PLASTO-COSMETICS IN SURGERY OE THE FACE. 
BY 
B. MERRILL RICKETTS, M.D , 
Clinical Lecturer on Plastic Surgery, Miami Medical College; Professor of Dermatology and Syphilo- 
graphy, Cincinnati Polyclinic; and Visiting Dermatologist to the 
German Protestant Hospital. 
A Paper read before the Mississippi Valley Medical Association at Evansville, 
Ind., September ii, 1889. 
CINCINNATI : 
Reprint from The Cincinnati Lancet-Clinic, September 21, 
1889. PLASTO COSMETICS IN SURGERY OF THE FACE. 
B. Merrill Ricketts, M.D. 
Mr. President and Gentlemen ;—When 
asked by your Secretary to present some- 
thing that would be of interest to the mem- 
bers of this, the most flourishing and pro- 
gressive medical society west of the Alle- 
ghenies, I hesitated, feeling that the most 
common medical and surgical subjects 
have been comparatively exhausted, as the 
frequent meetings of the various medical 
and surgical societies with their allies 
would indicate. But when we consider the 
subject of each and lay down the bars 
leading into their uncircumscribed areas,— 
areas which are themselves subdivided— 
we find that our exploits and discoveries 
are confined principally to the main area; 
that the bars lowered by Galen, Harvey, 
and Hunter are but a short distance in the 
background; that while during the past 
century many new and important dis- 
coveries have been made, thereby over- 
throwing doctrines which lead to practices 
that would now be condemned and looked 
upon as acts of malpractice, we cannot 
feel that the end has half been reached. 
While the subject I present to you— 
namely, “ Plasto-Cosmetic Surgery” — is 
somewhat an antiquated one, I feel 
assured that the demands for resorting to 
it are by far more numerous and the re- 
sults better. 
The demands for an unblemished ap- 
pearance are in proportion to the degree 
of civilization. In the early days of sur- 
gery, especially the time of Tagliocozzi, 
the operation for hare-lip, cleft palate, the 
replacing of a lip, eyelid, or nose, or any 
part thereof, was seldom practiced, and 
when they were good results were few. 
Although the demands for the correction 
of deformity were fully understood by 
many, it was not until the time that this 
public benefactor, Tagliocozzi, reported 
his observation on grafting the cock’s spur 
into his comb and the end of the rat’s tail 
into its back, that anything authentic 
was published or brought before the pro- 
fession. 
Not until the eighteenth century, a 
time when the process of waste and repair 
was more fully understood, was it that an 
era and system were inaugurated by which 
lost parts might be restored. In fact, from 
the time that the circulation of the blood 
was understood by Harvey, a few keen, 
observing men in the profession (men pos- 
sessing what might be considered a mor- 
bid desire to correct deformity) began to 
experiment upon the lower animals, that 
they might be able to serve their fellow 
men. How great the courage of an en- 
thusiastic man like he (Tagliocozzi) must 
have been when he made his first peduncu- 
lated graft. Surely it must have ap- 
proached that of Kentucky's bravest man. 
Then facial deformity was principally 
the result of disease; however, accompa- 
nied more or less with that of heredity. 
To-day the per cent, of the former (dis- 
ease) is but a small per cent., with about 
the usual per cent, of congenital deform- 
ity. Now from seventy to eighty per 4 
Plasto- Cosmetics in Surgery of the Face—Ricketts. 
cent, are due to traumacy as the result of 
the various kinds of machinery and occu- 
pations which characterize the age. They 
adopted plans which were the result of 
their own mental energy; we merely fol- 
low their teachings, with the addition of 
a small modicum of microscopy, electroly- 
sis, antisepsis, and more numerous oppor- 
tunities. Their experience and the means 
at our command for making microscopical 
examinations (which so definitely deter- 
mine the character of growth and disease), 
together with electrolysis and antiseptic 
measures, enable us to arrive at safer and 
earlier conclusions and adopt more radical 
measures with better results. The experi- 
enced microscopist or pathologist of to-day 
is seldom in doubt, and, when denied the 
privilege of making an operation, need not 
hesitate in making a diagnosis if allowed 
to excise but a small portion of the growth, 
a proceeding which should always be 
adopted when there is any controversy as 
to its character or the final result of the 
operation. We are not justified in basing 
our conclusions upon the clinical appear- 
ance alone, especially when the operation to 
follow may not result in all that could 
reasonably be supposed. However, there 
appear times when it would seem neces- 
sary to be governed by the surrounding 
circumstances, or when the services of a 
competent pathologist can not be had. 
