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 MUTTER 
 
 1900 
 
 JOHN B. ROBERTS, M.D. 
 
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THE SURGICAL TREATMENT OF CON^ 
 
 GENITAL AND PATHOLOGICAL 
 
 DISFIGUREMENTS OF 
 
 THE FACE. 
 
 ABSTRACT OF THE 
 
 MUTTER LECTURES OF THE COLLEGE OF 
 
 PHYSICIANS OF PHILADELPHIA, 
 
 FOR 1900. 
 
 BY 
 
 JOHN B. ROBERTS, A.M., M.D. 
 
 Professor of Surgery in the Philadelphia Polyclinic, Surgeon to the 
 Methodist Hospital. 
 
 fi^: 
 
 h. 
 
 PHILADELPHIA : 
 
 THE PHILADELPHIA MEDICAL PUBLISHING CO. 
 
 1900. 
 
AJ 
 
 / 9o o 
 
 
CONTENTS. 
 
 Lecture I. 
 
 PAGE. 
 
 A Brief Eeyiew of the Development of Reparative or Plastic 
 Surgery 1 
 
 Lectuee II. 
 A Rapid Survey of the Anatomy of the Human Face 4 
 
 Lecture III. 
 
 Characteristics of Surgery in the Face. — The Principles of Plastic 
 Surgery of the Face 10 
 
 Lecture IV. 
 The Removal of Disfigurements Due to Pigments, Cicatricial 
 Distortions, Errors of Development, Tumors and Skin Dis- 
 eases 12 
 
 Lecture V. 
 Deformities of the Lips and Mouth 17 
 
 Lecture VI. 
 The Reconstruction of the Lips and Cheeks -.20 
 
 Lecture VII. 
 The Correction of Deformed Noses 26 
 
 Lecture VIII. 
 The Construction of New Noses 34 
 
 Lecture IX. 
 The Operative Treatment of Deformed or Deficient Ears .... 42 
 
 Lecture X. 
 The Cosmetic Surgery of the Eyes 47 
 
 / 
 
DELPHIA rMEI 
 
 [Reprinted from The;j*hiladelphia:Medical Journal. J 
 
 ^ 
 
 ■X, 
 
 MUTTER LECTURES OF THE COLLEGE OP PHYSICL^NS 
 OF PHILADELPHIA.. 
 
 The Surgical Treatment of Congenital and Pathologic 
 Disfigurements of the Face. 
 
 By JOHN B. EGBERTS, M.D. 
 
 Professor of Surgery in the Philadelphia Polyclinic. 
 
 Lecture I. — A Brief Revieiv of the Development of Repar- 
 ative or Plastic Surgery. 
 
 [Abstract.] 
 
 It is often forgotten that, until the revival of plastic 
 operations upon the face about the year 1800, recon- 
 structions of lost areas of tissue and readjustments of 
 textural relations by operation had been practically 
 unknown to the scientific world for a couple of cen- 
 turies. The operative methods of Tagliacozzi at Bologna 
 detailed in his book, published in 1597, and the 
 methods employed for many centuries in India for 
 restoring mutilations of the nose had been forgotten or 
 disbelieved. Carpue in England and Graefe in Ger- 
 many aroused surgical attention to plastic surgery in 
 the second decade of the nineteenth century. It was 
 rhinoplastic operations that were particularly advocated 
 by these surgeons and their colleagues, and which gave 
 birth to a knowledge of the physiological possibilities of 
 reparative surgery. 
 
 About this time public attention was called to rhino- 
 plastic operations by a number of writers on non-medical 
 subjects. Dr. Ferriar in his "Illustrations of Sterne 
 with other Essays and Verses," published in 1798, said 
 truly that Sterne in his novel "Tristram Shandy'" 
 should have included among his allusions to the nose, 
 taken from literature, the operations of Tagliacozzi. 
 Ferriar says that the Italian surgeon was the more 
 entitled to notice because his fame had been unjustly 
 and unaccountably eclipsed. Ferriar in his enthusiasm 
 describes in detail the operation of rhinoplasty and 
 
compares the physiological deductions of the Italian 
 surgeon with those of John Hunter. Hunter had died 
 only five years before the publication of the " Illustra- 
 tions of Sterne " and his experiments on grafting tissues 
 were evidently known to Ferriar. The latter lays much 
 stress upon the fact that in Tagliacozzi's time the arteries 
 were supposed to be full of air and that the circulation 
 of the blood was unknown to him ; and that the Italian 
 investigator's views on the method of union of living 
 parts are exceedingly interesting and remarkably 
 accurate. The Gentlemen's Magazine of 1794 and Pen- 
 naafs Views of Hindoostan, published about the same 
 time, give accounts of the reconstruction of noses from 
 the forehead performed in India to relieve the horrid 
 facial disfigurements so common in that country. 
 Amputation of the nose was there frequently performed 
 as a punishment to prisoners and as retribution for 
 supposed marital unfaithfulness. 
 
 It is curious to read at the present time the doubt 
 felt by Hiester, Coote, and other surgical writers of 
 more or less recent date, as to the possibility of rhino- 
 plastic operations. This doubt of the professional mind 
 is a little difficult to understand, when it is recollected 
 that there was even then a considerable amount of 
 literature showing the possibility of the adhesion of 
 parts, entirely separated from the body, if they were 
 reapplied and sutured within a reasonable time. 
 
 In 1823 Biinger, of Marburg, made a new nose for a 
 woman from the tissue of her thigh. In Europe, Dief- 
 fenbach, Graefe, Blandin, Serre, Jobert and Zeis were 
 earnest advocates of reparative surgery. In America, 
 Warren, Mutter and Pancoast were the early advocates 
 of plastic operations. Thomas D. Mutter, the founder of 
 the Mutter Museum and the Mutter Lectureship, pub- 
 lished articles on plastic surgery a very few years 
 after his graduation in 1831. They were followed by 
 other American surgeons, among whom may be men- 
 tioned as conspicuous operators Post, Buck, Andrews 
 and Prince. 
 
 Szymanowski, of Russia, published in 1867 an 
 elaborate attempt to systematize the various oper- 
 ative procedures for the relief of deformities requir- 
 ing plastic surgery. He devoted many pages of 
 
his operative surgery to illustrations showing the 
 principles upon which the integuments can be satis- 
 factorily displaced. His experiments on the cadaver 
 aided him very much in the preparation of this 
 part of his book, which has become a classic. A 
 decided advance was made in 1871 by Reverdin, who 
 proposed epidermic grafting, often called skin-graft- 
 ing, for covering ulcers and granulating wounds. 
 Other steps in the progress of reparative surgery were 
 the announcement by Thiersch, in 1886, of his method 
 of transplanting large shavings of the upper layers of 
 the skin. Previous to this time, however, Wolfe, of 
 Glasgow, had shown that moderate size pieces of skin 
 could be transplanted without a pedicle with compar- 
 ative certainty of union. Krause has greatly improved 
 the method of transplanting skin without pedicles. 
 
 Other steps in reparative surgery are the substitution 
 of muscles for those torn away by accident or paralyzed, 
 the transference of nerve-trunks, and similar proced- 
 ures. Among the most interesting are the substitution 
 by Czerny of a fatty tumor from the thigh for a portion 
 of the mammary gland which had been excised for 
 malignant tumor. Gluck has succeeded experiment- 
 ally in repairing a defect of the carotid artery by patch- 
 ing that vessel with a piece of jugular vein. Van Lair 
 has suggested the possibility of taking portions of 
 organs, or possibly whole organs, at the moment of 
 death and using them for the restoration of internal 
 parts. The thyroid gland of the sheep has been im- 
 planted in the abdomen of man to act as a substitute 
 for his diseased or extirpated thyroid gland. The 
 ovary has been transplanted successfully, from one 
 animal to another and from one region to another of 
 the same animal. It is said that such ovaries have 
 carried on their function and even made pregnancy 
 possible. 
 
 Nicoladoni has recommended, for the loss of the 
 thumb, the grafting of a toe upon the hand. Glass 
 balls have been introduced into the eye to represent 
 the vitreous humor and maintain the globular shape of 
 the organ. Celluloid and metal supports are worn 
 within the tissues of the nose to give them a proper 
 shape. The mental distress of despondent men has 
 
been relieved by tbe substitution of similar materials 
 for extirpated testicles. This " implantation-therapy " 
 is susceptible of far greater use than is yet realized. 
 
 Lecture II. — A Rapid Survey of the Anatomy (Con- 
 structive, Regional, and Artistic) of the Human Face. 
 
 [Abstract.] 
 
 The frontal and temporal regions of the cranium 
 must be included in the present study ; because the dis- 
 figurements to be considered concern the ears and fore- 
 head, as well as that portion of the head usually called 
 the face in anatomical treatises. 
 
 Good surgery of any region is impossible without a 
 knowledge of the bony landmarks and the mutual re- 
 lations of the soft parts. The lecturer is therefore 
 obliged to spend a little time at least in describing the 
 bones, muscles, arteries and nerves of the region, the 
 surgery of which is to be discussed. The carotid, tem- 
 poral and facial arteries must be remembered, because 
 of the hemorrhage, which occurs from them during 
 operations, and because the bloodsupply of flaps made 
 in plastic operations is a matter of supreme importance. 
 The situation of the branches of the facial nerve and 
 the position of the duct of the parotid gland must be 
 always in the mind of the operator, lest wound of 
 these important structures occur. 
 
