface of the flap designed to form the covering of the nose, a method hampering free manipulation of the graft with a view to fixing it in the best position.
It is sometimes convenient to employ yet a fourth method, in which the support is built into its final position between the lining and the covering, before the flap is raised. This procedure has been successfully followed in the replace- ment of facial losses by pedicled chest-flaps. The part is fashioned upon the chest by the manipulation of small skin-flaps, the cartilage graft being introduced between two layers of a flap doubled upon itself, or between the flap and a Thiersch covering of its under-surface.
When a softer contour is desired than would be provided by cartilage, local fat and muscle flaps are used to fill the smaller hollows. The use of fat-flaps is most satisfactory, and should be employed for all depressed scars. They are discussed later in this chapter, and examples of their use are given in the section on Cheeks. For larger hollows, free fat and muscle grafts are used ; these are naturally more uncertain of result. All the author feels it possible to say of fat-grafts is, that when successful, the result is very satisfactory, arc! alteration of the contour from absorption has not occurred to any appreciable extent while the case has been under observation. It is not yet established lm\v they will be affected in conditions of wasting, or in old age. The fat-graft, however, owing to fat necrosis, often undergoes a partial absorption, which is
PRINCIPLES
15
FIGS. 3 and 4. — V. (Autologous graft.) — No reaction at cut surface. There is only a very shallow layer 1-2 cells deep of dead cartilage cells. Under the old perichondrial surface the cells have remained healthy. In the central parts of the cartilage the cells are arranged in small groups with deeply stained areas of matrix around them — very much the condition seen in normal adult costal cartilage. The general matrix stains more faintly and is generally faintly fibrillated. This is not excessive.
» V
-V... v
>->
•»-•
FIGS. 5 and 0. — V. rib. cart, in S. (Homologous graft.) — The
cartilage cells are throughout more active, and occur not in -$••
clumps, as in the donor, but in long columns — towards "'•*„. .»., ,*•
the perichondrial surface isolated cells of spindle form are
most numerous. In the deeper parts rounded groups with
darkly-stained secondary capsules occur also. Fibrillation of the general matrix is fairly frequent,
but not excessive. It looks as if the graft in the strange soil had proliferated more actively, and
was still remote from the quiescent stage which is seen in the autologous graft.
/
c.
16 PLASTIC SURGERY
carried to greater lengths if the products of this disintegration become infected ; but even in this latter unfortunate event not all the fat (or muscle) comes away, and eventually there is left sufficient substance to aid very materially in any future work on the part. Fat-grafts are frequently recommended as a pre- liminary to a bone-graft, and, in the author's opinion, rightly so.
Of other ways of building up the facial contour, the author would like to draw attention to the following, which are available only in certain localities. The malar prominence may be simulated satisfactorily by the svibcutaneous advancement of the adjacent temporal muscle, as described on p. 55. In partial or complete rhinoplasty, considerable help is sometimes obtained in building up the sides or bridge of the nose by the use of turbinate grafts and muco-cartilaginous flaps from the septum, before the skin covering is applied.
With regard to anterior palatal perforations involving loss of the premaxilla, it is not the author's practice to attempt a purely surgical repair. The goal of obtaining efficient mastication is more certainly achieved by a mechanical repair at the hands of the dental surgeon.
The Covering Tissues. — In the provision of a covering there is little choice in the way of material : one has to decide between using a skin-flap or one of the types of skin-graft.
Generally speaking, the application of skin-grafts is limited to superficial lesions. Where a gap is to be bridged, or where tension is likely to occur, a skin-flap is indicated.
Skin-grafts. — The preparation and manipulation of the various forms of skin-grafts with a nice judgment in their use constitute an important part of the plastic surgeon's stock-in-trade.
(1) Thiersch grafts. — In plastic work the simple Thiersch graft is not of very wide application, but in specialised forms its use covers a very wide range. The Esser Inlay has been already fully described. The author has adapted the Esser inlay to surface use in the method known as the " Epithelial Outlay," which finds its most important application in his operation for the relief of ectropion of the lids, as follows : An incision is made, skirting the lid edge, and the lid liberated by dissecting freely till closure can be effected without tension. In the resulting cavity is buried a closely fitting Stent mould covered with a Thiersch graft, over which the edges of the incision are sewn with horse- hair, the sutures taking up the edges of the skin-graft. After some eight days the Stent either falls out or is removed, and the lid falls easily into position. See section on Burns, pp. 376-7, and fig. 7.
The principle is applicable in many other localities, notably in cases of adhesions between the pinna and the scalp following burns.
(2) H'olje and W hole-thickness gmJts.~T\\e factors determining the successful
PRINCIPLES
17
use of these grafts are somewhat obscure, but it may be laid down that firm apposition and accurate coaptation of the edges are essential. It would seem also that tension assists — tension of a degree comparable with that obtaining in the area from which the graft is taken. Apposition is most easily achieved and maintained when bone or cartilage closely underlies the area to be covered,
IMCiSION, JUST ABOVE CiLiflRY BORDER
SCM CRAFT IN POSITION SHOWING SUTURES THROUGH EYELID *f(D TMIERSCM GRAFT
UPPER ADD LOWER EDGES OF IMCISIOM SUTURED OVER STEMT
INCISION ALONG LINE OF 3UTURE5
EYELID LOWERED SHOWING OUTLINE OF TMIEA5CM CRAFT
FIG. 7. — Stages in the Epithelial Outlay Operation.
as in the forehead or nose ; and it is only in such regions that immobility— obviously a desirable factor — is obtainable.
The fact that a large graft is less likely to take in its entirety than is a small one is improbably due to any inherent disability in the question of size ; it is very possibly explained by the fact that the above-mentioned factors are more difficult of attainment in a large graft.
2
18 PLASTIC SURGERY
These grafts are in routine use for covering raw areas upon the forehead left by the removal of rhinoplastic flaps, and for providing a healthy covering for the nose in cases of severe facial burns. For small areas the skin may be taken from the back of the neck ; for areas up to two inches in diameter the skin is taken from over the biceps — the conditions of tension in this region being suitable. Larger grafts are taken from the chest or abdomen.
The question as to whether the graft shall be skin-deep or contain a layer of fat is determined by the needs of the case, there being no marked disparity between the two in the matter of viability. If hair is required the scalp in the post-auricular region is employed ; the author has successfully used whole- thickness grafts from this region in the replacement of eyebrows lost through burns. (Case No. 338, p. 356.) The details of the method employed in a typical case may be of interest ; the example taken is the grafting of the raw area on the forehead after a rhinoplasty, where the returned pedicle is inadequate wholly to cover the defect.
By the time the pedicle is returned the area is covered by healthy granu- lations. It is customary to scrape these away, as in cases where they have been left the patients have complained of a feeling of constriction round the head, presumably caused by the contraction of this large mass of scar tissue. The area to be covered is accurately mapped out with tinfoil, and the foil outlined upon the chest or upper arm with the point of the knife. The graft is then dissected up, care being exercised to avoid bruising it with forceps. It shrinks greatly as it is freed. If the bone is exposed on the forehead, the graft is cut so as to contain a layer of fat, for though a graft will often take upon bare bone it is liable to adhere too closely for normal movement unless fat intervenes. Fixation sutures are now inserted at the corners of the graft, so as to ensure symmetrical tension, and accurate coaptation of the edges is then effected with continuous horsehair sutures. Meanwhile, an assistant has prepared a Stent- backing to the tinfoil map of the area, and this is firmly pressed into the slight depression now occupied by the graft while still in a semi-solid condition, and the whole firmly bandaged to the head. The pressure is maintained for about forty-eight hours, and the graft then observed. If the prognosis is favourable, it will by this time have assumed a somewhat forbidding livid and mottled appearance, and will have swelled considerably. Any portions that have died will appear white and opaque, or black (underiun by clot). Stitches are removed about the fifth day, and massage is applied after about three weeks.
Skin-flaps. — The delineation and manipulation of skin-flaps constitute the ABC of the plastic surgeon's metier. The subject has been worn threadbare in countless textbooks, and it is not proposed here to give a compendium of all possible flaps.
PRINCIPLES
19
Essentially, all flaps are similar, and consist of two parts — the part chiefly concerned with the traffic in circulatory fluids, and the part available for plastic use.
Broadly speaking, flaps may be grouped as follows :
A. Advancing flaps.
B. Transposed flaps.
The differences are portrayed in the following diagrams illustrating their use, the pages devoted thereto being intended as part of a glossary for terms used later in the book.
The majority of the terms used are self-explanatory. " Ascending " flaps are those in which the skin from below the defect is swung up on a base roughly on the same level as the defect. Thus, an " ascending neck-flap " is one the body of which has been raised from the neck, the base being, for instance, on the lateral aspect of the chin.
In actual use, modifications of these flaps are employed according to the locality ; thus, for rhinoplasty, instead of the traditional forehead bridge flap, the author is now employing a long flap containing the anterior branch of the superficial temporal artery, based on the pre-auricular region. The middle portion of the flap is " tubed " (see figs. p. 21), and when severed from the plastic portion after some ten days, is opened out and replaced upon the forehead, leaving a raw area no larger than that left by the Indian method. The blood- supply of this flap is remarkable ; its nourishing vessel spouts freely when the tubed portion is severed from the new nose.
The transposed flap (imbedded type) is usually employed about the eyes and mouth, a depression of the buccal orifice being relieved by transposing a flap from the corresponding naso-labial fold to a position below the orifice, the flap in this case being a " descending naso-labial flap." If the tissue in the naso-labial fold is scarred or otherwise unsuitable, an ascending neck-flap can be employed to produce, in a less degree, a similar result. But in this case the flap must be taken from the side of the neck, being swung through ninety degrees from a vertical to a horizontal position ; otherwise the gain of skin below the
Fio. 8.— Flaps. A. ADVANCING FLAPS 1. SIMPLE ADVANCEMENT (Forward type).
Defects.
Incisions and Excision.
Flap A. Advancing.
Suture.
PLASTIC SURGERY
2. " V. Y.1' ADVANCEMENT.
A-
.A'
Defect. Incision. Suture.
3. SWINGING ADVANCEMENT (Combination of Forward and Lateral Advancement).
Defect.
Incision.
Suture.
B. TRANSPOSED FLAPS
1. IMBEDDED.
Defect.
2. BRIDGE FLAPS.
(a) Simple Pedicle.
Incision.
""^ A
Suture.
Eyebrows lacking.
Incisions.
Suture.
PRINCIPLES
(6) With Pedicle "tubed." (Author's Method.)
^ L
21
Detect.
Flap Pedicle " tubed."
Flap swinging upon Pedicle.
Suture.
Pedicle being returned and unrolled.
PLASTIC SURGERY
mouth has to be written off against the loss which occurs when the bed from which it was raised is closed.
The use of flaps is not confined wholly to the provision of a skin covering. In many cases the flap is used as a vehicle for the introduction of a cartilaginous support previously imbedded in it, as discussed earlier in this chapter. A typical example occurs in the reconstruction of the nose, in which the bridge support — a cartilage rod— is imbedded under the skin destined to form the lining of the vestibule, and swung down upon its deep surface to occupy a position between the lining and the covering. (Figs. 388 and 389.) A similar principle has been employed in the reconstruction of the chin in a chest-flap previous to its elevation.
The plastic surgeon must early acquire an instinct for forecasting the viability of the flaps he uses. Apart from those containing a definite artery such as the superficial temporal (the base for which may be cut quite narrow), generally speaking the base should be at least as wide as any other part of the flap. The length which may be safely taken varies with the breadth and depth -particularly the depth. If the depth includes no more than the true skin, it seems in practice safer to use a graft than a flap : a skin-deep flap of any length is found rapidly to become cedematous, and often dies from the obstruction thus caused. The explanation perhaps lies in the fact that egress for the products of metabolism is inadequate. In the early stages of a free graft the ebb and the flow of tissue-fluids are conditioned by the same factor, the osmosis resulting from the biochemical activity of the cells : the matter is not complicated by the continued arrival of fluid from without, and marked congestion does not arise.
In the event of oedema of an intensity likely to jeopardise the life of the flap, it has been taught that multiple punctures are indicated. The author prefers gentle efferent massage, which avoids the creation of minute thrombi and of extra channels of infection, and which helps to dissipate the commencing lymphatic and venous stasis. Furthermore, hot moist dressings have a definite effect in helping the sluggish corpuscle back to the normal circulation. It is the author's opinion that in a flap thrombosis may be caused by merely a few minutes' pressure, as from a kink.
The viability of flaps varies greatly in different regions. Those based about the chin are never a cause of anxiety, whereas ascending flaps from the neck contain the possibilities of disaster and must be treated with the greatest respect. It is of advantage, when dealing with a flap whose chances of life are precarious, to wrap it with a hot saline pad during the ligature of arteries, etc. It goes without saying that in cutting a flap one should, if possible, avoid its containing scar tissue : in the altered condition of existence the scar is liable
PRINCIPLES 23
to swell, not only forming ah unsightly blemish but being highly prejudicial to the blood supply.
Among other conditions which are prone to affect the viability of a flap, the surface to which it is applied exercises a most powerful influence. It has been observed that flaps containing scar tissue which would certainly die if im- planted upon the face, will often live upon the same base if applied to form the lining of a mucous cavity, where warmth and moisture are present.
In this question of viability of flaps the personal equation of the patient and of the surgeon comes strongly to the fore.
ANESTHESIA (CAPTAIN WADE)
The administration of anaesthetics for the plastic surgeon is a highly special- ised procedure.
To begin with, the majority of plastic operations are unavoidably long ;
tthe insertion of sutures alone is apt to occupy a skilled surgeon more than half an hour. The type of patient, too, is often unfavourable, especially in cases of wounds involving the oral cavity, where a long convalescence has been hampered by ill nourishment.
Moreover, the airway, in many cases, is strangely distorted in some part of its course ; and, in addition, the surgeon must perforce trespass upon the territory usually regarded by the anaesthetist as his own.
Evidently, therefore, there is scope for any and every device that will diminish effort for the patient and the anaesthetist, and bring the prolonged strain within the limits of endurance.
An arrangement must be come to also by which the surgeon is spared the disability of disputing the possession of the parts.
For large operations upon the mouth region, intra-tracheal administration in some form has been adopted as a routine. Where the form of the parts permits, a catheter is introduced into the trachea through a Mosher's laryngeal speculum under the guidance of vision. This may be prevented by the pro- jection of splints fitted to the upper jaw, or by conditions of microstoma, trismus, contracted mandibular arch, etc., in which case intra-tracheal anaesthesia is effected by means of a laryngotomy, or, in rare instances, a tracheotomy. Ether t is the intra-tracheal anaesthetic of choice. It is given under positive pressure, being carried either by a stream of oxygen from a large cylinder or by a stream of air propelled by a small electrically driven motor, either way leaving the anaesthetist the use of both his hands for the manipulation of the stop-cocks, etc.
In smaller operations upon the mouth, it is found convenient to use a nasal
_u PLASTIC SURGERY
tube or tubes, the pharynx being shut off by plugging the hinder portion of the buccal cavity with loose gauze which is renewed from time to time.
When the operation is upon the nose, the nose and post-nasal space are plugged, and a Hewitt's airway is employed.
In all these cases, the anaesthetic is conveyed through a tube long enough to avoid interference with the surgeon, the means of propulsion being as in the intra-tracheal method.
Administration by positive pressure undoubtedly relieves the patient of much of the strain of a long operation, and the ease with which pure oxygen or air can be substituted for anaesthetic through the clear airway achieved by the methods described, diminishes the stress associated with cyanosis to a minimum. The difficulties consequent upon the routine adoption of these methods are easily overcome with practice. The anaesthetist must learn to depend almost solely on the respiratory movements and the pulse as his guide, with rare peeps at the pupil.
I propose here to discuss some of our methods in more detail :
Chloroform and Oxygen in the Sitting-up Position. — This method was intro- duced to us by Colonel J. F. W. Silk, Consultant Anaesthetist to the War Office, in September 1916. It is most suitable for upper lip operations — with or without loss of continuity in the maxilla. It is also useful for those cases of extensive loss in the mandible where the fragments cannot be held by suitable splints. The advantages of the method are, firstly, that the blood flows forward out of the mouth ; secondly, there is less bleeding ; thirdly, the surgeon has a very good view of the patient's face. But it is certainly a tiring position in which to operate.
In my experience, with healthy men it is a safe form of anaesthesia. In 200 cases I have never had to alter the position during the early stages. Very occasionally they become faint towards the end of long operations and have to be lowered to the horizontal, where they quickly recover. A very light anaes- thesia is required after the first half-hour. In some cases they pass into a stage of analgesia, during which they will answer remarks quite sensibly for half an hour or more before the operation is finished.
