A CASE OF RHINOPLASTIC OPERATION, PERFORMED FOR 
THE RESTORATION OF THE APEX OF THE NOSE 
AFTER IT HAD BEEN BITTEN OFF. 
W. W. G., aged 35, a resident of New York city, was brutally 
attacked on the evening of May 12, 1872, and, during the affray, 
had the apex of his nose bitten off by his assailant. At the first 
examination, twelve days after the occurrence, the condition of the 
parts was found to be as follows:—All inflammatory swelling of the 
nose had subsided. There 
remained a healthy suppurat- 
ing surface, and the loss of 
substance included the integ- 
ument covering the apex and 
adjacent ridge of the nose as 
high up as its middle, and 
also both sides of the nose 
as far towards the cheeks as 
a line passing within half an 
inch of the junction of the 
nose with the cheeks. The 
entire bare surface was equi- 
valent to at least one third 
of the superficies of the or- 
gan. The alae nasi were dis- 
connected anteriorly, and 
both had sustained an equal 
amount of loss of their an- 
terior portion. The colum- 
na remained entire, in situ, 
and the denuded ridge of the 
cartilaginous septum had es- 
caped injury. Fig. 1 shows the condition just described. 
Operation.—On Saturday, May 25th, an operation was performed 
at patient’s residence, with the aid of Prof. A. C. Post, Drs. T. E. 
Satterthwaite, J. N Beekman and N. S. Westcott, as follows : The 
By Gurdost Buck, M.D., New York. 
Fig. 1. 2 
patient was under the anaesthetic influence of ether. After paring 
the anterior edges of what remained of both ala?, and making them 
straight, an incision was carried upward in continuation of these 
edges on both sides of the nose to the inner extremities of the eye- 
brows. The patch of skin included between these incisions was dis- 
sected up from the dorsum nasi and from between the eyebrows. A 
pattern of the shape of the entire denuded surface was cut from 
oiled silk and laid vertically upon the right half of the forehead, in 
an inverted position, immediately above the inner half of the eye- 
brow, with one edge at the terminus of the incision on the right side 
of the nose. Short pins were then inserted temporarily in the skin, 
in an erect position, at intervals, around the margin of the pattern, 
and at a distance of one line from it, to allow for shrinkage. A much 
larger allowance, however, was made for shrinkage in the length of 
the patch of skin. The pattern itself was now dispensed with, and 
an incision, commencing at the inner extremity of the right eyebrow, 
where it would be continuous with the incision bordering the patch 
of skin that had been raised from the nose, was carried upward, 
along the line of the pins, and onward around the entire circumfer- 
ence of the defined patch. The p.ateh of skin thus outlined was it- 
self dissected up from the pericranium and left connected below at 
the margin of the orbit, where a branch of the ophthalmic artery 
emerges to supply the integument of the forehead. The patch of 
skin already detached from the nose and from between the eyebrows 
was still farther raised from the pericranium toward the left eye- 
brow, where it was left connected for support. By this procedure, 
a continuous bare surface was afforded with which the under sur- 
face of the forehead patch of skin would be in contact after being 
transferred to the nose. The forehead patch was now brought 
around edgewise from right to left and from above downward, de- 
scribing in its circuit a semi-circle, and was applied to its appropri- 
ate place, which extended downward to the apex of the nose. Spe- 
cial care was taken that there should be no strain at its pedicle 
where the patch was folded upon itself and where any obstruction 
of the circulation would endanger its vitality. The adjustment of 
the edges of the patch to the edges of the space was much facilitated 
by dissecting up the latter sufficiently to permit them to be everted, 
and thereby more exactly confronted to each other. Pin sutures, 
wound with cotton yarn, wrere inserted at selected points, and fine 
thread sutures between them to secure the adjustment. The free 
extremity of the patch was left elongated, and extending beyond the 
apex of the nose, the intention being to allow the process of shrink- 
ing to cease before making an attempt at adaptation. The patch of 
skin displaced from the nose and from between the eyebrows, and 
still retaining its connection over the left eyebrow, was carried up- 
ward and applied to the surface left bare by the forehead patch, and 
sufficed nearly to fill up the lower half of that space. The remain- 3 
ing upper portion of the space encroached upon the hairy scalp, and 
was left to heal by granulation. The two patches of skin, in being 
doubled upon themselves to reach their new destinations, formed at 
their pedicles prominent folds in the skin of a flattened, conical 
shape, one situated over each eyebrow. The uncovered, raw sur- 
face upon the upper part of the forehead, which measured nearly 
three inches vertically and one inch and a half transversely, was 
covered, first, with a layer of dry scraped lint and then with a 
second layer of lint saturated with collodion, which soon stiffened 
and formed an artificial scab, adhering closely to the surrounding 
surface. Wet applications were avoided, and a layer of woven lint, 
of double thickness, spread with cerate, was secured over the parts. 
