ADDRESS IN SURGERY. The Success of Operative Treatment in Facial Disfigurement. BY JOHN B. ROBERTS, A. M., M. D., PHILADELPHIA. Tire acceptance of an invitation to present a few surgical thoughts to a body like this carries with it a duty to bring forward material either new or at least not too trite. The topic which I have selected is certainly not novel; but it is possible that the members of this society have had their attention di- rected of late more to operations of greater magnitude and dan- ger, and may therefore find interest in a rather neglected but most interesting field of surgery. The medical profession in general appreciates what can be done to ameliorate the deformity in harelip and cross eye; but it remains more or less unfamiliar with the resources of surgery in the curing by operation of many other disfiguring lesions of the cheeks, nose, lips and ears. There is at times a want of perception or appreciation on the part of physicians. For in- stance, we know to our sorrow that many women with malignant disease of the breast come to the surgeon too late for successful extirpation because the doctor who first saw the growth ad- vised delay, failed to recognize the disease or was unaware of the frequency of permanent cure of these lesions by early and thorough operation. So in this matter of facial surgery, those afflicted with disfigurements curable by the most trivial opera- tion are often allowed to go through a long life without ever being told by their physicians that relief is obtainable. The pa- tients themselves are ignorant of surgical art; think of an opera- tion as a dangerous and bloody o rdea k-mssacia ted wilTitlie prob- able complication called by them Ipood^p|s^id therefore cover the chagrin due to their uncomeliness by endeav- oring to ignore it. Cyrano de Bergerac has many unfortunate colleagues whose lives might be made happier, as his would have been, by a skillful application of the knife to offending features. A Michael Angelo need not in these days have his artistic sense troubled by a necessary transmission to posterity of a countenance disfigured with a deformed or broken nose, nor need a modern Alexander have a twentieth century Apelles paint only the unmarred side of his face. The dislike of man for conspicuous deformity is known to all, and was utilized by the ancient general who advised his soldiers to strike at their ene- mies’ noses instead of at their hearts. Plastic surgery is a development of the universal desire to be comely and free from deformity, though the methods used may have been first employed for more utilitarian purposes. In times past mutilation of ears, eyelids, and noses was practiced upon malefactors and other unfortunates as a punishment or badge of servitude. This association of facial disfigurement with the brand of ignominy naturally led to an earnest search for surgical aid to repair the damage or to conceal its results. The attempts of Indian and Italian operators to make new noses, lips and ears led to a certain degree of interest and success in this branch of operative surgery in the sixteenth century, but little further at- tention was given it until the early years of the nineteenth cen- turv. The certainty of rapid union with little scarring and the freedom from septic fever obtained by aseptic surgery have, within the last twenty years, greatly extended the number and variety of operations performed for cosmetic reasons alone. The success of skin grafting, bone grafting and the insertion of for- eign bodies as supports and representatives of the tissues has given oppportunity for original work of a high order in plastic surgery. It is no longer necessary or wise to advise abstention from operations of convenience on the ground that it is better to be satisfied with disfigurement than assume the risks of operative treatment. Practically there are no risks of hemorrhage, sepsis, or gangrene, provided that the operations be done in accordance with recognized surgical principles; and if the operator be 3 familiar with the recent developments of the plastic art in sur- gery or have an original bent of mind, success is almost assured. It is a well established fact that in this department of sur- gical endeavor the worst cases give the most satisfactory results. The more horrible the disfigurement the greater is the patient’s delight at an improvement in appearance. The surgeon may therefore operate upon a very badly deformed face with almost a certainty of gratifying his patient, even if the final result is not a perfect physiological restoration. It is the man or woman with little abnormality in contour who is apt to be dissatisfied with even a perfect surgical result; because the mind has become warped by constant contemplation of a want, or supposed want, of personal comeliness. One of my most grateful clients is a man the side of whose face and head was the seat of a congenital deformity which caused him to be known as the dog-faced man. A series of opera- tions relieved him of the canine countenance and lifted him into a condition of mental exhilaration; though to more fortunate persons his final aspect was not that of an Apollo. Another in- stance is that of a woman whose eyeball and eyelids were de- stroyed, and cheeks and lips partially