The Correction of Nasal Deform- 
ities by Subcutaneous 
Operations. 
BY 
JOHN O. ROB, M. D. 
ROCHESTER, N. Y. 
The American Medicae Quarterly, 
REPRINTED FROM 
June, 1899. The Correction of Nasal Deform 
ities by Subcutaneous 
Operations 
BY 
JOHN O. ROE, M. D. 
ROCHESTER, N. Y. 
EX-PRESIDENT OP THE MEDICAL SOCIETY OP THE STATE OF NEW YORK; EX-PRESIDENT OP THE 
AMERICAN LARYNGOLOGICAL ASSOCIATION ; CORRESPONDING MEMBER OF THE SOt'IKTK 
PRANgAISE D’OTOLOGIE, DE LARYNGOLOGIE ET DE RHINOLOGIE ; MEMBER OP THE 
BRITISH MEDICAL ASSOCIATION; OF THE AMERICAN MEDICAL ASSOCIATION; 
OP THE AMERICAN CLIMATOLOGICAL ASSOCIATION ; OP THE AMERICAN 
LARYNGOLOGICAL, RHINOLOGICAL AND OTOLOGICAL SOCIETY; OP 
THE NEWYORK ACADEMY OF MEDICINE ; OP THE CENTRAL 
NEWYORK MEDICAL ASSOCIATION ; OP THE MONROE 
COUNTY MEDICAL SOCIETY, ETC. J LARYN- 
GOLOGIST TO THE ROCHESTER 
CITY HOSPITAL. 
The American MEPJTAE'tX;aktekett 
REPRINTED FROM 
June, 1899. THE CORRECTION OF NASAE DEFORMITIES BY 
SUBCUTANEOUS OPERATIONS.1 
By John O. Roe, M. D., 
Rochester, N. Y. 
THE method of performing operations subcutaneously 
is by no means new, for it is a century since Dela- 
evacuating cavities containing pus and blood by this 
method ; and since Abernethy adopted the plan of opening 
abscesses and diseased joints by valvular incisions so as to 
exclude the air. The practical advantages of this method 
were more fully demonstrated in 1816, by Delpech, who 
performed the operation of tenotomy in a subcutaneous 
manner, in order to avoid the subsequent inflammation 
which attended the operation when performed by the old 
method of exposing the tendon before it is divided. 
croix and Anel demonstrated the advantages of 
The object of performing operations subcutaneously, at 
that time, was chiefly for the purpose of excluding the air, 
for it was even then observed that when air is excluded 
from a wound no inflammation follows. But, with the 
recent adoption of antiseptic methods, it may be said that 
the only advantage which now remains, of performing 
operations subcutaneously, is the avoidance of wounding 
the skin on any of the exposed portions of the body. As 
*A portion of this paper was read before the Sixty-fifth Annual Meeting of the 
British Medical Association. 4 
THE CORRECTION OP NASAL DEFORMITIES 
the nose is the most prominent feature of the face, the 
facial expression depends to a great extent upon its appear- 
ance, and as deformities of the nose are especially unsightly, 
it is not only important that they should be corrected, but 
that the operation should be performed in a manner that 
will leave as few traces as possible of the previous disfigure- 
ment. 
Previous to the time that the writer demonstrated the 
methods by which nasal deformaties could be corrected by 
subcutaneous operations, all attempts that had been made 
to correct such deformities, so far as he is aware, involved 
the laying open of the skin in order to reach the deformed 
part and usually resulted in exchanging a deformity for an 
unsightly blemish. The unsightly scars left behind, there- 
fore, had the effect of discouraging such operations, and, 
unless the deformity was excessively hideous, the person 
generally preferred to bear the ill he then had rather than 
fly to others he knew not of. 
The importance of correcting nasal deformities, as well 
as other deformities of an unsightly nature, is evident from 
the conscious effect of such deformities in influencing the 
habits and thoughts of the person. On account of this 
distinguishing mark many are deterred from participating 
in the enjoyments of social life by the consciousness of the 
disadvantages under which they are continually laboring. 
So universally recognized are the disadvantages of a de- 
formed and unsightly nose, that, even in ancient times, 
much attention was given to the shape and appearance of 
this important feature. It is said that among the ancient 
Persians no man who had a crooked or deformed nose 
was allowed to sit upon the throne; and children of royal 
blood were accustomed to have their noses moulded into 
perfect shape by the eunuchs who had charge of the royal 
offspring. BY SUBCUTANEOUS OPERATIONS. 
5 
CLASSIFICATION. 
Nasal deformities are usually divided into two main 
classes: (i), Idiopathic or congenital, and (2), traumatic 
jVasa/ bone 
.Nasalproms of the 
super/or max/J/ary hone 
Sesamoid. 
cartilages 
.Upper lateral cartilage 
Lower lateral cartilage 
Fig. i. 
or acquired. Congenital deformities are frequently re- 
garded as mere accentuations of certain racial types, but, 
as no special deform- 
Fig. 2. 
Fig- 3- 
ity is characteristic 
of any particular 
race, no class of de- 
formities can be said 
to be governed merely 
by racial influences. 
Traumatic or acquir- 
Ed deformities sus- 
Fig. 4. 
Fig- 5- 
tain but little or no relation to the natural conformation 
of the nose, so they may assume 
any form in which accident or dis- 
ease happens to leave them. 