Technique.— One end of the operating-table must be capable of being raised to the perpendicular, and must be long enough to reach to the patient's shoulders in this position. A suitable head-rest must also be attached. Induction is carried out in the sitting position, the back of the table being raised to just short of the perpendicular. When induction is completed the head is bound firmly to the head-rest. The position of the head is important ; if it leans too far back blood will flow into the fauces, if too far forward the airway may be obstructed. It is sometimes easier to get the best position by adjusting the
PRINCIPLES 25
trunk to the head. When this is satisfactory, and the patient is breathing easily, a No. 10 rubber catheter is passed down one nostril to the pharynx. The catheter is connected by a suitable length of rubber tubing to a Shipway's warm ether and chloroform apparatus, to which an oxygen cylinder has been attached, and the oxygen made to pass through the chloroform bottle at the required rate. The oxygen should always be turned on before the rubber tube from the catheter is connected to the apparatus. As a rule, this is a very convenient method for the anaesthetist, but occasionally the jaw requires support. If anaesthesia becomes deeper than the operation requires, the oxygen rate can be slowed or the rubber tube from the catheter disconnected from the apparatus for a time, or connected direct to the oxygen if necessary.
The Nasal Tube. — This was described by my colleague, Captain J. C. Clayton, in the Lancet.
I always use the largest tube (size 20) which it is possible to pass down a nostril. If the tube is cut to a blunt point it will be found to pass more easily. If there is difficulty in passing one of the required size, it is better to pass a smaller one first, leave it in place a few seconds, and then try the larger one again ; in most cases this can now be passed easily.
One of the objections to this method is that the tube is liable to kink at the level of the ala. I have overcome this by cutting the nasal tube short at the ala, and inserting into it one end of a right-angled metal connection of the same bore as the tube. The other end of the metal connection is joined directly to the funnel-end of a Kahn's tube by a short length of rubber tubing.
This arrangement has two advantages : firstly, it provides a shorter length of tubing for the patient to breathe through ; and, secondly, the Kahn's tube, being metal, cannot be inadvertently compressed by the surgeon, and thus a clear airway is assured, always provided that the end of the tube is in its proper place just above the epiglottis and that the tube is not flattened too much in its passage through the nose.
The mouth and pharynx are then loosely packed with gauze so as not to compress the tube. The operation should not be commenced till the patient is breathing comfortably. Anaesthesia can be maintained, either by dropping chloroform on to a layer of house-flannel stretched over the funnel, or by blowing a warm ether or chloroform and ether into the funnel from a Shipway apparatus.
In some cases where the airway is just not sufficient there may be some cyanosis. This can be corrected by giving oxygen when necessary. It is very often necessary to support the jaw.
This method is very useful for lip plastics, provided that the tube is not in the surgeon's way ; and for epithelial inlays and cleft palate operations.
In the last-named I prefer to give chloroform or chloroform and ether
26 PLASTIC SURGERY
from a Shipway apparatus, through a catheter passed down the nose to the pharynx. The patient's shoulders are raised and the head fully extended. In this position it is impossible for the blood to enter the larynx. The difficulty is to keep the patient from coughing. This can be avoided by resting the little finger of the hand holding up the jaw on the larynx when any swallowing move- ment— the prelude to a cough — is at once appreciated.
The choice between this and the sitting-up position, provided the patient is healthy, rests entirely with the surgeon.
In operations for reconstructing the chin or lower lip, where there is ex- tensive loss of the mandible and the fragments are not controlled by splints, there is no support for the base of the tongue, and it is very difficult to maintain a clear airway. Laryngotomy or tracheotomy is the simplest way out of the difficulty, but there are two possible objections to employing either. The patient will probably require more than one operation or the surgeon may wish to take a flap from the neck. I have only employed laryngotomy once in these cases, and have found one or other of the following methods satisfactory.
(1) Chloroform and oxygen, in the sitting-up position, with the head slightly extended.
(2) Kahn's tube. — At one time this was used very frequently, but we gave it up because of the difficulty of being certain whether it was in the larynx or not. The following two cases were very interesting with regard to this point :
The first was a bone-graft where the jaws could not be splinted. I had a great deal of trouble with the airway, and as a last resort introduced a Kahn's tube. The head was lying on the left side and covered up with towels. It was most unlikely that the tube entered the larynx, but the patient at once breathed perfectly easily through it.
The second was a chin plastic. After a perfectly quiet anaesthetic through the Kahn's tube, the patient vomited at the end of the operation before the tube had been removed, and he vomited entirely through the tube, nothing coming into his mouth past it.
If the tube is in the larynx the anaesthesia is very good indeed, and in these cases it is often possible to reach the larynx with the finger and be certain that it is in position. If it is not in the larynx, it may still be serviceable, but there may be trouble during the operation. I have never seen shock during or following its use, even in operations lasting as long as four hours.
(3) A good airway may also be obtained by placing a small pillow under the patient's shoulders, extending the head, and at the same time making traction on the tongue.
Chloroform and oxygen can be supplied through a catheter passed down
PRINCIPLES 27
the nose. If the surgeon objects to the tongue being drawn out it can be levered forward by a sponge-holder, the upper teeth being used as the fulcrum.
Operations on the Nose. — For short operations (under two hours) anaesthesia may be maintained as follows :
After induction a silk stitch is passed through the tongue and a post-nasal plug introduced if necessary. A very convenient retractor for the soft palate can be formed by obtaining an ordinary copper retractor half an inch wide, and bending the last inch to a right angle. This can easily be slipped behind the palate, and takes up much less room than the finger. The swab is then introduced digitally, or with Luc's forceps. A Hewitt's airway is placed in the mouth ; the end of a short and suitably bent metal tube, about | in. in diameter, is placed just inside the mouth of the Hewitt's airway, and the other end connected by a rubber tube to a Shipway's warm ether apparatus. It must be remembered that this tube must not be too long or the vapour will have cooled by the time it reaches the patient. This apparatus is very econo- mical, and has the additional advantage of enabling the anaesthetist to maintain a very uniform anaesthesia. I have found that, using a mixture of chloroform and ether, one compression of the bulb to every third inspiration is sufficient to keep the majority of these men under.
If a constant stream of air or oxygen is passed through the apparatus there is loss of heat and waste of anaesthetic during expiration.
In long operations (over two hours), such as rhinoplasty, including, as a rule, the removal of a piece of costal cartilage, we were at one time accustomed to employ oil-ether anaesthesia, because of the lower incidence of post-anaesthetic vomiting with this method. This is especially important in rib cases on account of the pain.
In properly selected cases this is a very uniform and safe anaesthesia. During a personal experience of over 200 cases I have only been unduly anxious about one patient during the operation, and that was before I gave up using hyoscine in the preliminary hypodermic. This method should never be used if blood is likely to enter the air-passages, for bleeding may continue after the patient leaves the theatre, and, as they usually take a long time to come round, there is grave risk of blood entering the trachea.
It should not be employed if there is an obstructed airway — e.g. loss in lower jaw without fixation, unless the anaesthetist is prepared to stay with the patient from the time the oil-ether is run into the rectum until the patient is thoroughly round from the anaesthetic. Complete rhinoplasty involves little risk of post-operative bleeding, and I have rarely seen any trouble in these cases.
The post-nasal plug, if required for the operation, should be left in situ until the patient has recovered from the anaesthetic.
28 PLASTIC SURGERY
I prefer the paraldehyde mixture ; ether 5 oz., paraldehyde 2 drams, olive oil 2 oz., but the paraldehyde causes excessive sweating in some patients. Dose : It is difficult to form any fixed plan. Some men go under quite quickly, whereas others of the same weight require a great deal more anaesthetic for induction. We have been very much handicapped by being unable to obtain olive-oil, and the results have been much more uniform since it has been on the market again.
In cases in which blood is not likely to enter the airway (except in cases where the jaws are splinted together), anaesthesia may be maintained by means of a Shipway's warm ether apparatus, with a Hewitt's airway in the mouth, as described above under " Short Nose Operations."
Bone-grafts of the Mandible. — As the jaws are splinted in the closed-bite position intra-tracheal administration is out of the question.
For a long time we gave oil-ether anaesthesia for these, with good results. The tongue is held forward by the splinted lower jaw and does not fall back. It is better to ensure free nose breathing by introducing a nasal tube Additional anaesthesia may be given either through this or through a bent metal tube placed in the mouth. As an alternative, a general anaesthetic may be given through a nasal tube as described above, under " Operations involving the Mouth." During the last six months we have given up oil-ether anaesthesia for these cases and have employed chloroform and oxygen through a nasal tube with satisfactory results, and I think it is to be preferred, both on account of the lessened risk of pneumonia, and the quick recovery from the anaesthetic.
In this class of surgery there should be more than usual co-operation between the surgeon and the anaesthetist, both in regard to watchfulness over the patient's condition and in manipulations involving the airway.
R. WADE.
OPERATION
The general technique of a plastic operation differs slightly from that used in general surgery, in that the question of the ultimate appearance of the area of operation occupies a much more important place. The slightest insult to the skin of the face is in some subjects visibly recorded in scar tissue, especially where the blood-supply is poor from any reason, such as tension or the presence of scar tissue ; and it is therefore bad practice to use tissue forceps upon the skin edges, the grip being properly taken on the deep surface. The production of an invisible scar is a question constantly exercising the mind of the plastic surgeon.
A few points are given below descriptive of the author's usual practice with regard to general technique which may prove of interest.
PRINCIPLES 29
The skin of the patient is usually prepared at the time of operation by firm wiping of the parts with an ether swab. This removes saprophytes on the surface without damaging the epithelium. This is usually followed by a light coating of iodine, applied once only. In cases where the epithelium is tender, as in burnt cases, the ether is followed by methylated spirit, the iodine being omitted. It is also possible that iodine is an unsuitable preparation for skins that have previously been the seat of erysipelas. Similarly, in young subjects and in women where the epithelium is delicate, the iodine is omitted. The same holds good in the preparation of areas from which skin-grafts, either Thiersch or Wolfe, are to be removed. For Thiersch grafts, very vigorous rubbing with ether is practised until the whole area glows.
The general care of the patient with regard to fatigue, shock, and haemorrhage must be borne in mind, just as in other branches of surgery. The treatment, actual and preventive, has no features peculiar to this branch of surgery. A special note of warning, however, will not be out of place in regard to the in- halation of blood and mucus, which will further decrease an airway often already insufficient, and will greatly add to the patient's fatigue in these lengthy opera- tions. The amount of shock produced by an operation depends, among other things, upon the area of disturbed skin surface. This is particularly noticeable when large chest skin-flaps are used for the face.
Needless to say, the general and local condition must be the best possible before a major plastic operation can be undertaken. The original wound must have healed soundly, the condition of the upper respiratory passages and accessory sinuses must be above suspicion, and the skin must be free from pimples, acne pustules, and the like. In many cases certain preliminaries will have been completed, such as the excision of exuberant scars, or non-operative treatment to soften keloidal tissue and improve the blood-supply.
Stages. — Most of our operations consist of two or more stages. The use of bridge-flaps necessitates a second operation for the return of the pedicle, but this does not always need a general anaesthetic. The pedicle is returned not earlier than ten days in most cases, and it is of advantage largely to increase this interval where the blood-supply of the receiving bed is dubious. The returned pedicle covers most of the bare area from which the flap was taken, and the remainder is covered either by undercutting and advancing the margins, or by a Wolfe or whole-thickness graft. The graft, after being sutured, should be pressed firmly into place and held there by a pad of gauze or a Stent mould firmly bandaged to the head. The most frequent cause of failure of a Wolfe graft is lack of pressure firm enough to ensure complete apposition. Apart from the return of pedicles, our operations are frequently designed in stages ; for instance, in rhinoplasty the normal portions of the tip and alse have frequently
30 PLASTIC SURGERY
to be released from scar tissue and restored to their normal positions at a stage prior to the remaking. At this stage also the blood-supply of the prospective inturned flaps is secured by attaching their future base to the rich blood-supply of the nasal mucosa. Similarly, in large facial replacements for burns, the blood-supply of the flaps is rendered more secure by the preliminary tubing of the pedicles. Countless other examples of the necessity of dividing the restoration into stages will spring to the mind of the reader.
The simplest operation in plastic work is the excision of scars. This is important, not only from the cosmetic point of view. Apart from actual loss,
1. Depressed scar.
2. Incisions for excision of scar and delimitation of fat flap.
3. Fat flap swinging. 4. Flap fixed under new scar.
A. FAT FLAP BASED ON DEEP FASCIA.
JL 1
I
1. Depressed scar. 2. Incisions. 3. Suture.
B. FAT FLAP BASED ON THE SKIN. FlO. 9. — Showing use of subcutaneous fat flaps. (Sectional view.)
no factor so impedes function as does scar tissue, whether by hampering mobility or by constriction of tubular organs, such as blood vessels and ducts. The general aims in scar excision are :
1. Liberation of fettered tissue.
2. Restoration of contour.
In either case it is essential that all the scar be excised. It is remarkable to what extent a deformity will recur if only a small amount of scar escapes.
In unfavourable subjects it may be that the scar must be excised a second or even a third time before a presentable appearance is effected.
The restoration of contour is aided by the subcutaneous rolling in of fat- flaps, as indicated in the accompanying diagrams. In most cases the flap is
PRINCIPLES
31
based on the deep fascia (fig. 9 A : 1 to 4), the skin being undercut till the desired area of fat is exposed, after which the knife is carried deeper till the flap can be drawn across and sutured in its new position. In another method (Aymard) the flap is based upon the overlying skin. This is more difficult of execution, as the knife is invisible during the delimitation of the flap, but it is the method of choice on occasion, especially in the malar region.
Suture. — The insertion of sutures occupies about half the time taken by one of these long operations. Sewing up after a total rhinoplasty takes almost .1, one hour even in experienced hands : so that dexterity and smooth technique 9§
Fio. 10. — Author's instrument.
in this particular are of outstanding importance for the sake of the patient. The " No Touch " technique is fortunately compatible with this desideratum ; it is found that, with practice, stitches can be tied very rapidly with forceps, especially with the author's instrument depicted above. This instrument also embodies the property of scissors, and further saves time by allowing the surgeon to cut his own sutures.
The material usually employed for the apposing layer is horsehair ; its elasticity is of great importance in allowing a nice adjustment of the edges,
32
PLASTIC SURGERY
especially when employed in continuous suture, as is very often the case. In- terrupted sutures are first inserted at corners and other guiding points, and the continuous suture is carried right past them. A trial is now being made of " Japanese Silkworm Gut," a material of great elasticity, the strength of which, in proportion to its calibre, is even greater than that of horsehair. Retaining sutures are of silkworm gut.
The use of subcuticular sutures for the closure of facial wounds would at first sight seem to be ideal ; and, under certain conditions, this is the case. A long, straight incision, all portions of which are in the same plane, is best closed by this means. But where an incision is irregular or passes over an alteration of contour, the avoidance of " bunching " is so difficult with a subcuticular suture that a good scar is more likely to result by other means.
Subcutaneous sutures are of great value as retaining sutures. The author uses a modification of the " near-far far-near " suture to subserve the double purpose of retention and apposition as indicated in fig. 11, which prevents in- version of the edges.
SECTIOMflL VIE1W
THt SUTURE IN POSITION
FIG. 11. — Subcutaneous near-far far-near suture.
The material employed for subcuticular apposing sutures is usually horse- hair. Catgut is found to produce a heaped-up edge, and linen thread has, on more than one occasion, proved itself to be an irritant.
Catgut is the material of choice for subcutaneous retention sutures, chromic gut not being well tolerated in the face.
Invisible Scars.— The author has devoted much time and thought to the
PRINCIPLES 33
production of the optimum scar. It actually happens on occasion that a facial scar is for practical purposes invisible, but one must admit that the factors for ensuring such a desirable result are not always to hand.
The factors necessary for the production of the optimum scar are :
(1) Asepsis.
(2) Avoidance of tension on the apposing sutures.
(3) Perfect apposition of the skin edges.
(4) An often unknown personal factor in the patient.
(5) Early removal of sutures.
The avoidance of tension on the edges is found to be a factor of extreme importance : one often sees a transposed flap, the scar delimiting one edge of Avhich is clearly visible, while that along the other edge is almost invisible, the difference being due to the fact that there is inevitably more tension on the edge along the long or convex side. To avoid tension on the edges it is customary to insert deep retaining sutures wide of the incision, the ends being, if necessary, guarded by buttons to distribute the pressure. The apposing sutures should be inserted very close to the edges, and may be at very close interval if that is thought necessary to ensure a critical closure. Apposition is occasionally assisted by the insertion of a few everting mattress sutures about 3 mm. from the edge. With a view to ultimate invisibility of scar some surgeons make their incisions with the plane of the blade at an oblique angle with the surface, so that Avhen the wound is closed there is a slight overlapping of one edge by the other.
VLR.TICflL INCISION
OBLIQUE.
FIG. 12. — Incisions.
The author has not found that this method on the whole leads to a more perfect scar.
It is found that invisible scars more often occur in patients whose skins are ruddy and beset with small venules. Skin-flaps on such subjects are wont to acquire a florid habit, and their edges soon fade into their surroundings, the scars becoming permeated with the tiny vessels.
Dressings. — Dressings are but seldom required upon the face. Where a
3
34 PLASTIC SURGERY
wound has been closed with drainage an appropriate covering is naturally applied, and it is customary in the case of grafts to provide some means of maintaining firm apposition ; but for the most part the face is left exposed to the air. Where it has been necessary to use a flap of precarious viability, hot saline packs are applied at the close of the operation and are renewed two-hourly, with excellent results.