destroyed, by fire. The countenance was so improved by a dozen or fifteen operative attacks that she now is willing to go about the streets without keeping her face screened from view, and her mental equipoise is practically restored. It is certain that deformity of limb and face lias long been produced by the criminal classes for the purpose of inspiring wonder and commiseration and increasing thoughtless almsgiv- ing. Double monsters are said to have been made by grafting two children together by backs, buttocks or arms. The produc- tion of a laughing countenance by such sinister surgery has, as is well known, been used as the basis of a novelist’s tale. The plastic results obtained in the endeavor to diminish the size of the feet of Chinese girls, to alter the shape of the head in certain tribes of American Indians and to cultivate dwarf trees of fan- tastic shape by the Japanese, serve to indicate that the mind of man has long recognized the possibility of perverting nature’s processes. The utilization of these same processes should be 4 more generally brought to the attention of surgeons. Heretofore operators have been perhaps too much taken up with the cure of life destroying conditions to study with care the means of lessen- ing mere disfigurements. It was natural and fitting that the first efforts of surgery should be to prolong life and to lessen hu- man agony, and that its first and greatest triumphs should be won from death, disease and pain; but now that asepsis, hemos- tasis and improved technic have made operations safe, it is proper that surgical luxuries, so to speak, should be given due consider- ation. The refinements of life are developed after the physical safety of the individual has been assured, and the time has now come when modern surgery may turn its skill to the amelioration of uneomeliness. In this address it is impossible to describe the many opera- lions which are employed in remedying deformities of the face and ears, but a few may be mentioned as an intimation of those most frequently required. This branch of operative surgery is one in which unusual chance is given for originality. The lesions vary greatly in character and extent, and satisfactory results de- pend much on the effect the change in contour has upon the eyes of the observer. The newly constructed or altered feature must so conform to the rest of the face as to escape critical attention, or else it must serve to divert attention to other parts of the pa- tient’s countenance. Local anaesthesia, a few moments for excision and suturing and two or three days without pain for healing seem so insignifi- cant a combination that it is a source of surprise that fleshy warts, sebaceous cysts and epitheliomatous ulcers are so fre- quently permitted to remain as facial blemishes. Hairy growths and capillary angiomas are removable with great satisfaction by electrolytic depilation or by excision. Even a large but smooth and white scar will in some instances be less conspicuous than a port-wine mark. It is often not difficult to convert fistules, sinuses, and distorted scars into scarcely notice- able linear cicatrices. The ears gave a particularly'good opportunity for successful plastic surgery. The two ears are not, as a rule, completely seen at the same time, and as a consequence the surgeon will be con- 5 sidered highly successful even if the organ upon which reparative operation is done has not the exact shape of its mate. Large auricles may be reduced in size by V-shaped excisions, flaring ears may be drawn close to the head, big lobules decreased in size, keloid growths removed and fissures or openings due to wearing earrings neatly closed. I have recently been quite suc- cessful in making an elevated ridge in a congenitally deformed ear; it had no antihelix, because the cartilage was not normally crumpled. I am at present satisfactorily shaping by mechanical means an auricle in which the cartilage was “buckled” and made the ear lie too close to the head. The mouth is a feature of great importance in expression, and its impairment by congenital defects of development often re- quires more than one operation. Its congenital and acquired deformities furnish a wide field for mechanical and operative effort. Indeed a very small part of this field in oral therapeusis and prosthesis occupies the talents of the dental profession. To the cosmetic work of the dentist who corrects irregularly devel- oped teeth, decolorizes dead ones and replaces those lost with ar- tificial dentures, the surgeon may add a long list of operations upon the lips and cheeks. Protruding or everted lips are re- duced in size and altered in shape by well planned operations, hypertrophy of the mucous membrane, causing double lip, is treated by excision, and fissures in the upper or lower lip or at the angle of the mouth are closed by plastic procedures. The most familiar instance of oral disfigurement is hare- lip. It is so often complicated with deformity of the alveolus and the nose that it affords ample scope for artistic methods of oper- ating. Hare-lip operations may include osteoplastic procedure on the upper jaw, and sometimes must be supplemented by re- moval of part of the lower lip to obtain a proper balance in the bulk of the two lips. The cicatricial