But, from a surgical point of 
view, nasal deformities may more 
properly be divided into (1), the 
deformities which affect the bony 
portion of the nose, and (2), the 
Flg’ 6‘ 
ginous portion. This division can be clearly understood by 
Flg- 7' 
deformities which affect the cartila- 6 
THE CORRECTION OF NASAE DEFORMITIES 
reference to Fig. i, which illustrates the anatomical conform- 
ation of the different parts of the nose. Deformities of the 
bony portion may be sub-divided into 
(a), vertical, that is, those which dis- 
tort the dorsal profile, in which the 
dorsal line is too convex, or too con- 
cave, as illustrated in Figs. 2 and 3 ; 
and (b), lateral, that is, those which, 
when viewed from the front, present 
unusual deviation from the normal 
Fig- 8- 
contour, whereby the bony portion 
deflected, Fig. 5. Deformities of the cartilaginous portion 
may be confined to the tip of the nose, to the shield 
cartilages, or wings of 
may be either spatulated, Fig. 4, or 
the nose. They may 
therefore be sub-divid- 
ed into (a), those which 
affect the tip of the 
nose, whether excessive 
Fig. 6, or defective, 
Fig. 7, in the amount 
of tissue, or distorted 
Fig. 9. 
Fig. 10. 
from its normal direction, Fig. 8 ; and (b), those which 
affect the wings of the nose, which may be either collapsed, 
Fig. 9, or abnormally expanded, Fig. 10. 
For convenient reference, this classification can be more 
clearly shown in the following diagramic form : 
DEFORMITIES OF THE NOSE. 
Bony portion 
1 
Cartilaginous portion 
Vertical 
I.ateral 
Tip 
Wings 
I 
Convex 
I 
Concave 
I 
Spatulated 
I 
Deflected 
I 
Excessive 
or 
Deficient 
in tissue 
Deviation ( 
from 
Med. Line 
Collapsed 
Expanded BY SUBCUTANEOUS OPERATIONS. 
7 
This classification applies to ordinary nasal deformities 
only and does not include those extraordinary deformities 
which result from entensive destruction of the hard or soft 
parts by syphilis, lupus, or other diseases, or by accidents, 
in which metallic or other artificial supports or plastic 
operations involving the integument are required for their 
correction. 
ETIOLOGY. 
(/). Convex Vertical Deformity of the Bony Portion of 
the Nose. 
This deformity consists of an undue projection of the 
anterior process of the nasal bones giving to the nose an 
angular appearance and is sometimes termed, according 
to its different modifications of the nose, angular deformity 
of the nose, nez en bee de corbin, rabe Nase, nez a promontaire, 
nez a chanfrein. This deformity frequently causes the 
patient much annoyance not only on account of its unsightly 
appearance but also on account of the sensitiveness of the 
nose itself. In consequence of this sensitive condition the 
nose is easily and frequently irritated by contact with different 
objects, such as towels, handkerchiefs, etc. This sensitive 
condition is usually produced by one nasal bone overriding 
the other, the former presenting a sharp edge and in some 
cases nearly penetrating the skin. 
This deformity may be congenital, or it may be caused 
by a fracture of the nasal bones, the fragments being 
thrown forward and allowed to remain in that position ; or 
it may be produced by any injury to the nasal bones 
exciting a periostitis and causing an excessive amount of 
ossific deposit at this point. 
(2). Concave Vertical Deformity of the Bony Portion 
of the Nose. 
This deformity, sometimes termed saddle-back nose, con- 8 
THE CORRECTION OF NASAE DEFORMITIES 
sists in a lowering or flattening of the bridge of the nose, 
and may be either idiopathic or traumatic. The idiopathic 
variety may be due to lack of development of this por- 
tion of the nose, associated with a general lack of systemic 
development, or, it may be the result of local organic 
conditions. During the development of the face, the cen- 
tral portion, comprising the nose, the ethmoid and sphenoid 
bones and parts adjacent, is not only late in developing, 
but is also the last portion of the face to undergo ossifica- 
tion. At birth the nose, at its base and central portion, is 
flat and nearly level with the face, but later this depressed 
line is replaced by a more prominent one as the nose be- 
comes developed. From this it will readily be seen that 
anything, which interferes with the proper development of 
these parts, so as to cause them to remain in their infantile 
condition, while the end of the nose undergoes due develop- 
ment, will give the nose an unsightly shape, on account of 
the relative depression of the central portion. 
The development of this portion of the nose may also 
be interfered with by local organic conditions. The most 
important of these is nasal obstruction. This may operate 
to produce imperfect development (i), by disturbance of 
the circulation in the part, caused by intranasal pressure 
resulting from hypertrophy of the tissues; (2), by the 
suction-force produced in the interior of the nasal chamber 
during each act of respiration and deglutition. This suc- 
tion-force, exerted on the inner side of the yielding nasal 
tissues, tends to draw them inward, and to prevent their 
normal expansion and development. In some cases the 
concave vertical deformity may exist in appearance, but not 
in reality, for the reason that an abnormal development of 
the end of the nose might make a normal dorsum appear to 
be depressed and undeveloped. 
Of the traumatic causes, those injuries to the bridge of BY SUBCUTANEOUS OPERATIONS. 
9 
the nose which are sufficient to cause fracture and disloca- 
tion of the nasal bones are the most frequent. These injuries 
are the result of falls, or blows, or fistic encounters, and the 
injury may vary from a simple dislocation, to a compound 
comminuted fracture, with extensive laceration of the parts 
and complete destruction of the bony framework resulting 
in complete flattening of this portion of the nose. Very 
often this depressed condition of the nose is the result of 
fractures and dislocations, that have not been properly 
treated, or it may be associated with depression of the car- 
tilaginous part, the result of abscesses of the septum, or 
specific disease, causing destruction or dropping inward of 
the nasal bones. 
(j). Spatulated Deformity of the Bony Portion of the Nose. 