 The upper jaw is of major importance in the con- 
 struction of the face, forming as it does portions of the 
 walls of the orbit, nose and mouth. Its alveolar arch 
 must correspond with the same portion of the lower 
 jaw, in such a way that the upper teeth may lie in front 
 of the lower jaw when the mouth is closed. The in- 
 cisive portions of the two upper jaw bones are devel- 
 oped by special centers of ossification. They therefore 
 have much to do with the shape of the lower portion 
 of the face and mouth. Harelip and cleft palate 
 are the most conspicuous and most common con- 
 genital deformities due to improper development of 
 this portion of the facial skeleton. Another disfigure- 
 ment is that in which the lower jaw with its teeth 
 project in front of the upper jaw. This deformity is 
 said to be due at times to precocious ossification of the 
 
sutures between the body of the upper jaw and its in- 
 termaxillary or incisive portion. As a result, the upper 
 jaw and teeth do not develop in a forward direction as 
 much as they should and the lower jaw gains an undue 
 relative prominence. The lower segment of the face is 
 therefore altered in an unseemly manner. Mechanical 
 appliances to prevent this ugly alteration in the rela- 
 tion of the two jaws may be successfully employed in 
 young children. 
 
 The lower jaw varies greatly in shape in different in- 
 dividuals and at different periods of life. The angle 
 between ramus and body in the adult male is about 
 122°. It is very obtuse in infants, and more obtuse in 
 women than in men. Changes in the angle of the 
 mandible and the prominence of the chin, produced by 
 the loss of teeth and the absorption of the alveolus in 
 old age, give the characteristic appearance of the senile 
 face. Ankylosis of the temporo-maxillary joints pre- 
 venting movement of the lower jaw will, if occurring 
 in childhood, lead to atrophy or want of proper de- 
 velopment. An immature chin thus results, causing 
 conspicuous disfigurement of the individual. Burns of 
 the lower part of the face and neck in early life often 
 prevent proper mobility of the lower jaw and lead to a 
 lengthening and bending downward of the bone. Per- 
 sistent thumbsucking in young children after the 
 second dentition causes deviation of the teeth and an 
 abnormal relation of the jaw-bones. 
 
 The frontal eminences are better marked in young 
 persons and women than in adult males, because in the 
 latter the greater development of the frontal sinuses 
 brings the lower portion of the frontal bone forward in 
 the neighborhood of the superciliary ridges. The frontal 
 sinus begins to develop at about seven years of age. 
 
 A study of the facial angle and its measurement by 
 the goniometer of Camper are interesting to anatomists 
 and surgeons as well as to artists. 
 
 The face of the infant is small in comparison with 
 the rest of the head. The cranium of the baby is five 
 or six times as large as the face. The development, as 
 the infant grows, of the superciliary arches and frontal 
 sinuses makes the frontal eminences less conspicuous, 
 and the forehead therefore assumes a more receding 
 
character. The face at first is short in comparison with 
 its breadth and lacks the prominence of the adult face. 
 This is largely due to the absence of teeth. The 
 growth of the jaws, which occurs when the teeth have 
 erupted, changes the lower portion of the face into that 
 of the adult. 
 
 The appearance of the human face has varying char- 
 acteristics in different races of men and in different in- 
 dividuals of the same race. A protruding face is called 
 prognathous ; the nonprotruding face, orthognathous ; 
 and a broad face eurygnathous. The Caucasian face is 
 orthognathous and often prominent mesially and cen- 
 trally, while the African and Mongolian races have prog- 
 nathous faces. The Mongolians have faces which are 
 broad and centrally depressed as well as prognathous. 
 
 The muscular structures of the face differ from the 
 muscles of the extremities in that one end of many 
 
 Crude diagrams showiDg change in expression caused by change in shape of 
 
 mouth. 
 
 of the muscles is inserted into the skin, which 
 is movable and drawn into folds and wrinkles 
 at right ankles to the direction of the muscular 
 pull. In subjects whose skin is thin and flexible 
 muscular contraction causes many and delicate wrin- 
 kles. When the skin is thick and stiff by nature 
 or as the result of disease, a slight action of the muscles 
 of expression will produce no visible wrinkling. More 
 active contraction will cause few and thick wrinkles. 
 Under the latter circumstances delicate shades, and 
 variety and beauty, of facial expression are absent. 
 
 There are two main muscular landmarks on the 
 front of the face. One about the two eyes and one 
 around the mouth. They are in a certain sense sphinc- 
 ter muscles, closing the eyelids and the opening of the 
 
mouth. The orbicular muscle of the mouth has its 
 fixed attachments in the middle line above and below, 
 but the orbicular muscles of the eyelids have their fixed 
 points at the outer and inner ends. Many of the 
 muscles of expression are inserted into or blend with 
 the fibers of the orbicular muscle of the mouth and by 
 
 Action ot corrugators of eyebrow shown in expression of suftering. 
 
 acting upon it make great changes in the expression ot 
 the face. 
 
 The mobility of the lips, the bulk of which is chiefly 
 the orbicular muscle, gives expression to the face to a 
 much greater extent than any muscular movement 
 about the evelids and forehead. 
 
The muscles of the face occur in pairs. The frontal 
 muscle and orbicular muscle of the mouth, though each 
 is spoken of as single, are really two lateral muscles 
 usually acting as one. 
 
 The action of the frontal muscle is to raise the eye- 
 brows and make transverse wrinkles in the skin of the 
 forehead. It has been called the muscle of attention. 
 
 The nasolabial line and the transverse furrows of the forehead are well shown 
 in this photograph. 
 
 When acting excessively it produces the appearance of 
 astonishment. 
 
 The corrugator muscles of the eyebrows pull the eye- 
 brows inward and downward near their nasal ends, 
 making vertical wrinkles between the eyebrows above 
 the root of the nose. This expresses frowning shown 
 in mental and physical suffering. The greater zygo- 
 
matic muscles draw upward the angles of the mouth 
 and cause wrinkles under the eyes, thus giving rise to 
 the expression of joy. They are assisted by the elevators 
 of the angle of the mouth. 
 
 A well marked furrow in the face is the nasolabial 
 line extending downward and outward from the wing 
 of the nose to a point external to the angle of the 
 mouth. It is seen in all faces, especially in the aged. 
 The nasolabial line changes its shape with the action of 
 various muscles of emotion. It is important to the 
 surgeon, because incisions made along its groove show 
 little scar. In laughter the nasolabial line assumes a 
 double curve like the old italic S. In pain it is 
 straight; in grief, convex outward. In contempt it is 
 drawn in at the lower end and extended around the 
 anofle of the mouth. 
 
 Crude diagrams showing cliaoge of expression caused by changes in the naso- 
 labial lines. 
 
 Other emotions are shown by similar actions and 
 combinations of action of the small muscles of the face, 
 which are inserted into the skin or into the muscular 
 mass of the lips. 
 
 In true emotions the muscles of the various portions 
 of the face act in consonance involuntarily and produce 
 expressions which seem to us natural. We can, how- 
 ■ever, by distinct voluntary effort bring disassociated 
 muscles into action, and thereby produce a grimace. 
 It is interesting to observe how the anatomic situation 
 and nervous supply of muscles indicate what emotions 
 can occur together. This anatomic basis of expression 
 <;orresponds exactly with the psychic relations of the 
 phenomena. It is impossible, for example, to give 
 
10 
 
 attention to external objects and to be at the same time 
 in a state of meditation. The impossibility of such a 
 mental contradiction is anatomically shown in the fact 
 that the frontal muscle cannot carry the eyebrow up- 
 ward to indicate attention while the orbicular muscle 
 of the eyelids is pulling it down to indicate meditation. 
 
 Lecture III. — Characteristics of Surgery in the Face. 
 — The Principles of Plastic Surgery of the Face. 
 
 [Abstract.] 
 
 The skin of the face is thin, elastic, and very vascular. 
 Its vascularity and elasticity render it suitable for 
 jslastic procedures. Incision should be made in posi- 
 tions where there is usually a shadow, as under the 
 eyebrow or beneath the lower jaw, or in the bottom of 
 the furrows produced by the habitual expressions of the 
 patient. When these positions cannot be chosen the 
 surgeon's cut should be made parallel to the facial lines 
 rather than across them. A slightly curved line makes 
 a less conspicuous scar than a straight or abruptly 
 curved one. Accurate apposition should be made by 
 means of sutures. Oblique incisions through the skin 
 permit more accurate apposition than those dividing 
 the skin in a plane at right angles to the surface. The 
 intracuticular suture is sometimes valuable ; but is not 
 necessary, if thin silk is employed and the wound kept 
 aseptic. Formaldehyd catgut may be used instead of 
 silk, because it may be thin without being absorbable as 
 soon as the ordinary catgut suture. The infrequency 
 of valves in the veins of the face is said to be the cause 
 of the rapid spread of septic inflammations in this 
 region. Wounds should therefore be kept free from 
 contamination. The bones of the face have a good 
 blood-supply, and many of them are comparatively 
 soft. They may be utilized for plastic operations with- 
 out much danger of necrosis. 
 
 Portions of the nose, ear or lip which have been cut 
 off should be readjusted and sutured in position, for 
 there is a fair prospect of immediate union of such 
 parts accidentally separated from the face. 
 
 It is better as a rule to keep the wounds dry. They 
 may be covered with a small piece of aseptic gauze, or 
 
11 
 
 an aseptic scab may be formed by dusting a little boric- 
 acid powder over the wounds and allowing it to form a 
 crust with the serum. 
 
 Incisions in the cheek should, Avhen possible, avoid 
 perforating the mucous membrane. This prevents 
 infection from the bacteria within the mouth. Drainage, 
 when necessary, should be into the mouth and not upon 
 the surface of the face. The duct of the parotid gland 
 must be avoided. If cut, the proximal end should 
 be carried iato the mouth through a properly placed 
 incision. This avoids the occurrence of external fistula. 
 
 Plastic surgery is called into requisition to repair 
 congenital malformations and deformities, the result of 
 injury or disease. 
 
 Displacement of skin by stretching or sliding, trans- 
 ferring a flap with a pedicle, and transplanting por- 
 tions of tissue from the face or other regions, without 
 pedicles, are the chief methods employed. Occasion- 
 ally the flap to be used for repairing a gap is not put 
 into position until inflammatory changes have in- 
 creased its vascularity and thickness. 
 
 Plastic surgery may also have for its object the cur- 
 tailing of abnormally large organs, such as noses, ears 
 and lips. 
 
