Cosmetic Surgery of the Nose. 
'THE 
Read in the Section of Surgery and Anatomy, at the Forty-third annual 
meeting of the American Medical Association held at Detroit, 
Mich., June, 1892. * 
JOHN B. ROBERTS, M.D., 
BY 
PROFESSOR OP SURGERY IN THE PHILADELPHIA POLYCLINIC AND IN THE 
WOMAN’S MEDICAL COLLEGE OF PENNSYLVANIA. 
Reprinted from “Journal of the American Medical Association,” 
August 20, 1892. 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION. 
1892. THE COSMETIC SURGERY OF THE NOSE. 
JOHN B. ROBERTS, M.D„ 
PROFESSOR OF SURGERY' IN THE PHILADELPHIA POLYCLINIC AND IN THE 
WOMAN’S MEDICAL COLLEGE OP PENNSYLVANIA. 
Operative surgery can do so much to relieve disfig- 
uring nasal deformities that perhaps the topic will 
prove interesting for discussion at this representa- 
tive meeting. The medical profession fails to fully 
realize that nearly all undesirable distortions of the 
nose can be improved or entirely corrected by cosmetic 
operation. It is, therefore, not astonishing that 
many persons remain in constant unhappiness because 
of the consciousness that a congenital or accidental 
disfigurement is the occasion of impolite stare or im- 
pertinent remark. 
Operations, often quite trivial, change noses not- 
able for ugliness into organs of symmetrical lines. 
Such cosmetic improvement naturally makes the 
patient happier in mind; and not infrequently im- 
proves physical health as well, by restoring the nor- 
mal respiratory and vocal functions of the nasal 
chambers. Even when more extensive, such opera- 
tions, if properly performed, carry with them no risk 
to life. Haemorrhage of serious kind and violent 
inflammation are practically unknown; and un- 
seemly scarring does not occur to be an impediment 
to radical surgical work. Much can be done to the 2 
nose, through the nostrils or mouth, without making 
an incision in the skin of the face. Cuts on the 
cutaneous surface are inconspicuous, or even invisi- 
ble, when made in selected spots and with oblique 
division of the tissues, and when so treated that pri- 
mary union is secured. Such incisions should be made 
in the normal lines of the skin, not across them, or 
should be placed in the situations where shadows, 
rather than strong lights, usually fall. Careful 
asepsis or antisepsis, oblique incision of the skin, 
fine catgut sutures and iodoform with collodion as a 
dressing insure unnoticeable scars, even when the 
incisions are made in less desirable sites than those 
just mentioned. 
The recognition of tertiary syphilis of the nose 
and the recollection of its frequency among the edu- 
cated and refined are requisite qualifications for the 
Saddle-back nose. 
Tuberous nose. 
Angular nose. 
successful practice of this branch of general surgery. 
Many deformities, due to inefficient management of 
such curable lesions, have come to me for operative 
treatment. That physicians allow such disfigure- 
ments to happen is very astonishing. It should be 3 
a rule of practice to give all patients with stationary 
or chronic ulceration of the interior or exterior of 
the nose, full doses of mercury and iodide of potas- 
sium. The therapeutic test carried on for ten days 
will usually clear up doubtful cases, if sufficient 
doses of these drugs are given. A third or a half of 
a grain of green iodide of mercury taken before 
meals, and twenty to thirty grains of potassium 
iodide taken after meals will cure many ulcerated 
noses. It is the neglect of this active treatment that 
furnishes the most frightful disfigurements that fall 
into my hands for cosmetic procedures. 
It is useless to detail fully here the causes which 
may give rise to nasal deformity. Congenital im- 
perfections, such as epicanthus and the flattened and 
dilated nostril accompanying hare-lip can usually be 
greatly improved. The Roman nose, the Jewish nose 
and the nose with an angular prominence on its dor- 
sum can, in many instances, be satisfactorily modi- 
fied by careful chiseling away of the angular projec- 
tion of bone and cartilage. 
Here a single incision along the edge of the dor- 
sum allows the surgeon to stretch the skin open, so 
as to apply a sharp chisel to the whole breadth of 
the nose and shave the bridge into a becoming shape. 
I have found that the chisel often does best work 
when used with the beveled side of the cutting edge 
toward the bone. 
Fractures make, of course, all forms of irregular- 
ity, and may be accompanied by such blocking up of 
the nostrils as to require quarrying with chisels and 
burrs to open the air passages. 
I have seen ugly twists given to the cartilaginous 
nose by what seems to be an interstitial over-growth 
of the triangular cartilage of the septum. As this 
cartilage abuts against bone above and below, such 
over-growth causes marked curves in its outline, 
which secondarily displaces the cartilaginous por- 4 
tions of the external nose, 
giving it an ugly twist. 
