Cosmetic Surgery 
THE CORRECTION OF 
FEATURAL IMPERFECTIONS 
BY 
CHARLES CONRAD MILLER, M.D. 
WITH ONE HUNDRED AND FORTY ILLUSTRATIONS 
PHILADELPHIA 
F. A. DAVIS COMPANY, Publishers 
1924 COPYRIGHT, 1924 
BY 
F. A. DAVIS COMPANY 
Copyright, Great Britain. All Rights Reserved 
PRINTED IN U S.A. 
PRESS OF 
F. A. DAVIS COMPANY 
PHILADELPHIA. PA. PREFACE 
It will be observed in the text that the writer has 
given a brief description of local anesthesia by infil- 
tration, bnt nothing is said of the technic of nerve 
blocking. If the operator is master of the technic 
of nerve blocking it may well be used, but the writer 
does not believe that it should be used unless the sur- 
geon is experienced in its use, for to attempt to mas- 
ter nerve blocking and at the same time do the more 
or less difficult featural operations here described is 
to ask too much of the average beginner in this 
exacting surgery. 
Methods of plastic surgery are very old, and study 
of surgical literature of pre-antiseptic days will con- 
vince any thinking man that the great surgeons of 
the past (and there were many such) recognized and 
took advantage of quite all of the principles of plastic 
surgery in general use today. Writings of the old 
masters in surgery show that brilliant minds gave 
deliberate and thoughtful attention to plastic opera- 
tions, and their understanding cannot fail to impress 
deeply the surgeon who has had any practicable ex- 
perience. Fundamentally these operators of the past 
were well acquainted with surgical possibilities which 
III IV 
PREFACE. 
we use to advantage in doing the operations 
described in this manual. 
With the varied distractions to which present day 
operators are subjected, attempts to write are too 
much disturbed and our books show the effects of 
the exactions of modern life. Even our best sur- 
geons, when they write upon subjects in which their 
experience is extensive and their understanding 
great, are often given to the hasty practice of credit- 
ing originality to those writers who in the previous 
few years have written upon similar subjects. Mas- 
terpieces of description in older literature are thus 
lost, and men who have made inessential changes in 
details of technic are frequently credited with being 
originators of operations which they have really had 
nothing to do with developing. 
While it is profitable to flatter contemporaries by 
alluding to their work, and to give credit freely to 
those active in the same fields, and such policy often 
helps to establish congenial and valuable friendships, 
the writer has disregarded any such opportunities, 
for the benefit of the text, and has tried to briefly 
describe operations in a way which he hopes will 
make such descriptions most useful to his readers. 
When he has laid claim to originality, the reader 
should remember that such claims are merely for 
adapting to particular regions the well-known prin- 
ciples of plastic surgery. PREFACE. 
V 
With the tremendous changes in the character of 
the people, and the developing of a pleasure-loving 
race in place of the more serious types of the past, 
there has come more or less of a demand for cos- 
metic operations. A certain percentage of surgeons 
wish to take advantage of this demand, but feel more 
or less handicapped by the lack of accessibility of 
descriptions of plastic methods applied particularly 
to this part of the body, so with the hope of being 
helpful, in the face of possible strictures from the 
best in the profession, the writer offers these pages 
to those who may be interested. 
C. C. Miller. 
Chicago, III. CONTENTS 
CHAPTER I. 
Antisepsis 1 
CHAPTER II. 
Local Anesthesia 5 
CHAPTER III. 
Hemorrhage 8 
CHAPTER IV. 
The Head 16 
CHAPTER V. 
Folds, Bags and Wrinkles about the Eyes 19 
CHAPTER VI. 
Face Lifting Operations 57 
CHAPTER VIL 
Operations for Altering the Palpebral Fissure 96 
CHAPTER VIII. 
Operations for "Double Chin" Ill 
CHAPTER IX. 
Subcutaneous Sectioning of Face and Neck Structures for 
Eradicating Lines and Wrinkles 123 
CHAPTER X. 
Subcutaneous Sectioning for Softening Nasolabial Lines .... 127 
VII VIII 
CONTENTS. 
CHAPTER XI. 
PAGE 
Sectioning as an Aid to Other Operations 131 
CHAPTER XII. 
Scowl Lines 134 
CHAPTER XIII. 
Excision of Scars 136 
CHAPTER XIV. 
Formation of the Dimple 140 
CHAPTER XV. 
Reduction of the Bulbous Nasal Tip 144 
CHAPTER XVI. 
Partial Stenosis of the Nose 151 
CHAPTER XVII. 
Outstanding Al.e Nasi 156 
CHAPTER XVIII. 
Operations for Hump Nose through the Nasal Orifices 161 
CHAPTER XIX. 
Removal of Hump Nose through Skin Incisions 169 
CHAPTER XX. 
Operations about the Mouth 179 
CHAPTER XXL 
The Unduly Large Mouth 195 
CHAPTER XXII. 
The External Ear 201 CONTENTS. 
IX 
CHAPTER XXIII. 
PAGE 
Operations for Correction of Outstanding Ears 204 
CHAPTER XXIV. 
The Excessively Large Ear 212 
CHAPTER XXV. 
Microtia 215 
CHAPTER XXVI. 
Crescent-shaped Excisions from the External Ear 220 
CHAPTER XXVII. 
The Plaster Cast for Immobilizing the Ear after Operations 
and Injury 228 
CHAPTER XXVIII. 
Adherent and Undeveloped Ear Lobule 231 
CHAPTER XXIX. 
The Attached Lobule and the Pointed Ear 238 
CHAPTER XXX. 
Skin Grafting for the Correction of Featural Imperfections .. 243 
CHAPTER XXXI. 
Modification of Featural Types 246 
CHAPTER XXXII. 
Conclusion 251 
Index 261 ILLUSTRATIONS 
FIG. PAGE 
1. Early type of excision for fullness beneath the eyes 20 
2. Excision completed 21 
3. Crescent excision distant from the eye 22 
4. Crescent excision completed 23 
5. Narrow excisions for fullness beneath the eye 24 
6. Completion of narrow excision 25 
7. Crescent and median wedge excision beneath the eye 26 
8. Manner of completing crescent and wedge excision 27 
9. Inner wedge and crescent excision beneath the eye 28 
10. Manner of completing inner wedge and crescent excision .. 29 
11. Outer wedge and crescent excision beneath the eye 30 
12. Manner of completing outer wedge and crescent excision .. 31 
13. Double wedge and marginal excision along the lid border .. 32 
14. Manner of completing double wedge and marginal excision 33 
15. Multiple wedge and marginal excision along the lower lid . . 34 
16. Manner of completing multiple wedge and marginal excision 35 
17. A sliding flap operation inferior to the external canthus ... 36 
18. Manner of completing sliding flap operation below external 
canthus 37 
19. A sliding flap operation below the internal canthus 38 
20. Manner of completing sliding flap operation below the in- 
ternal canthus 39 
21. Excision of fullness above the eye distant from lid margin 40 
22. Manner of completing excision distant from lid margin .... 41 
23. Manner of excision of loose tissues close to lid margin .... 42 
24. Manner of closing skin interval close to lid margin 43 
25. Excision of lozenge of skin below external canthus 44 
26. Manner of completing excision at external canthus 45 
27. Excision above and external to outer canthus 46 
28. Manner of completing excision above and external to 
canthus 47 
29. Excision at outer canthus 48 
30. Linear closure of skin excision external to canthus 49 
31. Arrow excision well beyond the external canthus 50 
32. Manner of closing arrow excision beyond external canthus 51 
33. Excision close to external canthus 52 
34. Manner of closing excision close to canthus 53 
XI XII 
ILLUSTRATIONS. 
FIG. PAGE 
35. Diamond shaped excision external to canthus 54 
36. Manner of closing diamond excision external to canthus .. 55 
37. Median excision above hair line "forehead lift" 66 
38. Manner of closing median excision above the hair line .... 67 
39. Double lateral excision above the hair line 68 
40. Manner of closing double lateral excision above the hair line 69 
41. Excision above and external to frontal eminence for oblique 
lift 70 
42. Manner of closing excision above and external to frontal 
eminence 71 
43. Type of excision for direct upward lift in temporal region 72 
44. Manner of closing excised area for securing direct upward 
lift '. 73 
45. Type of temporal excision to secure upward and backward 
traction 74 
46. L shaped closure in temporal region 75 
47. Triangular excision in temporal region 76 
48. Inverted Y closure in triangular excision 77 
49. Sliding flap lift in temporal region 78 
50. Manner of closing to secure direct upward traction in slid- 
ing flap operation 79 
51. Oblique sliding flap operation in temporal region 80 
52. Manner of closing sliding flap operation to secure oblique 
upward and backward traction in temporal region 81 
53. "Face lift" carrying incision down in front of ear 82 
54. Manner of closing temporal and anterior auricular excisions 83 
55. Lozenge excisions above ear and in cranial vault for tissue 
retracting 84 
56. Manner of closing cranial vault excisions 85 
57. Sliding flap lift behind the ear 86 
58. Manner of closing to secure upward and backward traction 
as an adjunct to "face lifting" operations 87 
59. Arrow excision behind the ear 88 
60. Manner of closing arrow excision behind the ear 89 
61. Excisions near external canthus as an adjunct to "face lift- 
ing" operations 90 
62. Manner of closing excisions near external canthus 91 
63. Excisions at alse of nose adjunct to face lifting operations 92 
64. Manner of closing excisions close to alae nasi 93 
65. Line of incision in external canthotomy 100 
66. Manner of suturing skin and conjuctiva to insure perman- 
ence of external canthotomy 101 
67. Tissues denuded in operation for lessening palpebral interval 102 ILLUSTRATIONS. 
XIII 
FIG. PAGE 
68. Stitch of conjunctiva in operation at external canthus 103 
69. Manner of passing suture for narrowing palpebral interval 104 
70. Suture tied narrowing palpebral interval 105 
71. Marginal denudation in narrowing palpebral interval 106 
72. Manner of suturing to narrow palpebral interval 107 
73. High excision for reducing double chin 112 
74. Manner of closing high excision for double chin 113 
75. Long cross excision for reducing double chin 114 
76. Manner of closing after excision of tissues for reduction 
of double chin 115 
77. Low excision for double chin 116 
78. Manner of closing after low excision for double chin 117 
79. Median line excision for reduction of double chin 118 
80. Manner of closing wound after excision in median line for 
relief of double chin 119 
81. Double lateral excision for reduction of double chin 120 
82. Manner of closing wounds after excision for reduction of 
double chin 121 
83. One type of excision indicated for reduction of certain 
forms of bulbous nasal tip 146 
84. Another type of excision for reduction of bulbous nasal tip 147 
85. Line of division when septum is temporarily loosened to 
facilitate excisions from nasal tip 148 
86. Lines indicating area from which tissues may be excised in 
reducing bulbous nasal tip, 149 
87. Flap operation for partial nasal stenosis 152 
88. Maimer of overcoming partial nasal stenosis 153 
89. Skin turned up into nose in order that lines of union may 
be hidden 154 
90. Excisions within the nose for outstanding alae nasi 156 
91. Manner of closing wounds made in excisions from alae nasi 157 
92. Multiple incisions within the nose to reduce outstanding 
alae nasi •. 158 
93. Wounds allowed to gape in operations for outstanding alae 
nasi 159 
94. Buttons and suture to temporarily draw in alae nasi 160 
95. Manner of tipping nose to allow access to nasal hump 
through nostrils 164 
96. Line of incision within nose in operations for reducing 
hump nose 165 
97. Manner of passing chisel into nose to shave away hump ... 166 
98. Lateral incision to gain access to hump on nose 170 XIV 
ILLUSTRATIONS. 
FIG. PAGE 
99. Manner of closing wound in skin after removal of hump 
from nose 171 
100. Long median incision over hump 172 
101. Manner of closing long median incision after removal of 
hump 173 
102. External incision of choice for removing hump from nose 174 
103. Manner of closing transverse incision after removal of hump 175 
104. Type of excision within mouth for reducing eversion of 
the lip 181 
105. Manner of closing wound within margin of lip 182 
106. Lozenge excision to reduce median line eversion of lip .... 183 
107. Multiple incisions at right angle to lip margin to reduce 
eversion 184 
108. Line of multiple incisions changed by sutures to invert lips 185 
109. Several types of excision combined for inverting lips .... 186 
110. Manner of closing excisions in mucosa to invert lips 187 
111. Type of excision to effect inversion of upper lip 188 
112. Manner of suturing to invert upper lip after excision of 
mucosa 189 
113. Angular incisions to effect eversion of lips 190 
114. Manner of closing angular incisions to affect eversion of 
lips 191 
115. Angular incisions reversed 192 
116. Manner of closing angular incisions to effect eversion of 
the lips 193 
117. Primary incision in mucosa in operation on angle of mouth 195 
118. Manner of closing wound in operation to reduce size of 
mouth 196 
119. Another type of closure in operation for reduction of size 
of mouth 197 
120. Area denuded in reducing size of mouth 198 
121. Manner of drawing together tissues in reduction of the size 
of the mouth 199 
122. Area of skin excised behind ear in operation for outstand- 
ing ears 204 
123. Manner of closing in operation of excising skin for out- 
standing ear 205 
124. Skin incision in operation for outstanding ear, when carti- 
lage is to be stitched to pericranial tissues 206 
125. Method of closing skin after cartilages stitched close to 
cranium by buried sutures 207 
126. Crescent excision posteriorly for reducing size of ear .... 220 
127. Wound closed after excising tissues from ear 221 ILLUSTRATIONS. 
XV 
FIG. PAGE 
128. Another type of excision for reducing size of ear 222 
129. Manner of closing after excising tissues from ear 223 
130. Incision down to cartilage 224 
131. Segment excised from cartilage posteriorly 225 
132. Wound closed after posterior excision of segment of carti- 
lage from ear 226 
133. Lines of incision in forming new auricle 229 
134. First step in operation for shortening ear lobule 232 
135. Second step in operation for shortening lobule 233 
136. Lines of excision in reducing size of lobule 234 
137. Tissues excised from lobule of ear 235 
138. Wound closed after excision of tissues from ear lobule .. 236 
139. Operation for attached lobule 238 
140. Manner of closing after detaching lobule 239 COSMETIC SURGERY. 
CHAPTER I. 
ANTISEPSIS. 
All operations described in this book are performed 
with local anesthesia. Few special instruments are 
used and very little assistance is needed. The opera- 
tions can therefore be performed in the office quite as 
well as in a hospital operating room. It is necessary 
only that the surgeon take absolute care as to asepsis. 
This is possible if he does not hamper himself with 
unnecessary instruments and appliances. Carefully 
chosen, a small scalpel, a pair of straight and a pair 
of curved scissors, a few small hemostats, fine cambric 
needles, one or two short curved conjunctiva needles, 
and a glass syringe are all that are required for most 
of these operations. Instruments should be chosen 
with the greatest care. They should be kept in abso- 
lutely perfect condition. This small handful can be 
easily kept in order and the surgeon will not need a 
special assistant to find an instrument when he needs 
it. The operator who chooses carefully a few in- 
struments and works with them continuously will do 
1 2 
COSMETIC SURGERY. 
better work than one who clutters the table with a 
great variety and becomes well acquainted with none. 
Methods of aseptic preparation should be carried 
out with the greatest care, for an ability to secure 
healing without suppuration is an essential requisite 
to success in this field of surgical endeavor. The day 
has passed when mere scrubbing of the patient and 
of the surgeon's hands and boiling of instruments 
constitute the best surgical preparation. Antiseptics 
which years ago lost favor have again come into use 
and few surgeons make surgical toilets without using 
one or more antiseptics. The writer does not wish 
to condemn any form of antiseptic preparation. He 
feels that his readers are entitled to know some of 
the measures most generally used by him. Like all 
operators his technic in preparation of patients has 
changed from time to time, the object being to have 
a simple yet absolutely effective, pus-preventing 
method. The iodin preparation has been used the 
world over. Modifications without number have been 
suggested. The writer prefers the official tincture 
unchanged, painting the field before operation. The 
use of water before the application of iodin has been 
condemned. As most women who desire featural 
operations have considerable quantities of cosmetics 
upon their faces, it is the custom of the writer to 
remove these either with soap and water or with 
ether before the application of iodin. In either case ANTISEPSIS. 
3 
such removal has not interfered with the success of 
the iodin painting. When iodin is used care must be 
taken in dressing wounds not to seal, for under dress- 
ings impervious to air iodin is likely to blister. 
Complex antiseptic methods which found favor 
among surgeons during the war are not liked by the 
writer. When the iodin technic is not used scrubbing 
followed by the free use of chinosol solutions has 
proven very effective. This agent seems to have 
powerful antiseptic properties and at the same time is 
peculiarly non-irritating. After scrubbing the hands 
and field, the writer uses strengths of this agent 
varying from 1: 1000 to i: 5000. In wounds solu- 
tions of chinosol in normal salt solution cleanse with- 
out causing the least irritation. Operations involv- 
ing the nasal passages should be preceded by a thor- 
ough toilet with this solution. It is also helpful dur- 
ing operation to syringe clots from the field. 
Instruments should be kept clean when not in use. 
Immediately before operation they are boiled and 
during operation they are kept in order on sterile 
towels. Some surgeons object to boiling cutting in- 
struments, contending that the edge is affected by 
this treatment. The correct type of cutting edge will 
stand boiling. The surgeon should have at hand a 
carborundum razor hone. This will put upon a scal- 
pel an edge which allows accurate incising. Such 
edge is not so fine that it is materially blunted by 4 
COSMETIC SURGERY. 
boiling, provided the scalpel be a good one. For fea- 
tural surgery the operator cannot take too great care 
in selecting all cutting instruments. 
Suture materials should be obtained in sterile tanks 
or tubes of such type that they can be boiled each 
time they are used. It is only by taking extreme 
care in all operations that aseptic healing will invari- 
ably occur. Suppuration may be nothing less than 
a calamity and the surgeon who is unwilling to take 
extreme care to avoid infection should refrain from 
this kind of surgery. CHAPTER II. 
LOCAL ANESTHESIA. 
Books have been written upon the subject of local 
anesthesia and the surgeon who intends to practice 
in the cosmetic field should thoroughly master the 
technic for securing an insensitive condition of parts 
to be operated upon. Featural surgery is most ex- 
acting, haste is inimical to really good surgery, and 
it is to the surgeon's advantage to know not only 
how to secure a thoroughly benumbed surgical field 
but to know why as well. An exhaustive considera- 
tion of the subject of local anesthesia not only goes 
fully into the manner of infiltrating, the various 
drugs used and their preparation, but also explains 
the reason why they are effective. Here certain bare 
essentials of methods used by the writer will be 
described. 
Solutions of novocain or cocain have for vears 
been preferred by the writer to all others. Strengths 
vary according to the operation to be performed. 
When thorough distention of the tissues is not ob- 
jectionable dilute solutions are used. A very weak 
solution of cocain or novocain (i: 500) will entirely 
deaden tissues if the parts are distended sufficiently. 
These dilutions should be made up in normal salt 
5 6 
COSMETIC SURGERY. 
solution. When distention of the tissues is objec- 
tionable as it may alter relations of parts which it 
is important to preserve, stronger solutions varying 
from i to 2 per cent, are used. Such solutions in- 
jected in small amount will, after the lapse of a few 
moments, produce analgesia over a considerable area. 
For injection all-glass syringes with slip-on needles 
are used. Small needles should be chosen as most 
patients cannot refrain from watching the surgeon, 
and the larger needles add to the nervousness of such 
patients. When very weak solutions are used in in- 
filtrating the needle is introduced under the surface 
but not through the skin. The layers of the skin at 
the point of the needle are thoroughly distended, the 
needle is pushed to the edge of the distended area 
and another injection made. In this way the field is 
enlarged until the area to be incised is distended. 
The surgeon should then test before incising to make 
sure that he can operate without causing the patient 
discomfort, as good work cannot be done unless it 
is done painlessly. From the standpoint of feeling, 
the parts must be dead; then only can the surgeon 
operate with that deliberate care which is essential 
to good work in this field. A disturbed surgeon, a 
poorly made incision, a few badly placed stitches may 
mar what might otherwise be a perfect operative 
success. In operations involving bones when over- 
lying tissues are thoroughly deadened, the bone itself LOCAL ANESTHESIA. 
7 
may be chiselled or rasped away without pain to the 
patient. 
In the more extensive operations the surgeon 
should gauge the strength of his infiltrating solution 
by the amount he will need for performing the opera- 
tion. In other words, if it requires four ounces of 
infiltrating solution this amount of normal salt solu- 
tion should be taken and a safe dose of novocain or 
cocain added to it. In this way the surgeon does not 
exceed that amount of the drug which is safe. 
Infiltrating solutions should be freshly prepared 
and should be absolutely sterile. 
General anesthetics cannot be given without actual 
danger to the patient. For this reason it is well to 
avoid general anesthesia. As these operations are 
painlessly performed with local anesthesia, nervous 
patients tactfully handled can be operated upon with- 
out difficulty, and the surgeon who insists that pa- 
tients submit to these operations under local anes- 
thesia will find very few patients who are trouble- 
some after the operation is well started. CHAPTER HI. 
HEMORRHAGE. 
Hemorrhage during featural operations is not to 
be feared, although the tissues of the face are very 
freely supplied with blood. Open incisions bleed 
copiously if preventive measures are not employed. 
The featural surgeon soon learns that it is advan- 
tageous in several ways to prevent much bleeding. 
First of all, most patients submitting to such opera- 
tions are women with more than the usual amount of 
"nerves." It behooves the surgeon to prevent as 
much as possible those occurrences which tend to 
alarm such patients. Nothing is quite so harrowing 
to women or men unaccustomed to the sight of blood 
as to discover during an operation that they are 
losing quantities of blood. Nervousness of the sur- 
geon or assistant, abrupt movements, sudden noises, 
all disturb the morale of the patient, but such inci- 
dents are of minor importance compared with the 
sight by the patient of quantities of blood being lost 
during operation. Styptics are of little value in cos- 
metic operations, either those topically applied or 
solutions which are mixed with the the infiltrating 
solutions, and which are expected to temporarily con- 
tract arterioles and check hemorrhage. The agent 
8 HEMORRHAGE. 
9 
most frequently used is the solution of extract of the 
suprarenal gland. Personally the writer cares little 
for such compounds. 
Compression is the most effective way of control- 
ling bleeding. This is applied in several different 
ways and the surgeon who would please his patients 
and make possible deliberate, precise operations 
should utilize such measures effectually. 
Pressure beyond the limits of the wound may be 
useful in certain operations. In face lifting from 
the supra-frontal region and lifts in the temporal 
region a rubber cord may be fastened securely about 
the head just above the ears. This compression 
will check most of the bleeding during the time the 
surgeon is making his primary incisions. This 
method has the disadvantage that blood-vessels must 
be caught very quickly when the rubber band is 
loosened, as numerous vessels start bleeding at the 
same time. The first flush of blood which occurs 
when these vascular areas are incised is prevented 
by the rubber cord about the head and after excis- 
ions have been made to the satisfaction of the sur- 
geon the band can be loosened tentatively and the 
vessels inclined to spurt may be snapped with for- 
ceps. In conjunction with the cord about the head 
direct compression with a pad may be used by the 
assistant when the cord is loosened. 10 
COSMETIC SURGERY. 
In operations in certain regions compression be- 
yond the limits of the surgeon's knife may be af- 
fected by the fingers of the assistant or by compres- 
sion strips moulded from rather heavy strips of sheet 
lead. This method may be used, for example, in 
operations on the nasal tip or upon humps upon the 
bridge. Tissues divided in these operations are 
vascular to the extreme, and compression beyond the 
limits of the wounds may do much to check such 
bleeding. 
Sometimes operators gain the impression that by 
allowing the blood to flow down through the nose 
into the pharynx the patient will not suspect the loss 
of blood. Very few patients will fail to detect such 
bleeding, and when they find blood flowing into the 
pharynx, nine out of ten will refuse to swallow it 
but insist upon sitting up at frequent intervals to 
spit it out. To prevent occurrences of this kind it 
is the writer's custom to pack both nasal passages 
before beginning these operations. The escape of 
blood through the nostrils can be prevented either by 
compression of the tissues across the bridge of the 
nose by the fingers of the assistant or with properly 
shaped strips of lead. These strips can be formed 
before operation to fit the face of the patient. Such 
a strip should cross the nose above the hump or the 
tip, depending upon which part of the nose is to be 
operated upon. This strip is formed to fit firmly HEMORRHAGE. 
11 
against the side of the nose and to extend downward 
until it presses upon the superior maxilla on each side 
just above the teeth. Such an appliance may be held 
firmly against the face by the assistant using only one 
hand, leaving his other hand free to aid the operator. 
Direct compression of the wound as fast as it is 
made by the surgeon is the best method of control- 
ling bleeding. This technic should be systematically 
developed. It requires careful training of the assist- 
ant, but the surgeon will be well repaid for the 
trouble when the assistant becomes proficient in fol- 
lowing the surgeon in these operations. When the 
surgeon begins an incision the assistant should have 
a small compression pad in one hand and as the sur- 
geon's knife passes through the tissues this pad is 
rolled along immediately following the knife. As 
the tissues are divided they are immediately com- 
pressed. 
When care is taken by the assistant, the knife 
can be very closely followed without distorting 
the tissues and in no way interfering with the sur- 
geon, and bleeding is controlled to a degree which is 
startling to the uninitiated. As most of the vessels 
divided in these operations are small only a few 
moments' compression is required to allow them to 
close. Therefore, as the surgeon proceeds and the 
incised tissues are prevented from bleeding, not only 
is blood prevented from flowing at the time but it is 12 
COSMETIC SURGERY. 
controlled in such a manner as to prevent its being 
lost at all. 