 Plastic surgery should not be done upon a patient in 
 poor health nor when septic contamination is particu- 
 larly likely to occur. Syphilitic processes should be 
 stopped by treatment before the deformities caused by 
 them are corrected by operation. 
 
 A series of operations may be necessary to obtain 
 the best cosmetic result. A bulky resemblance to the 
 organ to be constructed is made first. Subsequent 
 improvement is then obtained by minor operations, 
 with suflicient intervals between them to permit the 
 absorption of inflammatory exudate and cicatricial 
 shrinking. 
 
 Flaps may be jumped across a bridge of skin, may 
 be turned upside down and skin-grafted upon the raw 
 surface, or one flap may be put upon the top of 
 another to raise depressed portions of the face. Flaps 
 containing periosteum and bone are sometimes used. 
 Plastic flaps should contain a good deal of subcutaneous 
 tissue, and should have a wide pedicle when possible. 
 
12 
 
 The flaps should be about one-third larger than the 
 space to be filled in. 
 
 In transplanting portions of skin without pedicles 
 the best results are usually obtained by removing the 
 subcutaneous fatty tissue, and keeping the wound 
 absolutely dry and free from antisej^tic solutions. 
 Asepsis, not antisepsis, is an essential here. 
 
 If gangrene occurs it is wise not to remove hastily 
 the tissue which seems to have lost its vitality. Very 
 often only the surface or the edges will actually die, 
 and a much better result will be obtained than the 
 surgeon expects when he sees the tissue beginning to 
 slough. 
 
 Lecture IV. — The Removal of Disfigurements Due to 
 Pigments, Cicatricial Distortions, Errors of Develop- 
 ment, Tumors and Skin Diseases. 
 
 [Abstract.! 
 
 Unburxt powder imbedded in the skin and subcu- 
 taneous tissue and intentional tattooing with black 
 pigments cause blue stains in the skin. Coal miners 
 often suffer similar disfigurements from wounds being 
 soiled with coal dust. Wounds soiled with gunpowder 
 or coal dust must be at once thoroughly scrubbed with 
 soap and lot water and a brush, to remove the particles 
 of carbon. Anesthesia, local or general, may be needed 
 for such treatment. When the skin has healed over the 
 imbedded carbon, the discoloration can only be re- 
 moved by excising the stained area or tediously remov- 
 ing each particle. Croton oil has been picked into the 
 skin to cause suppuration and extrusion of the black 
 particles. Combustive destruction of the carbon by 
 introducing a red hot galvanocaustic needle has been 
 proposed. Dermatologists employ chemical means to 
 remove intentional tattooing. The discolorations due 
 to accidental wounds are probably too deep for success 
 by this method. 
 
 Glycerole of papain has been picked deeply into the 
 skin with the object of removing the pigment after 
 tattooing. Another method sometimes employed is to 
 pick into the skin a solution of tannic acid. A stick of 
 silver nitrate is then firmly rubbed into the punctured 
 
13 
 
 area. Silver tannate is formed where the tannin has 
 been picked into the skin. Of course, scabs form and, 
 on removing the scabs in about two weeks, it is found 
 that the pigmentary stain is gone. 
 
 Cicatricial distortions, unimportant in other regions, 
 are unsightly upon the face. Operations producing 
 distorted scars should be avoided, if possible. Syphil- 
 itic ulcers should be treated early and vigorously. 
 Abscesses may be opened on the mucous surface of the 
 cheek. Tuberculous glands may be removed or drained 
 before they by spontaneous opening cause ugly scars. 
 
 Tumors should be excised by incisions so placed as 
 to prevent cicatricial distortion of the eyelids, mouth 
 and nose. Plastic operations to fill the gap left by re- 
 moval of the tumor will often be necessary. 
 
 Burns make extensive and horrid deformities of the 
 face. Keloid degeneration of scars is a cause of disfig- 
 urement in many scars otherwise unimportant. The 
 disease occurs more frequently in the black race than 
 in the white. It may attack leech bites, acne pustules, 
 smallpox scars and even fly blisters, as well as ordinary 
 wounds. The keloid growth may return after excision. 
 It is a disease of youth and adolescence, and usually 
 disappears spontaneously before middle life. Extract 
 of thyroid gland internally and local applications of 
 collodion have been used by White in hypertrophy of 
 scar tissue resembling keloid disease. Excision, if 
 employed, should be made at a considerable distance 
 from the boundaries of the keloid mass. 
 
 The unsightliness of depressed or irregular scars may 
 be lessened by excision and by transference or trans- 
 plantation of skin. Moderately depressed scars may 
 be treated by rubbing the skin with finely powdered 
 calcium carbonate. This attrition removes or prevents 
 the epithelial accumulation along the edges, which 
 makes the depression more conspicuous. The pits of 
 smallpox may be thus treated with some success. The 
 white spots of vitiligo may be made less conspicuous 
 by removing the excess of pigment which usually ap- 
 pears at the margin of the white spots. This is to be 
 done by applications similar to those used in the re- 
 moval of freckles. Corrosive sublimate, three or five 
 grains to the ounce, is a good application. 
 
14 
 
 Congenital fistules and fissures occur from imperfect 
 closure of the branchial clefts. They are usually best 
 treated by excision. Fistules due to suppurative dis- 
 ease of the accessory sinuses of the nose are difficult 
 to close because of the trouble in thoroughly sterilizing 
 the mucous-lined cavities from which they arise. Drain- 
 age and disinfection are important parts of the treat- 
 ment. 
 
 Meningocele and encephalocele cause tumors upon 
 
 Case of distigiireraent from burns. Improved by incising scar-tissue under 
 chin and taking two long flaps from back, which were brought around the 
 front of the neck like a cravat. 
 
 the face which should be treated by aseptic excision. 
 Deficiency and atrophy of the bones ot the face are 
 curious conditions due to irregularities in development 
 and nutrition. Osteoplastic operations may under 
 some circumstances be valuable. Prosthetic appliances 
 of wax, papier mache or celluloid are occasionally of 
 service in concealing excessive deformity due to these 
 cause'. 
 
15 
 
 Facial hemiatrophy is another disfiguring condition 
 due to a trophoneurosis occurring not only in children, 
 but also in adults. Hypertrophy of the bones of the 
 face occurs, giving a leonine appearance to the patient. 
 
 Case of hemiatrophy of the face, with small abscess communicating with one oi 
 the accessory sinuses of the nose on the same side as the atrophy. 
 
 The bulky bone may be reduced by chiseling opera- 
 tions. 
 
 Many skin diseases are most disfiguring when oc- 
 curring upon the face. A large number of them are 
 
16 
 
 readily removed by judicious treatment directed to the 
 general health of the patient and accompanied by 
 proper local remedies to alter the nutrition of the skin. 
 
 Comedo, sebaceous cyst, and various forms of acne 
 are characteristic dermal affections, which need a com- 
 bination of general and local treatment. Surgical man- 
 agement is sometimes required. 
 
 Warts, horns and moles are occasionally allowed to 
 become a source of great perturbation to the patient's 
 mind, and need mechanical treatment. Congenital 
 
 Case of dennatolysis treated successfully by excision followed by application of 
 flaps from the arm, neck and forehead and by skin-grafting. 
 
 moles are often large, pigmented and hairy. Such 
 growths require extensive surgical operations for their 
 removal. Hairy growths are best removed by electro- 
 lysis. The method is a slow one, but is effectual ; if the 
 electrolytic needle at the negative pole is inserted with 
 care into the hair-follicles. It has been proposed to 
 graft shavings of skin, taken after the method of 
 Thiersch, upon the surface left after shaving off the 
 pigmented tissue which forms the bulk of the mole. 
 
 Vascular tumors and discolorations may be treated 
 by extirpation with a knife and in some cases by elec- 
 
17 
 
 trolysis. When possible, excision is most expeditious 
 and radical. If well done, it leaves little scar to cause 
 disfigurement. 
 
 A circumscribed hypertrophy of the skin, called 
 dermatolysis, in which soft masses of thickened integu- 
 ment hang in loose folds over the face, is of occasional 
 occurrence in the face. It is to be treated by excision, 
 skin-grafting and the transference of cutaneous flaps. 
 
 Lupus, which is a cutaneous tuberculosis, causes 
 great ravages to the skin. It produces ectropion of the 
 eyelids and lips, a shrunken, beak-like nose or even 
 complete destruction of the external nose, contraction 
 of the opening of the mouth, and distortion of the lips 
 and ears. The disease should be removed by dissec- 
 tion and covering the space with skin-shavings, by 
 scraping the diseased structures away with the curet, 
 or by using strong caustics. The use of tuberculin was 
 supposed to be beneficial. A more prolonged experi- 
 ence with the remedy has, however, not proved its 
 claims to be wholly substantiated. 
 
 Lecture V. — Deformities of the Lips and Mouth. 
 
 [Abstract.] 
 
 The chief congenital deformity of the mouth is hare- 
 lip, which with its complications gives ample oppor- 
 tunity for the exercise of constructive skill. Other 
 congenital defects are atresia oris, macrostoma, micro- 
 stoma, cleft of the lower lip, hypertrophy of the lips, 
 and excessive eversion of the lower lip. Distortion of 
 the mouth and lips and deficiencies of the lips and 
 cheeks occur as the result of sloughing and injuries. 
 
 The treatment of congenital occlusion of the mouth 
 and of cicatricial contraction consists, in the former case, 
 in dividing the occluding membrane and preventing 
 readhesion of the lips, and, in the latter case, in mak- 
 ing horizontal incisions outward from the orifice repre- 
 senting the mouth. The mucous membrane must be 
 sutured into the end of the incision to prevent reunion 
 of the edges of the wound. Occasionally a V-shaped 
 piece of cheek must be removed with the point of the 
 V extending outwards. 
 