This deformity may consist in a spatulated condition, 
i. e., a flattening of the dorsum and bulging outward of the 
nasal bones, or in a deflection of this portion of the nose to 
one or the other side. The spatulated deformity of the 
nasal bones consists in an undue bulging outward, and is 
usually associated with the concave vertical deformity 
already described. This bulging of the bones may be uni- 
lateral or bilateral, and gives to the dorsum a flattened ap- 
pearance. When of idiopathic origin, it generally results from 
the same conditions of intranasal pressure, that give rise to 
the concave vertical deformity, causing the bones to bulge 
outward. This effect in many cases I have observed to result 
from, or to be associated with, an excessive hypertrophy of 
the middle turbinated bone. When of traumatic origin, it 
ordinarily results from blows on the nose, which, when 
coming from directly in front, may result in an outward dis- 
location of both of the nasal bones. Injuries to one nasal 
bone may cause an exostosis on that side alone, in which 
case the deformity will be unilateral. 10 
THE CORRECTION OF NASAL DEFORMITIES 
(y). Deflection of the Bony Portion of the Nose. 
Deflections of the bony portion of the nose may be due 
to an unequal growth of the two sides of the nose, or to 
injuries causing dislocations of the nasal bones, which, at 
the time of the injury, were not properly reduced. In the 
case of injuries, the distortion may result from a fracture, 
or inward dislocation and consequent depression of the 
nasal bone on one side, alone, or there also may be an 
outward discoloration and corresponding bulging of the 
bone on the opposite side of the nose, giving it the appear- 
ance of what is termed by blacksmiths an offset. 
(5). Excessive Development of the Tip of the Nose. 
The abnormal enlargement of the tip or anterior por- 
tion of the end of the nose may be due to an excessive de- 
velopment of the tissues of this region, consisting of a 
redundant amount of cartilaginous tissue, or to an excessive 
amount of fatty tissue, or to both combined. This enlarged 
condition of the end of the nose is what is commonly 
known by the term “snub” or “pug nose'' and is fre- 
quently associated with the concave vertical deformity of 
the bony portion. 
In some cases, excessive development of the end of the 
nose may be confined to the upper portion of the tip, not 
broadening the end of the nose but giving it an upward 
tilt, so that the dorsal line describes a curve. This form of 
nose is termed by the French “le nez retrousse,” and is 
sometimes termed the “ Celestial nose,” which gently 
curves upward from the root to the tip. This condition 
may be purely idiopathic, a family peculiarity, but is 
more often associated with defective development of the 
bridge of the nose and the result of the same local causes 
—nameljq obstructions of the nasal passage and intranasal BY SUBCUTANEOUS OPERATIONS. 
11 
pressure. This condition, too, causes a chronic engorge- 
ment of the end of the nose by interfering with the return 
circulation and also by the sympathetic irritation reflected 
from the interior of the nose, which, by lessening the in- 
hibitory resistance of the peripheral vessels, accounts for 
the fact of its being accentuated in “ alcoholics.” 
For these reasons, chronic engorgement and undue 
redness of the end of the nose is almost invariably indica- 
tive of chronic irritation in the interior of the nose, and the 
influence of these chronic conditions, in affecting the growth 
and development of the parts, as already pointed out, 
emphasizes the importance of giving attention to the con- 
dition of the nasal passages in children. 
(d). Defective Development of the End of the Nose. 
When the tissue of the lower portion of the nose is deficient 
in amount, we have a corresponding flattening of the end, 
termed “ nez camus,” “flochenosef and “ frog nose." In 
extreme cases the end of the nose is completely flattened 
upon the face. 
Flattening of the end of the nose may be due either to 
lack of development of the cartilaginous portion of the sep- 
tum and the columnar cartilage, or to destruction of this 
portion by diseased conditions. It may also result from 
deflection or wrinkling of the triangular cartilage, which 
may have been congenital, but is generally the result of 
injuries. In many cases which have come under my notice, 
the flattening of the end of the nose resulted from abscesses 
of the anterior portion of the nasal septum. In one case, 
the flattening of the end of the nose resulted from an 
injury inflicted upon the nose by the obstetric forceps at 
birth. 
Destruction of the upper shield cartilages, located in the 
dorsum of the nose, and which fill the gap between the 12 
THE CORRECTION OF NASAL DEFORMITIES 
lower shield cartilages and the nasal bones, sometimes takes 
place, giving to this portion of the nose an indented appear- 
ance as if the nose had been struck with a small round 
body, a poker for instance, as shown in Fig. n. 
The destruction of these cartilages is usually caused by 
abscesses of the septum (Fig. 12), 
following the hematomata so often 
resulting from external injuries, 
and frequently due to failure to 
recognize the abscess, before the 
destruction of these tissues has 
taken place. In other cases, these 
cartilages may become dislocated 
by external injuries, giving to the 
nose at this point the same indented 
appearance as shown in Fig. 11. 
Fig. 11. 
Fig. 12. 
(7). Deviation of the Cartilagiyious Portion of the 
Nose. 
Deviation of the cartilaginous portion of the nose may 
be due to the unequal vertical growth of the alae, forcing the 
nose over to one side, or there may be unequal development 
in the thickness of the two wings, distorting the nose, and 
giving it the appearance of being deflected. The most 
frequent distortion of the end of the nose results from 
injuries, inflicted on the nose by falls or blows during 
childhood, dislocating the triangular cartilage and causing 
deviation of the nasal septum, as shown in Fig. 13. The 
deformity at first may be so slight as to be almost unnotice- 
able, but later, as development takes place, the nose becomes 
increasingly distorted. 
Frequently pressure against one side of the nose may 
slowly cause bending to the opposite side, as is sometimes 
the case with persons who habitually use their handkerchief BY SUBCUTANEOUS OPERATIONS. 
13 
with one particular hand. This is especially the case when 
one nostril is obstructed, for, when blowing 
the nose, pressure on the open side is 
avoided, in order to give ample room for the 
expulsion of the discharge. In other cases, 
deflection of the cartilaginous portion may 
be associated with deflection of the osseous 
Fig- 13- 
portion toward the same side, so that the 
whole nose, though straight along the dorsal line, may be 
deviated to one side, often at a considerable angle from the 
medium line (vide Fig. 36). This condition may result 
from injury, or it may be an anatomical peculiarity. 