When two sides of the face are to be operated 
upon, the surgeon does his cutting on one side and 
the assistant compresses the tissues. While this 
compression is continued the surgeon makes his in- 
cision on the opposite side. When the division of 
tissues is complete upon the second side, the operator 
returns to the first wound and is ready to control 
any bleeding which may follow raising the compres- 
sion pad. The compression pad is turned up, begin- 
nmg over the area first incised. The pad is really 
rolled up, and as the wound is exposed any bleed- 
ing points are spotted and snapped with hemostats. 
The entire incised area or areas are thus exposed 
and as bleeding points show they are controlled. 
By the effective use of pads, as described, seg- 
ments of tissue can be excised from the face or neck 
with the loss of very little blood. If such method 
were not used, the blood would saturate all surround- 
ing towels and the field would indeed be a mess. 
By this method the surgeon has his operation abso- 
lutely in hand at all times and he can work rapidly 
without being hurried. 
When pads are lifted and all spurting points or 
other persistently bleeding vessels are caught with 
hemostats it remains for the operator to decide how 
to dispose of the hemostats. Ligation of small ves- HEMORRHAGE. 
13 
seis is objectionable from several standpoints. First 
of all, it takes too much time. Second, it leaves 
foreign materials to be disposed of. Buried liga- 
tures are objectionable in several ways. They inter- 
fere with exact approximation in some cases. They 
predispose to suppuration and they may cause the 
deposit of an infiltrate which is very slow to dis- 
appear. 
For this reason torsion has many advantages 
over ligation for the control of small vessels which 
persist in bleeding when snap forceps are removed. 
Torsion was the favorite method of controlling bleed- 
ing by the old time surgeons. This was due to the 
fact that ligatures used many years ago were of 
silk, linen or cotton and did not absorb. Besides, 
they favored the development of infection immedi- 
ately about the vessels tied and this made the surgeon 
fear greatly secondary hemorrhage. This frequently 
came on days after the operation and in amputations 
might be followed by fatal results. Torsion was so 
well thought of by surgeons in pre-antiseptic days 
that vessels as large as the femoral artery were 
treated by torsion rather than by ligation. The ab- 
sorbable ligature and the prevention of infection of 
wounds marked the decadence of torsion, but this 
old-fashioned method, which is both quick and effect- 
ive for small vessels, may serve the cosmetic surgeon 
to very good advantage. 14 
COSMETIC SURGERY. 
Torsion requires a little care, and it cannot be 
mastered in a day. The ordinary hemostat can be 
used by the featural surgeon in practicing torsion. 
The technic here is not such as was used by old-time 
surgeons in twisting large vessels. These operators 
drew the vessel well out of its sheath, compressed it 
with one pair of forceps, and steadied it, while they 
twisted with a second pair, which grasped firmly the 
tip of the severed vessel. The featural surgeon 
merely draws out the tissues in the grasp of his snap 
forceps, twists them carefully until he feels the 
slightest giving. If twisting were continued the tis- 
sues in the grasp of the forceps would be twisted ofif. 
At just the right moment, if the surgeon loosen his 
forceps, it will be found that the bleeding has been 
controlled. W hat has happened is that the delicate 
intima, the inner wall of the bleeding vessel, has rup- 
tured and curled inward closing the orifice through 
which the bleeding occurred. Should the twisting 
be continued too far, the support of the tissues will be 
removed, the slight curling which holds the blood 
before a clot has formed will be insufficient and the 
blood will begin to flow again. It is, therefore, nec- 
essary for the surgeon to learn not to twist ofif the 
tissue in the grasp of the forceps or to twist enough 
to remove their temporary support. 
Sutures are frequently utilized by general surgeons 
for' controlling bleeding. The wound while still HEMORRHAGE. 
15 
bleeding is sutured and the sutures drawn tightly so 
as to compress the tissues. Such methods cannot be 
practiced upon the face with good results. No stitch 
which exerts enough compression to check bleeding 
will give the kind of approximation which the fea- 
tural surgeon desires. No stitch drawn tight enough 
to control any amount of persistent bleeding will fail 
to cut to a degree which will leave a noticeable stitch 
mark. It, therefore, behooves the surgeon not to 
utilize this method upon operations involving the 
face. 
In excisions involving the temporal region and in 
operations above the hairline of the forehead, stitch 
marks are hidden by the hair. Here the surgeon 
may, if he elects, use sutures to control bleeding, 
though it is the belief of the writer that such technic 
even here is uncalled for. The excisions in these 
areas involve the skin and subcutaneous tissues down 
to the loose areolar tissue immediately over the peri- 
cranium. This is the so-called dangerous area of the 
scalp. This is an area which is easily and widely 
undermined by pus and blood. If the sutures control 
external bleeding but do not prevent oozing this blood 
may flow along under the scalp, and such blood in 
this region may easily become infected. It is, there- 
fore, better surgery in these cases as well as in face 
cases to control all bleeding before closing the wound. CHAPTER IV. 
THE HEAD. 
The plastic surgeon who would alter the physical 
appearance in a manner which will be pleasing to 
the majority of people will find it advantageous to 
consider not only individual features but the head as 
a whole. The head of a man of average height 
measures approximately one-eighth of this total. 
Women have more immature appearing heads and 
faces, more nearly resembling those of children. The 
woman of average height has a head which measures 
approximately ten seventy-fifths of the total height. 
The proportionate size of the head is smaller in tall 
people. Gross deviations from the average are sel- 
dom pleasing. The proportion of the face to the 
cranium may vary considerably. In the baby the 
natural state is to have a cranium which is very large 
and a face which is small in proportion. Mental 
defectives have frequently unusually large faces in 
proportion to the cranium. 
As the infant grows the head and face enlarge as 
the result of the growth and development of certain 
bones and cavities. As old age approaches there is 
a marked tendency to lose the teeth, following which 
absorption of the alveolar processes diminishes the 
16 THE HEAD. 
17 
size of the lower face, giving the characteristic ap- 
pearance of old age. To women the preservation of 
the teeth is all-important in staying the atrophy which 
will give the appearance of added years, for in 
women the lower face is small in proportion to the 
rest of the face and with the loss of the teeth and 
the absorption of the alveolar processes the effect on 
the appearance may be extreme. 
Books which go into detail regarding the different 
types of faces and heads, which study races and 
racial types, and others in which the study of man 
from the mental standpoint is taken up are of great 
interest to the student of this kind of surgery. 
The Scalp. 
The skin of the upper face and scalp differs from 
that of other parts of the body. This is of particu- 
lar interest to the featural surgeon as it favors 
greatly the success of the various "lifting" operations. 
The seal]) is made up of five layers, the first three 
being intimately blended forming, from a surgical 
standpoint, a single layer. In the outer layer the 
skin is thicker than in many other parts of the 
body; in the second layer, the subcutaneous tissues 
are well developed, being made up of strong fibrous 
bands intimately connected with the overlying skin; 
the third layer is made up of firm aponeurotic tissues. 18 
COSMETIC SURGERY. 
These well-developed, intimately connected tissues 
are cut through in performing the various lifting 
operations. They may be drawn together under firm 
tension and when tension plates or buttons are used, 
the stitches under tension cut slowly so that union 
can be secured even after considerable tissue is 
excised. 
Below the three layers described is the loose are- 
olar tissue and below this the periosteum, which 
when covering the cranium is known as the peri- 
cranium. The vascularity of the scalp is very great, 
the blood-vessels anastomosing freely so that slough- 
ing is very unlikely if infection is prevented. Blood- 
vessels running through the layers of the scalp are 
so held by the connective fibers about them that con- 
traction and closure is less perfect and occurs more 
slowly when the vessels are severed so that twisting 
of the points from which bleeding occurs is more 
often required than in other tissues. CHAPTER V. 
FOLDS, BAGS AND WRINKLES ABOUT THE EYES. 
Folds, bags and wrinkles about the eyes represent 
a diverse group of changes in the skin of this region. 
An enumeration of each particular type of change 
would develop the subject in greater detail than is 
necessary for a good understanding of the methods 
of correction- used by the writer. 
While many people who formerly opposed opera- 
tions for taking up slack in the skin of the face have 
come to admit that "face lifts" may be safely per- 
formed with striking results, many of these same 
people still object to operations about the eye, con- 
tending that there are elements of risk of disfigure- 
ment or bad result. Such is not really the case. 
Methods for removal of tissues about the eyes are 
the development of many years. Surgeons in all 
large centers of population do these operations suc- 
cessfully, but not much has been written for the medi- 
cal press, as such writings have been likely to invite 
criticism of the writer. Surgeons who consider such 
operations favorably may find in the writer's sugges- 
tions matter which will interest them. 
Changes about the eyes are the result of time, 
habits of muscular contraction or ill health. Cer- 
19 20 
COSMETIC SURGERY. 
tain types predispose to this bagginess and wrink- 
ling. Unless the conditions are due to a type of 
Fig. 1.-Operations originally performed for undue full- 
ness beneath the eyes were performed by excising tissues at 
points distant from the eye. There is a tendency in most 
people to form a natural line extending downward and out- 
ward from the inner canthus. This line has frequently been 
selected as the point for excision of excess tissues. 
squinting little can be clone in the way of prevention. 
Massage, plasters, drugs or other skin treatments are FOLDS, BAGS, WRINKLES ABOUT EYES. 
21 
either impotent or actually tend to increase the con- 
dition. Surgery offers a way out. 
Carefully performed, these operations about the 
Fig. 2.-Closure of wounds in exposed parts of the face is 
best accomplished with fine silk sutures closely placed. These 
sutures should be drawn together with great care to secure 
perfect approximation without undue tension. 
eyes are perfectly safe. Seldom indeed are the cases 
which cannot be relieved by operations so performed 
that scar lines are shadowed so as to be invisible to 22 
COSMETIC SURGERY. 
close observers. Many years ago, when this type of 
plastic surgery first attracted the surgeon, operations 
were performed without attempting to hide the scar. 
Fig. 3.-Another type of excision distant from the lid mar- 
gins. Some surgeons insist on avoiding the lid margins in 
operations for folds, bags and wrinkles about the eyes. Care- 
fully made excisions properly closed do not leave a con- 
spicuous scar line. 
A crescent or an ellipse of tissue was removed well 
below the eye, the line of union in one case being 
crescentic below the eye and in the other obliquely FOLDS, BAGS, WRINKLES ABOUT EYES. 
23 
Fig. 4.-The closure after excision of a crescent below the 
eye must be made with great care. Sutures should be of 
fine non-absorbable material. The stitches should be passed 
just to the depth of the wound. If a large mass of tissue is 
included in a stitch, more tension is required to effect closure, 
and tension always increases the danger of stitch marks. 
The usual way of taking deep bites with the needle and ty- 
ing sutures tightly should be avoided by the surgeon in 
these operations on the face. 24 
COSMETIC SURGERY. 
downward and outward from the inner canthus. 
Even today such operations are practiced by surgeons 
who fear to approach too close to the lid margins. 
Fig. 5.-Originally in performing operations below the eye 
a narrow strip only was excised. Some surgeons persist in 
making the excision along the base of the lid. This opera- 
tion is not nearly as effective as the excisions close to the 
lashes. 
There is no harm to be feared from operation 
along the lid margins. Tendencies to ectropion may 
be prevented by methods which are safe and effective. 
Injury to the eye or effect upon the sight need not FOLDS, BAGS, WRINKLES ABOUT EYES. 
25 
be feared. Excisions close along the lid border allow 
shading of the line of union by the lashes and in this 
operative choice the scar so blends with the lid mar- 
gin that it will pass close scrutiny without being 
noticed. 
Fig. 6.-Illustrating operation completed. 
Prevention of infection, very smooth, even excis- 
ion of the tissues and absolutely accurate approxima- 
tion of the wound edges are essential to success and 
the surgeon should in all these cases take more than 
ordinary care to attain perfection of lines of union. 
Analgesia must be complete to allow careful un- 
hurried operations. As the surgeon is likely to be 
disturbed by altered relations infiltration with weak 26 
COSMETIC SURGERY. 
solutions should be discarded for the older practice 
of injecting strong solutions of cocain or novocain. 
Fig. 7.-Operation for excision of fullness of skin beneath 
the eye. The surgeon above goes very close to the free 
margin of the lid. When a wide area of skin is excised 
eversion of the lid would occur if steps were not taken to 
prevent it. In this operation a wedge is taken below. This 
when drawn together counteracts the everting tendency of 
the excision. 
A small amount of two or four per cent, solution in- 
jected along the border of the lid will in a few FOLDS, BAGS, WRINKLES ABOUT EYES 
27 
moments produce insensitiveness to pain. These 
small injections do not bulge the tissues or materi- 
Fig. 8.-Manner of closing wound. The transverse line 
of wound union is so close to the lashes as to be effectually 
shaded. 
ally alter the relations. Nerve blocking may also 
be used. 
When there is a general bagginess or wrinkling 
under the eyes, the first incision should be close under 
the lashes. A very sharp scalpel is the best instru- 28 
COSMETIC SURGERY. 
ment to use in making this incision. The lid can be 
steadied by light pressure with the index finger and 
the incision should be carefully made so that irregu- 
Fig. 9.-After excising below the lid margin tissues neces- 
sary to overcome folds, bags, or wrinkles, a wedge may be 
removed at the inner canthus and the line of union away 
from the shadow of the lashes may be so formed as to 
correspond more or less to the natural line sometimes seen 
at this point. 
larity is avoided. The surgeon then marks off the 
amount of skin he is to excise with the point of his FOLDS, BAGS, WRINKLES ABOUT EYES. 
29 
scalpel, cutting through skin with a careful even 
stroke. A corner of the skin so marked off is then 
Fig. 10.-Illustrates manner of closing with interrupted 
sutures. Fine silk should be used and sutures removed 
within seventy-two hours. 
loosened and the segment carefully lifted and re- 
moved. 
If much blood suffuses the wound the assistant 
may follow the surgeon with a small compression 30 
COSMETIC SURGERY. 
pad. When the first incision is made and the bleed- 
ing is at all sharp, the compression pad in the hands 
of an assistant will control it and the operator can 
Fig. 11.-To prevent eversion after excision below the eye 
in some cases a wedge can be removed to the best advan- 
tage at the external angle of the wound. The line of closure 
can be so formed as to closely resemble the natural line at 
this point. 
turn to the other eye and make his excision during 
the time the compression pad over the eye first oper- 
ated upon is controlling the bleeding. In the second FOLDS, BAGS, WRINKLES ABOUT EYES. 
31 
area the surgeon has the assistant follow his scalpel 
with a compression pad and while this area is being 
compressed the pad over the first wound is slowly 
Fig. 12.-Illustrating operation completed. 
turned up. The surgeon spots any bleeding points, 
nips them with hemostats and twists them if it ap- 
pears that a few moments pressure will not control 
them. When all bleeding points are controlled the 
second area is similarly treated. By this time hemo- 32 
COSMETIC SURGERY. 
stats which are in the way may be removed from the 
field first exposed and the surgeon can tentatively 
draw up his tissues to see if the bagginess will be 
Fig. 13.-To avoid excision of a large wedge small wedges 
of tissue may be excised at each wound end. 
overcome. If more tissues need to be removed sharp 
scissors may be used and the edges of the skin care- 
fully cut away. So, too, if there is likely to be any 
eversion, segments of skin may be removed to make FOLDS, BAGS, WRINKLES ABOUT EYES. 
33 
possible the drawing up of the tissues without caus- 
ing eversion. When the amount of skin removed 
from below the eye is small there may be no tend- 
Fig. 14.-Operation completed. 
ency to eversion of the lid and the crescent space so 
formed is ready for suturing as soon as all bleeding 
is controlled. A very small amount of suprarenal 
extract will temporarily check bleeding when used 
in the infiltrating solution. If it is used the surgeon 34 
COSMETIC SURGERY. 
should operate deliberately so that its effects will 
have disappeared before the sutures are tied. 
The skin should be closed with interrupted sutures 
Fig. 15.-Several small wedges may be removed to pre- 
vent eversion of the lid. When considerable tissue must be 
removed this may prove the best procedure. 
of fine silk on cambric needles. The sutures should 
be placed close together so that when tied with barely 
sufficient tension to draw the skin edges together 
there will be no gaping of the edges. They must be FOLDS, BAGS, WRINKLES ABOUT EYES. 
35 
placed with the most absolute accuracy. An uneven 
union may greatly increase the tendency to scar for- 
mation. The general surgeon uses as few stitches as 
Fig. 16.-Small wedge excisions may be closed by a single 
stitch, larger areas may require two stitches. The scar line 
along the lashes is effectually shaded. Properly sutured 
short lines below the eye show very little. 
is possible, passing the needles through masses of 
tissue and drawing the suture tightly. All such 
practices are taboo in featural surgery. Interrupted 36 
COSMETIC SURGERY. 
sutures carefully placed so that no possible gaping 
can occur between stitches secure perfect approxima- 
tion with the least stitch tension. This minimizes 
Fig. 17.-A sliding flap operation sometimes more effect- 
ually overcomes fullness, particularly in those cases where 
the condition is localized externally or internally. 
the tendency to formation of stitch marks. Tightly 
tied stitches may mark the skin even if removed in 
forty-eight hours. Carefully placed stitches prop- 
erly tied may be left in three days without causing FOLDS, BAGS, WRINKLES ABOUT EYES. 
37 
stitch marks. This is long enough to allow union 
to occur. Some surgeons in face operations recom- 
mend removal of stitches in forty-eight hours. It is 
Fig. 18.-Illustrating manner of closing below the 
external angle of the eye. 
possible to get sufficient union in this time so that 
stitches may be safely removed, but the surgeon who 
uses correct judgment in stitch placement and stitch 
tension will have little to worry about his stitches. 38 
COSMETIC SURGERY. 
To avoid eversion of the lid excisions may be re- 
quired along the lower edge of the wound. In some 
cases a single wedge may be taken from the inner 
Fig. 19.-Operation below the inner canthus. The 
tissues are drawn upward and inward. 
angle of the eye. In other cases the resultant line of 
union will appear to best advantage if made to extend 
obliquely outward and downward from the outer 
angle. This line may best correspond to the features FOLDS, BAGS, WRINKLES ABOUT EYES. 
39 
and effect the required shortening. When it is 
desirable to avoid a line of any length short wedges 
of skin may be cut out at different points along the 
Fig. 20.-Manner of closing. One scar line is shaded by 
the lashes, the other corresponds to a natural line at this 
point. 
lower margin of the wound. When closed these are 
so short that they may not be noticed, when a longer 
line at one point might show more decidedly. When 
the operation is completed there should be no 40 
COSMETIC SURGERY. 
eversion. Years ago when the operations were first 
performed along the free margins of the lower lid and 
eversion occurred, surgeons would tell the patients 
Fig. 21.-Illustrating manner of excising fold above the 
eye. The operator here chooses to place the line of union 
at the base of the lid. The scar line is hidden when the eye 
is open. 
that the eversion would disappear in a short time. 
Sometimes this occurred and sometimes it did not. 
Fortunately these cases were remedied without much FOLDS, BAGS, WRINKLES ABOUT EYES. 
41 
trouble when they fell into the hands of other sur- 
geons who understood the principles of plastic 
surgery. 
Fig. 22.-When crescent of tissue has been removed skin 
interval is closed so that line of union is about midway be- 
tween the free margin of the upper lid and the eyebrow. 
Some lines and folds are conspicuous at either the 
inner or outer canthus. Tn such cases the crescent 
removed along the length of the lid may not be re- 
quired. An ellipse may be removed along the border 42 
COSMETIC SURGERY. 
of the lid for only part of the length of the lid. If 
such operation is effective a short line close under the 
inner or outer angle of the lid may be all the line of 
Fig. 23.-Certain cases may be operated upon to better 
advantage by removing skin from the upper lid forming a 
line of union close to the free margin of the lid. 
union that the surgeon need make. In other cases 
it may be necessary to extend the lines of excision 
so that one line runs close to the lid margin and the 
other angles away, forming a letter V. Such excis- FOLDS, BAGS, WRINKLES ABOUT EYES. 
43 
ion will allow the drawing of the skin upward and 
inward or upward and outward as the case may be. 
The same care as to excision must be practiced as 
Fig. 24.-Skin interval closed by closely applied inter- 
rupted sutures of fine non-absorbable material. Aseptic 
unions result in scar lines which pass unnoticed. 
has been described in the operation of excising a 
crescent below the lid. The technic to control bleed- 
ing is adaptable to this type of operation. In fact, 
this method of having the assistant follow the sur- 44 
COSMETIC SURGERY. 
geon with a compression pad is the standby of the 
plastic surgeon who takes more or less pride in doing 
nearly bloodless operations. 
Fig. 25.-Excision of lozenge shaped skin segment for 
undue fullness of tissues and lines at this point. 
It is well worth while to conserve the blood of the 
patient. While the amount lost might not be im- 
portant from the standpoint of the health of the 
patient, even if particular efforts were not made to 
prevent such loss, the effect on the patient of such FOLDS, BAGS, WRINKLES ABOUT EYES. 
45 
conservation is very good. It robs them of much of 
the nervousness that naturally is felt while under- 
going operation. We cannot be too careful not to 
Fig. 26.-Skin interval closed. The line of union should 
be made to correspond to the natural lines of this region. 
Care should be taken not to remove sufficient skin to cause 
pronounced tension as scar lines are likely to show plainly 
when parts are brought together under too much tension. 
jangle the nerves of our patients. Nine-tenths of 
the women who submit to these operations are high- 
strung, modern types who suffer enough from nerves. 46 
COSMETIC SURGERY. 
Operation is dreaded by them but they are so anxious 
to secure the effects of operation that they submit 
even though the surgery is likely to be a severe test 
for them. 
Fig. 27.-Removal of segment extending 
upward and outward. 
To avoid these ill-effects too much surgical display 
should be avoided by the surgeon. The room where 
the operation is to be performed need not be elabor- 
ately equipped. A few simple instruments only are FOLDS, BAGS, WRINKLES ABOUT EYES. 
47 
used in operation. These may be placed between two 
towels on a small table. One assistant only is needed 
by the surgeon. Several people bustling about get- 
Fig. 28.-Union of skin, placing line so as to correspond 
as nearly as possible to natural line. 
ting in each other's way is only a nuisance anyhow. 
When the operation is painless and bloodless and the 
patient is alone with two calm, unhurried people 
there is nothing to terrify and add a psychic trauma 
to tense nerves. 48 
COSMETIC SURGERY. 
Skin toilet should be very painstakingly made be- 
fore operation. Every precaution should be taken 
during operation to maintain absolute asepsis. Dress- 
Fig. 29.-Transverse excision. 
ings should be lightly sealed so as to protect the skin 
edges from outside contamination, and at the same 
time care should be taken in their application so that 
removal will be possible without disturbing the su- 
tured edges. Sutures may be removed in two days FOLDS, BAGS, WRINKLES ABOUT EYES. 
49 
hut as a rule it will be safer to wait somewhat longer, 
and if the precautions advised have been taken in 
closing the wounds no harm will occur when the 
Fig. 30.-Closure parallelling the natural 
lines of this region. 
stitches are left in three clays. Stitch marks are sure 
to follow too tight drawing of the stitches no matter 
how early they are removed. 
A seal of collodion, which is hard to remove, may 
endanger the slight union which occurs in the first 50 
COSMETIC SURGERY. 
few days. To avoid this a firm supporting dressing 
may be formed below the eye. Collodion is painted 
below until a thick false skin is formed. This should 
not come up on the lid. This may then be covered 
Fig. 31.-Excision well away from the eye may be 
necessary in a few cases. 
with a single strip of gauze saturated in collodion. 
This dressing below immobilizes the soft parts. The 
dressing of the wound itself may be lightly fastened 
to this. Such dressing may be made from a wisp of 
cotton painted over with a thin layer of collodion. 
When the surgeon wishes to inspect the wound a 
little ether will soften the light painting of collodion FOLDS, BAGS, WRINKLES ABOUT EYES. 
51 
over the cotton and allow its removal without dis- 
turbance to the tissues which have been incised. The 
heavy collodion below the eye should be left on for at 
least a week. 
Fig. 32.-Union forming lines well away from lid margin. 
Removal of Skin at the External Canthus.-Some- 
times operation below the eye will relieve fullness and 
wrinkling at the external canthus; in other cases it 
may be necessary to excise a lozenge of tissue from 
this neighborhood, making the line of union parallel 
the palpebral interval or angling downward from the 
outer canthus. These small lozenges of tissue may 52 
COSMETIC SURGERY. 
be excised and the tissues brought together so that a 
straight line of union is formed. The same extreme 
care must be taken as in all these operations so that 
the scar line will be insignificant. 
Fig. 33.-Excision above and below canthus forming 
lines of union close to the lid margins. 
In some cases removal of skin at the canthus can 
best be effected by staying close to the skin margin 
of the lid, removing some from below the canthus 
and some from above. In this operation the V- FOLDS, BAGS, WRINKLES ABOUT EYES. 
53 
shaped excision closely follows the lids, and the line 
of union is placed as close to the lid margins as is 
possible. 
Fig. 34.-Manner of closing with closely placed 
interrupted sutures. 
Removal of Skin From Above the Eye.-Opera- 
tions above the eye call for less modification to meet 
individual conditions than do those below. The clas- 
sical operations are more often useful here. 54 
COSMETIC SURGERY. 
Two general types of excision are applicable above 
the eye. The first of these consists in closely follow- 
ing the lid margin below the eye, as recommended. 
The second type of operation is the excision of a 
Fig. 35.-Diamond shaped excision. 
segment midway between the lid margin and the 
eyebrow. This operation tends to form the scar in 
the interval between lid margin and brow so that it 
will not show when the eye is open. This is per- 
haps the operation of choice in most cases. 
Sometimes the fold to be excised should include 
tissues somewhat beyond the outer canthus and the FOLDS, BAGS, WRINKLES ABOUT EYES. 
55 
inner end of the incision need not be carried inward 
as far as the inner canthus. Tendency to eversion 
is much less than below the eye so that when a cres- 
cent is removed along the lid margin this crescent 
Fig. 36.-Illustrating method of closing diamond shaped 
excision. The line of closure can be varied to correspond 
to natural lines. 
need not be modified by excision of segments to pre- 
vent eversion. When excision is made midway be- 
tween brow and free lid margin there is no tendency 
to eversion. 