AFTER-TREATMENT
Apposing sutures are removed on the third or fourth day, retaining sutures being left till their function is fulfilled. Thus, it is the author's custom at the conclusion of a rhinoplasty, to insert one or more horsehair stitches transversely through the new nose, and tie them so as to produce a narrowing of the organ at certain spots. These are left till they have caused a certain amount of in- flammation, so that the scar-tissue which ensues will take over their function permanently.
Massage is of great use in dispersing the oedema which often arises as a temporary disability in newly made flaps, and is indicated as a routine measure for assisting in the restoration of function.
The closest watch is maintained during the first forty-eight hours upon the site of operation, especially where a new or doubtful flap has been employed. Even in well-tried flaps cedema may occur, and lead to disaster unless promptly dealt with.
Electrical treatment in the form of vibro-massage for bone lesions, diathermy, ionisation, X and other rays, is part of the routine after-treatment, as in other branches of restorative surgery.
A trial is being made at present of the application of a rhythmic sinusoidal current as an aid to osteogenesis in mandibular bone-grafts. (Barclay.)
Early active movements are encouraged, generally speaking ; and this principle is applied to mandibular bone grafts where the gap is inconsiderable.
In conclusion, it may be said that Time is the plastic surgeon's greatest ally, and at the same time his most trenchant critic.
REPAIR OF THE CHEEK
CHAPTER II REPAIR OF THE CHEEK
IN discussing in detail the experience in the repair of the various sections, it is not possible to confine each case and its method of repair within exact categories ; but as far as possible I have divided the face into regions, and each region into groups, as judged by the extent of the destruction. In each group the methods of repair used are set forth and the results criticised, while examples of cases and methods are interspersed in the reading matter, so that reasons for many statements may be supported by illustrations of actual cases. Many of these cheek injuries secondarily involve the lower eyelid, the nose, or the mouth ; but the following cases, though thus complicated, have their main interest centred in the cheek repair. Owing, however, to the obvious overlapping of the injury from one to other regions, cross references will fre- quently be made to the part of the book where the illustration is to be found. Thus, Case 70, in the chapter on noses, shows a very severe cheek injury, but as the interest of the repair, to my mind, is centred in the smaller nasal part of the injury, it is not separately described in the present chapter.
The cheek is an area of plastic surgery which lends itself to good results. The lining membrane is not usually a stumbling-block, as in lip and nose work. The supporting structure, when not supplied by a dental prosthesis, is found in a bone graft for the mandible, cartilage for the superior maxilla, and muscle or cartilage for the malar-zygomatic prominence. The skin covering, when not available locally, is made good by flaps from the whole neck area or from the temporal region.
I have arbitrarily divided this region into :
(a) Depressed scars. (6) Loss of soft tissues only.
(c) Loss of soft tissues with loss of bony substructure which may be deficient in the following situations :
(1) Malar Prominence.
(2) Superior Maxilla — Alveolus, Antral Wall, Infra-orbital
Plate.
(3) Mandible.
(a) DEPRESSED SCARS
Depressed scars may be defined as those associated with such small losses of tissue that the majority of them may be repaired by excision of the scar, under-cutting the skin and approximation, without the necessity of cutting flaps.
37
38 PLASTIC SURGERY
They are usually the result of the exit of a bullet, of the glancing blow of a fragment, or of the entrance of a small shell or bomb fragment. The scar produced by an exit wound is stellate, while that of an entrance wound, though it may be irregular, is usually concentrated in the middle of the depression. Of the two kinds, the radiating scar is the more difficult of elimination. My usual practice carries me into a somewhat tedious individual excision of each scar in addition to the central core. Frequently, however, a compromise is carried out by the removal of the more important of the radiations, leaving the lesser to time and the end of the war: a method which hastens the man's return to duty and conserves the energies and time of the theatre staff for more important work. Not only the scar but the depression should be removed, and for this purpose it is of great advantage to roll in local fat and muscle flaps from the surrounding area under the new line of union, a practice which I have carried out from the beginning, and which is described in detail in Principles.
Apart from the filling of the depressions, which is the most essential part of the treatment of these scars, the success of the procedure is to be judged by the character and amount of the residual operation scar.
If a happy result is desired, considerable thought and care must be bestowed on the details of the skin closure. The incision must be clear of the cicatrix, not only of the visible but also of the palpable portion. Horsehair, fine and elastic strands being chosen, gives the best result, as no other suture material presents this elasticity. Stitch-marks are avoided by taking out the stitches on the second, third, or fourth day, according to the tension, and by taking up the tension by deep catgut sutures. If eversion of both edges is required a mattress suture is employed, if of one edge only, the semi-subcuticular mattress, while between these everting sutures the simple or the four- twist knot is indicated. The various little flaps should be brought together and deep catgut inserted, so that there be no tension on the horsehair edge-to-edge sutures. Frequently difficulties arise at this stage, and one is confronted with the necessity to make a decision as to whether the parts can be pulled together without undue strain, or whether a flap is necessary to complete. It is usually easy to make, by further incision, one of the little flaps into a bigger one, and so overcome the difficulty ; and I feel that a guiding principle which stands the tests in most cases is that " when in doubt, cut a small flap." The fine edge sutures should receive minute attention, so that the very edges of the cut skin are apposed. Round the centre of the depression, where the apices of the stellate flaps meet, suturing becomes difficult. Frequently it is better to put in a modified purse-string or a mattress method involving more than one flap, as there is no room for many fine stitches.
REPAIR OF THE CHEEK
39
FIG. 13. — A few days subsequent to a double shell- wound.
Fio. 14. — After the plastic on the cheek and simple healing of the chin. Note the restoration of cheek contour, but the indifferent operation scar.
CASE 83
Illustrated in the accompanying figs., requires little elaboration. He was wounded by shell, on 23.7.16, in two separate places, each wound being of an explosive nature. The wound of the chin, as shown in fig. 13, healed of its own accord, without any operation (see fig. 14), while the wound of the left antrum healed with a large depressed scar which was treated by excision of the scar tissue, and by rolling in fat-flaps, as described in the chapter on Principles. It will be noted that the patient's left eye was enucleated in the early stage by the ophthalmic specialist on account of the injuries it had received. The scar tissue was widely excised under general anaesthesia, and local fat-flaps were turned in to fill up the missing contour and sutured with catgut, the skin being united with interrupted horsehair stitches. The photographs, taken on the patient's discharge from hospital, show the result of this simple procedure.
In criticising this result, it appears obvious to me that the whole scar was not removed, and that, had palpation been made, the edges of the wound would have felt hard and un- yielding. The consequence of leaving this indurated subcuticular area is that the edge has remained heaped up in places, and does not lie as flat as it would otherwise have done. The condition is, of course, eminently suitable for further treatment in the way of re-excision, but such would probably have been unnecessary had the above-mentioned precautions been taken in the first instance. However, even when the whole scar tissue is successfully excised, the first operation scar is not usually as good as when a second or even a third linear excision is undertaken, suitable intervals being allowed to elapse between operations.
lo PLASTIC SURGERY
CASE 37
This officer received a long, gashing wound of the left cheek, which is well illustrated. At its maximum depth, it penetrated to the mouth (buccal fistula), and, during the course of the missile, the mandible was fractured with loss of bone, mainly alveolar. Two pointed ends of the lower border of the bone remained in close proximity in the bottom of the wound, and at the later operation scar tissue was excised between these points, which were them- selves freshened. Combined with dental splinting and necessary extractions, this freshening resulted in bony union, so that the injury may be classed as one without loss of bony contour.
The healed condition in a case like this is merely one of a very large depressed scar. The good result obtained was due, I think, to the use of fat flaps, as previously explained and as the diagram represents. On this occasion they were rolled in towards the depression, having their blood supply from the deep tissues : the skin, thus undercut, was drawn over the fatty prominence and accurately sutured. The skin edges were cut markedly on the slant or bevel, and the stitch used was the semi-subcutaneous horsehair mattress suture (vide p. 33), reinforced by a few edge-to-cdge stitches. The upper part of the scar was invisible as such before this patient left hospital, but there was still a slight depression which marked its site.
The final history of this gallant officer from the Dominions is pathetic. Soon after being posted back to duty he volunteered for foreign service again, was shot through the knee-joint, and died of wounds in the same Casualty Clearing Station as that which received him when his face was wounded.
REPAIR OF THE CHEEK
41
i g. — On admission 10 days after wound. Lower facial paralysis.
Fid. 1G represents^fat flaps rolled in towards the centre of the depression.
FIG. 1 7. — Result. — Note : the smudge beneath the chin was a result of shaving, and has been removed on the print. There was no appreciable facial paralysis at this stage.
42 PLASTIC SURGERY
Literally one might give hundreds of examples of these scars and of the results of their excision, and I need only here refer to my remarks in Chapter I, p. 33, where I have discussed the production of invisible wound scars.
(6) WOUNDS OF THE CHEEK, WITH LOSS OF SOFT
TISSUE ONLY
Here, again, the definition of this class can be no more than arbitrary, as some of the examples are merely extra large depressed scars, while others include in their lesion a loss of bone. They may be described as cases requiring the provision of flaps, but not including any serious operation for the restoration of the lost bone.
CASE 27
Gunner P. was wounded 22.7.16, and admitted to me on 10.12.16, in the healed condition, as shown in fig. 18. There was a large loss of soft tissue involving the left corner of the mouth and the region of the cheek extending outwards from this corner. The wound had healed by scar tissue, and besides considerable deformity, there was much loss of function through contraction. The first operation I per- formed on 10 . 1 . 17 was a complete failure, due entirely to a haematoma which formed under the flap. The flap had to be raised in order to evacuate the blood : none of the stitches held. The condition when healed, after this unfortunate occur- rence, was practically the same as on admission, but with one additional scar. On 5.3.17, the con- dition had been healed so long that a second operation was judged to be possible. On this occasion a large thick musculo-cutaneous flap, in breadth about 1 £ in., was taken from the left naso- labial and left infra-orbital regions and swung down towards the corner of the mouth (where, after the excision of the scar, there was a large deficiency of skin and muscle), as shown in the diagram, fig. 20. The scar tissue excised at the corner of the mouth included about a third of the upper lip, and did not penetrate farther than the deep surface of the mucous membrane of the mouth. On attempting to fit the flap in at the corner of the mouth, I realised that it had to be split, the larger portion going to the upper lip and the smaller to the lower.
Another interesting point in this case is to be observed in the fact that a large flap can be taken from this region without causing serious secondary deformity. The result of this operation was very satisfactory, and the value of a split flap at the corner of the mouth is established by this case and by Case 220 (page 56). This -Actual loss greater than apparent. patient was discharged from hospital on 1-1.5. 17.
REPAIR OF THE CHEEK
43
Fio. 19. — Flap.
FIG. 20. — Suture. Note splitting of flop to form angle of mouth.
FIG. 21. — After plastic. Lips apart, lower scars not treated.
FIG. 22. — After plastic. Lips closed. Split flap to form corner of mouth.
1 1
PLASTIC SURGERY
CASE 292
Fig. 23, of this case represents the condition of Sergeant 15. on admission into this department on 15.6.17. IK- was wounded on 10.9.10. Previous notes and photographs are not available. lint it is obvious that he had a shell wound pene- trating the left antnmi, with the loss of infra-orbital plate, and a large depressed scar on cheek. The sear was excised on 14.7.17, under general anaesthesia, and a large fat graft, measuring .'5 in. by 2| in. by ? in. thick was taken from left buttock and fixed" in the depression by "catgut. Everything proceeded normally until the fourteenth day, when first fat necrosis, and subsequently suppuration occurred. necessitating drainage from the centre and from the dependent portion of the sear. This suppuration continued for about four weeks. His condition when the suppuration ceased is shown in fig. 24. I illustrate this case to show that, although a fat graft
Fia. 23. — On admission — healed.
FIG. 24. — Left eye — enucleated. Fat graft to cheek.
may not succeed in toto, yet, even if it suppurates, very considerable improvement in the contour is invariably produced. In order to complete this case, it appeared advisable to implant a cartilaginous plate to take the place of the lost infra-orbital margin.
At the same time, it. was decided to utilise a piece of cartilage for a prosthesis of the eye socket, which was of a very shrunken character.
Two operations were therefore carried out at the same time on 10.9.17. An incision was made parallel to the lower lid and over the infra-orbital margin, and the skin undermined in the neighbourhood. A piece of cartilage, composed of a portion of two adjacent rib cartilages, was removed for me by Captain H. Montgomery, H.A..M.C.. IVoni this patient's right thorax, the attachment between the two rib earl Mages being left undisturbed. It was pared with the knife until it was of such a shape that the (•( ml our was accurately reconstructed, placed in position, and the skin reunited over it with siibcut icular horsehair. The sternal end of the 7th cartilage was then taken, in
REPAIR OF THE CHEEK
45
its whole thickness, and shaped into a cup and ball, as described in the chapter on Eye Plastics, p. 339. These two pieces of cartilage were inserted into the depths of tin- eye-socket through an horizontal incision made in the conjunctiva. The two wounds healed by primary intention, and, after the fitting of an artificial eye, the result was very satisfactory. Diagrams illustrating these later operations are appended.
FIG. 25. — After cartilage grafts to socket and cheek. Artificial eye fitted.
Flo. 26.-— Ditto. Same stage<
Sec tion
Cartilage , Prosthesis,
of L. Socket
\X7CM Costal N 8 ^[Cartilage
FIG. 27. — Diagram of cartilage implants.
46
PLASTIC SURGERY
CASE 73
Represents a type of case in which there was partial loss of the malar bone and fracture of the lower jaw. The deformity is not one which calls for definite recon- stitution of the bony framework.
Private C. was wounded on 1.7.16, and his condition on admission on 6. 7. 1C is shown in fig. 30, the result of a severe shell- wound. On 29.11.16 Lieutenant C. B. Tudchope, R.A.M.C., performed an operation. The large scar, extending from the outer orbital angle to half an inch below the lobule of the left ear, was excised. The fibrous tissue was so thick that the dissection led down to the remains of the malar bone and horizontal ramus of mandible. This dissection completely freed the lobule of the ear. In order to build up the contour, local fat-flaps were turned in and sutured with catgut but, owing to this being insufficient, a small free fat-flap from the buttock was implanted. The wound was closed by relaxation and horse- hair sutures, without drainage, the lobule of the ear being adjusted to position. Moderate suppuration of this fat-graft occurred, but the condition shortly before discharge was as shown in fig. 31. The fracture of the lower jaw necessitated the patient's stay in hospital for a longer period, and he was not discharged until 21.4.17. It is obvious that this wound involved the destruction of branches of the temporo- facial nerve.
.-
Fio. 28. — " Natural " flaps made by excision of scar.
Fio. 30. — Five days after wound.
Fia. 31. — Result plastic. Note : upper facial paralysis only.
REPAIR OF THE CHEEK
47
CASE 33
In this case the wound of the left cheek was complicated by loss of bone in the upper jaw. The wound also extended from the left corner of the mouth and opened widely into the buccal cavity. Unfortunately I have no record of the healed condition, and in view of one's experience, this spectacular result is to be, to a certain extent, discounted. The first operation (27.10.16) was performed three months after his shell- wound. The aim was to reform the corner of the mouth, adjacent portions of both lips, and a considerable amount of check ; and a large dense scar had to be excised. The mucosa was carefully dissected and sewn to reform the buccal lining and to complete the upper lip. My notes read that there was much less loss of tissue than was expected.
The result was gratifying, but as a considerable amount of scar tissue remained on the edges after excision of the main part of the scar, the line of union was not expected to be perfect. A particular twist of a mucous flap satisfactorily formed the corner of the mouth, and the wound healed well.
Two months later, a second operation was performed : the scar was excised, and fat flaps sutured beneath the line of incision, which was closed with horsehair sutures. In order to complete the case from a dental point of view, an extensive incision was made along the left alveolar border of the maxilla and a vulcanite plate inserted, held in position by elastic traction from a dental splint.
A denture was then adapted to the upper jaw, but I heard later from the patient that it had to be altered, which probably meant that scar tissue was reforming (vide notes of case 128, p. 60). Patient discharged on 14.3.17.
FIG. 3-. — Soon after wound.
Fia. 33. — Result of plastic. It is unfortunate that the healed stage of this case was not recorded.
48
PLASTIC SURGERY
CASE 41
This is an example of a large soft-tissue de- struction of the cheek and upper lip together with a small loss of the underlying alveolar bone of the maxilla. The tip and left ala of the nose arc likewise shot away ; but the interest of the repair is confined to that of the check. The first photograph shows the suppurating and granula- tion stage of the wound 10 days after the injury.
Two months later the plastic operation was performed, by which time the wound had healed by dense scar formation. This latter was freely excised, and the picture on the operating-table after such excision very closely resembled that of the original wound. The repair was made by transposing a large flap (A) from the side of the chin and submaxillary region of the same side, i.e. an ascending flap. Despite a mild infection, the repair was good. The secondary gap caused by raising flap A was closed with some difficulty, which was somewhat eased by 'a secondary in- cision (X) represented too short in the diagram.