(c?). Collapse or Flatte7iing of the Wings of the Nose. 
In the collapsed condition we have an undue flattening 
of the sides of the nose, interfering seriously with the nasal 
respiration. (Vide Fig. 34.) This may be due to defective 
or distorted development of the alse, or to paralysis of the dila- 
tores naris muscles. In other cases cicatrical contraction of 
the interior of the nose, the result of specific ulceration, 
lupus, burns, etc., may cause contraction of the nasal open- 
ing and consequent distortion of the alse on one or both 
sides. In other cases it may result from injuries causing dis- 
location or fracture of the alae and the consequent distortion. 
(p). Expansion or Spreading of the Wings of the Nose. 
This deformity is usually of congenital origin and con- 
sists of a marked distension or bulging outward of the 
lower shield cartilages, giving the end of the nose a very 
broad, prominent, and inordinately flat appearance. On 
examination, however, it will be found that there is but 
little thickening of the tissues, the concavity of the interior 
being proportionate to the extreme bulging. 
This bulging outward of the wings is oftentimes in- 14 
the; correction of nasae deformities 
creased by the habit of inserting the finger into the nostrils 
to remove the crusts and dried discharges, resulting from 
intranasal disease, with which it is very often associated. 
Marked expansion and distortion of the alse not infre- 
quently takes place from the pressure of intranasal growths. 
TREATMENT. 
As I have pointed out in previous articles on the Cor- 
rection of Nasal Deformities,1 the beauty of the nose de- 
pends almost entirely upon its symmetry, if the dispropor- 
tionate relation between the size of the nose and the size of 
the face is not too great. 
In correcting deformities of the nose, then, we have to 
study the symmetrical relations of the different portions of 
the nose to one another rather than its proportionate re- 
lation to the face. A nose which is originally proportion- 
ate to the face will, if deformed by loss or displacement of 
tissue of any portion, appear very unsightly, while the 
same nose, made one or two sizes smaller, will, if its differ- 
ent parts are made perfectly symmetrical, have a more or 
less handsome appearance. Therefore, in correcting de- 
formities of the nose, it is symmetry and not size that is to 
be considered. 
In this way it will readily be seen that the causes and 
conditions of the different deformities of the nose are so 
various, that the operations required for the correction of 
these deformities must be equally varied, and no two cases 
will be found exactly alike, requiring the same operation. 
There are, however, general underlying principles 
governing the different operations which must be observed 
I<l The Deformity Termed Pug-Nose audits Correction by a Simple Opera- 
tion,” Medical Record, N. Y., June 4, 1887. “ The Correction of Angular Deform- 
ities of the Nose by a Subcutaneous Operation,” Medical Record, N. Y., July 18, 
1891. “ The Correction of Deformities of the Nose Resulting from Abscess of the 
Nasal Septum,” New York Medical Journal, March 25, 1893. “The Correction of 
Depressed and Saddleback Deformities of the Nose by Operations Performed 
Subcutaneously, Without the Aid of Metallic or Other Artificial Supports,” Medi- 
cal Record, N. Y., June 5, 1897. BY SUBCUTANEOUS OPERATIONS. 
15 
in order to secure the desired result. Thus, in the convex 
vertical deformity of the bony portion of the nose and 
excessive development of the tissues of the tip of the nose, 
the excessive or redundant tissue must be removed; 
whereas, in the concave vertical deformity of the bony 
portion of the nose or of defective development of the tip 
of the nose, the low portions must be filled in. Usually 
this can be done with tissue taken from the elevated por- 
tions, so as to make the nose symmetrical, or when this 
cannot be accomplished by the transfer of tissue from the 
elevated to the low portion, the latter can be filled in by 
tissue taken from some other portion of the nose, where it 
can be spared, and the elevated portions lowered so as to 
make the nose symmetrical. 
In many forms of distortion of the nose, especially those 
resulting from injury, there is almost invariably a displace- 
ment rather than a destruction of tissues, which require 
only to be replaced to their original position. It is import- 
ant, however, that all these operations be performed subcu- 
taneously in order to avoid the wounding of the skin and 
the consequent disfigurement. In some instances fracture 
of the nasal bones and of the septum, too, may also be nec- 
essary in order to restore the parts to a normal condition. 
To particularise further, I will briefly describe, as near 
as I can, the steps taken in the different operations for the 
correction of these deformities. As already observed, how- 
ever, it is rare for one variety of deformity to exist alone, 
and to require but one form of operation for its correction. 
Convex Vertical Deformity of the Bony Portion of the Nose. 
This deformity is the one most often found uncompli- 
cated, and the operation for its correction is in the main 
performed as follows : 16 
THE CORRECTION OE NASAE DEFORMITIES 
The skin is first raised from the projecting portion by 
incising the wall of the nose from the inside of the nostrils 
through to the under side of the skin, great care being 
exercised not to wound the skin. The opening is then 
enlarged sufficiently to admit the instrument required, 
which may consist of bone scissors, rongier forceps, a slen- 
der saw, or such other instrument as may be necessary 
according to the conditions present. 
In removing the projecting portion, great care must be 
exercised not to remove too much of the redundant tissue, 
lest a depression be be left in the top of the nose which 
may be /nore unsightly than the original deformity. This 
mistake more readily happens in those cases in which the 
upper portion of the nasal passage extends all the way 
up into this projecting portion. In these cases the nasal 
passage is very easily opened on removing the projecting 
angular portion. 
By way of example, I will briefly cite from my records 
one or two typical cases, illustrating each of the different 
varieties of nasal deformities, together with illustrations of 
the appearance of the patient both before and after the 
operation. 