The same measures to prevent bleeding and the 
same care in technic should be exercised here as in 56 
COSMETIC SURGERY. 
other operations. Interrupted sutures should be 
placed close together. The protective dressings 
should be so applied that they may be removed with- 
out loosening the wound edges. 
W hen the surgeon has dealt with these conditions 
for many years the actual operation in his hands 
becomes very easy, and in each case he knows just 
about what he should do to get a satisfactory result. 
Those operators who have had but limited experi- 
ence in plastic surgery of this kind should make 
haste slowly in doing these operations, but if due 
care is taken and the surgeon is acquainted with the 
various methods described good results should be 
uniformly attained. CHAPTER VI. 
FACE LIFTING OPERATIONS. 
There are two ways of performing face lifting 
operations, one way easy, rapid, accurate, nearly 
bloodless; the other way blundering, awkward, 
bloody. I believe the surgeon who reads the follow- 
ing descriptions will get a clear conception of the 
writer's technic, and should he care to practice these 
operations find the suggestions useful. 
Several effects are secured by face lifting opera- 
tions. In excisions above the forehead the effect is 
purely a lifting one, but in the more common excis- 
ions in the temporal region a retracting laterally is 
secured as well as the lifting effect. This is advan- 
tageous for the lateral pull may do more to restore 
youthful contour to the face than the lift. 
Face lifting operations do not, of course, effect the 
complexion, but it is surprising how much they do to 
restore the contour of youth. The surgeon should 
keep this always in mind in his studies of the effect of 
the various excisions. In testing before operation 
the surgeon can with his hand draw the tissue up- 
ward and backward in the direction he expects to 
draw them when his excisions have been made, he 
57 58 
COSMETIC SURGERY. 
should note carefully the effects of these tests not 
only upon the hanging cheeks but upon the tissues 
about the eyes and the naso-labial lines. All these 
parts are effected by the lifting operation, and the 
surgeon should observe these various points so that 
he will not draw back too much in the region of the 
eyes and perhaps not lift enough below. 
All face lifting operations are, if possible, made 
within the hair line. By so doing the lines of union 
are hidden by hair and the surgeon has the added ad- 
vantage of the tough scalp layers to hold his sutures. 
The arrangement of the tissues of the scalp are 
peculiar to this region. In no other part of the body 
are skin and subcutaneous tissues so arranged. The 
skin itself is tough and dense, the underlying con- 
nective tissues well developed and with the fibrous 
and muscular layers beneath are intimately connected. 
This union of three layers makes from a surgical 
standpoint a single dense resistant layer which is 
freely movable over the fourth layer. The scalp 
can be pinched up into a fold, and cut through ac- 
curately. Thus depth of incision is easily deter- 
mined. Vascularity is such that the parts lend them- 
selves to plastic operations. Density of the scalp 
allows of a degree of tension not possible on other 
parts of the face. Sutures reinforced by tension but- 
tons or plates may be drawn tightly, closing consid- 
erable gaps. After operation the slight tendency FACE LIFTING OPERATIONS. 
59 
to sag which is natural to tissues of the face is so 
slow that the effects of the operations are seen for 
years. 
The Forehead Lift. 
This operation is performed for overcoming 
wrinkles in the forehead, and for lifting the eye- 
brows slightly. Effects lower than this are not to 
be expected. 
1'he first step in the preparation of the patient is 
to shave enough hair to allow a good aseptic prepara- 
tion of the field. These suprafrontal operations 
should always be practiced above the hair line, as 
any results possible with these operations may be at- 
tained by staying high up where scars will be hidden 
by hair. 
In operations on the side, in the temporal region, 
it is sometimes necessary to extend incisions below 
the hair line in front of the ear, and in some cases 
in women to come out on the face in the temporal 
region, but in this forehead lifting operation all the 
effect which may be attained by the operation is 
possible by staying above the hair line. 
All lifting operations should be performed after 
infiltration of the tissues with very dilute cocain or 
novocain solutions. These solutions made up in nor- 
mal salt solution are injected in sufficient quantity 
to blanch the skin. When so distended a one-fourth 60 
COSMETIC SURGERY. 
of one per cent, solution will completely deaden parts 
infiltrated. 
The scalp is cut through as a single layer. A con- 
venient way for the beginner is to pinch up a fold 
and divide the fold. In making the single median 
incision a slightly curved incision should be made. 
When the skin is first cut a sharp free bleeding 
occurs, but the quick application of snap forceps to 
bleeding points will prevent much loss of blood. 
Snap forceps left on for a few moments control 
nearly all bleeding points. Those which insist on 
bleeding after removal of the forceps may be re- 
snapped and twisted. 
When an incision has been made about the length 
the surgeon proposes to make, the skin may be 
drawn upward by hooks to determine just how much 
should be removed. Careful testing will allow the 
operator to estimate accurately the amount of skin 
which should be excised. This may then be cut away 
either with scalpel or scissors. 
All hemorrhage should be controlled before the 
sutures are tied. It is true that, as a general surgical 
practice, sutures are effective means of controlling 
bleeding but in these operations it is really better 
surgery to have bleeding controlled before suturing, 
as blood effused under the scalp becomes infected 
readily and the surgeon invites this when he depends 
on the sutures to control bleeding. FACE LIFTING OPERATIONS. 
61 
Heavy braided silk is the best suture material, and 
except in cases where very little tissue has been re- 
moved, tension buttons should be used. Tension but- 
tons may be either ordinary flat buttons which will 
stand boiling with the instruments, or special but- 
tons cut from sheet lead. Tension plates are made 
from sheet lead. They are merely strips of this 
material perforated at short intervals to allow pas- 
sage of sutures. Such plates can be moulded to con- 
form accurately to the cranium. Plates or buttons 
allow sutures to be placed under decided tension so 
that the skin may be held together and union occur, 
when without their use stitches would cut to such an 
extent as to allow the wound to gap. 
Scars are readily hidden in the hair. This is true 
even in men, so that in these operations the surgeon 
is not as fearful of scarring as upon exposed areas. 
Rigorous antiseptic precautions, before, during and 
after operation are necessary. Infections in the scalp 
tissues spread in the loose areolar spaces and may 
involve a wide area. The surgeon should make up 
his mind that no precautions are too irksome to pre- 
vent infection. It is true that resistance of scalp and 
face tissues to infection is usually pronounced, but 
the operator should never presume upon this and 
allow himself to be careless. 
Sutures may be mattressed or the interrupted 
stitch may be used entirely. The continuous stitch 62 
COSMETIC SURGERY. 
should not be used as one stitch bite giving way re- 
laxes all the stitches. 
Stitches should not be removed early. In opera- 
tions upon the face the very early removal of stitches 
is urged, but here time must be allowed for rather 
firm union. No stitches should be removed in less 
than five days, part or all of them may even be left 
for a week. If properly protected infection will not 
develop and stitches do no harm if infection is 
avoided. The double excision sometimes gives bet- 
ter results than the single incision in the median line. 
In this operation an incision is made above each 
frontal eminence, the desired amount of skin excised 
to draw up the parts, and the operation completed as 
described. 
The single excision across the median line is in- 
tended to remove the small group of lines which 
sometimes form across the forehead below the line 
of the excision. For relieving such condition the 
median excision will usually prove satisfactory in 
all respects, but when frown lines have formed and 
are found in conjunction with the transverse lines 
the double excision on each side of the median line 
will be more effective. This operation may also 
prove adequate for the removal of frown lines alone 
if the lines of excision are so formed as to draw 
upward and rather decidedly to each side. This may 
necessitate placing the excisions quite far over to- FACE LIFTING OPERATIONS. 
63 
ward the temporal region. No hesitation need be 
felt in doing these operations if the surgeon, from 
the point he expects to excise, can by traction draw 
out the wrinkles or frown lines. The amount of slack 
which can be taken out of any part of the face by 
these operations for excision of loose tissues is really 
more than the uninitiated suspects. 
In excising from each side of the median line, 
after the tissues have been rendered insensitive, the 
surgeon may hook into the skin and firmly draw it 
to one side. By so doing he can see in what direc- 
tion tension must be developed. The extent and 
direction of the excision having been determined, the 
scalp is cut through, and as the operator divides the 
tissues an assistant may follow the knife with a pad 
of gauze, controlling bleeding by compression. In 
this way a segment of the scalp may be excised 
quickly; as fast as bleeding points are formed the 
assistant pressing forward with his pad controls 
bleeding. The surgeon may then turn to the opposite 
side and while compression is continued upon the 
area excised, following a similar technic the second 
area is excised. 
By this technic both areas are cut out before 
any effort is made to control bleeding, except 
the compression which has been practiced by the 
assistant. Such compression will entirely control 
hemorrhage if it is properly applied. A clever assist- 64 
COSMETIC SURGERY. 
ant can follow the scalpel closely so that very little 
blood is lost. 
Turning to the first excised area, the gauze com- 
press is lifted at the corner where the operation 
started, and as it is rolled back exposing the raw 
surface any bleeding point may be snapped. The 
surgeon then exposes the second excised area, snap- 
ping any bleeding points. 
All bleeding is now under control, and the wound 
exposed. The area on the opposite is then exposed. 
The operator then removes the first snap forceps 
applied. Should the point bleed it may be resnapped 
and twisted. Each hemostat is now removed in turn. 
Some will have controlled bleeding, a few may re- 
quire resnapping and twisting. 
Excision was made rapidly, hemostasis effected 
quickly, all without haste. The surgeon now can 
prepare to close his wounds and, if his judgment 
was good and the correct amount excised, the opera- 
tion is over in a few minutes with very little loss of 
blood. 
Following the knife with a compression pad is a 
mere surgical trick but it is very effective in the 
vascular face and scalp tissues with which the fea- 
tural surgeon deals. It is a practice that enables 
one to perform an operation with a celerity which 
actually startles the uninitiated. The moment the 
tissues are incised they are compressed. The first FACE LIFTING OPERATIONS. 
65 
flush of blood which would suffuse the operative field 
is prevented. The small vessels severed have time 
to close, and when pads pressed over the wounds are 
tipped up gradually the operator without difficulty 
spots bleeding points which need snap forceps. By 
this technic and by going from one side of the face 
to the other and then returning the surgeon saves 
blood and time. Patients when told to expect ex- 
tensive excisions, as are necessary in some featural 
operations, feel sure that much blood must be lost 
during operation. It is a pleasant and mystifying 
surprise to find that the surgeon can not only do the 
operation painlessly but at the same time quickly 
and bloodlessly. 
The Side Lift. 
Several conditions are overcome or ameliorated by 
the various side lifting operations, and the surgeon 
will vary these operations to meet the indications of 
each individual case 
Some patients have pronounced wrinkling about 
the eyes which may best be overcome by the opera- 
tion in the temporal region. Other patients have 
the typical sagging cheeks and the operation must 
be a more direct lift, while not a few have pro- 
nounced nasolabial lines in conjunction with these 
other conditions. Collectively, changes such as have 
been enumerated give to a woman an appearance of 66 
COSMETIC SURGERY. 
age which she is most anxious to overcome. Her 
skin may be good, she may in all other ways belie her 
years, but the characteristics which rob her of her 
Fig. 37.-Median excision above hair line. Manner of 
excising for lifting tissues in median line. 
youthful contour must be overcome if the impression 
of age is to be avoided. The lifting operations over- 
come these characteristics as nothing else will and 
operations successfully performed result in actual 
transformations. FACE LIFTING OPERATIONS. 
67 
The operation most often indicated calls for the 
excision of a segment of skin extending obliquely 
upward and forward from just above the anterior 
Fig. 38.-Manner of closing using tension buttons. Heavy 
braided silk is usually the best material for closing these skin 
intervals. 
margin of the ear. This excision, varied more or less 
in width as the individual case may call for, serves 
in most cases to secure the desired result. When a 
greater lifting effect is required the excision may be 68 
COSMETIC SURGERY. 
triangular. Triangular excisions may be closed in 
several ways to vary the lifting and retracting effects, 
or in certain cases a quadrangle of tissue may be 
Fig. 39.-Excisions over frontal eminences for purpose 
of lifting tissues below. 
excised and the tissues below loosened and slid into 
the interval. The surgeon acquainted with the usual 
practices of plastic surgery may adopt any of the 
methods so used to accomplish his purpose. FACE LIFTING OPERATIONS. 
69 
The most radical of lifting operations includes the 
excision of tissues from in front of the ear. In such 
operations the surgeon abandons the cover of the 
Fig, 40.-Manner of closing. 
hair, and he will leave a mark, he should not lead 
his patient to believe he will not. As the line of 
union will be under tension, the scar left by a lifting 
operation is likely to be more distinct than the 
union which occurs when there is practically no ten- 70 
COSMETIC SURGERY. 
sion on wound edges. It is up to the surgeon to 
make plain to his patient just what to expect, it is not 
humane to take the woman who is unsuspicious of 
Fig. 41.-When tissues are excised over frontal eminences 
traction may be made upward and outward. One of the 
effective methods of overcoming scowl lines. 
such result and operate upon her. She should choose, 
she should know that she will have a scar line which 
can be hidden only by cosmetics and they must be FACE LIFTING OPERATIONS. 
71 
used rather heavily as a rule, or she must be prepared 
to dress the hair so as to hide the line. 
If a woman needs to lose these tell-tale signs of 
Fig. 42.-Manner of closing to overcome fore- 
head lines and scowl. 
age which sagging features give, if she has a calling 
in which lost youth is a detriment, she may gladly 
choose to cover the signs of the surgeon's knife, and 
be well content in so doing, but every woman should 72 
COSMETIC SURGERY. 
have this squarely put to her before operation, if the 
surgeon proposes to excise from any part of the ex- 
posed skin of the face. 
Fig. 43.-Direct upward lift. The illustrator has placed 
the excision too far back. The excision should be as far 
forward as the hair line will permit. 
'Phe lifting operation which extends the excision 
down in front of the ear requires a somewhat ir- 
regular excision as a rule, the surgeon should not 
feel that he need follow the lines particularly de- FACE LIFTING OPERATIONS. 
73 
picted in the illustrations of this article. The idea of 
all these operations is to lift and draw back the tis- 
sues without distorting, particularly, the region about 
Fig. 44.-The operator should not fail to note effect of 
lift upon the external canthus. Too much lift at the external 
canthus may cause an effect which will be a shock to both 
surgeon and patient. 
the eyes. If the operator has this in mind and ob- 
serves that he does not too greatly distort this region 
about the eyes, he can excise to meet the needs of 
each patient. 74 
COSMETIC SURGERY. 
In all these operations the three layers comprising 
the scalp are cut through, the same conditions as to 
Fig. 45.-Type of excision frequently adopted in face lift- 
ing operation. Backward and upward drawing of tissues 
usually needed. 
vascularity are met here as in the operations above 
the forehead. Bleeding should be controlled before 
sutures are applied. Tension should be relieved by 
buttons or plates. The suture material of choice is FACE LIFTING OPERATIONS. 
75 
braided silk. It should be coarse enough not to cut 
readily through the tissues. 
Fig. 46.-Manner of closing with tension buttons. The 
entire thickness of the scalp should be excised down to the 
loose subaponeurotic areolar tissues. 
As little excision as possible should be practiced 
below the hair line. Free excision above the hair 
line should always be given preference to excisions 
on any part of the skin uncovered by hair. When 76 
COSMETIC SURGERY. 
excisions must be made on parts of the face not cov- 
ered by hair, as little as possible should be removed 
from such region and as much as possible from above 
Fig. 47.-Type of excision where more lift than 
lateral drawing back is needed. 
the hair line. Sometimes excision below the hair line 
may be avoided by adding to the temporal operation 
an excision from behind the lobule of the ear. 
In this last type of excision a drawing back and 
lifting effect may be secured. The principles guiding FACE LIFTING OPERATIONS. 
77 
are the same as in other plastic operations. Tissues 
are excised to meet, as best one can, the individual 
needs. Closure should be in such manner as to 
Fig. 48.-Manner of closing triangular excision. 
secure the greatest amount of drawing back and 
lifting of the parts below and in front of the ear. 
The operation behind the ear may be used particu- 
larly in conjunction with the lifting operations in the 
temporal region. Alone, this operation of excision 78 
COSMETIC SURGERY. 
from behind the ear seldom attains as much as the 
patient desires. 
No operation for taking out slack from the face 
Fig. 49.-Flap sliding lift. A direct lift without drawing 
back the tissues from median line. The illustrator has drawn 
the excised area somewhat farther back than is indicated. 
should be begun before a careful survey has been 
made by the operator. He should study the face so 
as to determine just what has happened to destroy 
the youthful contour, for it is to restore this that the FACE LIFTING OPERATIONS. 
79 
operations are performed. W hen women have put oft 
operation until sagging is universal the surgeon may 
need the cranial excisions above, the temporal ex- 
Fig. 50.-Illustrating closure of rectangular excision. This 
is the adaptation of an old method of plastic surgery to the 
face lift. 
cisions and the excision in front of and behind the 
ear. All such excisions are practicable on the same 
patient. It may not be policy for the inexpert sur- 
geon to attempt them all at the same sitting, though 80 
COSMETIC SURGERY. 
if the method I have described in the previous pages 
is followed and the surgeon is sufficiently expert to 
adopt such technic, all such excisions are possible at 
one sitting. 
Fig. 51.-Modification of the rectangular excision to get 
backward as well as upward pull. 
In viewing his patient the surgeon may note fore- 
head lines and frown lines. These call for high 
temporal or even suprafrontal excisions. Lines 
about the eyes demand retractive excisions in the FACE LIFTING OPERATIONS. 
81 
temporal region. Some lines about the eyes are 
best overcome by excisions close to the margins of 
the lids. Such excisions carefully made leave traces 
Fig. 52.-Manner of closing. 
which are easily hidden and they lessen excisions in 
the temporal region. 
Too much backward and upward traction about 
the angles of the eye may affect this region in a way 
not desired. The surgeon must watch carefully not 82 
COSMETIC SURGERY. 
to distort this area. One will hear now and then 
of a plastic surgeon operating and producing a fixed 
smile. Such an effect is unlikely. It would require 
Fig. 53.-Face lift carrying excision down in front of ear. 
If any amount of tissue is removed from the region in front 
of ear and parts are brought together under tension distinct 
scar line is likely to result. The conscientious surgeon will 
advise his patient to this effect. 
a degree of tension which no surgeon is likely to 
make inadvertently, hut the excess tension about the 
eye angles is much more readily produced and should FACE LIFTING OPERATIONS. 
83 
be guarded against. Careful testing, caution in ex- 
cision is the best protection for the inexperienced 
surgeon. He should not attempt too much at one 
Fig. 54.-Manner of closing. Tension buttons are used if 
much tissue is removed. This operation secures the most 
decided effect of the face lifting excisions. 
time. Step by step he can cover the face when con- 
ditions demand these several operations. As his ex- 
perience grows he can group his operations, perhaps 
doing all at one sitting. 84 
COSMETIC SURGERY. 
Ldie straight lift of sagging cheeks when accom- 
plished by excisions low down in front of the ear 
are unlikely to present any particular difficulties to 
Fig. 55.-Sometimes excisions are made far back over the 
ears as adjuncts to excisions in the temporal region. 
the surgeon and the likelihood of distortion is remote. 
Usually patients who have the sag below the mas- 
seters have also nasolabial lines which may be over- 
come by effective retraction. A backward and up- FACE LIFTING OPERATIONS. 
85 
ward lift from about the level of the top attachment 
of the ear best eradicates these lines. When pro- 
nounced muscular contraction of the muscles of this 
Fig. 56.-Manner of closing. 
region has exaggerated these lines peculiarly, as is 
sometimes seen, subcutaneous section of the muscles 
may be used as an adjunct. 
The surgeon should not hope to overcome baggy 
folds beneath the eyes by temporal lifts or excisions 86 
COSMETIC SURGERY. 
from the region in front of the ears. These condi- 
tions are overcome by the methods described in the 
chapter on this subject. Such operations are very ef- 
Fig. 57.-Behind the ear lift. This may enable the surgeon 
to get sufficient lifting effect when used in conjunction with 
the lift in the temporal region. 
fective, those in which the surgeon places his scar- 
lines in the shadows of the lashes leave practically 
no trace. They are satisfactory and produce such 
excellent results when correctly performed that the FACE LIFTING OPERATIONS. 
87 
featural surgeon will usually he glad to utilize them 
for correcting the bagginess beneath the eyes. 
Temporal excision should be carefully planned. 
Fig. 58.-One method of closing behind the ear excision, 
tension should be upward and backward. 
The parts are infiltrated and with a sharp scalpel the 
surgeon begins his excision. The assistant follows 
the scalpel closely with a compression pad. The 
area to be excised is quickly loosened and removed. 
The assistant's pad now covers the excised area. By 88 
COSMETIC SURGERY. 
firm flat pressure with the fingers all bleeding is 
prevented. The surgeon now infiltrates the oppo- 
site side, maps out the segment to be excised and be- 
Fig. 59.-Another type of excision behind the ear. This operation 
chiefly useful as adjunct to face lifting operations. 
gins the excision. His assistant follows the scalpel 
as before and in a moment the second area is re- 
moved and this too is covered by a compressing pad. 
The surgeon now returns to the side first operated FACE LIFTING OPERATIONS. 
89 
upon, turning up the pad which is preventing bleed- 
ing, snapping any bleeding points the moment they 
appear. As a pad is lifted it is easy to spot bleed- 
Fig. 60.-Manner of closing. 
ing points and they are nipped with the hemostats. 
It is not necessary to nip exactly the bleeding point. 
The surrounding tissues may be pinched with safety. 
Face tissues are resistant, tissues squeezed by hemo- 
stats do not slough. Spotting and nipping bleeding 90 
COSMETIC SURGERY. 
points is very easy if the surgeon masters the tech- 
nic. A pad can be raised, rolled up so to speak, 
and in a few seconds all bleeding points are safely 
controlled by the hemostats. 
Fig. 61.-Manner of excising tissues in neighborhood of ex- 
ternal canthus as an adjunct to face lifting operation. 
Most bleeding vessels when firmly pinched with 
good hemostats even for a few minutes will close. 
When the operator has snapped all points on one 
side, and then the other side, he is ready to take off FACE LIFTING OPERATIONS. 
91 
the first hemostat applied. Taken off in rotation, it 
will usually be found that the bleeding is controlled. 
Should a vessel bleed when a forceps is removed, 
Fig. 62.-Manner of closing skin interval after 
excision of tissues. 
the instrument may be re-applied and the point 
twisted. Torsion will control any bleeding which 
follows removal of the hemostats, provided the sur- 
geon has mastered the knack of twisting. 92 
COSMETIC SURGERY. 
'The featural surgeon will usually wish to avoid 
buried ligatures. He will find torsion a help in con- 
trolling persistent bleeding. A little practice and a 
Fig. 63.-Excision in shadow of nose as 
adjunct to lifting operations. 
little care will make this one of the quickest and eas- 
iest ways of controlling bleeding. To practice tor- 
sion, the surgeon grasps the tissues at the bleeding 
point, controlling the bleeding. Traction is then 
made, the forceps turned. The tissues partly give FACE LIFTING OPERATIONS. 
93 
way. Too much twisting will tear off the forceps, 
too little will not control the bleeding. Just the right 
amount is a matter of judgment. The surgeon will 
Fig. 64.-Line of union must be placed close 
in the shadow of the nose. 
soon learn the trick. Once mastered it is the quick- 
est way to control persistent bleeding points. 
When all bleeding has been controlled, the surgeon 
is ready to close his wound. If he is experienced 
the right amount has been removed. If inexperi- 94 
COSMETIC SURGERY. 
enced, and cautious, too little may have been re- 
moved. If such is the case, the operator may draw 
together his tissues and find that the desired effect 
will not be produced by closing the wound. If such 
is the case more tissues may be excised. When the 
correct amount has been removed, the surgeon may 
close his wound in any of the ways outlined, or may 
modify these in several ways. The principles of 
plastic surgery apply. Wound edges are to be 
brought together and held. Seldom will an incision 
be made which will not be best closed with tension 
buttons or plates. These materially retard the cut- 
ting of stitches and should always be used in opera- 
tions of this kind when closures are under 
tension. 
As he closes, the surgeon should note carefully the 
effect of his operation. He should not realize several 
days after operation when healing has well advanced 
that he has produced a peculiar or undesired expres- 
sion. The dangers of this have been exaggerated by 
critics of cosmetic surgery. Such critics will per- 
haps continue such condemnations and circulate 
stories to discourage women from having these 
operations performed. 
As a matter of fact the surgeon who practices in 
this field will find these operations peculiarly safe 
and free from complications. The effects should in- 
variably be excellent. The restoration of youthful FACE LIFTING OPERATIONS. 
95 
contour is the object of these operations. It will do 
this and do it as nothing else will. 
Women may spend thousands having the skin 
treated. Every kind of treatment has been tried by 
women to check sagging of the skin. Massage is 
useless or harmful, drugs, lights, heat, cold, "skin- 
ning," it matters not what is tried, one or all are 
impotent, the only effective way to restore youthful 
contour to sagged features is by cutting out the 
slack. 
The writer said this twenty years ago. It was true 
then, it is true today. CHAPTER VII. 
OPERATIONS FOR ALTERING THE 
PALPEBRAL FISSURE. 
Operations for widening or narrowing the palpe- 
bral interval have been employed by specialists in 
eye surgery for many years. They are not essenti- 
ally cosmetic operations but may be used for the 
relief of affections of the eyes. 
Canthotomy is useful for the relief of blepharo- 
spasm and entropion, and also as an adjunct in the 
treatment of certain cases of trachoma. 
C anthorrhaphy is indicated in long-standing facial 
paralysis, exophthalmic goiter and cicatrization which 
produce ectropion or exposure of the eyeball. 
