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Proceedings of the International Conference on Information Technology & Systems (ICITS 2018) 1st Edition Álvaro Rocha
Recent Advances in Information and Communication Technology 2019: Proceedings of the 15th International Conference on Computing and Information Technology (IC2IT 2019) Pongsarun Boonyopakorn
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Fig.4. Totaltweetsbycontenttype-Day2
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F . 510b.—D C D C A R I C A .
Electrodes.—Having the circuit or current under control, it now becomes necessary to attach electrodes to the free poles to be able to properly apply it to the patient. These electrodes vary considerably according to their use. The author will refer to only those that are of service in electrolysis.
Sponge Electrode.—The one electrode held by the patient is usually made of a metal disk covered with felt or sponge attached to a wooden handle and is shown in Fig. 511.
F . 511. S E .
This electrode represents the positive; the negative pole is held by the operator. When used, the felt or sponge is moistened with warm water to which a little salt has been added and is placed into the palm of the hand, sponge inward.
The author prefers to use a plain metal disk with the sponge and places a piece of absorbent cotton or gauze over it when in use for hygienic reason.
When the operator prefers he may resort to arm or wrist electrodes which can be clamped upon the limb and be held in position and shown in Fig. 512
The hand electrode is of greater service since the patient can regulate or make and break the current at will, a matter of no small consequence when fairly large currents are being used to destroy a growth upon the skin of the face.
Needles and Needle Holders.—For the negative electrode the operator uses a needle holder with a needle of proper form and material.
Two needle holders are shown in Figs. 513 and 514.
F 512 A E
F 513 F 514
E N H .
When the operator desires he may employ an interrupting needle holder with which he can make and break the current at will during the operation. It is shown in Fig. 515.
F 515 I C N H
Such a device is not advocated, since the patient is liable to jump as the current is made suddenly, because of the sharp stinging pain felt at the point when the needle has entered the tissue or hair follicle, often resulting in the breaking of the needle and possible injury to the patient.
Other operators employ a small magnifying glass which may be attached to the holder, as in Fig. 516, and by a sliding arrangement be moved up or down the handle to adjust the lens to the proper focus. This arrangement is indeed novel and may be of service in removing fine superfluous hairs, but the author has never resorted to the method.
F . 516. N H M G .
The proper kind of needle to be used for electrolysis varies with the device of the operator The ordinary cambric needle usually advocated is too stiff and thick. Jeweler’s broaches are better, but are very brittle and easily broken. The ideal needle should be very thin and made of platinum or irido-platinum. The author prefers the sharp to the bulbous-pointed. For the removal of other blemishes than hair from the face the sharp needle only can be used.
REMOVAL OF SUPERFLUOUS HAIR
The moistened sponge electrode connected to the (+) positive pole of the circuit is placed into the hand of the patient, who lies in a chair with her head on a level with the physician’s chin when operating. The light should be southern, or such that the shafts of the hairs show plainly.
The operator turns on the current, holding the needle holder in the right hand which is connected by a flexible cord to the (-) negative pole. The rheostat handle is brought back so that just the least current is flowing. The needle is now thrust down into the follicle containing the hair. This must be done very gently so as to feel when the papilla has been reached by the needle. The depth to which the needle goes varies very much according to the size and place of the hair. It may be less than one eighth and more than one fourth inch.
The patient holding the sponge will at once feel a stinging sensation when the needle enters the skin, which is later not as objectionable. The current is now increased by advancing the handle
of the rheostat until about eight milliampères are shown by the index on the dial.
Within a few seconds a white froth will issue from the follicle, showing that decomposition of tissue is taking place. The operator must familiarize himself with the time and amount of current required to destroy superfluous hairs. Coarse hairs may require as much as fourteen milliampères, but it is advisable to use a moderate amount of current and to leave the needle a little longer in the follicle to avoid scarring of the skin.
The papilla having presumably been destroyed, the patient loosens her grip on the sponge and the needle is withdrawn.
The operator now takes up an epilating forceps, such as shown in Fig. 517, and removes the hair. If the hair does not come out of the follicle readily it shows that it has not been destroyed, and the same treatment, just described, must be repeated, but for a shorter duration.
When the hair is removed it will show more or less bulb according to its size and nourishment.