 Imperfect closure of the branchial clefts may cause a 
 
18 
 
 congenital horizontal fissure at one or both sides of the 
 mouth, extending outward into the cheek and causing 
 the condition termed macrostoma. This deformity is 
 treated by freshening the edges and applying sutures. 
 Similar deficiencies in closure of fetal structures cause 
 fissures in the upper lip, termed harelip, and occasion- 
 ally in the lower lip. In rare instances these fissures 
 may extend up as far as the orbit or down to the ster- 
 num. Sometimes a mere cicatricial line is seen in the 
 child's lip, as though an intrauterine cure of such a 
 fissure had taken place. The treatment of all these fis- 
 sures is based on the same general operative procedure 
 as that just described for macrostoma. 
 
 The lips may be enlarged from interstitial increase of 
 all the structures, from lymphedema, from chronic in- 
 flammation and from the presence of tumors. Chil- 
 dren, the subjects of cretinism, tuberculosis or in- 
 herited syphilis, sometimes have enlarged lips. Gen- 
 eral treatment directed to the cause of the trouble will 
 usually ameliorate or remove the deformity. Thyroid 
 extract is suggested in cretinoid cases. A hypertrophied 
 lower lip may be altered by excision of a V-shaped 
 piece in the middle line with the apex of the V near 
 the chin. This lessens the width of the lip. Its thickness 
 may require a second operation to remove a wedge of 
 tissue by incisions running across the free border of the 
 lip. Eversion of the lips, giving rise to what is some- 
 times called double lip, is to be treated by excision of 
 a section of the lip by means of transverse incisions 
 along the mucous surface. 
 
 Eversion of the lip, due to burns of the chin and 
 neck, must be corrected by sliding upward a V-shaped 
 flap from the throat or chest, transferring a flap with a 
 pedicle from the side of the neck, or transplanting a 
 piece of skin without a pedicle from some other part of 
 the body. Occasionally it will be found desirable to 
 employ the method of Tagliacozzi and use the arm for 
 supplying the flap. I have recently, in a case of everted 
 lip from burn, in which there was also a cicatricial 
 deformity of the hand, used the hand for carrying a 
 portion of the abdominal skin to the chin. This was 
 done by first grafting a flap of skin from the abdomen 
 to the back of the hand where the cicatrix had been 
 
19 
 
 freed by incisions. After adhesion had taken place, 
 the flap was cut loose from the belly and the hand 
 applied to the face, so that a portion of the abdominal ' 
 skin could be sutured to the raw surface made upon 
 the chin, by dissecting loose the scar-tissue in the lower 
 lip. Gypsum bandages held the arm in position until 
 the graft had become attached, when the hand was 
 cut loose. This method of using the hand for trans- 
 ferring tissue is a valuable one, originally suggested, I 
 believe, by Shrady. 
 
 When the cheek is distorted by operation or by in- 
 jury, a U-shaped flap may be turned up from the neck 
 and thrust through a buttonhole incision made along 
 the lower margin of the jaw, so that the skin-surface is 
 turned toward the teeth. This operation is only satis- 
 factory when there is not much beard upon the skin 
 turned inward. 
 
 Deformities of the lower part of the face arise after 
 excision of the mandible for necrosis or tumor, because 
 the muscles displace the portion of the lower jaw which 
 is retained. This displacement may be largely pre- 
 vented ; by having a dentist cap the teeth and anchor 
 the fragment of the lower jaw to the teeth of the upper 
 jaw, or in some similar manner arranging a spring 
 within the mouth to hold the normal portion of the 
 jaw in proper position. An artificial appliance may 
 subsequently be made to represent the removed bone, 
 and a vulcanite cheek-plumper may be adapted to fill 
 out the collapsed cheek. 
 
 The obliquity of the mouth due to facial paralysis 
 may be improved by excising an elliptical portion of 
 tissue from the cheek. Dental irregularities and mal- 
 formations and discolored teeth require skilful work 
 of a trained dentist. This branch of surgery has been 
 greatly developed in recent years. Contracted jaws, 
 irregular eruption of teeth, and abnormal relation 
 in the projection of the upper and lower jaws may be 
 corrected, it proper appliances are adopted. 
 
 Much harm is done by the erroneous extraction of 
 teeth, in the endeavor to make room for the eruption of 
 other teeth. The canines should seldom if ever be ex- 
 tracted for this purpose, because they have much to do 
 with the shape of the face. Careful study of the physi- 
 
20 
 
 ology of dentition is required before deciding which is 
 the proper tooth to extract. Prominence of the lower 
 jaw, causing prognathism, may be greatly improved by 
 a net cap worn at night with proper rubber bands at- 
 tached to a jaw support. A change in the bite, or ar- 
 ticulation of the teeth, may often be made, by means of 
 which the improper relation between the upper and 
 lower jaw may be gradually corrected. The success of 
 such corrective measures is greater and more promptly 
 obtained in adolescents than in adults. It is probable 
 that between the ages of 12 and 20 is the best period ; 
 but even up to 30 years of age much can be done by 
 patient, judicious mechanical treatment. 
 
 Where the lower jaw is greatly deformed by drag- 
 ging down of the lower lip from cicatricial contrac- 
 tion, a section removed from both sides of the jaw may 
 enable the surgeon to bring the chin and the lower 
 teeth into proper relation to the rest of the face. These 
 cases require careful study and aseptic operative treat- 
 ment. 
 
 I have at the present time under consideration a case 
 of relatively retracted chin ; on which it is possible I 
 may operate to bring forward the chin, by detachment 
 and displacement of the mental tubercle and the graft- 
 ing of bone taken from the tibia. 
 
 Lecture VI.- — The Reconstruction of the Lips and Cheeks. 
 
 (Abstract.) 
 
 Congenital fissure of the upper lip, usually called 
 harelip, is one of the most common deformities requir- 
 ing reconstructive operations about the mouth. Labial 
 fissure also occurs in the lower lip, but not as commonly 
 as in the upper. In the lower lip, the fissure is usually 
 in the middle line. In the upper lip, it is more com- 
 mon to have it at one side of the middle line. These 
 deformities are due to imperfect coalescence of the 
 branchial arches during fetal life. Eeconstructive op- 
 erations are also required after removal of malignant, 
 tumors of the lips and cheeks, and to overcome de- 
 formities the result of cicatricial contraction, particu- 
 larly from burns of the face. 
 
 Harelip may be unilateral or bilateral. It may be- 
 
21 
 
 complicated with cleft of the alveolar process of the 
 jaw, cleft of the entire palate, or with protrusion of 
 the entire intermaxillary bone, in addition to palatal 
 cleft. The intermaxillary bone is sometimes displaced 
 and attached, as it were, to the point of the nose, giving 
 the child a snout-like deformity of the upper lip and 
 nose. 
 
 The various forms of labial fissure are treated by 
 freshening the edges of the cleft, replacing protruding 
 portions of the intermaxillary bone, and suturing the soft 
 parts alone, or the soft parts and the replaced bony tis- 
 sues. The operation should, as a rule, be done before the 
 third month of the child's life, unless the child is sickly 
 or the operation is going to be a bloody one because 
 of the complicated nature of the case. An early closure 
 of the lip seems to aid in causing a tendency for an 
 accompanying palatal fissure to become less as the child 
 grows up. Anesthesia should always be employed. To 
 operate without anesthesia is a cruel practice. 
 
 Complicated harelips may be left until about the sec- 
 ond year, if the child's health is bad or the dagger of 
 hemorrhage producing ill effects great. The methods 
 of bringing the parts into apposition vary greatly with 
 different operators, but the principles are simple enough. 
 The edge of the cleft should be pared in such a way as 
 to give a broad surface of contact, and to make that side 
 of the lip, which is the shorter, long enough to make 
 the lip have the proper shape. To prevent the forma- 
 tion of a notch at the vermilion border, the incisions 
 should be so placed as to give plenty of tissue at the free 
 margin of the lip. Suturing should be done so care- 
 fully that the mucous membrane does not show upon 
 one side at a higher point than the other. 
 
 The length of the lip from the nose to the orifice of 
 the mouth should be made sufficiently great. Surgeons 
 often neglect this important point. The flattened nostril 
 should be altered by changing the position of the wing of 
 the nose. This can often be done by an incision outside 
 of the wing of the nose in the curve between it and the 
 cheek. It may be necessary to saw the alveolar process 
 and bring a portion of that bony structure toward the 
 middle line, in order to make a floor for the wing of the 
 nose to rest upon. This is easily done before closure of 
 the lip. 
 
22 
 
 Trusses to press the cheek inward toward the middle 
 line, metal supports to the lip, harelip pins and similar 
 devices are to be discarded. Properly placed incisions 
 with sutures of silk, silkwormgut or formaldehyde catgut 
 are all that is necessary. 
 
 The intermaxillary bone, if thrust forward, should be 
 bent backward, after fracturing the cartilage and bone^ 
 or excised. It is sometimes necessary to cut out a V- 
 shaped portion of the septum of the nose before pushing 
 backward the projecting intermaxillary bone. The soft 
 
 Double harelip with protrusion of iatermaxillary bone. 
 
 tissues over the intermaxillary bone may be used to con- 
 struct the columella of the nose or to aid in making the 
 central portion of the lip. 
 
 Very little dressing is required after the operation. 
 Gauze and collodion, dry gauze, or a little boric acid 
 powder may be used. Adhesive strips are a disad- 
 vantage because they are liable to lead to septic con- 
 tamination. 
 
 It is occasionally necessary to make long incisions 
 
23 
 
 outwards into the cheeks to get sufficient tissue to dis- 
 place towards the middle line. In cases when there has 
 been very little tissue to repair a double harelip, the 
 patient has, even after a well-performed operation, a 
 very taut and drawn upper lip, which contrasts badly 
 with the full and prominent lower lip. A V-shaped por- 
 tion of the lower lip should then be removed, in order 
 to make the balance between the two lips more nearly 
 like that in a normal patient. 
 
 It is sometimes necessary to improve the appearance 
 of the lip, in harelip cases, by minor operations after 
 the child grows up to adolescent life. 
 