From a cosmetic standpoint only, canthotomy and 
canthoplasty are most often indicated. Idle former 
consists merely in splitting the external canthus, 
without suturing the conjunctiva and skin, to pre- 
vent reunion. Simple canthotomy may be performed 
without fear of bad results if but a short slit is 
made. Inasmuch as many women want only a slight 
effect this operation answers all purposes. The 
division is made outward after the conjunctiva has 
been rendered insensitive by dropping in a few drops 
of a two to four per cent, solution of novocain or 
96 ALTERING THE PALPEBRAL INTERVAL. 
97 
cocain. By means of a dropper the solution is placed 
in the external canthus and while so doing the head 
should be turned to one side to prevent the flow of 
the solution into the lachrymal ducts. The drops 
are repeated every two or three minutes for ten or 
fifteen minutes. The lids may then be rendered in- 
sensitive by the injection of a few drops hypodermi- 
cally. A horizontal slit may be made with a small 
scissors to increase the separation of the lids. 
Stitches are not essential, provided the surgeon will 
see the patient each day and prevent reunion of the 
divided lids. As the lateral tarsal ligament is split 
horizontally it may be helpful to turn the scissors 
first obliquely upward in the wound and divide the 
fibers of the tarsal ligament above, then turn the 
scissors obliquely downward and divide the lower 
fibers. This further division may be done without 
disturbing the skin or conjunctiva, or the surgeon 
may avoid dividing the skin externally but may cut 
through the ligament and the conjunctiva. 
In operations for the relief of spasm and other 
diseased conditions, the use of an eye speculum is 
recommended for holding apart the lids as much as 
possible. When the operation is done merely for its 
cosmetic effect and the surgeon does not have to deal 
with spasm or contracture of the tissues, the opera- 
tion can be as well done, if not better, without the 
use of the speculum. 98 
COSMETIC SURGERY. 
When sutures are inserted to unite conjunctiva 
and skin edges with a view of preventing union of 
divided tissues the operation is termed canthoplasty. 
In this operation the tissues are divided horizontally 
from the external canthus. The tarsal ligament is 
severed as previously described. The conjunctiva is 
then picked up with tissue forceps and sutured above, 
below and in the angle of the wound. Extremely 
fine silk is the best suture material for this purpose 
as it produces no irritation of the parts to cause pain 
immediately following operation. 
While a few women will desire considerable 
division of the tissues, extending from the lateral 
canthus, there are limits to the extent of division 
which can be done advantageously for the pur- 
pose of altering the appearance. The attempt to 
produce a wide opening of the palpebral interval in 
order to make a woman have what appear to be un- 
usually large eyes is unlikely to prove satisfactory in 
all respects and the surgeon should not attempt to 
produce an extreme effect: by this operation. In 
many women the division of the tissues at the ex- 
ternal angle of the palpebral interval for a very few 
millimeters outward, will produce the best effect. 
When this slight nicking into the tissues is prac- 
ticed it is unnecessary to stitch; the surgeon may 
prevent reunion of the divided tissues by separating 
the cut each day. Should this slight division be in- ALTERING THE PALPEBRAL INTERVAL. 
99 
adequate further division may he practiced at any 
time, and there is no objection to the repeated 
division of these tissues. 
When an operator takes proper care to render all 
tissues, including the conjunctival cul-de-sac under 
the lid angles, insensitive, there is no pain felt dur- 
ing the operation and for this reason the patient will 
not object if it be necessary to repeat the operation 
several times. It may be better to do the operation 
cautiously in this way in order that the surgeon can 
effectually study his results. 
To insure that the desired effects will be realized 
the surgeon should have the patient photographed 
immediately before operation. After the first division 
a photograph should be made with the patient in 
the same attitude and at the same distance from 
the camera as previously. By comparison of the 
photographs the surgeon can better estimate his ef- 
fects than by judging from memory alone. 
Years ago the impression prevailed that canthot- 
omy gave to the features an oriental cast. This is 
not the case. The condition which produced this ef- 
fect was really the upward and outward traction 
upon the tissues at the external canthus from a poorly 
done or miscalculated face lift. The surgeon should 
be particularly careful in performing the face lift 
in the temporal region not to secure this effect for 
it tends to draw outward and upward the external 100 
COSMETIC SURGERY. 
canthus and at the same time to narrow the palpe- 
bral interval. Canthotomy or canthoplasty tends to 
Fig. 65.-Illustrating line of incision in external canthotomy. 
widen the palpebral interval and at the same time 
to slightly lengthen it. 
Canthorrhaphy.-Union of the lids at the external 
canthus may be indicated for the protection of the 
eye in certain cases of facial paralysis. Persons suf- 
fering from this condition frequently consult the ALTERING THE PALPEBRAL INTERVAL. 
101 
plastic surgeon. We should not forget that facial 
paralysis is nearly always a temporary condition and 
Fig. 66.-Illustrating method of suturing skin and conjunctiva 
to prevent reunion of tissues divided in canthotomy. 
that the exposure of the eyeball is harmful only from 
the possibility of foreign bodies getting into the eye. 
Protective measures taken from the beginning will 
prevent the annoying irritations from which certain 
of these patients suffer. If the surgeon insists that 102 
COSMETIC SURGERY. 
the patient with facial paralysis always wear goggles 
outdoors little foreign matter will get into the con- 
junctival recesses to cause annoyance. When the 
Fig. 67.-Tissues denuded in operation for lessening 
palpebral interval. 
condition is of long-standing and gives little or no 
sign of improvement the lids may be partially drawn 
together at the external canthus. 
Edge to edge closure of the lids may be attempted 
at the external canthus after denudation, but the ALTERING THE PALPEBRAL INTERVAL. 
103 
best chance of a lasting effect will follow operation 
in which the upper lid is drawn over the lower at the 
external angle. To perform this last-mentioned 
Fig. 68.-After excision of redundant conjunctiva interval 
closed by single stitch of fine gut. 
operation the conjunctival sac and the external ex- 
tremity of the lids should be cocainized by a hypo- 
dermic injection of a two per cent, solution. The 
object of the surgeon is to remove tissues from the 
under surface of the upper lid and the outer surface 104 
COSMETIC SURGERY. 
of the lower lid and to pass a suture through the 
remaining thicknesses of the two lids so as to draw 
the upper lid angle over the denuded angle of the 
Fig. 69.-Manner of passing suture of heavy braided silk 
for drawing upper lid down over lower lid. 
lower lid. Sufficient thickness of tissue should be 
removed from the lower lid to include the lash inser- 
tions and the same may be done from the upper lid 
though this is not essential here. Should lashes ALTERING THE PALPEBRAL INTERVAL. 
105 
growing from the upper lid be unnatural in appear- 
ance beyond the angle of the lids, electrolysis will 
easily remove them. Before the lids are drawn to- 
Fig. 70.-Suture tied over button, bringing denuded areas 
together lessening palpebral interval. 
gether in their new relation the conjunctiva should 
be loosened in the cul-de-sac and drawn toward the 
median line. When the stitch has been passed 
through the lid overlapping the parts the conjunctiva 106 
COSMETIC SURGERY 
may be trimmed and fastened beneath the lid 
edges so that an excessively deep recess is not 
left at this point. A braided silk suture is passed 
Fig. 71.-Margins of lid denuded in operation for 
lessening palpebral interval. 
through the upper lid, then through the lower lid 
so as to form the so-called mattress suture. The 
needle passes twice through each lid and when the 
suture is tied the upper lid is drawn firmly down ALTERING THE PALPEBRAL INTERVAL. 
107 
over the lower lid at the external canthus. This 
suture may be tied over a button on the external 
surface of the upper lid to minimize cutting and con- 
Fig. 72.-Sutures tied lessening palpebral interval. 
Aseptic healing essential to success. 
sequent marking of the skin. Moderate tension will 
hold the parts in the new position and union will 
occur in five or six days. The suture if not tied 
tightly will leave only a slight mark. If a button is 108 
COSMETIC SURGERY. 
not used and the skin is cut through by the stitch, 
considerable stitch marking will follow as the skin cut 
through is thin and will gape. Interrupted sutures 
may be used. They are inserted so as to appear 
at the edge of the upper lid and should include not 
merely a tiny nip of tissue but should draw the 
entire denuded area together. This is easily done 
and the sutures when tied will lie along the margin 
of the overlapping lid. 
Patients suffering from exophthalmic goiter seek 
relief for the staring eye which sometimes accom- 
panies this disorder. The plastic surgeon should not 
forget that this is a grave disease and the patient 
should be counselled to give particular attention to 
its care. Many patients with exophthalmic goiter 
have very rapid heart action and suffer from extreme 
debility. The featural surgeon will do well to urge 
these patients to forget the effects of the exophthal- 
mos upon their appearance. Operating to narrow 
the palpebral interval in such cases is more or less 
like Nero fiddling while Rome burned. 
Every patient suffering from undue prominence 
of the eye should be examined to make sure that the 
condition is not due to goiter. It is sufficient to 
determine that the patient has not the rapid heart 
action, the fine tremor, the swelling and pulsation of 
the thyroid gland. If these conditions exist opera- 
tion for narrowing of the palpebral interval is contra- ALTERING THE PALPEBRAL INTERVAL. 
109 
indicated as a cosmetic operation. This disease is 
too serious for the patient to be giving attention to 
a trifling physical characteristic such as undue 
prominence of the eyeballs. 
To narrow the palpebral interval by suture of lid 
margins the upper lid should be grasped by the cilia 
and lifted away from the eyeball. The point of a 
very fine hypodermic needle should be inserted into 
the lid margin, and a few drops of a two per cent, 
solution of cocain injected. The lower and the upper 
lid should be so treated in turn, and if the patient 
is quite nervous and contracts the palpebral muscles 
the entire conjunctiva may be cocainized by dropping 
in a few drops of cocain solution. Having rendered 
the tissues insensitive to pain the margins of the lids 
are denuded at the external canthus and a suture 
passed so that it will pass into the tarsal plate of the 
lid but not through it. The suture passed this way 
engages first the upper and then the lower lid ex- 
ternal to the conjunctiva. When tied, the denuded 
margins of the external canthus are brought to- 
gether. The degree of narrowing of the interval 
between the lids depends entirely upon the length 
of the denudation. 
Not infrequently in periodicals circulating among 
women an operation is described as distinctly Ori- 
ental, that is the operation of external canthotomy 
for the enlarging of the palpebral interval. 110 
COSMETIC SURGERY. 
External canthotomy is practiced frequently 
enough in this country by oculists in the treatment 
of diseased conditions of the eye. 
The value of this operation for improving the ap- 
pearance will vary according to the featural make-up 
of the individual. In properly selected cases carefully 
performed the effect of this operation is a satisfac- 
tory method of altering the appearance. The tech- 
nic of the operation is simple enough. The conjunc- 
tiva should be rendered insensitive by the repeated 
dropping into the conjunctival sac of a two per 
cent, solution of cocain. By hypodermic injection 
the tissues at the external canthus should then be 
benumbed. 
The blunt tip of a small pair of scissors is inserted 
under the lid juncture at the external canthus and 
the tissues cut through from conjunctiva to skin. 
The skin is then carefully stitched to the conjunctiva. 
Should there be a redundancy of skin at the ex- 
ternal canthus and "crow's feet," a portion of the 
redundant skin may be trimmed away and the cut 
skin sutured carefully to the free margin of the lid. CHAPTER VIII. 
OPERATIONS FOR "DOUBLE CHIN." 
Slight under the chin sagging in women of aver- 
age weight may best be controlled by the face lift. 
When this operation is effective no scars are made 
which are not hidden. If the incision in the face 
lift is carried down in front of the ear considerable 
softening of the well-marked double chin may be 
effected. In a few cases in addition to the face lift 
a slight but appreciable lift may be secured by re- 
moval of a segment of .skin from behind the ear. 
Such excision should be carried high enough to take 
the slack from above and low enough to reach the 
level of the ear lobe. The scar left by this opera- 
tion will be shaded by the ear and in women will 
not be seen. Professional women of the stage who 
submit to operations for lessening those characteris- 
tics of the face which indicate middle age are fre- 
quently willing to hide surgical scars under cos- 
metics and are well satisfied with any operation 
which tends to restore the contour of youth. These 
patients may be subjected to several types of direct 
excision of the tissues which go to make up the 
double chin. 
111 112 
COSMETIC SURGERY. 
The usual operation for removing the excess fat 
and cellular tissue which constitute the double chin, 
as practiced by many featural surgeons, is the ex- 
Fig. 73.-High excision for double chin, placing scar line 
where it resembles more or less the natural line seen at this 
point. 
cision through an incision directly across the most 
prominent part of the double chin. This is the least 
desirable route for the extirpation of these excess 
tissues. When they extend entirely across the neck OPERATIONS FOR "DOUBLE CHIN." 
113 
in a broad thick bulge, it may be best to attack from 
as low down as possible. In such operation a rather 
long incision is made across the neck following 
Fig. 74.-Manner of closing after excision of 
skin and fatty tissues. 
closely the natural line of the neck at about this 
point. The operator then pushing the skin upward 
loosens and trims away the fatty impregnated cellu- 
lar tissues. Hemorrhage may be sharp from some of 114 
COSMETIC SURGERY. 
the vessels supplying the mass of tissue to be ex- 
cised, and in such cases it is well to control the 
bleeding as the operation progresses. The incision 
Fig. 75.-Excision of double chin across its most prom- 
inent diameter. This operation usually produces a consider- 
able scar. 
is long enough to make room for a number of hemo- 
stats so that as freely bleeding points occur they are 
quickly snapped. A few minutes' pressure with a 
hemostat usually suffices to control these vessels. OPERATIONS FOR "DOUBLE CHIN." 
115 
Symmetrical removal of the fat impregnated tissues 
should be the object of the surgeon so that after 
reduction there is no unnatural irregularity. When 
Fig. 76.-Manner of closing after double chin excision. 
all tissue has been removed, and the operator de- 
sires to conclude the operation so as to produce the 
best possible results, the skin should be gently 
stretched and a careful estimate made of the amount 
which may be removed without exposing the wound 116 
COSMETIC SURGERY. 
edges to too much tension. This excess skin should 
be trimmed away with great care so that perfectly 
smooth, even skin edges are left to be approximated. 
Fig. 77.-Low excision for double chin. Some women pre- 
fer scars at this point when double chin operation must be 
performed. 
All bleeding should be completely controlled. If 
when the operator is ready to close the skin wound 
there is still some oozing from the depths of the 
wound a hot irrigation may help to control it and OPERATIONS FOR "DOUBLE CHIN.'' 
117 
free the recesses of the wound cavity from blood 
clots. For this purpose the chinosol normal salt 
solution can be used to good advantage. 
Fig. 78.-Wound closed. Scar low on neck. 
Skin closure should be accomplished with inter- 
rupted sutures placed close together so that perfect 
skin approximation with the least possible tension 
is secured. The tissues above the wound should be 
tightly strapped up with surgeon's plaster and the 118 
COSMETIC SURGERY. 
dressings arranged so that without disturbance of the 
healing tissues the skin sutures may be removed 
early. 
Fig. 79.-Perpendicular excision in median line adapted 
to certain types of double chin. 
In certain cases, rather than incise directly over 
the most prominent part of the double chin when 
access is possible through a comparatively short in- 
cision, the tissues to be removed may be reached OPERATIONS FOR "DOUBLE CHIN." 
119 
from above. There is below the chin a natural line 
which usually marks the beginning of the double 
chin. This line may be used to very good advant- 
Fig. 80.-Manner of closing with closely 
applied interrupted sutures. 
age for the skin incision. When the skin is divided 
at this point the skin is lifted and the operator re- 
moves the excess tissues as evenly as possible. The 
wound orifice is smaller in this operation than that 120 
COSMETIC SURGERY. 
which may be made below so that there may be 
somewhat less freedom of access to the tissues to be 
removed. The operator should carefully control all 
Fig. 81.-Double excision through openings on 
each side of median line. 
bleeding as he progresses so that his work may be 
accurate. W hen the excision of subcutaneous tis- 
sues has been completed, the operator will usually 
find it advantageous to trim away a certain amount OPERATION'S FOR "DOUBLE CHIN." 
121 
of skin. Great care should be taken to remove as 
much as possible yet not to sacrifice so much that 
approximation is under undue tension. Much skin 
Fig. 82.-Manner of closing. 
tension here is almost sure to cause more scarring 
than is desirable. The skin interval must be very 
carefully closed so that the approximation is per- 
pectly smooth and even. A dressing should be ap- 
plied, after tissues below the incision have been 122 
COSMETIC SURGERY. 
closely strapped with surgeon's plaster. The sutures 
should be removed in two or three days. 
Median line incision is suitable for a few cases 
where there is a small pounch-like double just under 
the chin, and in other cases where there is a pouch 
with a tendency to stringiness two incisions may be 
made, each about three-fourths of an inch from the 
median line. These incisions when closed make per- 
pendicular lines which may closely resemble the 
natural creases frequently seen in patients inclined 
to be stringy. 
The lift behind the ear described under the face- 
lifting operations may be used to aid in overcoming 
some of the effects of double chin. 
The double chin may also be attacked from either 
the angle of the jaw or somewhat behind this point. 
Operations through incisions which more or less 
parallel the natural neck lines should give compara- 
tively good results. Sometimes a much lined neck 
may be altered by excisions behind, close to the hair- 
line. Tn women, an incision well back on the neck is 
well shaded by the hair, and the neck may be greatly 
altered by such operation. CHAPTER IX. 
SUBCUTANEOUS SECTIONING OF FACE AND 
NECK STRUCTURES FOR ERADICATING 
LINES AND WRINKLES. 
Tenotomy and myotomy are old surgical proced- 
ures. Section of skeletal muscles or their tendons 
produces striking results. Such procedures and their 
effects were known long before present day surgery. 
Hamstringing of horses was the common practice of 
ancient warriors. Tenotomy of a skeletal muscle 
usually promptly renders the muscle useless, but sec- 
tioning of face muscles has not the same striking 
effect; in fact, sectioning these muscles to reduce 
action enough to satisfy the surgeon is sometimes 
difficult. The reason for this is that muscles of the 
face have indefinite bony attachments, their func- 
tion is not greatly affected by separation of these at- 
tachments, and the surgeon, if he would secure pro- 
nounced effects, must do what is not particularly 
easy, that is, subcutaneously dissect loose the rather 
intimate attachments of the muscle to the overlying 
skin. 
Facial sectionings are undermining operations, or 
at least are more like undermining operations than 
anything else. The surgeon must pass his knife, nec- 
essarily very small, just through the skin and then 
123 124 
COSMETIC SURGERY. 
along close under the skin. He must go through the 
skin because splitting the skin will not give the effect 
desired, but he cannot go too far beneath the skin as 
he will then merely form a cavity in the areolar tis- 
sues. Division of the cellular tissues accomplishes 
no more than splitting the layers of the true skin. 
Splitting the layers of the true skin is followed by 
prompt reunion without noticeable effect upon the 
muscle fibers and undermining beneath the muscle 
fibers is equally futile. 
As considerable sectioning of the tissues is neces- 
sary in these muscle sectioning operations, consider- 
able subcutaneous hemorrhage may follow. This 
may be minimized by the use of the compresses im- 
mediately after the operation is completed. Such 
compression continued for ten or fifteen minutes 
helps reduce subcutaneous hemorrhage and conse- 
quent discoloration. Patients should be warned to 
expect more or less ecchymosis Careful antiseptic 
technic invariably prevents infection. Punctures 
made by the myotome should be sealed with collod- 
ion. A light dressing should be placed over the 
parts undermined. 
Subcutaneous Section of the Corrugator 
Su perci li i. 
After novocain infiltration the muscle should be 
brought into action by the patient in order that the ERADICATING LINES AND WRINKLES. 
125 
surgeon may better define its location. The myo- 
tome is passed under it from above, and the fibers 
sectioned from their intimate attachments to the 
skin. A considerable undermining usually is re- 
quired if much effect upon the action of the muscle 
is to follow. With many patients who have pro- 
nounced frown lines, section should also be made 
close to the bone. The operator, with the anatomi- 
cal attachment in the mind's eye, passes his knife 
downward until it touches die orbital crest, and then, 
sweeping the knife along the attachment of the mus- 
cle to the bone, attempts to section the fibers as com- 
pletely as possible at this point. Sometimes, when 
the surgeon has done his work as thoroughly as pos- 
sible, the effect upon the frown is only partial. Fibers 
of the orbicularis may also be sectioned with a view 
of adding to the effect, nevertheless the operator 
may see only a partial disappearance of the frown 
lines, and his operation may have to be repeated 
one or more times to secure the desired softening of 
the skin line he wishes to overcome. 
In the chapter on face-lifting by excision of tissues 
above the hair line, semilunar excisions above and 
external to the frontal eminences are described. Such 
excisions may be made with safety and without fear 
of disfiguring scar as the scar will be hidden in the 
hair. This excision correctly made will draw the 
tissues somewhat upward and laterally and in con- 126 
COSMETIC SURGERY. 
junction with thorough subcutaneous sectioning of 
the corrugator muscles should effectually overcome 
scowl lines. 
Fibers of the orbicularis palpebrarum, toward the 
median line of the face, can be sectioned with a view 
to aiding in the eradication of frown lines, those ex- 
ternally may be sectioned to reduce or eradicate the 
so-called "crow's feet." Bony attachment of mus- 
cles of sphincteral type is indefinite and separation 
of these attachments does not prevent action of such 
muscles as the orbicularis palpebrarum. Division of 
the fibers at various points, passing the knife beneath 
the fibers and cutting carefully toward the skin sur- 
face, may be practiced with safety. Sectioning at 
short intervals or repeated sectionings at different 
times are safe procedures. 
Section of the Occipito-frontalis. 
Frontal fibers of the occipito-frontalis may be cut 
with a view to softening transverse forehead lines, 
though lifting operations are much more effective in 
eradicating these lines, and as the operation for re- 
moving a segment either in the median line or a 
segment from each side of the middle line is easily 
performed and the scar line is hidden in the hair, 
this operation will usually be the preferable one for 
the correction of frontal corrugations. CHAPTER X. 
SUBCUTANEOUS SECTIONING FOR SOFTENING 
NASOLABIAL LINES. ' 
While certain types are more inclined to develop 
nasolabial lines than others, these lines really are 
largely the result of habits of expression. The pa- 
tient who has a tendency to develop such lines, just 
as the patient who inclines to droop the angles of the 
mouth, can avoid progressive increase of such ex- 
pressions, and by attention over a period of time com- 
bined with voluntary exercise of the muscles may 
overcome both expressions. To suggest the syste- 
matic exercise of the muscles which will counteract 
development of these expression lines and rid the 
features of lines already present, or to suggest exer- 
cises which tend to prevent drooping of mouth angles 
and ultimately develop the much desired turned-up 
angles, is the duty of the surgeon. 
When immediate effects are desired and well- 
marked nasolabial lines are already present, subcu- 
taneous sectioning of these facial muscles requires 
the practicable dissection of the muscular bands from 
the overlying skin. 
To facilitate sectioning the operator has the pa- 
tient exaggerate the muscular action responsible for 
127 128 
COSMETIC SURGERY. 
the lines and with muscles in action the knife is 
passed through the skin and swept about, freeing 
attachments of the muscles to the skin. 
Sectioning the Platysma Myoides. 
Bands of the platysma show prominently in many 
women of slight build when other characteristics of 
advancing years are not present. Platysma sections 
can be made in any part of the neck if care is taken 
by the operator. Studies of the blood supply, particu- 
larly the venous supply, may aid the surgeon in 
avoiding excessive subcutaneous hemorrhage. Mod- 
erate compression usually prevents much venous 
hemorrhage in these operations. Care should be 
taken in passing the knife beneath the bands of plat- 
ysma to make sure that the knife is kept in close 
contact with the under surface of the muscles, as 
below the platysma are large vessels and nerves, 
division of which can cause troublesome complica- 
tions. By closely hugging the muscle bands to be 
divided and cutting from below upward, that is to- 
ward the skin surface, these divisions can be made 
without danger to the patient. 
Pronounced stringiness about the neck may be 
overcome by the excision of excess tissues, but the 
surgeon must be discreet in recommending extensive 
excisions, for some scarring nearly always follows 
operations of this kind. The traces of the surgeon's SOFTENING NASOLABIAL LINES. 
129 
knife may be hidden by cosmetics, and as such opera- 
tions do much to give to a woman youthful appear- 
ance, stage favorites may then add to their years of 
employment. It is a notable fact that America wor- 
ships youth and actresses soon learn that youthful 
lines are essential to secure contracts. These women, 
therefore, cheerfully cover scars where women in 
private life might regret their presence. 
Section of the Orbicularis Palpebrarum 
Muscle. 
This is an operation for "crow's feet." Its effects 
are sometimes of considerable value in eradicating 
these lines, especially when such lines are prema- 
turely formed. 
The location of the muscle may be easily deter- 
mined by having the patient contract it firmly. This 
is done when the eye is shut tightly. 
If nerve blocking is not used, externally for three- 
quarters of an inch above and below the external 
canthus of the eye, the tissues should be infiltrated 
with a one per cent, solution of cocain. 
The muscle is then contracted and the sectioning 
knife passed obliquely downward and outward from 
close proximity to the external canthus. The point 
of the knife being beyond the outer margin of the 
orbicularis muscle, the fibers of the muscle are cut 
through with a sawing motion, the sectioning being 130 
COSMETIC SURGERY. 
carried into the true skin, 'rhe knife is then with- 
drawn until its point nearly emerges from the skin 
and then its direction is turned obliquely upward and 
outward and it is again passed under the fibers of the 
muscle. In this way the muscle may be cut several 
times through a single puncture of the skin. 
Considerable discoloration of the skin follows this 
operation as the result of ecchymosis. Hemorrhage 
through the point of puncture will stop of its own 
accord owing to the smallness of the opening through 
which the blood may escape. CHAPTER XT. 