No attempt at rhinoplasty was performed at this stage, but later an effort with small local flaps was made to modify the nasal defect with but poor result. There is no question, in view of the later development of rhinoplasty, that an excellent repair could have been effected on the lines of a turncd-in flap, to complete the lining of the tip and left ala, and of a covering from the left frontal region carried on a tube-pedicle flap, as in case 627, p. 244. Patient refused further treatment.
FIG. 34.— Wounded, 1.7.16. Condition, 1 1 . 7 . 1 G.
Via. 35. — Result 4 weeks after operation, per. formed 19.9.16. No attempt at rhinoplasty.
FIG. 30. — Excision and flaps.
REPAIR OF THE CHEEK
49
CASE 144
" Loss of soft tissue without serious loss of the underlying framework " is the category in which I put this case. The patient was wounded on October llth, 1916, and was admitted to me on 17.10.16. The wound is a very remarkable example of the explosive type and it is instructive to note how this patient's enormous gaping wound healed without more than ordinary surgical methods. I think this case teaches a lesson to the in- experienced in regard to the way the camera occasionally represents an inaccurate concep- tion of the wound. Thus, fig. 38 repre- sents the condition when the tissues were healed, without any plastic operation what- ever.
The further treatment of this case was undertaken by Captain J. L. Aymard, R.A.M.C., and consisted of excision of scars, with satisfactory results.
FIG. 37. — Condition on admission.
FIG. .'{8. — The result of healing without any operation.
Fia. 39. — After 1st excision of scar. Note : no general facial paralysis.
50
PLASTIC SURGERY
CASE 296
This case, Private W., wounded on 1.7.16, and admitted a week later, is an example of buccal fistula situated in the exit wound of a bullet which entered the left check and carried some teeth through the right cheek. In fig. 40 is shown the exit wound with buccal mucous membrane everted through the hole. The corner of the mouth just escaped destruction. This is one of the cases in which early opera- tion is indicated.
An operation was performed on 21.7.16 under general anaesthesia. The buccal mucous membrane was dissected up, invaginated, and retained by two rows of purse- string sutures. Accurate suture of the rest of the wound was not attempted at this stage, but approximation of the skin was produced by means of the method shown in fig. 41. Pieces of blanket flannel, to which are sewn dress-hooks, are fixed with collodium to each edge of the wound and the hooks are then united by rubber bands. Drainage was provided. This method, as advocated by Kazan jian, is very valuable in the early approximation of wounds when deep sutures are liable to suppurate and to produce more scar tissue than was previously existing. The result of this operation was very satisfactory ; no salivary leak occurred and the wound healed by good secondary union. There was a long, irregular, depressed scar still present at the end of two months. This scar was then excised, but there was a slight breaking-down near the angle of the mouth. The scar was re-excised some six weeks later. The result, as shown in fig. 42, was practically perfect and the man was discharged from hospital to duty on June 13th, 1917.
Fid. 40.— Buccal fistula.
FlO. 41. — Use of approximating hooks and clastic (Kazanjian).
FIG. 42. — Result of plastic and excision scar.
REPAIR OF THE CHEEK
51
CASE 101
Lance-Corporal W., wounded on 7.10.16, was operated on by me on 15.1.17. The wound involved part of the malar and zygomatic ridge. It will be noticed also that botli eyelids are involved in and dragged outwards by the scar. Two flaps were raised on each side of the scar ; from the lower a local fat-flap was turned upwards, while from under the upper flap a small portion of the temporal muscle, with its overlying fat, was turned downwards. The result as to the contour was good, as is shown in fig. 44. Under local anaesthetic four months later, an attempt was made to release the eyelids from the outward drag. This was only partially successful, the method used being to make an incision \ in. external to the outer ocular angle, \ in. in length across the line of the scar and to sew up this perpendicular incision horizontally. To further raise the scar a small tunnel was made from this incision in a backward direction and a small amount of paraffin wax imbedded. This was only partially retained.
I do not consider that either of the last procedures is to be recommended. In order to release the outer canthus correctly either a flap should have been laid in between the end of the scar and the outer ocular angle, or else a sufficiently large skin-graft applied to produce the same effect.
In regard to the insertion of paraffin, I cannot express too strongly my disapproval of using this irritant foreign body. Undoubtedly the best method of using paraffin is to imbed a definite quantity of it into a prepared pocket. The immediate results are often very pleasing. But there are so many examples known to all surgeons of chronic thickening of the parts, induration of the skin, paraffin tumours and other complications, that its use should be strongly deprecated, not only in this work, but also in all forms of civilian cosmetic surgery.
Flo. 43. — -The healed stage. Loss of bone in malar region. Outer canthus dragged out by scar.
Fio. 44. — Result after an attempt partially successful to relieve the drag on the outer canthus.
52 PLASTIC SURGERY
(c) WITH LOSS OF BONE
The severer injuries of the cheek include those in which there is loss of the bony frame-work. One particular group (1) is well defined, viz., that in which the malar prominence is wholly or sub-totally lost. I have chosen to illustrate this group by four cases which have been treated by means of the temporal muscle turned forwards subcutaneously. In one of the cases (40) a previous unsuccessful implantation of a celluloid plate was made and, in the following case, a thin celluloid plate was inserted over the temporal muscle flap with satisfactory results.
CASE 28
This patient was received in a healed condition on 18.5.16, as shown in fig. 45.
He was wounded 26.9.15, eight months previously, no record being available as to his previous condition. On 30.6.16 I operated under general anaesthesia. After excision of the scar, an extension of incision into the temporal region enabled me to detach the anterior two-thirds of the temporal muscle. This muscular flap was separated from the rest of the muscle and swung down into the depression caused by the loss of the malar prominence, in which position it was sutured with catgut. The lower part of the wound was filled up by means of local fat -flaps. Horsehair was used for the skin edges. In fig. 47 the result of this operation is shown. The dimple underneath the left eye is due to the deep suture above referred to, which retains the temporal flap in position. Primary union followed this operation. 1 was not satisfied, however, with the reconstitution of the left orbital margin ; hence, a piece of shaped rib cartilage from the right thorax was taken and inserted subcutaneously to form the outer orbital margin. An acute infection followed this operation, performed on 21.7.16, which owed its origin to the proximity of the orbital cavity, and the graft was removed to avoid the possibility of orbital cellulitis. The condition rapidly cleared up and on 7.9.16 some of the scar tissue was excised under local anesthetic (novocaine). On 14.10.16 a final operation was performed for the still further improvement of the contour and scar. The upper part of the vertical scar was excised, skin cut on the slant, and a bed made for a triangular smooth piece of celluloid, which was implanted. The skin edges were carefully sewn up with horsehair. The result of these operative procedures is shown in fig. 46.
An interesting after-history of this case is that, on 26.3.17, this man was re- admitted suffering from a localised abscess over the centre of the celluloid plate and line of the scar. The abscess was located between the celluloid and the skin and had not burst. The celluloid plate was freely movable and the abscess was not painful. Within a week suppuration had ceased and the patient was again discharged with the celluloid plate still in place. It is interesting to note that this is one of the few celluloid-plate implantations which, in my experience, have been retained. Another point of interest in connection with this case is the suppuration following the cartilage graft operation. In view of later experience with cartilage, I believe that had this suppuration been drained, there is the possibility that a large amount of the cartilage might have been retained, and that I was over hasty in its removal.
REPAIR OF THE CHEEK
53
FIG. 45. — Healed condition.
FIG. 46. — After insertion of thin celluloid plate.
Fid. 47. — Soon after temporal muscle implant.
PLASTIC SURGERY
CASE 40
Is the next example of this group. The healed condition of this case will be seen in fig. 48. Private F. was wounded on 7.7.16. The wound caused loss of the right eye part of the lower lid and the malar prominence, combined with the external portion of the orbital ring. At that time I was giving celluloid plate implantations a thorough trial and a piece of celluloid i in. thick was cut in the shape of the missing bony substructure and implanted in situ. The result was a failure, as ha?matoma and suppuration followed, and the celluloid had to be removed. On 30.1.17 it was possible to perform a second operation. After excision of the scar, the temporal muscle flap was swung down in the usual manner to make good the contour but, in this case, I improved the operation by making the temporal incision in the hairy scalp. This " inverted U " shaped incision is shown diagrammatically in fig. 50 and the earlier result of this particular operation is shown in fig. 52, while the later result of the implantation, witli the addition of an artificial eye, is to be seen in fig. 53.
FIG. 48. — The healed condition showing large malar loss and dragging down and out of the outer canthus.
Celluloid. Kiji
FIG. 49. — The first operation included the im- plantation of a shaped piece of celluloid. Failure. Removed.
It should be noted that, in swinging this temporal muscle forwards and downwards, the intervening skin had to be undermined and raised to allow the muscle to be passed underneath it.
Care must be taken to detach the temporal fascia from its zygomatic attachment. When this is completed the muscle flap usually comes forward as far as is necessary. In some cases I have advanced it considerably further by dissecting downwards — towards the coronoid process, at the back of the muscle-flap. When this is done, the end of the muscle- flap can be easily stitched to the periosteum at the side of the nose, vide Case 215, p. 71. Even in this situation the temporal muscle continues to contract.
Two months later a small operation was performed to raise the lower lid at the inner and outer angles. At the outer angle a small skin-flap was turned into the socket after the adhesions were dissected out, while at the inner angle a small wedge-shaped piece was removed to bring the angle more towards the middle line. This enabled an artificial eye to be carried, but was not entirely satisfactory.
The result was perfect as far as the contour was concerned, and the temporal
REPAIR OF THE CHEEK
55
muscle, in its new situation, had a certain amount of contractile power, thereby giving expression. The eye socket and lower lid need further improvement.
This case has recently been seen, eighteen months after the temporal transplant operation, and the contractile power of the muscle is undiminished.
I MS,
FIG. 50. — Incision and preparation for the author's operation for temporal muscle transplant.
FIG. 51. — The flap of muscle sutured into position.
FIG. 52. — Soon after operation. Showing " U " temporal incision. Note the excellent contour.
FIG. 53. — Later. Artificial eye fitted. The lower lid still requires raising.
56
PLASTIC SURGERY
CASE 220
Wounded 27.2.17. First operation, 27.6.17.— After excision of scar, a flap (fig. 55) was swung up, and split to enclose the corner of the mouth, the larger portion going to the upper lip, the consequent gap being filled by advancement of flap ('. (figs. 56 and 57). Skin and mucosa were sewn separately, to ensure a lining. Mattress sutures were employed down as far as the upper lip. One or two edge-to-edge sutures were added in the middle of this part, the result being best here. Elsewhere interrupted sutures were used, giving a better scar than where mattress sutures were used alone. I do not condemn mattress sutures because of this experience, as I find that a scar in the temporal region is usually more marked than one in the mouth region. But I think mattress sutures should be assisted by the addition of edge-to-edge sutures. The upper six mattress sutures were of thread ; hence, possibly, the prominence of this part of the scar, the result being otherwise good.
An observation should here be made that in planning the flap for the upper lip, I allowed slightly for contraction. None has occurred, and I assert that where no raw surface is exposed, none will occur ; and the teaching that the flap should be cut one-third or more larger than the gap would appear erroneous. When an epithelial or mucous lining can be provided, the flap should be the exact size of the gap. The only modification I make on this has been discussed in Chapter I. I do not think it advisable to undertake plastic operations involving mucous cavities without seeing that the complete lining is available.
A second operation on 13.3.18, consisting mainly of excision of the redundant portion of the flap above described, resulted in great improvement of the line of the lip. At the same time, an ovoid piece of cartilage, from another case, was inserted into the eye socket through the usual conjunctival incision. The result, after fitting an artificial eye, is shown. The lower lid needs raising a trifle.
t'ia. 04. — Recent wound of cheek and upper lip. Fio. 55. — Diagram of excision of scar and of flap, A B.
REPAIR OF THE CHEEK
57
FIG. 56. — Flap, A Bt raised and split to form corner of mouth.
FIG. 57. — Suture. Flap, O, advanced to fill gap. Note relaxation buttons.
Fio. 58.— Day after operation, showing relaxation buttons and horsehair mattress sutures.
FIG. 59. — Final result. Lack of muscle power in lower lid spoils the eye effect.
PLASTIC SURGERY
CASE 192
Is interesting from the point of view of the very large hollow produced by the loss of the malar prominence, infra-orbital plate and adjacent parts of the superior maxilla. Though wounded on 24.8.16, this patient was not admitted until 9.3.17, when the photograph, fig. 60, was taken. Temporal muscle operation was performed on 16.4.17, but the operation had to be modified by the addition of a skin-flap. It should be noted that there was a small sinus leading into the left antrum at the bottom of the scar and the lower lid as well as the left eye had been shot away. The flap of skin was turned down from the left temporal region from the line of the temporal artery. It is marked " A A" in Professor Tonks's diagram, fig. 61. This flap was slightly bigger than is represented and was swung down beneath the eye. In order to fill the gap caused by the removal of this flap, a swinging flap B was taken from the scalp. The whole result was a very marked improvement. On arriving at the condition shown in fig. 62, one has brought into the bounds of possibility the question of the reformation of the left eye socket. A certain amount of movement is again present in the transplanted muscle. The secondary closure of the temporal region has resulted in an advancement of the hairy scalp — a condition which is not an unpleasant one.
The lymph-oedema of the upper lid gradually diminished. The treatment of the eye socket was carried out for me by Captain C. F. Rumsey, R.A.M.C., who did a Tripier operation, i.e. swinging a stirrup of skin from the upper to the lower lid, the flap ends remaining attached for the blood supply to both ocular angles. The resulting condition was such that the socket could retain a glass shell.
At this stage the patient was discharged from the Army, to return later for the com- pletion of the eye socket.
Fid. 60. — The healed stage showing large malar, and infra-orbital bony loss of lower lid, etc.
FIG. 61.- — Shows author's temporal muscle-flap being brought into position, and a temporal skin- flap, A A, to be swung down beneath eye to A' A'.
REPAIR OF THE CHEEK
59
The further treatment will probably consist of the insertion of a thin strip of cartilage into the lower lid to retain it at a correct level. It may be necessary to deepen the socket by means of an epithelial inlay.
FIG. 62. — Result of this operation.
FIG. 63. — Result of Tripier operation.
FIG. 64. — Incision for Tripier operation.
FIG. 65. — Suture.
60
PLASTIC SURGERY
CASE 128
Is not unlike the one which directly precedes this. Rifleman B. was wounded on 3.9.16 and admitted shortly after this date. No photographic record of the condition at this stage is available but on 15.2.17, the day of operation, the deformity was as is to be seen in fig. 66. The outer third of the left upper lip was drawn upwards and inwards and bound down against the ala of the nose, leaving a triangular opening in the cheek with the base downward. The apex of the triangle "|K'iis into the antrum while a large scar radiates out into the cheek from the outer extremity of the gap. The lower lip is involved in this cicatrix and is drawn
upwards.
Operation was performed on 15.2.17. The scar tissue was excised and the
lips freed. A small flap of skin from the upper and lower margin of the gap was turned to complete the epithelial lining of the aper- ture, so as to prevent cicatricial contraction later. To meet this inverted epithelial flap, a mucous flap was drawn up from inside the left cheek. The mucous membrane at the angle of the mouth was completed by swinging round a portion of the lower lip and suturing it with deep catgut and superficial horsehair sutures to the free edge of the upper lip. Diagram 67 illustrates the method of freeing the upper lip. The corner of this lip was brought down to help to form the corner of the mouth. The flap was then outlined and swung up to complete the closure. It will be observed that in fig. 68, a vulcanite support, taking the place of the alveolar margin where it was wanting, has been fitted by the dental surgeon. It was retained in position until the wound was well healed, which occurred with- out untoward symptoms. Black silk was used on this occasion to unite the skin edges. (25.1.17.) Some intra-buccal adhesions were cut by Captain C. F. Rumsey to allow a satisfactory denture to be fitted. Photograph, fig. 69, shows the condition on 16.7.17.
In regard to the cutting of intra-buccal adhesions, I feel very strongly that this is a
method which docs not often succeed ; more frequently than not it produces more scar tissue than before the treatment, and anything in the nature of an extensive freeing of the lip or cheek by the underlying bone by undercutting and insertion of a dental appliance is, in my experience, doomed to failure. I admit, however, that where the loss of mucous membrane is minimal and where there is a definite band of scar tissue this can sometimes be dealt with by this method. In all other cases recourse should be had to the epithelial inlay method of Esser.
Fio. 66. — The healed condition, 15.2.17. Note the shield on the obturator, also the iodius which spoils the photo.
REPAIR OF THE CHEEK
61
FIG. G7. — Scar excision and incisions. The inverted skin and mucous membrane flaps cut to complete the lining are not shown in this diagram.
FIG. OS. — Suture.
Fia 01).— Result, 16.7.17.