The physician now proceeds to remove the coarse hairs first. Hairs should not be removed too closely placed, as the current will destroy the tissue between the follicle and cause scarring. It is better to remove the hairs some distance apart, leaving the remaining hairs for later sittings.
About forty or fifty hairs may be removed at one sitting. This will require from half to an hour and a half of time, but the operator will soon accomplish considerable work in a minimum of time.
F . 517. E F .
Some of the hairs removed will return, showing as black or dark specks in the skin, in from five to ten days. The number returning depends on the operator’s skill. At first he should not be surprised to see fifty per cent come back, but this ratio is reduced so that only three or four hairs out of fifty may return, and perhaps these stunted in growth.
The electrolytic removal of hair does not stimulate the growth of the finer hairs of the skin; that general belief has been erroneous.
Where there is considerable hair to be removed, as with a beard on a woman’s face, several sittings may be given a week and at different parts of the face, but with the average patient only one sitting should be given each week.
More or less edema follows the removal of hair, which may remain for a day or more. Warm applications will help to remove it.
The operator should at no time state a definite fee to remove the hair on the face, unless he is certain of the number present. Such judgment is, indeed, very misleading.
REMOVAL OF MOLES OR OTHER FACIAL GROWTHS
Moles, warts, fibromata, fungoids, and other excrescences are best removed with this method, especially where they are of the nonpedunculated type. It is hardly necessary to state that very light currents should be used for the light flat growths, such as a dark freckle or a small yellow mole. The amount of current required varies from 6 to 24 milliampères, according to the size of the body to be removed.
The same procedure as with the removal of hairs is followed. Positive electrode in the hand of the patient, negative pole to the needle holder. The needle is thrust through the growth on a plane with the skin and slightly above it. The current will at once produce a pale color in the mass and white froth will issue about the shaft of the needle. A comparatively greater amount of current is needed for this
purpose than with the destruction of hairs. The operator must judge the amount and time required from experience.
The mass is punctured in stellate fashion to assure an even necrosis, as shown in Fig. 518.
F 518 E M D G
The mass will appear much softer after this treatment, is in some cases, as with flat moles, quite friable, but this disappears in a few hours and the mass begins to shrivel and dry up, forming a scab, which is between brown and almost black in color This scab falls off in several days, according to its size, leaving a pink eschar, which gradually turns white and shows very little, if the growth has not been too large and the electrolysis carefully done. If little tumefactions, or tips of tissue, still appear, they are removed as soon after the scab falls off as deemed advisable by the same method. Warts show more or less recurrence.
TELANGIECTASIS
In this condition there appear in the skin one or many dilated capillaries. It is quite common about the sides and lobule of the nose and just inferior to the malar prominence of the cheeks. To destroy these the fine platinum needle is thrust through the skin and directly
through the canal of the vessel. The same disposition of the electrode is used as heretofore described.
Immediately the current is made, a series of bubbles of hydrogen will run through the vessel which presently becomes pale and empty, as a result of the electro-chemical action.
The needle should be allowed to remain in the vessel from five to ten seconds, according to the size of the latter.
The object is to set up sufficient irritation in and of the walls of the vessel so as to occlude it when cicatrization has been established. Some edema follows such a treatment, subsiding in a day or more. Several vessels may be treated in the same sitting, and at either side of the face. The operator should guard against too strong a current, to avoid scarring of the skin. The final result in this treatment shows fine punctate scars, as after the removal of coarse hairs, and sometimes pale linear scars, but these are observable only on close inspection.
REMOVAL OF NÆVI
Birthmarks, port-wine marks, and other pigmentary conditions may be entirely or partly removed from the skin of the face, according to the size of the area treated and the nature of the case. For this purpose the single needle attached to the negative pole is hardly sufficient, unless the spot is exceedingly small, therefore a bunch needle electrode is used. This electrode has a number of fine steel needles set into it, as shown in Fig. 519.
In this treatment the needles are made to puncture the skin at right angles to them to a depth corresponding to the papillary layer. These pigments lie above that, so that it is not necessary to include
the derma. At each point of puncture a white spot will appear which soon turns red. In a day’s time a number of fine scabs, or a single scab, will form over the parts treated, which fall away in about five days eventually, leaving the parts paler than before, owing to a number of minute punctate scars.