SECTIONING AS AN AID TO OTHER OPERATIONS 
When the face lift or the lift at the base of the 
nose is not indicated or in cases where additional 
effects are desired the muscles involved in forming 
the nasolabial lines may be sectioned subcutaneously. 
The action of the muscles should be exaggerated by 
the patient, at the request of the surgeon. With the 
muscles tense and outlined as much as possible, the 
surgeon passes the myotome from below along the 
attachment of the muscles to the skin and severs 
them by a subcutaneous dissection. When passage 
of the knife at one point does not give sufficient 
access to the parts the instrument may be with- 
drawn and inserted at other points either from above 
or below. As in all sectionings of the face the 
division of the fibers involved calls for considerable 
subcutaneous division of tissues. 
The Nasolabial Lines. 
Several methods may be used to overcome the de- 
cided nasolabial lines seen in some women. When 
sagging of the soft parts are responsible, the face 
lifting operations of the temporal region are indi- 
cated. Some patients have a well shadowed recess 
131 132 
COSMETIC SURGERY. 
at the base of the nasal wing and a small crescent 
of tissue may be removed from the skin and the tis- 
sues so sutured that the lines of union are hidden by 
the ake nasi. The skin is carefully cut through close 
to the nasal junction. The incision is carried around 
the end of the nose and the tissues tentatively drawn 
upward and inward toward the median line. Surplus 
tissue is removed, hemostasis effected, and the parts 
carefully sutured with interrupted sutures. These 
sutures should be placed only under moderate ten- 
sion. Great care should be taken to insure perfect 
approximation of skin edges. Sutures should be re- 
moved within three days. 
Voluntary Exercises for Influencing the 
Lines About the Mouth. 
Certain facial types are more prone to develop 
lines about the mouth than others. Many women, 
through habit of expression, have marred the appear- 
ance of the mouth. A surgeon who will advise all 
women, who have either the lines about the mouth, 
or who show the effects of compression or drooping 
of the mouth angles, to exercise the muscles of this 
region each day, may help such patients to materially 
alter the appearance of the mouth. 
It is not hard to see the fault in these cases, and 
it is a matter of advising the patient to do those 
things which are likely to counteract the fault. SECTIONING AN AID TO OTHER OPERATIONS. 
133 
W hen mouth angles droop, and the woman daily 
before the mirror, exercises the lifting muscles, in a 
comparatively short time control over the angles 
of the mouth develops rapidly and the patient will be 
able to turn up mouth angles to a degree which is 
highly pleasing to her. As a result of such exer- 
cises, the mouth outline will be appreciably altered. 
Similar effects are possible in counteracting the 
results of compression of the lips and other faults 
of the region. CHAPTER XII. 
SCOWL LINES. 
Scowl lines are among the featural imperfections 
which the featural surgeon is called upon to treat. 
They are seen in many people, some scarcely out of 
their teens, and not a few patients are neurastheni- 
callv sensitive regarding them. The mental distress 
of some women where these lines have formed can 
be appreciated only by the surgeon who is consulted 
regarding their removal, and it is the writer's ex- 
perience that these lines are sometimes an actual 
menace to the health of the nervous systems of their 
possessors. 
Refractive errors and habit are direct causes of 
the condition. All cases should be carefully exam- 
ined ophthalmoscopically by a competent oculist. 
The correction of eye-strain by glasses should be in- 
sisted upon in all cases where the examination re- 
veals the presence of an error of refraction. As a 
rule, habit is controllable to a large extent. In such 
cases care to prevent scowling during the day 
coupled with the wearing of plasters at night may 
be followed by the gradual disappearance of fairly 
well-formed lines 
A lien lines are deep and habit fixed, surgical treat- 
ment offers about the only relief. Section of the cor- 
134 SCOWL LINES. 
135 
rugator supercilii muscles beneath the inner one- 
third of the eyebrow is one of the successful means 
of eradicating the lines of the frown. 
To perform this operation tissues beneath the 
inner one-third of the brow should be thoroughly in- 
filtrated from skin to bone. A very narrow bladed 
knife should then be inserted through the skin just 
above the brow and passed downward to the bone. 
The point is then turned and pushed onward so as 
to include practically all the tissues beneath the brow 
and by a sawing motion the tissues are cut until the 
edge of the knife has cut through all subcutaneous 
tissues and into the true skin. Single sectioning may 
be practiced, though it is advisable and quite safe to 
section the muscle obliquely at more than one point 
through a single puncture. The corrugator muscle 
is intimately connected with the skin and section of 
the muscle only partially checks its action. Opera- 
tion may be facilitated by having the patient make 
voluntary efforts to contract the muscle. Sectioning 
should extend well into the true skin. Sharp bleed- 
ing may follow withdrawal of the knife, but owing 
to the limited space for its escape through the minute 
opening made by the passage of the knife no fear 
need be felt and under compression after a few 
moments it will stop of its own accord. Consider- 
able subcutaneous effusion of blood follows this 
operation. CHAPTER XIII. 
EXCISION OF SCARS 
The careful competent surgeon can do much to 
lessen the noticeable characteristics of many scars. 
Many different forms of treatment have been sug- 
gested, yet when conditions are favorable excision 
and resuturing will do much more to diminish a 
scar than any other treatment. The linear scar 
lends itself to excision and careful closure. Broad, 
flat scars, such as those from burns, may frequently 
be much improved by the excision of irregular por- 
tions. Much has been claimed for skin grafting, 
yet grafts are far too conspicuous, even when they 
take perfectly, to be as desirable as some surgeons 
contend. The writer hesitates to resort to grafting 
on exposed areas. Smooth scars may be readily 
hidden by cosmetics. This should be pointed out to 
women and in such cases operation should not be 
urged. 
• Linear scars, at all wide or irregular, can nearly 
always be improved by excision, followed by careful 
closing. A scalpel should be used and a sharp, even 
cut made completely beyond the surface limits of the 
scar. This incision is carried along one side and 
then the other. The skin should be cut entirely 
136 EXCISION OF SCARS. 
137 
through. The scar can then be picked up and dis- 
sected free. Scarring below the skin is unimport- 
ant. The scarring in the skin, if possible, is com- 
pletely removed. The wound edges should approxi- 
mate without too great tension. 
Tension can be reduced by undermining. In cer- 
tain regions free undermining is possible, and large 
gaps in the integument may be closed without too 
much tension. In other situations, as about the 
face, too much undermining and sliding the tissues 
may deform the features. The operator should 
have this in mind when operating on the face. 
The manner of forming skin edges in past years 
has engaged the interest of surgeons to no little 
degree. Methods for dividing the skin and ways 
of suturing have frequently been the subjects of 
discussions in surgical gatherings. The actual tech- 
nic of cutting and suturing are less important than 
the care which is taken to secure accurate approxi- 
mation. The merits of different technics for skin 
incision and closure have been emphasized by many 
surgeons, some contending that the skin should be 
cut straight through, others advocating a slanting 
incision and overlapping of the edges. Years ago 
when it was the universal custom to suture wounds 
tightly, to pass stitches deeply through the tissues 
and strangulate masses within the grasp of the 
sutures, and to leave stitches in for five or six days, 138 
COSMETIC SURGERY. 
the buried suture and the running stitch beneath 
the skin had many advocates. All such technical 
errors should be avoided by the surgeon who would 
successfully operate upon the face and consequently 
he will not be likely to be as partial to buried 
sutures or the running stitch beneath the skin. 
Wounds of the face must be sutured with the 
most absolute accuracy. Stitches must pass deeply 
enough to draw all severed tissues together, but 
they should not pass far below the wound and in- 
clude a large mass of tissue. The surgeon will find 
that sutures passed with a needle which will not 
cut its way through the skin will give the best 
results. Round needles without sharp edges meet 
this requirement. Sutures of exposed skin are al- 
ways placed close together, so that no possible gaps 
may form between stitches. Sutures should be 
tied just tight enough to secure perfect closure with 
out excess pressure to cause rapid cutting of the 
stitches. Healing must be by first intention so that 
stitches may be carefully removed in two or three 
days. 
In excising scars, the scar tissue beneath the skin 
need not be dissected out. The skin should be cut 
completely through, the epidermal portion of the 
scar excised, but connective tissues which are even 
and which can be readily covered by drawing the 
skin over them may be left with impunity. W hen EXCISION OF SCARS. 
139 
the dermal portion of a scar has been completely re- 
moved the manner of closing and aseptic healing 
will determine the character of the result. 
Removal of Pigmented Spots.-Small pigmented 
moles can usually be best removed with the electric 
needle. The needle should be attached to the nega- 
tive pole, the circuit completed through a moist pad 
electrode and a current used as strong as the patient 
can bear without too much discomfort. Overlying 
epidermal cells soften and with a scraping motion 
the surgeon can remove them. With the current 
still on, the point of the needle can be used to pick 
out the cells containing the discoloration. This 
must be done thoroughly to prevent recurrence of 
the mole. 
This same technic is perhaps the most satisfac- 
tory for removing powder and tattoo marks. A 
little practice may be necessary to develop the tech- 
nic but when it is mastered these conditions can be 
overcome without danger of ill effects. 
Electrolysis takes time. The operator who is un- 
willing to spend considerable time upon a case 
should not consider electrolytic methods. CHAPTER XIV. 
FORMATION OF THE DIMPLE. 
The reader of this book may be inclined to con- 
demn the operation for the formation of a dimple, 
but the surgeon practicing in this field will have 
women consult him who know that the operation 
can be done, and he will find that they are deter- 
mined to have it done. If he cares the surgeon can 
refuse to do such an operation. That is really the 
status of all cosmetic surgery, the surgeon can take 
an interest in these operations, study the technic, 
and learn to do them and do them well or deny their 
value and have nothing to do with this kind of sur- 
gery. Many operations not ordinarily looked upon 
as cosmetic are largely for the sake of altering ap- 
pearance. Deformities which really do not cripple 
are often corrected because the deviation from the 
usual is embarrassing. Dentistry up to recent years 
has been nearly all cosmetic surgery, crowns, 
bridges and other dental creations being of more 
value to the patient from the standpoint of appear- 
ance than from actual value to health. 
If the surgeon decides that he cares to perform 
an operation for the formation of a dimple he has 
the choice of one of two routes. The operation may 
140 FORMATION OF THE DIMPLE. 
141 
be performed through a short incision through the 
skin or, the surgeon may evert the mucosa of the 
cheek through the mouth and make all incisions 
from within. This latter technic eliminates the ex- 
ternal scar which is formed in the bottom of the 
dimple when the skin is incised. 
In either of these operations infiltration of the 
areas to be incised should be practiced with a weak 
cocain or procain solution. The operation may then 
be performed without pain. 
When the operation is performed through the 
skin a narrow bladed knife is passed through the 
skin at the site where it is desired to form the 
dimple. This point should usually be chosen by the 
surgeon and he can best decide by having the pa- 
tient smile and note where there is the most natural 
tendency for this to occur. 
The puncture should parallel the long axis of the 
face and should be only from one-eighth to one- 
tenth of an inch in length. The point of the knife 
should pass through the skin and then the cellular 
and fatty tissues should be drawn through the punc- 
ture with forceps. By reaching around beneath the 
skin with the forceps, the cellular and fatty tissues 
may be drawn out and snipped off. Each case 
presents its own problem as to just how much tissue 
should be removed. If the surgeon operates 
through the skin he may use the strong cocain or 142 
COSMETIC SURGERY. 
procain solutions and not disturb normal relations 
by too much distention of the tissues. By so doing 
the surgeon of limited experience can probably suc- 
ceed best in estimating the correct amount of tis- 
sue to remove. Following the snipping away of the 
cellular tissues the deeper layers of the true skin 
should be cut away slightly and then the skin edges 
of the wound are everted by a suture so passed as 
to turn inward the wound margins. 
Cutting away of the tissues alone may be suffici- 
ent for the formation of a satisfactory dimple. In 
such cases the surgeon merely inverts the skin edges 
after all bleeding has stopped and dresses with col- 
lodion, favoring as much as possible inversion of 
the skin edges. When a suture is passed a more 
marked effect may be secured. Fine silk on a very 
short full curved needle should be used. The needle 
point is passed through the edge of the skin on one 
side, it is swept about and brought out so that it 
passes through the true skin on the opposite side. 
W hen tied this suture should invert the skin edges. 
The suture should be removed about the third day. 
Operation performed through the mouth should 
be through a fairly free incision. The line of in- 
cision should parallel more or less the nasolabial 
line or it may be slightly angular if the operator 
elect. Tissue should be cut through to the true skin 
at the point where the surgeon desires to form the FORMATION OF THE DIMPLE. 
143 
dimple. The fatty and cellular tissues are cut away 
and a slight amount of the true skin. Bleeding may 
be controlled by compression of the tissues between 
the fingers. When the surgeon has excised suf- 
ficient tissues, the wound edges may be searched 
for bleeding points and these controlled by torsion. 
The tissues are then closed with sutures. CHAPTER XV. 
REDUCTION OF THE BULBOUS NASAL TIP. 
While the bulbous nasal tip varies widely in ap- 
pearance, there are two general types from the sur- 
geon's standpoint. One type has only soft parts 
enlarged, the cartilages being approximately normal 
in size and shape, the other type has large and fre- 
quently irregularly formed cartilages, which not 
only add to the size but give an uneven or knobby 
outline. Both conditions may be present, in which 
case excision includes removal of both cartilaginous 
and cellular tissue excesses. 
Whenever possible, the operation upon these parts 
should be performed through the nasal orifices. It 
is true that direct access may allow the surgeon to 
work with more ease, and there may be less surgi- 
cal disturbance of tissues, yet scar lines on the 
prominent nasal tip should be avoided if possible. 
Incisions within the nostril parallelling the nasal 
wings will usually give access to the thickened tis- 
sues. Sometimes an incision close under the tip on 
one or both sides of the septum will allow most 
ready removal of the tissues involved. In either of 
these cases the parts are everted into the nostril and 
144 REDUCTION OF BULBOUS NASAL TIP. 
145 
the surgeon excises them with scalpel or scissors, 
whichever is more convenient to him. First incis- 
ions are followed by a sharp temporary hemorrhage. 
To facilitate operation, the tissues may be incised 
on one side, and then while the assistant compresses 
the incised tissues, the surgeon makes his incision on 
the opposite side. This side is then compressed by 
the assistant and the surgeon returns to the side 
first incised. Hemorrhage by this time may have 
ceased so that the operator may turn his operative 
field into view and excise the tissues he has elected 
to remove. 
By loosening the tissues of the septum just above 
the columnar cartilages the tip may be everted and 
good visual access to the involved parts may be 
secured. Should the surgeon find that such access 
is not satisfactory he may cut the cartilage free, 
making a skin incision across the septum. This 
will allow him to evert the tissues, turning the tip 
inside out, so to speak. Of course, the more skill 
a surgeon has, the quicker his judgment, the less he 
will actually have to see. Many of these operations 
can be performed with ease, others will tax the skill 
of the best surgeon, for the result of the excision 
should be a perfectly smooth uniform natural ap- 
pearing nasal tip. rhe writer has seen nasal tips 
which have been split in the median line to allow 
the surgeon to trim down excesses of this part. This 146 
COSMETIC SURGERY. 
manner of operating compares with the external in- 
cision for removing the nasal hump. It may allow 
of very good results, the scar line may be so slight 
Fig. 83.-One type of excision indicated for certain forms 
of bulbous nasal tip. 
as to escape the notice of the patient's associates, hut 
there is risk of a noticeable scar, and it certainly 
will be in a prominent part of the face. With 
enough care and patience these operations can be REDUCTION OF BULBOUS NASAL TIP. 
147 
performed so that external scars are avoided or they 
will be trifling and placed in a protected region. 
Before these operations are performed a careful 
Fig. 84.-Dotted lines illustrate area of soft parts to be 
excised in certain types of bulbous tips. 
toilet of the nasal passage should be performed in 
addition to the external cleansing, the writer pre- 
fers to pack the nasal passages with gauze and cot- 
ton soaked in normal salt chinosol solution. The 148 
COSMETIC SURGERY. 
operation can then be performed with the patient 
lying on his back on the operating table and the 
blood will not flow down into the nose. Most pa- 
Fig. 85.-The tip may be loosened by an incision across 
the septum. Parts are turned up and soft parts excised 
to reduce bulbous nasal tip or excessively long nose. The 
parts are then drawn back in place and sutured as illustrated. 
tients are a nuisance when blood is allowed to flow 
into the pharynx as they insist upon sitting up to 
spit it out, and sometimes they will insist on blow- REDUCTION OF BULBOUS NASAL TIP. 
149 
ing the nose, a harmful practice in these cases as 
it is almost sure to invite infection. 
When the thickening is at the base of the alae, 
Fig. 86.-Other types of nose require excisions from 
the tip of the nose itself. 
the incisions within may be macle so that access is 
obtained at this point though external incisions at 
the base of the aloe at its point of juncture with the 
face are fairly well shaded and likely to pass un- 
noticed after operation. 150 
COSMETIC SURGERY. 
Suturing of all external incisions should be done 
with the greatest care. The skin edges should be 
approximated with perfect evenness. No bleeding 
should be left to be controlled by sutures when tied. 
Hemostasis should be complete before skin sutures 
are tied. 
It is frequently the practice of general surgeons 
to depend upon the sutures closing a wound to com- 
plete hemostasis. This is not good practice in sur- 
gery of the face. 
Wounds within the nose may or may not be 
sutured, when excision of tissues is completed. As 
a rule sutures are not required, and are of little 
advantage. It is true that closely approximated 
tissues heal together very quickly, but the sutures 
within the nose are sometimes troublesome to place 
accurately and interfere with draining away of 
wound secretions so that it is really a question 
whether or not the patient is better off with these 
wounds within the nose sutured or left open. CHAPTER XVI. 
PARTIAL STENOSIS OF THE NOSE. 
Doctor Roe, of Rochester, New York, many years 
ago, described a flap operation for the restoration 
of the partially stenosed nasal tip. In the first edi- 
tion of this book in 1907, the writer described an 
operation in which the flaps are formed from within 
and the nasal orifice enlarged. By this technic no 
visible scar is left following operation, and it is the 
writer's belief, that such operation should be the 
operation of election in these nasal conditions which 
show more or less stenosis. In some cases, stenosis 
may be such, that considerable median incision is 
required to allow eversion of the tissues. Any 
redundant tissues may then be removed and the skin 
which has been left intact may be turned up into the 
nose and held in place by sutures. These stitches 
can be passed by very short curved needles, such as 
are used by eye surgeons in suturing the con- 
junctiva. 
Complete Nasal Stenosis 
This may be incised with a view of turning out 
the tissues and preserving skin flaps which may be 
turned up into the nasal passage to insure healing 
151 152 
COSMETIC SURGERY. 
without recurrence of the stenosis. Distortion may 
add to the difficulties but the plastic surgeon who 
understands well the various principles of this type 
of surgery can usually devise a method which will 
Fig. 87.-Flap operation recommended years ago by Dr. 
Roe, of Rochester, New York, for partial stenosis of the 
nose. 
allow restoration without unnecessarily mutilating 
the parts. Tt is not the object of this book to go 
into the subject of the pronounced deformities from 
birth deficiencies or injury, for this class of surgery 
has been extensively considered in all the systems of 
surgery published during the last one hundred years. PARTIAL STENOSIS OF NOSE. 
153 
Nasal Deviations. 
Sometimes the tip is deviated to one or the other 
side of the face. Such deviation can be overcome 
Fig. 88.-Operation recommended by the writer 
for partial stenosis. 
by freely loosening the tip and anchoring it in the 
median line with sutures passed within the nose. 
To insure success, the tip must be freely loosened 
so that it returns to the median line without 
resistance. 154 
COSMETIC SURGERY, 
After sutures are passed to hold the nose in the 
corrected position, slipping of the tissues may be 
further insured against by molding a cardboard, 
Fig. 89.-Flaps turned up within the nose. No 
external scars after this operation. 
hard rubber or celluloid splint. This is done by 
taking a piece of cardboard, soaking it in an anti- 
septic solution until it is perfectly soft, then after 
underlaying it with gauze it is pressed over the nose 
and moulded to an exact fit. It is corporated in PARTIAL STENOSIS OF NOSE. 
155 
dressings and as soon as dry will form a firm splint 
holding the tissues in the desired position. Hard 
rubber may be softened in boiling water and 
moulded as desired. Packing may also be used 
within the nose to hold alae and tip in the position 
elected by the surgeon. The nasal orifices alone 
should not be packed, but when packing is used it 
should be carried well back into the nose to insure 
stability of the pack. Gauze soaked in chinosol 
normal salt solution makes a convenient antiseptic 
pack. The old fashioned splints used in nasal sep- 
tum operations may also be used. These splints are 
hollow and allow the air to pass in and out, a matter 
of no great importance. In collapsed al?e a bit of 
rubber tubing sterilized and inserted may make elas- 
tic outward pressure to advantage in certain cases. CHAPTER XVII. 
OUTSTANDING AL2E NASI. 
Wide outstanding al?e nasi decidedly influence the 
personal appearance. It may be the single featural 
Fig. 90.-Excision of tissues for outstanding alae nasi. 
defect requiring correction, yet such correction is 
not as simple as the inexperienced would anticipate. 
In operating upon outstanding alae nasi it is not 
to be forgotten that absolute uniformity is essential 
156 OUTSTANDING ALT£ NASI. 
157 
to a pleasing result. If it is possible by deep in- 
ternal sectioning of the alae to cause a drooping in- 
ward of the outstanding nasal wings, this operation 
Fig. 91.-Manner of concluding operation. 
is to be preferred to any other. The removal of a 
segment of the inner surface of the alae may be 
necessary to secure the desired result. When a 
segment is removed and sutures are passed within 
the nose to approximate the wedge-shaped interval 158 
COSMETIC SURGERY. 
left by the excision care should be exercised that 
sutures are tied uniformly and that a good bite of 
tissue is included in the sweep of the needle point 
Fig. 92.-Multiple incisions within the nose 
for outstanding alae. 
so that the sutures will not cut out and allow one 
or the other side to arch outward producing that 
least to be desired result, asymmetry. 
Sometimes a conspicuous feature, outstanding OUTSTANDING ALzE NASI. 
159 
alae nasi, may be dealt with by multiple incisions 
within the nose, or the excision of a wedge of tis- 
sue. Either operation should be followed by dress- 
Fig. 93.-Incisions allowed to gape when alae 
are drawn in by sutures. 
ing with either the moulded cardboard splint or by 
the use of a few layers of plaster-of-Paris bandage. 
When a splint of plaster is moulded the patient should 
be left upon the table until the splint has set firmly, 160 
COSMETIC SURGERY. 
during which time it may be well for an assistant 
to continue gentle pressure with the fingers to insure 
Fig. 94.-Suture may be passed entirely through nose to 
hold outstanding alae nasi in altered position. 
the proper fit of the plaster. After it is firmly set, 
it should be sealed in place with collodion. CHAPTER XVIII. 
OPERATIONS FOR HUMP NOSE THROUGH 
THE NASAL ORIFICES. 
To those without experience with the operation, 
the surgical removal of a hump through the nasal 
orifices would appear difficult. Surgeons, who have 
given the matter no thought, have condemned this 
operation, as a result of their inexperience. Of 
course, the operation for the removal of a hump 
through an incision through the skin alongside the 
hump or along the bridge of the nose appears much 
easier, but observation will show one that such is 
not the case, and that the tip of the nose is readily 
pushed upward, so that the access to the hump is 
direct and the operation can be performed with the 
same accuracy through the nasal orifices as it can 
be performed if the skin is cut through above the 
hump. The advantage of the operation through the 
orifices of the nose is that absolutely no outside scar 
is made and nothing can be seen which indicates 
that any surgery has been performed upon the nose. 
Nerve blocking is effective or analgesia may be 
accomplished as in any of the featural operations by 
the injection of solutions of novocain. The solu- 
tion should be about one-half per cent, strength and 
161 162 
COSMETIC SURGERY 
made up with normal salt solution. The needle is 
passed along the free margin of the nasal bones and 
the analgesia made complete before any incision is 
made. When the operator has injected the dilute 
solutions some tumefaction will necessarily follow 
sufficient injection to produce complete insensitive- 
ness to pain, but this need not interfere with the 
operator. The tissues about the hump should be 
rendered insensitive by pushing the needle down 
against the nasal bones and the injections made as 
the needle point is pressed along the surface of the 
bone. By thus infiltrating against the bone the tis- 
sues can be lifted away from the bone and the bone 
itself cut away without pain. 
After the usual antiseptic precautions to render 
the skin of the face sterile, the nasal passages should 
be swabbed out with the normal salt chinosol solu- 
tion, i: 5000. This swabbing may best be done with 
small cotton or gauze pledgets. Both nasal passages 
should be packed before operation. 
As these operations are best performed with the 
patient lying upon a table both nasal passages should 
be packed. The writer is in the habit of passing 
into the nose a strip of gauze saturated in the 
1: 5000 chinosol solution, and then finishing the pack- 
ing with bits of cotton also saturated with this 
solution. Both passages are rather firmly packed 
so that the blood cannot flow down into the throat. OPERATIONS FOR HUMP NOSE. 
163 
Patients then will not be trying to sit up and spit out 
blood clots during the operation. 
Bleeding is sometimes rather sharp when the in- 
cision is first made loosening the soft parts along the 
margins of the nasal bones and when the soft parts 
about the hump are freed. This bleeding is unim- 
portant and should be disregarded by the operator 
as the amount of blood lost will be of no conse- 
quence. 
During the operation more or less obstruction of 
the surgeon's vision may occur from blood clotting 
in the field. To clear this it is convenient to have a 
one or two ounce rubber bulb syringe fitted with a 
large glass dropper tip. This filled with the 1: 5000 
chinosol solution can be used to wash out the opera- 
tive area. This, too, if rather warm or slightly hot 
tends to check any oozing which persists during the 
operation. The clearing of the field with this sim- 
ple irrigation requires a few seconds and is a con- 
venience which any surgeon will appreciate in opera- 
tions within the nose. It will be found helpful in 
other operations performed within the nose. 