62
PLASTIC SURGERY
CASE 14
The illustration, fig. 70, is an example of a very extensive cheek wound with loss of the supporting bony structures, especially of the superior maxilla. The corner of the mouth and left half of the upper iip were involved in the destruction. Wounded in the battle of the Sommc, the first plastic operation was pcrfoimcd thice months later, on 4.10.16, on which date the condition is as shown in fig. 71. Dur- ing this period the dental surgeon had made successful efforts to reduce the fractures of the upper and lower jaw and the healing process apparently diminished the loss of tissue. However, on excision of the scar, there was a very extensive gap, not considerably less than that shown in the original wound photogiaph. To meet this difficulty, two large flaps both of a swinging variety were taken. The larger one, A,
comprised the remains of the soft tissues of the cheek and was defined by means of an incision ex- tending from the side of the nose and carried outwards beneath the eye to the malar prominence; while the lower flap, B, was outlined by an incision carried down from near the corner of the mouth to below the mandible in the sub-maxillary region. These two thick flaps were widely under-cut and swung towards each other ; the upper flap completed the gap above the level of the mouth, while the lower one was sutured along its lower border. Owing to the large deficiency of mucous membrane, it did not seem possible to complete the mouth in its original size and some sacrifice in length of the lips was perforce made. Relaxation sutures were inserted to retain the untouched part of the lower lip to the large cheek flap. Drainage was provided at a suit- able spot. The result of this plastic operation was very satisfactory in so far as one operation pro- duced a result which satisfied the patient ; but it left the man with a whimsical, one-sided expression which, however, was not entirely unpleasant. The rest of the treatment for this patient consisted in the effort to get union of the right horizontal ramus of the mandible. An extensive freshening of the ununited fragments was carried out on 11.1. 17, but no union resulted after a period of three
months. On 25.4.17, the fracture ends were again exposed but, although found to be in good apposition, there was no bony union. The surfaces were again freshened, drilled and wired together with strong iron wire. This operation was carried out by Captain J. L. Aymard, R.A.M.C., and Captain F. E. Sprawson, R.A.M.C. No union had occurred at the end of two months but, at the end of five months, there was clinical union of the fracture and the patient was fitted with an upper and lower denture which enabled him to eat a semi-solid diet. He was discharged from the Aimy unfit for further service.
FIG. 70. — Showing condition a few days after wound on 1.7.16. Compare this with the healed stage, which gives a truer con- ception of the loss of tissue.
REPAIR OF THE CHEEK
63
FIG. 71. — The healed condition, 4.10.16.
Fio. 72. — Diagram showing excision of scar and flaps cut.
Fio. 73. — Suture.
Jfc
Fio. 74. — Early result operation, October 1910.
Fio. 75.— September 1917.
PLASTIC SURGERY
CASES COMPLICATED BY SUPERIOR MAXILLARY LOSS
A less defined group is one in which the bony support of the upper jaw is missing. The loss of bone may be in the alveolar process, the anterior wall of the antrum or in the infra-orbital plate. When the combined bone and skin lesion is not great, the difficulties are overcome with very satisfactory results ; but when there is a great loss of both soft and hard tissues, as in Case 215, the problem is one requiring much thought.
CASE 4
This man was wounded in the upper jaw and cheek, including the corner of the left upper lip, by a shell, on 1.7.16. The bony loss consisted of the alveolar process and the lower part of the antral wall. The condition cleared up sufficiently to allow the
FIG. 70. — On admission three weeks after wound.
first plastic operation to be peiformed on 29.9.16. The irregular scar was widely excised. The gap produced by this excision is well shown in diagram, fig. 78. In order to close this gap a large swinging flap, A' B', was swung upwards to meet A B, and the mucous membrane at the corner of the mouth was rearranged. On 2.11.16, some six weeks later, the scar tissue was excised and fat-flaps brought to fill up the hollow ; this was sutured with catgut, the skin with horsehair. The final result, seen in fig. 81, is sufficiently satisfactory. When fitted with dentures on discharge from hospital, the patient was able to eat most articles of diet.
REPAIR OF THE CHEEK
65
FIG. 77. — The healed condition.
FIG. 78. — Diagram representing excision FiQ. 79. — Diagram
of scar and cutting of flap A' B'. of suture.
a. 80. — Result of operation, 2(1. 9.1(i. Intermediate stage.
Fid. 81. — Result of operation, 2.11.16. Photo taken, 2 1.11. 1C.
66
PLASTIC SURGERY
CASE 142
The early condition of Private R. C., of the Scottish Rifles, wounded on 1.9.16, is represented in the accompanying figure 82. The condition had so far cleared up that I was enabled to perform the first plastic operation five weeks after this patient was wounded. Unfortunately the photographic record of his healed con- dition is missing. Too much was not attempted and the result was sufficiently satisfactory. Fig. 88 shows the result of this operative procedure, of which records were not accurately kept. But the large hole in the left cheek, involving the angle of the mouth and a portion of both lips, was closed by two swinging flaps, one from above and one from below. A further plastic operation was per- formed by me three months later and, here again unfortunately, the details are not available. The condition after this, when healed, is as shown in fig. 83. At this .stage, Captain Aymard undertook to finish the condition. After excising the scar, the lip was raised and sewn by the method shown in Professor H. Tonks's diagrams, the result being all that one could expect.
Fio. 82.— Wounded on 1.9.16. Showing condition a few days later.
FIG. 83. — Showing result of two plastic operations (author), 10. 10. 1C and 3.1.17.
REPAIR OF THE CHEEK
67
//?-<-^
FIG. 84.— Diagram (Tonks) of operation to raise corner of mouth.
FIGS. 85 and 80. — To show result of operation, 13.3.17 (Aymard).
(IS
PLASTIC SURGERY
CASE 49
Is another example of the ravages of shell. This private of the Royal Minister Fusiliers, whilst still in the condition shown in the photograph, fig. 87, was found one morning looking in the mirror and smiling with the remaining side of his face. His excuse for his amusement, he explained to his medical officer, was that he was thinking " phwhat an aisy toime the barber would have in future." This is charac- teristic of the cheerful resignation of face cases in general. The extensive injury in this patient comprised a large loss of substance of the left cheek, corners of the mouth and upper lip, together with the anterior and inner walls of the left antrum and alveolar margin. Strong cicatricial bands formed between the maxilla and mandible, the body of which was likewise fractured. An injudicious attempt to form the mucous lining of this cavity was made on 26.10.16 without, at the same time, closing in the gap by skin-flaps. Although the operation was carried out with great care and accuracy the want of skin covering over the mucous membrane flaps led to mal-nutrition of the mucous membrane and the giving way of the stitches. I have tried this method of building up the lining at a separate sitting to the covering both of mouth and nose openings, but have not had satisfactory results. Both lining and the covering should be done at the same time or, if it is impossible to find a lining, the covering should be epithelialised first. On 6.1.17 the patient still showed a very deep depression on the left side of the face, communicating widely with the nasal cavity. Much granulation and scar tissue was present, involving the left portion of the upper lip. The covering to this gap, after extensive excision of scar, was formed by two advancing flaps from the cheek, as indicated in the dia- gram, fig. 88. Similarly, the upper lip was cut across below the nose and sutured to the freshened surface beyond the angle of the mouth and, to round off the angle, a small mucous flap was turned upwards from the lower lip. An attempt was then made, by means "of a free muscle graft taken from the vastus externus, to close
over the hole into the nose and to fill up the contour. The closure was then completed, a relaxation suture being used to relieve the tension. The whole of the muscle graft became infected and apparently sloughed out. This is borne out in other similar experiences where the graft is exposed to a mucous cavity. Its place, how- ever, is taken by granulation tissue and later fibrous tissue which very materially aided in the final treatment and enabled me, three months later, to implant a piece of cartilage to make good the loss of contour. At this operation, date 11.4.17, there still existed a small per- foration into the nose which was closed by turning in over it small scar tissue flaps. A plate of cartilage about 2 in. by 1| in was taken from the right thoracic wall. The result of this implantation was satisfactory from a cosmetic point of view but, surgically speak- ing, it was not gratifying on account of a small leak into the nose, causing later infec- tion of the graft. The infection was of a mild character, however, and was controlled by Hicrs cupping. The result is shown in photograph, FlG. 87. — Healed, 20.10.18. fig. 90.
REPAIR OF THE CHEEK
69
\
Fia. 88. — Scar excision and flaps. FIG. 89. — Suture.
Note : another incision along the upper lip is missing in the diagram.
FIG. 90. — After plastic and cartilage implant.
70 PLASTIC SURGERY
CASE 105
Is a typical example of the shattering effect of an exit wound of a high velocity projectile which came into contact with a dense piece of bone. A considerable portion of the right angle of the mandibles as well as the tissues overlying it, were blown away, producing a large buccal fistula. After many months of suppuration and operations for scqucstrotomy, the wound eventually healed. Bits of the mandible had been blown down into the neck and one piece was removed from the right stcrno- mastoid. Examination of notes made at the time of the first plastic operation reveals that there was a deep scar over the region of the right angle of the mandible and radiating in all directions.
On 16.1.17 this operation was performed. Under general anaesthesia the scar tissue was carefully dissected out. Eatty tissue in the form of flaps was swung over the deepest portion of the wound and sutured into place. The skin edges were completely united with continuous silk suture. Examination on 12.3.17 revealed that the result of the previous operation was excellent, except that, from a contour point of view, there was too much prominence just anterior to the angle of the jaw. On examining X-rays, this prominence was found to be due to the fact that the body of the mandible had been split into two halves by the projectile and that the union with the ramus had taken place by attachment to the inner plate, while the lower border of the body had been deflected outwards and stood out as would an exostosis. It was decided to remove this prominence of bone and to cut a flap of thick tissue to be swung backwards toward the angle to simulate that prominence. The result of this procedure, on 12.3.17, was satisfactory in restoring the contour of the jaw. At this time, the right antrum, which was still somewhat infected, was drained through the nasal fossa. There still remained a certain amount of scar tissue which was excised, at my request, some five weeks later by Captain Ayniard. Owing probably to tin- fact that this operation followed too soon on the above, no further improvement was obtained, as there was some slight sloughing.
I think the most astonishing feature of this case is the fact that union of the mandible was obtained after such a long period of suppuration and exfoliation of bone.
The wound was so septic that the idea of early closure was unthinkable. But the question arises that if all the pieces of bone that were later exfoliated had been taken away in the early stages, in order to clear up the sepsis, would union of the mandible have been obtained ? I hardly think so. In my experience, as a rule, this class of explosive wound, with buccal fistula, rapidly cleans up on account of the free drainage. But in this ease- pieces of bone had been driven down, not only into the sub-maxillary region, but also as far back as the sterno-mastoid ; the drainage, though apparently adequate, was not really so.
Fio. 91.— Explosive type exit wound. FIG. 92.— After moderately successful plastic attempts to
improve the contour.
REPAIR OF THE CHEEK
71
CASE 215
One of the most extraordinary examples of loss of contour that I have had under my care. Literally the whole cheek and its supports have been blown away ; the left lower eye-lid, swollen with lymphatic obstruction and dragged down by scar tissvic, is all but joined to the angle of the mouth, which is likewise distorted by the cicatrix. Excepting a thin plate of the ascending ramus of the lower jaw, the mandible has been destroyed from the first molar region to the joint. The left eye has been enucleated. Working in conjunction with Captains C. F. Rumsey and Robertson, under whose care this case was placed, it was decided to replace the remains of the superior maxilla and mandible as far as possible into their normal positions. An impression of the upper jaw is shown in fig. 93, which shows the extraordinary approximation of the two alveolar borders.
First of all, the scar tissue was excised at the left corner of the mouth and carried out so that a large opening was made into the buccal cavity. The healthy mucous membrane was drawn out and stitched round to the margins, so that there should be less scar formation. In regard to the mandible, there was a plate of bone representing the left ascending ramus lying inwards from its normal position and having no connection with the joint. Its connection to the scar tissue and to the anterior fragment of the mandible was cut and, thus mobilised, it took a more normal position. As far as the maxilla was concerned, a small chisel was entered between the left canine and lateral incisor region and driven backwards along the palate without injuring the mucous membrane on the oral surface. This mobilised the left half of the palate so that it could be easily replaced into normal position. It was held there by a temporary support while a proper cap splint was being made. This was fitted in a few days and worn for some months. The impression of the palate as it is now, is shown in the accompanying fig.- 94.
FIG. 93. — Model of palate before its forcible replacement.
FIG. 94. — Same after the left half of the palate had been levered into position and retained there by appliance.
About five months later the plastic operation proper was performed, on 7.12.17.
The principle of this operation may be described in the following manner : The mucous lining was provided by raising the available mucous membrane from below and above the gap, as two flaps, and then suturing together. The intermediate, or supporting structures, were provided by means of a large temporal muscle transplant,
72
PLASTIC SURGERY
Fids. 95 and 96. Destruction of the greater portion of the left side of the face. Note the contour.
f
Fio. 97. — Result of opening up wound and forcibly FIG. 98.- — Diagram of flaps for next stage. The
replacing left half of palate. Retention apparatus in mucous membrane lining is represented by the shading. position. C is a post auricular flap.
REPAIR OF THE CHEEK
73
7 X
FiO. 99. — Diagram'of the four cartilage implants.
Fio. 100.— Final result.
FIO. 101. — Same. Note the difference in contour as compared with the original.
74 PLASTIC SURGERY
carried out in the usual manner. The anterior portion of the left temporal muscle was detached from its origin and swung down beneath the eye to fill up the contour of the check. An incision in the hair line was necessary to get at this muscle and it was then possible to undermine the skin from the zygomatic region to enable this muscle to be detached. Deep catgut sutures holding this in position had for their purchase the left lateral aspect of the nose. The main skin-covering was provided by a large transposed flap with its base in the left sub-maxillary region and its apex in the left mastoid region. Its design is well shown in Professor Hcmy Tonks's diagrams. It met the main deficiency of cheek skin. The area behind tin- ear, caused by the removal of this flap, was only partially closed by undermining and advancement of the skin and was left to granulate. The flap healed remarkably well, as did the granulating area, and this, despite a chronic suppurative otitis media which was present in the left ear immediately above the site of operation. The healing properties of this particular patient are indeed remarkable.
There remains to describe the replacement of the eye socket. This was merely sutured into a higher level after excision of the scar which bound it down to the mouth region. The corner of the mouth was regulated and reconstituted by a special cut, which enabled the upturned corner of the upper lip to drop to its normal level.
Examination in April 1918 revealed the fact that the upper jaw was firm in its new position and, with the strip of bone mentioned above, the remains of the left ascending ramus of the mandible have become firmly united to the rest of this bone, thus producing a very considerable functional improvement as far as mastication is concerned. The jaw cannot be opened to its fullest extent but the trismus is not of a disabling character.
Having a large piece of cartilage to spare from another operation case, this was inserted subcutaneously over the manubrium sterni, under local anaesthesia. Five days later, under general anaesthesia, the cartilage was extracted from its bed and divided into four pieces, the largest piece being utilised to complete the contour of the mandible. The second, a long thin strip, was inserted beneath the eye socket to retain the lower lid at a higher level. The third piece was placed in the external orbital region, while the remaining piece was inserted into the temporal region, whence the muscle had been taken.
I am greatly indebted to Major C. W. Waldron, C.A.M.C., for permission to complete this Canadian case after it had been officially transferred to him for treat- ment and I had the benefit of his advice and assistance at this latter operation.
It is still doubtful whether a really satisfactory artificial eye can be fitted ; but, as this man states he is returning to a very cold part of Canada, and is therefore not anxious to have this fitted, the case is now completed.
"v,
INJURIES OF THE UPPER LIP
CHAPTER III INJURIES OF THE UPPER LIP
THE repair of the upper lip after gunshot wounds is to be considered from three main points of view: (1) the provision of the skin-covering; (2) the provision of the muscular and subcutaneous layer ; (3) the provision of the mucous membrane lining and vermilion border.
Taking the first of these problems, the skin, the subjects being all men, it is a great advantage that your flap should contain hair-bearing follicles : this is more especially the case since it is quite unusual to find an upper lip that is totally destroyed and does not present portions bearing moustache. It would seem, therefore, that the flap of election for an upper lip would be an ascending flap with its base opposite the line .of the upper lip and its extremity situated in the lateral chin region. This method violates one important principle, viz. the direction of the blood supply, as it is obvious that it cuts across the facial artery at its division into the coronary arteries. It is, however, as a matter of practice, a satisfactory flap, but there have been occasions when one has lost portions of it by sloughing caused by scar tissue in the neighbourhood of the blood supply, or when it has been cut too long. Each case has to be taken as a problem by itself.
The second main method of making new portions of the upper lip is one which includes the use of descending lateral nasal flaps, with their bases in more or less the same position as the above-mentioned.
This flap has the advantage of an excellent blood supply, and shows little tendency to depress the corner of the mouth, which is not uncommon with the ascending flap. On the other hand, there is no hair-bearing skin in the flap, and, if the mucous membrane is to be included, there is only a small available amount under the flap, and its length is limited by the undesirability of encroaching on the lower eyelid region.