Mrs. C., age thirty, was referred to me by her family physician on 
account of an unsightly angular convexity of the nasal bones, as 
shown in Fig. 14. The natural conformation of her nose was angular, 
but about five years before, she met with a slight accident, striking 
her nose against a table, which rendered it exceedingly sensitive ; so 
much so that she scarcely could use a towel or a handkerchief without 
pain. 
The operation for the removal of this deformity was performed 
according to the plan already described. After the skin was elevated 
from the deformed portion, the projecting portion of the nasal bone 
was sawed off, and the edges trimmed smoothly with a pair of slender 
bone-clipping forceps, so as to give the nose the exact contour desired. 
After the parts were thoroughly cleansed and rendered aseptic, the 
skin was replaced, and a gentle compress was placed over the dorsum of BY SUBCUTANEOUS OPERATIONS. 
17 
the nose to hold the skin closely coapted against the bony framework. 
The parts speedily healed, but, before the healing was complete, 
she accidentally dropped onto her nose a small hand mirror, with which 
she was inspecting it, while lying in bed. This injury brought about 
Eig. 14, 
Fig- 15 
a highly inflamed condition and a slight abcess at the seat of injury. 
This was evacuated antiseptically and subcutaneously as soon as the 
pus was manifest, antiphlogistic measures adopted. The disturbance, 
however, soon subsided, and the nose became perfectly well and 
symmetrical in every way, as shown in Fig. 15, much to the delight of 
the patient. 
Miss D., Buffalo, N. Y., twenty-one, was referred to me on account 
of a convex vertical deformity of the bony portion of the nose, 
associated with a deflection of the whole nose to the right, both of the 
osseous and cartilaginous portions, together 
with a deviation of the septum to the same side. 
This deformity of the nose followed an in- 
jury from falling on the ice when she was a 
child twelve years of age. Previous to this time 
her nose was perfectly straight, but since that 
time the deformity had been slowly but steadily 
increasing. 
In correcting this deformity, the operation 
for removing the angular projection was per- 
~.//eta//ic 
Worm 
dd/tes/re 
Waster 
Fig. 16. 
formed in a manner very similar to the one just described. In this 
case, however, the septum also required straightening and the whole 18 
THE CORRECTION OF NASAE DEFORMITIES 
nose resetting to the median line. This was done at the same time that 
the septum was straightened, by refracturing both nasal bones so as to 
elevate one and depress the other, while bringing the nose over to the 
median line. 
Fig. 17. 
Fig. 18. 
This was accomplished by a method devised by myself, that 
obviated all danger of injuring the skin. It consisted in raising the 
skin from the nasal bones so as to apply the forceps to the bone from 
underneath the skin. After the nasal bone and septem were fractured, 
the nose was put in place, irrigated with a bichloride solution and 
made thoroughly antiseptic, and a dressing applied to the interior of 
each nostril in the form of a splint wound with cotton, so as to maintain 
the bone in an elevated position, and at the same time to hold the 
fractured septum in a vertical position until healed. The form em- 
ployed by the writer for treating fractures of the nose, as shown in 
Fig. 16, was also applied to the exterior of the nose, so as to maintain 
symmetry throughout until healing had taken place. Figs. 17 and 18 
illustrate the appearance of the patient both before and after the 
operation. 
Concave Vertical Deformity of the Bony Fortiori of the 
Nose. 
The operations for the correction of this deformity are 
entirely different from the last, and consist in filling in the 
depressed portions with flaps of tissue taken from the BY SUBCUTANEOUS OPERATIONS. 
19 
unduly prominent portion, subcutaneously, thereby lower- 
ing that portion at the same time. 
The methods by which this is done cannot be more 
clearly shown than by citing an. illustrative case : 
Mr. E , aged nineteen, was referred to me for the correction 
of a marked saddle-back deformity of his nose, which had resulted 
from being struck with a base-ball club, four years before. On exam- 
ination it was found that the nasal bones had been fractured, and the 
upper portion of the alse of the nose and the shield cartilages were 
driven upward and inward, causing the sides of the nose to bulge 
somewhat outwTard, giving to the center of the nose a depressed and 
spatulated appearance. A large, perpendicular ridge, on the right 
side of the septum, at the osseo-cartilaginous junction, was also pro- 
duced by the injury. This flattened condition of the center of the 
nose gave to its end the appearance of being unduly prominent, as 
seen in Fig. 19. None of the tissues, however, had been destroyed, 
but simply displaced from their normal position by the external 
force. 
Fig. 19. 
Fig. 20. 
In this case the indications were to use the displaced tissues for 
filling in the depressed portion. The displaced tissues found on the 
sides of the nose were restored to the top, by raising the skin from the 
dorsum, through an incision made from the interior of the nostril, 
and turning the flaps, made of this displaced tissue, upward, to fill in 
the depression in the center of the nose. A portion of this displaced 20 
THE CORRECTION OF NASAE DEFORMITIES 
tissue consisted of bone, which was sawed loose with a sharp, slender 
saw. When this was completed, a flap was made of the redundant 
cartilaginous tissue, constituting the ridge on the right side of the 
septum. In order to get this latter flap to the desired place on the 
dorsum, it was necessary to turn the flap twice to reach the spot. 
This was done by cutting the lower part loose and turning it up, 
allowing the upturned end to become attached sufficiently to supply 
it with nutriment, when the other end was cut away and again turned 
upward. When the further end had again become firmly attached, 
the lower end was cut away and turned into place, which completed 
the filling of the top of the nose very nicely. The end of the nose 
still projected slightly above the line of the dorsum. This was 
lowered by removing sufficient tissue to bring it down to the line of 
the dorsum, making the nose perfectly symmetrical, as shown in Fig. 
20. The nose was then held in place for a considerable period, by an 
external dressing, until the parts were thoroughly healed, and the 
nose showed no tendency to become distorted. 
Spatulated Deformity of the Bony Portio7i of the Nose. 