changes made in the mouth by sloughing supply a great variety of operative possibilities. A distorted or contracted oral opening may be altered in shape or diminished or enlarged in size. The tissues of one or other lip or of the chin or throat may be utilized in these plastic repara- tions. Nasal deformities and deficiencies cause most noticeable facial disfigurement. The frequency of such conditions arises from the easy occurrence of fracture of the nasal bones and car- tilages and the liability of syphilis to attack the nasal structures. Ulcerative destruction may require an ala or the columella of the nose to be made from the cheek, upper lip or a portion of a fin- ger; or may necessitate the construction of an entire nose from the fissues of the forehead and cheeks, the arm or some inorganic material such as celluloid, gutta percha or aluminum. Flat noses, saddle-back noses, crooked, twisted and angular noses, sunken noses and noses with bifid or bulbous ends are all susceptible of improvement by nasal or intra-nasal operation. It is quite surprising to some physicians, as well as to most pa- tients, to see what can be done in these directions without notice- able scarring. These operations on the nose are often valuable, not only for cosmetic reasons, but because they at the same time restore the patency of the nasal chambers and give the patient opportunity to breathe through the nose instead of with a perpetually open mouth. This establishment of physiological breathing improves the voice and lessens the tendency to pharyngeal and laryngeal irritation often so conspicuous. An operation which improves appearances and at the same time improves the health can cer- tainly be claimed as satisfactory. The eye is currently supposed to be the most expressive por- tion of the face, and, although this is to a great extent untrue, it is indisputable that imperfections in the cornea and eyelids and want of parallelism in the axes of the eyeballs cause instantly noticeable disfigurement. Bulging or unduly sunken eyeballs may mar an otherwise comely face, and the unsightliness of dis- torted eyelids is recognized by all. The various forms of cross-eye have long been treated by operation, but the operation must in many cases be supplemented by a careful correction of the refraction. The wearing of glasses may sometimes be useful in rendering an ocular condition less conspicuous, even when no refractive error is present. For ex- ample, a blind and shrunken eyeball may be made to look equal in size to its normal companion by having a convex lens worn in 7 front of it. .V piece of plain glass adjusted in front of the normal eye will have no effect upon its vision or appearance, but will serve to balance the lens on the other side of the nose. Small eyes, associated as they often are with hyperopia, look larger when proper convex glasses are worn to relieve the asthen- opia due to the refractive error. Drooping upper eyelids, everted or inverted lids, redundant lids and lids the seat of tumors are all susceptible of operative treatment, which in many instances gives surprisingly satis- factory results. The uncomely bulging seen after recovery from exophthalmic goitre may be relieved by freshening and suturing the eyelids at the outer extremity of the palpebral fissure. This insignificant operation is, however, seldom done. On the other hand a sunken eye may be brought forward by cutting the rectus muscles. This procedure, however, requires special care, as the division of tendons might cause double vision or strabismus. It is perhaps only applicable to blind eyes. Tattooing of white scars on the cornea, removing conjunc- tival and corneal growths, and inserting glass eyes, are all cos- metic measures that deserve the attention of the profession. Many of these operations are done frequently by the ophthalmic specialist, but they are either unknown to, or unappreciated by, the surgeon and the general practitioner. All of them may be done by the surgeon if he has trained his hand to the delicate manipulations required. He will be a better general surgeon if he has acquired such delicacy of touch; as, on the other hand, the ophthalmic surgeon will do better eye- work if he is familiar with the procedures of operative surgery in general. It is perhaps due to a too high degree of specialism that the cosmetic surgery of the face has had so few exponents. Those who are acquainted with, and can do well, eye operations, nose operations or ear operations may know too little of general sur- gery to attempt the more bloody operations upon the face. Those who usually deal with operations like resection of the jaw and excision of the tongue or larnyx may not possess the technical skill to make them safe operators upon the special organs often concerned in facial disfigurements. The object of this paper is to remind the members of the society of the ease and safety with which operations for the re- lief of facial disfigurement are performed, the interest of the manipulations, the satisfaction of the results and the wide field which they offer for scientifically beautiful and original work. In conclusion, I shall illustrate by crude diagrams, made on the blackboard, the methods by which some of the deformities mentioned may be corrected.