Transference of hair-bearing skin from a distance is the third method of external covering for a lip. Hair-bearing skin is swung down from the temporal region, as in Case 324, or from the forehead, or from the temporal region on tube pedicle flaps as described in Principles.
77
78 PLASTIC SURGERY
These arc merely methods of getting hair-bearing skin from the scalp to the lip, and all have the advantage of introducing new tissue to the region of the mouth and of leaving no secondary facial scars.
A rough comparison of the pros and cons of the three methods follows, giving ideas which may be found useful in upper -lip plastics.
ASCENDING :
(a) Advantages. — Hair-bearing, ample mucous membrane underlying,
wide mouth.
(b) Disadvantages. — Blood supply less good, more twist, depresses
angle of mouth if any of lip remains at corner, muscular movement indifferent. Scars noticeable.
(c) Indications :
(1) When a scar runs up and out from lip.
(2) When there is accompanying loss of cheek near
upper lip.
(3) For half-lips when there is a good half moustache
remaining.
Fid. 102.— Ascending flap. FiO. 103.— Descending flap.
DESCENDING :
(a) Advantages. — Good blood supply. Angle of mouth not depressed.
Muscular movement good. Scars negligible.
(b) Disadvantages. — No hair. Shortness of mucous membrane lining,
apt to be cut too short, and therefore contracts the mouth and puckers the lower lip.
(c) Indications :
(1) Where a portion of the upper lip remains near the
corner.
(2) When a scar runs down and out from the mouth.
MIXED :
(a) Advantages. }
(b) Disadvantages.^™*^* th°SC °f "* ab°Ve>
(c) Indications. — When corner and small part of adjacent upper lip
remains on the one side (diagram, p. 85), and a loss right
INJURIES OF THE UPPER LIP 79
up to the corner and extending to cheek on the other (see diagram). This method slews the mouth in toto to one side, but has given me one good result.
See Case 106, p. 84. Scalp -flap.
(a) Advantages, — -Provides moustache, and new tissue introduced from a
distance, no secondary scars on face. The lining may be pro- vided at same time by including portion of non-hairy forehead.
(b) Disadvantages.- — Blood supply not always reliable (I have seen
several failures due to gangrene), no musculature in flap. The operation is a considerably larger affair.
(c) Indications. — (1) Where the loss is great and much scar tissue lies
in and around base of ordinary flaps. (2) In an otherwise perfect face where the skin covering only is required. (3) After failure of other methods.
Fio. 104. — Temporal artery scalp flap.
In sub-total and half-lip losses, the same principles are involved, but there are a few additional methods which deserve mention.
(a) The advancement of the remaining portion of the lip to meet
a new flap.
(1) Advantages. — Second flap need not be cut so long.
(2) Disadvantages.— Very apt to shorten lower lip and to
make it pout, also to upset the subsequent applica- tion of a denture.
(3) Indications.— Small losses, and to make full use of exist-
ing lip and red margin. No harm is done by this incision, and it is a useful manoeuvre provided that the corner of the mouth is carefully preserved.
80 PLASTIC SURGERY
(b) Advancement with parallel cut through existing corner — a larger
gain of length is obtained than by the simple advancement. But derangement of the corner occurs and always requires a secondary correction, often an enlargement of the mouth.
(c) Advancing swing — transferring part of lower lip to upper, a new
corner being made. This method has its uses, but my ex- perience with it is not large enough to see clearly its limitations. When the cut includes the mucous membrane, the secondary deformity is very considerable and difficult to correct ; but when the skin only is slid over the deep tissues to the upper lip, like one card over another, the secondary deformity is not serious either functionally or aesthetically.
A further method, and probably the best, is available for a loss of the central portion of the upper lip.
(d) An ascending whole thickness flap is let in above, through or
below the existing third of lip on one side. This depresses the angle of the mouth and needs a subsequent correction at a later date when a portion of this flap is returned to the lower lip to raise the angle. This secondary correction is easy to obtain. Several examples are illustrated among the cases.
(e) The ascending bridge flap with hair for moustache is indicated,
when skin only is required. The pedicle is returned to the cheek. Vide Case 295, p. 114. (/) Similarly, moustache bridge flaps may be cut from the scalp
and swung down to the upper lip with successful results, (g) Method of Esser. See Annals of Surgery, March 1917. Secondary corrections to the new upper lip are of only too frequent neces- sity. I have seldom produced a satisfactory upper lip in one operation. Corrections of the level of the mouth corners, of the red margin, of microstoma, of adhesions between lip and jaw, and of general tightness, all present problems which cannot be usefully discussed at the present time.
In regard to the second provision for an upper lip, the muscles and sub- cutaneous tissue, both the main methods of repair above mentioned provide this tissue body for the new lip. Thus, the ascending flap from the chin region includes the orbicularis and various portions of muscles attached in the region of the chin, while the descending flap has muscular fibres.
It is doubtful whether either of these muscular flaps gives as much move- ment in its new position as the main flap for making a lower lip, which is mentioned in the next section. But in both cases a certain amount of muscular function appears to persist, It is, however, to be admitted that the move-
INJURIES OF THE UPPER LIP 81
ments of a new lip are very inferior to that of the normal, and as the form of the lip depends, to a very great extent, on the normal muscular poise, it is obvious that the reformation of a normal upper lip is not, so far, within the maximum of possibility. The most that I foresee as a result is a new upper lip, which, in a position of rest, gives a normal appearance. The production of the filtrum is a subtlety which does not seem to be worth attempting until one has produced a higher grade lip than at present. I have made attempts, as in Case 177, in which the tissue of the new lip was very thick under the nose, and gradually became thinner as the red border of the lip was approached, to roll down the flap of subcutaneous tissue from the upper and nasal aspect of the lip to the free border. This partially succeeded. It may be that very thin strips of cartilage inserted under the skin might produce a satisfactory edge to a lip as well as a filtrum.
In regard to the provision of the mucous membrane, this is a matter which requires very close examination in each case, for frequently a good deal of useful mucous membrane has been saved after the injury. Frequently small flaps of skin in the neighbourhood can be turned, with . their skin surfaces inwards, to keep the lip free, and, in addition, the ascending flap mentioned above, which not only contains skin and muscle as well, can be made to include mucous membrane. In such a case the whole new upper lip is made with one design. Personally, I have not used this flap on many occasions, either because it was not necessary, or because some complicating scars were present. The only disadvantage of taking the mucous membrane with this ascending flap is a certain amount of shortening of the cheek mucous membrane, and if there is any septic process occurring after the operation, one is liable to create adhesions in one or other sulcus affecting the efficiency of mastication; but, with a well-cut flap and proper attention, I do not think this complication should occur.
Another method of providing mucous membrane for a vermilion border of the new upper lip is one involving the transference, in two stages, of the mucous membrane flap from the lower lip.
If the vermilion border missing is situate on the outer third of the lip, then the mucous membrane flap from the lower will have its base near the corner of the mouth. But if the missing portion of the vermilion border is in the central portion of the upper lip, a flap is conveniently turned up, in a vertical direction, from the centre of the lower lip, with its base towards the free margin of the lip.
In this latter event, it is necessary to stitch the two lips together while union is taking place and before the pedicle is divided. For the details of such operation see Case 184, p. 150,
0
82 PLASTIC SURGERY
A few other general points about upper lips are worthy of mention. Com- plete loss of the upper lip does not occur, in my experience, without the loss of the pre-maxilla, and quite half the difficulty of forming a satisfactory upper lip in a complete loss is to be found in the difficulty of restoring the bony contour by means of a dental appliance. There are usually very few teeth left in the upper jaw on which to carry a satisfactory prosthesis ; in addition, one fre- quently makes a mistake in making an upper lip with flaps insufficiently long, and consequently there is a tightening and flatness, and the denture becomes very liable to be pressed on and easily displaced. Another of the mistakes that I have perforce fallen into is that one did not at first realise that the prominence of the central portion of the upper lip was due not entirely to the pre-maxilla, but to what I describe as the suspension of the upper lip from the columella of the nose. The upper lip hangs like a curtain from the columella. With one's fingers in the vestibules of the nose, gripping the columella, one finds that the upper lip is suspended by that portion of the nose. Looking at a normal upper lip from the side, one is aware that it runs well up into the columella, whereas in actual practice the majority of the new upper lips do not present this suspension from and incorporation into the nose ; they seem to run straight across from one ala to the other in an abnormal manner. Frequently, of course, this condition results from the accom- panying loss of the columella and anterior nasal spine ; but, in repairing the upper lip, the anatomical attachments that I have mentioned should be aimed at.
I am indebted to Professor Henry Tonks for pointing out to me the defects in the upper lip from this point of view, especially from the loss of the pre- maxillary prominence, and, on thinking the matter over, the suspension of the upper lip from the columella presented itself to me.
It is quite reasonable, as mentioned above, to turn a portion of the lower lip into the upper; but when this process is overdone, the result is most unpleasant. The greatest care must be exercised in this manoeuvre to see that ugly deformity of the angle of the mouth is not produced.
In comparing it with the lower lip repair, it would seem to me that the shortening of the upper lip is a very much greater defect than a similar shortening of the lower. In a few words, it is quite possible to sew up a lower lip which has lost nearly a third of its bulk without causing either a serious functional or aesthetic deformity, whereas a similar loss of the upper lip cannot be produced without very serious impairment of function, accompanied by a most unpleasant effect, and it is probably for this reason that, in my experience, the formation of the upper lip is more difficult than that of the lower.
INJURIES OF THE UPPER LIP 83
ILLUSTRATIVE CASES
Those that I have chosen to demonstrate loss of the upper lip and its repair have been grouped in the order of decreasing severity ; thus the first few are examples of complete loss, whereas the last are of minor injury of the lip.
Total loss of the upper lip, as I have already stated, is not met with without the accompanying loss of the pre-maxilla, either in part or as a whole. Fre- quently these severe injuries of the upper lip involve the lower portion of the nose, and in some cases the whole of the nose, as well as the pre-maxillary and central two-thirds of the upper lip, has been destroyed by one projectile.
The problem of the repair is to a large extent dependent on this loss of the pre-maxilla. I have divided the severe upper lip injuries into those accompanied and those unaccompanied by loss of the bony structure. It is with the bony loss type of lip that the aid of the dental surgeon must be urgently invoked. In all cases a prosthesis should be prepared, which will ensure that the new lip is efficiently supported from underneath, and at the same time that the incisions of the mucous membrane do not lead to cicatricial contraction of the upper sulcus. It should be designed so as to have as perfect a fit as possible, and, if necessary, it may be supported from the lower teeth or even from a lower denture. This dental appliance must be so made as to ensure that the new lip is of sufficient size. After the under-lining of the new lip is satisfactorily made of mucous membrane or skin turned inwards, very little — if any — contraction need be allowed for, but if any raw areas on the under-surfaces of the lip are exposed to the buccal secretions, ulceration will cause severe contraction. No upper lip should, therefore, be designed which does not include its most important element, the mucous lining. In this class of case, the following is a good example :
84 PLASTIC SURGERY
CASE 106
This R.A.M.C. Orderly was wounded by a shell fragment on 28.4.16, and admitted for plastic treatment on 27.6.16, two months after he actually received his injury. His condition was most repulsive — complete loss of the upper lip was accompanied by total loss of the pre-maxilla and by destruction of the anterior portion of the floor of the nose, and of the adjacent walls of left antrum. The nose was considerably deformed and dragged downwards in the healing process. A satisfactory dental appliance having been made by Captain L. A. B. King, L.D.S., and his staff, the patient was operated upon under general anaesthesia.
Preliminary laryngotomy was performed by the Butlin method and the anaesthetic given through this opening. The pharynx was packed off so that blood did not enter the lower air passage. The main design of the operation is shown in diagram 107, which needs little amplification. The main part of the upper lip was made by a descending lateral nasal flap which was swung from the right side across to the left. This flap included muscle and mucous membrane, and, in order to lengthen it, the knife was carried through the corner of the mouth in a parallel direction to the first cut. This flap reached about two-thirds of the way across the lip. On the left side, the broad flap, as shown in the diagram, was outlined and swung up to meet its fellow. This flap was broader at its base than at its extremity ; it also included mucous membrane. In regard to the nose, the left ala, which was tied down to the remains of the nasal floor, was elevated, and re-sutured into position. On the whole the result of this operation was fairly satisfactory; the mouth, however, was small and the upper lip did not present very good lines, nor did the muco-cutaneous junctions show at all as a vermilion border. The manoeuvre of pulling over the right flap towards the left had narrowed the mouth. Subsequent correcting operations were performed on various dates. Under a local anaesthesia, the right corner of the mouth was enlarged by a simple incision and the pulling out of the mucous mem- brane. On 16.1.17 examination notes read that deep scars were radiating from the left angle of the mouth into the lower lip, while other scars were present at the junction of the flaps making the new upper lip, and in the left cheek. All these scars were more pronounced than usual. Under general anaesthesia, they were dissected out —that in the upper lip was dissected out in a diamond-shaped fashion, there being a slight notch at this point, and sewn up vertically to give extra depth. This manoeuvre was quite satisfactory, but not quite sufficiently radical. The notch in the lower lip was rearranged by swinging flaps, as shown in fig. 110. A small excision was carried out just above the right angle of the mouth to raise the same, while the ala of the left nostril was carried farther to the left. All sutures were carefully made with interrupted horsehair. The results of these corrections were satisfactory on the whole, except that the scar lines were still very prominent. Three months later, 17.4.17, the mucous membrane of the upper lip was brought farther out to become more prominent, and one of the scars of the lower lip was re-excised and sewn up with subcutaneous catgut. The scar-line thus produced was again unsatisfactory, and it was apparent that this man's skin, though it always united well by primary union, was of an unusual character. The reason may be forthcoming in the fact that there is a considerable amount of acne present. The later history of these scars is inter- esting, as they are apparently becoming more obliterated than usual by tiny bridges of skin growing across, and already one of the scars is invisible.
This case has opened up the question of the histology of good scar production.
The two small palatal perforations were closed by mucous membrane flaps on 7.6.17; one of the flaps partially broke down. In order to fill up the depression in the left cheek, the lateral scar, shown in fig. 1C 9, was excised, and the skin under- cut in its neighbourhood and free fat-graft from the subcutaneous tissue of the abdominal wall inserted; the skin was sewn up with subcutaneous horsehair.
Like many other fat-graft operations in this region, the union was primary and it
INJURIES OF THE UPPER LIP
85
was not until a week after the stitches were out that a slight oozing of fat occurred followed by some suppuration. This condition was cleared up with Biers' cupping, and th.3 final result is satisfactory. Even after the first operation, it was a great satisfaction to hear this man speak with his native brogue again. Before operation he was a man who was so sensitive about his appearance that he did not like mixing with his fellow patients or with the outside public.
Fio. 105. — On admission.
FIG. 100. — Prosthesis in position. (Discoloration due to Iodine.)
Fio. 107. — The (laps. Right, descending. Left, ascending.
Fio. 108. — Suture.
80
PLASTIC SURGERY
Fid. 109. — First result.
Fio. 110. — Upper and lower lip corrections. Incisions.
Fio. 111.— Suture.
FIG. 112. — Final.
INJURIES OF THE UPPER LIP
87
CASE 525
An example of total loss of upper lip. This man on admission to a Base hospital in France still possessed an upper lip, but it was in a damaged and semi-gangrenous condition, and, in spite of the utmost care, the whole thing sloughed, leaving the condition shown in fig. 113. Partial attempt to relieve the deformity had been made prior to admission to my service, the result of which procedure is shown in fig. 114. The mouth is very contracted and the lower lip pouted. The new upper lip is insufficient and short, while the whole nose is lengthened and depressed. It was decided to reconstruct the wound and to replace the nose in its normal position.
Operation, 23.7.18. Scar tissue in the centre of the new upper lip was excised, as was that around the attachment of the nose. The stumps of the upper lip were allowed to retract into their normal position, in which situation the mucous membrane was brought out and sewn to the skin. No attempt was made to repair the lip at this stage. The nose was gradually freed until it could be raised into its position. The only blood supply re- maining to the nose being a small bridge in its upper part, this undercutting and raising had to be done with the greatest of patience and care. The alae were brought together beneath the tip and the nose sutured. This was a very risky procedure, and I was more than thankful for its satisfactory result.
It now remained to repair the upper lip uncomplicated by the false attachment of the nose. Elaborate diagrams by Mr. Hornswick of this operation are included, and show the developments of diagrammatic illustration for this form of record in an exceedingly difficult case.
Haps A and B from the left and right cheeks respectively were turned skin-surface inwards over a large dental appliance fitted by Captain W. Kelsey Fry, M.C., R.A.M.C. ; they were sutured together. The mucous membrane off the stumps of the upper lip was cut into two flaps (C and D), one on each side, and by advancement came to lie along the lower borders of A and B, where they were sutured, not only to each other, but also to A and B. These mucous membrane flaps were broad enough to complete the lower border and to curl round for the vermilion edge of the new lip.
FIG. 113.
Fid. 114.
FIG. 115.
FIG. 113. — Total loss of upper lip and underlying bone. (Photo taken in France.)