 Reconstructions of the lower lip are necessary at 
 times, even if it is impossible to restore the expression 
 and beauty of the mouth in anything like a perfect 
 manner. The operation is desirable because it will 
 prevent the escape of saliva and mucus, improve speech, 
 enable the patient to keep the tongue within the mouth, 
 permit drinking and taking of food, and lessen the in- 
 terference with digestion which is apt to result from 
 imperfect mastication and insalivation. Even if the 
 expression of the face, after the lips and cheeks have 
 been restored, is imperfect ; and even if the newly con- 
 structed part is absolutely immobile, the operation 
 makes the patient less ugly and makes him more will- 
 ing to mix in the society of his fellows. 
 
 It is difficult to give definite directions for cheiloplas- 
 tic procedures, because the surgeon must be governed 
 by the peculiarities of the case under observation. 
 Almost every time one operates the method must be 
 varied to meet the requirements. Often, indeed, the 
 necessities of the case determine the lines of incision 
 only after the operation has been commenced. 
 
 Pancoast said in 1843 that there is scarcely any loss 
 of substance, however hideous, of the mouth and lips, 
 which cannot be remedied by the skill and ingenuity of 
 modern surgeons. This statement is even more true 
 today than it was fi fty years ago. 
 
 The tissues of the cheeks are usually so mobile that 
 unless the cicatricial deformity involves them, they can 
 be displaced by proper incisions so as to construct an 
 upper or lower lip. The structures beneath the chin 
 and of the neck are also used for making lower lips. 
 
24 
 
 A large flap from the chin with the pedicle towards 
 the angle of the jaw may be turned upwards to make a 
 lower lip. If necessary, a portion of the lower jaw 
 forming the chin may be cut away to lessen the tension 
 on a flap. A bridge-shaped flap dissected from the 
 region below the chin may be lifted up over the chin 
 and put in the place of the removed lower lip. It has 
 been suggested to take a strip of the periosteum from 
 the jaw in such a flap, in order to give it a little more 
 rigidity. This rigidity is to take the place of muscular 
 tissue in the flap. 
 
 Both lips may perhaps be made by taking a large 
 flap from the front of the neck near the hyoid bone, 
 with pedicles at each side of the neck, and carrying it 
 like a bridge above the chin and fastening it below the 
 nose. A slit may then be made in it to represent the 
 mouth. 
 
 A. Shows lines of ircisions for one method of cheiloplasty. 
 sutured in position. 
 
 B. Shows flaps 
 
 A good lower lip may be made, after excision of the 
 whole lip for malignant disease, by flaps made by two 
 parallel vertical incisions, one running downward from 
 the corner of the mouth ; the other starting in the 
 cheek from a point a little outside of and below 
 the wing of the nose. These incisions are connected 
 below by an incision parallel to the margin of the jaw. 
 The two flaps are united in the middle line in such a 
 way as to construct a lower lip. This displacement 
 modifies a little the corners of the mouth, but this is 
 unimportant. Another method is to cut flaps in the 
 
25 
 
 region of the nasolabial grooves, as is shown in the 
 illustration. 
 
 The upper lip may be constructed in a somewhat 
 similar way by two lateral flaps made by parallel inci- 
 
 IncisioQS for flaps to reconstruct the lower lip. 
 
 sions following the general direction of the nasolabial 
 furrows. These flaps will have the base upward and 
 are turned inward towards the median line, to make 
 the upper lip, very much as the lower lip is constructed 
 by the flaps just described. 
 
 If a portion of a lip near the corner of the mouth is 
 lost the absent portion may be replaced by cutting a 
 
 Incisions to make flap to reconstruct a portion of a lip. 
 
 triangular flap from the other lip, swinging it down- 
 ward or upward around the corner of the mouth to 
 bring it into position. It is also possible to make a 
 
26 
 
 lower lip by cutting a flap from the neck with its base 
 upwards and making a buttonhole incision through the 
 skin near the chin. Through this incision the turned- 
 up flap may be thrust. By twisting the flap the skin- 
 surface may be directed outwards. A similar operation 
 may be done without making a buttonhole incision in 
 the skin near the chin. Then the flap is simply 
 jumped across the normal skin on the chin ; or it is 
 laid in a groove, made by a vertical incision in the tis- 
 sues covering the chin. 
 
 After making new lips in any of these ways the edge 
 may be lined with mucous membrane by taking flaps 
 of mucous membrane from the inside of the cheeks 
 near the normal lip and twisting these flaps into proper 
 position. They are then sutured to the newly made 
 organ. 
 
 It is also possible to get tissue for a lip, by the method 
 of Tagliacozzi, from the arm by binding the hand to the 
 head. A method which I have used satisfactorily is to 
 transfer the skin of the abdomen to the hand and then 
 transfer from the hand to the lip, after the abdominal 
 flap has become united to the hand. 
 
 Portions of the cheek may be made by flaps from 
 other portions of the face or from the neck. A con- 
 venient way sometimes is to turn up a flap from the 
 neck and thrust it through a buttonhole incision along 
 the edge of the lower jaw. The skin surface may 
 thus be turned inward and the outer surface skin- 
 grafted. This operation is not satisfactory if the skin 
 of the neck is covered with a heavy beard, because the 
 hair grows into the mouth. 
 
 Lecture VII. — The Correction of Deformed Noses. 
 
 (Abstract.) 
 
 Many nasal deformities are quite insignificant anatom- 
 ically, but are the cause of much distress to the patient. 
 Though there be little or no obstruction to breathing, 
 and little deformity to the eye of the observer, the dis- 
 figurement causes worry on the part of the patient. In 
 other cases the deformity, from congenital malforma- 
 tion, fracture of the bones and cartilages, ulceration or 
 gangrene, is so great as t6 greatly disfigure the patient's 
 
27 
 
 countenance. Syphilis, giving rise to necrosis of tlie 
 bones and cartilages which form the support of the 
 nose, is a potent cause of nasal deformity. Epithelio- 
 matous ulcers occurring upon the nose may render such 
 cutting operations necessary as will leave deficiencies, 
 which must be filled by operative treatment. 
 
 Destruction of tissue, from the application of caus- 
 tics, to relieve real or supposed malignant growths, is not 
 infrequently the cause of disfigurement. Some of the dis- 
 tortions of the nose are due to deviations of the 
 cartilaginous septum. Many of these deviations are the 
 result of fracture following comparatively insignificant, 
 and perhaps forgotten, blows upon the nose. The 
 saddleback nose arises from a want of proper develop- 
 
 Saddleback Nose. 
 
 Tuberous Nose. 
 
 Angular Nose. 
 
 ment of the bones and cartilages forming the septum. 
 A somewhat similar sunken-in-nose is found in inherited 
 syphilis. These are much less conspicuous disfigure- 
 ments than the dreadful deformity of this organ, which 
 arises from syphilitic necrosis of the internal structures 
 of the nose, which give shape to its external contour. 
 In these cases the middle of the nose sinks inward be- 
 cause of lack of support. The tip of the nose, there- 
 fore, rises and the nostrils instead of pointing down- 
 ward look directly forward. The saddleback nose, the 
 angular nose due to undue prominence of the lower end 
 of the nasal bones, and the nose with a tuberous lobule 
 are all amenable to operative treatment. In the saddle- 
 
28 
 
 back nose a piece of metal or celluloid may be steril- 
 ized and slipped underneath the skin in such a way as 
 to fill up the hollow on the dorsum of the nose, and 
 give the organ a straight, or nearly straight, surface 
 from the forehead to the tip. 
 
 The sunken or saddleback nose of inherited or ac- 
 quired syphilis requires much more active surgical 
 intervention ; at least in the majority of cases. Here it 
 is necessary to elevate the parts; and then support 
 them. Chiselling portions of bone from the nasal pro- 
 cesses of the maxillary bones, or from the nasal bones 
 themselves if they have not been destroyed has been 
 adopted. These detached fragments are displaced in 
 such a manner as to give support to the nasal tissues 
 which have previously been elevated by subcutaneous 
 
 Twisted Nose. 
 
 Bent Nose. 
 
 incisions. The introduction of intranasal -supports of 
 metal, to hold up the external nose, has been employed. 
 In syphilitic cases foreign materials used for this pur- 
 pose are more apt to set up irritation than in nonsyph- 
 ilitic cases. It is probably better to build up the dorsum 
 by flaps taken from the cheeks or forehead, than by 
 using internal supports made of metal. 
 
 The angular nose is usually remedied by the very 
 simple operation of making an incision, and chiselling 
 away the redundant cartilage and bone. It is usually 
 better to make the cut along the edge of the nose, rather 
 
29 
 
 than directly in the middle lioe. The elasticity of the 
 skin permits the surgeon to displace the flap laterally, 
 and get access to the prominence to be removed. The 
 scar, being a little to one side of the anterior surface of 
 the bridge of the nose, is less conspicuous than if in the 
 middle. 
 
 Bent and twisted noses are remedied by incising the 
 septum, removing redundant portions of the septal 
 cartilage and bones, separating the soft tissues of the 
 nose from the bony supports beneath by the free use of 
 a tenotome, and forcing the distorted organ into proper 
 position. It is held here by means of pins introduced 
 through the nostril and from the external portion of the 
 nose. The use of pins is often more satisfactory than 
 intranasal splints or tubes, because the nostrils are kept 
 free from obstructing foreign bodies, and can be easily 
 irrigated or sprayed with antiseptic solutions. In cor- 
 
 Use of pins to hold incised septum in corrected position. 
 
 recting bent or twisted noses, the surgeon should usu- 
 ally overcorrect the deformity, because there is a 
 tendency for the nose to return to its abnormal position. 
 Chisels, saws, and the surgical engine are instruments 
 very useful in correcting the septal deformity which is 
 often associated with these external disfigurements. 
 
 Tarbed Needlp. 
 
 Surgeons should not forget the importance of examin- 
 ing all recent fractures of the nasal bones and cartilages 
 with great care. Imperfect examination and conse- 
 quent inefficient treatment are the causes of many 
 deformed noses. 
 