Delay should not then be indulged in, but 
the patient operated upon at once. When 
the lesion is slight, involving cutaneous 
structures other than that of the eyelid, 
lip, nose, or ear, removal may be accom- 
plished by either the curette, caustic paste, 
actual thermo, or galvano-cautery, or it 
may be excised with the knife, which to 
my mind is the most rational means in the 
majority of cases occurring, especially 
upon the former location (eyelid, lip, nose, 
and ear). When the deformity is the re- 
sult of traumacy, heredity, or any other 
like cause, the knife is the quickest, surest, 
and in fact the only means at our com- 
mand by which the irregularities resulting 
therefrom can be corrected. 
Here I find it not only convenient but 
necessary to make three classifications, 
each of which requires a different kind of 
treatment: 
i st. Removal of malignant growths. 
2d. Correction of deformity due to loss 
of parts from either congenital or trau- 
matic causes, or from previous operation 
or disease of any kind, including pug nose 
and ptosis. 
3d. The removal of naevi, warts, moles, 
hairs, pigmentary deposits, cicatrices, al- 
veola, fistulse, enlarged glands, or anything 
abnormal other than malignant growths 
that may appear upon the face or neck. 
1st. Removal of malignant growths. 
In this class I include all growths which 
have a tendency to recur. They are of 
the most importance, and should in conse- 
quence thereof be given precedence. The 
growth should be removed as soon as pos- 
sible, and when found in its incipiency 
should be done with the knife, encompass- 
ing as much healthy tissue as can be 
spared. 
If upon the eyelid, lip, or nose, a com- 
plete and thorough excision should follow, 
and the parts immediately restored by an 
individual or pedunculated graft from either 
the face or arm. When the malignancy 
has existed for some time, secondarily in- 
volving the eyelid, wing of the nose, lip, 
or ear, together with destruction of osseous 
tissue, some form of paste may be used; 
and when sloughing has been followed by 
the necessary granulation, a pedunculated 
flap may best be taken from the arm. 
While the formation of cicatricial tissue Plasto-Cosmetics in Surgery of the Face—Ricketts. 
5 
should be avoided so far as possible, it is 
this upon which we must depend for re- 
covery when there has been extensive de- 
generation of tissue, with or without caries 
—a condition which is so often found in 
the long-standing cases of epithelioma. 
There is no course to be adopted that 
promises more for a good base upon 
which to graft in these extension cases 
than a thorough curetting, followed by the 
application of some form of arsenical paste. 
However, the old theory, that malig- 
nant growths, after being excised or re- 
moved by cautery, of any kind, and allowed 
to heal by granulation, is less likely to 
return, can no longer be entertained by 
the most experienced observers. 
The removal of malignant tissue, until 
within the last half-century, was princi- 
pally done with caustics or the actual 
cautery and the healing left to care for 
itself, which in the majority of cases re- 
sulted in dreadful cicatricial contraction, a 
deformity which should always be avoid- 
ed. Here I might say that the use of 
caustics in the treatment of malignant 
growths, especially of epithelerica of the 
face, has been sadly neglected and allowed 
to sink into almost oblivion. My experi- 
ence and what I have been taught by the 
literolum upon the subject by both profes- 
sional and non-professional workers has 
led me to thoroughly investigate the treat- 
ment by these means, so that what I have 
to say will be found in a paper read by me 
before the Ohio State Medical Society in 
June, 1886, and published in the Lancet- 
Clinic of June 12, same year. 
When a malignant growth occupies a 
prominent place upon the cheek or neck, 
places where the skin is plentiful, the co- 
apting of their edges following the incision 
is all that will be necessary to complete the 
operation, which will result in practically 
no deformity whatever. If the integument 
be wrinkled from old age or any other 
cause and the operation be made, resulting 
in a smooth surface so that there is a con- 
trast in the two sides, a similar section 
may be excised from the opposite side with 
cosmetic effect. I havfc recently had a 
case fully demonstrating the necessity and 
efficacy of such an operation. 
2d. The correction of deformity due 
to the loss of parts from either congenital 
or traumatic causes, or from previous ope- 
rations or disease of any kind, including 
pug nose and ptosis. 
In this class about the same course 
should be adopted as in the first class after 
an excision has been made. 
If the brow be destroyed, with the loss 
of tissue, a flap taken from the correspond- 
ing temple, the line of incision having 
been through the hairy integument of the 
temple, will be found suitable to adhere 
with but little difficulty. True, they 
would not be perfect, but by frequent 
trimming and a little care they will answer 
the purpose and correct a deformity that 
is always more or less objectionable. 
If the reasons are such as not to justify 
the taking of tissue from either the face or 
arm for grafting purposes, the skin of the 
chicken removed from under its wing or 
the skin taken from the under surface of 
the frog may be substituted with equally as 
good results; or, if there is left to heal by 
granulation a surface that will be covered 
with cicatricial tissue, one or more small 
individual epithelial grafts may be made to 
attach themselves. 