FIGS. 1 14, 1 15. — Condition on admission. These show the indifferent result of making a lip by advancement methods. Both the lips and the nose are backwardly displaced. The mouth is contracted, and the lower lip is pouted. [Note : These defects have, in this case, been accentuated by the failure of part of the flaps to survive.]
88
PLASTIC SURGERY
The skin covering was the next problem, and double ascending flaps A' B' were taken from the lateral aspects of the chin and sutured together over the inturned flaps A and B. To their lower borders were sutured the lower free borders of the mucous membrane flaps C and D.
The secondary closure did not present any great difficulties. The most anxious part of the operation was flap A', which had a great deal of scar tissue in it. In fact, the only clear bit of skin was a minute portion on its lower border. I had great fears of losing the whole flap. However, the blood supply returned and was maintained satisfactorily. Apart from some slight breaking down of the suture line A' B', the healing process was satisfactory. The columella had been brought out, lengthened and sutured in the middle of the upper lip : this wants rearrangement, as is evidenced from the photograph which merely represents the present stage of the repair.
Fio. 116. — Diagram of the ex- cision of scar tissue, practised to bring about replacement of the nose upwards and forwards, and to allow the corners of the mouth to separate.
Fio. 117. Fio. 118.
l'io. 117. — Shows the result of putting into practice the author's principle of replacing the remnants into normal position. Skin is sewn to mucous membrane so that no raw area occurs. An upper prosthesis is now fitted, replacing the lost hard tissues.
Fio. 118.— Profile of same stage, showing the vast improvement in the nose. No apparatus was employed to retain the nose.
FIG. 1 1 9.— The incisions.
Fio. 120.— The flaps.
Fio. 121. — Suture of the interned and mucous flaps.
Fio. 122. — Final suture. Fio. 123. — Sectional view.
FIGS. 119—123. — A and B = cheek flaps, inverted to form the posterior epithelial surface of the new lip.
C and D = mucous membrane, advanced flaps taken from the lip stumps to form the mucous membrane lower border of the new lip.
A' and B' = ascending cheek-chin flaps to form the outside skin covering to the whole. The raw areas caused by the cutting of these two flaps is closed by approximation.
FIG. 124.
Fid. 125.
Fio. 124.— Result of the six-flap plastic operation portrayed in the diagrams. A permanent upper prosthesis ; fitted.
FIG. 125. — Profile of result. Note the pi apparatus representing the missing maxilla.
S FIG° 125.— Profile of result. Note the prominence of the new upper lip, which is supported by a vulcanite
90
PLASTIC SURGERY
CASE 7
In the next case also — one of similar but less destruction of upper lip — the prc-maxilla was destroyed ; but a small and valuable piece of upper lip remained at the left angle (a point not evident in fig. 126, taken a fortnight after the wound). Fig. 127 shows the healed condition, a remarkable improvement. The lower lip has become almost normal, and little scarring has resulted, but the remains of the left upper lip have become attached and drawn upwards.
Primary suture was expressly avoided, and the main repair of the upper lip^was per- formed over an effective dental support ten weeks after the wound. Lateral nasal flaps were used on both sides (fig. 128), and by advancement of the mucosa of the left side, it was made to cover half the under aspect of the new lip, and to line not only the left but
FIG. 120. — On admission twelve days after injury.
Fio. 127. — The healed condition.
part of the right side. Ihe lining was completed by advancing a descending flap of mucous membrane from the right cheek near the angle of the mouth. The result is shown in fig. 130.
A month later, a more extensive operation was made, to level the mouth and to adjust the relation of mouth to nose : the lower nose was freed from bone, and swung to the right. and the upper lip to the left, both being sutured in their new position. Though the nose pointed somewhat rightward, yet, viewed with the mouth, it gives a more symmetrical face.
A right chin flap was then swung up to the upper lip, to deepen it, and was lined by an advancement of mucosa. As usual, this flap depressed the angle of the mouth slightly, a defect not hard to overcome.
An effort was first made to raise the angle by a horizontal incision through all thick- nesses of the lip opposite the seat of the depression, sewn up vertically. This resulted in a partial improvement of the deformity, and is a method not often indicated. Two and a half months' rest was given, during which massage and movements were undertaken. The diagram, fig. 13, shows the method of curing the depression of the angle of the mouth, and is in reality a partial replacement of the original flap. A satisfactory result of this is shown in the final photograph. All scars were fading rapidly when the patient was dis- charged, and the total eflect was gratifying.
INJURIES OF THE UPPER LIP
91
Fio. 128. — Incisions. Fid. 129. — Suture.
The clotted area represents a mucous membrane flap.
Fid. 130.— First result.
FIG. 131. — Shows method of curing a depressed angle of mouth. Xote: this condition had occurred owing to an operation referred to in the text but not illustrated.
Flo. 132. — Final result.
92 PLASTIC SURGERY
CASE 21
This case is one of a very similar character to the last, and about the same amount of the upper lip remained after the injury. The denture fitted to represent the pre-maxilla is shown in the accompanying figure, No. 133. This case, treated on similar lines to No. 17, has not shown the same satisfactory results. The lip was made too short, and considerable difficulties were experienced in fitting a satisfactory denture after the new lip had been made. The probable reason why this case has not done so well as the previous one is that there was less mucous membrane remaining after the injury. Trouble was also experienced in retaining the denture, and adhesions formed between the new lip and the remains of the upper jaw. There were also adhesions to contend with between the cheek and the lower jaw, which made the dental treatment more difficult. In this case it would have been wiser to use a skin flap, turned inwards, to line the new lip. It will be noted that an ascending flap was not available on the right side on account of the scar tissue there. A modified descending flap was therefore used on both sides, and that on the right had a bend in it which turned it in to an advancing flap. The patient had erysipelas about six weeks after receiving his wound. The first operation was undertaken about three months after the date of his injury. This was performed on 9.10.16, when adhesions tying down the nose were divided and scar tissue excised ; about £ in. of the red margin on the left side was intact. A flap, including this portion of the lip as its base, was cut from the left side of the nose and brought down under the nose. A skin and tissue flap from the right side, with its base opposite the mouth, was cut and straightened out to meet the corresponding flap from the other side. A mucous flap from the inside of the right cheek was cut with its base on the lower lip and curled around part of the new upper lip. A hare-lip condition was thus left, but it was not deemed advisable to form a double mucous flap. No relaxation sutures were used, but several silk-worm-gut deep stitches were inserted. There appears to be some tension.
Fio. 133. — Denture with artificial pre-maxilla.
Examination of the condition after this operation showed that the new mucous lining to right half of upper lip was satisfactory. There was a U-shaped gap in the middle of the upper lip, and no columella. On 2.11.16 an excision of the scar was made round the U, and prolongation of the incisions laterally on the left through the angle of the mouth and through the line \ in. above it, and through all the layers of the lip ; this was brought over to the right and sutured into position with catgut and horsehair sutures. The columella of the nose was formed by cutting out the anterior portion of the remains of the septum ; in this upper part the knife was entered behind and brought forward towards the tip, and this made a satisfactory columella, which was inserted into the incision of the upper lip. In spite of careful suturing the left angle of the mouth drooped. Adhesions were divided between the lower jaw and mucous membrane on the right " side. The attachmsnt of the new columella broke down, but otherwise the results are fairly satis-
INJURIES OF THE UPPER LIP
93
factory. Great difficulties were experienced in keeping the lip well supported with the denture, and adhesions reformed. I think the flap on the right in the original operation should have been taken right through to the mucous membrane instead of making two flaps, one of skin and muscle and one of mucous membrane. The appearance after these
Fia. 1 34. — On admission two months after injury.
FIG. 135. — Healed. The dental appliance displaced to show its composition. Note the scar on right cheek referred to in text.
FIQ. 130. — Flaps. (A mucous membrane flap not outlined.)
Diagrams by H. T.
Fio. 137. — Suture.
PLASTIC SURGERY
FIG. 138. — Result first two operations. Note droop of angle : denture not in place.
FIG. 139. — Flap to raise angle.
FIG. 140.— Suture.
FIG. 141. — Result of this. Denture fitted.
INJURIES OF THE UPPER LIP
95
two operations is shown in the accompanying fig. 138. The falling in of the lip without the denture and the droop of the left corner of the mouth is well seen. A small operation was performed on 13.3.17 in order to raise the corner of the mouth, and this was successful in carrying out this object. In order to fit the denture in, Captain Rumsey divided the upper sulcus.
Scar tissue formation, however, gradually filled up this sulcus, and prevented the further wearing of the denture. In addition, trismus was present, which, on investigation, was found to be due to a band of scar tissue from upper to lower jaw on the right side of the cheek, and which had formed as a result (a) of the injury, and (b) of the intra-oral operations.
On 9.1 .18 an operation to remedy these defects was undertaken, the principle being that of the Esser epithelial inlay.
To repair the upper sulcus, an incision was made at the upper border of the upper lip and carried down to the mucous surface. Care was taken to excise a portion of the scar band above mentioned. The cavity produced was of some size, and extended from just to the right of the scar band to where the sulcus became normal again on the left side of the mouth. The usual Stent model and skin graft was inserted.
A similar procedure was carried out along the lower sulcus. The models were taken out on the tenth day through intra-buccal incisions.
Considerable difficulty was experienced in keeping the newly epithelialised cavities patent, and, as the upper sulcus was the more important of the two, it received more attention. The successful establishment of this sulcus was to a great extent due to the careful efforts of Captain Kelsey Fry, M.C., R.A.M.C. The lower sulcus operation was not so successful. It would have been better to have done this at a separate operation.
The upper lip is now maintained in a forward position.
On 4.6.18 the columella was re-made in a manner similar to the first procedure but of a greater length, so that the tip of the nose was even .pushed up a little bit by this new columella.
FIG. 142.
Final after Esser inlays and columella operation.
96
PLASTIC SURGERY
CASE 151
This is one of the Australian patients who have been under my care. He was wounded in the later battle of the Somme, and came to me at Aldershot, six days after receiving his wound on 20.10.16.
The condition, when healed, showed a considerable loss of the pre-maxilla, and the floor of the nose in its anterior part, while the soft tissue loss consisted of about two-thirds of the upper lip, together with the left ala, columella, and anterior portion of the septum of the nose. The tip of the nose was dragged down by fibrous tissue and loss of support.
The first operation was undertaken on March 3rd, 1917. It was of an orthodox type, and consisted of two lateral nasal descending flaps, A B and A B. These were whole-thickness flaps which contained the mucous membrane. That on the left proved to be satisfactory as it contained the remaining normal part of the upper lip, but that on the right contained much scar tissue, and the result was not gratifying.
Diagrams representing the next stage are appended, and the details of this operation follow :
The main principles of it were, in regard to the nose, that two higher lateral nasal flaps were tucked in beneath the alse to allow the tip of the nose to rise. And in regard to the right half of the lip, it was deepened and reconstituted by turning downwards a flap of skin as a lining and the superimposition of a long pedicled bridge flap from the left cheek and chin.
When this case was transferred under Lieutenant-Colonel Newland, D.S.O., A.A.M.C., he very kindly allowed me to continue the treatment, and I have had the encourage- ment of his advice and assistance in this somewhat long and difficult procedure. The case is not yet completed, but is well in hand, and the final result should repay one for the efforts and length of time expended on the case.
FlO. 144. — Six days after wound.
FIG. 145, — When healed.
FIG. J4G. — Side view. Same stage.
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97
Copy of Case Sheet Notes given below :
10.3.17. Operation.— An upper lip was formed by cutting a flap from right cheek and swinging it down to meet a similar one from the left ; but this latter contained normal mucous membrane.
FIG. 147. — Showing descending flaps.
Fia. 148. — Suture.
Fio. 149. — Result of lirst operation.
The tip of the nose was freed and nasal passages restored. Tissue representing remains of columella was dissected up and sutured to middle line of lip. Small mucous flap was turned up from lower lip to form red line for remainder of upper lip. Deep catgut sutures were used, and artificial plate was inserted to support new lip. Nasal plugs, supported by vulcanite head piece, were adjusted with the object of holding tip of the nose in position.
20.9.17. Condition. — Previous operation for upper lip moderately successful. Con- siderable deficiency middle of right half of upper lip. Deformity of nose partially cor- rected, but columella has not become attached.
20.9.17. Operation. — For correction of upper lip. Owing to the scarred and pustular condition of the face, no flap was available from the right for the lip. In order further to raise the right ala, a small flap was taken from the lateral aspect of the nose and swung down beneath the ala. A similar flap was swung down on left side beneath the remains of the left ala and sutured to the top of the upper lip. This enabled the tip of the nose to be considerably raised.
98
PLASTIC SURGERY
A skin-flap of the existing right portion of the upper lip was turned downwards, with its skin surface inwards, and into this raw area was laid the end of an ascending pedicle bridge flap with its base opposite the upper lip on the left side. The area from which this flap was taken was completely sewn up. The grafted end of this flap obtained linn union into the upper lip and the pedicle of the flap was cut under local amrsthetic on October 13th. No attempt at replacing the pedicle was made, and it was cut short at its base. This free lump of skin was left sticking out from the lip for possible future use in the nose. Massage was employed from the first day.
24.10.17. — Condition satisfactory. It is possible to train this flap of skin upwards towards the nose for later attachment there.
Operation (Major Gillies with Lieutenant-Colonel Ncwland). — The cut pedicle referred to above had rounded itself off into what looked like a tip of a nose lying on the
FIG. 1 50. — 1 ncision for inverting portion of lip to complete the lining
FIG. 151. — Diagram showing bridge pedicle flap A. Terminal portion only used.
upper lip. It was partially re-detached, and sewn up underneath the columella and left ala. Lip support was made by Captain Russell, A.D.C.
4.2.18. Operation (Major Gillies with Lieutenant-Colonel Newland). — Further de- tachment from lip and completion of right half of columella.
16.5.18. Operation (Major Gillies with Lieutenant-Colonel Newland). — The left side of columella and lining of nostril was made, and the remainder of flap was used to form the left ala.
20.12.18. Operation (Major Gillies). — Cartilage taken from rib and inserted through the columella in two pieces, one down the columella and one up the bridge. The bridge piece was fixed at its upper end to the existing nasal cartilage through a separate incision made across the bridge at a spot where an existing scar was present. Result — satisfactory. Hut owing to the pustular condition of the face, which has continued despite special treat- ment, a slight infection of the cartilage occurred. No material damage, however, eventuated, and the sinus rapidly healed.
INJURIES OF THE UPPER LIP
99
FIG. 152. — The pedicle cut near the base and allowed to curl up.
FIG. 153. — Utilising the pedicle for nasal restoration.
FIG. 154. — Result after further adjustment and cartilage implant to nose and columella.
FIG. 155. — Ditto, side view.
100
PLASTIC SURGERY
CASE 245
This sergeant was admitted in a healed condition. There was partial loss of the pre-maxilla, and loss of more than half of the upper lip, together with an iigly twisting of the nose, and depression of the tip. This patient was operated on four months after the receipt of his wound. It will be noticed in the appended operation notes that he developed bronchitis after the operation. Therefore the failure to get a really satis- factory result may well be put down to this trouble, as the coughing which followed undoubtedly prejudiced the union of the flaps. Three weeks after this operation the patient, when at a Convalescent Hospital, developed septic pncuziionia, from which he recovered slowly.
Although the record number is a late one, this was one of my early cases, and it brought home to me the necessity for some different form of anaesthesia from that usually employed in mouth cases, and in those of chin and upper lip in particular. In the pages on anaesthesia this matter is fully dealt with. A fairly satisfactory result was obtained from an aesthetic point of view, and, functionally, it was good. It should be remarked,
FIG. 150. — Condition on admission — healed. Loss o£ right half of lip.
however, that a secondary deformity of the lower lip was produced. Since the date on which the last illustration, fig. 161, was taken, this sergeant has done a year's duty witli Home troops. Details of operations on this case follow :
22.6.16. Operation. — Formation of upper lip. The flap of skin and mucous mem- brane representing the remains of the upper lip was dissected out from left nostril, and by an incision parallel to the lip margin the flap was brought over towards the right to meet two flaps from the right side which were separated by a piece of excised scar. The lower of these flaps was a small one, containing the angle of the mouth. Result : The dental shield for the new lip which had been made was not tolerated by the patient, who had some bronchitis after the operation. A certain amount of breaking down occurred at the junction, and owing to the absence of intra-oral apparatus the new lip became adherent to the alveolus of the upper jaw. Apparatus for distending of lip after division
INJURIES OF THE UPPER LIP
101
of adhesions is shown in photograph. Three minor operations were carried out to widen the mouth and to produce a mucous membrane line to the upper lip. Functionally the result was good, cosmctically there was still an ugly arrangement of the lower lip. Dis- charged for duty, 3.3.17.
FIG. 157. — Advancing flaps.
FIG. 1 58. — Result, flat lip.
FIG. 159. — Suture.
FIG. 100. — Attempt to bring forward and stretch new lip.
FIG. 161. — Result of later operations. Denture fitted. Note : the lip is still flat and has no central prominence. The lower lip is pouting.