The amount of treatment given in each case varies with the extent of the lesion. If the result from the first sitting has not accomplished as much as desired, it can be repeated over and over until the parts assume a normal tint. There may be more or less bleeding following the treatment; this is easily checked by pressure. If the part worked on is quite large, dry aristol dressing should be used to avoid infection. The scab should not be picked off by the patient, but allowed to fall off.
REMOVAL OF TATTOO MARKS
The best method of removing such pigmentations of the skin is to remove them with the knife when possible, and to cover the wound by sliding flaps made by subcutaneous dissection at either side of the wound, as in the Celsus method. Some authorities advocate their re-tattooing with papoid solution, while others prefer caustic agents, with the object of destroying the pigmented area. These methods are not to be preferred, since they leave unsightly burn scars.
Electrolytic needling may be tried and is quite successful when the marks are very small, but, as with gun-powder stains, they are best removed by punching, or cutting out, a little cone of skin containing the pigment. The secondary wounds thus made leave only very small punctate scars that are hardly noticeable. Of course a number of such removals would not be advisable.
Where the pigmentation is very pale, recourse may be had to the peeling method, as will be later described.
THE TREATMENT OF SCARS
Not infrequently the cosmetic surgeon is called upon to remove or improve unsightly scars about the face, the result of injuries or burns and after the careless coaptation of such wounds. The scars vary in extent and degree, from a mere pit due to varicella or variola to the broad areas following the cicatrization of lupus and burns. Surgical scars vary also from a mere line to areas of greater or less extent, dependent upon the ablation of neoplasms or the granulation of wounds due to any cause.
The treatment of scars depends upon their size and location. A mere linear scar may be reduced by electrolysis, the needle, negative pole, being introduced equidistantly, from one sixteenth to a quarter inch apart, with the hope of causing a breaking down electrochemically of the scar itself and waiting for secondary cicatrization. In other words, making a scar within a scar.
This mode of treatment may be repeated in two or three weeks and has the tendency of breaking up the shiny line of light that makes the scar stand out prominently from the skin.
Such scars, where nonadherent, or flat with the plane of the skin, may also be tattooed to reduce their white color.
For this purpose, the red or carmine pigment used for tattooing is diluted and pricked into the scar tissue with a fine cambric needle by hand or electric process.
When the scar is small the line is punctured here and there and the aqueous solution of the pigment is painted over the area, which is again worked over to make it take.
For larger scar surfaces multiple needles are used. These are composed of from four to ten needles soldered together at their eye ends, leaving the points at an even level.
The electric method is the most serviceable for tattooing large scars.
These instruments are electro-magnetic devices made to accommodate single or multiple needle points and can be obtained from instrument makers.
The author has had a special electric synchronous reciprocal apparatus made, as here shown in Fig. 520, which is much more compact than the ordinary electric apparatus found on the market. It works on the principle of the sewing machine needle.
F 520 A ’ E A T S
In using the electric apparatus the needle ends are dipped into the pigment paste, to which a little glycerin is added to bind it, and this is tattooed or pricked into the scar.
If, after the parts are healed, the color is too light, the scar may again be gone over until the tint matches somewhat the tint of the skin. Other pigments may be used, according to the complexion of the patient.
Some scars, the resultant of negligent coaptation, are to be excised according to the Celsus method and are brought together with a number of fine silk sutures.
If the skin is found to be attached too closely to the subcutaneous structure, it must be dissected up to render it mobile.
When the scar cannot be removed by excision the hypodermic use of thiosinamin may be tried.
Thiosinamin or rhodallin is only slightly soluble in water, but the addition of antipyrin according to Michel renders it useful for hypodermic use. The formula preferred by the author is made as follows:
℞ Thiosinamin grs. ij
Antipyrin grs. j Aqua dest. gtts. xx.
The above solution makes up a single injection, which is to be made directly under the scar or into the muscular tissue below it. Two injections are given each week.
The treatment is to be continued until the texture of the cicatrix is equal to that of the skin.
These injections are more or less painful and may be supplanted to advantage with the hypodermic use of fibrolysin (Mendel), in which each 2.3 c.c. correspond to three grains of thiosinamin.
For very small scars, as those occasioned by blepharoplastic operation, the author employs the twenty-per-cent thiosinamin plaster mull made by Unna. These are to be applied every day or night, according to the convenience of the patient, and allowed to remain on for several hours each day.