With the patient recumbent, the nasal passages 
packed, the tissues insensitive, the operator takes a 
sharp knife and steadying the tip passes the knife 
within the nose, and divides the tissues along the 
margin of the nasal bone. The knife is then passed 
within the opposite orifice and the tissues freed 164 
COSMETIC SURGERY. 
along the lower margin of the nasal bone. The 
nose is then tipped to one side and the incisions 
brought together over the septum. The tip is now 
Fig. 95.-When the tip is tilted the surgeon will realize how 
readily accessible the hump is through the nostrils. 
pressed high up and a dissector or elevator used to 
free the tissues about the hump to be removed. 
Humps are cut away with a stout knife, gouge or 
chisel. Care should be taken not to shatter the OPERATIONS FOR HUMP NOSE. 
165 
hump or drive a chisel too far under it. It should 
be cut through so that a little dressing with a sharp 
rasp will leave a smooth symmetrical condition. A 
Fig. 96.-Diagrammatic illustration of site of internal incision 
in operation on hump nose through the nostrils. 
good deal of time must be taken by the surgeon with 
limited experience in removing the hump, otherwise 
the case will prove disappointing, for the slightest un- 
evenness of the bony tissues will show with startling 
clearness through the soft parts after the operation. 166 
COSMETIC SURGERY. 
There is danger in trying to cut off a large hard 
hump, and sometimes even a small hump, of lift- 
ing hump and nasal bones in a solid mass. The de- 
Pig. 97.-Manner of using chisel. The hump should be 
carefully shaved off. Unless very careful the surgeon can 
loosen the nasal bones, an accident which should be avoided. 
taching of one or the other or of both of these bones 
is an accident to be avoided as it may cause the 
operator to produce an inaccuracy in dressing the OPERATIONS FOR HUMP NOSE. 
167 
bones clown to the correct proportions so that the 
after condition appears far from natural. 
It is better to spend a good deal of time and care 
in rasping the bones down to the proportions de- 
sired than to cut out a chunk with the chisel and 
fail to get the parts smooth and even. Bleeding 
can be controlled by external pressure. There is 
usually sharp bleeding during this operation just 
after the soft parts have been loosened freely. 
These operations may be done through a short in- 
cision on one side manipulating through it to re- 
move the hump and smooth the tissues, but the 
beginner in surgery will find that free loosening of 
the tissues below the hump will make the operation 
easier for him. The all-important thing is to get a 
smooth natural reduction in the hump. Attention 
to hemorrhage and to everything else should be 
made secondary to this. 
When the operator has smoothed the tissues to his 
satisfaction and with the syringe has thoroughly 
washed out any bits of bone or cartilage digital com- 
pression for a few minutes will stop any bleeding 
which persists. When all bleeding has stopped the 
nasal passages are unpacked and the patient per- 
mitted to go home. 
This concludes the operation as no stitching should 
be done within the nose. A bandage in these cases 
is not essential. Of course the patient should have 168 
COSMETIC SURGERY. 
been told before operation that considerable ecchy- 
mosis may follow the operation so that it is not un- 
usual to have two "black eyes" as an after effect. 
The nasal passages may be sprayed or gently irri- 
gated with the chinosol normal salt solution as an 
after treatment, though as a matter of fact the heal- 
ing of these cases seldom if ever manifests any evi- 
dences of infection. CHAPTER XIX. 
REMOVAL OF HUMP NOSE THROUGH 
SKIN INCISIONS. 
While the experienced plastic surgeon will always 
choose the operation through the nasal orifices ex- 
cept in cases of severe chronic infections of the nasal 
passages, many surgeons hesitate to attempt opera- 
tion on humps through the nasal orifices and prefer 
to make a skin incision. Those who think this is an 
easy way and who expect to produce excellent re- 
sults with little care because of a choice of this route 
may be surprised to find that first-class results call 
for just as much care as do operations through the 
nose. 
Operations through skin incisions may be per- 
formed through short or through comparatively free 
incisions. These incisions may be either parallel to 
the nose or across it. Incision along the median line 
is supposed to be less likely to heal as closely as one 
along the side of the nose, though actually there is 
little difference in placing them in either situation 
when this phase is considered. With the hump re- 
moved it is possible to draw the skin edges together 
without tension. The incision along the side of the 
nose is supposed to be in a more shaded position and 
169 170 
COSMETIC SURGERY. 
to be less likely to show. This is in a small measure 
true. No surgeon should place an incision along 
either the median line or the side of the nose unless 
Fig. 98.-External incision along side of nose to 
enable removal of hump. 
he has had sufficient experience to be very sure of his 
technic so that he may expect the most trifling lines 
to be left. The inverted V across the nose has been 
used, the lines of the incision parallelling the naso- REMOVAL OF HUMP NOSE. 
171 
labial lines. There is no particular advantage or dis- 
advantage to any of these lines of attack; they all 
give excellent access to the hump and they necessitate 
Fig. 99.-Illustrating skin closed after excision of hump. 
equal care to secure an insignificant scar. Perhaps of 
all external operations, the spectacle bow incision is 
most easily hidden. Soft parts, when deadened, are 
cut to the bones and the tissues freed so that access 
to the hump is direct. This is then shaved away with 172 
COSMETIC SURGERY. 
the gouge or chisel and the nasal bridge smoothed 
with great care. Bleeding points are pinched and 
twisted, and when all hemorrhage is perfectly con- 
Fig. 100.-External incision in median line for removal 
of hump. The incision illustrated is unnecessarily long. 
trolled and the operator has made sure that the bony 
tissues are freed from the slightest trace of irregu- 
larity, the soft parts are closed by sutures which very 
closely and exactly close the skin incision. These REMOVAL OF HUMP NOSE. 
173 
sutures must be removed early. The aseptic technic 
should be absolute, the sutures must not be drawn 
overtight and the skin edges must make a perfect 
Fig. 101.-Manner of closing after excision of humpi. Per- 
fect smoothness of bone and cartilage are essential to a good 
result. 
hairline contact. Plaster or collodion dressings may 
be used to reinforce sutures and by insuring immo- 
bility of the surrounding tissues may help to insure 
perfect union. The patient should remain quiet for 174 
COSMETIC SURGERY. 
a few days, and avoid emotions which contort the 
features, so that no motion of the skin edges will 
draw lines of union apart. 
Fig. 102.-The external incision of choice for removal of 
hump. High humps are reached through this incision with 
ease. 
The Tip Tilted Nose. 
This sometimes affects the appearance greatly, par- 
ticularly when the alae are thick and the tip blunt or 
bulbous. REMOVAL OF HUMP NOSE. 
175 
Before operating the surgeon must decide whether 
or not bringing down the tip is all that is needed, 
or whether or not it will be necessary to reduce the 
bulk of the tip or alae as well. 
Fig. 103.-Skin closed. 
Thorough infiltration permits an absolutely pain- 
less operation. The object of the operation is not 
only to loosen the tip and draw it down but to ef- 
fectively anchor it in its lowered position. 176 
COSMETIC SURGERY. 
The first step is to free the tip from the septum. 
This is best accomplished by passing a knife from 
above downward beneath the tip. This incision is 
made through one of the nasal orifices and should 
begin just below the free margin of the nasal bones, 
extend downward under the tip, and turn backward 
below the cartilaginous septum until it is close to the 
base of the philtrum. The tip is freed so that it 
conies down readily. In some cases the soft parts 
should be sectioned within the nose along the lower 
border of the nasal bones. 
When the tip can be pressed into the desired 
lowered position without resistance of the soft parts, 
it should be held in this position, and sutures applied 
through the soft parts above and then through the 
cartilaginous septum at a lower point, so that the 
suture when tied holds the tip in the position de- 
sired by the operator. The exact point for passing 
the suture above and through the soft parts and the 
point on the cartilaginous septum depends upon the 
individual case. The bite of the suture in the soft 
parts should include an ample amount of the soft 
parts so that the suture will not cut through quickly, 
the stitch through the cartilage should be low enough 
so that the tip is held down as much as is desired 
without drawing the stitch tightly, for cutting of the 
stitch through the soft parts will allow the tip to 
return somewhat to its elevated position. The tend- REMOVAL OF HUMP NOSE. 
177 
ency of all tissues of the face when thus loosened and 
held in an altered position is to return to the original 
position, and if sutures are tightly drawn cutting 
from pressure necrosis will allow this. More than 
one stitch may be used if the operator elects. The 
material easiest to handle is heavy braided silk. Silk- 
worm-gut may also be used or twenty-day catgut. 
Of course, the twenty-day gut should be removed as 
it is not necessary when the parts are loosened well 
to attempt to hold them in the altered position for 
many days. If the operation is properly done sutures 
may be removed in five or six days and the parts will 
be found to stay in position. 
The writer believes that operators will usually find 
it most convenient to do these operations upon the 
nasal tip with the patient recumbent. If the passages 
are packed on both sides with the chinosol saturated 
gauze the blood will be prevented from flowing into 
the pharynx and clots can be syringed away with the 
chinosol normal salt solution. 
Celluloid or thin sheets of hard rubber heated in 
boiling water can be moulded into a splint which 
will fit accurately over the nose outside and hold the 
tip in the changed position. Plaster bandage can 
be used in the same wav or a bit of cardboard soaked 
J 
in the chinosol solution can be moulded into the shape 
of the nose. Any of these splints held in place by a 
close collodion dressing or by surgical plaster will 178 
COSMETIC SURGERY. 
aid in immobilizing the tip and relieve tension on the 
sutures. While splints might do to hold the tip in 
the position desired, it is my opinion that sutures 
within the nose should also be used. Outside dress- 
ings should be so placed that the nasal passages may 
be syringed two or three times daily with the chino- 
sol normal salt solution. Packings in the passages 
should, of course, be removed at the conclusion of 
the operation. CHAPTER XX. 
OPERATIONS ABOUT THE MOUTH. 
Mouth proportions seldom harmonize entirely with 
the other features. A perfect mouth from an artistic 
standpoint is hard to find. The surgeon who would 
judge the type of mouth best suited for the individual 
face should study carefully artistic proportions. 
Photo studies of the patient are of considerable value 
for this purpose, and those on a large enough scale 
to allow easy measuring of the various features may 
help the surgeon a good deal in deciding just the type 
of mouth which will harmonize to the best advantage 
with other features. Of course to expect to take the 
patient with a mouth far from normal and give to 
such patient a mouth which meets all artistic stand- 
ards is not to be expected of the surgeon, but should 
the surgeon know correct proportions he may better 
succeed in altering a mouth which deviates far from 
the standard. 
Appearances, regarding the mouth, are frequently 
deceiving to the casual observer, the mouth which 
appears too large may merely have lips which evert 
too much, the thin compressed line-like mouth, may 
appear to have much greater faults than it really has, 
179 180 
COSMETIC SURGERY 
and comparatively simple eversion operations may 
strikingly change its appearance. 
Unlike the ears which are hidden in women, when 
not pleasing to their owners, and usually disregarded 
in men, and consequently not frequently called to the 
attention of the featural surgeon, the mouth is the 
subject of much concern, and operations to alter 
this part of the face will frequently be in demand. 
The Everted Lip. 
The everted lip often appears as the too thick lip 
to its possessor. Both lips everted make the mouth 
appear too large. Inversion of the lip may perfectly 
correct what is considered a too thick lip, and inver- 
sion of both lips may satisfactorily reduce the appar- 
ent size of the mouth. 
Preparatory Steps to Oral Operations. 
The mouth should be subjected to thorough cleans- 
ing with toothbrush and soap, several times daily 
for several days before operation At the time of 
operation mouth and teeth may be scrubbed with a 
dental soap and the mouth rinsed with chinosol 
solution. 
The mucosa is rendered insensitive by infiltration. 
Cuts in the mucosa are most conveniently made 
with small sharp scissors. The mucosa pinched into OPERATIONS ABOUT THE MOUTH. 
181 
a fold can be cut through quickly and accurately. It 
is not necessary to secure perfectly smooth edges to 
sutured wounds as in operations upon exposed sur- 
faces. Sutures need not approximate with the per- 
Fig. 104.-Type of excision of mucosa of lower 
lip for eversion. 
feet exactitude demanded in successful operations on 
skin surfaces. The important feature of suturing is 
to secure good deep bites within the grasp of sutures 
so that they will not cut through before the healing 
has advanced far enough to insure successful union. 182 
COSMETIC SURGERY. 
Braided silk is the best suture material. It should 
be fairly heavy. Bleeding is sharp when incisions 
are first made in the labial mucosa. This may be 
Fig. 105.-Manner of closing. Braided silk interrupted 
sutures probably allow most satisfactory closing. 
checked by twisting bleeding points or by pinching 
such points with hemostatic forceps for a few 
minutes. 
Perfect hemostasis is not as essential before clos- 
ing wounds as it is in operations upon the exposed OPERATIONS ABOUT THE MOUTH. 
183 
skin, in fact the surgeon may even leave to his sutures 
the task of checking some of the oozing. 
Stitches are left in four or five days. Stitches tin- 
Fig. 106.-Where median line eversion is greatest this type 
of excision serves well. 
der tension may cut somewhat and a line of union 
may be marked by quite a scar, but such scars out of 
sight within the oral cavity need cause no concern. 
Mouth washes of an antiseptic nature should be 
used every two or three hours for several days after 
operation. Healing of the mucosa is usually rapid. 184 
COSMETIC SURGERY. 
Sutures might be removed in three days without risk- 
ing failure, but braided silk sutures cause no incon- 
Fig. 107.-Illustrates method of inverting lip by multiple 
slits which are to be changed in direction by sutures. 
venience and do no harm so that it is a more certain 
guarantee of success to leave them in longer. 
Operations for Inverting the Everted Lip. 
The simplest inversion operation is a single incis- 
ion altered in direction for median line inversion. OPERATIONS ABOUT THE MOUTH. 
185 
In this operation an incision is made through the 
mucosa of the lip in the median line. The two ends 
of the incision are brought together by a suture. 
Fig. 108.-Operation completed by stitching multiple slits in 
direction opposite to direction when made. 
When the angles are drawn together, and so held, 
the mucosa of the lip is drawn inward. Any gape on 
either side of this central stitch is closed by subsidi- 
ary stitches. Should the mucosa project too much on 
each side, forming a nipple-like tag, this may be 186 
COSMETIC SURGERY. 
trimmed off and the raw edges of the wound margins 
brought together by sutures. This operation may 
be performed without the excision of any of the lip. 
Fig. 109.-Combination of several plastic surgical principles 
in one case. This surgery allows the operator much dis- 
cretion as to choice of methods. 
A more radical effect may be possible if a lozenge 
of tissue is excised from the median line and the in- 
terval in the mucosa closed so that the,free border of 
the lip is inverted. To secure an effect along a OPERATIONS ABOUT THE MOUTH. 
187 
greater length of lip a crescent of tissue from the 
mucosa either close to the free border of the lip or 
Fig. 110.-Illustrates the completed operation. 
close to the gum. Such wounds when closed tend to 
draw in the everted lip. 
A T-shaped excision may be used. • This draws in 
tissues at the median line and also tends to draw tis- 
sues toward the median line. This operation some- 
times alters a lip very satisfactorily. 188 
COSMETIC SURGERY. 
Numerous short incisions at right angle to the lip 
altered in direction by sutures invert the entire lip. 
A long strip of mucosa excised parallel to the free 
Fig. 111.-Excision of mucosa of upper lip to effect greater in- 
version at angles of mouth than along interval between. 
margin of the lip and closed with sutures turns in the 
lip, usually the operation of choice to overcome the 
so-called 'double lip.' 
To invert the upper lip a long strip within the 
mouth may be removed. This strip if wider at each OPERATIONS ABOUT THE MOUTH. 
189 
end draws in more at the angles of the mouth than 
in the median line, a desirable effect in certain cases. 
To determine just how much eversion is needed to 
secure the result desired temporary suturing of the 
Fig. 112.-Operation completed. 
mucosa may be practiced. Such sutures passed and 
tied quickly show just how much effect an excision 
will produce. Such sutures are then cut and with- 
drawn and the excision made. 
In a few instances it will be found that lips are 
actually too thick. When there is a real excess of 
tissues such excess may be cut out, the surgeon excis- 190 
COSMETIC SURGERY. 
ing a strip of the submucous tissues. After bleed- 
ing has been controlled by the usual methods, the 
interval in the mucosa of the lip is closed. 
Fig. 113.-Method of using an angular incision. 
In a few cases when the lip is excessively thick 
there will be an apparent excess of glandular cells 
beneath the mucosa. This tissue can be removed 
in the same way. 
Excessive vascularity of the lip due to growths in 
which there are more than the usual number of blood- OPERATIONS ABOUT THE MOUTH. 
191 
vessels may require mattress sutures to control bleed- 
ing. Such sutures passed so as to compress all the 
divided tissues may at the same time be used to 
Fig. 114.-Angular incisions sutured to evert lips. 
close the wound in the mucosa. These bleeding 
points so compressed by mattress sutures are effectu- 
ally closed so that the bleeding will cease. Tn very 
vascular tissues mattress sutures can be passed so as 
to engage each other and all tissues effectually com- 
pressed. 192 
COSMETIC SURGERY. 
The Inverted Lip. 
The lip which appears too thin is frequently merely 
inverted. Alteration of such condition may be af- 
Fig. 115.-Reversing the angular incision, where near the 
border of the lips, may assure a more even eversion. 
fected in two ways, either by an operation for evert- 
ing the lip or by subcutaneous sectioning of the mus- 
cle fibers which invert the lip. The type of inversion 
due to overuse of the muscles about the mouth results 
from the habit of compressing the lips and in this OPERATIONS ABOUT THE MOUTH. 
193 
case sectioning of the muscle fibers of the orbicularis 
oris is indicated. 
Single transverse incision converted into an incis- 
Fig. 116.-Operation completed. 
ion in the median line of the face, by sutures, tends 
to evert the lip adjacent to the point of operation. 
Numerous short incisions made parallel to the lip 
margin and altered in direction by sutures evert the 
lip along its entire border. Multiple A7 incisions may 
also be used. Such incisions can be placed close to- 194 
COSMETIC SURGERY. 
gether or an incision or two only used at selected 
points as the needs of the case indicate. 
Eversion and inversion operations may be per- 
formed on the same patient with a view to altering 
the appearance of the lip to suit the needs of the 
case. In some cases the lip is everted to advantage 
in the median line and inverted near the angle. Fre- 
quently slight eversion near the angle of the mouth 
practiced upon the upper lip will attain just the effect 
desired to alter the appearance of the mouth. 
The surgeon doing these various operations to 
alter the lip margins may desire to section the orbi- 
cularis oris and other muscles about the mouth at the 
same time. Subcutaneous sectionings should not be 
practiced from within. It is better to pass the tiny 
myotomy knife from the outside. Muscles of the 
face are close to the skin and intimately connected 
with the skin. For this reason the external puncture 
gives better access. The knife can be swept under 
the skin severing the tiny bands of muscle fibers to 
the best advantage. CHAPTER XXL 
THE UNDULY LARGE MOUTH. 
Sometimes the patient who has what appears to 
be a mouth of excessive size will prove to have upon 
Fig. 117.-Incision for operation for advancing 
angle of the mouth. 
closer examination a mouth in which the lips are 
everted too much or are actually too thick. Of 
course, the lessening- of the interval between the 
195 196 
COSMETIC SURGERY. 
angles of the mouth would not give to such a patient 
a mouth which would be satisfactory; the undue 
eversion of the lips must be overcome or actual ex- 
cess of labial tissues removed. 
Fig. 118.-After loosening of tissues and advancement of 
angle of mouth toward median line, closure may be made as 
illustrated. 
When the surgeon notes that the mouth which ap- 
pears too large does so because of too thick or 
everted lips, the operations indicated are those to cor- 
rect such conditions. THE UNDULY LARGE MOUTH. 
197 
Several methods may be used to lessen the interval 
between the angles of the mouth. The angle may be 
advanced toward the median line by an operation 
which is largely subcutaneous. To do this operation, 
Fig. 119.-Method of closing to secure maximum effect. 
Sutures are passed deeply into tissues to immobilize until 
healing in the altered position has occurred. 
an angular incision is made through the mucosa just 
within the muco-cutaneous juncture. This incision 
is used to gain access to the area just beneath the 
skin. These tissues are loosened, the angle of the 198 
COSMETIC SURGERY. 
mouth is then drawn toward the median line of the 
face and sutures are passed from within so as to 
engage the thickness of the tissues between the 
Fig. 120.-Manner of excising in operation for 
diminishing oral interval. 
mucosa and the skin, the needle being carefully 
passed into the layers of the true skin, but not 
through the skin; the needle includes a semicircle of 
tissue emerging within. As the angle of the mouth 
has been drawn toward the median line and as the THE UNDULY LARGE MOUTH. 
199 
labial tissues within the mouth have not been drawn 
forward toward this point, the angle of the mouth is 
advanced in this direction. Tying sutures firmly 
Fig. 121.-Manner of closing to reduce size of mouth. 
enough to immobilize the skin included in the needle 
bite allows healing with the angle of the mouth ad- 
vanced. The tying should be just firm enough to 
hold the tissues in the position desired but an undue 
tension should be avoided as the bite of the deeper 200 
COSMETIC SURGERY. 
lavers of the skin may cut out before union 
occurs. The angular incision in the mucosa can be 
closed so as to form a line parallel to the lip line or 
if this angular incision has been rather long, it may 
be closed so as to form a line of union shaped like the 
letter Y. 
A second method of operation may be practiced by 
first splitting at the point of juncture of the skin of 
the lip and the mucosa so as to separate the skin and 
mucosa. The mucosa is now dissected free from 
areolar tissues upon which it rests and an area of de- 
nudation formed within the mouth. Sutures within 
the mouth are used to draw together the tissues so 
that the angle of the mouth is advanced toward the 
median line of the face. The skin at the angle is 
approximated by a fine silk or horsehair suture. 
After both operations for reducing the size of the 
mouth precautions must be taken to prevent yawning 
or wide opening of the mouth for any cause for a 
number of days. 
The operations for reducing the size of the mouth 
can be used in conjunction with operations for in- 
verting or actually reducing the size of the lips. CHAPTER XXII. 
THE EXTERNAL EAR. 
The pinna or auricle, as the external ear is called, 
is made up of a framework of yellow elastic covered 
with integument. The organ is of slight functional 
importance, hearing not being perceptibly affected by 
its loss. Its size, outline and development are of pro- 
nounced importance from the standpoint of appear- 
ance, and a faulty ear, unless hidden, strikingly 
affects the appearance. 
The free margin of the ear curves forward form- 
ing the helix. Near the highest point of the ear is 
a distinct tubercle on the margin of the helix which 
is known as the Darwinian tubercle and is said to be 
the analogue of the pointed tip seen in lower animals. 
W hen this point is well developed high upon the crest 
of the ear and there is an undeveloped wedge-shaped 
attached lobule, the animal characteristics of the 
organ are accented, sometimes materially affecting 
the cast of the features. In such cases resemblance 
to one of the lower animals may be unpleasantly sug- 
gested and surgical treatment of the organ, overcom- 
ing these characteristics, may influence greatly the 
impression created by the features. 
201 202 
COSMETIC SURGERY. 
Internal to the helix is a groove known as the fossa 
of the helix and internal to this is the eminence of 
the antihelix. The antihelix above divides, form- 
ing the fossa of the antihelix. The antihelix curves 
about a large concavity known as the concha, internal 
to which is the opening of the auditory canal. The 
anterior wall of the auditory canal is continued out- 
ward as a rather prominent projection known as the 
tragus, opposite to which is the less marked project- 
ing antitragus. The interval between the two points 
is the incisura intertragus. 
Below, the ear terminates as a soft pendant mass, 
varying in shape and degree of development and 
known as the lobule. This part is made up of fibro- 
areolar tissue covered with skin. It contains no car- 
tilage. While making up but a small part of the ear. 
the lobule plays an important part in influencing the 
impression created by the organ as to its beauty or 
lack of beauty. The lobule should be well formed, 
lobular, not wedge-shaped. The undeveloped lobule 
has been characterized as one of the stigmata by a 
widely read criminologist. 
A very small amount of subcutaneous tissue inter- 
venes between the skin and underlying cartilage. 
This tissue is practically devoid of fat. The arrange- 
ment of the vessels supplying the ear is such that 
the auricle receives a rich supply of blood from 
branches of the superficial temporal, occipital and THE EXTERNAL EAR. 
203 
posterior auricular arteries. The manner of distri- 
bution of blood-vessels supplying the ear make pos- 
sible a variety of plastic operations which might 
otherwise be impracticable. When infections are 
avoided healing is very satisfactory. CHAPTER XXIII. 
OPERATIONS FOR CORRECTION OF 
OUTSTANDING EARS. 
These are the most frequently indicated of the 
operations upon the ears. Correction of outstanding 
Fig. 122.-Illustrating operation for outstanding ears. By 
extensive excision of skin from back of ear and side of 
cranium the ear may be drawn closer to the side of the head. 
ears will frequently alter the appearance of the ear 
in such manner as to obviate the need for other 
operations which seem to be indicated. Patients will 
204 CORRECTION OF OUTSTANDING EARS. 
205 
consult the surgeon with an idea that the ears need 
to be reduced in size or some other type of operation 
needed. Careful examination will show that bv 
I NTERRUPTED 
STITCH 
OR 
CONTINUOUS 
STITCH 
Fig. 123.-Illustrating methods of closing after excision 
of skin for overcoming outstanding ears. 
placing the ear closer to the side of the head the 
appearance of the organ will be satisfactory. 
Infiltration offers a simple and effective way of 
securing a painless field. The tissues involved in the 
operation should be thoroughly distended with cocain 
or procain, one-fourth of one per cent, in normal 206 
COSMETIC SURGERY. 
salt solution. Distention of the tissues interferes but 
little with the operator. 