The correction of this deformity usually consists in 
sawing off portions of the bulging nasal bones, and placing 
these bone flaps, together with the attached soft tissues, in 
the median line in such a position as will fill in the depressed 
portion. This deformity is almost always associated with 
an enlarged condition of the end of the nose, which requires 
a corresponding amount of reduction in order to make the 
nose symmetrical, as illustrated by the following case : 
Mr.'B., aged thirty, was referred to me on account of a flattened con- 
dition of the central portion of the nose, which caused him much annoy- 
ance, on account of its disfiguring appearance. 
This condition was attributed to an abscess in the nose, occurring 
when he was a lad, the cause of which, however, was unknown, that 
resulted in the lack of development of this portion of the nose, as 
shown in Fig. 21. 
On examination, the dorsum of the nose was found to be much 
flattened, and the nasal bones bulged outward. The end of the nose 
was not hypertrophied, but the shield cartilages were very much 
dilated or expanded, giving to the nose a markedly pugged appearance. BY SUBCUTANEOUS OPERATIONS. 
21 
In the examination of the interior of the nose, the middle turbin- 
ated bodies were found very greatly hypertrophied, which doubtless 
had much to do with the outward bulging of the nasal bones. 
Fig. 21. 
Fig. 22. 
The operation in this case consisted, first, in removing the hyper- 
trophy of the middle turbinated bones. Bone flaps were then 
made from the bulging portion of the nasal bones, subcutaneously, 
and placed on the dorsum, which gave that portion of the nose 
normal contour. The expanded portions were then reduced by sub- 
cutaneous incisions through the cartilage. They were, however, so 
much expanded that it was necessary to resect a portion of the shield 
cartilage, in order to reduce the end to a size proportionate to the 
dorsum of the nose. The parts were then held in place until firmly 
fixed in position, as shown in Fig. 22. 
Deflection of the Bony Portion of the Nose 
This deformity may be corrected by two different 
methods. First, by refracturing the bones and holding 
them in the desired position until firmly fixed. Second, by 
a subcutaneous osteo-plastic operation, which consists in 
elevating the skin from the dorsum, sawing off with a 
slender saw the projecting portion and placing it in the 
depression on the other side of the nose. 22 
THE CORRECTION OF NASAE DEFORMITIES 
The first method has been illustrated in the second case 
cited of angular deformity of the bony portion of the nose. 
The second method is illustrated by the following case : 
Miss 8., of New York, was, by her medical adviser, referred to me 
for the correction of a deformity of the nose, which resulted from being 
thrown from a carriage and striking on the nose and fracturing it, ten 
years before. She was so ill for a short time after, that cerebral com- 
plications were feared and, in consequence, the nose was allowed to 
go uncared for. As a result of the fracture, the right nasal bone was 
depressed and the left one displaced outward, making the nose very 
crooked and producing the condition which would be termed by a 
blacksmith “an offset” in the middle of the nose, as shown in 
Fig. 23. 
Fig. 23. 
Fig. 24. 
The condition of the nose was such that refracturing of the nasal 
bones so as to elevate the right nasal bone and depress the left one 
was not advisable. The only resource left, therefore, was an osteo- 
plastic operation. The skin from the dorsum was accordingly raised 
and the bulging portion of the left nasal bone was carefully sawed off, 
leaving as much of the soft parts attached to it as possible. It was 
then carried over the bridge of the nose and placed in position in the 
depression on the right side, completely filling it. Union of this flap 
with the bone was encouraged by denuding the bone of the periosteum 
at this point before the flap was placed in position. It was carefully 
held in position until united and thoroughly fixed. The two sides of BY SUBCUTANEOUS OPERATIONS. 
the upper portion of the nose were then perfectly symmetrical. The 
lower portion of the nose was distorted to the left by a deviation of 
the cartilaginous portion of the septum. This deformity of the 
septum was corrected, making the nose perfectly straight. A third 
operation was found necessary to remove a redundancy of the alse on 
the left side. The nose was then carefully held in position by a 
dressing adapted to it until it had become thoroughly fixed in the 
desired shape, leaving the nose perfectly symmetrical, as shown in 
Fig. 24. 
Excessive development of the tip of the nose. 
The so-called pug, or snub nose, is corrected by removing 
the redundant tissue from the end of the nose subcutane- 
ously. The operation is performed from the interior of the 
nostrils as illustrated by the following case: 
Miss F., age twenty-three, was referred to me for the correction of 
a deformity of the nose due to excessive development of the tissues 
at the end of the nose, giving it a very pronounced pug, as shown in 
Fig. 25. This condition had existed since childhood and was 
steadily becoming more pronounced 
Fig. 25. 
The mucous membrane is first turned back from the anterior sur- 
face of the interior of the nostrils, and the superfluous tissue removed, 
after which the mucous membrane was replaced. Bulging of the 
P'ig. 26. 24 
THE CORRECTION OF NASAE DEFORMITIES 
wings was also present in this case and the operation for reducing 
them was performed by very carefully incising the cartilage through 
to the skin in several places, so as to remove all elasticity without 
wounding the skin. The nose was held in place by an external dress- 
ing until healed in the desired position, as shown in Fig. 26. In 
some cases it is necessary to supplement the main operation by minor 
ones until the desired degree of perfection is attained. 
Defective Development of the End of the Nose. 
This deformity is corrected by filling in the deficiency 
with tissue from adjacent parts, by plastic operations, 
performed subcutaneously, varied according to the require- 
ments of the case. The method by which this defect can 
be rectified is demonstrated by the following two typical 
and interesting cases: 
Case I.—A young man, aged eighteen years, was referred to me by 
his family physician for the correction of a deformity and flattened 
condition of the end of the nose, which was congenital, or at any rate 
Fig. 27. 