At first these plaster mulls are inclined to cause erythema and exfoliation of the epithelium, therefore they might be used on alternate days to keep the parts more sightly.
For scars of large extent the above method will answer best. If there is considerable contraction, the parts should be massaged daily to soften and stretch them. Eventually the depression of contour may be corrected by hydrocarbon protheses introduced subcutaneously following subcutaneous dissection, if deemed necessary.
Small pits, where discrete, are best removed with a fine knife and brought together by a fine suture which is to be removed on the fifth day.
Confluent pittings, as after variola, must be removed by decortication or peeling methods.
The pits, if spread about the face promiscuously, may be treated separately by the peeling method, but when they lie less than one inch apart, it is best to treat the skin of the whole face.
This is done by applying pure liquid carbolic acid to the skin with a cotton swab. The skin at once assumes a white color. If the pittings are not very deep, one application of the acid is sufficient. If deep, one or two more applications are made as the preceding one dries. In very deep pits, the surgeon should apply the acid to the pit proper several times, blending off the application at the periphery.
When the surface thus treated has become dry, adhesive plaster, cut in half-inch strips of desirable length, are put on the face, one above the other, slightly overlapping, until the whole treated surface is well covered, mask-like.
The author uses Unna’s zinc oxide plaster mull for this purpose, as it is backed with gutta-percha, which readily adapts itself to the curvatures of contour.
The adhesive plaster mask is not removed until about the fourth or fifth day, when it will be practically forced away from the skin by the excretions thrown out from the derma. In some cases there is considerable pus.
After removal of the mask the skin, now very red and tender, is cleansed with a solution of bichloride, 1 in 10,000.
After the cleansing a mild soothing ointment, such as zinc oxide in vaselin, is used for several days until the skin takes on its normal epitheliar layer and appears normal in color.
No water or soaps are to be allowed during the latter period. In the later days of the treatment the skin may be cleansed with a little borated vaselin or even olive oil used with absorbent cotton.
If there is a pigmentation of the new skin this should cause no alarm, as it will fade out in from six to eight weeks.
Tincture of iodine has been used for the same purpose, as well as its mixture with carbolic acid.
Resublimed resorcin is also advocated, but the resultant peeling will not prove thick enough to give a satisfactory result.
If, for any reason, the effect obtained is not as desired, the patient should wait for several weeks and have the treatment repeated.
It is hardly necessary to say that the application used should not get into the eyes. The upper eyelids should not be treated, since no benefit arises from it. If there is a redundancy of tissue, it should be removed surgically, as heretofore described.
CHAPTER XVIII
CASE RECORDING METHODS
Every case, whether of little consequence or of important nature, should be properly and fully recorded in a thorough and systematic manner. Apart from the value of such a record, to the operating surgeon it often proves of the greatest importance in cases where operations of a purely cosmetic nature are undertaken.
Patients who beg us to make them more beautiful, or less unsightly in the eyes of the ever-critical observer, are the most difficult to please, and often complain, after a few days of constant mirror study, of the parts changed by methods that are the result of years of hard-earned experience, that the nose or the eyes or the ears have not been changed as much as they desired—in fact, so little that their closest friends have failed to evoke ecstatic remarks about the improvement.
This is not unusual with the most intelligent patients and is due to the fact that cosmetic operations performed on an ugly though otherwise normal organ have not yet become very frequent, and while friends are inclined to remark a change in lesser defects, they fail to credit this to the cause, owing to a lack of the knowledge of cosmetic surgery, or their ignorance of the art entirely
Photographs.—Where a pathological defect, wound, or scar or traumatic deformity is to be corrected, the patient is usually kind enough to permit of photographs being made of the parts to be operated on, but where the defect is hereditary, or the result of age, objections are invariably raised by all concerned, for fear their pictures will be used in some outlandish way.
The objection to photographs is obvious, since it usually requires visits to a studio, and the necessary loss of time to the surgeon,
whose presence is nearly always necessary to secure the proper negative.
This is especially true of the nose. Very few photographers will make a satisfactory sharp profile picture. It is less artistic, but most desired by the surgeon, and when the patient is presented for a second negative after the operation has been performed, the picture varies more or less in pose from the first taken.
It would be well for physicians to have a camera for use in the operating room, and those who can manipulate one will find that taking a 5 × 7 negative the most suitable.