80 
 
 In removing cartilaginous excrescences upon the 
 septum, a long barbed needle is often valuable. It is 
 thrust into the mass, which is thus steadied, until it is 
 excised with knife or saw. The long needle gives the 
 surgeon control of the little tumor, and permits the 
 removal to be quickly done. 
 
 Ala of nose and portion of upper lip made from flap cut from the cheek. Flap 
 doubled invvard to make naris by a double stitch tied over a piece of rubber 
 tube placfd alongside of the bridge of the nose. (Taken a few days after 
 operation. ) 
 
 Loss of the ala of the nose may be repaired by mak- 
 ing a flap from tbe upper lip and cheek, and turning 
 it into the gap. Sometimes it is better to take the new 
 tissue from the cheek alone, making the incisions in 
 the nasolabial furrow. Portions of the nose have been 
 constructed from the tissues of one of the fingers. This 
 
31 
 
 may be done by splitting a finger of the left hand on 
 its palmar surface, removing the phalanx, and stitching 
 the laid-open soft tissues to the stump of the nose. The 
 nail is removed either before or after the plastic opera- 
 tion which attaches the digit to the nose. After the 
 lapse of about two weeks the finger is amputated from 
 the hand. Nearly a complete nose has been made by 
 using a finger in a somewhat similar way. The color 
 of the skin of the hand is apt to difi'er from that of the 
 
 Portion of ala of nose made from tip of finger. (Dr. J. P. Tunis' ca=e.) The 
 notch in the new ala was subsequently repaired by the author with a flap 
 taken from the cheek. 
 
 face. Flaps may be taken from the forehead, with or 
 without periosteum, and turned or twisted downward 
 to close a gap on the top or side of the nose. The color 
 is then more natural. 
 
 The contour of a syphilitic nose may be improved 
 by a transverse incision across the depressed nose at 
 the deepest part of the furrow above the lobule of thfr 
 
32 
 
 -organ. This incision opens the nasal chambers and 
 •enables the surgeon to pull down the tip of the nose, 
 so that the plane of the nostrils is horizontal, as it nor- 
 mally should be. The great gap left between the root 
 of the nose and the tip must then be filled. I have 
 done this quite satisfactorily by taking flaps from the 
 cheeks and turning them inward toward the middle 
 •line, so that the skin-surface presented toward the nasal 
 
 Three diagrams showing a sunken syphilitic 
 nose and one method of repairing it. 
 
 cavity. The tissue of the forehead was then brought 
 downward to cover these flaps, and make the mass of 
 tissue thick, so as to give rigidity to the newly formed 
 portion of the nose. Another method is to make a V- 
 shaped incision between the eyes with the point of the 
 V upward, and displace this flap downward to fill the 
 gap left by the original transverse incision, which was 
 made to bring down the point of the nose. This flap 
 is scarcely rigid enough, but may be held in position 
 
33 
 
 by spectacles supplied with a spring, like eyeglasses. 
 Many modifications of these two plans will suggest 
 themselves to operators. 
 
 I have made a forehead flap containing periosteum 
 and a thin shaving of bone, turned that downward and 
 thrust it through a transverse buttonhole at the base of 
 the nose. This was done with the hope of giving more 
 solidity to the new dorsum. 
 
 Patient deformed by burns so that the nose was twisted to the left, the naris 
 closed, the lips ererted and the eyelids distorted. Much improvement was 
 obtained by a series of operations. 
 
 The columella of the nose may be made by two ver- 
 tical incisions extending downward through the upper 
 lip. The central portion of the lip is then turned up- 
 ward and stitched to the tip of the nose in such a way 
 as to make a partition between the two nostrils. The 
 gap in the Up is then closed by stitches as in hare-lip. 
 The mucous membrane which then covers the external 
 
34 
 
 surface of the new columella soon assumes an appear- 
 :ance similar to that of skin. I have on the cadaver 
 <3onstructed a satisfactory columella by cutting a verti- 
 cal piece from the inner surface of the lip and turning 
 it upwards through a transverse buttonhole made at the 
 junction of the nose and lip. 
 
 It is probable that the ala of the nose may be lined 
 "with mucous membrane in a similar manner. This may 
 be necessary when occlusion of the naris takes place 
 .after reconstruction of an ala. A portion of mucous 
 membrane and muscle may be cut from the inner sur- 
 face of the lip and turned upwards through a button- 
 hole made in the lip at the lower border of the nostril. 
 It is perhaps possible to make the columella from the 
 •dorsum of the nose, by cutting a flap containing peri- 
 osteum from over the nasal bones themselves, and 
 thrusting this cutaneo-periosteal flap through a trans- 
 verse buttonhole made near the tip of the nose. The 
 ■flap should then be stitched to the upper portion of 
 the lip. 
 
 This same method might perhaps be employed in 
 the treatment of saddleback noses by thrusting flaps 
 cut from the cheek through buttonholes made in the 
 skin at the side of the nose. If the cuticle is removed 
 from these cheek flaps, they would probably become 
 adherent to the deeper tissues of the nose, and build 
 up a mass of connective and fibrous tissue underneath 
 the skin at the front of the nose. A hollow creating 
 the saddleback condition could probably be thus oblit- 
 erated. These operations I have only tried upon the 
 cadaver, but they seem to promise success. 
 
 Lecture VIII. — The Construction of New Noses. 
 
 (Abstract.) 
 
 Rhinoplastic operations, for the construction of an 
 entire nose or a portion of that organ, are required to 
 repair the damages of syphilis and lupus and of inten- 
 tional and accidental mutilations. American and Con- 
 tinental surgeons have very little experience with these 
 operations, except in cases due to syphilis and lupus. 
 English surgeons in India have very many patients 
 with the cartilaginous portion of the nose cut ofl" 
 
35 
 
 by sharp instruments. This mutilation is frequently 
 adopted in India as a means of revenge. Keegan states 
 that the number of such mutilations effected in a single 
 year in India is unknown. That it must be large is 
 ■evident from his statement that in the year 1897 there 
 were 152 rhinoplastic operations performed in that 
 country. -In a single evening he saw, while riding 
 through one of the native cities, as many as three or 
 four women with mutilated noses, sitting near their 
 huts. As a consequence of this distribution of rhino- 
 plastic work, American and European surgeons have 
 had much less experience than Indian surgeons. The 
 ■cases seen outside of India are usually much more 
 ■difficult to bring to a satisfactory conclusion by opera- 
 tion, because the tissues which remain have been 
 distorted and altered by the syphilitic or tubercular 
 ulceration which has destroyed the nose. In many of 
 these nasal deficiencies, due to disease, the internal 
 bony and cartilaginous structures have been entirely 
 destroyed. In some instances even the nasal bones 
 which support the nose at its bridge are also absent, as 
 the result of the syphilitic necrosis. 
 
 Until recent years the technic of total rhinoplasty was 
 somewhat imperfect ; and, as a consequence, surgeons 
 undertook the construction of a nose with considerable 
 hesitation. More recent studies and the advantages of 
 aseptic surgery have improved conditions to such an 
 ■extent that these operations are now undertaken with 
 much more certainty of obtaining an improvement in 
 the patient's appearance. A very great deal can be done 
 when only the soft parts of the external nose have been 
 cut off. Quite a satisfactory gain is possible, even in 
 ■cases greatly deformed by cicatricial contraction, subse- 
 quent to syphilitic ulceration of the hard and soft parts. 
 In the latter cases the main difficulty is to get support 
 to the flaps of skin which are used to make the new 
 nose. Metallic supports and bridges of various sorts 
 have been employed to hold up and give the requisite 
 projection forwards of the flaps of skin which represent 
 the new nose. In some cases these have been worn for 
 a number of years and apparently with satisfaction. In 
 others they have set up irritation, which has finally led 
 to their removal. 
 
36 
 
 Portions of bone have been chiseled, from the nasal 
 bones and from the superior maxillary bones, and dis- 
 placed in such a way as to hold the integument for- 
 ward. These osteoplastic operations have been to a 
 certain extent satisfactory. Oilier, Koenig and Israel 
 have made interesting suggestions in this connection. 
 Sabine, of New York, constructed a new nose from a 
 finger, which he attached to the sides of the chasm left 
 by the loss of the nose. The finger-nail was removed 
 and the palmar surface of the finger split so as to form 
 lateral flaps. The hand was then applied to the face 
 and the finger stitched to the edges of the nasal cavity. 
 After circulatory connection was established, the finger 
 
 Langenbeck and Oilier split the nose vertically, laid the soft parts to each 
 side, and then sawed bony flaps from the edges of the nasal aperture above 
 and below on each side. They then bent these bony flaps forward to give 
 support to the frontal flap or the replaced soft structures. 
 
 was amputated from the hand through the first phalanx ; 
 and the end of the portion of finger, left attached to the 
 face, was bent at the joint between the first and second 
 phalanx, so as to make the end of the nose and its 
 columella. A number of minor operations were subse- 
 quently done to improve the shape of the new nose. 
 
 The usual methods of rhinoplasty are the Italian, in 
 which the tissues of the arm are attached to the stump 
 of the nose ; the French — sometimes called the German 
 — method, in which the new organ is constructed from 
 flaps taken from the cheeks ; and the Indian method, 
 in which the skin of the forehead is utilized in the 
 nasal reconstruction. 
 
