Page:Gillies plastic surgery 1920.djvu/24

Rh it would sound, is fraught with dangerous pitfalls. One has seen a case in which a point a quarter of an inch above the angle of the mouth really belonged to the infra-orbital margin. The tissues had been stretched to this extent without dragging down the lower lid to any marked degree, and one might have been forgiven for regarding the stretched skin as part of the cheek.

Here, as elsewhere, the aim is to estimate first the amount of loss; and, secondly, the possibility of correcting displacement.

It is often impossible to do so till one has undone some previous effort at repair.

A moment's consideration will show that no estimation of the loss or distortion of soft tissues can be of use unless coupled with a knowledge of the condition of the bony tissue. When there is greater loss of the underlying mandible than of the skin, one is apt to conclude that there is no great loss of skin. In such a case, one must visualise a completely restored mandible, and then judge whether the remaining soft tissues are sufficient to cover it. In this connection, if a photograph is obtainable of the condition before injury it will often be of great assistance. In the case of any organ forming the wall of a mucous cavity, such as the lip, it is necessary to make an accurate estimate of the loss of mucous membrane. In fact, estimation of loss should be made separately in regard to (1) the mucous lining, (2) the bony or cartilaginous support, and (3) the skin covering. The estimation of bony loss necessitates intranasal and intra-oral and radiographic examination in addition to surface palpation, and even then is often difficult to make in cases where the injury is symmetrical. One has seen an intrinsically well-made nose constructed upon a bed at least one inch posterior to the normal plane : the loss of the nasal spine and premaxilla had not been taken into consideration, and the face, to the surgeon's disappointment, presented an undershot appearance.

To overcome such difficulties, Surgery calls Art to its aid. A plaster cast of the face is made, and thereon the sculptor, aided by early photographs if available, models the missing contours. With radiographs to confirm that the apparent loss is not merely displacement, the surgeon now has data for adequate diagnosis.

The diagnosis established and recorded, the surgeon plans his repair. The first principle is one which the author believes to govern the whole treatment of facial injuries, and this is that all normal tissue should be replaced as early as possible, and maintained in its normal position. In treating an early wound there is a natural disposition to try to close unsightly gaps. More harm than