Fig. 28. 
had existed from infancy. This deformity was so conspicuous that 
people on the street and elsewhere would frequently turn to observe 
him. This was so annoying to him that he rarely mingled in 
society, and shunned people as much as possible. In this case the 
anterior and superior portion of the triangular cartilage was missing, BY SUBCUTANEOUS OPERATIONS. 
25 
and the flattening of the end of the nose and the consequent lateral 
bulging of the alee gave it the appearance of a frog-shaped nose, as 
shown in Fig. 27. Besides this, the frenum of the nose was attached 
so low down on the lip as to cause the end of the nose to slant back- 
ward, and the nostrils to stand prominently open, which was accentu- 
ated by the upward tilt of the end of the nose. 
To correct this deformity, it was necessary to adopt a special plan 
of operation for raising the end, instead of depressing it, as in the 
operation for pug-nose just described. In order to reduce the width 
of the nose and at the same time to raise the end and take away the 
very flattened appearance, sufficient tissue was taken from the interior 
of the alse 011 each side to form a flap, which was carried upward and 
held in place under the skin, which had previously been raised at the 
tip of the nose. It required two operations at different times to 
accomplish this. In order still further to raise the point of the nose, 
the frenum was lengthened and its attachment to the upper lip 
set higher up. This was done by cutting through the anterior column 
of the frenum on a line with the upper lip, then carrying the incision 
upward about half the length of the frenum and then backward, 
forming a stair, and then upward to a distance equal to the length of 
the first horizontal incision through the frenum, so that the lower end 
of the frenum would fit into the second stair, so to speak. The lower 
end of the frenum was then set into the second stair, and carefully 
stitched there. The skin on each side of the lower end of the frenum 
from which the anterior column had been removed was then raised and 
the edges drawn together in front of this denuded surface, so that on 
healing no perceptible scar was left. Two or three minor operations 
were required to complete the work, as shown in Fig. 28. So 
symmetrical and perfect is the nose that those unacquainted with the 
young man would not suspect that his nose had been at any time 
deformed. 
Case II.—A girl sixteen years old had had from infancy an 
extremely flattened condition of the nose, the result either of an 
unrecognized abscess of the septum or a congenital defect, there being 
no history of inherited specific disease or evidence of tuberculosis 
taint. Examination showed that the nasal bones were normal, but 
the triangular cartilage of the septum was entirely absent. The soft 
parts were present in their normal proportions, but so flattened upon 
the face, from lack of central support, as to give the girl a very 
unsightly appearance, as shown in Fig. 29. The difficulty in this case 26 
THE CORRECTION OF NASAI, DEFORMITIES 
was to find enough material to render the septum sufficiently firm to 
hold up the end of the nose. There was, as is usual in these cases, a 
marked widening and thickening of the dorsum of the nose propor- 
tionate to the amount of flattening. This thickened ridge of tissue 
was incised through to the under side of the skin on both sides a short 
Fig. 29. 
Fig. 30. 
distance from the septum, at a point where it thinned into the alse of 
the nose. The skin was then raised from the dorsum of the nose, and 
the flaps were turned upward and held in place by small ivory splints, 
having holes through which sutures were passed from one to the 
other through the flaps and tied so as to hold them firmly in place 
without strangulating the parts. This relieved the flattened condition 
of the nose, and also gave the dorsum a sharper appearance. The end 
of the nose was, however, altogether too low. 
Owing to the entire absence of the triangular cartilage, there was 
not sufficient central support to hold the nose up. In order to do this, 
and to increase the solidity of the septum, I 
first scarified each side of the lower portion of 
the septum and the floor of the nose, and 
divided the anterior portion of the septum, 
leaving the front portion of the skin intact. I 
then cut wide, thick flaps from the floor of the 
Fig- 31- 
nostril opposite the portion of the septum 
which I wished to render more rigid. The end of the nose was then 
raised and the flaps turned up and held together with clamps in a 
manner similar to the upper flaps, and their upper ends connected to BY SUBCUTANEOUS OPERATIONS. 
27 
the under end of the cut portion of the septum with fine sutures. 
The result was most excellent; for the flaps, when united, were found 
sufficient to support it and to give the nose a very presentable appear- 
ance—so much so that it would not be suspected that the previous 
very flattened condition ever existed, as shown in Fig. 30. In order to 
maintain the nose in position until the parts became thoroughly 
healed, I placed in each nostril small spiral springs (Fig. 31), the 
upper arm being bent to the proper contour, so as to lie along under 
the dorsum, the other arm lying along the floor of the nose. The 
tension was regulated by turning the small screw in the stern. These 
springs were worn until the tissues had become firmly fixed and self- 
supporting and their further use unnecessary, the nose having then 
assumed a symmetrical appearance. 
Deviation of the Cartilaginous Portion of the Nose. 
The correction of this deformity consists in loosening the 
nose by subcutaneous incisions so that it can be placed in 
its normal position in the median line of the face, and held 
there until firmly fixed, as illustrated by the following case: 
Mr. C., aged forty, was thrown from his wheel, striking the end 
of his nose against a curb, causing some contusion of the nose, fol- 
lowed by a considerable swelling and inflammation. When this had 
Fig. 32. 
Fig. 33- 
subsided, the end of the nose was found to be deflected markedly to 
the right. This condition was allowed to go uncared for, and at the 
time when I saw him, two years later, the end of the nose was set 
over to the right side, and there was, at the same time, a marked 
bulging of the left nasal bone, giving the nose a very distorted appear- 
ance, as shown in Fig. 32. There was also a marked depression in the 
center of the nose at the junction of the upper shield cartilage with 
the nasal bone. 28 
THE CORRECTION OF NASAE DEFORMITIES 
An examination showed that the triangular cartilage had been 
dislocated, to the right, and the left nasal bone fractured, and thrown 
outward. The operation in this case consisted, first, in cutting loose, 
subcutaneously, the cartilaginous portion along its base, and also at 
its junction with the vomer, and setting it in the median line. The 
bulging portion of the left nasal bone was sawed off and placed in 
the depression in the dorsum, which filled the gap completely. 
