The Surgical Treatment of Common Deformities of the Face. A PAPER READ BEFORE THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA, MAY xB, 1898. BY JOHN B. ROBERTS, M.D., Professor of Surgery in the Woman’s Medical College of Pennsylvania. REPRINTED FROM THE THERAPEUTIC GAZETTE, JUNE 13, iBqB. DETROIT, MICH. * , WILLIAM M. WARREN, PUBLISHER. 1898. THE SURGICAL TREA TMENT OF COMMON DEFORMITIES OF THE FACE. John B. Roberts, M.D. The effect of facial disfigurement upon the earning capacity of an individual is generally recognized. Those desiring positions as household servants, nurses and salesmen are rejected at once if unsightliness of feature is at all conspicuous; and they may be refused by hypercritical employers when the want of comeliness is not great. Facial blemishes sufficient to produce these results are likely to be subjected to surgical treatment in most urban communities; there the popular mind has become familiar with the resources and safety of surgical science. In more sparsely settled districts, however, and in cities of less advanced culture, men and women are frequently seen with most hideous deformities, which could easily be removed or greatly lessened by simple and innocuous surgical procedures. The effect of physical deformity upon the mental characteristics of the afflicted individ- ual is often most deleterious. The timidity and consequent social ostracism, due to even very slight facial blemishes, are only fully realized by those whose professional activi- ties bring them into contact with such cases. Because of these influences upon the char- acter and earning capacity of the patient, surgical interference is to be adopted for the relief of even slight deformities, which in other parts of the body would be deemed un- worthy of attention. Much more can be done to relieve these conditions than is generally appreciated. They require, however, the knowledge usu- ally possessed by the general surgeon to be supplemented by the special training and manipulative skill of the ophthalmologist, rhinologist, and oral specialist. It is probable that the limited attention given to the cor- rection of these facial defects is largely due to the differentiation of specialism. The operator who knows how to relieve an ectropion or to properly adjust an artificial eye, for example, may have had no experience in correcting deformities of the nose. He is an oculist alone, and therefore not accus- tomed to osteoplastic operations upon the nose and jaws. Again, the work may not be undertaken, or not completely done, because the surgeon is familiar with amputations at the hip-joint and extirpation of the uterus, but has never split up a canaliculus, or sawed an intranasal spur associated with a crooked nose. The partition of the facial structures to the various specialists has had, I am sure, a dele- terious influence upon the development, and proper realization of the resources, of what may be called the cosmetic surgery of the face. This branch of surgery is very interesting, but requires for its successful performance an artistic appreciation of proportions, a delicate touch, and the specialized and small instruments of the oculist, aurist, and rhi- nologist. These must be added to the opera- tive experience of the general surgeon, who is accustomed to large wounds and resections of bone, and who is not startled by hemor- rhage from the internal maxillary or carotid arteries. 3 The operator can approach these cases with a great deal of confidence; because the very abundant blood-supply of the face makes anemic gangrene of flaps unusual, the bleeding which occurs is so accessible to operative hemostasis, and the shock of opera- tion is in most cases unimportant. It only needs to have the operation well planned and neatly and artistically performed to insure success. The worse the deformity the greater as a rule is the satisfaction of the patient; because the improvement is so manifest, even when the final result leaves a condition that in normal faces would be considered a dis- figurement. It is the patient who has very little deviation from the normal, and who has become morbidly sensitive, that is apt to be dissatisfied with the result of the operative treatment. In these cases the mental condition must be treated both before and after opera- tion. The line of treatment is that adapted to neuroses in other departments of medi- cine. Pleasant mental occupation, distrac- tion from one’s self, nerve tonics and the usual hygienic accompaniments are needed in these as in other neurasthenic patients. Surgeons are too apt to overlook these valu- able adjuncts to a perfect operative recovery. An important point to insist upon is the necessity for repeated operative procedures. The patient as well as the surgeon should understand that it is often impossible to 4 obtain a perfect restoration by one opera- tion. It is frequently necessary to wait until Nature has absorbed the inflammatory exu- date and caused shrinking of the flaps before determining what is the next step to be taken to further improve the appearance. Haste at this stage often leads to unneces- sary operations or to unwise selection of lines of incision. At first a crude restoration of parts may be all that can with propriety be done. The methods used in plastic or reparative surgery of the face cannot be recapitulated in the time assigned me by the committee, and need not be, since they are those well known to the profession. Skin-grafting, sliding and interpolation of flaps, osteoplastic operations, the introduction of non-absorba- ble substances, the construction of artificial organs such as eyes and teeth, and the ad- justment of celluloid or metallic substitutes for areas of lost tissue, are employed. The selection and adaptation of these expedients must vary with the condition to be remedied and be left to the individual judgment and experience of the operator. The conditions which can be improved by surgical and prosthetic treatment are numer- ous and varied. A catalogue of these would include nearly every disease of the differen- tiated facial structures. The field of cosmetic surgery of the face is almost limitless. It extends from tattooing a white scar on the cornea to the construction of an acceptable lower jaw or nose; from making a pair of ears comely to straightening a crooked nose or curing a salivary fistula; from removing a few freckles to remedying the distortion due to extensive burn or gunshot wound. 5 The object of this paper is to call attention to a greatly neglected branch of surgery; to urge the general surgeon to cultivate the thoughtfulness and manipulative skill of the specialist; and to make the profession and public familiar with the great relief that can readily be given to a large class of unhappy patients—patients who are permitted to go through life handicapped because they know not the relief accessible to them, FEBRUARY 15, 1898: WHOLE SERIES. VOL. XXIT. No. 2. THIRD SERIES, VOL. XIV. Therapeutic Gazette T HE the THERAPEUTIC GAZETTE FEBRUARY /