The simplest operation includes the excision of a 
large ellipse of skin partly from the ear and partly 
Fig. 124.-When free excision of skin is objectionable as 
in men the ear may be loosened through an incision at the 
juncture of ear and cranium posteriorly, a small amount 
of skin is removed and the ear stitched in altered position. 
from the side of the cranium. This should extend 
along the entire posterior attachment of the ear. 
After outlining the area to be excised with iodin or 
with the point of the scalpel, the surgeon begins his CORRECTION OF OUTSTANDING EARS. 
207 
excision, the assistant following with a compression 
pad to control bleeding. As the skin is lifted the area 
exposed is quickly covered by the compression pad 
so that little bleeding follows. When the ellipse has 
Fig. 125.-Method of closure. Completing operation. 
been excised from one ear and the adjacent cranium, 
the operator turns to the other ear, infiltrates and 
excises a segment, the assistant following the excis- 
ion with the compression pad as before. While the 
operator is working upon the second ear the exposed 208 
COSMETIC SURGERY. 
area behind the ear first operated upon is subjected 
to continuous compression. When the operator turns 
to the first excised bleeding will have stopped from 
all except one or two points. These may be snapped 
and twisted as soon as exposed so that hardly any 
blood need be lost in an operation of this kind. In 
excising the skin from the ear it is easy to take 
enough of the cellular tissues as the surgeon follows 
the lines of separation which naturally develop when 
the skin is cut through. In excising from the cran- 
ium the loose cellular tissues should be included as 
much as is possible with the skin. 
If there is much outstanding a wide area must be 
removed. In men this may cause the skin of the 
cranium to be attached far out toward the edge of 
the ear and produce an unnatural appearance when 
viewed from behind. The coil of hair extending 
down over the ear from above will hide such condi- 
tion in women, so that the operation may be per- 
formed and sufficient skin removed to permit the 
surgeon to draw the ear as near to the side of the 
head as he desires. Testing alone will determine 
exactly how much skin must be removed and as 
there is considerable cartilaginous resistance in ears 
turned far out, the excision of skin must be con- 
siderable. By drawing the divided edges together 
the surgeon can see the efifect he will secure. In men 
if it is seen that too much skin must be removed to CORRECTION OF OUTSTANDING EARS. 
209 
draw the skin in as much as is desired, the ear may 
be loosened from its attachments by undermining. 
This is best done with a blunt dissector as much as 
is possible. When the organ is loosened it may be 
turned back against the side of the head and held in 
place by sutures through the cartilage and then 
through the pericranium. To pass these sutures the 
short, strong, full-curved needles, such as are made 
for suturing the cervix uteri, serve very well. With 
a needle of this kind chromicized catgut sutures may 
be passed through the cartilage of the ear and 
through the pericranium. When tied these sutures 
will hold the ear closer to the side of the head. At 
least two such sutures should be used on each side. 
Should the operator desire to avoid buried sutures, 
the concha may be punctured by the needle and 
braided silk used to hold the cartilage in the corrected 
position. The suture should be passed so that it may 
be tied over a button in the concha. This suture 
over a button will hold the ear securely in place pro- 
vided the firm fibrous tissues down to the cranium 
are included in the stitch. 
When there is much curling in the cartilage caus- 
ing outstanding in men, this curling may not be sat- 
isfactorily overcome unless the cartilage is sectioned. 
After the skin has been removed, the cartilage may 
be firmly and evenly divided. The operation may 
then be concluded by suturing the skin or the cartil- 210 
COSMETIC SURGERY. 
age may be sutured to the pericranium, or in certain 
cases a segment of the cartilage of the ear may be 
excised. After excising a strip of cartilage it is 
usually well to suture the edges of the cartilage with 
chromicized catgut. Continuous or interrupted su- 
tures may be used for closing the skin. As these 
sutures are under tension they should be of coarse, 
braided silk or catgut. If gut is used it should be 
chromicized and it should not be left to absorb but 
should be removed in about a week. 
When the skin edges of the ellipse are evenly 
sutured the ear will be held at the angle desired by 
the operator provided the right amount of skin has 
been removed. 
Whenever there is any tension on the sutures, 
either of the skin or those through the cartilage when 
such have been used, the operator should dress the 
ear against the side of the head. Strips of plaster 
may be used to hold the ear against the side of the 
head but the most effective dressing is the moulded 
plaster cast. This should be held solidly in place by 
several turns of plaster bandage about the head. 
Such dressing will insure immobility of the parts and 
also relieve most if not all of the tension on the 
sutures. CORRECTION OF OUTSTANDING EARS. 
211 
Formation of the Ear Lobe Surgically. 
The ear occupies a position on the head which ex- 
poses it to various kinds of external trauma. Partial 
loss of the organ offers to the surgeon opportunities 
for the use of the remaining parts for the formation 
of a natural appearing organ. Each individual case 
presents its own problem. When the entire ear is 
lost the best advice to the patient is to secure an 
artificial organ if the loss cannot be hidden by the 
hair. The writer has never seen an ear formed from 
the soft parts adjacent to the auditory canal which 
looked at all like an ear, or in fact resembled any- 
thing slightly. 
Sometimes women have a rudimentary lobule which 
may be improved by surgical treatment and which, 
showing through the hair, may produce the impres- 
sion of a normal organ. 
Sometimes the rudimentary fragment of the ear 
can be augmented by loosening the tissues from 
above and drawing them down so as to add to the 
size of a rudimentary lobule. Of course, such sur- 
gery must meet individual conditions, and the opera- 
tor must be guided largely by these individual char- 
acteristics of the case. CHAPTER XXIV. 
THE EXCESSIVELY LARGE EAR. 
In women large ears sometimes give an undesired 
masculinity of appearance. Reduction is not as easy 
as bringing the ear close to the side of the head. 
Outstanding ears in men may appear large and such 
patients may desire reduction in size, when reducing 
the angle of the ear to the cranium may give the 
result desired. By pressing the ear to the side of 
the head the surgeon can determine whether or 
not an operation for outstanding would be satisfac- 
tory. Ears too small in men do not improve the 
personal appearance, so that reduction, which at best 
is rather severe operative treatment of the organ, 
should not be performed without thought as to the 
actual effect. Sometimes ears vary in size and it 
may be possible to reduce the large ear to a propor- 
tion more nearly the same as the small ear. When 
the cartilages of one are closely curled, this condi- 
tion may be largely overcome by surgery so that the 
appearance of the two ears may be made to more 
nearly correspond. Very rarely, the ear may be so 
attached to the head that its deviation from the nor- 
mal is noticeable, in which case it may be loosened 
212 THE EXCESSIVELY LARGE EAR. 
213 
and made to more nearly correspond to the usual 
type of ear. When the ear is loosened, it should be 
held away from the head, and if skin cannot be 
easily slipped into the gap, a small graft may be 
shaved from the arm and placed in the interval to 
hasten healing. 
'bhe simplest operation for reducing the size of the 
ear is to excise a wedge of tissue from the organ. 
Such wedge may have its base above and point down- 
ward, or it may be placed at any angle which the 
operator elects. A survey of the organ before ex- 
cision will allow the operator to determine at just 
what angle the least abnormality of appearance will 
occur. W hen wedge-shaped excision has been deter- 
mined as satisfactory, the wedge should be marked 
off as elected by the surgeon, the skin cut through 
and pushed back slightly from the cartilage. The 
same technic should be followed behind. Then the 
cartilage should be smoothly excised. All hemor- 
rhage should be controlled and the cartilage then 
brought together with fine chromic gut. In cutting 
through the cartilage the edge may be made so that 
the cartilage will overlap, one edge upon the other. 
Such technic may add steadiness to the union before 
healing occurs. When the cartilage is cut through 
without this overlapping effect being produced, if 
the sutures are carefully placed and tied with the 
right degree of firmness slipping is very unlikely to 214 
COSMETIC SURGERY. 
occur. The sutures closing the gap in the cartilage 
should bear all tension, the skin should be closed with 
fine silk, preferably using the interrupted stitch so as 
to insure the most exact union without irregular 
tension. CHAPTER XXV. 
MICROTIA. 
Both ears may be unduly small and imperfectly 
developed but usually the condition is seen on one 
side only. There may be auricular appendages or a 
second imperfect ear in the neighborhood. A curled 
and twisted organ is sometimes seen. The latter 
offers the best chance for the cosmetic surgeon, as it 
is not really as difficult as it seems to unroll the 
curled-up organ, but to make a big ear out of a little 
ear is certainly a task which to say the least is un- 
promising. The curled-up ear may be straightened. 
Careful surgery may demand that the work be done 
in stages, but inasmuch as the operations can all 
be done with local analgesia this is little against such 
a course. Making a big ear from a truly microtic 
ear, one which may be but a small mass of tissue, is a 
task for the surgeon who wants it. The writer is 
inclined to suggest to these patients that the de- 
formed tag which euphemistically may be called an 
ear should be cut away and an artificial member pur- 
chased. Of course, surgery may be demanded here 
for the purpose of opening an occluded auditory 
canal. A few x-ray views help the surgeon in such 
operations, provided he has a radiologist who can 
215 216 
COSMETIC SURGERY. 
interpret intelligently. Infants are usually the sub- 
jects presented with the occluded canals and restora- 
tion of the passageway is not as easy as it looks. 
Merely opening a passage does little good. Keeping 
the passageway patulous with a plug is seldom a so- 
lution of the difficulty. The walls do not epithelize, 
the plug may be left in for weeks but when removed 
the passage fills with granulations. 
Flaps of skin must be used to form a canal. They 
cannot be too much detached. Here the rudimentary 
blob, which has been called an ear because it is 
where the ear should be, can be used to furnish neces- 
sary skin flaps. After the canal has been made patu- 
lous, remains of the so-called rudimentary ear may 
be extirpated to make way for an artificial member. 
Amputation of the Auricle. 
This is recommended for badly deformed, microtic 
ears and for malignant disease. Lupus may some- 
times destroy so much of the ear that the remains of 
the organ are best removed. The cosmetic surgeon 
should carefully preserve sufficient skin flaps to allow 
covering of raw surfaces, and an effort should be 
made to place lines of closure where they will be 
least conspicuous or most easily hidden. MICROTIA. 
217 
Wounds of the Auricle. 
Wounded auricles are common. When carelessly 
treated a perichondritis may occur, resulting in a 
marred and disfigured auricle. Open wounds should 
be carefully sterilized, foreign matter removed, and 
wet dressings of chinosol normal salt solution ap- 
plied. Gaping cutaneous areas should be closed with 
'horsehair. Drainage, when necessary, should be pos- 
teriorly if possible. When the cartilage is torn or cut 
through it is always possible to drain from behind; 
in fact, if the injury is such as to demand drainage 
the skin should be punctured and the drain brought 
out behind rather than risk an unsightly scar by 
anterior drainage. 
Through-and-through sutures should not be used 
in closing a lacerated auricle. Sutures should be 
placed from behind in suturing the cartilage, the 
sutures going through the skin posteriorly and the 
cartilage not the anterior skin. This should be care- 
fully closed by fine horsehair. These stitches should 
be removed within three days so that stitch marks 
will not be left. Such sutures should be placed with- 
out tension. The attachment of the ear to the body 
is firm, the weight of the body being insufficient to 
detach an ear, so one learns by a perusal of authorities 
in anatomy. Partial detachment is common. When 
sutured in place and an efficient antiseptic dressing 218 
COSMETIC SURGERY. 
used, ears usually heal quickly in place. Completely 
detached ears replaced and sutured and kept dress- 
ing in warm normal salt solution have been known to 
become reattached, so medical literature reveals. 
Warm wet dressings with no attempt to change the 
dressings for a week or ten days are recommended. 
If the ear is found black and shrivelled it should not 
be cut away. Leave it until it literally falls off, 
continuing warm wet dressings no matter how un- 
promising it appears so long as it stays in place. 
Mass grafts in the writer's experience practically all 
look like failures a few days after operation. By 
leaving them in place and continuing the dressings 
it will be found that apparently hopeless grafts take. 
Lupus Vulgaris. 
Scars left by lupus ulcerations are more frequently 
seen than active ulcerating processes. Lupus usually 
begins with a dry, indolent nodule; several form; 
becoming itchy the patient scratches or picks them, 
the surface skin gives way to expose an ill-defined 
erosion; this gradually deepens until a well-defined 
ulceration exists. Lupus attacking cartilage causes 
rapid destruction of tissue, but in the skin alone, as 
on the cheek, the ulcerations which heal without sec- 
ondary infection leave scars that are not at all bad 
looking. The surgeon should insist that care be 
used to keep ulcerations dressed with antiseptics MICROTIA. 
219 
which prevent secondary infections. Treatment for 
lupus has come to be confined largely to the use of 
radium or x-ray. Having a supply of the former, the 
writer is in the habit of using it in preference to the 
x-ray. 
Scars left by lupus can be treated surgically with 
impunity. The process is unlikely to recur in an area 
which has fully healed. Excision often greatly im- 
proves the appearance. It is not necessary to excise 
the entire area left by lupus ulcerations. The more 
unsightly portions of a lupus scar may be excised and 
approximation of scar tissue to scar tissue remaining 
heals perfectly provided antiseptic precautions are 
taken. CHAPTER XXVI. 
CRESCENT-SHAPED EXCISIONS FROM THE 
EXTERNAL EAR. 
This plan of operation usually consists in removing 
a crescent of tissue from the concha with a small part 
Fig. 126.-A method of reducing size of the ear. 
of the helix and antihelix, the object of the operation 
being to place the line of union as much in the 
shadow as is possible. The part of the helix to be 
excised should be carefully chosen so that the scar- 
220 EXCISIONS FROM THE EXTERNAL EAR. 
221 
line across this prominent aural landmark be as in- 
conspicuous as possible. The portion of the helix 
removed may be from above close to the attachment 
Fig. 127.-Method of closing after excision of tissues. 
of the cranium, from below, or from any intermedi- 
ate point. Inconspicuousness of scar lines is really 
secondary in importance to the symmetry of outline, 
so that before operating the surgeon must study 
carefully the effect of the operation. More than one 222 
COSMETIC SURGERY. 
surgeon intent in hiding scars, controlling hemor- 
rhage or other secondary matters has failed to note 
the actual effect of his excisions until too late and 
Fig. 128.-Another type of excision of portion of ear. 
parts have been sacrificed which might better have 
been saved. The plastic surgeon now and again dur- 
ing his operations should stand off and study effects 
just as does the artist when painting a picture. 
Shape, size and extent of excisions in altering the EXCISIONS FROM THE EXTERNAL EAR. 
223 
external ear are a matter of judgment in each in- 
dividual case. Tissues should be infiltrated so that 
when divided they are absolutely insensitive to pain. 
Fig. 129.-Method of closing after excision of portion of ear. 
Unless well experienced, the surgeon should mark 
off lines to be followed during the excision. The 
skin should be cut and loosened from the cartilage 
before the cartilage is cut through. Skin incisions 
should be evenly made so that accurate approxima- 224 
COSMETIC SURGERY. 
tion is possible subsequently. Small projections of 
skin, or irregularities in the cartilage will show years 
after operation. The immediate appearance at the 
Fig. 130.-Skin incision down to cartilage where section- 
ing of cartilage is indicated. 
conclusion of the operation should be neat and work- 
man-like, for time will not improve a botchy looking 
result. Slanting incisions through the skin and also 
through the cartilage may allow overlapping of these EXCISIONS FROM THE EXTERNAL EAR. 
225 
parts as has been mentioned in previous descriptions. 
Some surgeons are strongly in favor of overlapping 
methods for securing approximations to leave mini- 
Fig. 131.-A segment of cartilage excised. 
mum after-effects. Such technic does not prevent 
poor results from imperfect approximations. Skin 
along the cartilage should be redundant, but only to 
the slightest degree. All tension on the skin edges 
is thus avoided but much excess may leave a ridge 226 
COSMETIC SURGERY. 
along the line of union, a more or less objectionable 
result. 
Surgeons in the past describing these operations 
Fig. 132.-Operation completed by sutures through 
skin and cartilage. 
have illustrated excisions along the prominent anti- 
helix. There is hardly an ear which would not be 
conspicuously deformed by such operation. Excis- 
ions should be in the shadows, and with a little care 
lines of union so situated will be inconspicuous. Tl- EXCISIONS FROM THE EXTERNAL EAR. 
227 
lustrations on normal organs serve poorly to typify 
methods for abnormally developed organs. Some- 
times excisions can best be accomplished by the re- 
moval of tissues from the posterior surface, care- 
fully refraining from removing portions of the an- 
terior part of the ear which are conspicuous. If 
skin is so preserved it should be loosened so that it 
will not form a prominent ridge, but may retract and 
flatten more or less. 
The surgeon in these operations selects the type of 
excision which he believes will most successfully 
reduce the organ. He works from behind, excising 
all tissues except the skin on the exposed surface, the 
closing the wound after all hemorrhage has been con- 
trolled. The ear is dressed close to the head, using 
by preference the plaster dressing described. CHAPTER XXVII. 
THE PLASTER CAST FOR IMMOBILIZING THE 
EAR AFTER OPERATION OR INJURY. 
The plaster-of-Paris cast forms the ideal dressing 
for immobilizing the ear after operations or injury. 
It is made with sterilized plaster-of-Paris and plaster- 
of-Paris bandages. Bandages of doubtful sterility 
should not be used unless baked in an oven. This 
dries out the plaster and insures quick and complete 
setting. The bandages should be soaked in freshly 
boiled water before applying. 
The hair is first enveloped in gauze dampened in 
chinosol normal salt solution. Any irregularities in 
the gauze are then removed with sharp scissors so 
that the gauze lies smoothly over the organ. The 
plaster bandage is then carried back and forth be- 
hind the ear until this space is filled, the bandage 
being carefully moulded to conform to any of the 
natural irregularities of the ear. The plaster band- 
age is then carried back and forth until the ear is 
completely surrounded by a firm pad of plaster. A 
single layer of gauze saturated in sterile petrolatum 
is now spread over the organ and plaster band- 
age layers formed so that the ear is covered. 
The wet bandage can be gently pressed into 
228 THE PLASTER CAST. 
229 
the irregularities of the ear. As a final step the 
plaster bandage is carried about the head a num- 
ber of times so that the organ is buried in a plas- 
Fig. 133.-Lines followed in loosening soft parts for form- 
ing auricle. The writer has never seen an auricle formed 
from such soft parts which really resembled an auricle. 
ter dressing, which is steadied by a firm plaster band 
about the cranium. If the operator desires, the turns 
about the head may be separated from the cast 
moulded over the ear by paraffined gauze. This 
dressing insures absolute immobility of the organ in 230 
COSMETIC SURGERY. 
the position chosen by the surgeon. No ordinary 
contact with the dressings will disturb parts injured 
or operated upon. While precautions as to asepsis 
should be extreme, with a view to leaving the organ 
undisturbed for a week or more, the band about the 
head and the overlying cover to the ear may be 
removed without disturbing the ear so that the parts 
may be inspected if the surgeon desires. 
Reconstruction of the Ear. 
In the first and second editions of this book the 
operative technic for reconstruction of the ear was 
described. There was also a photographic illustra- 
tion of one case where the writer had secured what 
was considered a truly excellent result. Descrip- 
tions of this operation are omitted from this edition 
and the writer suggests that operators interested in 
such operations look up descriptions in detail in the 
larger systems of general surgery. The ear which 
is made from adjacent or transplanted soft parts is 
seldom presentable and in most instances the effect 
in no way repays the effort. The average person 
will find the artificial ear much more satisfactory and 
when cleverly made it is hard to distinguish it from 
the natural organ. 
Grossly deformed faces may be the subject of in- 
dividual operations. Such surgery belongs to a dif- 
ferent field from that considered in this book. CHAPTER XXVIH. 
ADHERENT AND UNDEVELOPED EAR LOBULE. 
There may be without the pointed tip to the ear an 
adherent and undeveloped lobule. This may have a 
good deal of effect upon the appearance and the 
lobule may be detached and reformed by the surgeon. 
When he does so he may take more or less of the 
skin and soft parts from the side of the face and so 
close the interval left by sutures that a line of union 
is formed in the shadow of the lobule. At the same 
time by careful planning, lines of union on the lobule 
may be so formed that the lobule itself shadows 
these. 
Effects from so slight an operation may seem of 
doubtful importance but in certain cases this is not 
true, for this type of change may have a good deal to 
do with softening the impression created by a defici- 
ent lobule. 
Of course, in most cases, operations for reforming 
the lobule or altering its size or shape are indicated 
in connection with other operations. To overcome a 
certain cast of features it may be necessary to oper- 
ate upon the ears, eyes, nose and mouth. Of course, 
it is a gross exaggeration to lead gullible patients to 
believe that the surgeon can model the features as 
231 232 
COSMETIC SURGERY. 
the sculptor can clay, but he can at least do more or 
less in patients to change undesirable featural effects. 
There is no denying that the most striking thing 
which the trained featural surgeon may do is to 
Fig. 134.-Preliminary incision for shortening lobule. 
eradicate the effects of age upon the features, pro- 
vided the patient is willing to put up with more or 
less scarring. If too much is not demanded these 
scar lines can be hidden in the hair and in the shadow 
of the eyelashes. ADHERENT AND UNDEVELOPED LOBULE. 
233 
Reduction in Size of the Lobule. 
It is not particularly unusual to see a large lobule, 
one so conspicuously out of proportion as to affect 
Fig. 135.-Method of closing to shorten lobule. 
the entire appearance, to be in fact the outstanding 
characteristic of the man. Such a lobule should be 
reduced in size. There are several ways in which 
operations of this kind may be performed. 234 
COSMETIC SURGERY. 
If the lobule is too long and not excessively bulky 
it may be shortened without the removal of much or 
even any tissue. To do such operation an incision is 
Fig. 136.-Line of excision of portion of lobule. 
made behind along the middle of the lobule. This 
perpendicular incision will give access to the soft 
parts making up the body of the lobule. A narrow, 
even strip should be removed if it is desired to actu- 
ally reduce the size of the part. This should be more ADHERENT AND UNDEVELOPED LOBULE. 
235 
or less crescentic and taken from across the lobule. 
It produces more or less of a cavity, but this is eas- 
ily closed by the sutures used in completing the 
operation. 
Fig. 137.-A portion of lobule excised. 
When much tissue is to be removed from the lobule 
of excessive size care should be taken to remove this 
in even regular strips, as a chunk cut from the lobule 
will give it an unnatural irregularity which will be 
far from pleasing. 236 
COSMETIC SURGERY. 
The incision for reducing the size of the lobule 
should be fairly free so as to give good access to the 
tissues to be excised. To attempt to remove a chunk 
Fig. 138.-Method of closing. 
through a very small incision is of no advantage and 
the likelihood of getting a perfect result is very much 
lessened. 
When the lobule is incised, bleeding may be free 
but it can be controlled easily by pressure while the ADHERENT AND UNDEVELOPED LOBULE. 
237 
dissection is being made for the removal of excess 
tissues. When the operator has removed all he 
desires he should control all bleeding points before 
suturing. Sutures should be passed well into the tis- 
sues of the lobule and the pendulous tip elevated. 
This may better be accomplished by changing the 
direction of the external wound so that the perpen- 
dicular line is changed by the sutures to one extend- 
ing transversely across the back of the lobule. 
Portions of the lobule may be cut away and the 
lobule turned upward so that the excised interval 
is closed. 
This operation may be done in such manner that 
little external scarring is produced. 
In both of these operations fairly strong procain 
solutions may be used to produce analgesia. In this 
way the normal relations of the part are less dis- 
turbed. If a two or four per cent, solution be in- 
jected into the lobule only a few drops will be needed 
to produce insensitiveness provided the operator wait 
a few moments after injection. 
Tn amputating a segment of the lobule the amount 
to be removed should be carefully measured before 
operation. It may be well to mark out with iodin 
or other coloring the exact size and shape of the 
segment to be excised, 
o CHAPTER XXIX. 
THE ATTACHED LOBULE AND THE POINTED EAR. 
Strange to say, men who have this type of ear 
often little suspect how it influences their appear- 
Fig. 139.-Operation for attached lobule. The lobule 
detached from side of head. 
ance. Such patients may have no idea that this con- 
dition creates an expression of which they would 
be rid, and they seek the featural surgeon to have the 
nose or eyes changed attributing to either of the 
238 ATTACHED LOBULE AND POINTED EAR. 
239 
parts the responsibility for their expression. When 
the surgeon notes such an ear he can safely advise 
its alteration, as the effects are necessarily consider- 
able in men. 
Fig, 140.-Operation completed. Lines of union should be 
placed posteriorly so as to be shaded by the lobule. 
The pointed ear effect may not be actually due to 
a point on the superior margin so much as to a ful- 
ness here and a deficiency adjacent. Operation to 
overcome this effect is not particularly difficult. The 240 
COSMETIC SURGERY. 
so-called Darwinian tubercle in this situation may be 
excised with a small amount of the helix, or in some 
cases an excision may be made from behind which 
does not actually involve the circumference of the 
ear. In this way scarring on the prominent helix 
may be avoided. 
The object of the surgeon will be to overcome the 
effect at the superior outer aspect of the ear, with 
the removal of as small amount of tissue as is pos- 
sible when the ear is small, and a greater amount 
when the ear is large. The shape of the excision 
should be carefully studied beforehand and every 
effort made to place lines of union in shadowed 
situations. 
The attached lobule can be dealt with in several 
ways. It may be cut free close to its attachment and 
the pointed extremity turned upward and inward so 
that it is given the desired rounded appearance of the 
normal lobule. Sutures carefully placed to close the 
small raw surfaces left will prevent much 
scarring. 
Small flaps of skin may be formed on the side of 
the head and on the lobule so that the scars of union 
are thrown entirely in the shadow, that is, can be 
seen only from behind. This operation may require 
a little careful manipulation of the tissues, but it will 
be worth the while of the surgeon to take consider- 
able trouble to secure the best possible results as the ATTACHED lobule and pointed ear 
241 
lobule has much to do with the appearance of the 
organ. 