87 
 
 The Italian method was brought to the notice of 
 surgeons in 1597 by the Latin treatise of Tagliacozzi. 
 Before that time, however, rhinoplastic operations were- 
 
 Diagrams of Serre's method of rhiaoplasty 
 
 Diagram showiug Keegan's outline for the frontal flap in rhinoplasty. AVhen- 
 ° the flap is rotated downward the point A is stitched at A' and B at £ . 
 
 performed by Sicilian operators. A brief reference is 
 found, it is said, in a publication of Benedictus. dated 
 1497. Tagliacozzi's method was subsequently modified 
 
38 
 
 in various minor particulars, and is sometimes used at 
 the present day. In fact, flaps are taken from the arm 
 at times for reconstructing other portions of the face, 
 such as the hps. Taghacozzi himself speaks of this 
 application of his method, and gives illustrations of it. 
 The brachial method, as it may be called', of Taglia- 
 cozzi, is tedious to the patient and requires a more or 
 less complicated apparatus for holding the arm to the 
 face during the time necessary for adhesion to take place. 
 Hence, either the frontal method used in India from a 
 
 Diagram of Roberts's nifthod of recorstructing a sunken-in-nose. The dotted 
 lines indicate the flaps taken from- the chetks to cover the opening into 
 the nasal chambers left by the detachment and drawing down^ward of the 
 cartilaginous nose. 
 
 very early time, or that in which flaps are taken from 
 the cheeks, is more usually adopted. 
 
 Keegan has, as the result of his great experience in 
 India, modified the usually described method of frontal 
 rhinoplasty. He cuts a flap from the forehead, with 
 its pedicle near the supraorbital notch of one eye, ex- 
 tending obliquely upward across the forehead. The 
 upper border of the flap has a projection, from which 
 he constructs the columella of the nose. He first makes 
 
39 
 
 a pattern of the flap by using a piece of banana leaf, 
 which is flexible and supple. Having made this pat- 
 tern, he cuts from stout brown paper an exact dupli- 
 cate in shape. This is fixed to the forehead by an ad- 
 hesive materia], so as to render it easy to make a flap, 
 exactly satisfactory both as to size and shape. The 
 soft tissues over the nasal bones are then converted into 
 two flaps, which are turned downward upon a hinge, 
 as it were, near the inferior border of the nasal bones. 
 This maneuver puts the skin-surface of these flaps in- 
 wards towards the nasal cavity. The frontal flap is 
 
 ^^ 
 
 The cheek flaps sutured to close the opening. 
 
 "then'cut and, by twisting its pedicle, it is carried down- 
 ward so as to cover the denuded nasal bones and the 
 raw surface of the turned-down tissues, which pre- 
 viously covered those bones. The columnar portion 
 of the frontal flap is then properly sutured into_ a 
 groove or bed at the upper part of the superior lip. 
 Sutures are applied to close the frontal wound and fix 
 the edges of the flaps in proper relation. Drainage- 
 tubes are inserted in the newly-formed nostrils. The 
 
40 
 
 pedicle at the root of the frontal flap is divided at the 
 end of about ten days. 
 
 The object in using the tissue covering the nasal 
 bones to form the internal surface of the nostrils is to 
 prevent contraction of the nostrils. These underlying 
 flaps also give support and strength to the new nose, so 
 that it is less likely to beconae flattened. 
 
 Portions of noses may be constructed by various 
 rhinoplastic procedures, but they need not be further 
 discussed here. Some of them have been already men- 
 
 The dotted lines show the outlines of the two frontonasal flaps. 
 
 tioned in the previous lecture. The tissues of the lips 
 and cheeks may be utilized for the formation of the 
 necessary flaps, which are then displaced, so as to fill 
 the gaps which are the cause of the nasal deformity. 
 
 The construction of a portion of the nose in cases of 
 sinking-in, due to syphilitic destruction of the internal 
 cartilaginous and bony supports, is often a difiicult 
 problem. In these cases the middle portion of the nose 
 is greatly depressed and the tip of the nose turned up- 
 wards so that the nostrils look forward instead of down- 
 ward. In some cases the nasal bones are destroyed, 
 
41 
 
 but they often remain uninvolved by the syphilitic 
 necrosis. I have recently reconstructed such a nose in 
 a very satisfactory manner by a combination of plastic 
 procedures which is, so far as I know, new. The first 
 step was to make a transverse incision in the hollow 
 above the tip and alae of the nose, where the depres- 
 sion due to cicatricial contraction and want of support 
 was the greatest. This enabled me to pull down the 
 lower end of the nose and bring it forward so that the 
 nostrils looked downward and the tip of the nose had its 
 
 The frontonasal flaps sutured on top of the cheek flaps. 
 
 normal projection forwards. This left a large openiDg 
 between the cartilaginous nose and the lower end of the 
 nasal bones. This space was covered by lateral flaps 
 cut from the cheeks and turned inward towards the 
 middle line with the skin surfaces towards the nasal 
 chambers. These flaps should be cut in the line of the 
 nasolabial furrow in order that the linear scar may cor- 
 respond with this line more or less accurately and there- 
 fore be comparatively inconspicuous. 
 
 After these flaps had become united in this position, 
 
42 
 
 the irregularity due to the twisting of their pedicles was- 
 removed by a small plastic operation on each side. 
 The next major step was to make two diverging inci- 
 sions from the middle of the forehead, downwards and 
 outwards, in the manner shown in'the diagram. Two 
 other incisions were made just above the granulating 
 surface, situated at the point where the cheek-flaps 
 had been united in the middle line. A median vertical 
 incision was made to connect the apices of the inverted 
 V's made by these four incisions. The two flaps thus 
 made over the nasal and frontal bones were then dis- 
 sected from the underlying tissues and turned down- 
 ward so that the upper point of the right flap could be 
 attached to the base of the left ala, and the uppermost 
 point of the left flap turned over to the right side of 
 the patient, so as to fit, against the other flap, below the 
 inner canthus of the right eye. The wound left in the 
 forehead was then closed vertically and numerous su- 
 tures applied to hold the displaced flaps in their new 
 positions. 
 
 This maneuver covered the granulating surface of 
 the cheek flaps that closed the opening in the nose ^ 
 and gave thickness and solidity in the region where 
 firmness is so essential, in order to maintain the outline 
 of the organ. A number of minor operations were 
 subsequently necessary to get rid of the irregularities 
 produced by the coaptation of so many flaps, but a 
 very satisfactory outcome has resulted. The new nose 
 has a fair degree of prominence and the nostrils and 
 alae are in proper position and of normal shape. The 
 dorsum of the nose, while not beautiful, is free from 
 the marked and disfiguring depression which formerly 
 existed. 
 
 In order to make the prominence of the nose and 
 upper lip relatively greater, a portion of the lower lip 
 was removed by a V-shaped incision. 
 
 Lectuee IX. — TJie Operative Treatment of Deformed or 
 Deficient Ears. 
 
 (Abstract.) 
 
 Operations for the relief of aural disfigurement have 
 received very little attention until within the last six or 
 eight years. This is rather remarkable because the 
 
43 
 
 deformities are quite conspicuous and the operations 
 for their relief free from serious risk. It is the more 
 strange because Itahans of the time of Tagliacozzi and 
 earlier did plastic operations upon the ear, and it is 
 said by Szymanowski that such operations are men- 
 tioned in Sanscrit writings. 
 
 The ears of prize-fighters often receive injuries which 
 
 Congenital deformity of ear, treated by elliptical incision and bending of the- 
 cartilage. 
 
 result in permanent cicatricial deformity. Sexton called 
 attention some years ago to the fact that the ancient 
 Greeks must have been familiar with deformed ears in 
 boxers, because the characteristic disfigurement is^ 
 according to him, shown in statues representing ancient 
 Greek pugilists. 
 
 The external ear is quite often the seat of incised and 
 
44 
 
 lacerated wounds which require accurate suturing to 
 reproduce the normal outline. The auricle may be 
 torn almost completely from the skull and yet be easily 
 restored to its position by a few sutures. Completely 
 detached portions should be cleansed and sutured into 
 position, even if some time has elapsed since the acci- 
 dent. Union may sometimes be obtained even in these 
 unfavorable cases. 
 
 Sloughing after frost-bite is a not unusual cause of 
 aural disfigurement. Plastic operations may improve 
 the appearance of the organ. A common injury is 
 laceration of the lobule from earrings having been torn 
 out of the ear by children, grasping at the trinket, while 
 being carried by their mothers. The fissure so made 
 may be easily closed, even if cicatrization has previ- 
 ously occurred, by freshening the edges of the cleft and 
 applying sutures. I have operated when the ear has 
 had several such cicatrized tears in its lobule. A simi- 
 lar plastic operation is necessary after the removal of 
 the keloid growths that occasionally result after piercing 
 the ears for earrings. A little ingenuity will greatly 
 improve such cases, as I have proved in operating 
 upon a good many patients. 
 
 Burns of the side of the head cause sloughing and 
 cicatricial disfigurement. Pancoast many years ago 
 made a new lobule to an ear by two crescentic incisions 
 which enabled him to lift up sufficient tissue to con- 
 struct a lobule. 
 
 A great loss of tissue from sloughing may need to be 
 replaced by taking a flap from the hand, applied to the 
 side of the head until circulation has been established. 
 The tissue may then be cut from the hand. A large 
 piece of tissue may be transferred from the abdomen. 
 In such an operation the graft would first be attached 
 to the hand, and two weeks later cut from the ab- 
 domen ; and the hand would then be applied to the 
 side of the head in such a way as to permit the new 
 tissue to be attached to the region of the ear. 
 
 Irregularities of the auricle, enchondromatous nod- 
 ules in the neighborhood of the ear, and fistulous 
 openings occur as congenital defects. They are due to 
 irregular coalescence of the branchial arches and im- 
 perfect closure of the branchial clefts. Sometimes there 
 
45 
 
 is a deficiency of cartilage in the pinna which allows 
 the external ear to assume abnormal positions on ac- 
 count of its flaccid character. I recently operated upon 
 the case of this sort which is shown in the figure. 
 At other times the cartilage in the pinna may become 
 buckled or bent during birth or soon afterwards, and 
 asymmetrical ears result from want of correction of 
 this abnormality. The lack of cartilaginous material 
 may perhaps be compensated for by excising a portion 
 of the skin back of the ear and stitching it to the side 
 of the head. It has been suggested that a thin sheet 
 of platinum or other material be inserted beneath the 
 skin, to give rigidity and a proper contour to the external 
 ear. This could perhaps be bent into shape, even after 
 the tissues had healed over it. The deformity due to 
 bending or buckling of the cartilage may be remedied^ 
 if the child is treated when young, by bending the 
 organ in the opposite direction and holding it there 
 by means of adhesive strips, or some form of spring 
 going across the top of the head and having a pad ta 
 press upon the ear. If the deformity is slight, the con- 
 tracting influence of collodion may be utilized. 
 