Where the surface is large the same re- 
sult can be obtained with but one graft, 
cut one-third larger than the surface which 
it is intended to cover, shrunken in hot 
water a few minutes, dried with towel, and 
applied immediately. 6 
Plasto-Cosmetics in Surgery of the Face—Ricketts. 
Since the introduction of sponge graft- 
ing the epithelial coating is completed 
very much sooner in indolent granulation, 
and, when cared for carefully, will greatly 
benefit the reparation process in the major- 
ity of granulating pounds. 
Rhinoplasty.—One of the greatest diffi- 
culties, to overcome in operations about the 
nose, is to preserve its prominence. If the 
septum or cartilage be absent, or if it is 
found necessary to remove one or both of 
them, it is almost out of the question to 
elevate it with muscular or cutaneous tis- 
sue. In either of these events they should 
be replaced by cartilaginous or bony tissue 
from the patient or from one of the lower 
animals as soon after its birth as possible. 
If the septum alone is wanting it may be 
replaced by the tibia and fibula or the 
radius and ulna of a guinea pig, kitten, 
rabbit, or puppy. If these are objection- 
able and the patient is willing to sacrifice a 
finger, a better result will follow than with 
any other proceeding. Should the subject 
of the operation be so fortunate as to have 
a friend or find any person who is willing 
to part with a superfluous finger, which is 
occasionally due to congenital malforma- 
tion, no difficulty will be found in utilizing 
it to make the part more prominent. The 
finger being divested of the nail and the 
matrix destroyed, is then prepared for 
attachment by a longitudinal incision in 
the palmar surface. It is then attached by 
sutures and the hand and head perfectly 
secured by bandages until union has taken 
place; which when thoroughly accom- 
plished the finger is amputated, leaving 
enough of the integument to properly 
cover the lower end of the bone. One 
case I recall was so cleverly done that the 
graft had not the appearance of having 
been a finger. 
When the septum and bony parts of 
the nose are remaining (from injury or 
otherwise), in either case a different pro- 
cedure is to be followed. In these eases a 
section with a pedicle may be taken from 
the cheeks, forehead, or arm. When 
taken from the cheeks, which I think the 
most practical in the majority of cases, the 
union takes place in the naso-median line, 
leaving but a slight cicatrix. If but little 
of the cartilaginous alae is left remaining 
it can be utilized in making the tip of the 
nose more prominent. To remove the flap 
from the forehead is the most objectionable 
operation of the three, as there is always a 
large cicatrix as a result upon one of the 
most prominent parts of the face. The 
principal objection to removing the flap 
from the arm is in the time required before 
the tissue can be detached from the arm. 
As a rule these flaps are attended with 
very good results indeed. They seldom 
fail to unite if properly cared for, but the 
distress the patient experiences from the 
arm being bound up so long is such as to 
question the proceeding as being prefer- 
able to taking the flap or flaps from the 
cheek. 
In those cases of thickened alee, Lin- 
hart’s operation, which consists in excising 
elliptical pieces, should be made. 
Pug nose, when to the extreme, can be 
made to appear without much deformity by 
the now accepted operation, which con- 
sists in removing a small section of the 
septum, thus lowering the tip of the organ 
to any desirable degree. 
Deviated Septum. — Should the bony 
structures of the nose deviate from the 
median line, it can be made straight by 
simple means. That these operations ter- 
minate successfully is no longer a question, 
the good results depending upon the skill 
of the operator and the care exercised in 
the after-treatment. Plasto-Cosmetics in Surgery of the Face—Ricketts. 
7 
Eyelid. — Ptosis, that much-neglected 
deformity, can easily be relieved to a great 
degree by simply removing a part of the 
eyelid, as in the operation for entropion, 
and relief should be given in all cases, it 
being better at any time to expose a part or 
all of an eye than to have it completely cov- 
ered, as is often the case following paraly- 
sis of the third nerve, the levator palpebra 
muscle being involved. Surgical inter- 
ference is especially demanded if the 
branch supplying the upper eyelid alone 
should become paralyzed by some trau- 
matic lesion or an exostosis or tumor, Von 
Graefe’s operation being the most desirable 
in the majority of cases. It is always de- 
sirable to leave one-quarter, or at least 
one-eighth, of an inch of the palpebral 
margin. 
Lips.—As the operation for hair-lip is 
the most common, and the good results 
therefrom so well known, I will not enter 
into detail with reference to the various 
procedures. Suffice it to say that more has 
been accomplished in these operations than 
any other in plastic surgery. Most of them 
are accomplished with flaps taken from the 
face. However, many brilliant achieve- 
ments are secured with grafts taken from 
the arm. 
Fissures. — Lesions of this character, 
especially when chronic or showing a ten- 
dency to recur at stated intervals, should 
be excised, thus enabling radical measures 
to be adopted. Union by first intention is 
nearly always the result when the edges 
are perfectly adjusted and held secure with 
sutures. 