Efficient treatment of this 
abnormal shape of the organ 
must include excision of a 
considerable portion of the 
septal cartilage. Sometimes, 
but not always, this may be 
done by sub-mucous resec- 
tion. 
Tumors involving the tip 
of the nose can readily be 
removed by a Y-shaped in- 
cision ; the nasal lobule is 
afterwards reconstructed by 
bringing the flaps together 
in a judicious manner. The 
Twisted Nose. 
fact that the nares are laid open by the incision 
makes no difference. The wound can be protected 
from septic infection by thoroughly cleansing the 
mucous membrane before operation, and plugging 
with antiseptic gauze after operation. 
The improvement in the 
patient’s appearance made 
by excision of tubercular 
excresences of the nose due 
to acne is most astonish- 
ing. Yet, many patients go 
through life with these de- 
formities, never knowing 
their remediable character. 
An insignificant operation 
will cure promptly the horri- 
ble and often disgusting dis- 
figurement. Tumors involv- 
ing the alee will often 
require the surgeon to con- 
struct a new ala from the 
Bent Nose. 
cheek after excision of the growth. 5 
Syphilitic destruction of the bones and cartilages 
give us the most difficult cases to remedy because of 
the actual loss of substance. If the external 
tissues are intact, however, great destruction of 
the internal parts of the nose may be suc- 
cessfull}7 neutralized. I have satisfactorily used 
the tissues of the forehead and upper lip for making 
a bridge and a columella respectively. In a somewhat 
similar manner I have propped up a sunken bridge 
in fracture by turning up a flap 
cut from the septal cartilage 
and changing its direction. 
Chiselling loose the nasal bones 
and pinching them together 
towards the middle line will 
elevate the bony dorsum in 
saddle-back nose, and by nar- 
rowing it at the same time, give 
it a relative height which will 
lessen deformity. 
After syphilitic ulceration of 
the internal structures, the ex- 
A Form of Syphilitic Nose. 
ternal soft parts are often drawn into the nasal cav- 
ities by cicatricial contraction and respiratory suc- 
tion. To elevate and to keep elevated the external 
nose, so as to restore the nasal projection and facial 
conformation, is sometimes quite a problem. If the 
ulae are pared from their abnormal deep connections, 
by means of a tenotome freely used through the nos- 
trils, the cutaneous and subcutaneous tissues can be 
unfolded and drawn out so- as to reconstruct the 
nasal elevation. There may not be sufficient rigidity 
in the tissues, however, to keep them in the desired 
position; and if the bony bridge has been destroyed, 
the problem is more difficult. It has been proposed 
to dissect up the nose by an incision from within the 
mouth, under the upper lip, and to insert a metal 
bridge or support. This can doubtless be done with 
success. I have accomplished a good deal with plugs 6 
in the nares, used until the new position was con- 
firmed ; have used spectacles of special construction 
to pinch up the soft tissues into a bridge; and have 
employed plastic devices with much satisfaction. 
The straightening of crooked noses can be accom- 
plished only after very free separation of the cartil- 
age and skin from the nasal and superior maxilliary 
bones. This is best done with a tenotome passed 
into each nostril in turn. With it the mucous mem- 
brane is pierced and the tissues freely cut away from 
their bony attachments. The septum is then divided 
by knife or saw, and the nose forcibly bent into the 
straight position. A great deal of force should be 
applied so as to twist the parts completely out of their 
abnormal relation. It is always well to over-correct 
the distortion because there will be a tendency of the 
old condition to return. If the nose is bent to the 
right, the surgeon should give it a marked twist to the 
left of the middle line, and similarly to the right in 
left deviations. After this has been done, steel pins, 
one and one-half inches long, are thrust through the 
skin just below the nasal bones, and through the col- 
umella at the margin of the anterior nares, and used 
as levers to hold the nose in its corrected position. 
The pins should be retained about ten days or two 
weeks. 
I have not considered the more elaborate proced- 
ures for reconstructing new noses from the arm, fin- 
ger and forehead, nor gone into the present topic in 
great detail, because this paper is only suggestive. 
A consideration of all the operations of a cosmetic 
nature practicable upon the nose would make this 
communication much too long. I have, moreover, in 
another place, discussed many matters pertaining to 
this branch of surgery (“The Cure of Crooked and 
Otherwise Deformed Noses,” Philadelphia, 1889). At 
this time I especially desire to call the attention of 
the medical profession to the fact that much can be 
done to aid sufferers from nasal disfigurements, and 7 
that those with bent, twisted, angular, tuberous or 
syphilitic noses should be given to Understand that 
the condition is capable of great cosmetic improve- 
ment. The surgeon must use in this work his knowl- 
edge of plastic surgery, and adapt his operation to 
each individual case. Much more can be success- 
fully done, in an operative way, to the nose than is 
usuallv believed.