Rhinoplasty in Nose Destroyed by Cancer. BY B. L. EASTMAN, M. D., Kansas City, Mo. Surgeon and Gynecologist to the Missouri Hospital for Women, former Professor of Gynecology in the University Medical College, Kansas City. T HE report of this case is prompted by the desire to contribute modestly to the current literature on Rhinoplasty, which is almost a minus quantity in English. The barrenness of our literature as compared with that of the French, Italian, and German, is surprising when one starts to investigate it even in a small way, as the writer did prior to the beginning of this paper. The chapter on Rhinoplasty in Binnie's Surgery is probably the best and clearest resume of the subject in any of our modern works. To this most excellent book this article owes the modicum of historic and scientific data that it may contain. Rhinoplasty, the operative correction of deformities of the nose, is a branch of constructive surgery that has developed most in France and Italy, surgeons there reporting series of cases far in excess of any in England or America. The reason of its wider application there may lie in more virulent and neglected syphilis in the lower classes, and the, until recently, fashionable Code Duello among the gentility. Nasal defects are roughly grouped in two large classes; the partial or sub-total, and total, loss of the nose.. The latter is rare even in Europe, and is scarcely ever seen in this country. Sub-total defects include all the minor losses of substances, such as destruction of one ala, loss of the fleshy tip, loss of the whole end, defects in the skin and cartilage or septum or all, and saddle-back deformity with flattening of part or all the organ. The causes of these partial defects are variable and may be anything from mules to mayhem, but in this country, cancer, accidental injury, freezing, and late syphilis, are the chief factors in about the order named. Whatever the cause and however slight the defect, it is noticeable on the individual and a nuisance to him out of all proportion to its anatomic importance. With an extensive defect, the otherwise welcome person becomes repugnant almost beyond toleration. The technic of nose repair broadly follows one of two methods; first, pedunculated living flaps swung down from the forehead, or, second, living flaps attached to the hand, forearm, or elbow. The one is known as the Indian, the other as the Italian method. The French school a generation ago tried to impress its individuality on the method of sliding flaps from the face and cheeks and would have it that this should be called the French method. The name, however, is not generally adopted. As between the Italian and the Indian methods the choice is always with the latter; pedunculated flaps from the forehead are easier to plan, easier to handle and simpler in their mechanics. The Italian method shapes the flap from the living finger or arm, later attaching it to the defect in the face until it becomes vitalized in its new location. Such a method is complex to say the least; it requires two or more operations to get the flap in place, and a complicated apparatus to hold the donating limb solidly. Patients who have the fortitude and toleration to stand such treatment will be hard to find in our restless and impatient Occidental civilization. November, 1909. Photograph not retouched. Shows one inferior turbinate and part of cartilage of septum. It grew slowly and under improper treatment finally destroyed the nose in its greater part. She at last went to Dr. Huff, who stopped the cancerous progress and healed the sore in a short time. The immediate result of the cancer was a ghastly facial deformity, the woman driven into seclusion and her nervous system badly wrecked. After the line of granulation had been well established, and the cancer entirely below the eyes was almost that of the cheek. Operation. November 22, 1909. Ether anesthesia preceded by H. M. C. one-fourth grain. For giving ether the open method with a thick mask was employed first. After anesthesia was complete, a modified Junker inhaler was used, the delivery tip being a large douche point carried well back in the mouth towards the fauces. CUT No. 2. Semi-digrammatic; done by artist from sketch made directly after the operation. Shows outline of flap on forehead. Both nares packed with gauze to stop the flow of blood backwards and to compel mouth breathing. The steps of the operation were four. First.-Freshening the edge of the entire circumference of the defect, loosening it from the underlying bone and periosteum for onefourth inch all around. Second.-A pattern was made from sterile rubber tissue to fit the defect, then a flap slightly larger than this pattern was cut from the forehead, running obliquely upwards and to the right side close to the hair line. The neck of this flap joined the upper end of the defect at the base of the nose on the right side while its left edge was carried one inch outward and just above the orbital ridge. The flap CUT No. 3. Same process as No. 2. Sketch is materially correct, except that artist gives patient too high a forehead. As a fact, the forehead was so low that the end of the flap almost touched the hair line. Photograph not retouched. Taken March, 1910, four months after first operation. Scar on forehead shows prominent and dense. Mass at left side of base of nose prominent and spoils perfect vision. The edges of nose scar are still slightly uneven. did poorly at first, only the upper and the lower grafts healing, the rest died and sloughed out, leaving the frontal bone exposed through the greater part of the wound. This wound looked quite bad at first, healing of this wound was astonishing. The new nose was excellent and thor oughly healed, and the nostril, which was at first collapsed, had retracted slightly more than desirable, but the defect was hardly noticeable. Photograph not retouched. Side view of face, same sitting as Cut No. 4. atrophy if left alone, but the patient was sensitive and wished it corrected if pos sible. Second Operation. March 23, 1910. Four months after the first, under ether anesthesia, with the Junker inhaler. The hump on the left side of the bridge of the nose was dissected loose from the underlying bone for a distance of one inch above and below. The edges were trimmed away so that they could be brought together flat and pearance and with very good reason to be. The scar on the forehead had decreased to one-third of its original size. was becoming vitalized throughout and scarcely noticeable. The new nose had a surprisingly good shape and was almost perfect in contour. The left nostril was perfect, but the right had been drawn up perhaps one-eighth inch owing to the contraction of the flap on this side. On the whole, the result from a cos |