 Exceedingly large ears, due to a sort of hypertrophy 
 of all the tissues, occasionally require curtailment. This 
 may be done satisfactorily by excising a V-shaped por- 
 tion of the auricle with the base of the V towards the 
 outer margin of the organ. Careful suturing will restore 
 the general outline and maintain the regularity of the 
 natural elevations and depressions. The exsection of 
 a crescentic piece from the central part of the pinna, with 
 a tongue-shaped process extending from the convex 
 border of the crescent to the border of the pinna, makes 
 a rather neater operation and restores more accurately 
 the normal contour. This method was, I believe, first 
 suggested by Dr. Parkhill. Such elephantine ears are 
 greatly improved by these operations. Flaring or out- 
 standing ears are very ugly, especially when the flaring 
 condition is associated with great size. Such ears may 
 be brought closer to the head by the excision of an 
 elliptical piece of tissue behind the auricle, and the in- 
 sertion of stitches so as to draw the cartilage nearer to 
 the surface of the cranium. The elliptical portion re- 
 moved should have its long diameter in the vertical 
 
46 
 
 direction and should be wide at the point where it is 
 desired to draw the cartilage inward to the greatest 
 extent. The portion removed should be quite large and 
 its outer edge on the posterior surface of the pinna 
 should extend far outwards as the amount of retraction 
 desired is greater. 
 
 The inner border of the ellipse on the surface of the 
 skull should be comparatively close to the bottom of 
 the furrow between the ear and the head. By the 
 insertion of stitches in an oblique direction the axis of 
 the ear can be somewhat changed. 
 
 Some operators have removed only the skin and sub- 
 
 Biagram of method of Parkhill for reducing size of ear. 
 piece to be excised. 
 
 Dotted lines sliow 
 
 cutaneous tissue; others have taken out the entire 
 thickness of the pinna, including the cartilage and the 
 skin on both the back and front. It is probably best 
 to remove a large portion of skin and subcutaneous 
 tissue on the posterior surface of the ear and the skull, 
 and to excise a wedge-shaped portion of the cartilaginous 
 structures; but the cartilaginous piece which is re- 
 moved should be much narrower than that cut out of 
 the skin. This method I have used satisfactorily. It 
 is usually not necessary to carry the incision through 
 the skin on the front of the ear. 
 
47 
 
 Congenital absence of the ears may be treated by the 
 adoption of an aluminum ear properly tinted and held 
 in place by a spring inserted in a slit in the soft tissues. 
 Westlake adapted such a contrivance to a man's head, 
 and the patient was able to unlock the artificial organ 
 and remove it. This was done by means of a spring 
 situated behind the artificial ear. 
 
 Method suggested by Szymanowski for constructing an auricle in congenital 
 absence of the external-'ear. A. Dotted lines show incisions by which 
 the ^kin is raised and doubled so as to mate a crude auricle. The posterior 
 flap is thrust under the anterior one and sutured by through-and-through 
 sutures. B. Shoivs incisions made at a subsequent operation to model 
 the crude auricle into more perfect shape. 
 
 Szymanowski has suggested the making of a cutaneous 
 ear in these cases of congenital absence of the organ. 
 The diagram shows the incisions for the reconstruction 
 of a rudely shaped ear which is afterwards to be mod- 
 elled by smaller incisions and proper suturing. It 
 seems as if it might be possible to insert an aseptic 
 piece of metal into such a cutaneous reconstruction to 
 give it risiditv and a contour like that of an ear. 
 
 Lecture X. — The Cosmetic Surgery of the Eyes. 
 
 (Abstract.) 
 
 Much can be done for improving disfiguring condi- 
 tions of the eyeball and eyelids. One of the most 
 common of the ocular conditions causing an unseemly 
 expression of the countenance is strabismus. The 
 internal form is usually associated with hyperopia 
 and requires proper correction of the refractive condi- 
 
48 
 
 tion, in addition to section of the internal rectus 
 muscle. Failure to wear lenses to correct the refrac- 
 tive defect causes not infrequently a return of the 
 cross-eye condition. I have now under my care a 
 patient in which the strabismus returned, apparently 
 from neglect of this precaution on the part of the former 
 operator. The various operations for correcting internal 
 
 New eyelid made with flap from forehead. Photograph taken three weeks 
 after operation. 
 
 and external squint, or strabismus, by cutting the 
 muscles, advancing the tendons, or by a combination of 
 both operations, need not be discussed in detail ; they 
 are familiar to all ophthalmic surgeons. 
 
 Disfiguring white spots upon the cornea may be 
 tinted with India ink. This little operation must be 
 frequently repeated in order to get the tint of the scar- 
 tissue sufficiently dark. Such eyes are defective in 
 
49 
 
 vision and the tattooing is simply to make the con- 
 spicuous white spot of such a color that it will not 
 attract attention. 
 
 Blind eyes, due to injury or any other lesions which 
 destroy the appearance and shape of the globe, may be 
 covered with artificial eyes of glass so colored as to 
 correspond with the normal eye on the other side. 
 
 -,-:w'Sfe«.£l'?8«fi«ii3»»*-J 
 
 New eyelid made with flap from forehead, takeu at a later date than 
 other figure. 
 
 Anterior section may be required, if there is a promi- 
 nence of the diseased eyeball due to anterior staphy- 
 loma. Mules's operation, in which a glass ball is 
 inserted into the eviscerated sclera to give sufficient 
 prominence to the globe, is a very satisfactory method of 
 maintaining the prominence and the motions of the 
 eyeball. The glass shell or eye placed in front of this 
 has a much more normal appearance than when it is 
 
50 
 
 used after the globe of the eye has been entirely re- 
 moved. A small eye due to atrophy may, if it is blind, 
 be made to appear larger by wearing a strong convex 
 lens in front of it. In front of the opposite eye a piece 
 of plain glass may be inserted in the spectacle frame. 
 
 Ectropion of upper eyelid, due to cicatrization after avulsion of entire scalp. 
 Operation consisted in using flaps from temporal region and side of nose. 
 Incisions marked with ink. Head shows result of skin-graftiog on ulcer- 
 ated surface. 
 
 In conditions of exophthalmos, and especially in that 
 form due to the disease called exophthalmic goiter, the 
 disfiguring bulging of the eyes may be relieved by 
 stitching the outer canthus of the eyelids so as to lessen 
 
51 
 
 the size of the palpebral fissure. This operation should 
 not be done until the active symptoms of the disease 
 have subsided. At any time, if the bulging of the eye 
 persists, the removal of a little of the mucous membrane 
 at the outer angle of the eyelids and the insertion of a 
 couple of stitches will so cover the eyeball as to make 
 the bulging disappear. 
 
 Excision of epithelioma below the eye. Flap from temple used to prevent 
 eetijBpioD. Outline of flap marked with ink. 
 
 There are many operations possible upon the eye- 
 lids Avhich improve the appearance of the upper part 
 of the face. The congenital condition called epican- 
 thus, in which folds of skin extend over the inner 
 angles of the eyelids, is improved by the removal of a 
 vertical ellipse of skin at the root of the nose. Drooping 
 of the eyelids, technically called ptosis, is remediable 
 by removing a section of the skin of the upper lid or 
 
52 
 
 giving a new attachment to the elevator muscle. Warts 
 and other tarsal tumors are very disfiguring, but most 
 of them are easily removed by simple operations. 
 
 Wounds of the eyelids should be made aseptic and 
 sutured with care to prevent cicatricial distortion. One 
 
 Epithelioma near outer cantlius removed, the space tilled in with flap from 
 temple, shavings of skin applied to surface lett by transfer of the flap. 
 
 of the Ugliest of the deformities of the eyelids is ever- 
 sion of the lid caused by cicatricial contraction follow- 
 ing burns, lupus, or ulceration. Thoughtless surgeons 
 sometimes cause this deformity by removing tumors of 
 
53 
 
 the face and placing their incisions so that cicatricial 
 contraction drags the lower lid downwards or the upper 
 lid upwards. This contingency should always be recol- 
 lected in operations in the neighborhood of the eyelids. 
 If the incisions cannot be placed in such a way as to 
 make the drag of the cicatrix operate so as not to dis- 
 turb the position of the eyelids, a plastic procedure to 
 transfer the tension to another position should be 
 adopted after the excision of the growth. Adhesion of 
 the eyelids to the eyeball after burns of the conjunctiva 
 are very diflBicult to repair with satisfaction. Many of 
 them, however, may be relieved by plastic operations 
 upon the conjunctiva or the transplantation of skin or 
 mucous membrane. These conditions of symblepharon 
 tax the ingenuity of the surgeon. Ankyloblepharon is 
 another deformity difficult to deal with surgically. In 
 it the two eyelids are united by cicatricial adhesion. 
 Various operations have been devised and are more or 
 less successful. 
 
 The plastic procedures required to make new eyelids, 
 after their removal by sloughing or accident, or to fill 
 in a space left by the replacement of an eyelid which 
 has been dragged outwards so as to cause ectropion, 
 must be performed in accordance with the principles 
 of plastic surgery already laid down. The various 
 forms of skin grafting will be of some value, but as a 
 rule it is necessary to turn a flap of skin and subcu- 
 taneous tissue into the gap left by replacing the eyelid. 
 The space left by the removal of this flap may then 
 with advantage be covered with skin-grafts. It is 
 usually better to thus utilize the skin-grafting process 
 for covering the original seat of the flap than to depend 
 on it for lessening the tendency to cicatricial con- 
 traction. 
 
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 The surgical treatment of conqenital and 
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