Othematoma or Hematoma. 
When recent, othematoma or hematoma should be 
drainage of blood and serum from beneath the skin, 
the cavities formed should be syringed with the 
chinosol normal salt solution and the ear encased in 
the plaster dressing described. Incisions for drain- 
age should be as short as possible and situated as in- 
conspicuously as possible. These incisions properly 
made need not be sutured. After syringing the cav- 
ities free from blood clot and serum, the skin is care- 
fully adjusted before the plaster dressing is applied. 
Sebaceous cysts and fibrous tumors are excised 
from the ear in the same manner as from other 
parts of the body, the skin incisions being made in 
as inconspicuous situations as possible. Keloid 
should be treated with x-ray and radium. 
Repair of Clefts and Fissures of the 
External Ear. 
The most common form of cleft or fissure is that 
formed by the tearing out of an earring. Proper 
treatment at the time of injury prevents formation 
of a fissure. A surprising number of surgeons will 
allow these lesions to heal without properly sutur- 
ing them and when healing has been completed it 242 
COSMETIC SURGERY. 
is necessary to reopen the healed edges of the wound 
and resuture separated parts. The scars formed 
by healing should be studied and line of suture 
should be so placed as to leave a scar as inconspicu- 
ous as possible. Sometimes tissues are lost and it 
may be necessary to operate and draw tissues from 
adjacent parts of the skin to add to the bulk of the 
lobule. In some- instances when a portion of the 
edge of the lobule is noticeably scarred, this scar 
tissue should be so loosened that it will be behind 
the ear and the line of union on the outer surface 
of the lobule should be smooth and as free from 
scar as possible. CHAPTER XXX. 
SKIN GRAFTING FOR THE CORRECTION 
OF FEATURAL IMPERFECTIONS. 
The inexperienced surgeon may feel that the skin 
grafting furnishes a means of correcting many fea- 
tural imperfections, but such is not the case. Skin- 
grafting must be looked upon as an expedient for 
the overcoming of the most unsightly deformities 
only, as it is usually impossible to secure a natural 
looking surface after grafting. Following burns 
and injuries of portions of the body usually hidden 
by clothing, grafting furnishes a means of securing 
dermal covering which may be entirely satisfactory, 
but this is due to the fact that the patient who has 
an irregular and unusual appearing surface upon his 
leg or body is little concerned so long as it is pain- 
less and otherwise not troublesome, but about the 
face it is different as skin-grafts usually show plainly 
enough and are only a partial correction of the de- 
formity which it is their object to replace. 
ddie excision of a lesion or scar may be followed 
by immediate suture of the edges of the deficiency in 
some cases. This may be true especially if the edges 
of the wound are undermined. Undermining is ac- 
complished by the passage of a blunt or fairly dull 
243 244 
COSMETIC SURGERY. 
cutting instrument beneath the skin separating the 
skin by burrowing through the subcutaneous tissues. 
The undermining should always be through the sub- 
cutaneous tissues. No effort should be made to 
separate the layers of the true skin. Separation 
without cutting is preferable to the sharp dissection 
of the tissues, as blood-vessels frequently resist the 
trauma incident to the separation and the margins of 
the wound secure a better blood supply in conse- 
quence. 
Distortion of the features by undermining or flap 
formation may prevent the operator from closing 
certain deficiencies by immediate approximation of 
the edges, and in such cases skin-grafting may be the 
only means of closing a skin interval unless the 
wound be permitted to heal from the edges. 
Healing of a raw surface by granulation must nec- 
essarily leave considerable scar formation. This 
manner of healing may be unavoidable, in certain 
cases, following injuries, and in such instances the 
medical attendant can do much toward the formation 
of a smooth and sightly scar by the proper care of 
the raw surface. 
A granulating wound left by a burn or extensive 
injury which is not to be covered by grafts should be 
irrigated thoroughly with either a dilute iodin in 
normal salt, or a chinosol solution. Both these solu- 
tions are actively germicidal and when the surfaces CORRECTION OF FEATURAL IMPERFECTIONS. 
245 
are thoroughly cleansed, they should be dressed with 
gauze dampened in one or the other of these solu- 
tions. When chinosol is used it should be about 
i: 5000 in normal salt solution, the iodin may be 
about 1: 4000, if the wound is not sealed with silk 
or other impervious material. Dressings which ex- 
clude the air entirely have not found much favor with 
the writer. When no silk or rubber is used it is true 
that dressings must be dampened rather frequently, 
but this inconvenience is more than made up by the 
better results which follow. 
lodin solutions have been highly commended for 
their effect in stimulating epithelial cells. With 
iodin or chinosol solutions tendencies to the develop- 
ment of exuberant granulations do not occur. 
Smooth healthy granulations cause healing with 
smooth scars which are seldom unsightly. A smooth 
scar as a rule is more natural appearing than a 
grafted area. CHAPTER XXXI. 
MODIFICATION OF FEATURAL TYPES. 
The greatest degree of success, no doubt, can be 
attained in featural surgery by one with an eye for 
artistic beauty, who has knowledge of correct pro- 
portions in features and who in addition is also a 
skillful surgeon. 
Beauty is not necessarily dependent upon correct 
proportions of features. Many women with irregu- 
lar features have great charm, properly enough they 
are classed as beauties. Of course, artists criticize 
such classifications, they would admit that such 
women *have charm but they deny they are beauties 
from the artist's standpoint. The featural surgeon 
cares little for the quibbles of artists as to what 
really constitutes a beauty. If the women have ir- 
regular features and such irregularities are pleasing, 
the featural surgeon has no desire to alter such fea- 
tures. It is the irregularities which destroy charm 
which the surgeon would alter. 
To decide the effect of a deviation of a feature 
from normal proportions, it may be necessary to do 
much study of the features of the patient. An excel- 
lent way to study many of these patients is with well 
made sets of photographs. These should be of two 
246 MODIFICATION OF FEATURAL TYPES. 
247 
general kinds, sharp focused views which give much 
detail, and vague, partly out of focus studies which 
show only the general characteristics of the features. 
The first type should be made with a commercial 
camera, rather than the usual portrait camera; the 
second type may be made with any good camera not 
quite in focus. 
To study features effectually as above outlined 
a considerable number of pictures are required, and 
in doubtful cases where single features are not strik- 
ingly at fault, the method is of decided value to the 
surgeon. Photographs allow best possible measure- 
ments of the features to be made. With pictures of 
a standard size, a measuring frame is used and many 
different measurements quickly and accurately noted. 
When the surgeon by a study of this kind has de- 
cided that certain features can be altered to advant- 
age, he may before testing his conclusions upon the 
patient have negatives of certain photographs re- 
touched so that the features which he expects to 
alter are shown in the altered state. Clever re- 
touchers can easily do this. The surgeon thus may 
see what actual effect would result from his proposed 
operation. 
Every expression or featural characteristic which 
a patient shows offers opportunities for modification. 
Whether or not such modification will be advantage- 
ous is for the surgeon to decide. If photographs re- 248 
COSMETIC SURGERY. 
touched show that such modification alters the fea- 
tures in a way that is likely to be pleasing, the sur- 
geon may institute those surgical measures to secure 
such effect, provided such modifications are within 
the limitations of his ability. A slight change in a 
line or feature in one patient sometimes does more 
to give that patient charm than the alteration of a 
gross defect of feature in another patient. 
Measurements which are useful for determining 
what is considered correct featural proportions can 
be obtained by a study of books prepared for artists. 
Such works are useful to the surgeon in cases where 
lack of charm is due to deviation from such propor- 
tions. But measurements may not reveal the fault, 
for too often both in men and in women unpleasing 
featural effects are due to faults in expression. 
No one can study better faults of expression and 
no one will be able after study to tell as well as the 
trained featural surgeon what influence faults of ex- 
pression have in marring beauty. Many women who 
present themselves to featural surgeons for altera- 
tion of certain features can secure the charm they 
desire not by surgery but by a change of expression. 
It is the duty of the surgeon to see this. It is his 
duty to tactfully advise the patient. By careful 
advice he can, without offense, establish a system of 
muscle exercises which will alter such expressions. 
He can have the patient assume various expressions, MODIFICATION OF FEATURAL TYPES. 
249 
point out those which are advantageous, that is, 
charming, and help the patient to cultivate such ex- 
pressions until they become fixed habits. 
A volume of no small proportions might be 
written upon the study of featural types, but 
the brief mention in the preceding paragraphs 
will serve to make clear the point, that there 
is much more to featural surgery than mere 
surgery. How little does the average surgeon sus- 
pect this! So often we see the advice to patients 
seeking information regarding featural surgery, "Go 
to your family physician, let him send you to a sur 
geon." Nine times out of ten the family physician 
will send the unfortunate patient to a general sur- 
geon, one perhaps who does his appendicitis work, 
and nine times out of ten this general surgeon has 
not even a passing interest in this class of surgery. 
But general surgeons are ever ready to do any kind 
of operation. Courage is the basic essential to gen- 
eral surgery, but courage does not make good fea- 
tural surgeons. It is only by careful study, a broad 
understanding of the subject, and the display of much 
skill that the best effects are possible in this branch 
of surgery. It is a virgin field, one which is crying 
for the scrupulous surgeon. It is not the field in 
which the specialist can be developed in four weeks. 
No short postgraduate course gives the skill needed. 
Time, patience and careful study will fit the surgeon 250 
COSMETIC SURGERY. 
to do this work well. Early efforts must be discreet. 
That which appears difficult or impossible becomes 
practicable as the surgeon develops, and develop he 
will if he gives the subject the attention it deserves. 
As any difficult art is mastered, so the field of cos- 
metic surgery widens with skill and experience. The 
technical difficulties of operations upon the face are 
usually not great. They demand care, exactness 
and particularly attention to detail. These are pos- 
sible to any man; they are a matter of training. The 
surgeon who succeeds as a specialist in this field 
must take a great deal of trouble preliminary to 
operation. He needs to be equipped with an under- 
standing of his case which few people suspect. He 
must conduct his surgical maneuvers with the most 
absolute care and exactness as to details and assure 
aseptic healing by a technic which leaves nothing to 
be desired. Ender such circumstances he can most 
often produce effects which will be a source of satis- 
faction and even happiness to his patients. CHAPTER XXXII. 
CONCLUSION. 
Cosmetic surgery, now attracting a good deal of 
attention, is a subject old to the writer. For this 
reason his opinion may be of interest to surgeons 
more recently interested in the work. 
From 1903 to 1907 the writer contributed many 
articles to medical journals and in this latter year 
brought out his book on Cosmetic Surgery. This 
was a work devoted exclusively to this class of sur- 
gery. It placed in compact form before the profes- 
sion descriptions of numerous surgical operations of 
the kind which the writer had described in various 
medical journals during the four or five preceding 
years. The book itself like the present volume 
avoided descriptions of old plastic surgical procedures 
which are available in all works on surgery and was 
confined to essentially "beauty" operations, largely 
developed by the writer to meet the demands of the 
times. 
Since 1907 there has been a great deal of cosmetic 
surgery done by ranking surgeons in all our medical 
centers, but few indeed of these surgeons care to 
write even articles for the medical press upon the 
subject. This, of course, is due to the desire of these 
251 252 
COSMETIC SURGERY. 
surgeons to escape criticism by their professional 
brothers, for like all new specialties, cosmetic sur- 
gery has been subjected to criticism. Much of the 
cosmetic surgery of our leading surgeons is poorly 
done. W hen one stops to consider the circumstances 
this is readily understood. General surgery does 
not necessarily develop those qualities which foster 
good cosmetic surgery. Few general surgeons fail 
to acquire a habit of operating rapidly and hasty 
work is not smooth, perfect surgery such as is de- 
manded in featural operations. Very careful incis- 
ing, excising and suturing are essential to good re- 
sults in featural surgery. The method of suturing 
alone usually adopted by general surgeons will effec- 
tually mar the results of a featural operation if prac- 
ticed as it is nearly always practiced by general sur- 
geons. Irregularity of incisions, sutures too deep, 
too wide apart and drawn too tightly will give a very 
poor surgical result upon the . face when the same 
technic would be satisfactory on any other part of 
the body. As these details are not available to sur- 
geons generally, they cannot be expected to observe 
them in operations. It is for this reason that the 
writer hopes even expert surgeons may find matter 
of interest in this volume. 
Plastic surgery presents endless possibilities. Sur- 
gery usually calls for a fixed technic, but plastic sur- 
gery allows, even requires, the meeting of numerous CONCLUSION. 
253 
deviations by modifications of the usual technic. At- 
tempts to describe all such variants are unnecessary 
for a good understanding of the subject. The pres- 
ent work includes a variety of modifications of many 
of the operations described, but no attempt has been 
made to include all possible operations of the face, as 
the book is intended more as a working guide to 
interested readers rather than an exhaustive con- 
sideration of the subject. Such steps as the author 
considers important have been emphasized, some- 
times causing more or less repetition. 
While it is important to know how to cut and how 
to suture and how to effectually secure an insensitive 
field, it is also important that the surgeon study his 
prospective patients and learn to estimate just what 
surgical procedures are likely to be satisfactory in 
each case, for surgical operations which are perfect 
successes in some people's estimation are failures in 
the estimation of others. Cosmetic surgery presents 
striking examples of this. Few surgeons care to 
promise to do more than they really can do, there- 
fore, it behooves the operator if he expects to give 
satisfaction to advise his patient as to just what to 
expect. Some operations for altering featural con- 
ditions can be done without causing any scarring 
upon exposed parts. These operations which in- 
clude subcutaneous sectionings, operations within the 
mouth and nose, and operations beyond the hairline 254 
COSMETIC SURGERY. 
are always operations of choice to conscientious sur- 
geons. The second group of operations include those 
which place scar lines in shaded areas; the third 
group includes those in which the natural lines are 
followed, and finally the fourth group, in which in- 
cisions are made irrespective. It is foolish for a sur- 
geon to pretend that he can consistently operate and 
avoid scars. Sometimes scar lines are so trifling 
that they can be said to be invisible, aseptic healing 
of properly made and closed wounds usually leaves 
very insignificant scars, but patients should be given to 
expect some subsequent scar lines after operations on 
exposed regions. Tissues brought together under ten- 
sion nearly always leave distinct scars. Such wounds 
should not be made on exposed surfaces unless the 
patient is given to expect this result. Of course, it 
is possible sometimes to avoid much scarring by a 
type of double operation. The operator excises the 
tissues and draws the wound edges together under 
tension, placing his stitches close to the wound edges, 
removing them early to avoid stitch marks. After 
the tissues have adjusted themselves to the new con- 
ditions the noticeable scar left by the first operation 
is excised. The tissues when adjusted by time can 
afterwards be brought together with little tension 
and the scar line usually perceptibly improved. A 
few surgeons may not scruple to excuse excessive 
promises with the plea that they can thus attain a CONCLUSION. 
255 
result. Such reasoning is chicanery, if the patient 
is not fully warned beforehand that this is the plan 
of the surgeon, for even present temporarily a rather 
noticeable scar may cause a psychic trauma which 
may permanently unsettle the patient's nervous equil- 
ibrium. 
Cosmetic surgery, like all new specialties, has 
suffered from the influx of more or less incompetent 
opportunists who are looking for a surgical field 
which is not overcrowded. This is the history of all 
new specialties. Such operators may promise any- 
thing to secure patients. In the long run such prac- 
tices result in failure of the operators. The surgeon 
who hopes to continue in this field of surgical en- 
deavor will do well to develop a conscience and strive 
consistently to establish a reputation for veracity. 
Even then he will have to learn to discriminate in 
the selection of patients. 
Cosmetic surgery appeals to vain people. There 
are many idle men and women who have nothing to 
do but study themselves. These people are fre- 
quently extremely neurotic and selfish. They will 
expect marvelous transformations from operations. 
If the surgeon in this field expects to enjoy peace of 
mind in his practice he will carefully study character 
and learn to avoid these psychopaths, for with 
nothing to do, after an operation which would prove 
satisfactory to a reasonable person, such patients 256 
COSMETIC SURGERY. 
may work up a degree of discontent which is appal- 
ling in its intensity. 
Sometimes women consult, seeking operations 
which they desire performed without the knowledge 
of any in the family. Most of these are women who 
are dependent upon their husbands. They may have 
a real need for all their charms and it may be good 
policy for them to have operations performed which 
will restore to them more or less of their lost youth- 
ful appearance. W hile such patients may have a 
right to have such operations performed without 
their husband's knowledge and consent, they are sel- 
dom in a position to maintain such right and it be- 
hooves the featural surgeon to consistently refuse to 
be party to any such arrangements. 
Professional beauties make up a certain percentage 
of the patients who consult the featural surgeon. 
These women in America must retain youth. The 
most beautiful women of middle life cannot charm 
American audiences. Signs of maturity in women 
must go. Featural surgeons can do much to per- 
petuate youthful contour, but usually it cannot be ac- 
complished without a good deal of scarring, for most 
of the surgical steps which accomplish these effects 
require the excision of rather large segments of 
integument. So long as too much effect need not be 
produced the surgeon can hide his scars within the 
hair, but time makes more and more demands for CONCLUSION. 
257 
sacrifice and finally the surgeon must come out in the 
open. When he does he should advise his patient 
frankly. Women who otherwise would he retired 
from public appearance will accept as a choice scars 
which they must subsequently hide with cosmetics. 
They may prefer such scars and contracts to no 
scars and no contracts, but they should have the right 
to so elect. The featural surgeon if he is what he 
should be will only operate after advising them to 
this effect. 
The variety and extent of the operative steps 
which are used in some instances for the sole pur- 
pose of restoring youthful lines is little suspected 
even by surgeons. It is no uncommon thing to see 
women who have been operated upon by our best 
general surgeons, and to find the latter performing 
operations which are entirely inadequate, merely 
because they have no way of knowing just how much 
tissue it is necessary to remove to lift or retract the 
features. Using their own judgment, and not having 
done enough of this work to acquire the necessary 
experience, they perform operations which disap- 
point their patients merely because they do not re- 
move anything like the amount of tissue which is 
necessary to secure a noticeable effect. 
It is no uncommon thing to see in other cases the 
results of hastily performed operations which are far 
from satisfactory. Patients will present where in- 258 
COSMETIC SURGERY. 
cisions have been made hastily and closed imperfectly. 
The scar lines are literally tell-tale. One can actually 
picture the operation, the manner of the surgeon, 
his way of incising and his way of closing. The 
same may be said of the operations involving the 
excisions of tissue, soft parts, bone or cartilage. An 
unnatural irregularity tells forever after of the hasty 
imperfect technic of the surgeon. The writer would 
feel repaid for the considerable trouble it has been to 
rewrite this book if he would, by his warnings, pre- 
vent surgeons from attempting to do these operations 
without taking the extreme painstaking care which is 
essential to really good results. No one knows bet- 
ter than the writer how flagrantly vicious is much 
of the criticism of cosmetic surgeons. Surgeons of 
nimble wit who wish to secure patients for operations 
upon the face do not write about despised and criti- 
cized beauty operations, but seek publicity in the 
medical press by descriptions of plastic restorations 
of gross deformities. Individual operations on gross 
lesions are described in detail, operations a century 
old are re-phrased as original contributions, and the 
slightest modifications in procedure put forward with 
emphatic seriousness. It is the right of surgeons to 
tabulate their experiences. They are often interest- 
ing if not particularly valuable. That such methods 
are effective in advancing a surgeon's reputation as a 
featural surgeon, more than one operator can testify. CONCLUSION. 
259 
In spite of criticism it devolves upon some one to 
describe the various operations demanded today to 
satisfy the desires of so many for an altered appear- 
ance. When the writer was contributing to medical 
journals fifteen or twenty years ago, articles describ- 
ing operations as they have again been described in 
the present volume, he was subjected to criticism 
which was actually censorious. In one way he felt 
flattered for his own knowledge of medical history 
reminded him of the numerous dull savage books 
written by contemporaries of Pasteur criticizing this 
man's greatest discoveries. Of course, he who con- 
tributes to the literature of cosmetic surgery can 
make no claims to greatness, for the operator who 
gives a few added seasons to an actress by helping 
her to counterfeit youth cannot seriously lay claim to 
rendering distinguished service to the community, 
but the exactions of this kind of surgery are such 
that the operator who applies himself carefully to 
attain really good results will be inspired by his work, 
as all men are who attempt difficult tasks, and there 
are many compensations to the surgeon who masters 
the details and does well these operations. The flare 
of enthusiasm which comes to the operator who dis- 
covers that he has mastered the difficulties and is 
enabled to do superior featural operations may in- 
spire him to announce himself as a specialist in this 
field of surgery, but it is the humble suggestion of 260 
COSMETIC SURGERY. 
the writer that while general surgery is only a par- 
tial training to the featural surgeon, the mastery of 
featural surgery in its finer details develops surgical 
technic which makes of adept featural surgeons 
superior types of general surgeons. So it is the sug- 
gestion of the writer that the featural surgeon 
should not exclude himself from the field of general 
surgery, for as one grows older one finds more sat- 
isfaction in doing operations which cure disease 
rather than those which merely satisfy vanity. INDEX 
Alae nasi, outstanding, 156 
Anatomy, of ear, 201 
Anesthesia, infiltration, 6 
local, 5 
Antisepsis, 1 
Arrow excision, 50 
Attached lobule, 238 
Auricle, amputation, 216 
excessively large, 212 
excision from, 220 
of cartilage, 225 
forming, 229 
lupus vulgaris of, 218 
plaster dressing for, 227 
wounds of, 217 
Bags, beneath eyes, 21 
Bleeding, control of, 64 
Blood, saving of, 65 
Braided silk, 61 
Bulbous nasal tip, 144 
Buried ligatures, 92 
Buttons, 160 
Canthoplasty, 96 
Canthorrhaphy, 96 
Canthotomy, 96 
Canthus, excision at, 90 
Cartilage, excision, 224 
Chin, "double," 111 
Chinosol, 162 
Clefts, of ear, 241 
Closing wounds of, alae nasi, 157 
double chin, 117 
ear, 223 
skin, 137 
Compression, 9 
Corrugator supercilii, sectioning, 
124 
Crescent excision, 22 
and inner wedge excision, 29 
and median wedge excision, 26 
"Crow's feet," 126 
Darwinian tubercle, 240 
Denudation, 106 
Detaching lobule, 238 
Dimple, formation of, 140 
"Double chin," 111 
excisions, 11 
lateral excisions, 120 
"Double lip," 188 
Double frontal excisions, 62 
Ear, anatomy of, 201 
excessively large, 212 
excisions from, 220 
cartilage, 225 
skin excision, 205 
plaster dressing of, 227 
lobule adherent, 231 
attached, 238 
clefts, 241 
formation of, 211 
operation, 232 
resection, 233 
wounds, 217 
Electrolysis, 105, 139 
Excisions at external canthus, 90 
behind ear, 76 
for neck lines, 118, 129 
in shadow of nose, 92 
Exercises, 132 
Exopthalmic goiter, 108 
261 262 
INDEX 
Eyes, excisions above canthus, 
46 
excision at canthus, 52 
excision of fullness above, 40 
caution in operation, 99 
to enlarge, 98 
wrinkles about, 65 
Face lift, 82 
wounds, 138 
Facial paralysis, 101 
sectioning, 123 
Fat, excision of, 115 
Featural types, 246 
Flap operation, for nasal steno- 
sis, 152 
Forehead lifts, 59 
wrinkles, 59 
Frown lines, 62, 80, 125 
Head, 16 
Hematoma, 241 
Hemorrhage, 8 
High excision of "double chin," 
112 
Hump nose, operations, 161 
Instruments, care of, 3 
lodin technic, 2 
Lift, direct, 77 
Lifting operations, 58 
Lines about mouth, 132 
Lips, everted, 180 
Lobe of ear, formation, 211 
Lobule of ear, adherent, 231 
attached, 238 
clefts, 241 
operations, 232 
resection, 236 
Low excision of "double chin," 
113 
Median frontal excisions, 62 
Microtia, 215 
Mouth angles, droop of, 133 
lines about, 132 
operations, 179 
unduly large, 195 
Muscle sectioning, 85, 124 
training, 248 
Myotomy, 123 
Nasal splint, external, 171 
tip bulbous, 144 
eversion of, 145 
incisions, 150 
septal incisions, 148 
Nasolabial lines, 127 
Nerve blocking, 161 
Nose, external incisions, 169 
hump, 161 
inverted V incision, 170 
spectacle bow incision, 171 
suture through, 160 
tip tilted, 174 
Occipito frontalis sectioning, 126 
Orbicularis oris sectioning, 194 
Orbicularis sectioning, 125, 129 
Oriental cast to feature, 99 
Othematoma, 241 
Pack, nasal, 147 
Photographs, 99, 246 
Perpendicular excisions, 118 
Plaster dressings, 227 
Platysma myoides, 128 
Powder marks, 139 
Refractive errors, 134 
Scalp, 17, 58 
dangerous area, 15 
hemorrhage, 60 
scars in, 61 
Scars, shadowed, 21 
Scowl lines, 134 
Sectioning muscles, 123 INDEX 
263 
Side lift, 65 
Silk, braided, 61 
mattress sutures of, 61 
Single excisions, 72 
Skin, excision of, 205 
grafting, 136, 243 
strapping, 117 
wounds, 137 
Spasm orbicular, 97 
Splint, nasal, 154, 171 
Spectacle bow incision, 171 
Stenosis, nasal, 151 
Subcutaneous sectioning, 123 
Suprarenal extract, 33 
Sutures, buried, 92 
in featural surgery, 35 
to control hemorrhage, 60 
Tarsal ligament, 97 
Tenotomy, 123 
Tension, buttons, 61 
plates, 61 
Tip tilted nose, 174 
Torsion, 14, 91 
Triangular excision, 68 
Types, featural, 246 
Undermining, 137 
Wedge, double excision, 32 
excision, 34 
inner excision, 28 
outer excision, 30 
Wound, gape of, 159 
closure, 119 
of face, 138 
Wrinkles, 63