Stencil Record.—For those who cannot provide themselves or bother with a photographic apparatus, the stencil record is recommended.
For this purpose a picture of a normal eye and its lids, a nose, lip or ear, is drawn upon a piece of oiled or stencil paper, or upon any thick, stiff book board.
The paper is laid down upon a plate of glass and the outlines of the picture are cut out, wide enough to allow the sharpened point of a pencil to pass. Where the lines are long it is advisable to allow connecting links to remain at various intervals as desired to keep the stencil stiff and to prevent cut margins from slipping or rolling up.
(See Fig. 521.)
F . 521. N S .
The stencil thus made is laid upon the record card and a tracing is made upon the latter by passing the lead-pencil point along the cut outline.
The stencil is now lifted and the defect sketched into the picture of the normal organ.
If this should be the anterior nasal line, a perfect sketch can be made of the defect by placing a card alongside of that organ and drawing the outline upon it as the pencil is made to glide over the nose, the point facing the card in such a way that a true profile outline is obtained. The card is then cut along the pencil line.
The nasal section of the card is now placed upon the stenciled nose and its outer border traced into or over it, as the case may be, by drawing the pencil point along the outer margin.
The same method may be followed post-operatio. This method can be employed for the other parts of the face as well, as, for instance, the mouth, ears, base of nose, etc.
Distances in measurements should be put into the record drawing to make it more exact.
The Rubber Stamp.—Another method is to make outline sketches of normal parts of the face with India ink upon drawing board and have those reproduced in rubber stamps, using the stamp in place of the stencil and marking in the defect in the manner before mentioned.
The Plaster Cast.—The best method by far, however, and the one found most accurate, is the plaster cast. It is not a difficult thing to make a cast of a nose, eyelid, lip, or ear, and the latter is much more preferable to any other method of record.
For this purpose some modeling clay is required, which is molded into a strip and laid around the part to be reproduced.
This forms a sort of raised ring or border and prevents the overflow of the semiliquid plaster, and avoids the annoyance of trickling the liquid upon other parts of the face about the site of the part worked on; at the same time it permits of neatness and uniformity in the size and shape of the casts to be filed away as records. (See Fig. 522.)
F 522 M M N P C
The skin surface, and hair, if any, within this ring area, before using this plaster of Paris, is now thoroughly coated with clean oil, or petrolatum, applied with a soft sable brush. The inner and upper part of the wax ring is also coated.
If there are openings in the parts of the face, such as the nostrils or the auricular orifice, they should be plugged lightly with dry absorbent cotton, care being taken, however, to avoid distending the alæ.
The plaster is now prepared in a small porcelain or soft rubber bowl by adding warm water to it until the powder, upon stirring, forms an even semiliquid paste.
This is poured first upon the area to be reproduced to fill all the finer crevices and to avoid air holes, and is then put on with a spatula, or wooden slab, until the space within the clay boundary is properly filled, covering the organ all over with a layer ¼ to ½ inch in thickness on all sides. Over the eyelids a thin coating of plaster should be used, whereas over other parts of the face a thickness of half an inch can be allowed without discomfort to the patient.
It is well at first to make the plaster thick, as the mold is liable to be broken upon removal or in drying. After a little experience splendid results are obtained with very thin walls of plaster.
The plaster is allowed to dry and harden, while the patient is instructed to remain still and silent. If a cast of the nose is made, the patient should refrain from talking and breathe gently through the mouth.
Tapping on the plaster now and then with a lead pencil will show when it has hardened sufficiently to be removed.
A
firm, quick pull relieves the mold.
In molds of the ear an anterior and posterior impression should be made, if a cast of the entire organ is desired. This can be done by first applying a layer of plaster to the posterior surface up to the outer rim, allowing this to harden and painting the anterior ear and the exposed plaster border with petrolatum before putting the plaster over it. Upon traction, when set, the plaster will separate readily at the point of the separation.
The removed piece of set plaster is called the mold.
It is allowed to dry thoroughly and then preferably coated inside with a thin coat of liquid petrolatum, which is found to be much better than oil.
A thinly prepared paste of plaster is poured into it at the outer brim and allowed to harden. The best results are obtained by setting the mold into a small pasteboard box in which it is held in proper position and prevents the thin plaster from running over the depressed edges.