The nose was then held in place until the parts were entirely healed 
in their normal position, as shown in Fig. 35. 
Collapse or Flattenirig of the Wings of the Nose. 
The operation in these cases consists in incising the 
lower shield cartilage, and in some cases the upper shield 
cartilage also, sufficiently to overcome their elasticity, and 
then to hold them in the desired position until fixation of 
the tissues has taken place, as illustrated by the following 
case ; 
Miss 8., aged twenty-three, had had difficulty in breathing through 
the nose for several years. On examination, the wings of the nose 
were found flattened and collapsed against the septum, giving very 
Fig- 34- 
Fig. 35- 
little space for respiration. To overcome this contracted condition, 
the interior of the nose had previously been cauterized, in order to 
increase the patency of the nostrils, but which had had the effect to 
contract, rather than to increase, their capacity. BY SUBCUTANEOUS OPERATIONS. 
29 
The nostrils were not only collapsed against the septum, as shown 
in Fig. 34, but the lateral shield cartliages were set so close to the 
septum as to give little opportunity for expanding the nostrils. In or- 
der to overcome this condition, the base of the lateral shield cartilages 
■were cut loose, subcutaneously, and the outerlying tissues dissected 
up sufficiently to allow each one to be set out a sufficient distance to 
give ample room for the nasal passage. This was done subcutane- 
ously, so as to prevent any cicatrical contraction of the interior of the 
nostril on healing. The elasticity of the lateral cartilage was over- 
come by subcutaneous incisions with a very slender knife. The 
nostrils were then held in the desired position by an internal support, 
consisting of a hollow tube of celluloid, formed in the desired shape. 
This support was maintained until the parts were firmly fixed in posi- 
tion, as shown in Fig 35. 
Expansion or Spreading of the Wings of the Nose. 
The operation for the correction of this condition con- 
sists in overcoming the elasticity of the wings by incisions 
through the shield cartilages subcutaneously with a slender 
knife in several places, and then holding them in place by 
an external form until they are firmly fixed in the desired 
position. In some instances the cartilage is so redundant 
that a portion of it must be excised. 
It is unnecessary to cite cases to illustrate this condition, 
for the method of correcting this deformity has been illus- 
trated in two or three of the cases already cited. 
Deflection of the Whole Nose 
Fig. 36 illustrates a case of devia- 
tion of the whole nose, which was 
evidently of congenital formation, as 
there was no history of any acci- 
dent that might have caused the 
condition. Usually, however, this 
condition is the result of accident. 
The operation for correcting this 
the nasal bones on both sides in the manner already de 
Fig. 36. 
deformity consisted in fracturing 30 
THE CORRECTION OF NASAE DEFORMITIES 
scribed, and liberating the septum along its base. The 
nose was then placed in the center of the face, and held 
there, in the manner described in the report of the second 
case of angular deformity of the bony portion of the nose, 
until fixed in its normal position.1 
As I have stated in the previous papers already referred 
to, no two cases of' nasal deformity are exactly alike or 
require exactly the same operation, for, no matter how 
much they appear alike externally, the conditions will be 
sufficiently varied to require a special study of each case 
before any operative procedures should be undertaken, as 
briefly illustrated in the few cases I have selected for 
demonstration. 
There are three conditions which must be observed in 
order to ensure success in these operations. In the first 
place, although unnecessary to state, the utmost anti- 
septic and aseptic precautions must be adopted, for, if 
supperation in the wound should take place, engrafted 
tissues would be destroyed, and not only would the object 
of the operation be defeated, but the deformity of the nose 
would be increased thereby. In the next place, the plan 
of the operation must be carefully studied in order that the 
tissues at our disposal may be utilized to the best advantage. 
In the third place, and not less important than the opera- 
tion itself, the greatest care and the most vigilant attention 
are required, for no matter how well directed the operation 
may be, the object cannot be attained unless scrupulous 
attention is paid to the healing process. 
These operations on the nose, therefore, are not attended 
with the immediately brilliant results possible in many opera- 
‘Three of the cases cited have been used for the illustration of previous articles. 
They are, however, typical and, to save the necessity of making other similar 
cuts, I have reproduced them here. BY SUBCUTANEOUS OPERATIONS. 
31 
tions performed on other parts of the body, which can be 
completed at one time, the wound requiring only to be 
maintained aseptic until the cure is complete. On the 
contrary, these operations on the nose require frequent and 
most careful attention. The parts must not only be held 
in place by retentive appliances, but the shape of these 
appliances and the dressing must often be changed from 
day to day as the swelling subsides and the union of the 
parts takes place. It may be necessary to add a little inter- 
nal or external pressure here and remove a little there until 
the fixation of the tissue is complete. 
Without this careful attention to detail by the surgeon, 
and the most faithful compliance on the part of the patient 
with regard to all instructions, failure and disappointment 
will be the almost inevitable result, for, in no part of the 
body is the tendenc}7 of the tissues to revert to their former 
condition and position so strong as in the nose. 
Frequently the principal or main operation must be 
supplemented by minor operations for the correction of 
slight defects. An unduly prominent portion may require 
lowering, a depressed portion may require raising, and so 
on until the work is completed. To paraphase, we might 
say in these cases that eternal vigilance is the price of a 
perfect nose. 
When considering the vast change made in the appear- 
ance of the nose by a slight alteration or departure from its 
symmetry and the wondrous changes made in the facial 
appearance and physiognomy of the person by its disfigure- 
ment, it is readily seen why the nose is regarded as one of 
the most distinguishing of racial characteristics. 
28 CLINTON AVENUE, NORTH.