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

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FIGS. 5 and 0. — V. rib. cart, in S. (Homologous graft.) — The

cartilage cells are throughout more active, and occur not in -$••

clumps, as