A few ligatures only were required to secure bleeding vessels, and 
these were brought out to the surface at the nearest point of exit. 
The operation occupied about two hours, and was well borne by the 
patient. The anaesthetic acted kindle. 
May 2Gth. — Patient has 
had some sleep. A mode- 
rate febrile reaction has tak- 
en place. The inflammatory 
tumefaction is moderate. 
Changed the cotton yarn on 
the pins. Milk and HjAfttor 
were allowed for nourish- 
ment. 
27 th.—Changed the yarn 
and commenced removing 
the alternate thread sutures. 
28th.—Removed the pins 
and additional thread su- 
tures. 
29th.—Removed the re- 
maining sutures. 
31st. — Suppuration hav- 
ing looosened the collodion 
scab, it was removed and a 
healthy granulating surface 
was exposed, which, there- 
after, was dressed with un- 
guentum basilicum and adhesive plaster. 
June 1st.—Primary union has taken place at almost all points. 
Pus escapes freely from underneath both the elevated folds of 
skin upon the forehead. Appetite is good. The patient sleeps well 
and goes out of doors. 
28th.—The granulating surface upon the forehead has steadily di- 
minished in size, and now measures half an inch in width and two 
inches in length. The result of the operation is shown by Fig. 2. A 
Fig. 2. 4 
second operation was this day performed for the purpose of level- 
ing the prominences—a and b, Fig. 2—on the forehead, which were 
situated over the inner half of the eyebrows, and separated from 
each other by a smooth space nearly an inch in width. They still 
retained their flattened, conical shape. The operation was as 
follows:—A curved incision was carried half around the base of 
each prominence on its broadest side, and the prominence itself 
raised from its underlying surface, split across, and then unfolded 
and spread out flat. The redundant portion was then pared away, 
arid the opposite edges matched together and secured by sutures. 
The redundant extremity of the patch of skin brought down from 
the forehead and left projecting beyond the apex of the nose, was 
trimmed away at the proper time, and adapted itself very exactly to 
its new location. 
Fig. 3, showing the final result, is from a photograph, taken Oct. 
12, 1872. At this time, the 
following particulars were 
noticed. The cicatrix on 
the upper part of the fore- 
head had shrunk to small 
dimensions, and was easily 
concealed by the hair. The 
other cicatrices upon the 
lower part of the forehead 
and nose were linear, and 
but little conspicuous. By 
daily manipulation of the 
parts, the skin upon the fore- 
head and nose had become 
supple and moveable. Sen- 
sation, which, for several 
weeks after the operation, 
had been referred to the 
original locality of the part 
irritated, was at this time 
referred normally to the ac- 
tual seat of irritation. The 
skin covering the lower half 
of the nose which had been taken from the hairy scalp, continued to 
yield its hairy growth, and required to be shaved at short intervals. 
The patient was, however, waiting a convenient opportunity to have 
it radically destroyed. 
Fig. 3.