102
PLASTIC SURGERY
CASE 4.3
These cases of upper lip arc dealt with here in order of decreasing severity, and this one shows a loss which is less than the previous one. The result is correspondingly better. In addition to an upper lip injury, there was a slight deformity of the lower, combined with loss of the angle. The condition within forty-eight hours of the wound is shown in the first illustration, and I am indebted to Major Valadier, C.M.G., for allowing me to have the early wound record of this case. The second photograph is an illustration of the result of an early suture, performed by Major Valadier in France. The mucous mem- brane of the upper lip was preserved by sewing it to the chin, and the tag on the cheek was sutured into place, the mucous membrane being also brought out to the skin edge. This system undoubtedly helps the later plastic repair as it decreases the scar tissue. Accompanying this injury was a very large loss of bone in the lower jaw, involving the angle and adjacent portions of the mandible ; there was also a considerable loss of bone in the superior maxilla and alveolar process. The further method of repair is illustrated in the accompanying diagrams, and consisted in a whole thickness flap swung down from the left lateral nasal region to meet the remains of the upper lip which was split to receive it, the lower portion of the split containing the vermilion border being made to extend along the new portion of lip.
To complete the mucous membrane, that of the lower lip was swung round the corner to the upper, a slight advancing of the flap marked " B " enabled the lower lip to be satis- factorily corrected. No further operations on the lip were undertaken, and a satisfactoiy result was produced. Discharged to duty.
Kio. 162. — Shortly after wound. Taken in France (Valadier).
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103
FIG. 163. — On admission — healed.
Fio. 104. — Descending and ascending whols thickness flaps.
FIG. 105. — Suture.
Fia. 100. — Result.
Fio. 107. — Same later.
104
PLASTIC SURGERY
FIG. 108. — Prior to admission to Queen's Hospital.
FIG. 109. — On admission healed. Part loss of upper lip, nose, and cheek.
CASE 324
This is included in this series as an example of the use of a temporal and scalp flap for the external covering of a portion of the upper lip. One half of the upper lip remained on the left side, the right half being completely absent, as well as a large portion of the cheek, nose, and right superior maxilla ; there was an accompanying fracture of the right mandible,
FlO. 170. — A and B are interned epithelial FIG. 171. — E the temporal flap
flaP8- sutured to form the covering. Fl(J , -2 _Result after return of temporal
flap. Note deficiency of upper lip, and of contour.
INJURIES OF THE UPPER LIP
105
with deformity of contour. The patient was transferred to this hospital eleven months after being wounded. The mandible had united by approximation. The first operation was undertaken as a combined lip, nose, and cheek plastic. In fig. 170, flaps A and B were turned skin-surface inwards to form a lining for the right ala and right half of the upper lip. The latter was sutured to the mucous membrane on the back of B, which is the re- maining portion of the upper lip. Over the raw area thus produced a shaped flap, E, from the right temporal region was sutured into position on 24.9.17. Three weeks later the pedicle of flap E was returned. This was done for me by Captain C. F. Rumsey, R.A.M.C., and the result of these two operations is shown in the next fig. 172. Considerable time was allowed to elapse during which cpilation by X-rays of the hairy surface of the nose was undertaken. As the new upper lip was too shallow, it was decided to turn skin surface inwards a portion of this new flap and to bring up an ascending flap from the right side of the chin, and at the same time a flap of mucous membrane was brought up from the lower lip for a vermilion border.
Rhinoplasty was performed on 18.11. 18, and at this operation the pedicle of the mucous membrane flap of the previous operation was divided to form the right corner of the mouth. When the pedicle of the rhinoplasty was returned a depressed scar, caused by the ascending lip-flap, was excised, and a notch in the new upper lip was corrected by a Rose operation (Captain Ferris N. Smith, R.A.M.C.). Cartilage was inserted over the right mandible and further scars excised on 3.2.19. Present result is shown.
Fro. 173. — 1. Deepening the lip by an ascend- ing chin flap.
2. Mucous membrane flap from lower to upper lip.
3. Preliminary to radical nasal reconstruction.
FIG. 174. — Final result of lip, cheek, and nose plastics. Note the improved cheek contour by cartilage graft.
10(5
PLASTIC SURGERY
CASE 143
There arc several interesting features about this case which need defining. I have included it in the " Upper Lips," as I have learned a principle in connection with its repair. It is also one of my first cases. I designed the upper lip operation with two superimposed flaps so as to produce depth at the spot where the hare-lip type of notch was present. Tin- two flaps were made to overlap after the replacement of the vermilion border to its normal level. A good deal was allowed for contraction, and the right-hand flap was cut in such a \\ay as to produce considerable drooping of the right half of the upper lip.
Fio. 1 75. — Hnre-lip type of deformity with loss of substance.
FIG. 1 70. — Scar excision.
Fio. 177. — Scheme of the flaps.
FIG. 1 "8. — Diagram of overlapping flaps to pro- duce depth.
FIG. 179. — Result of Jip operation. Xote redundancy.
INJURIES OF THE UPPER LIP
107
There was no important loss of the mucous membrane lining of the upper lip, and consequently the retraction and contraction following the operation was very limited. Therefore I had to excise portions of this flap until the correct level of the vermilion border was obtained. Another principle involved in this repair was to use pointed overlapping flaps to produce depth.
In regard to the nose plastic, the scar running down the right aspect of the nose and across the bridge was excised ; the nose was raised and the right ala was sewn down at a lower and normal level. This was done on the occasion of the second operation. A month later a bone graft was taken from the left tibia and inserted into the bridge of the nose to raise it. The bone was cut with the Albce double electric saw. The periosteum was not included. In regard to the fixation, the periosteum over the glabella region was raised and a groove made into the bone into which the upper end of the graft was fixed. The distal end of the graft was pushed down subcutaneously into a cavity made for it nearly as far as the tip of the nose. A misfortune occurred at the end of this operation, as the patient vomited freely before the graft was quite fixed in position and the asepsis of the field of operation was thereby violated. A slight suppuration followed, but this practically cleared up except for an occasional drop of pus which could be squeezed out. Later a small portion necrosed and was taken away from near the left internal canthus. The skin then healed up satisfactorily, but no bony union occurred with the frontal bone. When last examined, the graft was still in position, but is presumably in process of being replaced by fibrous tissue, and the bridge had not been sufficiently raised. It was decided, there- fore, to insert some cartilage, which was done through an incision over the tip of the nose and into the columella. A piece of costal cartilage was then superimposed over the remains of the bone graft. When in position, the extremity of the cartilage was bent into the tissues of the columella to support the tip. The incision over the bridge of the nose was likewise reopened at this operation, and an attempt was made to get union with the frontal bone by turning down an osteo-periostal flap beneath the original bone graft. Whether bony union occurred or not was not established as the patient was discharged to duty, but the cartilage operation was satisfactory in every way except at the bridge of the nose, where it became slightly displaced. As far as the left eyelids are concerned, mal-union of the upper lid had occurred, completely obliterating the palpebral fissure. This upper lid was freed by a mesial descending incision, and the lid was sewn up at a higher level. The lower lid was also freed by carrying a curved incision from the inner angle outwards beneath the lower lid, and this also was sewn at a higher and more mesial position. A moderate amount of vision remained in the left eye, and considerable benefit accrued to the patient by reopening his palpebral fissure both in regard to appearance and function. The final result is shown in fig. ISO.1
FIG. 1 80. — Excision of excess lip and nose and eyelid plastics.
1 This is the only case in which I have used bone alone for raising the bridge of the nose. Compare this case with case 252, p. 228.
108 PLASTIC SURGERY
CASE 48
Another type of upper lip is shown in the following case. The patient was received after many plastic operations in the condition shown in fig. 181, and there was a large muss of scar tissue making up the substance of the upper lip. There was a blob of mucous membrane at the left corner, which was utilised by extending it along to the right. The patient was edentulous. This also was one of my early cases. The result of the first operation is shown in the second picture. The main feature of this operation was the excision of the scar which was present in the upper lip and around the depressed angle of the mouth. This left a very large gap to be filled in, which difficulty was met by a descend- ing flap from the left cheek. The flap united satisfactorily in its new position, but the suture of the cheek after the removal of the flap broke down somewhat badly, as is evident in the photograph. A subsequent operation was performed to widen the mouth, but this had to be curtailed owing to anaesthetic difficulties and blood collecting in the patient's throat. The scar of the face was excised, but again this broke down. I decided, therefore, to give him a prolonged course of X-ray treatment, massage and special vaccine made from culture of his own micro-organisms. An attempt was again made to excise the ugly scar on the left cheek; but, as on previous occasions, this broke down, but only partially. The total result was a very considerable improvement in appearance and function.
INJURIES OF THE UPPER LIP
109
FIG. 181. — Large portion of upper lip occupied by keloidal scar.
FIG. 182. — Note breaking down of secondary suture area, after the descending lateral nasal flap had been brought down to upper lip.
Fio. 183. — Final result.
no PLASTIC SURGERY
CASE 242
This case shows an injury of the lip without serious bony damage, with less of teetli only. The loss of the lip is a little more than a third, but the loss of the skin surface is greater than that of the mucous membrane. The condition when it had healed is shown in the next illustration, which, however, does not adequately represent the amount of scar tissue to be excised. The morphology of the original wound was therefore reproduced, but to a slightly diminished extent. The diagram illustrates the amount of scar tissue which had to be excised and the flaps used to repair it. It should be remarked that the vermilion border b?longing to the right-hand flap was separated from this flap and advanced on to the lower border of the left-hand flap, so that the skin-joint was not at the same site as that of the mucous membrane. In criticising the result of this procedure, which was, in general terms, a descending flap and partly an advancement method, it will be observed that the upper lip slightly overhangs the lower at the left-hand corner of the mouth, and the lower lip is somewhat pushed out of position thereby. This, I think, is due to the advancement of the flap, and bears out my contention that the upper lip will stand little in the way of shortening by advancement flaps.
INJURIES OF THE UPPER LIP
111
FIG. 1 84. — One week after injury.
FIG. 185. — ftesult. — Note the overlapping at the angle produced by an " advancement " flap. This is amenable to secondary correction, but only the one operation was performed in this case.
FIG. ISO.— Excision and Incision. No mucous membrane was excised, as might bo inferred from diagram.
FIG. 187.— Suture. Note skin and mucous membrane suture at different sites.
112 PLASTIC SURGERY
CASE 177
This private was received after a gunshot wound which had destroyed half the skin of the upper lip and one-third of the veimilion border. He was admitted into the depait- msnt in the scarred and healed condition as shown in fig. 188, and had already received two or three plastic operations on the lip. The amount of loss of tissue is well shown in the diagram, representing the healthy tissue remaining after excision of the scar tissue in the upper lip. The scar tissue in the cheek was similarly excised. Under chlorofoim oxygen anaesthesia, in the sitting position, the scar tissue in the upper lip was excised com- pletely, except where it had involved the mucous membrane on the posterior suifacc. A large ascending flap from the cheek was taken to fill up this gap, as illustrated in dia- gram 189, and the mucous membrane surfaces readjusted. The healing was by first intention, but the result of the operation was to depress the corner of the mouth.1 This was due to the base of the pedicle, flap " A" being too wide. Another secondary deformity occurred as a result of this operation on 3.4.17 in that, in drawing the two cut surfaces of the mucous membrane together, an unpleasant pouting of the corner of the mouth was produced. On 3.9.17 operation was again performed, the objects of which were to restore the left angle of the mouth to its proper level, to evert the mucous membrane and to attempt to thicken the border of the lip. In the first place, a reverse flap to that taken at the original operation was swung from the upper to the lower lip to correct the level of the corner of the mouth. This flap was not as big as is shown in diagram 190, and it should be noted that it runs across the scar line of the first flap, and is in reality a partial replacement of the original flap. This manoeuvre was quite successful, as usual, in restoring the level of the corner of the mouth. In regard to the eversion of the mucous membrane of the upper lip, an arrow-head piece of skin was excised, as shown in the diagram ; the edges when sewn up produced a satisfactory eversion of the mucous mem- brane. To make this border more prominent, the subcutaneous fat and muscle from the upper part of the lip was dissected from above downwards, and, whilst still partially attached, was rolled down as a flap of tissue, which was then sutured into the free border, the method of which was by mattress sutures, as indicated in the diagram, fig. 191. The result of this procedure was quite definite in producing a prominence of the border of the lip, and the aesthetic result was satisfactory. Functionally, it was quite good, except that the mouth was not sufficiently large. But, as the patient was quite satisfied, he was discharged.
1 See also Case 7, pagci 90, for method of avoiding this droop of the corner by excision of part of the natural lip.
INJURIES OF THE UPPER LIP
113
FIG. 1 89. — Excision of scar and ascending flap.
FIG. 188. —Healed condition.
Fio. 1 90. — Correction for depression of angle of mouth.
FIG. 191. — Scheme to show arrow-head excision of skin, and method of rolling down the soft tissues of the lip to its edge, to produce prominence and presentation of the vermilion border. 8
FIG. 192.— Result.
114
PLASTIC SURGERY
CASE 295
Is that of an officer in the Field Artillei y. who was struck by a shell on September 27th, 1916. He was admitted nine months later for plastic treatment in the condition shown in the first illustration. A large depressed scar ran horizontally across his check, ending in various small scars in the remains of the right half of the upper lip. The underlying loss of bone comprised the major portion of the right upper alveolar process and antciior wall of the right antrum. The mucous membrane loss was practically nil, whereas the skin of half the upper lip had been shot away, the vermilion border being drawn up by the scar tissue, producing a marked ectropion. The right corner of the mouth was normal, and the question of supplying the necessary amount of skin to cure this deformity presented many difficulties. Had I used an ordinary imbedded ascending flap, the corner of the mouth would undoubtedly have been seriously displaced, necessitating further correcting operations. Descending flaps were contra-indicated on account of the scar tissue and no hair being thereon. Two further designs presented themselves to me, both of the ascending flap variety, the first of which necessitated excising the already existing corner of the mouth, so as to imbed the flap, and it was therefore discarded ; the remaining method, which was the one adopted, was to use an ascending flap, but to imbed only the terminal portion of it, thus making it into a bridge flap, the pedicle lying over healthy, untouched skin. The vermilion border was carefully preserved and resutured, as is shown in the intermediate stage illustrations. The under raw surface of the bridge was protected by waxed gauze, while two silk-worm sutures were passed through the vermilion surface of both lips, at the right corner, in order to steady the parts and to prevent oral secretions reaching the wounds. The return of the pedicle was carried out on 7.9.17, i.e. on the eleventh day the bridge of the flap was cut in a slanting direction just clear of where it had been sutured into the upper lip, and the remaining free end of the graft was sutured into place. The pedicle of the bridge was re-fitted into the check, and in doing this a small amount of granulation tissue had to be cut away before the pedicle was replaced into its original position. It should be noted that the under surface of the bridge was kept exceedingly clean, No. 7 Ambrine wax dressing being used. The result, so far as the moustache and upper lip arc concerned, was all that one could desire, and at the second stage of the operation a small portion of the redundant mucous membrane was excised. As to the reinsertion of the pedicle, I doubt whether any advantage has accrued. Owing to the slight granulations on its under surface, there was a distinct tendency at first to present a somewhat rounded appearance ; but, although this has subsided, there was no necessity to preserve this piece of skin in this particular case, and the resulting scar-line might have been better than it is.
In regard to the depression of the check and the long scar, a dental apparatus — designed by Sir Francis Farmer — has materially aided in bulging out the cheek ; but this did not fill up the hollow in the cheek. A considerable free fat graft was successfully implanted under the skin at a later stage, but the result of this is not illustrated.
Fio. 193. — Illustrating " bridge " pedicle flap for upper lip and moustache.
INJURIES OF THE UPPER LIP
115
FIG. 194. — The healed condition nine months after wound. Ectropion from loss of skin surface.
FIG. 1 95.— Bridge pedicle flap in position.
Flo. 190. — Pedicle returned. Moustache grown,
Fio. 1 97. — Ditto. Note : the hollow in the cheek was filled by a free fat graft and excision of scar at a later stage.
116
PLASTIC SURGERY
CASE 270
This case of a minor injury of the upper lip is included for one or two reasons. It was due to the exit wound of a bullet which entered behind the right angle of the mandible, which it broke, passed through into the month, and carried a few of the front teeth through the upper lip. The blow in this case was very severe, and the officer told me that he felt as if the whole of the face had been shattered. There is no important loss of tissue, but the method of repair is interesting as an illustration of the value of overlapping flaps in producing depth. The wound had caused the stellate explosion of the upper lip, and when the case was sufficiently healed to conic for operation, six weeks after the battle of the Somme, it presented a somewhat similar appearance to that shown in the illustration which was taken in the semi-healed condition. The diagrams accompanying this record indicate how each radiation of the scar was excised, and the little flaps thus outlined were each prolonged by incision to a slight extent and then interlocked the one above the other. Comparing this case with that of 143 and others in section on lower lips, the value of this method of producing depth at the place one most wants it is, I think, estab- lished. The second illustration is that of the condition just after the removal of the stitches and the scar lines are plainly visible. When this officer returned to duty, he sent me a photograph taken by an ordinary lay-photographer ; the