Thickened lips may be reduced to their 
normal condition by removing a section 
by means of either a longitudinal or trans- 
verse incision, as the case may require. 
The operations of Koenig, Linhart, 
Langenbeck, Malgaigne, Graefe, Colles, 
Szymanowsky, Roser and Buck are per- 
haps all familiar to you, and their results 
fully appreciated. Surely it is to these un- 
selfish characters we owe our thanks for 
the high standing these operations have 
attained. 
The Ear.—Here is an organ which has 
suffered greater neglect than any of those 
about the face. It is, I think, due to the 
difficulty in finding suitable tissue for graft- 
ing purposes. A small degree of it may 
be due to the fact that a partial destruction 
is not so much realized on the part of the 
subject. Where the entire auricle is ab- 
sent it seems at present best to replace it 
with an artificial one made of paper, 
rubber, celluloid, or some other one of the 
compositions used for that purpose. But 
when the lobule has been destroyed a 
pedunculated graft from the arm will com- 
pletely restore it. Should the helix alone be 
removed it is very difficult to replace it. 
However, if any part of it be absent, espe- 
cially when due to having been bitten out 
by human teeth (which is the most fre- 
quent cause), leaving a concave surface, the 
edges may be brought together after having 
been made raw, a triangular piece re- 
moved, and union secured with but slight 
deformity. I consider grafting for the 
restoration of an auricle in its infancy. 
Drooping of an ear and the adhesions 
of an auricle to the scalp are easily ob- 
viated and should not be overlooked. 
3d. The removal of naevi, warts, moles, 
hairs, pigmentary deposits, cicatrices, al- 
veola, fistulae, enlarged glands, or anything 
abnormal other than that of malignancy 
that may appear upon the face and neck. 
In these it is always entirely for cos- 
metic effect that their removal is resorted 
to. However, some of them are not un- 
frequently the origin of malignant growth, 
epithelioma being the most common. 8 
Plasto-Cosmetics in Surgery of the Face—Ricketts. 
Electrolysis.—Now that this has been so 
perfected and its results so radical and effi- 
cacious, and no pain or discomfort expe- 
rienced, the subjects of such growths are 
easily induced to submit to their removal. 
From three to fiv§ milliampdres will answer 
to any emergency in the total destruction 
of hairs, while from ten to twenty will be 
found necessary to completely destroy 
naevi, warts and moles. 
As to the number of cells required to 
secure a current of given strength, that de- 
pends upon the kind of battery and the 
length of time in use. The chloride of 
silver battery is but half the strengh—that 
is, it will require ten of its cells to generate 
a current of equal strength as that of the 
ordinary battery under like circumstances. 
No current should be applied without 
being registered by a galvanometer, or, 
what is more accurate, a milliampermeter, 
which will enable us to determine exactly 
the amount of electricity applied. 
Pigmentations. — These, being either 
smooth or elevated, must necessarily be 
managed differently. Where the pigmen- 
tation is smooth and limited to a small 
area, total excision is no doubt the most 
radical measure and the cicatrix smaller; 
but when there is more or less elevation, 
electrolysis is the most satisfactory way of 
removal. In a few cases, however, where 
there is no elevation, this course may also 
be followed with satisfactory results. In 
this event the strength of the current need 
not exceed one-half that used in destroying 
warts or moles. As in the former, the ob- 
ject is not to destroy tissue, but to so act 
upon the structures of the skin as to dis- 
continue the deposit of pigment cells. 
When a wart or mole is to be removed, 
something more is necessary—the destruc- 
tion of tissue—which will require double the 
amount of electricity. 
Cicatrices of any kind that are irregular 
or elevated, making the outline of the face 
appear broken, should be removed, as 
should alveola and fistulse also, so that the 
line of union should be linear and corre- 
spond to the folds of the skin. In this 
way many lines of union are completely 
hidden or remain unnoticed. 
Glands, when enlarged, should be ex- 
cised before suppuration occurs, no gland 
being allowed to remain until it degenerates 
into pus. Poultices and the various applica- 
tions should no longer be tolerated by the 
profession as means of either relief or cure. 
They are only means of inconvenience, 
expense and torture, that should be placed 
upon a shelf too high to be reached and 
allowed to become musty from old age and 
disuse. We have all seen the havoc as 
the result of neglect in cases of enlarged 
glands. 
As to asepsis, I do not think that that 
is anything more than absolute cleanli- 
ness, secure it as you may. There is no 
question but that it should always be ac- 
complished. Just what advantages the 
natural chlorides will have remains to be 
seen. I mean by natural chlorides the 
new solutions that are made to represent 
the cutaneous secretions, such as that 
known as perspiration, which contains 
about one-half per cent, of sodium chlo- 
ride. By the use of such a solution the 
raw surfaces are to be irrigated constantly, 
thereby promoting a more certain and 
rapid reparation process.